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NC049469 | Non-accidental injuries to a 13-month-old child of African-Caribbean ethnicity (Child M), including bruising to the face and transverse fractures to both femurs in June 2016. Father found not guilty of grievous bodily harm but both parents were found guilty of child cruelty. Both parents had criminal records, the father for possession of class A drugs. A half sibling (Sibling 1) to Child M had an excessive weight problem and visits to A&E. Child M was taken to A&E at age 3 weeks and again at age 5 months with what looked like non-accidental injuries and after the second incident both children were made subject to a child protection plan, Sibling 1 for emotional abuse and Child M for physical abuse. Mother had no recourse to public funds and this may have resulted in avoidant behaviours. Following unsupervised contact with father, Child M was returned home in pain and swelling on both thighs, refusing to walk or sit so the following day mother took him to A&E prompted by a social worker. Lessons learned: examples of parental avoidant behaviour or disguised compliance which exacerbate risks to children; occasions where more robust professional curiosity or challenge would have been justified; professional responses appeared more positive than the available evidence would suggest particularly concerning the child's injuries. Recommendations include: to enhance confidence within professional networks in the context of respectful certainty/cognitive dissonance to develop plans and interventions to respond to the possibility of deliberate harm even in the absence of conclusive evidence; support practitioners working with avoidant families, frequently fluctuating circumstance and disguised compliance.
| Title: Serious case review: Child M. LSCB: City of London and Hackney Safeguarding Children Board Author: Fergus Smith Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CITY OF LONDON & HACKNEY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD M FERGUS SMITH Published March 2018 Contents 1 INTRODUCTION 1 1.1 Event triggering this serious case review 1 1.2 Purpose, scope & process of the review 2 2 SIGNIFICANT ISSUES IN PRE-REVIEW PERIOD 5 2.1 Introduction 5 2.2 Parents’ criminal records 5 2.3 Domestic incidents (1 & 2) 5 3 SIGNIFICANT EVENTS DURING REVIEW PERIOD 6 3.1 Emerging professional concerns about sib.1. 6 3.2 Domestic incident (3) 7 3.3 Family support offered 7 3.4 Initiation of assessment by Children’s Social Care 7 3.5 Probation Service involvement with father 9 3.6 Ante-natal care 9 3.7 Birth of child M 11 3.8 Housing referral & GP referral of sib.1 11 3.9 First potential non-accidental injury to child M 12 3.10 Parents’ criminal conduct 14 3.11 Resumed contact with Ante-natal Service & Children’s Social Care 15 3.12 Second potential non-accidental injury to child M 17 3.13 Initial child protection conference 19 3.14 Domestic incident (4) 20 3.15 Review child protection conference 22 3.16 Partial engagement with ‘parenting support’ 24 3.17 Follow-up paediatric consultation 27 3.18 Third potential non-accidental injury to child M 28 4 ANALYSIS / RESPONSE TO TERMS OF REFERENCE 29 4.1 Introduction 29 5 CONCLUSIONS 36 6 RECOMMENDATIONS 41 7 BIBLIOGRAPHY 43 TERMS OF REFERENCE 44 Introduction 44 CAE 1 1 INTRODUCTION 1.1 EVENT TRIGGERING THIS SERIOUS CASE REVIEW 1.1.1 On a date in late June 2016 child M (a 13 month old Black British child1 of African-Caribbean ethnic origin) was taken by mother to ‘hospital 1’. On examination, the toddler was found to have bruising to the face and transverse fractures to both femurs. 1.1.2 Child M and an elder sibling had been subject to child protection plans since November 2015. At the time of incurring what are considered to be non-accidental injuries, child M was in the birth father’s care. Father was arrested on suspicion of grievous bodily harm (GBH) and mother was arrested on suspicion of neglect. Both children were placed with foster carers and during the course of this review made subject of Care Orders by a court. 1.1.3 Subsequent proceedings resulted in the court directing the return of the children to their mother’s care. At the criminal trial, father was found not guilty of GBH, although both parents were found to be guilty of child cruelty and sentenced in February 2018. CONSIDERATION OF A SERIOUS CASE REVIEW 1.1.4 In accordance with the Local Safeguarding Children Board Regulations 2006 and local procedures, child M’s injuries were discussed at the ‘Serious Case Review Sub-Group’ on 19.07.16. Following receipt of further information from some local agencies, the independent chairperson of the City & Hackney Safeguarding Children Board (CHSCB) decided on 06.09.16 that one of the required criteria (reproduced in paragraph 1.2.1) was satisfied and that a serious case review would be commissioned. 1.1.5 The Department for Education (DfE), regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE)2 were informed of the above decision. This review was undertaken between October 2016 and April 2017 in accordance with the terms of reference appended. 1.1.6 Following approval by the City and Hackney Safeguarding Children Board a copy of this report is being sent to the NPIE and to the DfE. 1 Because the gender of the children is irrelevant to the findings and represents an unnecessary identifying detail, all references in the report are gender-neutral. 2 The NPIE was established by central government in 2013 in order to advise Local Safeguarding Children Boards on the initiation and publication of serious case reviews. CAE 2 1.2 PURPOSE, SCOPE & PROCESS OF THE REVIEW 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died or has [as in this case] been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. An SCR is not concerned with attribution of culpability (a matter for a criminal court), nor (when that is relevant), the cause of death (the role of a Coroner). 1.2.3 The period of review was agreed as June 2014 through to the date on which it has been estimated that child M was injured (mid-June 2016). An independent report was commissioned from www.caeuk.org so that on the basis of material supplied, lead reviewer Fergus Smith would: Collate and evaluate it Design and conduct consultation / learning events with relevant professionals and Develop for consideration by the serious case review team a narrative of agencies’ involvement and an evaluation of its quality, conclusions and recommendations for action by the City & Hackney Safeguarding Children Board, member agencies and (if relevant) other local or national agencies 1.2.4 An initial consultation session was held with relevant staff and the purpose and process of the serious case review explained and discussed. A second event was convened at the point when it appeared that all relevant issues had been identified. The aims of such involvement were to ensure the accuracy of information within the report and the justification for conclusions drawn, and to encourage acceptance and application of the learning that was emerging. 1.2.5 The SCR review team was comprised of representatives of: City & Hackney Safeguarding Children Board (CHSCB) City & Hackney Clinical Commissioning Group (CCG) Hackney Children’s Social Care Hackney Learning Trust Homerton University NHS Foundation Trust (HUHFT) National Probation Service (NPS) Metropolitan Police Service (MPS) CAE 3 AGENCIES’ CONTRIBUTIONS 1.2.6 The following agencies supplied information to the SCR review team: Hackney Learning Trust (a brief report of universal nursery settings) Homerton University Hospital NHS Foundation Trust (HUHFT) (midwifery, medical and health visiting services) NHS City & Hackney CCG (GP Services) Royal London Hospital (emergency post-injury treatment) National Probation Service (London) (supervision of child M’s father) Hackney Children’s and Young People’s Service (family support and safeguarding-related contact) Metropolitan Police Service (responding to crime reports) FAMILY INVOLVEMENT 1.2.7 Both parents were informed that a serious case review was being completed, although the need to avoid undermining the criminal investigation necessitated postponement of any direct involvement with them. 1.2.8 Whilst their views will be established, the absence of these at this point will not delay the publication of this report. Anything of significance will be included as an addendum as necessary. TIMETABLE FOR COMPLETION OF SERIOUS CASE REVIEW Milestone Date/deadline date SCR agreement date 06th September 2016 Scoping Meeting (+ chronologies produced) 12th September 2016 First Review Panel Meeting 13th October 2016 Submission of first draft agency IMRs 18th November 2016 First Practitioners Focus Group 22nd November 2016 Submission of final agency IMRs 09th December 2016 Second Review Panel Meeting (+ IMR authors) 06th January 2016 Submission of first draft overview report 13th January 2017 Third Review Panel Meeting (+ IMR authors) 26th January 2016 Submission of second draft report 31st January 2017 Second Practitioners Focus Group 02nd March 2017 Submission of third or final draft report 13th March 2017 Fourth (final) Review Panel Meeting 29th March 2017 CAE 4 STRUCTURE OF CHILD M’S FAMILY ONLY THOSE FAMILY MEMBERS REFERRED TO IN THIS REPORT ARE SHOWN ABBREVIATIONS USED Abbreviation Meaning A&E Accident and Emergency Department BMI Body Mass Index (body mass divided by the square of height) CPS Crown Prosecution Service EDT Emergency duty Team FRT First Response Team ICE Immigration Compliance & Enforcement LSCB Local Safeguarding Children Board NPIE National Panel of Independent Experts SARA Spousal Assault Risk Assessment SCR Serious Case Review Father Age 28 Mother Age 25 Father of sib.1 Maternal grandfather Maternal aunt Grandmother Sib1 Sib 1 Child M CAE 5 2 SIGNIFICANT ISSUES IN PRE-REVIEW PERIOD 2.1 INTRODUCTION 2.1.1 Though the period under review is June 2014 to June 2016, it is helpful to consider some older information so that events and professional decisions during those 2 years can be placed in context. 2.2 PARENTS’ CRIMINAL RECORDS 2.2.1 Mother’s criminal conduct was first recorded by Police when she was aged 12 (a reprimand for shoplifting). Between the ages of 17 and 19 she was formally warned for theft after snatching a phone from a victim, found ‘not guilty’ of a robbery in the following year and later received a Community Order for aggravated vehicle taking. A detail (arguably still of relevance) with respect to the latter incident is that mother had held a knife to the throat of her victim and inflicted a cut. 2.2.2 Father’s recorded criminal history began in 2008 when aged 20, he was sentenced to 8 years of imprisonment for conspiracy to rob. Released in November 2010, he was recalled to prison in 2011 for offences of possession and intent to supply ‘class A’ drugs (Heroin and Cocaine). He was sentenced in July 2011 to 36 months custody for possession with intent to supply offence and re-released on licence on 21.03.13. According to the report supplied by MPS, on 18.12.15 father was fined for possession of a controlled drug. His release from prison remained conditional and his licence had been due to expire in February 2017. 2.3 DOMESTIC INCIDENTS (1 & 2) 2.3.1 In February 2014 mother (then aged 22) in the midst of an argument with an (unidentified) partner had made an abandoned 999 call. Officers who attended did not record the name of the other individual and because no offences were alleged, took no further action. Comment: sib.1 (then 2.5 years old) may not have been there; no formal notification (referred to as a ‘Merlin’) to Children’s Social Care or Health Services was initiated (an expectation if a child is present); mother later claimed that sib.1 had been with maternal grandmother at the time of the incident. 2.3.2 In March 2014 mother received significant injuries requiring hospital treatment during an altercation with child M’s father. Mother later withdrew her allegation and although the matter was still passed to the Crown Prosecution Service (CPS), no action was taken against father. 2.3.3 The report submitted by Homerton University NHS Foundation Trust (HUHFT) refers to completion of a DASH3 risk assessment by HV1 in April 2014 which provided a score of 2 (low risk). 3 DASH is a standardised checklist for identifying, assessing and managing risk used by all Police Services and most partner agencies. CAE 6 3 SIGNIFICANT EVENTS DURING REVIEW PERIOD 3.1 EMERGING PROFESSIONAL CONCERNS ABOUT SIB.1. WEIGHT OF SIB.1 3.1.1 In late June 2014 health visitor HV1 shared her concerns with GP1 about sib.1’s excessive weight. The child was well over the 99.6 centile4 and mother was refusing to accept that this represented a problem. HV1 planned to make a referral to Children’s Social Care. Comment: HV1’s response was well-informed with respect to the relative weight of a sib.1 and by mother’s explicit rejection of evidence-based health advice. The referral to Children’s Social Care was made in July. 3.1.2 Sib.1’s attendance at a nursery (which had begun in January that year) was checked by HV1 and noted to be erratic with none for the previous 3 weeks. Sib.1’s weight was reported to be increasing and causing practical difficulties and mother was described as uncooperative. Though mother denied that her current partner (child M’s father) was involved with her first child, he was often observed (as described below) collecting his step-child from nursery. 3.1.3 The records and recollection of nursery staff were sought during this serious case review. They reported that sib.1 had settled and was confident in making relationships, was polite, managed feelings well and had excellent communication and language skills. The relationship between sib.1 and step-father was noted to be positive. Staff never met sib.1’s biological father. 3.1.4 Nursery staff had no concerns about child M’s mother and the only issues noted had been the child’s erratic attendance and weight both of which had been raised with mother. A ’27 month integrated review’ at nursery 1 was completed on 14.07.14. Sib.1 was fully up to date with immunisations, confident, active and progressing well. Only weight remained of concern and staff recall a referral to the Dietetic Service being ‘agreed’ (albeit mother was ‘not keen’ on that option). Comment: it appears that the referral was not actually made until October 2014 and the opportunity anyway not taken up by mother; other examples of disguised compliance are described below. 4 Obese children are more likely to be ill, be absent from school due to illness, experience health-related limitations and require more medical care than normal weight children; obese children are also more likely to become obese adults, and have a higher risk of morbidity, disability and premature mortality in adulthood – Public Health England website CAE 7 3.2 DOMESTIC INCIDENT (3) 3.2.1 There was a further domestic incident involving Police on 18.07.14 when mother and father argued over the ownership of some articles. No offences were disclosed and no further action was required of attending officers. It is uncertain whether sib.1 was present. 3.3 FAMILY SUPPORT OFFERED 3.3.1 HV1 made a referral to the Children’s Centre ‘Multi-agency Team (MAT) panel seeking family support. The case was opened at ‘risk assessment level 3’5 and allocated to the Centre’s family support team. 3.3.2 In mid-August HV1 received ‘child protection supervision’ and it was agreed that she should liaise with the allocated family support worker, monitor sib.1’s growth 2-3 monthly, and refer to Children’s Social Care if mother failed to co-operate. 3.3.3 By September 2014 family practitioner FP1 was reporting that she had been unable to contact the family in spite of numerous attempts to do so and that nursery attendance of sib.1 was poor. The MAT panel determined that the Health Visiting Service should refer the case to Children’s Social Care and following confirmation from HV2 that this had been done on 04.09.14, the case was closed to the MAT. 3.4 INITIATION OF ASSESSMENT BY CHILDREN’S SOCIAL CARE 3.4.1 On 04.09.14 Hackney’s Children’s Social Care First Response Team (FRT) received the referral sent on behalf of HV1 (which omitted the name of mother’s possibly unknown partner). A decision was made to open the case and it was allocated to the ‘Access & Assessment (A&A) Unit 2’. 3.4.2 In mid-September at a consultation with her GP, mother revealed that she was pregnant with child M. At social worker SW1’s initial home visit on 30.09.14, mother’s pregnancy was not referred to. SW1’s observations of sib.1 who was playing with toys did not identify concerns about mobility or breathlessness. Mother disagreed with HV1’s concerns and SW1 encouraged her to consult the GP about sib.1’s weight. Mother consented to agency checks with GP, health visitor and nursery. Comment: mother misled SW1 when she claimed to have pressed charges against father but not know the outcome following the incident in April 2014. 3.4.3 On 14.10.14 mother presented sib.1 at the GP and a check on weight indicated a reduction of 3Kgs. 5 ‘Risk assessment level 3’ refers to the MAT Family Support Impact Evaluation Risk Assessment tool that enables a practitioner to score identified risk factors that may impact upon family functioning and safeguarding. The intention is to work with families to reduce identified risks and lower the initial score. Level 1 = moderate risk; level 2 = moderate to serious risk, level 3 = serious risk and level 4 = severe risk which would result in case closure and referral on to Children’s Social Care. CAE 8 3.4.4 Mother was seen in the office on 17.10.14 by SW1 and appeared more receptive to discussing sib.1’s weight. She accepted a referral to a healthy eating group in the New Year. Her pregnancy was discussed and mother acknowledged the possibility the child was the result of sexual relationship with an individual described as an ‘ex-partner’ (whom she declined to identify). Immigration and housing issues were also discussed. Comment: it is uncertain whether mother’s use of the healthy eating group was to be confirmed. 3.4.5 Sib.1 began attending a nursery school on 20.10.14 having been withdrawn with no notice from nursery the previous week. Sib.1 remained on roll until transfer to Primary School in Summer 2016. Described by staff as a sensitive loving child who made good progress in all areas of learning and exceeded expected outcomes in the Early Years Foundation Stage curriculum. Weight remained a concern. 3.4.6 Child M’s father (sib.1’s step-father) has been described as a consistent person in sib.1’s life, who from time to time brought or collected the child from the nursery school. Staff contrasted father’s ‘quiet, emotionally available and warm attitude’ toward sib.1 and mother’s ‘emotional detachment’, which had been observed for a while. The nursery school had no contact with sib.1’s birth father (until sib.1’s last day which was also when sib.1 and child M entered foster care). 3.4.7 On 21.10.14 SW1 followed up the office contact with mother and called sib.1’s birth father. She was told that his child was a ‘fussy eater’ but he denied that the diet was unhealthy and said that he had been overweight as a child. He asserted that he and mother maintained a good relationship ‘for the sake of sib.1’, had no concerns about his ‘ex-partner’s parenting and ‘enjoyed looking after sib.1 when he visited’ (the frequency of such visits was not captured). Comment: contacting the child’s birth father was good practice often not evident in cases audited / reviewed by the author. 3.4.8 Mother re-presented sib.1 to the GP on 28.10.14 and records refer to a long discussion and a referral (not confirmed in electronic records) on to a ‘fussy eaters service’ (not the one identified by SW1 earlier in the month). An ante-natal referral to hospital 1 was initiated. At a second home visit by SW1 on 30.10.14 sib.1 was seen alone. Mother insisted that she had not seen her ‘ex-partner’ since May rather than September as recorded by the nursery school. She described a meeting at her mother’s house in May when she might have become pregnant. Mother resisted discussing any other intimate relationships. A health visitor phoned Children’s Social Care next day, was updated about progress of its then ongoing assessment and was told of mother’s reassurance to the social worker that she was making use of the Dietetic Service ‘fussy eaters service’. Comment: mother did not make use of the Dietetic Service. CAE 9 3.5 PROBATION SERVICE INVOLVEMENT WITH FATHER 3.5.1 On 05.11.14 at a planned office visit father (still subject to licenced release from prison until February 2017) acknowledged to PO1 a casual relationship with a female who had informed him some weeks ago that she was pregnant with his child. He reported that although not wanting a serious relationship with her, he had accompanied her to her hospital ante-natal appointment that day. 3.5.2 Father said that he continued also to be in regular contact with an ex-partner and their children in another borough [the Probation Service and the City and Hackney Safeguarding Children Board have alerted Children’s Social Care in the relevant borough to child M’s experience and consequent potential risk to these children]. Comment: in accordance with the National Probation Service safeguarding policy, and reflecting the history of violence and a class A drugs offence, Children’s Social Care should have been notified of the pregnancy of father’s partner. 3.6 ANTE-NATAL CARE 3.6.1 HV3 documented a call from mother on 19.11.14 when mother was ‘abrupt’ to a colleague and declined without explanation any further health visiting services saying she would not be attending for a weight check or health review of sib.1. In accordance with HUHFT ‘No Access policy’ HV1 records indicate that she alerted an unnamed social worker. COMPLETION OF SOCIAL WORK ASSESSMENT / MONITORING OF SIB.1’S WEIGHT 3.6.2 Aside from noting that sib.1’s obesity was being monitored by the GP, the report of the assessment completed on 27.11.14 referred to mother having taken ‘appropriate action’ with respect to domestic abuse in March. In fact she had declined to support Police action at the time and she later admitted, had gone on to become pregnant by the same man. Housing and immigration status were identified as unresolved issues but mother’s relationship with sib.1 was noted to be warm and responsive and no role for Children’s Social Care was identified. The case was therefore closed and mother, GP and Health Visiting Services as well as sib.1’s nursery school were sent copies of the completed assessment. Comment: with respect to mother’s ‘protective action’ earlier in the year and her apparent choice of ‘single parenthood’, the conclusion of the assessment (risk of domestic abuse ‘low’) was based upon false and misleading evidence; in addition, the safety net usually represented by health visiting was assumed. CAE 10 3.6.3 At a ‘link meeting’ between GP and health visitor on 01.12.14 it was reported that sib.1 had been seen only once since October and there appeared to remain uncertainty about a referral to the Dietetic Service. It was thought sib.1’s weight might have reduced since concerns were first raised and that a review at the end of January 2015 would be sufficient (a formal referral was subsequently sent on 10.12.14). 3.6.4 HV1 received child protection supervision again on 05.12.14. It was agreed she liaise with GP, midwife and nursery school head teacher with respect to ongoing concerns. On the same day HV1 received the Children’s Social Care assessment confirming that mother had stated she was willing to engage with universal services including health visiting with respect to sib.1’s weight and that she was pregnant. 3.6.5 The reassurance offered by mother conflicted sharply with her earlier rejection of health visiting and HV1 and SW1 spoke by phone. HV1 proposed to offer mother an alternative source of support via the GP and pointed up the imminent involvement of the Midwifery Service and that a different health visitor would be allocated when the new baby arrived. HV1 was asked to re-refer if her further efforts to engage with mother proved unsuccessful. Comment: in the absence of further discussion between a health visitor and social worker, there was no face-to-face contact with sib.1 for 12 months and hence no monitoring of weight or wider welfare needs. 3.6.6 At a further office contact with PO1 on 10.12.14, father offered more reassurance about his ongoing ‘not serious’ relationship with mother as well as a willingness to support her with their child. Father repeated his account of supporting mother before and after the birth of their child and of maintaining contact with his ex-partner and their children. Comment: had SW1 been aware of the involvement of Probation she could have compared and contrasted the parents’ accounts. 3.6.7 Mother ‘stormed out’ of a GP2 consultation (attended jointly with a man recorded as ‘father’, but in all probability step-father) on 09.02.15 because she was dissatisfied with the explanation offered of some spots on sib.1’s face. She returned at a later date and accepted the diagnosis (a self-limiting common childhood viral infection). The doctor has reported feeling threatened by the adults’ responses to her advice. Comment: the presence of step-father offers evidence of his ongoing involvement with the family; also any such perceived threat has significant implications for any child who was dependent upon such adults. 3.6.8 At an ante-natal check on 26.03.15 the midwife noted the presence of a man presumed to be father though her records did not explicitly confirm identity. In mid-April 2015 mother self-presented at an A&E Department for minor symptoms and was provided with routine medical responses. Comment: it is in virtually all circumstances, helpful to enquire about and capture responses to the issue of paternity. CAE 11 FIRST A&E PRESENTATION OF SIB.1 3.6.9 In the very early hours of 10.04.15 sib.1 was presented to hospital 1’s A&E Department with a 2 week history of self-resolving nose bleeds and an acute upper respiratory tract infection (mother reported that a GP had prescribed a de-congestive nasal spray). Sib.1 was noted to be happy and no safeguarding concerns were identified. The GP Practice was notified of this presentation. 3.6.10 HV1 received further child protection supervision a week before child M was born. It was agreed that if mother persisted in her refusal to accept health visitor involvement a new referral to Children’s Social Care was to be made. Meanwhile HV1 should liaise again with other agencies. 3.7 BIRTH OF CHILD M 3.7.1 On a date in late May child M was born without complications. Mother and baby were discharged home and a community midwife completed an uneventful first visit 2 days later. A more challenging visit was made when child M was 5 days old. Father was present and MGM presented the baby to the midwife. Mother repeatedly refused to meet her and in consequence, routine checks of her well-being could not be completed. 3.7.2 Several attempts were made by HV1 or colleagues to complete a ‘new birth visit’. Only when a different health visitor was offered, would mother agree to a visit which was completed on 01.06.15 (day 13 after child M’s birth). The priority was the baby and an observation of a clearly very overweight sib.1 was not developed further. 3.7.3 The home was noted to be clean and tidy and mother reported that she was coping and being supported by her boyfriend (assumed to be the father of child M) and her mother. The baby had regained his birth weight and no immediate concerns were identified. 3.7.4 Father’s update to his probation officer PO1 that month suggested that he and child M’s mother might become ‘a couple’. PO1 spoke of completing a home visit at this time though did not do so (such a visit is an expectation of the National Probation Service). 3.8 HOUSING REFERRAL & GP REFERRAL OF SIB.1 3.8.1 Children’s Social Care received a referral from Hackney Homes on 12.06.15. Child M’s father and child M had attended ‘Housing Options & Advice’. He reported they had been kicked out by mother who was he claimed, depressed following child M’s birth. Father planned to take the baby to the child’s paternal grandmother, though refused to provide her address. The case was re-allocated to A & A2 for a further assessment. Comment: it was helpful to re-allocate the case to those with some familiarity with the family; it is unclear whether the risk inherent in entrusting child M to father’s care was tested nor if mother’s consent (as sole person with parental responsibility had been obtained. CAE 12 3.8.2 Sib.1 was seen again at the GP Practice on 16.06.15 in response to a referral from a pharmacist who was concerned about the child’s ‘off the scale’ weight / height. A referral was made to the Paediatric Department at hospital 1. Mother failed to make any appointment and the child was subsequently discharged back to GP care on 13.07.15. Comment: the pharmacist’s initiative was commendable; mother’s response offers a further example of her disguised compliance. 3.9 FIRST POTENTIAL NON-ACCIDENTAL INJURY TO CHILD M 3.9.1 A week later in the early hours of 22.06.15 child M (aged 3 weeks) was presented at the A&E Department of hospital 1 and admitted to the Paediatric Ward. The baby was reported to have an unexplained history of nose bleeds, a bleeding gum and marks under the right eye and cheeks whilst in the care of his father. 3.9.2 Health Visiting Services and Children’s Social Care were notified and in a phone call from a paediatric registrar to the ‘First Access and Screening Team’ (FAST), she reported her suspicions that the injuries were non-accidental. A CT scan was completed and a full skeletal survey and an ear nose and throat (ENT) examination scheduled. Child M was admitted and the parents were noted to have ‘shut down’ after the examining consultant 1 discussed a referral to Children’s Social Care e.g. no eye contact and no responses to questions. 3.9.3 By 23.06.15 completed tests had revealed nothing abnormal. The results of an ophthalmological test by Great Ormond Street Hospital were awaited. A reference was made to mother’s post-natal depression. An aunt had by this time provided the medical staff with a clearer account which had somewhat allayed professional anxieties. 3.9.4 A discussion on 23.06.15 with the FAST ‘screening and referral manager’ resulted in agreement to hold the case until all the medical results became available. The hospital was asked to alert Children’s Social Care to any further A&E presentations. The paediatric consultant reportedly suggested a joint visit by a health visitor with the social worker. Police were not involved. 3.9.5 A GP consultation by mother on 24.06.15 included no reference to the hospitalisation of child M. Mother reported no mood disturbance and spoke of the support provided by MGM, sister and ‘partner’ [sic]. Comment: it is reasonable to conclude that mother’s failure to mention her child’s emergency admission was avoidant behaviour. 3.9.6 On the same day as mother’s consultation with her GP (whether before or after is unclear from the records) and following a brief discussion at the hospital’s paediatric psycho-social meeting there was a recorded intention to further discuss the case at a second meeting. Child M was discharged from hospital and an email referral was sent to Children’s Social Care. CAE 13 3.9.7 The FAST record captured the above events and prompted an ‘alert’ on child M’s health records to reflect recent referrals from Housing and Hospital. A further conversation with consultant paediatrician 1 revealed that remaining tests had confirmed nothing untoward (an additional test for haemophilia was awaited). It was agreed there remained no evidence for originally suspected non-accidental injury. 3.9.8 A call to mother by SW1 in Children’s Social Care (to whom the case was re-allocated on 26.06.15) elicited consent to initiate agency checks and an agreement to meet at the office. Mother diminished the significance of the relationship with child M’s father by saying he provided no financial support. She admitted feeling ‘low’ but reported her GP had not identified depression. She claimed (inaccurately) to be supported with respect to sib.1’s weight by a Children’s Centre. Comment: ‘financial support’ was of little relevance to the fact or nature of the relationship or risk father posed mother and children; a comment ‘advised whilst at her mum’s house Children’s Social Care cannot visit’, required challenge. 3.9.9 In a subsequent phone contact, mother denied father’s account of being ejected from her home and said that he had taken sib.1 out for the day. A conversation on the same day between SW1 and HV1 shared concerns about family engagement though established that the latter professional and a colleague HV3 who had made a joint visit with a midwife, had no concerns about either child (except sib.1’s weight). Comment: records of Housing and FAST earlier in June refer to father and child M (not sib.1) – possibly an attempt to deceive or confuse professionals. 3.9.10 The recorded output from the further paediatric psychosocial meeting held on 01.07.15 concluded that there would be no further active involvement from the safeguarding children team because Children’s Social Care was actively managing the case. An unidentified health visitor met MGM on 02.07.15 at the family home. Mother and child M were reported to have gone out. The GP Practice was notified of child M’s A&E presentation. 3.9.11 At his monthly report to PO1, father reported on 10.07.15 that he and mother had presented child M to Great Ormond Street Hospital for an eye check-up. He made no mention of the concern that child M’s observed symptoms had been suspected to be non-accidental. 3.9.12 The hospital contacted SW1 on 13.07.15 and she confirmed a meeting that day when she would ask mother to contact health visitors. Father was present at the meeting (which revealed no immediate concerns) and admitted contact with Housing had been an attempt to obtain his own accommodation. Comment: father’s responses to PO1 and SW1 indicate he too was seeking to mislead professionals; 3 days later, mother refused access (claiming to be asleep) to the health visitor making an opportunistic visit. CAE 14 3.10 PARENTS’ CRIMINAL CONDUCT MOTHER’S ARREST 3.10.1 On 16.07.15 mother was arrested for assault of her sister and criminal damage. Child M’s aunt was reported to officers (by mother) to have been looking after the baby for 3 weeks. Mother allegedly wanted (according to her sister) to resume care ‘so as to give child M away to Children’s Social Care’. Child M (not present at the time of mother’s arrest) was left with his MGM. Police subsequently ‘NFAd’ the episode because the sister refused to provide a statement and MGM was a reluctant witness. A notification was sent to Children’s Social Care. Comment: this episode offered a useful insight into the relationships of wider family; it was shared with the Health Visiting Service a week later by which time the account was of the baby being left only ‘at night’ for 3 weeks. 3.10.2 Mother subsequently offered a different explanation in which her sister had cared for child M for only 1 week and had argued only about money. Mother denied ever wanting to relinquish care of child M, saying that the break was to enable her to deal with her need for re-housing. Comment: no evidence has been provided that mother used the 1 or 3 (it remains uncertain which) weeks to address housing-related issues. 3.10.3 On 20.07.15 Children’s Social Care was alerted to the inability of the health visitor to contact mother. Mother was seen by her GP 2 days later and given what appears to be a thorough medical examination. No signs of depression had been noted in a ‘chatty and engaged’ mother and (aside from weight about which mother had taken no action) sib.1 appeared well. A 6 week child health examination was also completed on 20.07.15 and child M’s BCG vaccination were administered. A GP record referred to ‘puerperal depression’ (now known to have been a recording error). Contraceptive advice and assistance was provided. 3.10.4 At a ‘link meeting’ between health visitor and GP that day, the doctor reported no concerns about mother’s affect. A letter was sent next day to Children’s Social Care in which the above findings were shared. On 24.07.15 social worker and health visitor shared and agreed a concern about some form of ‘disconnect’ between mother and child M. SW1 subsequently liaised with her agency’s ‘Clinical Hub’ (a source of therapeutic assistance in this case potentially offering a programme ‘New Beginnings’ for mothers and babies). 3.10.5 Mother failed to present child M for outstanding immunisations and the health visitor informed Children’s Social Care. SW1 made further attempts during the remainder of July to establish contact with mother and on 31.07.15 updated the clinician colleague whose intervention she planned to engage (subject to mother’s consent). Comment: the health visitor and social worker were making substantive individual and joint efforts to encourage mother to access relevant services. CAE 15 3.10.6 Child M’s immunisation was eventually administered on 10.08.15 by a GP. Also that day mother phoned SW1 to report she could no longer remain at her mother’s address. She was advised to consult the Housing Service and the charity Shelter to discuss options. Several further (unsuccessful) attempts were made by the Social Work Unit to contact mother and text messages were left. 3.10.7 Mother initiated contact with the Social Work Unit on 14.08.15 and explained that she was staying with a friend outside of London. An appointment was made for 19.08.15 though postponed on several occasions and eventually completed on 03.09.15. 3.10.8 Mother turned down the suggestion of the ‘New Beginnings’ programme and other unspecified Multi-agency Team (MAT) services. She claimed that a GP referral to a paediatrician concerned sib.1’s height not weight and that she needed no further help in that regard. Mother’s interactions with her children gave no cause for concern. A check with the Practice on 04.09.15 confirmed the issue prompting a paediatric referral had been weight not height as claimed by mother. Comment: SW1’s action taken showed commendable and wholly justified caution, given that many other claims by mother were demonstrably inaccurate or false. FATHER’S ARREST 3.10.9 On the same day mother finally ensured that child M received the outstanding immunisations, father (in the company of others) had been arrested on suspicion of possession with intent to supply a large quantity of cocaine and cannabis. The Probation Service was informed. Comment: within Probation it was agreed that if charges were brought, father would be recalled to prison; in the event after several months on bail, the Crown Prosecution Service decided in April 2016 to take no further action. 3.10.10 Insofar as mother sought an update about events from Probation, it seems her partner had not (3 days after arrest) shared the news. SW1 discussed the case at a Unit meeting on 19.08.15 and in view of mother’s resistance to engage, concluded she would need to complete her assessment without the involvement of a clinical colleague. 3.11 RESUMED CONTACT WITH ANTE-NATAL SERVICE & CHILDREN’S SOCIAL CARE 3.11.1 On 03.09.15 midwifery notes refer to mother’s refusal of a random blood sugar test and her report that she had ceased to take recommended vitamins and iron supplements. On the same day mother, child M and sib.1 were seen at Children Social Care (the first face to face contact since July that year). The issue of weight was again raised with mother still refusing to access support. Observations of her interactions with the children were more positive. CAE 16 3.11.2 A call was made by SW1 to the GP Practice next day and the concerns about mother’s response shared. It was thought the referral initiated by GP1 had not been followed up and the GP agreed to check this out. Comment: this was an example of good (and in terms of the national picture, atypical) collaboration with a GP Practice. 3.11.3 In SW1’s view (as recorded by the GP with whom she spoke), sib.1 was not ‘at risk of significant harm’. The social worker later held a discussion with a consultant social worker and on 23.09.15, with a service manager. The latter manager directed that a ‘professionals meeting’ should be convened in an attempt to formulate a plan. If that failed, consideration should be given to initiating s.47 enquiries. 3.11.4 In a later phone exchange with mother, SW1 referred to the planned meeting to which mother proposed to bring a solicitor, indicating she was being ‘picked on’ because she was single parent. At this time, father was offering PO1 a consistent account of continuing contact with child M though he claimed that he and ‘the baby’s mother were no longer in a relationship’. By the end of September mother had decided that she would accept a family support worker. PROFESSIONALS (TEAM AROUND THE FAMILY/ NETWORK) MEETING 3.11.5 The meeting was held on 08.10.15 with mother and father who by then had admitted their resumed relationship, present. Concerns felt across the network were shared. Mother continued to deny that sib.1’s obesity was a problem. Attendance at nursery school was reported to be good. The attending health visitor later provided feedback to GP colleagues. Comment: only days before this, father was denying the relationship had resumed. 3.11.6 A consensus was apparently formed at the meeting that there were no concerns that would justify s.47 enquiries. The family was to be supported by the ‘Family Support Service’. If mother sustained her refusal to engage in meeting the emotional needs of her children, a referral back to Children’s Social Care was contemplated. Comment: the position with respect to sib.1 following the meeting was no different than that which preceded it. 3.11.7 Only 4 days after the above meeting mother failed to bring sib.1 for his paediatric appointment. Father (further undermining earlier claims that his relationship was over) presented child M to a ‘baby clinic’ on 19.10.15 though declined to wait until seen by a health visitor. 3.11.8 Children’s Social Care’s re-assessment was completed on 14.10.15 and highlighted the concerns about sib.1’s weight and mother’s varying levels of warmth with her children. Father’s inconsistent contact was identified as unhelpful, though observed direct care was of no concern. CAE 17 3.11.9 The assessment characterised the adults’ relationship as ‘long-standing friends’ but (because of his lack of support) no longer in a relationship Comment: the parental description of their relationship (which appears still to have included sexual intercourse and significant co-parenting) could usefully have been explored further. 3.11.10 A handover visit was completed at the office on 26.10.15 and mother met a family support worker. She and father indicated they would co-operate. Mother claimed to have no mobile and asked for contact via her partner. An initial appointment was agreed for 03.11.15 at the nursery school because mother reported that child M’s grandmother with whom she was again living, remained unwilling to receive Social Care agencies in her home. Comment: being denied access to where the children were living placed the staff at a disadvantage; it would have been worth making direct contact with the children’s grandmother to test out her reported opposition. 3.12 SECOND POTENTIAL NON-ACCIDENTAL INJURY TO CHILD M 3.12.1 At 04.38 on 31.10.15 child M (nearly 6 months old) was presented to hospital 1’s A&E by mother and father, maternal aunt and an unnamed ‘God mother’. The child was examined and noted to have bruising and a minor head injury. Of particular concern was that father who had reportedly been in bed with the baby at the time was unable to provide a consistent explanation. An account to the Emergency Duty Team of Children’s Social Care by the hospital’s paediatric nurse differed in some respects to father’s initial accounts. 3.12.2 Notes of a medical examination indicated …’bruising to the right upper eyelid and inferior to right eye, with bloodshot area on sclera [white of the eye] visible latero-superiorly [above and to the sides] to the iris. 2 linear marks extending from between the eyebrows diagonally left to the hairline, right one 0.5cm width, left one slightly narrower. Lateral to this to the left, some streaky red marks, less well defined’. 3.12.3 Although consent for photographs was reportedly taken, this is not evident from notes and no photographs were taken. A body map was completed but no written report accompanied it. The report submitted to the review points out that father’s account of his 5 month-old baby standing up in a ‘Moses basket’ was very unlikely to be developmentally possible6. A report from a speciality doctor at the hospital cited by Children’s Social Care indicated that mother had reported that she did not believe father’s account of events. 6 According to Denver Developmental Screening Test (DDST), commonly known as the Denver Scale, an average age for a baby to pull to a standing position is 8-10 months old. CAE 18 3.12.4 In a phone call between the above doctor and SW1 it was agreed that the child could return to care of mother (then living with the child’s grandmother), pending completion of an assessment. The parents signed an agreement that father would not access child M and that if he did so, mother would alert Police. Comment: though not all the evidence (father’s criminal record etc) was available to SW1 at this time, mother’s misleading accounts of her ongoing relationship with father indicate that she could not be relied upon to comply with any such agreement; in addition the grandmother was (according to the account provided by her daughter) opposed to any visits by Children’s Social Care staff. 3.12.5 In the view of consultant paediatrician 2, the parental explanation provided was ‘plausible’ and further investigations not required. The report submitted to the serious case review by HUHFT points out that the medical team’s records do not offer an explicit conclusion e.g. whilst accepting the plausibility of father’s account, the report sent to the GP implies an ‘unexplained’ injury. In the period between child M’s first and second hospital presentation, a move toward ‘electronic paper records’ (EPR) had resulted in some staff being unaware of the need to complete a child protection form / report in addition to standard documentation on EPR. The GP Practice received notification of this incident on 31.10.15. 3.12.6 On 02.11.15 a management decision was made, that in the light of the injury the case would transfer back to A&A Unit 2 for further assessment. A home visit and a conversation with sib.1 (alone) revealed nothing more. He said he had been asleep when child M was hurt. This was recognised as possibly true or the result of coaching. Mother agreed to stick with the safeguarding agreement and SW1 planned to meet father and to speak with sib.1 again at his nursery. Records indicate a strategy discussion (preceding s.47 enquiries) might follow. At an office visit on 04.11.15 father gave a further account of how child M was injured. At a case discussion on 06.11.15 involving SW1, consultant social worker and the service manager, the overall family functioning was considered and a decision made that a child protection conference was justified because: Of the observed injury to a pre-mobile baby Father’s accounts were inconsistent In the light of a previous injury, doubts existed about his capacity to keep child M safe Of insufficient confidence in mother’s protective capacity Comment: this response was evidence-based and proportionate. 3.12.7 A subsequent strategy discussion with Police on 09.11.15 acknowledged that although there was no evidence to confirm non-accidental injury, there were real doubts about the capacity of both parents to safeguard their children and a conference was required. CAE 19 SECOND A&E PRESENTATION OF SIB.1 3.12.8 Before the initial protection conference was convened, sib.1 (3.5 years old) was again presented to A&E on 07.11.15 and seen by the Primary Care Service due to an insect bite. Because the child was known to Children’s Social Care, a ‘safeguarding alert’ was completed and the Safeguarding Children Team informed Children’s Social Care and (via its team planner) initiated a request for a follow-up by a health visitor. 3.13 INITIAL CHILD PROTECTION CONFERENCE 3.13.1 The initial child protection conference was held on 26.11.15. All those who were invited attended i.e. health visitor, head-teacher, Police, social worker and mother. It would appear that GPs were invited but did not attend (or provide a report) and Probation, the involvement of which remained unknown to Children’s Social Care, was not invited. Comment: Both GP and Probation services held relevant information and would have been useful contributors. 3.13.2 A report from Children’s Social Care referred to an agreed view of the speciality doctor and SW1 that father’s account of the injuries to child M in October were ‘plausible’. They retained concerns about his capacity to offer safe care of very young children. Conference records indicate a plan to refer father for a ‘parenting support for risk and safety awareness’ programme. The case was to be transferred to the CIN Unit 9 for ongoing service delivery. 3.13.3 The MPS representative referred to a 2007 incident in which father had been questioned over a potential rape though not charged. It would appear that although a comprehensive account of father’s criminal record including lengthy prison sentences and current bail was shared, the fact that he was on licensed release was not considered. Comment: it was known mother had ‘no recourse to public funds’ and it is unclear how agencies perceived she was feeding or clothing her children7. Her wish to avoid the attention of ‘Immigration, Compliance & Enforcement’ (ICE) may have been a factor in avoidant behaviours. 3.13.4 The formal decision of the conference chairperson was that both children should be made subject of a child protection plan: Sib.1 for emotional abuse Child M for physical abuse Comment: that decision was wholly reasonable and proportionate; the records of discussion and agreed actions appear sparse and the child protection plan that was formulated was rooted in an apparent belief that child M’s injuries to date had been accidental rather than (more precisely) of uncertain causation. 7 ‘Supporting people with no recourse to public funds (NRPF): Guidance for homelessness services’ May 2016 offers some guidance to this complex issue. CAE 20 3.14 DOMESTIC INCIDENT (4) 3.14.1 Within a week of the initial child protection conference, police officers chanced upon mother chasing father up the road. She alleged that an altercation at her doorstep had ended with him slapping her and that officers had witnessed what followed. 3.14.2 Father was arrested for the alleged assault but as a result of mother’s unreliable evidence only a charge of cannabis possession was proceeded with (and resulted in a fine). Mother claimed that her relationship with him had ended in June and that he was not interested in maintaining contact with his child. She claimed (inaccurately) to be seeking an injunction against him. Mother also referred to 2 incidents in which child M had sustained bruising whilst in father’s care. Scrutiny of text exchanges confirmed mother had lied in order to get him to visit her. Officers had confirmed that child M was safe in the care of MGM and Children’s Social Care was notified via a ‘Merlin’. Comment: it seems likely that child M (aged less than 6 months) was just left at the doorstep while the parents acted out their disagreement; MGM’s denial that she had been aware of what was going on stretches credulity. 3.14.3 The chronology provided to this review indicates that there was an appointment for sib.1 with consultant paediatrician 1 on 01.12.15 (in the event a registrar completed the examination). Aged 4 years and 2 months sib.1 was recorded as being over 99.6 centile for weight and height. Mother refused the offer of a referral to Dietetic Services. The clinician was unaware of the earlier safeguarding concerns which were on the Community ‘Rio’ system but not on the hospital’s electronic patient record (EPR). 3.14.4 At a home visit by newly allocated social worker SW2 mother repeated what she had previously said i.e. that she did not want child M’s father having unsupervised access to his child. On 07.12.15 child M was brought to the Health Centre. Weight was on 75th centile and the child appeared well and appropriately dressed. CORE GROUP 1 3.14.5 A timely first ‘core group’ was held on 08.12.15 at the nursery school and attended by SW2, nursery staff member and health visitor. It was noted that neither the father of sib.1 nor the father of child M were permitted to collect the children from nursery school. A further meeting was scheduled for 22.01.16 and results of the December paediatric appointment were to be chased up. 3.14.6 A further ‘link meeting’ was convened at the Health Centre on 14.12.15 when the fact that child M and sib.1 were subject of protection plans was shared. Comment: health visitor - GP liaison appears to have been a consistent strength. CAE 21 3.14.7 A home visit by SW2 was completed on 22.12.15 and mother complained that father was not helping and that she did not want him to have child M. Just after Christmas mother was hospitalised briefly for pregnancy-related symptoms. About 2 weeks later, on 05.01.16 SW2 was told by mother that her relationship with child M’s father had resumed. Mother said that she ‘wanted him to move back in’ [sic]. Mother was noted to be affectionate toward the baby but dismissive of sib.1 when that child sought some attention. Comment: without regard to what father was telling PO1 (and his account of the December altercation differed from mother’s), he had clearly been cohabiting (at least part-time) with child M’s mother and thus misleading his probation officer. 3.14.8 PO1 informed father that as a result of his arrest and discovery of cannabis, a senior colleague would be consulted and the possibility of a recall to prison considered. PO1 commendably sought confirmation from Children’s Social Care on 11.01.16 that it was involved and asked to be alerted to any safeguarding concerns. His email included an assertion by father that he was to be involved in an impending parenting class. A ‘manager’s warning’ was sent to father on the same day reminding him of the possibility of a recall to prison. 3.14.9 PO1 received a prompt confirmation from SW2 of agency involvement, that the children were subject of protection plans and that the family was engaging. SW2 sought and was later sent a proportion of the information about father’s current criminal conduct and licence conditions. PO1’s intention to seek an update from SW2 was unfulfilled. 3.14.10 An 8-10 month development review of child M (who presented and appeared well) was completed on 19.01.16 and prompted no concerns. A joint home visit was made by SW2 and consultant social worker CSW1 on the same day and elicited from mother a promise of co-operation. Mother reported her wish for child M’s father to remain involved but that they were no longer in an intimate relationship (this contradicted what SW2 had been told as recently as 05.01.16). 3.14.11 By 25.01.16 (when MGM presented sib.1 with an injury / bite to his left 4th finger) the GP had still not received a report of sib.1’s paediatric assessment of early December. Its findings would have been of relevance for the imminent review conference. In response to a request from Children’s Social Care for a report, the GP Practice sent its July 2015 report and the recent A&E discharge note. Comment: material submitted should have been more current and considered. 3.14.12 At a further unannounced home visit on 01.02.16 mother was forewarned of the recommendation that the protection plans should continue, primarily because of father’s lack of engagement. Mother again indicated that she no longer wanted his inconsistent involvement. CAE 22 3.14.13 The case was allocated to Family Unit 7 on 18.12.15 with a view to starting parenting sessions (aimed at enhancing father’s confidence in parenting both children) in the New Year. A planning meeting scheduled for 18.01.16 was postponed because the social worker had been unable to contact father. 3.14.14 The account being provided by father to PO1 at this time was of approximately twice weekly visits to child M. Father also claimed a parenting programme which he was due to attend had been postponed until 10.02.16. Comment: records supplied by Family Unit 9 show parenting support workers PSW1 and (from March 2016) PSW2 remained unable to contact father; hence the delays in starting the planned work were a function of his lack of engagement (as well as a refusal by his grandmother to allow staff in her house whilst she was away on holiday). 3.15 REVIEW CHILD PROTECTION CONFERENCE 3.15.1 At a Unit meeting the day before the review conference on 10.02.16 a decline in sib. 1’s nursery school attendance was noted. The conference included parents, social worker and health visitor, parenting support worker and head teacher. Neither GP or Police were present (though the latter provided a report). Probation was not invited. Comment: Probation had a relevant contribution and had demonstrated a willingness to collaborate; its absence denied the network valuable intelligence. 3.15.2 The conference re-iterated the expectations of more responsivity from both parents and asked mother to produce the paediatric report of her elder child’s weight-related assessment in December. Father was asked to sign a written agreement that he would refrain from use of drugs when in contact with the children. The substantive decision of the chairperson, informed by the evidence of little change in circumstances or reduction in risk was that both children would remain subject of protection plans under unchanged categories. Comment: ‘agreements’ depend upon a level of honesty and openness that (in the light of history) was questionable for this couple; the decision to continue the protection plan was, on the basis of engagement to date, wholly justified. 3.15.3 A further core group meeting was planned for 25.02.16 (though postponed until 03.03.16) and the review conference for 19.07.16. Attempts a few days later by both social worker and clinical worker to make contact were initially thwarted but the social worker made a second unannounced home visit and saw both children who were being cared by MGM. Sib.1 was seen alone and responded well to the attention offered. Child M was sleeping. CAE 23 3.15.4 Contact continued to be difficult to achieve for both social worker and health visitor. On 24.02.16 the case was discussed at Family Unit 7 meeting and a decision made by the service manager to re-allocate the case as SW2 was leaving. 3.15.5 At the health visitor’s safeguarding supervision that week, she usefully clarified the salient issues: mother continuing to allow father unsupervised access to his child and her lack of insight into professional concerns. Set against that, the health visitor discerned some signs of engagement and the basic needs of her children were being met. Comment: a reference in the health visitor’s supervision to there being ‘no sign of mother attending the paediatric registrar-led community clinic’ may be a reference to the December appointment and doubts that she had actually presented her son; this could have been checked. 3.15.6 Father’s reports to PO1 at this time refer to seeing child M a ‘2 or 3 times a week’ at the paternal grandmother’s home. He also indicated that he was awaiting confirmation from SW2 about the availability of a parenting programme. Comment: at his last session, father had reported it would begin on 10.02.16. CORE GROUP 2 3.15.7 The core group on 03.03.16 was held at the nursery school and proceeded without father who could not be contacted. SW2 observed sib.1 and noted that he was clean, appropriately dressed and appeared happy. SW2 also made a home visit that day and was reassured by her observations of mother with child M. Mother reported that sib.1’s father had had phone contact with his child and might be visiting that night. 3.15.8 SW2 arranged an office appointment with sib.1’s father for 08.03.16 but he failed to appear. A further appointment was made and also failed. The father of child M also failed to attend an appointment that day to discuss the plan for contact with his child. EXECUTION OF DRUG WARRANT 3.15.9 On 10.03.16 Police executed a drugs warrant at mother’s home address. The subject of the warrant was child M’s maternal uncle. His response was recorded as ‘obstructive’. Mother and child M were present. No drugs were found and a strong smell of cannabis was attributed by MGM to be a result of her smoking in the garden whilst watching sib.1 play. 3.15.10 Though clean and the kitchen well-stocked, the house was very cluttered. Child M was noted to appear happy. A standard notification to Children’s Social Care was initiated. A case discussion was undertaken on 15.03.16 by the CIN Unit 9 meeting. The social worker’s difficulty in maintaining regular home visits was noted (mother was advocating only pre-arranged visits). CAE 24 3.15.11 Later that day SW2 made an announced home visit and observed mother shouting at sib.1.The issue of MGM smoking cannabis was raised and mother claimed that she did not allow it in front of the children. SW2 informed mother there would be a new social worker allocated. Planned ‘parenting support work’ had yet to begin. 3.15.12 Contact with child M’s father resumed briefly when he provided a new mobile number and agreed to attend the office next day (17.03.16). He failed again to attend his appointment. 3.15.13 On 21.03.16 mother made a call to enquire about the next child health clinic. She was given the date and encouraged to contact her health visitor if any concerns could not wait until 04.04.16. Also on 21.03.16 SW2 was involved in a ‘clinical consultation’ involving a clinician colleague and PSW1 (parenting support worker). They provided information about ‘child-centred’ play and the lack of mother’s engagement was acknowledged. After the above session a planned joint visit by SW2 and the PSW1 was arranged for 22.03.16. Mother was not in, and the visit was re-scheduled for a week later. 3.15.14 A further case discussion in Family Unit 7 was undertaken on 23.03.16. The approach to be taken was modified and became an exploration of whether mother could supervise contact between the avoidant father and child M, seeking father’s agreement to random drug tests and the (previously agreed) need to complete a parenting course. Only 1 drug test was subsequently administered. Comment: In Hackney, cases are discussed and decisions made in Unit meetings rather than individuals’ supervision sessions, which instead focus upon professional development. 3.16 PARTIAL ENGAGEMENT WITH ‘PARENTING SUPPORT’ 3.16.1 A week later a ‘planning meeting’ was held with the Parenting Support Service’ (PSS) in which work by it and the parents was ‘agreed’. Comment: all reasonable attempts to meet familial needs had been denied or diverted by both parents though a degree of engagement did in fact follow. 3.16.2 The planned joint home visit was completed by SW2 and PSW1 on 29.03.16. Both children were seen and mother reported that she had supervised a recent visit lasting some hours by child M’s father. 3.16.3 Father was meanwhile reporting to PO1 that that the delay in starting a parenting programme had been due to illness and that he was awaiting contact by the social worker. He also reported seeing child M 2 / 3 times a week when the child was brought by his partner to father’s given address (father’s grandmother’s home). Comment: liaison between PO1 and social worker at this time might have clarified the real reasons for the failure to begin a parenting programme. CAE 25 3.16.4 Mother brought child M (45 weeks old) to the Health Centre Baby Clinic on 04.04.16 where the baby was assessed as looking well and dressed appropriately. Weight had risen to above 99.6th centile according to chronology and BMI was 24.3 (ideally it would be 13.9 -16.8). Mother was noted to be ‘receptive to advice on diet and nutrition’. Comment: if the examining health professional has been aware of the history of care of sib.1 she might have been more sceptical. THIRD A&E PRESENTATION OF SIB.1 3.16.5 A presentation of sib.1 to hospital 1’s A&E Department on 10.04.16 raised no safeguarding concerns (nocturnal nose bleeds and no reported trauma). Sib.1 though clearly overweight, appeared to be alert, happy and active. 3.16.6 On 12.04.16 SW2 introduced mother to her replacement SW3. Observations of the children raised no new concerns. What was described as ‘parenting support session 2’ (the first had been held a week earlier) also took place that day. Mother, MGM and father met PSW2. Father stated that he wished to engage and spoke of wanting to work to support his family. 3.16.7 Mother subsequently failed to bring or present sib.1 for a check-up at the GP Practice on 2 occasions (13.04.16 and 14.04.16) and an examination on 15.04.16 focused on apparent eczema. Though sib.1’s weight was reportedly checked, the result was not included in the records provided. 3.16.8 ‘Parenting support session 3’ took place at the nursery school on 19.04.16 when father reported that he was calmer and more confident in handling his child. He said that he would like to take up the offer of an employment-related course – ‘Ways to Work’. 3.16.9 The case was again debated at a Family Unit 7 meeting on 25.04.16. PSW2’s report was that she had observed sib.1 at his nursery; also that the parental relationship seemed more relaxed. SW3 made a home visit on 26.04.16 when her only concern was a cot that needed to be replaced. The social worker undertook to ask her agency to pay for the required replacement. 3.16.10 At his regular reporting session to PO1 on 27.04.16 father was still reporting that the parenting programme had ‘not begun’. It is unclear whether father was misleading PO1 or just confused. PO1 anyway obtained confirmation from Police on this date that no further action was to be taken with respect to his potential ‘possession with intent to supply class A drugs’. 3.16.11 At a link meeting at the GP Practice on 25.04.16 an agreement was reached to chase up the report of December’s paediatric appointment. Sib.1 was seen again at the GP Practice 2 days later (and for the last time within the review period on 12.05.16 for a routine eczema review). CAE 26 3.16.12 On 03.05.16 PSW2 undertook a further home visit and observed improved parental interactions. She suggested ways of improving his interaction with sib.1 and at the next planned visit, said that she would observe father bathing child M. CORE GROUP 3 3.16.13 At the core group meeting held at the nursery school on 11.05.16 (parents, health visitor and nursery present) the need for father of child M to be accompanied by child M’s mother was repeated. Father had reportedly signed an agreement not to use any drugs whilst in contact with the children and had agreed to random drug testing. 3.16.14 Father was said to have attended 4 ‘parenting support sessions’ though confusingly, father’s report to PO1 was that he had only just signed consent forms for a parenting programme; mother was said to have attended 1. Mother was asked (again) to provide a letter relating to the paediatric appointment of 01.12.15. 3.16.15 At a link meeting on 16.05.16 with GP and health visitor, it was noted that a report of the paediatric appointment had still not been received. Comment: after a 6 months delay the apparent unavailability of the anticipated paediatric report should have been followed up. 3.16.16 At a CIN Unit 9 meeting on 17.05.16 the signed agreement requiring supervision by mother / MGM when father was present was noted. Mother remained unwilling to address the issue of sib. 1’s weight. Comment: weight had been the originating and real concern and had become overshadowed by a high level of avoidance and disguised compliance by both parents. 3.16.17 At a home visit on the day of the Unit debate, SW3 and PSW2 met parents and MGM. They observed ‘vast improvements’ with respect to interactions. The next session was to be the final one because all targets ‘had been met’. SW3’s contact with the family included administration of a drug test on father (which proved to be positive for cannabis). Comment: records latterly provided to the serious case review confirm the (delayed) contact by PSW2 and positive observations of some of father’s practical skills e.g. bathing the baby’; the drug test result offered further confirmation of father’s dishonesty and (had Probation been informed of it) could have helpfully informed its assessment of father’s compliance with licence conditions. CAE 27 3.17 FOLLOW-UP PAEDIATRIC CONSULTATION 3.17.1 On 20.05.16 at an outpatient appointment in a general paediatrics clinic, a junior doctor reviewed sib.1 for weight and possible syndrome (Prader-Willi8). A referral was made to the Royal London Hospital. Comment: sib.1’s unremarkable behaviours and high achievement levels at nursery school (if shared with the clinician) would have contra-indicated this condition. 3.17.2 At father’s contact with PO1 he was still referring to a future parenting course (possibly a reference the planned final session on 17.06.16 which was anyway postponed by mother until 21.06.16). SW3 completed a further child protection contact on 26.05.16 in a park when father sought to explain away his positive test result for cannabis. 3.17.3 At a safeguarding supervision the health visitor referred to a ‘completed re-assessment of the children’s weight’. Mother was to ‘consider the types of food she offers to the children’, though it remains unclear whether she was aware of the results of either paediatric assessment. Comment: there was over 12 months-worth of evidence that mother’s feeding of sib.1 (and it appears child M) were placing their health at a real risk of harm. 3.17.4 On 08.06.16 both children were seen at a child protection visit to the nursery. Sib.1 reported to SW3 a parental instruction not to talk about ‘the flat’ and would offer only positive comments about father. At a home visit that day SW3 met a man who entered with a key. Father claimed not to know him (though was by then admitting that he stayed there often). Mother claimed it was an uncle who was living there. Comment: the ‘child’s voice’ was being stifled by his parents’ instructions and this required robust challenge. 3.17.5 Mother further explained that she, father and the children were currently staying at her brother’s flat (for which she offered an address) because she said, he had been remanded to prison. On 10.06.16 sib.1 (aged 4 years and 7 months) was brought to the Health Centre by mother and child M’s father. Relative weight remained at over 99.6th centile and BMI 24. Once again diet was ‘discussed’. 3.17.6 The case was again debated, this time by CIN Unit 9. SW3 described a growing confidence in the parents’ renewed relationship. She described their temporary residence at the new location. The positive drugs result was not discussed though the need for a further test was noted. SW3 was asked to consider further, father being allowed unsupervised (perhaps hour-long) contact with his child. 8 According to www.nhsdirect/conditions Prader-Willi syndrome (PWS) is a rare genetic condition that causes a wide range of problems including a constant desire to eat food, which seems driven by a permanent feeling of hunger and can easily lead to dangerous weight gain, restricted growth, leading to short stature, reduced muscle tone (hypotonia),learning difficulties, lack of sexual development and behavioural problems, such as temper tantrums or stubbornness. CAE 28 3.17.7 On 21.06.16 SW3 completed a home visit to the temporary address of the family. Sib.1 was seen to be less boisterous than usual and child M sleepy. The flat was clean and tidy and all the belongings seemed to be those of mother and the children. The risk of eviction was discussed. It was agreed that father would have an hour of unsupervised contact with child M over next weekend whilst mother took sib.1 out to the park. Comment SW3 completed careful observations of the environment but her proposed plan appeared to take little account of the accumulated evidence that neither parents could be relied upon to be honest or open. 3.17.8 Also on 21.06.16 final parenting support session was completed and offered reassurances about the parents’ ability to relate well to both children. Sib.1’s nursery school attendance had meanwhile improved from about 60% to 90%. The nursery attributed an observed improvement in mother’s warmth and positive affirmation of sib.1 to the encouragement and modelling of nursery staff. 3.18 THIRD POTENTIAL NON-ACCIDENTAL INJURY TO CHILD M 3.18.1 On 23.06.16 (a Thursday) mother phoned SW3 to report that child M had had an accident during unsupervised contact (previously agreed for the weekend) with father and appeared to be in pain. Mother readily agreed to present the child to A&E at her local hospital. SW3 alerted the Police and sought a strategy discussion. Comment: existing knowledge of mother would have justified accompanying her or at minimum forewarning the hospital so that further action could be taken if she failed to bring child M; such action might also have served to accelerate child’s examination which was not completed for 3 hours after presentation. 3.18.2 Mother’s subsequent report at A&E was that father had returned with child M at about 15.00 on 22.06.16 having been to visit a friend. Father reported that the toddler had self-inflicted a leg injury with a walking stick. In the morning mother reported noticing swelling on both thighs and that child M was refusing to walk or sit. She reported administering pain relief. By the afternoon her concern about further swelling had become such that (prompted by SW3) she had attended A&E. 3.18.3 A member of the CIN 9 Unit phoned mother at the hospital and advised her not to allow father or anyone else implicated in the injuries, access to child M. The bi-lateral displaced femoral fractures were described by the attending paediatrician in her alert to the EDT as ‘horrendous’ and child M was transferred to the Royal London Hospital for surgery. Bruising to the head was also noted. A prompt strategy meeting was convened on 24.06.16. At that point father had been arrested and was in custody and mother was not considered a suspect. The Health Visiting Service was also informed. CAE 29 4 ANALYSIS / RESPONSE TO TERMS OF REFERENCE 4.1 INTRODUCTION 4.1.1 In order to render the report more accessible, the elements of the detailed terms of reference appended to this report have been summarised in this section and the performance of each agency relevant to that element evaluated. The broader learning that emerges is outlined in section 5. AWARENESS / SENSITIVITY TO NEEDS OF CHILDREN ? Homerton University Hospital NHS Foundation Trust (medical and community services) 4.1.2 Hospital and community staff remained unaware of the criminal history of both parents and were therefore dependent upon clinical observations and information provided by GP or Children’s Social Care. Because the possible bruising noted at the first presentation in June 2015 of the then non-mobile child M faded soon after admission, no skeletal survey was completed (as anticipated by the Royal College of Paediatrics and Child Health (RCPCH) Child Protection Companion 2013). 4.1.3 In the view of the authors of the Trust’s report, the 2nd presentation of child M would have benefitted from a discussion with the named or designated doctor for safeguarding and presentation at a safeguarding peer review. They highlight the fact that such an arrangement had been introduced into the Paediatric Department in June 2015. GP Service 4.1.4 Whilst GPs appear to have been attentive to the needs of mother at the times she sought help, it is less clear to what extent they considered the needs of her dependent children and what implications mother’s health-related condition / conduct might have for either child. For example the referral for a paediatric view of sib.1’s gross obesity was not followed up with any rigour. Nor was the implication for very young children of mother’s (and accompanying partner’s) threatening manner at the consultation in early 2015, recognised. 4.1.5 The absence of any response in Summer 2015 and submission of outdated material to Children’s Social Care when asked for a report to inform its review conference in 2016, suggests insufficient regard for the welfare of the children who were known to be vulnerable and by late 2015, subject of child protection plans. CAE 30 National Probation Service (NPS) 4.1.6 The probation officer maintained an active interest in father’s role as a partner and parent throughout the period under review. However, he overlooked from November 2014 to January 2016, the implication of this relationship for sib.1 and the then unborn child M. NPS safeguarding policy and procedures required him (on the basis of the drug-related offences) to alert Children’s Social Care. The reported domestic abuse further reinforced the need to involve that agency. 4.1.7 A home visit (intended but not accomplished) would have rendered the children more than just names and accounts from the father / step-father. Similarly, had a ‘Spousal Assault Risk Assessment’ (SARA) been completed it might have highlighted the associated risk to children in the context of domestic abuse between parents. Metropolitan Police Service 4.1.8 It seems likely that there was no child present at the Summer 2014 parental altercation, hence no ‘Merlin’ notification triggered. On the other occasions that the family came to notice, the required notifications were sent. Police also supplied routine information and updates to the initial and review child protection conference. Children’s Social Care 4.1.9 Enquiries made at the time of child M’s 2nd observed injuries in Autumn 2015 illustrated a sensitive awareness of the possibility that sib.1 really knew nothing of the circumstance triggering child M’s injuries or was being primed to adopt that position. 4.1.10 The newly allocated consultant social worker and independent conference chair showed recognition of the children’s needs at the initial child protection conference in 2015. They put on record that they were unconvinced by the father’s changing accounts, were aware that mother sometimes told professionals what she thought they wanted to hear and recognised therefore, the risks that remained for the children. However the record of the discussion (and the emerging protection plan) suggest some ‘cognitive dissonance’ i.e. – a discomfort arising from not knowing whether injuries to that date had been non-accidental and (in order to resolve that discomfort) a preference to regard and report the incidents as ‘accidental’. 4.1.11 Contact levels with the family (and with sib.1 at nursery school) were good and significant efforts made to engage with and encourage sib.1 to contribute. 4.1.12 Sib.1’s voice was effectively silenced in early June 2016 when SW3 was told and apparently accepted that the child was not allowed to talk about the home and when only positive comments were made about the step-father. CAE 31 ASCERTAINMENT OF CHILDREN’S EXPERIENCES ? Homerton University Hospital NHS Foundation Trust (medical and community services) 4.1.13 Insofar as child M was and remained ‘pre-verbal’ throughout the period under review, an understanding of the child’s experiences was of necessity derived from direct and indirect / reported observations. These were adequately represented by hospital and community professionals at core groups and conferences. GP Service 4.1.14 Though sib.1 and child M were seen on a number of occasions at the GP Practice and relevant diagnoses made, few observations were captured (or anyway reported to the serious case review). Records refer for example to a ‘well and happy child’ but none offer elaboration about behaviours in the (known) context of children subject of child protection plans. National Probation Service (NPS) 4.1.15 In consequence perhaps of a lack of training coupled with inexperience, the probation officer may have lacked certainty about the subject areas that were (or should have been) of common interest between NPS and Children’s Social Care. Even when in early 2016 there was mutual awareness of each agency’s involvement, there remained insufficient focus on the implications for each child of father’s behavioural history and relationship with the mother of sib.1 and child M. Children’s Social Care 4.1.16 Social work staff were observant of and appropriately recorded the mother-child interactions and relationship. In the course of the assessment completed in 2014, sib.1 was helpfully seen alone as well as with mother and SW1 commendably sought the views of the birth father in order to better evaluate the child’s obesity. 4.1.17 Staff also drew on the observations of nursery staff whose opportunity to get to know sib.1 was naturally greater. It is regrettable that the proposed joint health visitor / social worker home visit in June 2014 did not take place. It might have offered further insights into the actual experience of sib.1 and child M. 4.1.18 Sib.1’s report in early June 2016 of not being allowed to talk about home should not have been accepted without challenge of the parents. It may have been that the level of (justifiable) suspicion about the ‘lived experiences’ of the children had been lowered by the positive reports provided by those who had completed ‘parenting support work’. CAE 32 KEY POINTS / OPPORTUNITIES FOR ASSESSMENT & DECISION-MAKING Homerton University Hospital NHS Foundation Trust (medical and community services) 4.1.19 The 2 A&E presentations of child M aged less than 6 months in the context of sole care of father represented the key opportunities for assessment and decision making. During the second such event, there was a clear recognition of risk leading to a safeguarding agreement pending a completed social care assessment. 4.1.20 Had a strategy discussion / meeting been held on this occasion it seems likely that at least the recent history of domestic abuse (if not father’s earlier serious criminal history) would have been recognised and factored into professional thinking. GP Service 4.1.21 Within the review period, the most substantive opportunity for the GP Practice centred around the paediatric referral. This offered the possibility of excluding alternative diagnoses and enabling the GPs and health visitors to focus on the quantity and quality of food being provided to sib.1 (and indeed child M). 4.1.22 The Practice could also (potentially) have gained a more holistic appreciation of both children’s health needs if it had actively contributed to either child protection conference. National Probation Service (NPS) 4.1.23 The probation officer PO1 appears to have been unaware of his agency’s expectation that he alert Children’s Social Care when father reported in Autumn 2014 that his partner was pregnant with his child. 4.1.24 The report supplied by the National Probation Service explains the expectations of officers’ responses when a client on licenced release commits further offences. The report points out that in the context of a lengthy delay before the Crown Prosecution Service decided not to charge with respect to the class A drugs, the possibility of a ‘licence warning’ should have been considered. 4.1.25 In January 2016, when PO1 became aware of the domestic abuse and father’s possession of cannabis (he had been claiming not to use this drug) contact was appropriately made with Children’s Social Care. Children’s Social Care 4.1.26 The need for an assessment in early Autumn 2014 and re-assessment in 2015 (by the same staff) was clearly recognised. A strategy meeting at the time of child M’s first A&E presentation would have been useful. CAE 33 4.1.27 Though the convening of a strategy meeting following child M’s second presentation was delayed, it provided an effective response and triggered the required initial child protection conference. DID ACTIONS ACCORD WITH ASSESSMENTS / DECISIONS ? GP Service 4.1.28 The January 2015 consultation during which the doctor felt threatened by the parents offered (though it was not recognised as such or acted upon) a useful insight into the children’s lived experiences. 4.1.29 Given the extensive experience of mother’s reluctance to address sib.1’s obesity, the GP Practice should also have acted more decisively in pursuing the long overdue report of the paediatric assessment of December 2015. National Probation Service 4.1.30 PO1’s appropriate decision made in Summer 2015 to complete a home visit to father (which might have clarified where he really lived) was not followed through. 4.1.31 Though it had been PO1’s initiative that had triggered the inter-agency communication with Children’s Social Care (and that agency’s responsibility to invite him to contribute to protection conferences), he could have been more active in pursuing during June 2016, liaison with SW3. Children’s Social Care 4.1.32 Staff showed a high level of commitment in their assessment of need and in their attempts to encourage sufficient engagement and delivery of clearly much needed services. 4.1.33 The value of the child protection plan developed in consultation with partner agencies, was inevitably limited because it did not explicitly address the possibility of non-accidental injury and how that risk might be mitigated. 4.1.34 The value of communication between health visitors and social work staff was inevitably reduced when in the period preceding child M’s birth, mother maintained her refusal to engage with the Health Visiting Service. 4.1.35 Whilst there existed amongst some staff a wholly justified level of scepticism about mother’s honesty or openness, there was relatively little challenge of her deceitful assertions. CAE 34 ISSUES IN COMMUNICATION / INFORMATION SHARING ETC IN & OUT OF OFFICE HOURS ? Homerton University Foundation Trust & Children’s Social Care 4.1.36 Until child M’s third presentation to A&E in June 2016 there had been no issues linked to any ‘out of office hours’ constraint. On that occasion, though SW3 had notified Police of mother’s report of an injury while child M had been in father’s care, she had not forewarned the hospital (nor it is presumed, her agency’s Emergency Duty Team EDT). 4.1.37 Child M arrived at the hospital at 16.13 on 23.06.16 but was not examined by a paediatrician until 19.30. EDT was then immediately involved and subsequent liaison between them, medical staff and family was efficient. WAS PRACTICE SENSITIVE TO RACIAL, CULTURAL, LINGUISTIC & RELIGIOUS IDENTITY ? All involved agencies 4.1.38 Records of individual family members capture their age, gender and ethnicity but none record their preferred language. 4.1.39 Mother’s immigration status was noted in the records of Children’s Social Care but its implications for her or her children had been addressed only by means of a suggestion that she seek specialist advice (if such advice was later shared with staff, it was not included in reports of completed assessments of need submitted to this review). WERE SENIOR MANAGERS / OTHER ORGANISATIONS INVOLVED WHEN NEEDED ? All involved agencies 4.1.40 Members of the hospital team were not invited to the initial child protection conference of October 2015 and the probation officer was not included in those invited to contribute to the review conference in February 2016 though his involvement was by then known. The issue of which agencies or professionals may be relevant inevitably needs to be determined on a case-by-case basis. 4.1.41 Within Children’s Social Care, there were regular reviews within the Units dealing with the case as well as involvement of experienced consultant social workers. EDT had also appropriately sought advice from senior management at the time of child M’s Autumn 2015 presentation. 4.1.42 The GPs’ source of challenge or reflection was limited to the link meetings with health visitors, though the author has been assured that the opportunity for routine and regular case reflection is now available across all Hackney-based GP Practices. The health visitors made use of safeguarding supervision from the named nurse. CAE 35 4.1.43 WAS WORK CONSISTENT WITH AGENCIES’ & LSCB POLICY & PROCEDURES ? All involved agencies 4.1.44 Aside from the absence of and delay in convening strategy discussions, other response within Children’s Social Care was consistent with London’s Child Protection Procedures. 4.1.45 Some actions taken by the allocated probation officer and which are specified in the above report were inconsistent with his agency’s policies or procedures i.e. not reporting to Children’s Social Care father’s acknowledged paternity of child M; not completing a home visit; not capturing the Police account of the class A drugs-related incident; not recording the rationale for the decision made not to recall father to prison and not completing a ‘SARA’. ORGANISATIONAL DIFFICULTIES E.G. LACK OF CAPACITY (STAFFING OR RESOURCES)? All involved agencies 4.1.46 The absence (since February 2015) of a designated doctor for safeguarding children denied the named doctor at hospital 1 what would otherwise have been routine supervision. 4.1.47 No such organisational deficits have been identified in any other involved agency, though it seems that there was an unmet need for training within Probation and the GP Practice. CAE 36 5 CONCLUSIONS 5.1.1 In spite of considerable commitment and the persistence of many professionals in this very difficult case, there are several examples of familiar systemic weaknesses. AVOIDANCE & DISGUISED COMPLIANCE 5.1.2 Examples of parental avoidant behaviour or ‘disguised compliance:’ Mother’s apparent ‘agreement’ in July 2014 at the nursery and subsequent failure to follow up the GP referral to the Paediatric Clinic later that month A pattern of non-attendance at agreed health appointments and failure (of father as well as mother) to attend pre-arranged meetings with Children’s Social Care staff Mother’s agreement then failure to follow up and use the two sources of advice about nutrition / diet Deceptive reassurances in December 2014 that mother had reversed her negative stance and would accept health visiting support and advice Mother omitting to mention to her GP in June 2015 to child M’s first suspicious presentation to A&E only 2 days earlier (Having accepted Midwifery Services) a refusal in September 2015 to accept routine tests or make use of standard prophylactic medication Attempts in early 2016 to accept only ‘pre-arranged’ (more easily avoided) visits from the allocated social worker INSUFFICIENT PROFESSIONAL CURIOSITY / CHALLENGE 5.1.3 On occasions a more robust challenge would have been justified: The GP Practice was well positioned (mother’s frequency of use and level of engagement seems to have been higher than with other professional sources) to make good use of the trust extended and to link events / professional concerns, challenge discrepant accounts and form and share a holistic view of risk Mother’s report that her mother would not allow home visits by Children’s Social Care required exploration and challenge Acceptance of father’s positive test for cannabis in spite of his repeated reassurances of ‘no use around the children’ Establishing the extent to which father was actually staying with the mother of child M not his required residence with his own grandmother The vulnerability arising from mother’s NRPF status and the extent to which it rendered mother more dependent upon her partner might usefully have been further explored CAE 37 OPTIMISM 5.1.4 There were examples when professional responses appeared more positive than available evidence would suggest: The assessment of November 2014 capturing mother’s misleading account of her domestic abuse in April and end of her relationship with her unborn baby’s father The hope shared by health visitor, GPs and social workers that mother would in due course come to appreciate that sib.1’s weight was likely to be harmful PO1’s acceptance of the accounts provided by father, not following up his useful initial contact with Children’s Social Care and not completing an intended home visit The medical assessment at child M’s 2nd A&E presentation The absence of conclusive evidence confirming non-accidental injury led participants at the initial child protection conference to give insufficient consideration to which protective measures might be required if a risk of deliberate harm existed e.g. supervision of contact was left with a mother known to be unreliable and non-protective The decision made by the Probation Service (for which the rationale may have been that father was not going to be charged in relation to his arrest in Summer 2015) not to recall him to prison LEARNING & SERVICE IMPROVEMENT OPPORTUNITIES 5.1.5 The narrative and commentary on professional practice in section 4 has identified scope for improvement in the following areas: The ability of professionals to hold in mind the possibility of accidental and non-accidental injury rather than resolving discomfort / uncertainty by moving to an insufficiently-informed conclusion GPs’ appreciation of child protection processes (by means of more effective information sharing, more reflective supervision and linking the impact of an aggressive parent to its implication for a dependent child) More robust and explicit safeguarding documentation e.g. body maps from the hospital Paediatric Department even in cases not progressing to s.47 enquiries A shared and clear appreciation of the required responses if parent/s within family cases closed to Children’s Social Care, subsequently CAE 38 refuse to or insufficiently honour commitments to co-operate with universal services A heightened recognition of and a greater readiness in Children’s Social Care to identify and involve all relevant professionals at forums e.g. child protection conferences Confidence in the lawfulness and expectations of information sharing Ensuring that probation officers are up to date with safeguarding training and have associated confidence in risk assessments and liaison with Children’s Social Care A clearer appreciation across the network of the role and expectations of probation officers THEMES ANTICIPATED BY THE SCR SCOPING GROUP 5.1.6 The ‘scoping’ group had at its meeting in September 2016 asked that agencies consider the following anticipated themes as they formulated responses to the elements of the appended terms of reference: Communication: was this clear within and across agencies? 5.1.7 There was scope for improved efficiency in record-keeping and responsivity to information–requests within the GP Practice though the use of regular link meetings for GPs and health visitors was commendable. Perhaps if, aside from sib.1’s weight, the wider variety of concerns had been shared more explicitly with the GP Practice, medical staff might have felt encouraged to think in a more ‘whole family’ manner e.g. information known to the GP Practice (and Probation) records suggested a more full-time and ongoing parental relationship than was offered by parents to either health visitors or social workers. 5.1.8 The most substantive communication difficulty was that there remained an unawareness of father’s serious and extensive criminal record (in particular licenced prison release) from mid-2014 until January 2016 when PO1 contacted Children’s Social Care. 5.1.9 It appears that the reasons for the above difficulty are that the original Children’s Social Care assessment did not include Police checks on the then unidentified father. The extremely comprehensive material supplied by the MPS for the protection conference in November 2015 did include references to lengthy periods of imprisonment. This, an apparently early release and the fact that he remained on license were not extracted from the large volume of material provided, recognised as significant and discussed. 5.1.10 Communication of relevant facts would have been more efficient and decision-making better informed, if Probation had been invited to contribute to the child protection conferences and share relevant information with the safeguarding network. CAE 39 5.1.11 Whilst the GPs’ ‘flagging’ of vulnerability and incorporation of conference records into medical records were helpful practices, the local practice of setting up individual records of new-borns at the time of their 6 week ‘baby checks’ is not helpful. It runs the risk of overlooking an A&E attendance of a neonate. 5.1.12 During child M’s second hospital admission, the documented opinion of the paediatric consultant was insufficiently clear with respect to whether the injuries should be regarded as ‘accidental’, ‘non-accidental’ or ‘unexplained’. At child M’s discharge the record suggests ‘accidental while the discharge summary sent to the GP suggests ‘unexplained’. 5.1.13 With respect to child M’s latter presentation to A&E, SW3 should have alerted the hospital to the anticipated arrival of the child. Understanding: was there an agreed and complete understanding of risk across involved agencies? 5.1.14 The feeling of discomfort / threat felt by the GP at a consultation by mother and child M’s father in February 2015 should have triggered a concern about the lived experience of sib.1 and child M as highlighted in Ofsted’s 2011 publication9. 5.1.15 The risk associated with childhood obesity (as well as exposure to domestic abuse) was recognised by the health visitor allocated in 2014. 5.1.16 The probation officer (who qualified in April 2016) has reported he cannot recall receipt of safeguarding children training which is surprising and of concern. Practice: was practice and intervention within and across agencies appropriate and proportionate to identified concerns ? 5.1.17 Whilst other biographical detail was captured, most agencies seems to have omitted to confirm any religious affiliation or preferred languages. 5.1.18 The initial decision within Children’s Social Care in Autumn 2014 to complete an assessment was prompt and appropriate (though under-informed because the referring health visitor had not noted and probably not known father’s name). At child M’s 2nd A&E presentation in Autumn 2015 the required strategy discussion was belated and non-compliant with London’s Child Protection Procedures. 5.1.19 The response to father by Housing and Children’s Social Care in Summer 2015 may not have taken sufficient account of ‘parental responsibility’ (records provided are unclear with respect to whether father was named on child M’s birth certificate and thus enjoyed parental responsibility). 9 Report summary: The voice of the child: learning lessons from serious case reviews – a thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010 CAE 40 5.1.20 The decision to make both children subject of child protection plans (though done without key information held by Probation) was sufficiently well-informed, prudent and proportionate to the known circumstances. The subsequent plan was based though upon a mistaken presumption that non-accidental injury had been ruled out as a potential risk. 5.1.21 The probation officer was at risk of under-estimating the risk to mother and children when he did not seek from Police further information to enable completion of a ‘Spousal Assault Risk Assessment’ (SARA). 5.1.22 The knowledge gained in 2016 that Probation was involved with father should have triggered further exploration by Children’s Social Care. 5.1.23 Provision of ‘parenting support’ was justified and reported to have improved parenting skills, but could not of itself, prevent abuse. CAE 41 6 RECOMMENDATIONS CITY & HACKNEY SAFEGUARDING CHILDREN BOARD (CHSCB) 6.1.1 CHSCB should seek reassurances with respect to the responses of non-statutory services in dealing with poor or non-engagement following case closure by Children’s Social Care (by 30.09.17). 6.1.2 CHSCB should also seek reassurances from member agencies that there exists, or is being developed sufficient: Clarity and confidence about the circumstances in which ‘personal data’ may lawfully be sought from other sources with and without consent (by 30.09.17) Appreciation of the role and working practices of Probation Service Providers (by 30.09.17) 6.1.3 CHSCB should develop and disseminate best practice guidance to: Support practitioners working with avoidant families, frequently fluctuating circumstance and disguised compliance Enhance confidence within professional networks in the context of ‘respectful uncertainty’10 / ‘cognitive dissonance’11, to develop plans and interventions which respond to the possibility of deliberate harm even in the absence of conclusive evidence Remind practitioners of the need to remain aware of the significance of bruising in pre-mobile children (as per section 3.9 London Child Protection Procedures 5th ed. 2016) (by 30.09.17) 6.1.4 The CHSCB should also seek reassurance that network checks are comprehensive and engage all key partners at the point of a referral to FAST [by 31.07.17] 10 Respectful uncertainty = In his 2003 inquiry report into the death of Victoria Climbie, Lord Laming used the phrase ‘respectful uncertainty’ to describe the attitude social workers need to strike in trying to spot an abuser (viz: maintaining some scepticism and mistrust about what might really be happening behind closed doors). (John Dewey explained the respectful uncertainty principle well much earlier (1910)….’genuine ignorance is profitable’ …’because it is likely to be accompanied by humility, curiosity, and open mindedness’. 11 Cognitive dissonance = the mental stress (discomfort) experienced by a person who simultaneously holds two or more contradictory beliefs, ideas, or values; when performing an action that contradicts existing beliefs, ideas, or values; or when confronted with new information that contradicts existing beliefs, ideas, and values CAE 42 CITY & HACKNEY CLINICAL COMMISSIONING GROUP (CCG) 6.1.5 The CCG should ask GP Practices to: Separate maternal and baby records at birth (a temporary file for the baby should be set up on the system) and triangulate them at the joint mother and baby post-natal checks (by 30.09.17). Establish and maintain a summary of safeguarding concerns within GP EMIS records (by 30.06.17) Ensure that ‘child in need’ ‘Read codes’ are placed in records (by 30.09.17) 6.1.6 The CCG should re-issue the 2016 ‘Safeguarding Children & Young People Resource Pack (2016) (by 31.07.17). HOMERTON UNIVERSITY FOUNDATION TRUST 6.1.7 Child protection documentation relating to acute services should be strengthened by requiring full completion of child protection medical reports regardless of the conclusions of the associated enquiries (by 31.07.17). 6.1.8 A protocol should be developed with relevant hospitals so as to make explicit the expectation of a written medical discharge summary if a child presents with a suspected non-accidental injury (by 31.07.17). NATIONAL PROBATION SERVICE 6.1.9 The ‘Head of Cluster’ should confirm that all relevant staff have completed / are scheduled to complete safeguarding training required by current policy (by 30.09.17) and initiate any required response 6.1.10 Guidance on the criteria for reviewing OASys risk assessments should be re-issued and a sample of relevant cases audited (by 31.07.17) and any further required steps taken (by 30.09.17). HACKNEY CHILDREN’S SOCIAL CARE 6.1.11 In accordance with Working Together to Safeguard Children 2015 and London Child Protection Procedures, Children’s Social Care should take steps to ensure the involvement of relevant professionals e.g. paediatricians / relevant other health professionals in strategy discussions about suspected non-accidental injury (by 31.07.17). HACKNEY CHILDREN’S SOCIAL CARE & NATIONAL PROBATION SERVICE 6.1.12 In the context of the current wider review of information sharing process across London, these agencies need to jointly achieve clear operational arrangements for information exchange [by 30.09.17] Overview draft child M City & Hackney Safeguarding Children Board March 2018 (based on draft of 30.03.17) CAE 43 7 BIBLIOGRAPHY Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008 Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1April 2007 to 31 March 2008 Published December 2008 The Child’s World Jan Horwarth Jessica Kingsley 2008 Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE Healthy Child Programme DH 2009 A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009 Working Together to Safeguard Children, HM Government 2010, 2013 & 2015 Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Munro Review of Child Protection: A Child-Centred System TSO www.tsoshop.co.uk Professor Munro 2011 Learning together to safeguard children: a systems model for case reviews SCIE January 2012 New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012 Improving the Quality of Children’s Serious Case Reviews Through Support & Training@ NSPCC, Sequili, Action for Children; DfE 2013 (revised Feb. 2014) Multi-Agency Working and Information Sharing Project HOME OFFICE Final report July 2014 JUDICIAL REVIEW; (R (AB and CD) v Haringey London Borough Council (2013) EWHC 416 (Admin) Festinger, L. (1962). ‘Cognitive dissonance’. Scientific American. 207 (4): 93–107. doi:10.1038/scientificamerican1062-93 . CAE 44 TERMS OF REFERENCE INTRODUCTION The trigger event, process of initiating the SCR, membership of the nominated review group and the scope of the review are described in section 1 of this overview. The remaining text describes the required approach and methodology. APPROACH TO THE REVIEW Building on learning from previous cases, the objective of this review is to consolidate learning about what is working well and what presents challenges to organisations both child and adult-facing. We will do this in line with the principles for learning and improvement in Working Together 2015 (para.4:11) as outlined below. SCRs and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight Is transparent about the way data is collected and analysed and Makes use of relevant research and case evidence to inform the findings Agencies will be asked to comment specifically on: Communication – Was communication clear within and across involved agencies? Understanding - Was there an agreed and complete understanding of risk across involved partner agencies? Practice - Was practice and intervention within and across agencies appropriate and proportionate to the identified concerns? CAE 45 Contributing agencies should have regard, where applicable, to the following issues: 1. Were practitioners aware of and sensitive to the needs of the child in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? 2. When, and in what way, were the child’s experiences ascertained and taken account of when making decisions about the provision of services? Was this information recorded? 3. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did you agency liaise/engage appropriately with other agencies? 4. Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments and was the family signposted to appropriate support? 5. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 6. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? 7. Were senior managers or other organisations and professionals involved at points in the case where they should have been? 8. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 9. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? 10. Was there sufficient management accountability for decision making? CAE 46 METHODOLOGY The review will take a forensic, evidence-based approach. The reviewer will draw on agencies’ written reports, the integrated chronology and key documents from case files. Drawing on information submitted, the agency lead and review group members will meet with practitioners both individually and as a group in order to better understand why decisions were made. From the pooling of this intelligence, the reviewer will identify areas of good practice and areas of actual or latent vulnerability within our systems. TIMESCALES Milestone Date/deadline date SCR agreement date 06th September 2016 Scoping Meeting (+ chronologies produced) 12th September 2016 First Review Panel Meeting 13th October 2016 Submission of first draft agency IMRs 18th November 2016 First Practitioners Focus Group 22nd November 2016 Submission of final agency IMRs 09th December 2016 Second Review Panel Meeting (+ IMR authors) 06th January 2016 Submission of first draft overview report 13th January 2017 Third Review Panel Meeting (+ IMR authors) 26th January 2016 Submission of second draft report 31st January 2017 Second Practitioners Focus Group 02nd March 2017 Submission of third or final draft report 13th March 2017 Fourth (final) Review Panel Meeting 29th March 2017 FAMILY INVOLVEMENT Family members will be notified and provided with the opportunity to contribute to the review insofar as it does not impact on any ongoing legal proceedings. QUALITY ASSURANCE PROCESS Chronology work and agency IMRs will be shared with members of the Review Panel. The final report will be quality-assured on behalf of the CHSCB by the SCR Sub-committee and signed off by the Executive Group and the Independent Chair on behalf of the CHSCB who have agreed to delegate this action. CAE 47 ACTION PLANS As necessary, agencies will be required to submit an action plan detailing recommendations for improvement. Action Plans are monitored by the SCR Sub-Committee until all recommendations are implemented and then reviewed annually to ensure still in place. Where lessons are able to be identified during the process they will be acted upon as quickly as possible without waiting for the review to be completed. DISSEMINATION OF LESSONS LEARNED The findings from this review will be considered alongside learning from previous reviews undertaken by the CHSCB and findings from relevant research. The following arrangements are proposed for the dissemination of lessons learned from this review: A series of multi-agency briefing sessions Development and circulation of training materials Key themes circulated via social media and monthly ‘Things You Should Know’ (TUSK) briefings and Further arrangements to be made during the process of the review …………………………………………………………………………………………………………… |
NC048972 | Death of a 21 month old girl, Polly, in May 2014 after attempts of resuscitation in hospital failed. Polly's mother was convicted of murder and child cruelty, and her boyfriend of allowing the death of a child.Polly was subject to child protection plan (CPP) at birth due pre-birth concerns about possible neglect. Polly was in foster care for a period in 2013 following a reported incident of domestic violence at home, but returned to her mother's care in October 2013 with a supervision order which included regular contact with her birth father. In October 2013 Polly's mother started a new relationship. Between January and April 2014 Polly was involved in a number of medical incidents, there were reports of domestic arguments, and the family moved from supported living arrangements to rented accommodation in a neighbouring county. Issues identified and recommendations made include: the child protection plan did not assess the implications of the mothers mental health needs on her capacity to parent; lack of authoritative professional practice that saw Polly as the primary client; lack of understanding by some professionals about their role and responsibility when Polly was subject to a supervision order which may have deflected their focus from original safeguarding concerns; little recognition of the role of the boyfriend and father were playing in Polly's life; and medical staff did not consider the possibility of child abuse or neglect when Polly presented with medical issues. Additional learning points cover: parental drug use; the housing of young vulnerable adults; cross border moves and notifications and the use of written agreements.
| Title: Serious case review ADS14: Polly: executive summary. LSCB: Derbyshire Safeguarding Children Board Author: Jenny Myers Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Derbyshire Safeguarding Children Board 1 Executive Summary Serious Case Review Serious Case Review ADS14 Polly* Executive summary Lead reviewer and independent author - Jenny Myers [25/08/17] *The full report will be published in line with statutory guidance. This is an executive summary of the published report. In order to preserve the anonymity for the child in this family, the author has: • used initials to represent people • used a pseudonym for the subject child PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 2 1. Table of Contents 1. Table of Contents .................................................................................................... 2 2. Glossary of abbreviations and terms used in the report. .................................... 3 3. Introduction ............................................................................................................. 4 4. Scope of the Review ............................................................................................... 5 5. Brief family background and synopsis of the case .............................................. 5 6. Summary .................................................................................................................. 7 7. Key findings and recommendations ..................................................................... 8 8. Additional Learning points ................................................................................... 14 9. Conclusion ............................................................................................................. 16 PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 3 2. Glossary of abbreviations and terms used in the report. Polly -Subject of the SCR M Mother of Child BF Birth Father SW1 Social Worker 1 SW2 Social Worker 2 B1 Boyfriend 1 B2 Boyfriend 2 MGM Maternal Grandmother MGF Maternal Grandfather PGM Paternal Grandmother HV1 Health Visitor 1 HV2 Health Visitor 2 Cafcass Children and Family Courts Advisory and Support Service CAMHS Child and Adolescent Mental Health Services DTHFT Derby Teaching Hospitals NHS Foundation Trust DSCB Derbyshire Safeguarding Children Board MASH Multi Agency Safeguarding Hub MARAC Multi Agency Risk Assessment Conference ICPC Initial Child Protection Conference DCHSFT Derbyshire Community Health Services NHS Foundation Trust NAI Non-Accidental Injury ALTE Apparent Life Threatening Event AD Assistant Director LAC Looked After Child DCS Derbyshire Children’s Services SCR Serious Case Review ED Emergency Department IMR Independent Management Review SSCB Staffordshire Safeguarding Children's Board BHFT Burton Hospitals NHS Foundation Trust CIN Children in Need Plan CPP Child Protection Plan MHT Metropolitan Housing Trust Ltd ToR Terms of Reference DCC Legal Services Derbyshire County Council Legal Services ICO Interim Care Order DHCFT Derbyshire Healthcare NHS Foundation Trust PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 4 3. Introduction This executive report summarises the findings of an independently led Serious Case Review (SCR) commissioned by the Chair of Derbyshire Safeguarding Children Board (DSCB) following Polly's death in 2014. Throughout Polly's short life, there was regular multi agency professional involvement. She was placed on a Child Protection Plan (CPP) because of pre-birth concerns about possible neglect in July 2012, and remained on this plan until the commencement of care proceedings in May 2013 when she became the subject of an interim supervision order and then an interim care order. The outcome of these proceedings was a supervision order made in October 2013. On May 1st 2014, the local Ambulance Service attended the family home and on arrival found the mother’s boyfriend (B2) giving cardiac massage to Polly; she was reported by him to have ‘gone floppy’ and had stopped breathing. She was taken by ambulance to Queen's Hospital Burton where, after further attempts at resuscitation, she was pronounced dead. The mother (M) and B2 were subsequently arrested and later charged with her murder. On the 11th April 2016, M was convicted of murder and child cruelty and her boyfriend (B2) of allowing the death of a child. As a consequence of the court convictions and new information that was given in evidence at the trial, DSCB asked the lead reviewers to complete the overview report taking account of this new information. M subsequently appealed against her conviction and sentence duration. Her conviction was upheld but her sentence was reduced. This SCR identifies some key themes for learning and improvement through an appraisal, analysis of practice, in light of what was known at the time, and the subsequent information received following the criminal trial. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 5 4. Scope of the Review The review covers the period from 1st May 2012 until the death of Polly on 1st May 2014. Two highly experienced independent reviewers led the review. A multi-agency SCR Panel established by DSCB and was chaired independently. There were representatives from: Derbyshire Police Staffordshire Police East Midland's Ambulance Service Derbyshire County Council Children’s Services Staffordshire County Council Children’s Social Care Barnardo's Leaving Care Service Derbyshire County Council Multi Agency Team Derbyshire NHS Clinical Commissioning Groups Derbyshire Community Health Services NHS Foundation Trust Derbyshire County Council Youth Offending Service Derbyshire Healthcare Foundation Trust Burton Hospitals NHS Foundation Trust Metropolitan Housing Trust Ltd Stafford and Stoke on Trent Partnership NHS Trust Derby Teaching Hospital NHS Foundation Trust Cafcass Derbyshire County Council Legal Services The SCR lead reviewer and author took account of the experiences of both practitioners and those in Polly's family who wished to contribute. Their views have informed the learning and analysis. 5. Brief family background and synopsis of the case Family Composition-The family is white British as are the significant others. Immediate family Significant others Mother to Polly (M) Boyfriend 1 (B1) Birth Father to Polly (BF) Boyfriend 2 (B2) Maternal grandmother (MGM) Maternal grandfather (MGF) Paternal grandmother (PGM) Brother to M Polly lived for most of her life with her Mother (M) in supported accommodation and then latterly in privately rented accommodation. She was a lively and loving toddler. MGM described M's childhood as ‘fairly normal’, but rather dominated by the additional health needs of her father and brother. As a teenager, there were some concerns around her emotional health, and she was referred to CAMHS (Child and Adolescent Mental Health Services) though never took up the offer of support. Other emotional health issues developed which resulted in M being seen by the Crisis Team due to PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 6 thoughts of ending her own life and self-harm. In June 2010, a discharge letter was sent to her GP and the consultant in CAMHS, stating that she had no evidence of mental illness but was noted to have a history of aggression against others and of self-harm. Further contact with the Crisis Team in June 2010 resulted in their analysis that M may have traits of borderline personality disorder. M's parents’ marriage ended during M’s later teenage years and she remained living with her father and brother, though maintained close contact with her mother who moved away with a new partner. In 2012 M became pregnant and at the time was living in the converted garage at her father’s house. When the midwife became aware of the pregnancy, she was concerned about M and her unborn baby (Polly) and referred her to the perinatal mental health services. They did not accept the referral, as she was not deemed suitable for services. Due to agencies’ concerns in relation to M's history of substance misuse, emotional health issues and potential for violent behaviour towards others, it was agreed at a pre-birth initial child protection conference (ICPC) that the baby would be made subject to a (CPP) at birth. By the time Polly was born in July 2012, M's relationship with Polly's father had ended. M was observed over a period of time by professionals in the core group to have attached well to her baby and her care was deemed to be good enough for agencies to begin to consider that the CPP could cease. However, professional concern increased early in 2013, as M became involved with a violent partner (not BF) so Polly remained subject to a CPP. Following a reported incident of domestic violence, legal proceedings were initiated in May 2013 when Polly was 10 months old. At the commencement of the care proceedings there was a brief period when Polly and her mother went to stay with MGM, but this arrangement was unsuccessful and Polly came into local authority foster care'. BF was party to the legal proceedings, but following some issues regarding paternity; a DNA test was ordered in June 2013, this confirmed he was the biological father. Whilst Polly was in foster care M was seen to have complied with all the expectations of professionals to ensure her child was returned to her care. The outcome of the Care Proceedings in Oct 2013 was a supervision order. It was agreed by all professional parties, M and BF that the original risk posed had decreased enough to allow Polly to return to M's care, subject to supervision of them in the community. In the final care plan the local authority recommended that BF had contact with Polly, once a week for three hours, and this was to be supervised by PGM or M. BF from then on, had regular contact with his child, which eventually included Polly staying overnight and at weekends. In Oct 2013, M started a new relationship with B2 who quite quickly took on a role of caring for Polly and being involved in her everyday life. The extent of this relationship and his role was not shared by M with all professionals working with the family. There were a number of medical incidents and minor injuries that involved Polly between January and April 2014, the most significant being alopecia (hair loss) and a suspected febrile convulsion in February 2014. M and Polly, who was now 18 months old, moved out of the supported living arrangements in February 2014 after an eviction notice for damage to the property and began living in a neighbouring county in a rented flat. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 7 Domestic arguments between M and B2 led to police involvement and a growing sense of unease by professionals about once again the risks to the Polly and M of domestic violence. This led to a multi-agency risk assessment conference (MARAC) being held on 30th April 2014. The following day Polly died. 6. Summary There was evidence of initial appropriate multi-agency practice by a group of committed workers who mostly communicated and worked well together, regularly attended Core Group meetings and saw M and Polly often and remained consistent throughout the case. They were also adequately supervised and well trained. This is not a case characterised by a repeated lack of adherence to procedures. However, the multi-agency practice became less organised once the supervision order was made and this is significant. Polly came into contact with a variety of child protection professionals, both within social care and health settings, including an admission to the Emergency Department in February 2014 with a suspected febrile convulsion. Adequate health visiting practice is evident in the DCHSFT records for Polly and her mother both in the antenatal period and post-natal period right up to the transfer out of records to Staffordshire in March 2014. There is however some learning and improvement needed around weighing frequency and record keeping. There must be clarity within CIN plans around how often a child should be weighed and measured. Health visiting must record for every visit, whether planned or unannounced, and identify whether or not it resulted in access to the child. Records should be made within 24 hours of the contact and regular record keeping audits should be undertaken. What is clear from the review is that Polly's weight and growth were not regularly monitored, despite it being part of the CIN plan. Polly grew at a sub optimal rate, she had the potential to put more weight on as had been demonstrated when in foster care but she was not recorded to be actually losing weight. Despite the concerns professionals had for the mother and her child, all agencies commented on the positive and warm relationship between them, which was evidenced through the child meeting developmental milestones, general attachment and her compliance with completing a domestic abuse programme, which were considered as beneficial to both her and her child. The concerns that were raised tended to focus on mother’s relationships with other young people, her vulnerability to domestic abuse and her propensity for involvement in violent outbursts, threats or damage to property. The author considers that some of these concerns should have resulted in a more rigorous analysis and assessment of risks that M herself posed to Polly. From January 2014, professional concern began to rise, and there were a number of incidents that suggested that whilst there was no evidence of non-accidental injury to Polly, there was evidence that in addition to increased concerns about domestic violence between M and B2, her supervision and care might also be deteriorating. There were occasions when DCS were given legal advice to move to move into the Public Law Outline process (January 2014) and thereafter to initiate care proceedings (April 2014), once in January and once in April 2014. Whilst this does not mean Polly would automatically have been removed from her M's care it does mean the opportunities to place the case back before the court were lost. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 8 7. Key findings and recommendations The fully published SCR provides a detailed summary of the professional involvement with Polly. The key findings, recommendations and learning points are summarised below. Finding 1: The Child Protection Plan did not consider whether M should be subject to more detailed assessment to fully explore the implications of her mental health needs and drug use on her capacity to parent. CPPs are the key to ensuring that all aspects of risk to the child are addressed. In Polly's case this was especially important after her birth. Their purpose is clearly specified in Working Together (HM 2015): a plan should include specific, achievable, child-focused outcomes intended to safeguard and promote the child’s welfare and include realistic strategies and specific actions to bring about changes necessary to achieve the planned outcomes. The core group are responsible for delivering the plan alongside full engagement and participation of the parent. The danger is that whilst initial assessments pre-birth may appropriately identify the risks, once a child is born, the everyday needs of the adults become the primary focus of the work in the core group. For Polly, the importance of establishing facts about her mother's psychological functioning and how that might impact on her parenting capacity and ability to keep her daughter safe, was not embedded in the CPP and the relevance of her past history was lost. A series of stress factors existed for M at certain times, such as domestic abuse, a dependence on drugs and alcohol, alongside changes in circumstances, and her daughter’s behaviour, all of which can exacerbate underlying mental health problems, which may increase risk to the child. In examining this case, the author believes that all of the above probably did affect how M coped with her daughter. For M this was particularly evident after Polly came back from foster care in Oct 2013 when she described her daughter as seeming like a different child, having changed in the three months she was in care from a baby to a toddler. The impact of her eviction in Jan 2014, house move, isolation and very latterly emergence of a reliance on cannabis, were clues that she was indeed under a lot of stress. The learning for this review is that professionals never really explored if M did have a significant psychological disorder that would increase the risk to Polly, or her capacity to parent as stress factors increased. Recommendation 1: The impact of hypothesised personality disorder, or other parental mental health issues, should always be assessed as part of a Child Protection Plan, any drug use and past history should be taken into account when assessing future risks. Further appropriate assessments should be considered where a parent’s mental health presentation is identified during assessments by other professionals as being of significant concern or having the potential to have significant impact on the care of the child. Finding 2: There was not enough evidence of authoritative professional practice that saw Polly as the primary client and this resulted in a fixed view that attachment and parenting continued to be good enough as risks increased. A significant number of SCR's have over the years found that professionals had an undue sense of optimism about a case, missed the signs of disguised compliance and focused too much on the parent or carer at the expense of the child. There is a risk that whilst collectively working very hard to support a family, challenging and unacceptable behaviour is not always addressed in a meaningful way which highlights what the PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 9 consequences will be. The author would argue that whilst there was not endemic poor practice in this case there was a lack of authoritative practice. Some of this was caused by the professional view that M was difficult to engage with. In exploring in more depth with the practitioners as to why this was, and what strategies were used to address it with her, it became clear that it is a feature for professionals working with not just this case, but others, and that this leaves some of them feeling immense frustration. Authoritative practice is also about being clear about what a home visit entails, the complexity of managing the often unpredictable environment and how to make it meaningful in carrying out assessment tasks. It is as Harry Ferguson (2016) discusses in his article in Qualitative Social Work, the place where most social work practice goes on but is largely ignored in terms of research and social work literature. Any non-engagement with service users should be recognised not just as a frustration as reported by professionals in this case, but as central to a child's welfare and carrying the potential to harm a child as it also prevents an assessment of their needs. It is not clear whether there was a level of disguised compliance by M with services, or of more concern, that professionals had just not considered enough whether she had the emotional ability to change patterns of behaviour due to self-esteem, personality, previous history, or even recognise when someone posed a danger to her child. As previous SCRs highlight it is this combination of multiple risks that puts a child at risk of serious harm, and this was missed. Research in Practice published a series of briefings about engaging with resistant, challenging and complex families. They stress the importance of relationship-based practice (RBP) that is best summarised as, 'Empathy and relationship skills balanced with an ‘eyes-wide-open’, boundaried and authoritative approach'1 (Fauth et al, 2010). This was something that was at times missing from the work with Polly and her mother. Recommendation 2: Agencies must review their professional supervision/training/models of practice to ensure that they adequately address the need for authoritative/relationship-based practice and challenge the use of the term non-engagement. Finding 3: There was a lack of understanding by some professionals about their role and responsibility when Polly was subject to a supervision order that resulted in a lesser degree of protection than when she was subject of a Child Protection Plan. One of the other most significant practice issues that the review has identified was the impact that the supervision order seemed to have on some of the professionals involved. The statutory order was made as a result of care proceedings where the risk identified related to mother’s association with a violent ex-partner, and the perceived risk that he posed to the child had decreased. The professional view at the time was that M had complied with all that was required of her, was demonstrating a good level of contact and attachment to her child and had ended contact with her violent ex-partner. All professionals felt that the decision to place the child back home and be considered as a child in need was the right one. 1 Fauth, R., Jelicic, H., Hart, D., Burton S., and Shemmings, D. with Bergeron, C., White, K. and Morris, M. (2010) Effective Practice to Protect Children Living in 'Highly Resistant' Families. London: Centre for Excellence and Outcomes in Children and Young People's Services. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 10 From the making of the supervision order to Polly's death there continued to be regular professional involvement with the family. However, professionals reflected at the learning event that they were actually not as clear of their role in relation to the supervision order, as they were when a CPP was in place, feeling that it was somehow a lesser process. In trying to understand why this was the case, it became clear that they did not have enough legal knowledge or understanding of the implications of the order, had never received a copy of the supervision order from the social worker, or had sight of the plan, which was included within the terms of the order and outlined the work they collectively should be undertaking and which should have been transferred to the CIN plan. The CIN plan for Polly needed to ensure that not only the professionals, but also her parents were clear about expectations whilst their child was subject to the supervision order and what the consequences of non-compliance would be. The plan should be shared and kept updated and reflect changing circumstances and risks. It should also have had good management oversight. An additional issue that also needs to be emphasised is to ensure that professionals are clear that if concerns about the safety or potential harm to the child begin to escalate then a supervision order does not prevent a parallel process of child protection taking place. There seemed to be an assumption made by professionals that the main option open to them in light of their increasing concerns was to go back to court. This finding has wider significance for the child protection system and the author questions the value of supervision orders in current practice. They are frequently obtained for children where there has been previous child protection concerns, resulting in care proceedings, and used as a tool to test out rehabilitation. If there is on-going risk then it might be more appropriate for children's services to consider if a care order with placement to parent/s would be a more suitable option. Alternatively supervision orders should as a minimum have a CPP, rather than a CIN plan alongside it. Recommendation 3: Any child who is returning to a carer where there have been safeguarding concerns should have a Child Protection Plan rather than Child in Need Plan, running parallel to the supervision order for at least the first six months. Recommendation 4: Derbyshire Safeguarding Children Board should undertake a multi-agency audit of children subject to a supervision order, to assure themselves that there is good evidence that care plans made post supervision orders are robust and outcome focused. Finding 4: There was little recognition of the role the boyfriend (B2) and father (BF) were playing in Polly's life. This resulted in a lack of professional assessment of both the benefits and risks they posed both to the mother (M) and Polly. Throughout DCS's involvement with M she had a number of male friends or partners. Whilst some of these relationships appeared transitory, there was too much reliance on M to self-report on them. The NSPCC’s document "Hidden Men” (2015)2 highlights the very important role men have in children’s lives and influence on the children they care 2 NSPCC (2015) Hidden Men: Learning from Serious Case Reviews PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 11 for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care the children receive from their mothers. There was also a lack of professional curiosity about the role B2 was playing in Polly's life, or discussion with M on her own as to the nature of their relationship, which continued to be volatile. Explanations that she was no longer in a relationship with him were accepted, and her previous history not properly taken into account. A feature of this case review was the way professionals worked with BF. An initial viability assessment of him by DCS had concluded that he was not viewed as a suitable permanent carer. This effectively influenced the amount of contact professionals had with him and PGM. As his contact increased with Polly it was felt by Children’s Social Care that he ought to undergo a parenting assessment, but the way this was explained was not helpful and the relationship between BF and SW2 deteriorated and contact. between them came to an end. In the meeting with the lead reviewers BF explained his situation at the time and he felt that he had not been listened to or consulted by SW2 or health professionals, especially when he was voicing concerns about the care and safety of his child by M, at the time of the child’s hospital appointments for hair loss and following the admission for a suspected febrile convulsion. Contact arrangements and any issues resulting in them should have been specified in the CIN plan, regularly reviewed, and a package of support offered to BF help him take on his new parenting role and assess any other risks. This finding is a common feature of many cases where there are young, vulnerable fathers. There was no evidence that BF posed a risk to Polly and, in fact, he was actually providing some good protective care and financial support, but it would seem that his parental role was not seen as that significant by any of the agencies involved. Recommendation 5: Where there are safeguarding concerns for children, fathers/male partners must be adequately consulted, supported and assessed in the care of children, even if they are not the primary carer. Finding 5: ED and paediatric staff did not sufficiently consider whether child abuse or neglect was a possibility when Polly presented with medical issues during the last few months of her life. Professionals in paediatric and accident and emergency teams have a vital role to play in the identification of some of the most hidden but severe forms of child abuse and neglect. Medical staff, especially those who are less experienced must be mindful of the potential for abuse to have taken place and not be so focused on medical diagnosis that other explanations are not sought. Recognising signs of abuse is difficult and even with inquisitive and wider questioning easy to miss, sometimes with fatal consequences. However, the taking of a detailed history and consideration of social circumstances when reaching a conclusion about the cause of a medical presentation is crucial. In the months before her death, Polly had a growing number of minor injuries and medical concerns. She been admitted to hospital following a suspected febrile convulsion, had developed alopecia areata, and had had a cut lip (mother’s explanation for this had been accepted). When Polly was found in a collapsed state by B2 in February 2014 her temperature was recorded to be 35.2 C, (which is below normal) yet PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 12 both the ambulance crew and the hospital staff record this as being a possible febrile convulsion 3despite there being no evidence of a high temperature, (during the trial this event was identified as ‘life threatening’). Because the ED (emergency department) attendance was reported as a febrile convulsion and this continued to be the medical view, the potential for a differential diagnosis was never challenged. Staff may have presumed that it was a febrile convulsion, as these are more common in small children, and as mentioned earlier, there was indication of a viral infection that could have caused fitting. The Consultant Paediatrician who reviewed practice for the criminal court case concluded that the febrile convulsion was in fact an apparent life-threatening event (ALTE). 4The health IMRs and lead reviewer considered whether there had been adequate professional curiosity by medical staff at the hospital to look at alternative explanations for the suspected febrile convulsion and cut lip and conclude that there was not. It is important that when a diagnosis is not certain that safeguarding issues are fully considered by conversations with the social worker and health visitor as part of any differential diagnosis and seen chronologically. The injuries themselves may be minor, but they should be seen in the context of any change, additional stresses that may be impacting on the parent and reviewed as part of any CIN plan. It is also vital that there should be liaison with health, and social care about any follow up appointments, and to consider the impact of parental avoidance when a follow up appointment is missed, in this case the follow up to the supposed febrile convulsion episode. In 2014, an alert system (which would flag any safeguarding concerns on a child to medical staff ) was only available to medical staff in ED in Queen's Hospital Burton if the local authority children services had previously shared the information. Staffordshire Children’s Social Care and BHFT did have a process for sharing information on children in their area who are known to be at risk, but it did not include Polly as she was still seen as a Derbyshire child and no such cross border agreement to do so existed. It is hoped that the CP-IS project (Child Protection Information Sharing) in the NHS will deliver a higher level of protection to children who visit NHS unscheduled care settings. Before this project is 'live' across England, unscheduled care settings must be more proactive in ascertaining whether there are safeguarding concerns and these should be part of the differential diagnosis and care plan that includes not just children that are on a CPP but also a supervision order, something which at present the CP-IS system is not set up to consider. Both Derbyshire and Staffordshire NHS Trusts have signed up to the CP-IS project. There was liaison between the paediatric consultant who undertook the child protection medical and SW2, when Polly was not taken to two follow up appointments with the dermatologist for the alopecia; however, this was not viewed in the context of potential signs of parental neglect. 3 A febrile convulsion can be described as seizure (or fit) that can happen in a young child (usually aged between 6 months and 5 years) who develops a temperature. Febrile convulsions are common, affecting about 1 in 20 children and do not usually cause long-term problems or require any specific treatment. 4 An ALTE is a clinical presentation that may have a number of different causes, for example cardiac, seizures, infection and, importantly, non-accidental injury. Events are characterised by apnoea (stopping breathing), colour change, change in muscle tone (usually diminished), and / or choking or gagging, with no cause apparent on history taking or examination. In some cases, the observer fears that the infant has died. A number of authors/ guidelines consider the definition to apply to infants under 1 year of age and for those over 45 weeks of age to be at low risk. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 13 Recommendation 6- ED and paediatric staff must ensure that they always consider abuse or neglect within their differential diagnosis 5when considering the reasons for a child’s presentation. Where this remains a possibility, this should be recorded and appropriately risk assessed, considering all available information. This is particularly important for young children who present with a seizure, febrile convulsion or ALTE. Consideration should also be given to obtaining an examination of the child’s eyes by a paediatric ophthalmologist. This may provide additional clues to the cause of the event, including retinal haemorrhages in the case of shaking. Recommendation 7: Both Derbyshire and Staffordshire Social Care and Healthcare Partners should ensure that Child Protection – Information Sharing (CP-IS) is implemented. Recommendation 8: Missed medical appointments for children on a child protection or children in need plan should no longer be recorded as DNA (did not attend) but always seen in the context of 'was not brought', to ensure that parental neglect is considered as a factor. A risk assessments should be considered and appropriate action taken as a result of this classification . Finding 6: There was insufficient consideration of the importance of the provision of suitable housing for M and the impact of it on Polly. Metropolitan Housing Trust (MHT) initially provided regular support to and monitoring of, M and Polly whilst they lived in the supported accommodation. However, they also issued first stage warnings for breach of M's occupancy agreement during this time. It is not clear if the implications of this were shared with other professionals or seen as relevant, though it clearly was. Metropolitan Housing Trust went through significant changes to their contract with Derbyshire County Council at the end of October 2012 resulting in a reduction in support to their vulnerable residents including that to M and Polly. These changes did not appear to be widely understood by the professionals involved in the case. The consequence was that the input regarding Polly and M’s housing situation was not available to practitioners. This review has highlighted the need for robust assessments to be undertaken when considering the provision of housing for vulnerable young mothers. During the review it was identified that the accommodation M lived in from 2012 was not suitable once Polly was born. This was especially so once the service provided was reduced, which resulted in increasing concerns over the security of the building, and included damage to the property and the volatile behaviour of M and other residents. There was a lack of assessments in relation to the safety and welfare of Polly during this time and none of the issues in relation to why M was eventually evicted were addressed before M and Polly were rehoused. There was an over optimistic view that the rehousing of M and Polly would solve long standing problems. Recommendation 9: DSCB Partner Agencies should consider how more robust assessments are undertaken when vulnerable parents with children, where there are safeguarding concerns, are housed. These assessments should consider the risks associated with housing being offered and its suitability in relation to the age of child/ren. 5 The process of differentiating between two or more conditions which share similar signs or symptoms. PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 14 8. Additional Learning points from the wider appraisal and analysis of practice Parental drug use The initial referral to DCS prior to Polly's birth made reference to mother's use of cannabis and this was explored in the pre-birth conference. M stated that she had stopped using cannabis as soon as she became pregnant, though she later admitted to the midwife some use at 20 weeks pregnant. The suggestion of possible cannabis use remained a feature of the case but it never became a focus, even after M refused to take drug test in January 2014 and after two separate observations in mid and late April 2014 by professionals that she was under the influence of some substance. There was a sense, and this was reflected in SW2's court statement, that mother was young and mixed with people who were or might be users of cannabis. There are two areas for learning in relation to this issue. Firstly that it is important for views about what might be “normal” behaviour around cannabis use for groups or communities to be challenged through good supervision and critical analysis. Secondly that there is a need to ensure that the use of drugs testing within a child’s plan is specific and that the adults are clear as to the consequences of either a refusal of a drugs test or a positive drugs test. There was an anomaly in social work practice in DCS in that social workers were expected to undertake drug swab testing. Skilled and experienced drug workers originally supported this practice but as funding ran out, social workers that received the training carried it on and it became custom and practice. However, it has become clear that the practice is too often employed without clarity on what it is trying to achieve and doing drugs tests in an ad hoc way is not appropriate for children’s social workers. As a result of this SCR the practice is being reviewed by the AD for DCS and some clear guidance for social workers written. Housing of young vulnerable adults When pregnant in March 2012, M moved to live in supported accommodation for up to eight vulnerable young women; a full time support worker was on site. The funding for this service ended in September 2012, M, and Polly, when she was born, continued to live there until February 2014. The only replacement support offered was a limited housing management and two hours per qualifying resident weekly floating support by another agency. The role of the support worker in 2012 had been very positive, as she was involved in multi-agency arrangements for support and safeguarding/protection. Her daily presence also meant that she was able to offer some supervision of the family, when direct engagement was a challenge. It transpired from the learning event that knowledge of this change in circumstances was not widely known or understood amongst professionals who attended the premises. Therefore, professionals may have assumed that there was at least some support at close-hand to M and Polly, but, in fact, this was not the case. When full-time support ended in September 2012 a risk assessment by all agencies would have been expected and to have reasonably identified the likely impact of the withdrawal of full-time residential support. As a result, this may have relocated such a vulnerable family to another supported housing scheme. No such risk or impact assessment seems to have been considered. Although it was not specifically designed to accommodate children after support funding was withdrawn, two of the residents did have young children. There was considerable concern from the professional group about the suitability of a young mother being in this accommodation, which became PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 15 known locally as a place where drugs and alcohol were used and young men hung around, often causing nuisance or criminal damage. Furthermore, there were violent incidents at the property, resulting in requests for police attendance, some of which involved M and, therefore, Polly was exposed to these incidents. Finding 6 makes some additional recommendations around the need for appropriate assessments to be undertaken when considering provision of housing for vulnerable families. Cross border moves and notifications The professional view of the move to Staffordshire, albeit a short distance away, was that it was a positive step, ‘a fresh start’ for M and Polly. The growing tensions and violent incidents in the previous supported accommodation had resulted in an eviction notice. Whilst some of the incidents had been between M and other residents, the majority, which triggered the eviction, had occurred between M and her current partner, B2, so there was also a significant element of the existing conflict travelling with the family to their new home. HV1 and SW2 worked hard to support the move and both felt that things were initially better once the family had moved out of the flats. There were, however, some issues with the way Staffordshire Children’s Social Care and health services were made aware of the family’s move into the area. Although the case was not going to be formally transferred, it was important that Staffordshire had relevant information of the family history so that any emergency calls or incidents, or requests for service could be appropriately responded to. The notifications system has now been reinforced and business support ensures that the receiving local authority is notified in writing that a child that is subject to a supervision order or care order has moved to their area. A system is well embedded for informing other local authorities when a child that is the subject of a CPP moves into their area and a transfer-in conferences takes place. Whilst other local authorities are informed when children who have been receiving services under a CIN plan move into their area, this is sometimes done by telephone and sometimes in writing. A consistent approach is recommended whereby local authorities are informed in writing. When the family moved to Staffordshire, M was advised by SW2 to register with a local GP. She did not follow this recommendation through, though it appears she did try to register at one point. Health visitors were at this time attached to GP practices and, as such, the primary source of information on patients/children who transfer into the area is dependent on them registering with a GP, unless there are safeguarding concerns and a child is the subject of a CPP. In such cases, there should be direct contact between the Health Visitors with an expectation there will be formal contact for a full and proper handover of information. Polly was not on a CPP, but was subject to a legal order and she and her mother had previously been living in accommodation where visits from agencies were frequent. Therefore, it was important for services in the area to engage with M and Polly as soon as possible. If a family fail to register then this should be seen in the context of a wider risk assessment about their children and alert professionals to the possibility of wider concerns. The electronic registration in child health-Staffordshire indicates that M had moved into the area some six weeks prior to them receiving the records. There was no handover provided to HV2 in Staffordshire at the point the family had moved into the area The use of written agreements The use of written agreements is still common social work practice and is used in a number of ways. Most commonly in the lead up to issuing possible court proceedings a written agreement can highlight to parents the seriousness of a situation if circumstances do not change and outline any expectations the social worker may have PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 16 of their behaviour in order to avoid such proceedings. However in the authors view written agreements and requiring individuals to sign them needs to be used with caution. They may be effective if the adult/s are central to their development, feel able to comply with realistic expectations, and are clear what the consequences are if they are not adhered to. 9. Conclusion This SCR has sought to address the effectiveness of professional practice, including decision-making, assessment and information sharing over the two-year period of the review. It has also sought to identify wider learning points for the safeguarding system. The death of any child is a tragedy, however, when the death is considered to be due to abuse or neglect there is a temptation to try and ascertain if the death was predictable or preventable. As Eileen Munro said following her review into the child protection system6, "it is important to be aware how much hindsight distorts our judgement about the predictability of an adverse outcome" Once we know what the outcome was we look backwards and want to explore why signs that seem obvious now were missed. The triennial review (DfE 2016) urges us to move away from this approach, "children can be harmed within the contexts of risk and vulnerability. There may be opportunities for prevention and protection, even without being able to accurately predict when children will be harmed and in what manner". The important point is that we need instead to acknowledge room for improvement in the local safeguarding systems as expressed through the learning points and findings in this report. It was appropriate that Polly was made the subject of a CPP at the time of her birth. However, 10 months later the concerns by professionals were too focused on the needs of her mother, and the risk she was deemed to be at as a victim of domestic abuse. The failure not only to continue to consider wider past history, including a thorough exploration of early childhood, but also to re-evaluate their assessment of M's parenting as being good enough as Polly grew older continued to ensure that an unduly positive picture of M’s capacity to parent safely went unchallenged and the daily lived experience of life for Polly was somewhat lost. In addition, the supervision order may have deflected professionals’ focus away from the original safeguarding concerns, which were present before birth. There was a lack of an outcome-focused CIN plan. That said, the evidence available to professionals at the time (there had been no medical diagnosis of NAI), led them to believe that the attachment and parenting of Polly by M was more than adequate and though she still had volatile relationships with friends and partners, it did not suggest that she posed a direct risk of physical harm to Polly, although in the latter weeks of the child's life she clearly did. Recent SCRs indicate that only 4% of non-accidental deaths of children are perpetrated by birth mothers, so whilst elements of risk and failure to protect or neglect are common, understanding the complexity and indicators in order to predict that a mother, especially one who demonstrated strong attachment, may kill her child is extremely difficult. From the facts and evidence in this case such an act by M could not have been predicted. The birth father himself admitted to the review author that whilst he had many concerns about his ex-partner's behaviour, the people she associated with and her reliance on alcohol, at no time did he anticipate that she would fatally harm their daughter. 6 The Munro Review of Child Protection, Final Report; a child centered system 2011 (DfE) PUBLIC Derbyshire Safeguarding Children Board Executive Summary Serious Case Review - ADS14 17 It must be acknowledged that whilst some risk elements were recognised, in the months leading up to the Polly's death it would appear the violence between M and her then partner was escalating, yet being minimised by her. Professionals made much of the positive relationship observed between M and her child and this appeared to lead, at times, to a prevailing sense of optimism and a lack of professional curiosity about the current partner, violent incidents, drug use and his care history and background. Professionals should have been more inquisitive about the impact of M’s new partner and her other relationships on the safety and health and welfare of Polly. There was also a missed opportunity to go back to court or invoke child protection procedures between February 2014 and April 2014. Tragically, as professional concern was once more escalating, and recognised and steps were being taken to return the matter back to court, Polly died before any further protective action could be taken. Lead Author Print Name Jenny Myers MM AA CQSW Date 25th August 2017 Independent Chair of the SCR Panel for ADS14 Print Name Glenys Johnston OBE Date 25th August 2017 |
NC52172 | Death of a 17-year-old girl in March 2017 whilst a patient in a mental health unit. Clare was her mother's only child. Parents separated before she was 1-year-old. Father met a new partner, and had two children. Mother also met a new partner who had a child - both joined the mother's household. Clare remained with her mother but had contact with her father and his new family. In June 2015 Clare moved to a new area to live her father and his family. Evidence that the parental separation had a significant impact on Clare's emotional and mental wellbeing, and that her mother experienced bonding and attachment issues. Clare and her mother were first referred to child and adolescent mental health services in December 2009. Moving schools in 2015 gave rise to challenging behaviour, truanting and going missing. Evidence of increased incidence of self-harm, reported anxiety and attempted suicide lead to hospital admissions and detention under the Mental Health Act on several occasions during 2016. Clare's ethnicity or nationality is not stated. Key lessons: the need for early intervention based multi-agency approach that includes the school, Children's Services and relevant agencies; the need for schools to be aware of their students emotional and mental health needs and to share any concerns with the school's designated safeguarding lead. Recommendations: agencies should consider how best to maximise the voices of young people and their parents in decision making processes; and have awareness of the importance of early recognition, intervention and treatment of children and young people with mental health issues.
| Title: Serious case review concerning the young person ‘Clare’. LSCB: North Yorkshire Safeguarding Children Partnership Author: Paul Sharkey Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 75 Serious Case Review concerning the young person ‘Clare’ Approved by NYSCP Executive July 2020 Publication Date: August 2020 Lead Reviewer: Paul Sharkey (MPA) Page 2 of 75 Contents Part 1 – Introduction ............................................................................................................................... 3 Part 2 - Aims and Objectives, Terms of Reference and SCR Process Issues ............................................ 4 Part 3 - Background and Agency Involvement ........................................................................................ 4 Part 4 - Suicide and Self-Harm-Definition and Context .......................................................................... 8 Part 5 - Children and Adolescent Mental Health Policy: The National Context ..................................... 8 Part 6 – Analysis ...................................................................................................................................... 8 Terms of References 1/2/4 ..................................................................................................................... 8 (See appendix 1) ..................................................................................................................................... 8 TOR 3 - How well were the voices of Clare and her parents heard and included in the Assessment, Planning, Intervention and Review (APIR) process? Was the process sufficiently child focused, if not, why not? ............................................................................................................................................... 43 ToR 5 - Why was compulsory intervention under the MHA 1983 and Out of Area placements necessary? ............................................................................................................................................. 47 Part 7 - Findings, Key Lessons and Current Agency Developments since Clare’s death TORs 1/2/4 ... 49 Part 8 - Improvements and Challenges ................................................................................................. 59 Glossary ................................................................................................................................................. 63 References ............................................................................................................................................ 64 Appendix 1 Aims, Terms of Reference and SCR Process....................................................................... 65 Appendix 2i -NICHE Findings (Root Causes) .......................................................................................... 69 Appendix 2ii NICHE Recommendations ................................................................................................ 70 Appendix 3 - Suicide and Self-Harm - Definition and Context .............................................................. 71 Appendix 4 - Children and Adolescent Mental Health Policy: The National Context ........................... 73 Page 3 of 75 Part 1 – Introduction 1. The subject of this Serious Case Review (SCR) is Clare1 who died on the 19th March 2017 aged seventeen, whilst an in-patient at Hospital 1 in Norfolk . She was found with a dressing gown cord tied around her neck as a ligature, which she appeared to have placed there herself. 2. Clare was born, brought up and attended schools in West and North Yorkshire. She was an only very young child when her parents separated. Her father met a new partner when Clare was aged 5 and later married, subsequently having two children. Clare remained with her mother but contact with her father continued as did contact with his new family. Clare’s mother met a new partner who had a child. Both joined the mother’s household. 3. Clare began to experience emotional and mental health difficulties in early adolescence that required intervention from Child and Adolescent Mental Health Service (CAMHS). Her difficulties escalated into episodes of self-harm and suicidal ideation as she got older, this continued following the move to live with her father and his family, in June 2015. 4. Following a suicide attempt in November 2015, she was admitted to Hospital 2 in Sheffield as an informal in-patient for a four-week assessment of her emotional and mental health needs. The purpose of the assessment was to determine whether Clare could return home safely, receive support from community CAMHS and resume her schooling. 5. Clare’s presenting behaviours increased whilst at Hospital 2 and she was sectioned under the Mental Health Act, 1983 in both January 2016 (section 2) and February 2016 (section 3). Such were the perceived increased risks of self-harming and suicidal ideation that she was transferred in early December 2016 to Hospital 1, a low secure unit for adolescent in-patients where, tragically, she died on the 19th March 2017. 6. A criminal enquiry was started by Police 1 into Clare’s death and a file was sent to the Crown Prosecution Service which in June 2018 decided there was insufficient evidence for a prosecution. 7. Both the Care Quality Commission (CQC) and the National Health Service (NHS) England have undertaken their own investigations into Clare’s death. Niche Consulting 2 was also commissioned by Hospital 1 group to produce an independent report into the circumstances. 8. The North Yorkshire Safeguarding Children Board (NYSCB) was notified of Clare’s death on the 28th March 2017 and in April 2017 commissioned this SCR. 1 Not her real name. Changed to protect her identity 2 Niche Health and Social Care Consulting Ltd is an independent consultancy that specialises in supporting health care providers with all issues of safety, governance and quality, including undertaking independent investigations following very serious incidents (https://www.nicheconsult.co.uk/) Page 4 of 75 9. Family Structure3 Clare 17 at the time of her death Anne Clare’s mother Patrick Clare’s father Sue Clare’s step-mother Michael Anne’s partner Paternal grandparents Patrick and Sue have two children younger than Clare Michael has one child younger than Clare 10. What was Clare like? Despite the tragic content of this Serious Case Review, Clare had many positive aspects to her character. Her parents describe her as fun loving, witty, caring, easy going with a big heart, being intelligent, artistic, a wonderful girl, articulate, having opinions on the world, sociable, somebody who loved animals and nature. She wanted to save all the animals of the world. Part 2 - Aims and Objectives, Terms of Reference and SCR Process Issues See Appendix 1 Part 3 - Background and Agency Involvement This section of the report seeks to set out the narrative and does not attempt to make judgements about decisions, actions and practice. This is done in the later sections of analysis and findings. 11. Clare was born on the 14th December 1999 and died on the 19th March 2017. She was the only child of her mother (Anne) and father (Patrick) who separated prior to her first birthday. Anne moved to Leeds and Clare lived with her during the week and with Patrick at the weekends and occasionally during the week when she was very little. Clare started to go to her father’s every other weekend at age 11 until age 13 when she requested not to anymore. Sometime later Anne formed a relationship with a male (Michael) who already had a child. The family continued to live in Leeds until Clare moved to live with Patrick, Sue, and Clare’s half-siblings in North Yorkshire in June 2015. Clare attended a secondary school (S1) in North Yorkshire whilst living in Leeds and a further school (S2) on moving to her father’s. 12. The parental separation had a significant impact on Clare’s emotional and mental wellbeing from an early age. Anne, from CAMHS 1 records, had bonding and attachment problems with Clare since Clare’s early childhood. Clare was seen by her GP aged four 3 The family’s names have been changed to protect identities. Page 5 of 75 years old as Anne had noted she frequently cleared her throat for no apparent reason. The GP recorded this as possibly a nervous habit. 13. Patrick and Sue had a child (the first of two) in 2009 when Clare was nine years old. This triggered feelings in Clare that the baby’s arrival meant her father would not also care for her. Both Clare and Anne were referred by the GP to the CAMHS 1 team4 and received therapeutic and parenting services between December 2009 and June 2010. 14. At fourteen, Clare was again referred to CAMHS 1 in February 2014 for attempted suicide and reported anxiety and self-harm during the previous summer. Clare and Anne then received community based therapeutic services (including individual, dyadic5 and family therapies) from CAMHS 1 between June 2014 and March 2015. Clare’s school (S1) was not informed by the GP or CAMHS 1 of her emotional or mental health issues, and had no record of parental communication about this or her self-harming. This represents a missed opportunity to support Clare and her family. 15. Shortly after starting treatment with CAMHS 1, Clare was admitted to Hospital 3 emergency department on the 10thJuly 2014 following ingestion of paracetamol the previous evening. It was recorded that Clare indicated she did not want to kill herself. The reported trigger for the overdose was ‘low mood, frustration at low mood and anxiety at not being taken seriously’. Professionals considered this a significant suicide attempt which was recorded as the first of several. 16. Following discharge from CAMHS 1 in March 2015, Clare and Anne were again referred by their GP to the same agency in April 2015 for Anne’s report of deterioration in Clare’s emotional wellbeing. No intervention by CAMHS 1 took place due to waiting times of the service. Clare subsequently moved out of area to live with Patrick, Sue and half-siblings in June 2015. Claire was subsequently referred to CAMHS 2. 17. Shortly after the move, on the 6th July 2015, Clare was reported to Police 2 by a member of the public as she was walking on the hard shoulder of the A19. She was found later by the Police and subsequently returned to her father’s home. 18. Clare started at a new school (S2) on the 7th July 2015. The disruption involved in moving schools gave rise to challenging behaviour and truanting in the following autumn term6. There was poor communication between School 1 and School 2 about Clare’s educational background and poor emotional wellbeing. School 1 was unaware of CAMHS 1’ involvement, and School 2 only became aware of Clare’s suicidal ideation on the 18th September 2015 when staff were informed by Patrick. Clare left School 2 in late November 2015 following admission to Hospital 2. 19. Clare attended the Accident and Emergency department at Hospital 4 on the 12th November 2015 following an overdose of 30-40 paracetamol tablets. She was admitted for assessment and seen by a psychiatrist from the CAMHS 2 who was concerned about 4 CAMHS 1 5 Therapy involving two people. 6 September to December 2015 Page 6 of 75 Clare’s mental health. Clare remained on the paediatric ward and was seen the next day for a psychological assessment by CAMHS 2. Clare said she did not regret the attempt on her life and wished her suicide attempt had succeeded. She returned home on the 14th November 2015 subject to a safety plan and a referral to ‘CAMHS 2’7, on the 16th November 2015. 20. Clare was seen by the Psychiatric team at CAMHS 2 on the 16th November 2015, where she met with her care co-ordinator. Significant concerns around her self-harm and suicidal ideation were identified by the psychiatric team and the option of an in-patient admission was discussed. The option was a referral to the inpatient CAMHS service. This took a little time to set up she was seen there on the 19th November and in the meantime was assessed as ok to return home on a short term basis under a safety plan, pending going to CAMHS Inpatient Service 1 on the 19th November. CAMHS Inpatient Service 1 recommended a four-week in-patient assessment. A safety plan for a short-term return home was developed prior to the option of admission to CAMHS Inpatient Service 1. 21. On the 19th November 2015 the CAMHS Inpatient Service 1 suggested Clare be admitted. Clare and her parents were unsure about this option and wanted further time over the weekend to consider both it, and the potential alternative of local community based out-patient (Tier 3) services. 22. The family was informed by the CAMHS 2 care co-ordinator on the 23rd November 2015, that there was no longer a bed available at CAMHS Inpatient Service 1 and other options needed to be explored. A community CAMHS option to meet Clare’s need was not viable because of the degree of risk she presented as well as there being no assertive outreach service to offer crisis intervention or support. Patrick and Sue said they wanted to proceed with an in-patient admission as they felt they were not in a position to manage Clare’s risk at home long term. 23. Clare was admitted as an informal patient to the Hospital 2 on the 25th November 2015. She was later detained under Section 2 of the Mental Health Act, 1983 on the 8th January 2016 and under Section 3 of the Mental Health Act, 1983 on the 3rd February 2016 due to Claire’s refusal to return to the hospital after a family outing. Clare later transferred to the Psychiatric Intensive Care Unit (PICU)8 on the 15th February 2016 due to her increased risk of self-harming and aggression towards staff. She was diagnosed with an emotionally unstable personality disorder, although parents recall that this diagnosis was not shared with them at that time. 24. Whilst in the PICU Clare continued to have suicidal ideations and was at risk of self-harming. Such were the risks that she was allocated one to one nursing observation in April 2016. In May 2016, she underwent an Autistic Spectrum Assessment (ADOS) which found she did not meet the criteria, though she did show signs of having some autistic traits. In June 2016, a multi-disciplinary team decided to refer Clare to a Mental Health 7 Adolescent Mental Health, Tier 3, CAMHS 2 outpatient unit in York. 8 The term PICU is in line with national specification. Page 7 of 75 Low Secure Unit as she had not been engaging in therapy, meaning managing her risk in the PICU was problematic. 25. Clare attended Hospital 5 on the 22nd September 2016 to receive treatment on her arm where she had inserted a screw. She did not allow the doctor to examine her and was later discharged. Clare absconded from her escorts and ran out in front of a car, resulting in a car-versus pedestrian collision leaving her with a fractured pelvis. 26. Clare was transferred to Hospital 1 (a low secure mental health facility)9, on the 6th December 2016 under Section 3 of the Mental Health Act, 1983 which was seen as more appropriate option for a long term patient. She was given the diagnosis of (emerging) borderline personality disorder and initially subject to Level 4 supportive observation10. However, this was later stepped down to Level 2 supportive observation11. Clare refused to take medication and did not take part in education. She was selective in her engagement with staff at the Hospital. Clare had eight self-harm incidents between admission and her tragic death on the 19th March 2017. There were two Care Plan Approach’s12 held on the 18th January 2017 and 16th March 2017 respectively. Both involved working with Clare towards a step-down move to a support unit, with a view to discharge and eventual return home. 27. Clare returned to Hospital 1 following her two-day Section 1713 Mental Health Act 1983 leave at her mother’s; returning on the 12th March 2017. Clare had left a suicide note in her room at Hospital 1 which was found by staff on the 11th March 2017, who noted deterioration in her mood and demeanour on her return. Staff also discovered Clare had smuggled vodka in a cola bottle into her room. On the 16th March 2017, at the Care Plan Approach meeting it was agreed to work with Clare to accept some treatment, to help her progress towards a more settled mental health state and eventual discharge. It was also agreed to revisit Clare’s prescribed medication, which she was not taking. 28. On Sunday the 19th March 2017, Clare was found in her room at Hospital 1 unconscious with a dressing gown cord tied around her neck; it having been used as a non-suspended ligature. She had been on Level 2 intermittent observation of four observations per hour i.e. at 15 minute intervals. However, on nine occasions between 20:30 on the 18th March 2017 and 01:57 on the 19th March 2017, she was not observed within the specified fifteen minutes as per the local Hospital 1 Observation Protocol for Level 2 intermittent observations. The largest gap was of fifty-seven minutes between 01:00 and 01:57, when she was discovered. Clare was taken by the Ambulance Service 1 to Hospital 6 where she was pronounced dead on the 19th March 2017 at 04:18. 9 A Tier 4 Low Secure Hospital which is an independent provider. 10 Constant observation of the patient by up to two staff. 11 Observation Levels 1-4; Level 1-Interact once per shift with patient; Level 2-Intermittent checks at least four times per hour; Level 3-Close proximity observations, one to one staff to patient; Level 4-Close proximity observations, two staff per patient. 12 A Care Plan Approach (CPA) is a package of care for people with mental health problems. 13 Section 17 of the Mental Health Act 1983 allows the Responsible Clinician (RC) to grant a detained patient leave of absence from hospital and is the only legal means by which a detained patient may leave the hospital site. Page 8 of 75 29. A police enquiry into the death was started by Police 1. The post mortem recorded Clare’s death as hypoxic ischaemic brain injury14 and ligature compression of the neck. Part 4 - Suicide and Self-Harm-Definition and Context (See Appendix 3) Part 5 - Children and Adolescent Mental Health Policy: The National Context (See Appendix 4) Part 6 – Analysis 30. What follows is an analysis of practice, actions taken and decisions made against the five terms of reference. Key findings, learning15 and current agency developments are set out in Part 7. Terms of References 1/2/4 (See appendix 1) Assessment, Planning and Service Provision of Clare’s Needs and Risks and Multi-Agency Working Together Clare in Leeds: January 2014 - June 2015 Health Agencies 31. Whilst living with her mother in Leeds between January 2014 and June 2015 when she moved to her father’s in North Yorkshire, Clare and her mother were involved with three Leeds health agencies: Clinical Commissioning Group 1 via Clare’s general practice (GP) service, CAMHS 1 via community CAMHS, and Hospital 3 through Clare’s attendance at Hospital Emergency Department in July 2014 following paracetamol ingestion. 32. Clare’s first contact with a health provider was with the GP in late January 2014 following episodes of self-harm. Clare had been using a blade at school to inflict superficial cuts to her thighs since the previous summer. The GP diagnosed that she was experiencing some stresses at home and at school with workloads, which seemed to be underlying her self-harm. Clare was referred to CAMHS 1 in early February 2014. However, given the long waiting list for CAMHS it was suggested that contact be made in the interim with ‘Leeds Market Place’16. 14 Deprivation of oxygen to the brain. 15 Given the closure of Hospital 1 Norfolk in December 2017, all lessons and actions for improvement in parts 7 and 8 are directed at the Huntercombe Group. 16 The Market Place is a young people’s support centre that provides a range of support services in Leeds, especially for mental health, sexual health and crisis support. Young people can self-refer as well as access the drop in centre. Page 9 of 75 33. CAMHS 1 triaged the referral as urgent on the 3rd February 2014 due to Clare self-harming and the anxiety she was suffering. An ‘opt in’ letter was sent on the 17th February 2017. Anne contacted the service via a duty call on the 3rd March 2014. She was signposted to additional agencies and advised to make contact again if needed, all prior to a CAMHS appointment being offered. 34. An appointment letter was sent on the 6th May 2014. Clare and Anne were seen for by the CAMHS care co-ordinator on the 25th June 2014 and an initial assessment was undertaken. It included information on family history, significant events, relationships and presenting difficulties. The next appointment was on the 9th July 2014 and was attended by Clare and Anne. Therapy modalities, including Cognitive Behavioural Therapy (CBT) were explored and a follow up was arranged. 35. Clare was admitted to Hospital 3 Emergency Department on the 10th July 2014 at 08:44, having taken a paracetamol overdose (approximately 40) on the 9th July 2014 at 19:00 and had not told anyone. Anne was made aware of this when one of Clare’s friends told her that Clare had taken an overdose. Anne then took Clare to hospital and Clare was treated to prevent long-term damage from the overdose. She was seen by a Paediatric Physician in the Emergency Department and admitted as an in-patient overnight, pending a standard CAMHS review before being considered for discharge. Clare denied any suicidal intent to the Paediatrician but disclosed ‘frustration and low mood’. 36. Whilst on the ward Clare was seen by the ‘on call’ Doctor with lead responsibility for her care during the admission. Anne and Michael were present during the stay. Clare told the doctor that the trigger for the overdose was ‘low mood, frustration and anxiety at not being taken seriously’. Clare denied suicidal intent or any previous overdose incidents, about which Anne was said to be ‘dubious’. There was no recorded exploration by the Doctor with Clare or Anne into the background and circumstances leading up to the overdose, or Anne’s ‘dubious’ comment. 37. As outlined within the local guidance17 Clare was reviewed at 15:45 the next day by the duty hospital CAMHS worker before being discharged. A mental state examination was completed. Clare repeated that the trigger for the overdose was ‘low mood, frustration and anxiety at not being taken seriously’ and that a factor had been her CAMHS session on the 9th July 2014. However, Clare had been feeling low for some months, during which time she had been considering taking an overdose and had been storing paracetamol for the purpose. Professional opinion was that the incident was a significant suicide attempt, given the delay (over 12 hours) in treatment. The CAMHS worker’s observation was that ‘research into method (of overdose) is of concern’ as was Clare’s storing paracetamol. 38. Liaison was made with Clare’s named CAMHS 1 worker who was apprised of the incident. Safety and monitoring strategies were discussed with Anne prior to Clare’s discharge on the afternoon of the 11thJuly 2014. Clare was given a follow up appointment 17 Leeds Safeguarding Children Board Self-harm and Suicide Behaviour Protocol Page 10 of 75 within two weeks. CAMHS 1, GP and Specialist Community Public Health Nurse (School Nurse)18 were notified of the admission and the incident. 39. Clare had no previous involvement with the 5-19 Healthy Child Service (School Nursing Service) prior to the overdose in July 2014. On notification on the 15th July 2014, the School Nurse contacted Clare and Anne to offer support, though she was aware of on-going CAMHS 1 involvement. Clare and Anne chose not to take up the offer of support and there was no further contact with this service. 40. Clare and Anne attended a CAMHS session on the 23rd July 2014 with Clare’s named care co-ordinator and a psychologist who had seen her in hospital during her admission. An in-depth exploration took place into the mother/daughter relationship and systemic factors were considered. Following this a referral for psychotherapy with a psychiatrist was made. 41. Clare’s behaviour was assessed as being, in part, ‘a function of her early experiences of parental separation and associated attachment/relational difficulties, compounded by her mother’s own insecure parenting as a child.’ Clare’s position as a child in the wider family of her half-siblings from her father’s second marriage and the arrival of her mother’s partner’s child, seemed also to have produced uncertainties and insecurities for Clare. It seemed to CAMHS professionals that, ’there was a strong sense of systemic factors regarding connection, relationships and bonding’19. A structured programme of twelve inter-personal therapeutic (IPT) sessions involving individual, dyadic and family therapy was arranged, running from September 2014 to January 2015. Clare was reported to be ambivalent towards attending which was explored by the therapeutic team who sought to offer her appropriate therapeutic interventions, namely from interpersonal therapy to family therapy. 42. The GP was notified and information was shared, including practitioner discussions with Clare and Anne about safety and minimising future risk of self-harm and suicidal ideation. This was in line with official guidance.20 43. Anne told practitioners at a session in January 2015 that ‘there had been some improvement in the relationship with Clare and that they were planning a holiday together’, although things had become strained with Michael. There had been no further incidents of self-harm according to Anne. Clare decided to discontinue the therapeutic work with CAMHS 1 in January 2015 stating that ‘she and her mother had worked things out and their relationship had improved’. It was agreed to wait six weeks before making a formal discharge to allow Anne an opportunity to call back in the event of any deterioration in Clare’s emotional well-being. The GP was informed. 18 Part of the North Yorkshire 5-19 Healthy Child Service. 19 LCH SCR report, page 14, paragraph 9.7 20 Department of Health (2007), ‘Best Practice in Managing Risk’. Page 11 of 75 Discussion Delay and Waiting Times 44. The delay of nearly five months (early February 2014 to 25th June 2014) before the first CAMHS 1 appointment offered was not to Clare’s advantage. Although Clare and Anne were signposted on the 3rd March 2014 to additional agencies, which may have been able to offer support in the interim period. It would have been beneficial had she received a quicker and more timely response from CAMHS 1, notwithstanding demand pressures on services. 45. Long delays and a lack of timely intervention for young people from the full range of Children’s Mental Health Services, including CAMHS21, are recognised nationally by Government22 and professionals23as being detrimental to children and young people’s mental well-being24. ‘Unfortunately, all too often, children and young people have a poor experience of care or they struggle to get timely and appropriate help (‘Right care at the right time’) that meets their needs’25. 46. The CQC report states that Community CAMHS nationally needs to improve waiting times. Many local CAMHS services, in conjunction with their local commissioners, set their own waiting time targets. This can result in considerable variation that can lead to a, ‘post code lottery’ for timely service provision. The CQC report noted that crisis care was limited because of availability only during normal office hours (9:00-17:00) or that out of hours support was provided by adult psychiatrists who do not specialise in children and young people’s mental health. The CQC report identifies the importance of easily accessible crisis care and gave an example of a team being co-located in the emergency department of a local acute hospital operating seven days per week from 08:00 to 23:00. 47. ‘Future in Mind’ 2015, the governmental blue print for a step-change in mental health services for children and young people has an aspirational target that by 2020, ‘In every part of the country, children and young people have timely access to clinically effective mental health support when they need it’26. With additional funding, this would be delivered by a five-year programme to develop a comprehensive set of access and waiting times standards bringing the same rigour to mental health as in physical health. An additional objective involves improving care for children and young people in crisis so they are treated in the right place at the right time and as close to home as possible27. 48. The Leeds Local Transformation Plan 201528 is a five-year strategic plan aiming to deliver whole system change to children and young people’s emotional and mental health 21 This refers to the full range of children and young people’s mental health services, from Tier 1 (Universal), Tier 2 (Schools and Third sector), Tier 3 Community CAMHS and Tier 4 In-patient, CAMHS 22 ‘Future in Mind’ 2015 and the Green Paper on Mental Health Services for Children, December 2017 23 CQC report, ‘Review of children’s and young peoples’ mental health services, phase one report October 2017; Children’s Commissioner 2017) 24 39% of specialist community CAMHS are rated as requires improvement and 2% as inadequate according to CQC (see CQC, October 2017, 13) regarding waiting times. 25 CQC, 2017, pg 2 26 Future in Mind, 2015, pg 14 27 Future In Mind – Objective 6 pg 15 28 Leeds Local Transformational Plan for Children and Young People’s Mental Health and Wellbeing: 2015 Page 12 of 75 support and service provision. It incorporates priorities from primary prevention through to specialist provision and focuses on improving children and young people’s experiences and outcomes. It is overseen by the Clinical Commissioning Group 1 Partnership, the Health and Well-being Board, the Family Trust Board and is a key programme in the Leeds Children and Young People’s Plan (2015-2019)29. 49. Part 6.1.1 of the plan (Access to Services) states that ‘following consultation with local children and young people about their experiences of CAMHS 1 services, concerns were noted at the length of waiting times.’ A specific request for support during the wait, such as self-help, peer support and on-line support was made. This SCR, however, notes that despite this, there appears to be no waiting time target included in the Leeds Local Transformation Plan. The CAMHS 1 website (at 6th April 2018) states that ‘We aim to see children and young people waiting for a first consultation clinic appointment within 12 weeks. Unfortunately, we are experiencing longer wait times than the normal 12 weeks. We apologise for this and are working hard to try and ensure that wait times are reduced as quickly as possible’. As of February 2018, 90% of the children and young people attending a first consultation clinic appointment were seen within 27.2 weeks with an average wait of 9.3 weeks30. Education – School S1 50. Although living with her mother in Leeds, Clare had attended Secondary School (S1) in North Yorkshire since 2011, having previously attended a Leeds Primary School. Clare had been a good student at School 1 with an acceptable attendance record, who presented no real concerns until January 2015. School 1 reported that it was not aware of her involvement with CAMHS 1 or her previous self-harming and suicidal ideation in 2014. There is no recorded communication with Clare’s GP or CAMHS 1 and no recorded communication between School 1 and Anne regarding Clare’s difficulties. However, there is a discrepancy in accounts. Anne states that she had spoken to a member of School 1’s staff the day after Clare’s first self-harm episode. Anne said the staff member did not take the incident seriously and she did not feel listened to. She also said that she had informed School 1 of Clare’s involvement with CAMHS 1. 51. In January 2015, Clare was involved in a fire alarm incident where she and another girl set off the school fire alarm and was excluded for one day. This was seen as a ‘one -off’ episode. A re-integration meeting was held with Clare and Anne in late January 2015, but no mention was made of the recent CAMHS involvement or Clare’s emotional wellbeing. A bespoke career interview was conducted with Clare during which it was identified that she ‘lacked motivation’ to do well in her studies, although there were no other concerns noted. 52. Uncharacteristically, Clare was absent for seven days in April 2015, which resulted in the school’s support officer contacting Anne. It transpired that she had been staying with her 29 The Integrated Commissioning Executive (ICE) functions as the formal commissioning sub-group of the Health and Well-being Board. 30 Information given in e mail (30.04.18) from Clinical Commissioning Group 1 Page 13 of 75 maternal grandparents. The episode had coincided with a referral by the GP to CAMHS 1. This referral was not known by or notified to the school which, as mentioned above, had made no record of being made aware by Anne of any underlying emotional or mental health difficulties regarding Clare. Following discussions with Anne, Clare was offered a place in the school’s nurture unit that offered support to vulnerable students. Clare took this up in late April 2015. Her programme noted weak literacy skills and significantly low self-esteem. Interventions aimed to re-engage her with the school, strengthen her learning given this was an important pre-GCSE year, increase her motivation and support for her anxiety over exams. 53. Despite support from the nurture unit, Clare’s attitude and mood deteriorated to the extent that the school advised Anne to visit Clare’s GP with a view to making a referral to CAMHS. Unbeknown to the school the family GP, at Anne’s request, had already re-referred Clare to CAMHS 1 in mid-April 2015 due to concerns about Clare’s self-reported depression. There was a delay in CAMHS seeing Clare due to waiting times. She was again signposted to another support agency in the meantime. Anne had indicated that Clare was not self-harming at that time. Clare was not seen by CAMHS 1 as by June 2015 she had moved to live with her father in North Yorkshire. 54. Several contacts took place between Anne and the School’s Support Officer (School 1) in May 2015 and early June 2015 when they discussed what progress had been made with a CAMHS referral. Clare’s last day at School 1 was on the 10th June 2015. The school received a phone call from Sue (Clare’s step-mother) on the 15th June 2015 informing them that Clare was living with them in North Yorkshire. Patrick and Sue met with the school on the 19th June 2015 to discuss Clare’s future education but no decisions were made. Clare started at a local secondary school (School 2) in North Yorkshire on the 7th July, nine days before the end of term. She was taken off School 1’s roll on the 17th July 2015. Discussion 55. March 2015 to mid-June 2015 was a critical time for Clare and her family. There appeared to be a notable deterioration in her emotional and mental health, possibly related to changes in family dynamics leading to her move to her father’s home in North Yorkshire. Notwithstanding the length of service waiting lists a timelier and early intervention in spring 2015 by CAMHS 1 could have been to Clare’s advantage. CAMHS 1 has pointed out that this was a routine referral, and that even if the service could have met the standard waiting time the earliest Clare would have been seen was mid-July 2015, by which time she had moved to her father in North Yorkshire. Additionally, the move to a new school (School 2) came at a very significant and potentially negative point in Clare’s education. Page 14 of 75 56. School 1 reportedly had not been informed by the GP, the School Nurse or CAMHS 1 of Clare’s emotional wellbeing difficulties, or her previous self-harming/suicidal ideation31. Without this information sharing, and given it held no record of the information Anne claims she had shared with School 1, the school did not take these issues into consideration in planning and offering pastoral support for Clare’s mental health needs. Steps had been taken to address her academic educational needs through inclusion in the nurture unit. Clare’s father recalls that she was spending the entire school day in ‘safe house’ classroom with her head in her hands although this had not been communicated with him at that time. There should have been an attempt, with parental consent, to undertake a more multi-agency approach between School 1, GP, CAMHS 1, School Nursing and the family via an Early Help assessment, seeking to meet Clare’s needs for therapeutic and pastoral support. Consideration by any of these agencies should have been given, if circumstances warranted, to make a referral to Local Authority 2 with a view to assessing her as a possible ‘Child in Need’ under Section 17 of the Children Act, 1989. 57. Had there been a record made that Clare’s mother had informed School 1 about her daughter’s emotional wellbeing, behavioural troubles and recent involvement with two key health agencies, this may have led to School 1 providing extra pastoral and educational support whilst Clare was on CAMHS 1 waiting list from April to June 2015. North Yorkshire: Mid-June 2015 to 25 November 2015 58. Following the move to her father’s Clare remained with him, Sue and her half-siblings, from mid-June 2015 to the 25th November 2015 when she was admitted on an informal basis to Hospital 2 in Sheffield. During this time, Clare was involved with six agencies: School 2 Police 2 Local Authority 1 Hospital 4 CAMHS 1 CAMHS 2 School 2 59. Clare started at School 2 on the 7th September 2015 and remained there for eleven weeks until the 11th November 2015. Regardless of having started there in July 2015 there was no record of Clare’s school files being formally requested from School 1, despite there being a process in place to facilitate this. The agency report from School 2 states that key staff had left prior to the start of this SCR and that there was some difficulty in both accessing information and locating records. We must conclude there was a problem with vital record keeping at School 2, certainly in relation to Clare. 31 Although a GP letter referring to Clare’s anxiety and depression was sent directly to the exam board in mitigation of her absence of the 16 April 2015 when she missed a GCSE PE assessment. The letter was not made available to the school (S1). Page 15 of 75 60. The transition of Clare’s records from School 1 to School 2 fell short of required standards. Formal records were not shared between schools. A phone conversation was held between the schools about Clare, but there were no records of the content of that discussion, what information was shared, or what actions were agreed regarding support for Clare. Given School 1’s reported lack of knowledge of the extent of Clare’s vulnerabilities via her parents or health agencies, School 2 also remained unaware of these until the 18th September 2015 following e-mail communication with Clare’s father; he mentioned Clare’s previous self-harm and suicidal ideation. However, Sue reported that she had already discussed Clare’s issues with the school in previous meetings’. Patrick’s disclosure was the result of Clare’s challenging behaviours and problematic attitude to School 2’s staff. She was placed in ‘isolation’, in line with the school’s behavioural policy, and given an opportunity to discuss her behaviour with the school’s Assistant Head Teacher. 61. Following the disclosure by Patrick, School 2 staff met Clare’s step-mother, Sue on several occasions, none of which were recorded, thus falling short of acceptable practice. Legally, at this stage Clare’s mother Anne should also have been consulted by School 2 given she retained parental responsibility under the Children Act, 1989. In any event, the outcome of the discussions with Sue was the organisation by School 2 of a work placement for Clare and a bespoke timetable when in school. There was no attempt by School 2 to follow up the information from Patrick regarding Clare’s self-harm and suicidal ideation and the implications of one or both for her safety and wellbeing as well as her behaviours in school. Discussion 62. This episode was a missed opportunity for School 2 and other agencies to share crucial information and develop a co-ordinated plan to address Clare’s needs. More effective information sharing between School 1 and School 2 would have supported a more holistic assessment of Clare’s needs, and consideration by School 2 and other agencies of any additional actions necessary to support Clare and her family. The NYSCB Vulnerability Checklist was available and could have helped the school determine Clare’s level of need, but was not used. 63. Clare’s mood and behaviour in school did not improve as the term progressed. She then opted out of involvement in the work experience placement. Her last day at School 2 was on the 11th November 2015 prior to a missing episode and her leaving a suicide note at home on the 12th November 2015. Discussion 64. Clare’s social, emotional and mental health (SEMH) needs were not adequately considered or assessed by School 2 due to several factors including: failure by School 2 to request formal pupil transfer information from her previous school, a lack of effective Page 16 of 75 recording of telephone calls and meetings with Sue, a failure to follow up with health agencies, including the Healthy Child 0-19 Service, ‘Compass Reach’32 programme on learning from Patrick about Clare’s previous self-harm and suicidal ideation, a lack of holistic assessment processes or consideration of any additional actions necessary to support Clare.’ Arguably, she was viewed as a troubling adolescent with challenging behaviour rather than a troubled young person with significant and serious emotional and mental health issues that underlay her behaviours. 65. Due to the non-availability to the reviewer of relevant key School 2 staff, who have left since Clare’s death, it has not been possible to gain an understanding of why systems and processes designed to facilitate pupil transfers and assessments of individual needs, including SEMH, were not functioning as the law requires between July 2015 and November 2015. This was a critical time for Clare, involving significant changes in her life around family, school, location and friends. This review concurs with the comment in the relevant agency report that, ’A more structured approach (from S2) may have enabled more evidenced based interventions to be sought by the school with greater involvement of outside agencies’. North Yorkshire Agencies 66. Clare had two contacts with Police 2, the first in the early hours of the 6th July 2015 when she was located walking on a main road near her father’s home, attempting to walk to her mother’s home in Leeds. The police considered she did not present as being, ‘at risk’, nor was she displaying self-harming behaviour or suicidal ideation. Because her step-mother had reported her absence from home after she was found by the Police, the incident was not logged as a missing episode. In policing protocol terms there was no need to institute a ‘Missing from Home’ process. The Police ensured that she was safe, re-united her with her mother Anne, informed Patrick and Sue of the situation and recorded the incident for future reference. 67. The next contact with Police 2 was on the 12th November 2015 when Patrick reported Clare missing as he found a suicide note indicating what he considered was a serious intention to kill herself. Clare was located at the end of the street and re-united with her very concerned father and step mother as Sue had found the suicide note. Clare agreed to attend Hospital 4 with Patrick and Sue and a referral was made to Local Authority 1 by the Police on the 20th November 2015. 68. Clare was taken by Sue to the Emergency Department at Hospital 4 and admitted at 20:38 on the 12th November 2015. Four hours later Clare told a Psychiatric Senior House Officer (a Junior Doctor from the CAMHS 2) that she had taken 30-40 paracetamol tablets (500mgs) the previous day at around 15:00. Clare said that she felt suicidal and continued to have such thoughts. This disclosure was made whilst Sue was waiting outside the 32 This provides a service to children and young people aged 9-19 in relation to emotional well-being and mental health issues. Also included are individuals with moderate or high levels of need in regard to substance misuse/alcohol and /or sexual health. Page 17 of 75 room. Evidence was found of healed self-harm wounds and Clare said that she had been in a low mood feeling ‘awful’, for some months. She expressed no regret at taking the overdose and wished that she was dead. 69. The Nurse in the Emergency Department telephoned the Local Authority 1 Duty Team (EDT) to establish whether Clare was known to Children & Families Services and was advised to send in a referral. There is no written evidence this was done, or any recording that the Emergency Department staff had discussed this referral with ward staff. Moreover, there was no evidence the hospital staff had discussed with Sue the option of support for her to manage Clare’s behaviour through the Local Authority’s Prevention Service. 70. The psychiatrist assessed Clare as at high risk of suicide and self-harm given her presenting behaviour and self-reporting. There were also concerns for her mental health. A decision was made to admit her to the paediatric ward for further CAMHS 2 risk assessment and treatment for the paracetamol overdose. Clare was assessed in the late morning of the 13th November 2015 by two clinical psychologists who obtained a history of her previous involvement with CAMHS 1. 71. The assessment concluded that the episode had been a serious attempt to end her life, which she had planned for over a week. Clare had e-mailed the school pretending to be her father stating that she would not be in school that day. She had bought the medication online and had written a note which included music that she wanted playing at her funeral. 72. Clare was kept on the paediatric ward overnight and was assessed the next morning, following blood tests which showed that her paracetamol levels had normalised, thus indicating that she was medically fit for discharge. She was seen by the on-call psychiatrist in the afternoon and discharged at 19:30 on the 14th November into the care of her step-mother and father under a safety plan33 and given an outpatients’ appointment to attend CAMHS 2 at on Monday 16th November at 09:30. Discussion 73. The evidence shows Clare’s physical and emotional/mental health needs were well met by staff at CAMHS 2 and Hospital 4 in the Emergency Department and on the paediatric Ward. Her paracetamol overdose was treated appropriately. There was a thorough assessment of her mental health and risks of further self-harm and suicidal ideation prior to her discharge into the care of her paternal family. An early CAMHS outpatient appointment was secured in compliance with the North Yorkshire Pathway of Support for Children and Young People who deliberately self-harm. 33 This involved the removal by Clare’s father and step-mother of all medication from her bedroom and bathroom and to be moved to a safe place. An emergency number and contacts were given in the event of any further incidents. Page 18 of 75 74. It is not known why a referral was not made to Local Authority 1 Children’s services by the hospital staff, or why the option of exploring the possibility of support from the Prevention Service was not pursued with Clare’s paternal family. This SCR would judge such practices as unacceptable and not in Clare and her parent’s best interests. 75. Key learning from this practice episode is that agencies should formally follow up concerns with a referral to the Local Authority 1 Children’s Services in line with already established organisational and partnership policies. 76. Clare, Patrick, Sue and Anne met with the CAMHS 2 care-co-ordinator on the 16th November 2015 as arranged. The ensuing assessment raised significant concerns regarding previous self-harm, recent suicidal incidents and Clare’s on-going suicidal ideation. Options were discussed involving an in-patient admission to the CAMHS Inpatient Service 1 facility in York for further assessment, to which Clare and her parents agreed. A safety plan was developed to manage the risk in the interim. It involved Patrick and Sue keeping Clare under constant supervision at home advice was given to remove as many objects as possible which Chare could use to harm herself. The family were also asked to undertake one hourly observation during the night. The family reflect that this was difficult to deliver with other commitments e.g. work and other children, as well as damaging the relationship between Clare and parents. The care co-ordinator made the necessary arrangements for admission to a Tier 434 service and scheduled a further assessment for the 19th November 2015 at CAMHS Inpatient Service 1. 77. Local Authority 1 Children and Families Prevention Service received a referral on the 20th November 2015 from Police 2 following the missing incident of the 12th November 2015. The eight-day interval between making the referral and the Prevention Service receiving it was caused by the shift pattern of the attending Police Officer. This meant the service standard of completing a return interview within 72 hours was not met. However, the Missing from Home Care Protocol was followed as the family were contacted on the 18th November 2015 and offered an interview. This was declined by Patrick as Clare was due to be admitted to CAMHS Inpatient Service 1 for a four-week in-patient assessment the next day and appropriate support was therefore being offered. The family was advised how to request future support from the Prevention Service and the case was closed. There was no further involvement from this service. 78. In April 2017, as part of developments in the Safeguarding Unit, the missing process was reviewed. The Police now notify the Safeguarding Unit when a child goes missing and make a further notification when they are found; this prevents delays. 79. The CAMHS Inpatient Service 1 assessment of the 19th November 2015 concluded that a four-week in-patient admission could be beneficial for Clare. This followed the 34 A Tier 4 service involves admission of an individual as an in-patient. Since 2013, NHS England has had commissioning responsibility. Page 19 of 75 commissioning principles of identifying the least restrictive environment as close to home as possible. It was noted, that due to previous changes in her life a further move could have had a de-stabilising effect on her. The care plan’s purpose was to seek to understand the causes of her difficulties, providing an opportunity for further assessment around Clare’s risks of self-harm and potential suicide, seeking to understand the underlying causes of her emotional instability and establish what could be done to address, reduce and manage risks. This would enable further therapeutic work in the community, endeavouring to keep her safe. 80. The admission would be informal and would not require recourse to compulsory admission under the Mental Health Act, 1983. An important element was development of a therapeutic relationship with Community CAMHS, to progress future treatment and support after the in-patient assessment. 81. At Clare’s parents’ request an alternative option was offered involving a community care package from CAMHS 2, entailing weekly/fortnightly sessions with the care co-ordinator, involvement with a psychiatrist and the availability of a duty clinician in the event of future concerns. Patrick and Sue recall that there was an expectation that parents would be with Clare on a 1:1 basis all day, every day to reduce the risk of self-harm which would be difficult to achieve for working parents with other children. However, there was no facility at the time for the provision of an assertive, out of hours, outreach/crisis service. Clare and her parents said that they would like the weekend to think about their options. 82. On the 23rd November 2015, Clare and her parents were informed by the CAMHS 2 care co-ordinator that there was no longer a bed available at CAMHS Inpatient Service 1 because of acuity factors, with five young people on 1:1 observations. This prevented the planned admission. Clare’s parents did not feel in a position to safely manage Clare’s behaviour whilst waiting for a bed. Given the already agreed and identified risks, they were not in a position to agree to the community package over the longer term. They wanted CAMHS 2 staff to look for a bed elsewhere. It was not recorded what Clare’s views were. 83. The care co-ordinator and the NHS England case manager (see next paragraph) went through the process of sourcing a suitable Tier 4 in-patient placement in another hospital by working their way through the list of available beds across the country, starting with those with any proximity to Clare’s home. The option of an in-patient facility in Leeds was explored but the facility was full. Clare was eventually admitted to Hospital 2 in Sheffield on the 25th November 2015 as an informal patient. Her CAMHS 2 care co-ordinator remained involved as the responsible professional throughout her time there, and later whilst she was placed at Hospital 1. 84. The NHS England Yorkshire and Humber Specialised Commissioning team had a role in commissioning admission to Hospital 2. The allocated NHSE case manager (Mental Health Commissioning Manager (MHCM)) works with local services and the Tier 4 provider, in Page 20 of 75 this case the CAMHS 2 care-co-ordinator and Hospital 2 staff. Their role is crucial in ensuring that an individual’s needs are addressed and links are maintained with the home area. This is especially important given individuals placed in secure units can spend lengthy periods away from their families, increasing the risk of losing significant relationships. This was the case with Clare. Hospital 2, Sheffield: 25 November 2015 – December 2016 and November 2015 to February 2016 85. Clare was admitted on an informal basis to the Hospital 2 in Sheffield on the 25th November 2015 and placed on a general adolescent unit. Hospital 2 is an independent specialist mental health hospital35 providing low secure and locked rehabilitation services for women and children, and adolescent mental health services for males and females aged between 11 and 18 years. Two wards serve adolescents: a 15-bed mixed gender acute general adolescent ward and a 12-bed mixed gender Psychiatric Intensive Care Unit (PICU). 86. Clare’s admission was due to concerns regarding potential risks of being unable to manage her safely in her home community. The aim was to undertake a four-week assessment to gain a better understanding of her mental health needs, including the risks she presented, to establish a plan with the home community mental health team (CAMHS 2) to enable a successful discharge. More specifically, CAMHS 2, as the referring agency36 wanted Hospital 2 to undertake an assessment of risk regarding Clare’s self-harming and also consider an Autistic Spectrum Condition (ASC) assessment. 87. Clare’s stated aim was to gain a better understanding of ‘Why I am feeling this way?’ Her parents’ aim was to work together to understand Clare’s difficulties and agree how to support her. Hospital 2 recognised that ‘Clare and her family ultimately need to address her difficulties by developing a therapeutic relationship with the community adolescent mental health team, namely the CAMHS 2’. 88. It was recognised by Hospital 2 that Clare needed a safe environment in which to engage in the assessment work but that she had also recently experienced unsettling changes in school and home locations in her move of home between parents. The further move to Sheffield, albeit ostensibly for only four weeks, could potentially have had a further de-stabilising effect, as could being in an in-patient setting. In the event, Clare’s stay at Hospital 2 was for 54 weeks after which she was transferred on the 6th December 2016 under Section 3 of the Mental Health Act, 1983 to Hospital 1, around 200 miles away from home. 89. Following her admission on the 25th November 2015 Clare was given a preliminary diagnosis of a severe depressive episode with suicidal ideation. Her consultant 35 The hospital is run by Hospital 2 Limited and part of Universal Health Services (UHS), the largest provider of behavioural health care in the USA. 36 NHS England (Yorkshire and Humber Specialised Commissioning Team) also had a role in the commissioning and oversight of the placement at Hospital 2- see later paragraphs. Page 21 of 75 psychiatrist had identified a key risk as being her contemplating running out in front of road traffic. 90. Clare continued to engage in self-harm from early on in the admission. This escalated to the point where it was beginning to have a significant detrimental impact on her life, starting on the 6th December 2015 when a TV remote battery from her room went missing. It was suspected she had secreted it with the possible aim of swallowing it. Clare declined to discuss the incident. There was no mention of the incident in the risk assessment/care plan, which was not updated to consider this new factor. 91. Following a ward round on the 22nd December 2015, Clare was allowed unescorted home leave to her mothers, which was to take place on Boxing Day. There were no details in hospital records of the planned duration, time or location of the leave. Nor was there a recorded risk assessment regarding the potential for Clare’s self-harm or suicide. 92. Clare was noted as finding it difficult to engage in the care and treatment plan during this early phase at Hospital 2. She had also started to neither eat nor drink. This was seen as self-neglect and deemed symptomatic of her self-harm. Her resulting physical health needs were then met by the Physical Health Care Team. They oversaw her self-neglect/feeding issues and sought advice from Children’s Services regarding safeguarding. They treated her self-harming injuries, undertook blood testing and liaised with the local GP and hospitals when required. 93. In response to Clare’s ongoing deteriorating behaviour, a decision was taken by Hospital 2 professionals to the PICU on the 8th January 2016 under Section 2 of the Mental Health Act, 1983. This was undertaken without any recorded consultation with Clare or her parents. The Section provided hospital detention for up to 28 days and for a further assessment following her first ligating incident earlier that day. The assessment was completed ‘in house’ by the ward clinical team37. No record was evidenced that included the ligating incident and no update was made to her care plan and risk assessment. Her transfer to the PICU meant she experienced a change of clinical team. This would likely to have been experienced as yet another set of significant transitions, albeit her psychologist and schooling remained the same. Arguably, these changes would likely not have benefitted Clare’s condition or facilitated Hospital 2 assessment of her needs and attempts at a therapeutic intervention with the aim of addressing the underlying reasons for her emotional distress and the reduction self-harm and suicidal behaviour. Discussion 94. Clare’s section on the 8th January 2016 marked a further critical phase in her pathway through the adolescent mental health system, having entered Tier 4 CAMHS services on a voluntary basis through admission to Hospital 2 on the 25th November 2015, where she was compulsorily detained under the Mental Health Act, 1983, after a process in which her parents had not been consulted. 37 Section 2 requires the approval of two doctors and an approved mental health practitioner. Page 22 of 75 95. The CAMHS 2 care co-ordinator, at Hospital 2’s request, contributed information regarding the Mental Health Act assessment. She also received weekly reports and meeting minutes on Clare’s progress at Hospital 2, albeit there was no evidence that she had attended - or been invited to attend - any of the multi-disciplinary meetings such as a Care Programme Approach (CPA).38 Discussion 96. Hospital 2 was proactive in ensuring Clare’s physical safety, seeking to meet her physical health needs and managing her self-harming behaviour, during the initial four weeks prior to her being detained under Sections 2 and 3 of the Mental Health Act, 1983. However, there was little evidence of what, if any, purposive work was being done with her and the parents on the aims and objectives of the original four-week admission. Good practice indicates professional intervention, whilst needing to ensure a young person’s safety and well-being, should also engage with the individual and attempt to understand underlying reasons for self-harming and suicidal ideation. 97. Sullivan (2017) suggests a correlation between a person’s behaviour and the degree of control they exert over their environment. The greater the degree of environmental/external control, the more likely an individual will engage in reactive and protest behaviour (flight or fight) to try to regain control. This can result in a negative feedback loop of interaction resulting in ever more challenging behaviour which is then matched by a regime of ever increasing control and coercion by the institution. The focus of intervention then becomes ensuring the individual’s safety through enhanced control, at the cost of forming constructive, and trusting relationships designed to address underlying problems and work towards solutions and positive outcomes. Sometimes there is a tendency for agencies to focus on the ‘troubling teenager’ and their behaviour, rather than trying to engage with the adolescent and their underlying issues. 98. The evidence provided by Hospital 2 raises questions about the balance between care and control, the engagement of Clare and the need to ensure her safety. In short, was there an over focus on control at the expense of engaging her through the development of a constructive and trusting relationship? 99. With regard to consultation with Clare and her parents about going to an out of area facility, there is little indication in the reports from CAMHS 2 and Hospital 2 as to how much discussion there was about the admission. Albeit that there was agreement that Clare needed in-patient intervention, and commissioners had tried without success to place her nearer to home. In addition, there was little or no evidence of the care co-ordinator communicating with and keeping Clare’s parents up to date with developments during her stay at Hospital 2. In this respect communication fell significantly short of acceptable standards. Patrick, in a subsequent contact with the Author, described the 38 The CPA is a way that services are assessed, planned, co-ordinated and reviewed for someone with mental health problems. Page 23 of 75 poor communication as a fundamental failing that made things very difficult and upsetting for him and Sue’ 100. It is documented that Clare did not want to be at Hospital 2. She wanted to return to her mother or live with her maternal grandparents, which at the time was not a safe option because of difficulties in managing her risk at home. Clare was clear she was unhappy living with her father. 101. In any event, it would seem the original aims and objectives of the four-week assessment were not met, partly for reasons to do with the hospital’s approach to Clare; her escalating presentation of self-harming behaviours and limited engagement with staff. 102. Hospital 2 and the CAMHS 1 care co-ordinator co-operated in relation to the provision of reports and minutes of multi-disciplinary meetings, input into Clare’s compulsory detention under the Mental Health Act, 1983 and the Autism Diagnosis Observation Schedule (ADOS) assessment. However, the care co-ordinator should have taken a more proactive role, for example in attending some CPA meetings whilst Clare was at Hospital 2. Given this was an out of area placement this only served to emphasise the key pivotal and linking roles that should have been played by the CAMHS 2 care co-ordinator between Clare, Hospital 2, family and home agencies, including the Local Authority Children Services39, this latter being especially important given Clare was compulsory detained under the Mental Health Act, 1983. Commissioners and Regulators: NHS England and the Care Quality Commission (CQC) 103. This SCR notes that NHS England (NHSE) started a single item Quality Surveillance Group in December 2015, focusing on three hospitals belonging to Alpha Hospital of which Alpha Sheffield was one. Hospital 2 Group acquired Alpha Hospitals on the 19th August 2015. The Quality Surveillance Group are part of the quality monitoring and assurance system used by NHS commissioners and other stakeholders, including Local Authorities and regulators40, specifically where there are concerns regarding a provider. The group was convened due to escalating concerns regarding Hospital 2 Sheffield. Several key themes were identified including the hospital’s understanding of its core business, the climate and effectiveness of organisational learning, leadership, embedding governance and staff retention. 104. Following acquisition of Alpha Hospital by Hospital 2 Group a new board structure was put in place, along with a mechanism of introducing and implementing improvements to Hospital 2’s processes. The Quality Surveillance Group looking into Hospital 2 closed in March 2017 as it was deemed sufficient progress had occurred to remedy commissioner and CQC concerns. Throughout the process there was increased surveillance on the service by the Yorkshire and Humber Specialised Commissioning Team and NHS England case managers. This involved carrying out service reviews with key lines of enquiry 39 There was a legal duty for Hospital 2 and CAMHS 2 to notify Local Authority 1 of Clare’s placement at Hospital 2 once she had been there for three months (i.e. at the end of February 2016) 40 (namely, the Care Quality Commission, CQC) Page 24 of 75 relating to CQC concerns and NHS England case managers attending Multi-disciplinary team and Care Programme Approach meetings. Quarterly contract meetings to review and monitor quality and safety were carried out and further supported by attendance at monthly Hospital 2 governance meetings. 105. It is noted that Hospital 2 was subject to four CQC inspections in February 2015, January 2016, June 2016 and August 2017. Five requirement notices 41were issued by the CQC in February 2015 because the hospital was failing to meet regulatory standards within the safe domain. A rating was not given. 106. In response to concerns from the CQC and NHS England in regard to ongoing issues in child and adolescent mental health services, Hospital 2 commissioned an external Independent review of the child and adolescent wards in December 2015. A CQC action plan was developed, and reviewed at the next inspection in January 2016. The Inspection team was assured that all actions were completed against the plan. A rating was not given. The subsequent report issued on the June 2016 identified that the hospital was in breach of Regulation 13 HSCA (i.e., ‘Safeguarding service users from abuse and improper treatment’), namely that, ‘Informal young people were not able to leave the ward at will’.42 Hospital 1: 15th February to 7th July 2016 107. Clare was made the subject of Section 3 of the Mental Health Act, 1983 on the 3rd February 2016, providing for detention and treatment in hospital for up to six months. It is not known what either she or her parents thought of this. Nor is it clear what their involvement was in any consultation as no records were produced. We must conclude none were made, or kept, that would have evidenced this. Likewise, it is not known what involvement the CAMHS care co-ordinator had in the decision, albeit she continued to receive weekly updates from Hospital 2. 108. A Care Programme Approach (CPA) meeting was held on the 4th February 2016 involving the Clinical Team from the adolescent ward, Patrick, Anne and Sue. Neither the NHS England case manager nor the care co-ordinator from CAMHS 2 were present, nor was Clare. These absences, especially that of Clare, fell short of good practice (as admitted by the Hospital 2 report at page 10) and did not respect her participation rights or afford her a direct voice in decisions about herself. The Clinical Team had assessed that the ward could not meet her emotional and mental health needs because of both the acuity of her clinical presentation and the severity of her risk-taking behaviour. 109. Clare was engaging in almost daily self-harm and her involvement with the assessment and therapeutic programme43 was mixed. Reportedly she often remained silent, spoke infrequently or did not attend. It was agreed she should move to the PICU to meet her 41 This requires an agency to take actions to address the shortcomings in services identified by the CQC inspection. 42 In breach of regulation 13 (4) (b) (5). 43 (this included a range of individual and group interventions) Page 25 of 75 treatment needs and better manage her risks. The move happened on the 5th February 2016. 110. Due to the absence of any supporting documentation, it is not known precisely what the care plan and risk assessment were whilst Clare was on the PICU. It would seem the focus was on the containment and control of her increased risk of self-harm. Arguably such behaviour can function as a means of emotional regulation and/or as a coping mechanism in response to environmental factors. This should have featured in her plan, but it did not. Indeed: ’Enforced interventions to stop patients injuring themselves are likely to produce a confrontational rather than a therapeutic environment that increases levels of distress and reduces the chance of a positive outcome in the longer term………Many individuals who self-injure have a history of abuse or trauma and preventative measures may increase their feelings of powerlessness and in extreme cases result in additional trauma and therapeutic alienation’ (Sullivan: 2017) 111. The NHS England case manager attended a CPA meeting in March 2016 which sought to identify and support Clare’s future pathway following her transfer from wards within Hospital 2. The least restrictive options, including going to CAMHS Inpatient Service 1 or a facility in Leeds (neither of which had a PICU), were considered. However, the clinical consensus was that Clare’s level of risk militated against a transfer back to a General Assessment Unit (GAU). It is recorded by NHS England that the family agreed with this, although Clare’s views were not known. The care plan presented at the CPA, according to NHS England felt, ‘clinically appropriate’. A new NHS England case manager was allocated to Hospital 2 Sheffield which included Clare’s case. 112. The negative spiral of interaction between Clare and the staff at Hospital 2 continued. Clare was frequently involved in several self-harming incidents ranging in seriousness from aggravating and picking at pre-existing wounds, inserting foreign objects in wounds, fresh cuttings, ligating on two occasions in January 2016 and May 2016 and running out in front of vehicles on two occasions. Clare attended the Emergency Department at Hospital 5 overnight on the 12th February 2016 for a self-harm wound to her wrists. Emergency treatment was provided and a plan put in place for follow up at the Trust’s specialist hand centre. On the 27th May 2016, having jumped out in front of a car, she was assessed as having not sustained any injuries and returned to the care of Hospital 2. 113. Clare’s care co-ordinator from CAMHS 2 met with her on two occasions in late May 2016 and completed an autism assessment44 in conjunction with Hospital 2 staff. This concluded that Clare did not meet the criteria for the disorder. Of note, Clare reported to staff in May about an episode that had taken place whilst at the Leeds primary school where she had reportedly told a member of staff that something had happened to her. However, there was no commentary regarding this in Hospital 2’s documentation. 44 An ADOS (Autism Diagnostic Observation Schedule) was undertaken. Page 26 of 75 114. In any event the task for the hospital, which proved problematic, entailed balancing Clare’s safety whilst seeking to engage her in assessment and purposive therapeutic work. The hospital’s response became increasingly focused on risk management, restrictions of liberty and control of her behaviour, involving allowance of a restricted number of items in her room, the use of items under close supervision, the use of restraint, time in the enhanced care suite, 3:1 observation, seclusion and restrictions of Section 17 of the Mental Health Act, 1983. 115. By the summer of 2016, it was clear to Hospital 2 that Clare’s stay was having a minimal impact on alleviating her emotional and mental health wellbeing. A clinical decision was made that the risks were too high either to proceed to a ‘step down’ to a general adolescent ward or, even more unlikely, discharge into her home community. The stalemate position on the Hospital 2 ward was deemed not in her interests and unsustainable. In light of the non-availability of other options a recommendation was made on the 7th July 2016 for Clare to be treated in a Tier 4 Low Secure Unit45. Discussion 116. Whilst acknowledging the challenges of working with Clare, it must be noted that interventions by Hospital 2 were unsuccessful in engaging her in the aims of assessing her risks, understanding underlying reasons for her self-harming and suicidal ideation, or working towards positive outcomes of community and family rehabilitation. The hospital did succeed in preventing her ending her life whilst she was a patient. However, the evidence indicates that the levels of self-harm and suicidal ideation increased to the point where the Hospital 2 team felt it could not safely manage the risks to Clare. This resulted in the multi-disciplinary team’s decision to seek a transfer to a low secure unit. 117. In analysing the reasons for the above, several factors can be identified. As acknowledged in Hospital 2 agency report for this SCR, there were a number of internal practices that did not meet the required standards and a number of organisational issues that did not facilitate positive outcomes for Clare. 118. The first was with regard to care planning. The care planning structures and processes in operation were predominantly nursing plans which had limited input and review by the wider multi-disciplinary team. This raises questions of professionals’ involvement and how effective the assessment was of Clare’s wider holistic needs, risks, the quality of planning, implementation and review: in essence, the quality of the CPA process. 119. Two sets of care plans ran simultaneously, with contradictory aspects. For example, the observation levels outside Hospital 2 were recorded as 3:1 in one plan and in another, 2:1. Clearly, there should have been only one plan. The existence of two reflects a lack of co-ordination, communication and collaboration within the multi-disciplinary team working with Clare. 45 See definition and criteria for admission. Page 27 of 75 120. Secondly, poor recording within Clare’s patient record is noted. Care plans were produced electronically with communication mainly via e-mail both internally and externally in providing updated care plans, risk assessments and reports. However, the plans were not copied or placed in Clare’s patient record, making it difficult to understand what information had been shared by the multi-disciplinary teams, with whom, or when. Compounding this is that previous versions of plans were overwritten when individual members of the multi-disciplinary team came to update and review the patient record. This resulted in a lack of clarity for staff as to whether Clare’s care plan and current risk assessment had been updated and amended to reflect changes in her presentation, or following key events such as the two ligature episodes in January and May 2016 (see below). 121. There was no effective process for updating the care plan and risk assessment following a significant event or incident. Of concern in light of the manner of Clare’s death at Hospital 1, the two ligature incidents did not result in the completion of an incident form as per Hospital 2 Policy, nor an up-dated risk assessment included in the care plan. There are also questions about the accuracy of recording of these incidents, which were described as historic. There was no contextual detail or analysis surrounding the ligature events or what was meant by 'historic’. These were serious events requiring, in one instance, the use of a knife to release Clare from the ligature tie. Both these and other self-harming events were viewed in isolation and not analysed and understood within a wider dynamic risk context for Clare. 122. Of significant concern, there is no evidence to show these two critical ligature incidents were included in the referral information sent to Hospital 1 in December 2016. 123. The record keeping and documentation practices did not provide an accurate or up to date assessment of Clare’s complex needs and risks. Moreover, the infrequent care plan reviews compounded the ineffectiveness of the whole APIR (assessment, planning, intervention and review) process, resulting in a lack of an accurate up to date understanding of Clare’s circumstances and her ‘bigger picture’. 124. Thirdly the operation of the fortnightly ‘ward rounds’, is of concern, as incidents occurring in the previous two weeks were not discussed with the wider multi-disciplinary team (MDT). This meant there was only partial information input into the ward rounds concerning Clare’s care and treatment, all of which could result in an incomplete understanding of her needs, risks and progress and therefore a misdirection of practice in her case. Such practice also raises the question as to which professionals were present on the ward rounds and why the full Multi-disciplinary team was not in attendance. 125. Hospital 2’s agency report indicates that there was a lack of multi-disciplinary team oversight of the whole care package and planning process. What passed for planning was completed by the nursing team in a uni-disciplinary manner that lacked input from the wider team. This may explain the re-active focus on day to day risk management of Clare (perceived as a troubling individual) at the expense of a more proactive attempt to Page 28 of 75 address her underlying emotional and mental needs and consider her longer-term welfare, post discharge. 126. A further factor was the poor quality of transition between the two Hospital 2 wards in mid-February 2016.There was no formal process for transitioning patients from one service (general adolescent ward) to another (PICU). The lack of a record of a formal handover meeting and effective information sharing between the two clinical teams did not make for a smooth transition. Crucially, there was no evidence that risk incidents identified on the adolescent ward, such as the ligature episode of early January 2016, had been noted or addressed by the PICU. Moreover, the two clinical teams had different consultant psychiatrists and nursing staff. The change in care regimes and the more restrictive care environment would have been problematic for Clare to negotiate, given her developmental history of a lack of secure attachments and trust within her family. 127. High staff turnover was an issue identified by Patrick and Sue and in the August 2017 CQC report (see below.) Patrick and Sue stated they ‘Never saw the same consultant’ when attending CPA meetings. They noted that at one CPA meeting the consultant was helpful and suggested the family communicate with him directly but two weeks later he had moved positions. Communication with staff was very poor. The family claimed Clare did not have a key worker and felt it was impossible to get through to the ward via telephone to speak with her. 128. They stated that ‘Clare felt she wasn’t cared for in Sheffield and any staff member she did get close to would eventually move jobs’. High staff turnover would not have facilitated the development of constructive therapeutic relationships given Clare’s needs for healthy emotional attachment to caring adult figures, a sense of continuity, existential security and the development of trusting relationships. 129. Of significant concern was the lack of effective action by staff in regard to two safeguarding incidents which were not properly documented by the hospital or shared with the appropriate agencies. Care Quality Commission (CQC) 130. Deficits and sub-standard practices identified above in respect of Clare’s experiences at Hospital 2 were systemic. Evidence of this is found in the CQC inspection reports of December 2016 and August 201746. The former reported on a visit in late June/early July 2016 which rated Hospital 2 Sheffield as ‘Requires Improvement’. Regarding the category ‘Are child and adolescent mental health wards safe?’ it was found to be ‘Inadequate’. Parents recall that they we not made aware of the outcome of the CQC inspection result. The August 2017 report in respect of the PICU identified several issues and shortfalls that gave rise to significant concerns for the health and wellbeing of patients. As a result, the CQC sent an urgent letter of concern to the provider requesting them to provide assurance about what actions were to be taken. The PICU ward was closed for further 46 Based on an inspection carried out in July 2017 following a serious incident on Haven ward. Page 29 of 75 admissions by the provider to allow for the implementation of an improvement action plan. 131. Some of the key findings, mirrored by evidence in this SCR, included: Shortfalls to the processes of individual risk assessments and limited information in care records about patient’s warning signs. Records and care plans not always including known risks relating to the patient. No consistent system to inform staff about all newly admitted patients to the ward. The operation of two alternate shift groups at night with the same staff working in each shift. Differences in how staff found out background information about patients when they were not on shift. Shortfalls in the reporting and learning of incidents which although documented and described were not always entered on the incident reporting system. Learning from incidents was not shared with staff at ward level. No staff routine feedback about incidents unless they were serious. Post incident debriefs did not always take place. Safeguarding procedures did not protect patients from the risk of exposure to harm. Staff not identifying safeguarding incidents and logging them. Not all staff were knowledgeable about the ways they could report safeguarding matters, in particular when they occurred out of hours. Management of environmental risks was not robust; it was unclear what ligature risk assessment staff were expected to follow. Risks in the environment, such as access to screws in fixtures and fittings which had led to repeated incidents of self-harm by patients. 132. The most recent CQC report of November 2017, following an inspection visit in August 2017, rated the hospital still as ‘Requires Improvement’ overall. The category of ‘Are child and adolescent mental health wards safe?’ resulted in ‘Requires Improvement’. 7th July 2016 to 6th December 2016 133. A referral was made by the hospital on the 7th July 2016 for a low secure placement. This was agreed to by Hospital 2 staff, CAMHS 2 and NHS England (as the commissioner of Tier 4 services). It is not known if Clare and her parents were asked for their views about the transfer. Patrick and Sue reportedly felt that they did not want her to move again, despite previous incidents, as they believed that any change would be disruptive for Clare. They only became aware of the move to Hospital 1 Norfolk on the 6th December 2016 on receipt of a ‘Welcome pack’, from the hospital. Clare’s views were not known or recorded, although her father reported that she wanted to move back to a voluntary ward and no longer to be the subject of a Section under the Mental Health Act, 1983. 134. Tier 4 low secure settings are subject to complex commissioning arrangements by NHS England and at the time of Clare requiring a transfer there was an increased demand for Low Secure Services, which impacted on the waiting time. She was considered by two Page 30 of 75 low secure units and eventually provided with a place at the low secure setting of Hospital 1 in Norfolk some 200 miles from North Yorkshire. She was admitted on the 6th December 2016. 135. Clare’s situation continued to deteriorate during the five months prior to her transfer to Hospital 1. The focus of professional intervention continued to be around containment and control of Clare’s self-harm and suicidal ideation. Such was the frequency and seriousness of her self-harming injuries during the period (often involving the insertion of foreign bodies into her arm) that they necessitated admission to hospital and treatment during August and September 2016. The latter admission involved Clare being taken to the Emergency Department at Hospital 5 by a 3:1 nursing escort from Hospital 2. Unfortunately, she absconded and ran in front of a car incurring further injury and the attendance of officers from Police 3, resulting in a week’s in-patient stay. There is no record of how such an absconding incident happened given 3:1 supervision was in place from Hospital 2. 136. Of some significance, the named professionals for Safeguarding Children at Hospital 5 identified that during this period there were significant numbers of young people from Hospital 2 attending the Emergency Department, each of them with self-harming injuries. Concerns were escalated to the Designated Nurse for Safeguarding Children, Clinical Commissioning Group 2 on the 24th October 2016 and were subsequently escalated to NHS England. Discussion 137. There were difficulties of inter-agency working between Hospital 2 and Hospital 5 regarding Clare’s self-harming injuries. An example of this was Clare’s admission to Hospital 5 in September 2016. The acute staff had limited understanding of Clare’s mental health needs, albeit they were aware that she was subject to Section 3 of the Mental Health Act, 1983. There was a lack of information sharing about Clare between the two health providers and poor if any evidence of a shared collaborative care plan to meet her physical and mental health needs and risks whilst in the care of both providers. There was no effective discharge planning and inter-agency planning. This pattern creates serious concerns 138. There were also gaps and deficits in the transfer of information about Clare from Hospital 2 to Hospital 1. The Hospital 2 report presented as part of this SCR noted that the health records did not evidence clearly what information was shared with Hospital 1 on Clare’s discharge from Hospital 2. There was a deficit regarding the storage of records and a lack of clarity on what information had been either shared or documented. The additional information should have included at least the following: current care plans, risk assessments and management plans. These were absent. Hospital 1, Norfolk 6th December 2016-19th March 2017 Page 31 of 75 139. Hospital 1 in Norfolk was a Tier 4 Child and Adolescent Mental Health (CAMHS) hospital providing low secure and psychiatric intensive care (PICU) for 30 young people aged between 12 and 18 years of age. It was part of the Huntercombe Group, an independent provider of hospital services to the NHS with facilities throughout the UK. The hospital provided services to young people with a range of mental health disorders, detained under the Mental Health Act, 1983. However, following CQC inspections in 2017 and other considerations, the Huntercombe Group deemed that the hospital was not meeting the expected standards of service provision. It took the decision to close Hospital 1 in December 2017.47 140. What follows draws heavily from two sources, firstly the September 2017 independent investigation and report undertaken by NICHE48 at the behest of Hospital 1, consequent to Clare’s tragic death on the 19th March 2017. The investigation used the NHS England (NHSE) Serious Incident Framework of March 2015. Secondly, this review relies on the Police 1 case summary of the force’s inquiry into Clare’s death. Assessment and Management of Risk and Care Planning 6th December 2016 to 10th March 2017 141. Clare was transferred from Hospital 2, Sheffield, to Hospital 1 on the 6th December 2016 under Section 3 of the Mental Health Act, 1983 to a low secure ward. She arrived with a diagnosis of (emerging) Borderline Personality Disorder and an implication from Hospital 2’s clinical notes that she was also depressed, though no formal diagnosis of depression was made. Clare said she had suffered an episode of depression which had led to her current admission. She felt that she had recovered from this and no longer needed either to be subject to a Section 3 of the Mental Health Act, 1983 or be on medication. 142. On the 7th December 2016 a clinical risk inventory was completed. It was informed by information from the referral and handover from Hospital 2. Clare was noted not to have engaged with staff regarding treatment. The inventory considered: violence and aggression, suicide, vulnerability, other risks and precipitants. Identified risks included: self-harm by cutting, inserting objects into wounds, head banging, absconding, jumping in front of cars (sustaining a fractured pelvis) and physical aggression to staff. Of significance, no mention was made of the two ligature episodes at Hospital 2 because this information had not been passed onto Hospital 1. Indeed, none of Hospital 1 staff interviewed by the NICHE investigator showed any awareness of the previous ligature history. Non-sharing of information, and a lack of such knowledge, are both causes of concern for this review. 47 See letter from Huntercombe Group medical director to NYSCB (14 September 2018) 48 NICHE Health and Social Care Consulting is an independent management consultancy that specialises in supporting health care providers with all issues of safety, governance and quality, including undertaking independent investigations following very serious incidents. The author of the report into the death of Clare was Ms. Sue Denby. Expert clinical advice was provided by Dr. Leahy, consultant psychiatrist for inpatient adolescent psychiatry. Page 32 of 75 143. The resultant initial care plan assessed Clare as being subject to Level 3; that is two-to-one intermittent observations. She also had a CGAS (Children’s Global Assessment Score) of 31, placing her in the category of having serious emotional, self-harming and suicidal ideation problems, major impairment in several areas and being unable to function in one area. 144. The ward round notes of 15th December 2016 stated that the observation level had, on the authority of the responsible clinician, RC1, been reduced to Level 2, which according to custom and practice at Hospital 1 meant an observation of no more than 15 minutes should pass between checks. The NICHE report took the view that the decision to reduce from Level 3 to Level 2 observations was appropriate as Clare was reported not to be presenting with psychotic symptoms or prolonged periods of low mood. Anne had reported that Clare had made good progress since her admission and a recent short family visit from her mother had gone well, including Clare having unescorted leave with her family. 145. Whilst at Hospital 1 Clare was reportedly difficult to engage and deemed secretive, refusing sessions with the assistant psychologist and not attending education. She refused medication and did not talk to ward staff about her difficulties. However, on a positive note, she developed relationships with two support workers with whom she was able to express some of her thoughts and feelings. 146. There were eight self-harming incidents which included cutting and inserting objects into her wounds whilst at Hospital 1. In addition, Clare brought alcohol onto the ward in a Coca-Cola bottle following home leave on the 10th and 11th March 2017. 147. The overall care plan was understood by support workers to be ‘helping Clare to find different ways of coping so that she could live somewhere less restrictive, to be discharged either to an open unit or home leave.’ The use of Section 17 leave was dependent on the level of risk Clare presented at any one time. The Named Nurse perceived the care plan as indicating Clare wanting to go to an open unit. Reportedly, Clare did not want to return to live with Anne, preferring to move to Social Care provided supported accommodation. The responsible clinician (RC1) had told her that the quickest way to move back closer to her family was for a transfer to a step down unit in the area where she wished to live. Clare did not want to return to the York area. Given her equal reluctance to return to her mother’s in Leeds, she acknowledged that her preferences reduced the options open to her. 148. The RC1 identified that an external Local Authority Social Worker would be required to enable the step down plan and eventual discharge to supported accommodation and/or return home. This led to a request for the Hospital 1 Social Work Department to facilitate the plan with the Local Authority. The NICHE report noted that there were no timescales recorded for these plans. Early discussion of a step down took place at the first CPA on the 18th January 2017 at which Clare was present, with involvement from Anne via conference call. The RC1 indicated the need for the CAMHS 2 care co-ordinator to liaise with the Community CAMHS 1, the GP and the Local Authority. This step down appeared Page 33 of 75 to be the objective of Clare’s care plan until her home leave on the 10th and 11th March 2017. 149. This changed on her return to hospital on the 12th March 2017, when she was discovered on the ward with vodka in a coca cola bottle. This in part led to a suspension of step down. The following week was a sustained period of cumulative and escalating risk, evidenced by her low mood, the finding of a suicide note, conversations with support workers around suicidal intent, ongoing difficulties with her mother, the news that her grandparents could not take her, her mother’s expressed concerns for her safety and Hospital 1 decision to suspend step down. Events from the 10th-19th March 2017 leading up to Clare’s self-ligature and death 150. Whilst Clare was on Section 17 home leave on the 10th & 11th March 2017, Hospital 1 staff found a suicide note in her room on the 11th March at 03:00 stating: ‘F**k you all, I’ll just do it……. f**k you all, I will, just you wait’. The letter was not specific about when Clare intended to take her life, although on her return to Hospital 1 she told staff she would have attempted to end her life if the opportunity had arisen during her home visit. 151. The letter caused concern for Clare’s two support workers who reported it to the nurse in charge who contacted the doctor on call for advice. The support workers wanted someone to check on Clare. Given it was 03:00 the doctor advised to document the letter in her case notes and hand it over in the morning to the day staff, who would contact Clare at home and ascertain her wellbeing. 152. Anne was contacted later that morning. It is recorded that Clare had been in a positive mood, that they had made dinner together and watched some films on the previous evening and were planning to go out for the day. The suicide note was not discussed with Anne because it was felt not to be the right timing. She was therefore not warned about the issues Hospital 1 staff considered were of concern. 153. On Clare’s return on the 12th March 2017 she was searched by staff who made no mention of a dressing gown cord being seen or found during that search. It is believed Clare was given the dressing gown as a gift following home leave. Items thought to have been a ligature risk were restricted by the hospital. There was no indication from the police investigation that a dressing gown cord was, as it should have been, on the hospital’s list of ligature risk items49. Clare was overheard that evening telling another patient that there were no razors around when she was on home leave but if there had been she would have used them. 154. Later that night she was found by staff with the coca cola bottle containing vodka. She was observed to be giggling and slurring her words. She had to be restrained in order for staff to retrieve the bottle and to prevent her from self-harming as she had started to bang her head against the wall. Her room was searched again and all risk items (save, 49 The police investigation was not able to produce the list as it was not seized initially with subsequent requests having found it was not available. Page 34 of 75 crucially, the dressing gown cord) were removed on the 14th March 2017. A datix incident form50 was completed. 155. On the 13th March 2017, during a one to one conversation with Clare and support worker 1 about the note she had left on her bed, she said ‘that she had written it because she had generally meant it.’ She implied there was another note she had written for staff, which could be found by them in the event that she did not return. Clare told Support Worker 1 she had given up and if the right opportunity had arisen when on leave she would have ended her life, but her mother was a light sleeper which meant she could not do anything whilst at home. 156. On the 14th March 2017 Clare was noted to be in a low mood and seemed to have stopped eating and drinking. She told Support Worker 2 that she had spoken earlier that day to her mother on the phone which had been a difficult conversation. Anne followed this up by phoning the ward to raise her concerns about Clare’s behaviours and presentation. 157. In light of Clare’s deterioration, a STAR51 risk assessment was carried out on the 14th March 2017, jointly by the RC1, the staff nurse, the clinical team leader and the ward manager. The risk assessment concluded that: She remained at current risk of self-harm and that she had done so in the past; She had been a suicide risk in the past; She had self-neglected in the past and that these risks had remained; She had been at risk of self-cutting and ligaturing in the past and was currently at risk of head banging; She had been at risk of overdosing in the past. 158. None of the columns identified the severity or frequency of various hazards. None had been marked (1-5), except for ‘Jumping in front of vehicles’, which was recorded as 5 (severity) and 1 (frequency). The risk assessment documented that, ‘Clare appears to self-harm impulsively without pattern, unknown if risk increased but staff have noticed low moods, particularly after leave’. The responsible clinician (RC1) told Clare that in light of recent events the proposed move to a Step down less secure environment was being suspended. 159. Of significance, in the light of the nature of Clare’s death, the NICHE report noted that there was a ‘Medium’ grading risk recorded for suicide, with ligature use identified as a risk prior to admission to Hospital 1, having previously occurred at Hospital 2. 160. The identified mitigating factors that could lessen the risk of suicide were: staff support and good therapeutic relationships, positive peer relationships, psychology sessions, restriction of potential risk items, detention under Section 3 Mental Health Act, 1983 and 50 Datix is a patient safety software product used in the NHS for recording incidents. 51 Salford Tool Assessment of Risk. Page 35 of 75 a safe and secure placement. There was no mention of increasing the observation levels or consideration of ligature use as a potential risk. 161. On the 15th March 2017, during a session with support worker 1, Clare said that she could not pretend to be okay any more when she felt so low. Clare reported that her home leave had been ‘rubbish’ because her mother was careful with what she left around the house and was a light sleeper. If she had tried to get out of the house her mother would have noticed. On being asked how she got on with her mother, Clare said that ‘she was not her mother.’ On further questioning Clare said that ‘Her mother had played a part in what had happened to her in earlier life but there was more than one reason’52. 162. Clare told Support Worker 1 that although she did want to talk to someone about the reasons for ending her life, she was reluctant to do so as she would want that person to stick with her and not leave. She felt staff on the unit could not give her that support. Support Worker 1 asked her to think about speaking to someone with whom she felt most comfortable with. Clare said she would think about it but was pretty sure her mind was already made up. 163. Clare had asked her grandmother if she could live with her but this was declined on the grounds that her grandfather’s health was not good – a response which Clare saw as another rejection. She took the news badly and was reportedly upset. She said that she wanted a mother figure to care for her. Even though she was 17 years old she felt unable to look after herself because she felt too ‘shit’. 164. The Care Planning Assessment (CPA) meeting of the 16th March 2017 included Clare’s mother and the care co-ordinator from CAMHS 2, both via conference call. Clare refused to attend as she was upset at the decision to stop future Section 17 Home leave and the move to a Step Down. The NHS England Case Manager had not been invited and had not participated in any of the previous CPA meetings. It was understood that Clare did not want to return to her mother’s straight away and would eventually need a supportive placement somewhere in North or West Yorkshire. The step down, assuming it was to happen given recent concerns, would involve transfer to a unit at the hospital to prepare for discharge. The 16th March 2017 CPA noted that some progress had been made since the last CPA that included periods of more settled behaviour. On reflection Patrick and Sue felt that there was a lack of consultation and communication around the proposed step down process. 165. A team handover briefing took place at 20:30 on the 18th March 2017 to cover the weekend and bank holiday. In compliance with the agreed staffing model at Hospital 1 and identified patient needs (see paragraphs 3.123 to 3.164 of NICHE report) there were eleven nurses on duty on the ward, comprising of one registered (agency) nurse and ten support workers. The agency nurse was also the Designated Nurse in Charge of the ward night shift of the 18th March 2017. 52 NICHE report, paragraph 3.207 Page 36 of 75 166. The Designated Nurse in Charge had previously worked at Hospital 1 on both day and night duty and had received an induction. This consisted of being shown the staff handbook, fire exit locations, medication times and familiarising himself with the patients. Of significance, the Nurse in Charge role, according to the CAMHS safe and consistent staffing policy, placed responsibility and accountability for the decision to delegate supportive observation to other staff members, in this case Support Worker 4; and for ensuring that staff were sufficiently competent and knowledgeable to carry out the task. The Clinical Team Leader (CTL1) was also present at the handover meeting. It was their first shift following a period of leave. 167. The NICHE report noted that three members of the night shift on the ward had accompanied a patient for admission to a general hospital. One patient was on 2:1 observation with another on 1:1. Clare was on a Level 2 observation, namely every fifteen minutes. The shift planner detailed that nurses were allocated to Level 2 observations every hour between 20:30 on the 18th March to 08:30 the following day (i.e. over a 12 hour shift). It was hospital policy to have hourly change of allocation in order to avoid staff strain and to maintain levels of attention. 168. According to the National Institute for Clinical Excellence (NICE) guidelines (2005); Principles of Supportive Observations53 , ‘It is the nurse in charge of the unit who is to take responsibility to ensure visits are accrued out by the nomination of people commensurate with their skills. They should be familiar with the patient’s history, risk factors, background and be aware of the unit, its policies and environmental risks. They should be familiar with significant events since the patient’s admission, the care plan and initiate one to one interaction particularly where the patient is uncommunicative’. 169. Notwithstanding staffing demands of the shift, the NICHE report concluded at paragraph 3 (163) that ‘The systems in place for safe staffing are adequate, there were no concerns about the competency of their staff and staffing issues did not impact adversely on Clare’s care and treatment’. 170. Crucially, both the Clinical Team Leader and the Nurse in Charge were unaware of current concerns and escalation of risk regarding Clare that had emerged during the previous week. Neither was briefed on these concerns at the handover meeting. The Nurse in Charge told the NICHE enquirers that he had been informed at handover that Clare was on a Level 2 observation due to risk of self-harm. Of great significance and concern was that no information was passed on about her active suicidal thoughts, plans and intentions. It is not known why this had not occurred, given it was very important information which could have improved staff vigilance and risk management during the shift, especially in regard to observations. In the event, Clare was understood to have presented as ‘Medium’ risk, in line with prevailing assessments and plans. 171. She was found at 01:57 on the 19th March 2017 in her room with a dressing gown cord tied around her neck as a non-suspended ligature. The ligature was cut, emergency services called for and Clare was taken by ambulance to the Hospital 6 where she was 53 NICE guidelines (2005) in dealing with disturbed and violent patients in A and E and psychiatric units Page 37 of 75 pronounced dead at 04:18 on the same day. The post mortem recorded the cause of death as hypoxic ischaemic brain injury and ligature compression of the neck. Discussion Care Delivery Problem 1 172. The NICHE investigation identified two key care delivery problems underpinning the circumstances surrounding Clare’s death. The first identified that: ‘Clare was not observed on nine occasions between 20:30 and 01:57 on the 18th and 19th March 2017 within the specified 15 minutes as per the Hospital 1 local protocol for Level 2 intermittent observations, with the biggest gap being 57 minutes between 01:00 and 01:57’54. 173. Given the importance of Level 2 observations at 15 minute intervals it is not known why this did not happen. It is clear the Nurse in Charge had the responsibility to ensure Clare was seen at intervals of no longer than 15 minutes. Support Worker 2 had spoken to Clare earlier in the shift and subsequently mentioned to the Nurse in Charge at 01:29 that she had talked of ‘going under the covers and killing herself as staff did not check.’ CCTV evidence from Hospital 1 showed 58 minutes had passed since Clare’s last checked by staff. At least three or four visits were missed before the final check took place at 01:57. The Police enquiry indicated that the Nurse in Charge had signed the observation sheets to show all checks had been made. However, CCTV evidence in possession of Police 1 proves this not to be the case55. Poor practice at handover, and the fact that the realities of missed 15-minute checks required on Clare’s care plan do not match the records signed by the Nurse in Charge as if they had in fact taken place, are matters of grave concern to this review. However, the ongoing police enquiry56 has prevented the lead reviewer speaking to the Nurse in Charge and other Hospital 1 staff to find out why the agreed protocol was not followed. 174. The NICHE investigation identified several contributory factors that precipitated Clare’s death. Firstly, there was a discrepancy between the Huntercombe Group Supportive Observation Policy and the local Hospital 1 policy in use at the time. The former document itself out of date and in need of review, stated that ‘observations should be carried out for example, at 5 minute, 10 minute, but not exceeding 30 minute intervals’. The local protocol set out a requirement of observations at least five times in a one-hour period, undertaken at random intervals, 10 to 15 minutes apart but with never more than 15 minutes between checks. 175. Staff, and the hospital’s custom and practice at the time57 meant that nurses understood Level 2 intermittent observations to be every 15 minutes. This was the level of checking to which Clare was subject to. Both the Groups Policy and the local Hospital 54 (Niche report, September 2017, page 8) 55 This may have been after the event and is the subject of the Police inquiry. See Police report, page 10 and NICHE paragraph 3.226/3.227 and page 17. 56 Currently being conducted by Police 1. 57 The local protocol was reportedly revised on 14 June 2017. Page 38 of 75 1 Protocol stated that ‘the timing and interval should be explicit in the care plan, risk assessment and reviews’. The NICHE report found that the exact timing required for intermittent observations of Clare was not explicitly stated in her health and wellbeing or risk care plan. This was a significant gap in Clare’s care and a breach of practice guidelines both within this setting and across the Group. This is a matter of serious concern. 176. As previously noted, CCTV evidence of the 18th & 19th March 2017 indicated that there were nine occasions between 20:30 and 01:57 when Clare was not observed as per the local protocol. The longest gap was 57 minutes between 01:00 and 01:57. The intervals of over 15 minutes between checks were 20, 26, 30, 20, 20, 23, 27, 33 and 57 minutes. In compliance with the local Hospital 1 Observation Policy, there should have been 28 checks over the 12-hour shift. Only 14 were completed. Again, this is a matter for serious concern. 177. A significant finding by the NICHE report was that the Supportive Observation Policy template for intermittent observations did not allow for the exact time of the observations to be recorded. This meant there was no accurate, timed, written record of observation intervals for Clare on the night shift of the 18th and 19th March 2017. Moreover, there was a discrepancy between the record of engagement form and the template shift planner. The former had pre-set observation intervals of 15 minutes for every hour starting on the hour. This did not correspond with the latter, which had pre-set times for allocating staff to observation gaps of 15 minutes across every hour, starting on the half hour. 178. The NICHE report at paragraph 1.44 noted that ‘The combination of the differences in the Groups and Hospital 1 Norfolk supportive policy and local protocol, plus the template for intermittent observations not allowing for the exact time of the intermittent observations undertaken to be recorded, and the lack of correlation between the pre-set observations levels and the shift planner pre-set times of allocating staff to observations may have allowed for human error to occur. The agency nurse-in-charge allocated to observing Clare between the hours of 00:30 and 01:30 told us, and recorded, that he had last observed Clare at 1.30 a.m. However, CCTV indicated that he had last observed her at 1.00 a.m.’ 179. This led to false assumptions by Support Worker 4 who took over the allocated observations for Clare at 01:44, that the interval for the last observation had been 14 minutes rather than the actual time of 44 minutes. Support Worker 4 undertook the last observation at 01:57 on the assumption that Clare had last been observed at 01:30, some 27 minutes previously, when in fact it was 57 minutes since the last observation. Even if it had been 14 minutes, according to the local Hospital 1 Protocol there should have been a check no longer than 15 minutes after. This both begs the question of why this did not happen, and must lead to questions about whether the outcome for Clare could have been different had observations been both better and more frequently carried out, and recorded as they should have been. Page 39 of 75 Care Delivery Problem 2 180. The NICHE report identified that ‘There was no evidence of a comprehensive multi-disciplinary review of risk or aligning risk assessment and management of levels of observations for Clare. This meant that Clare remained on Level two intermittent observations. The exact timing of the intermittent observations for Clare were not explicitly stated in her health and well-being or risk care plan, neither were they recorded as being discussed in the ward round or CPA minutes of the 16th March 2017, despite an apparent cumulative and escalating risk following her return from leave on the 12 March 2017’58. Discussion 181. By way of contributory factors, the following were identified. 182. The CPA of the 16th March 2017 was a key opportunity to review the care plan and update the risk assessment. This opportunity was missed. Moreover, there should have been some consideration of firstly, whether in light of Clare’s recent deterioration, a change of intermittent observation levels was warranted; and secondly, what the appropriate actions should be to support the eventual aim of discharging Clare back into the community. Neither discussion took place. 183. The NICHE report noted that communication between multi-disciplinary team members responsible for Clare’s care was not effective. This resulted in the reports submitted to the CPA meeting on the 16th March containing no detailed up to date risk information regarding her discussions with Support Workers 1 and 2 between the 13th – 15th March 2017, which included very significant information about both her emotional state and suicidal intent. Moreover, the risk assessment did not include consideration of her previous eight self-harm episodes. 184. As noted by the NICHE report, the Groups Risk Assessment Policy59 should have been, but was not, based on Department of Health frameworks for best practice in managing risk. Additionally, the nursing report for the CPA was completed on the 2nd March 2017 and did not contain up to date information, or crucial commentary, on Clare’s home leave, simply stating that ‘She has accessed unescorted leave back home which she has used appropriately’. This lack of commentary represents a further missed opportunity. 185. In addition, there was no evidence of a formal psychiatric mental health assessment being undertaken at Hospital 1 with Clare, in response to the hospital’s knowledge of her suicidal intent on return from home leave. The NICHE investigator’s view was that this was ‘Essential in the light of her deteriorating mood and increase in risk issues. Had this been done it could have contributed to the discussions on risk at the CPA meeting’60. Use of Ligatures 58 Paragraph 1.47 59 It was due for review in September 2016 60 Albeit that the NICHE report notes that it could not say with certainty that a mental state examination would have made a material difference to the outcome because of Clare’s unwillingness to discuss her mental state. Page 40 of 75 186. An important finding of the NICHE report was that there was a lack of clarity regarding Clare’s risk history in relation to her use of ligatures whilst at Hospital 2. None of the staff interviewed seemed to know that there was a known history of the use of ligatures, despite it being identified as a past risk in the self-harm and suicide risk assessment on the 13th January 2017. Clare’s use of ligatures had not been recognised as a possible contemporaneous element of potential risk by the time of the 16th March 2017 CPA meeting. It is not known why such a fundamental gap in knowledge existed. In the opinion of this SCR lead reviewer such a gap should not have been present. Clare’s previous use of ligatures and the not uncommon occurrence of ligation at Hospital 1 ’should have indicated that self-ligature may have been a method of choice’61, for her, as tragically was the case. Ligature incidents at Hospital 1 were running at 2.5 per day and 1.8 per night being the commonest means of self-harm62. Compounding this issue was the lack of recognition of the potential risks of ligature use. The NICHE report found, after reviewing nursing records, that risky items had been locked away on the evening of the 16th March 2017, but that the dressing gown cord had not. The Groups Policy document on Rescue from ligature and use of ligature cutters does not explicitly include dressing gown cords in its list of restrictive items. The CPA Meeting of the 16th March 2017 Discussion 187. The minutes from the CPA meeting held on the 16th March 2017 do not record any discussion about the risks and concerns regarding the level of observation to which Clare was to be subjected. The NICHE report noted that the responsible clinician indicated in an interview that this was discussed in the meeting and a team agreement was made for Clare to remain on Level 2 intermittent observations. Given previously mentioned professional concerns for Clare after home leave, it must be questioned as to whether there was a realistic and accurate assessment of the risk level in regard to her situation in the week prior to her death. In particular, it must be asked whether the decision for her to remain on Level 2 intermittent (15 minute) observation a reasonable one in all the circumstances. That the routine involved was then not followed is also, clearly, at issue, given gaps of almost an hour between observations were recorded by the CCTV system at Hospital 1. 188. The NICHE report indicates at paragraph 1.51 that all staff were aware of an increase in Clare’s risk profile. It remains debateable as to whether the full range of risks, including Clare’s sessions between the 13th – 15th March 2017 with Support Workers 1 and 2, were sufficiently taken into consideration by the STAR risk assessment on the 14th March, 2017 which graded Clare as ‘Medium’ risk of suicide, and the CPA meeting of the 16th March 2017. It would certainly have been helpful for the two support workers to have been at the CPA meeting to report on their sessions with Clare, or alternatively for a written 61 (see paragraph 1.61 of NICHE report), 62 See Niche report at paragraph 3.118 Page 41 of 75 report by them to have been presented. Neither happened, representing a further missed opportunity to join up professional practice in support of Clare. 189. The NICHE report identified no evidence of a comprehensive multi-disciplinary review of risk, or of aligning risk assessment and management plans for Clare with levels of observation. It states that had this been done it ‘Might have led to a different outcome’ and that ‘Although Clare’s risks were compounded by her unwillingness or inability to engage in any form of treatment, we believe that there were opportunities to intervene in terms of reviewing and increasing Clare’s observation levels’63. 190. Regarding observation levels and risk management, the NICHE report noted that Clare’s risk plans to manage and reduce her self-harm did not contain either specifics of levels of observation to be applied, or evidence that these levels or risks were consistently reviewed or updated following incidents. There was no evidence of discussions of reviews of supportive observations in clinical records. Moreover, at Hospital 1 there were separate care plans for Clare’s health, wellbeing and risks; none of which were integrated into an overall care plan. Health and wellbeing were not joined up with assessment and management of risk, presenting gaps through which Clare could, and in the end did, fall. 191. The investigators concluded that, ‘Without the agreement, the observation intervals and the rationale aligned with the escalating risk being recorded, it is difficult to consider whether the decision for Clare to remain on Level 2 intermittent observations was reasonable’64. 192. The NICHE report concluded that: ‘In our view this (CPA meeting) was a missed opportunity to review the care plan and observation levels aligned with the risk. A decision to increase the level of observation65 could potentially have protected Clare until she was more settled. However, we are aware that increasing observations to a one-to-one observation level is very intrusive and believe that this is a balanced decision that can only be made by the team at the time to ensure that the risk management plan is consistent with the long-term treatment strategy’66. This SCR concurs with this conclusion. CQC Inspection of Hospital 1, Norfolk-2017 193. The CQC inspection on the 13th and 14th March 201767 gave an overall rating to Hospital 1 of ‘Requires Improvement’ and under the category of ‘Are child and adolescent mental health wards safe?’ an ‘inadequate’, judgement. It identified many of the shortcomings in practice and policy highlighted in the NICHE report, and found by this review in Clare’s case. These shortcomings included: the review of supportive observations, wards left 63 (page 10, paragraph 1.50) 64 (page 34, paragraph 3.74) 65 To level 3, one-to one, observation for a period of time, as stated at page 35, paragraph 3.75 of NICHE report. 66 (page 11, paragraph 1.57) 67 Published on the 19.05.17 Page 42 of 75 with no registered nurse for a short period, deficiencies in risk management, staff not consistently reviewing and updating care plans following risk incidents, care plans not reflecting multi-disciplinary team goals, staff not being aware of ligature audits or environmental risk areas for each ward, a vacancy rate of 51% for registered nurses across the site and 23% for support workers, mitigated by the use of agency staff and out of date policies ( e.g. supportive observations). The hospital was required to take improvement action by the 31st August 2017 but was closed down by the Group in December 2017. 194. Given this section of the SCR has been extensively informed by the NICHE Report and the case summary of the Police 1, it makes no commentary on any additional findings or lessons learned from those set out at pages 12-13 of the NICHE report (see appendix 2i of this report). The seven recommendations made by NICHE (see appendix 2ii of this report) also serve as those from this SCR to the Group. Multi-Agency working Discussion 195. There was minimal evidence of multi-agency working between Hospital 1 and any external agencies. Both the NHS England case managers and CAMHS 2 care co-ordinators had little or no involvement with either Clare or her parents despite both having important roles in overseeing her care and maintaining regular contact. The CAMHS 2 care co-ordinator did not see Clare whilst she was at Hospital 1 and her direct participation at meetings was limited, albeit she did receive regular reports. More involvement could have provided a stronger and more proactive link with Clare’s parents and local agencies (GP, CAMHS and both Local Authorities) particularly in regard to the proposed post discharge planning. The appropriate Local Authority should also have been notified of Clare’s placement at Hospital 1, in compliance with Section 85 of the Children Act, 1989. This did not occur. 196. The CAMHS 2 report noted that there were no policies and procedures in place at the time concerning the role of the care co-ordinator in regard to young people placed out of area. Self-evidently there needs to be clear guidance provided by the Trust regarding the roles, responsibilities and remit of the care co-ordinator in relation to children and young people placed at out of area CAMHS 2 facilities. 197. NHS England was not involved whilst Clare was at the hospital. This is regrettable and a cause for concern, given its attendance at the March 2017 CPA, ‘Would have provided a wider representation of professionals that had involvement in Clare’s case, in order that her needs were examined, understood and addressed when deciding her future pathway’68. 68 (NHSE agency report, p.14) Page 43 of 75 TOR 3 - How well were the voices of Clare and her parents heard and included in the Assessment, Planning, Intervention and Review (APIR) process? Was the process sufficiently child focused, if not, why not? Leeds Agencies 198. There was a mixed record of Clare and her parent’s views being heard and included in decision making and actions then being taken by the three Leeds agencies69. The GP spoke to Clare and Anne in late January 2014 following an episode of self-harming. However, prior to the referral to CAMHS 1 in early February 2014, there was no recorded evidence of Clare having had a conversation on her own with the GP about her wishes, feelings and views on the options available to help her. Such a discussion was her right, and should have taken place. 199. On the several occasions when she was seen by various GPs in 2014 to address physical ailments, professionals did not ask about her emotional health or wellbeing. Given her history of self-harm and involvement with CAMHS 1 it should have been expected that exploration of her emotional wellbeing would have happened. Anne told the lead reviewer that Clare felt that the GP ‘Laughed it off’ and that she ‘Wasn’t taken seriously’, in the early part of 2014. Clare presented well and according to Anne, the GP believed that Clare was ‘Ok and put it down to being a teenager’. Anne said that Clare found it hard to express her feelings and to communicate with others. 200. However, Clare did speak to her GP in April 2015 and disclosed that she did not find her previous experience with CAMHS 1 helpful. Anne said the weekly one-hour family therapy sessions were not enough and that Clare felt they were ineffective. As a working professional it was sometimes difficult for Anne to get time off in the week to attend the sessions and she felt home sessions might have been more useful. 201. CAMHS 1 stated in their report prepared for this SCR that there was evidence of both Clare and her parent’s views being heard and included in assessment, planning and review. Any changes in therapeutic interventions were based on family reports, with Anne making most of the contact with the therapist and Clare’s level of engagement being, ‘ambivalent’. 202. Clare’s Accident and Emergency admission to Hospital 3 in July 2014 did not involve Clare being seen on her own, but always with her mother. The Leeds Teaching Hospital agency report noted that there was a missed opportunity for Clare to have spoken with a doctor on her own, especially given the context of her self-harm, suicidal ideation, low mood and anxiety. There was a tendency at the time to rely on CAMHS 1 to do this work. Action has since been taken by CAMHS 1 to upskill appropriate staff with a bespoke training package that seeks to encourage discussion with adolescents about their wider emotional and mental health issues. 69 Clinical Commissioning Group 1, CAMHS 1, Hospital 3 Page 44 of 75 The Schools 207. Although there was discussion between Clare, her parents and both schools about her behaviour, motivation and educational development, there was no evidence of dialogue regarding her emotional wellbeing and mental health needs in either setting. Previous mention is made in this report regarding Anne’s account that she had spoken to School 1 immediately after Clare’s first self-harming episode in July. The school in her view did not take the incident seriously. Anne also said that she shared with School 1 the CAMHS involvement. Additionally and as already reported, School 2 did not contact Anne about Clare at the point of transfer, despite Anne having legal parental responsibility. North Yorkshire Agencies 203. Clare and Anne were seen by the Specialist Public Health Nurse in July 2014 following the overdose and A & E admission to Hospital 3. The agency report states that Clare was given an opportunity to be heard by a different professional as she was involved with CAMHS 1 at the time, and was provided with links to other agencies that could have offered an alternative approach. 204. Clare’s initial contact with Police 2 in July 2015 resulted in her being spoken to by an Officer and providing some background information. The Police facilitated Clare in speaking to her mother in accordance with her wishes. Anne and Patrick were spoken to for background information which was recorded on Police systems for future reference. On the second occasion in November 2015 Clare did not engage with the attending police officer and Patrick was informed that she had been located. Clare agreed to attend Hospital 4 with Patrick and Sue. 205. Hospital 4’s report stated that Clare’s voice was heard on admission and staff acted in accordance with her stated wishes. However, it was difficult to conclude with any certainty whether her voice was heard consistently. Clare was described as quiet with poor eye contact. There was no written record of any reference to her mother. 206. The in-patient CAMHS 1 involved Clare, Anne, Patrick and Sue. It was not documented whether Clare was seen on her own, or was able to speak freely. The agency reported that both Clare and her parents as actively involved in decision making and planning about the option of an in-patient admission for treatment to address her self-harming and suicidal ideation. 207. CAMHS 2 states in its report for this SCR that the voices of Clare, Anne and Patrick were heard during the assessments conducted by the Trust prior to admission in November 2015. The options of in-patient and community care were explained by the care co-ordinator. Patrick and Sue commented in an interview with the SCR Chair that the care co-ordinator’s input was ‘useful’. They said that she had communicated with them very well in an inclusive manner and had provided objective advice and support. They said that for the first time it seemed that they had been listened to and that someone wanted to help them. After considering the available options for Clare, the family concluded that Page 45 of 75 a four-week local in-patient assessment admission was in her best interests. It was unfortunate that having made the decision, a local bed was not available, for reasons already given. The care co-ordinator located an out of area bed at the Hospital 2. It was not clear from the CAMHS 2 records as to how much discussion took place with Clare and her parents about this. Clare’s mother told the lead reviewer that she was still unsure how a bed was originally offered in York but that Clare ended up in Sheffield. Hospital 2 208. Hospital 2 state that there was generally good communication with Anne, Patrick and Sue who were reportedly invited to attend ward rounds and CPA meetings and provided with updates following incidents. Conversely, Patrick and Sue’s view was that ‘communication with staff was very poor’. High staff turnover meant that they never saw the same consultant twice, which they say was a major factor in poor communication. They cited an example of attending a CPA meeting where they met a consultant who was very helpful by suggesting that the family communicate directly with him. However, two weeks later he had moved positions and they did not see him again. 209. Patrick and Sue maintained that Clare did not have a key worker and felt it was ‘Impossible to get through to the ward via telephone to speak with Clare’. They believed difficulties in contacting Clare made it problematic to stay in touch with her. Hospital 2 admits that there were some occasions when the parents were not invited to meetings. Patrick and Sue have reflected that there was a lack of consistent communication with parents who hold legal parental responsibility. The parents made two sets of complaints which were upheld. 210. Concerning Clare, Hospital 2 state health records evidence her inclusion in discussions and plans about her care and treatment (albeit she did not always engage in them). She was encouraged to participate in the process but only signed a couple of care plans. She did not attend ward rounds although the hospital states that ‘her thoughts were obtained beforehand and the outcomes were relayed back to her’, albeit that there were sometimes delays. The hospital acknowledged that there was a need for more timely and consistent feedback from the ward rounds. 211. Patrick maintained that his daughter had only attended one CPA and that staff did not explain their roles or the purpose of the meeting. He felt that ‘she was not included in decision making’. He also thought that ‘the CPA meetings were ineffectual’ and at one meeting he noted that none of the staff introduced themselves. Apparently, there was a high staff turnover thus making it difficult for him and Sue to understand what the professional roles were. There was ‘lots of talking at us’. The parents did not have sight of meeting minutes in a timely way, often getting them handed out after the meeting and none were received at all when they were unable to attend, despite Clare being the subject of the meetings concerned. 212. Hospital 2 state that Clare was regularly offered advocacy which she declined. She had her legal rights read and recorded monthly although there were four times when this was Page 46 of 75 not done. She was also legally represented during a Mental Health Act 1983 tribunal process. 213. It is not known how far Clare and her parents were involved in the decision for her to leave Hospital 2 and move to Hospital 1. Anne maintains that it was minimal. 214. Regarding Clare’s admissions to the Hospital 5, the trust states that recording shows ‘Clare’s wishes and views were respected regarding both her acceptance and refusal of care’. Given that she was 16 years old all decisions regarding her physical care would have been discussed with her. Any contact or sharing of information with her parents-there was none-would have only been completed with Clare’s informed consent. However, in this case no contact or information was shared with her parents. Norfolk-Hospital 1 215. Given the distance involved between North/West Yorkshire and Norfolk, communication between Hospital 1 and the parents was problematic. Anne was able to take part in the two CPA meetings via conference call. There was no known contact with Patrick and Sue. According to Patrick, neither he nor Anne wanted Clare to be moved, despite the previous incidents, as they believed that any change would be disruptive for her. They perceived that Clare was seeking to move back to a non-secure ward on a voluntary non-section basis. It is not known how far Patrick and Sue participated in the decision to move their daughter to Hospital 1. Indeed, they only became aware of the move on receipt of a, ‘Welcome Pack’ from the hospital. That said, Anne told the lead reviewer that her daughter seemed more settled at Hospital 1 and appeared to be relatively positive about her situation. 216. The NICHE report at paragraph 3.112 notes that ‘there seemed to be little active attempt to engage with the parents, (indeed, there is no record of any contact with Clare’s father at all), with no documented face to face clinical meetings or any reference to a need for them’. Parental involvement appeared minimal save for Anne’s involvement at the two CPA meetings via conference call. There was no evidence that she had been signposted to the appropriate local authority (Leeds) for a carer’s assessment or evidence that the NICE70 guidance had been followed in providing help on the management of self-harm during Clare’s Section 17 Home Leave. Patrick had no contact with his daughter for over a year which the authors of the NICHE report found concerning. The SCR would concur with this view. Discussion 217. The lack of family involvement was a critical and at times a deeply concerning and negative issue in the care and treatment of Clare. As referenced by the NICHE report: ‘The role of the family in the treatment of young people with borderline personality disorder is critical to consider. Issues with the family, both past and present, are likely to be highly relevant to the development or maintenance (or both) of the young person’s 70 See NICE guidance on self-harm in the over 8s-long term management (2009). Page 47 of 75 problems’71. As noted by the NICHE report: ‘Family involvement was essential and not an ‘Add on’, given the reported nature of the difficulties. Albeit that the family may have declined invitations or that Clare may have refused to meet with them, but this is not documented’. This SCR would strongly agree with the above views. ToR 5 - Why was compulsory intervention under the MHA 1983 and Out of Area placements necessary? 25 November 2015 - Informal Admission to Hospital 2, Sheffield 218. The rationale and reasons for Clare’s admission to Hospital 2 have been set out and analysed above at paragraphs 82-83. 8 January 2016 - Hospital 2, Sheffield: Section 2 Mental Health Act, 1983 219. This episode marked the start of Clare’s patient experience as a young person compulsorily detained under the Mental Health Act, 1983 in a Tier 4 setting. She was placed under Section 2 of the Act because of her escalating self-harming behaviour which the hospital deemed could not be managed within her status as an informal patient. This allowed for a 28-day assessment to be undertaken. (See above at paragraphs 92-92 for more detail) 3rd February 2016 - Hospital 2, Sheffield: Section 3 Mental Health Act: 1983 220. Clare’s self-harm and suicide ideation continued to escalate to the point where the Hospital 2 multi-disciplinary team felt that the attendant risks could not be managed on a general adolescent ward. In consultation with the NHS England case manager, Clare was made the subject of a Section 372 on the 3rd February 2016 and transferred to the Haven ward (a PICU) on the 5th February 2016. (See paragraph 106) Transfer to Hospital 1, Norfolk: Low Secure Unit 221. By the summer of 2016, little progress had been made by the Haven ward in addressing Clare’s need and managing the increasing risks. A stale mate position was reached73. In conjunction with the CAMHS 2 care co-ordinator and the NHS England case manager, the multi-disciplinary team at Hospital 2, on the 7th July 2016, assessed that a transfer to a Low Secure Unit (LSU) was deemed necessary and proportionate. This was compliant with the least restrictive option principle in order to better manage Clare’s risks and seek to address her underlying problems through treatment over a longer term. 222. Two mental health tribunals were held in July and October 2016 which upheld her Section 3 status. 223. Despite a search by NHS England for a local secure unit none could be found in the Yorkshire region or the North East/West region of England. A suitable placement was 71 (NICE guidance on borderline personality disorder, 2009). 72 detained for up to 6 months 73 see paragraph 140 Page 48 of 75 eventually found at Hospital 1 in Norfolk on the 6th December 2016, some 200 miles or so from her home. Lack of available bed capacity within the entire Northern region prevented Clare’s admission being closer to home. Best practice indicates that she may have been better served had she been placed in a local secure unit as close to home as possible for reasons already mentioned. On this occasion such a close placement was not possible. 224. The shortage of Tier 4 local secure unit places nationally has been well documented (Frith, July 2017)74. Such problems are exacerbated by the speciality, age factors and a geographical disparity in the distribution of beds. The Royal College of Psychiatrists has proposed a proxy measure of appropriate bed numbers as between 2 and 4 beds per 100,000 of the population75. The average for England is 2.5 (at the lower end of the range) with the number for Yorkshire and Humber being 1.6 per 100,00076, the second lowest in England after the South West at 1.1 per 100,00077. 225. A 2014 NHSE Review of CAMHS Tier 478 capacity concluded that, ‘The overarching aim should be that all children and young people in England are able to access age-appropriate services as close as possible to where they live. Some of these services may be at a greater distance from home because of their specialised nature (sub-speciality) but they should nonetheless still be accessible through having a defined catchment area’. 226. This SCR agrees strongly with this statement, given that Clare’s case illustrates it starkly, as reflected in this report. Current Developments with NHS England, Yorkshire and Humber Region 227. In 201479 the NHS England National CAMHS Review identified insufficient Tier 4 in-patient CAMHS beds in the Yorkshire and Humber region. Some immediate steps were taken to increase capacity. A Mental Health Programme Board is presently leading the process and a service review is being locally directed and driven so services can come to meet the needs of the local population. There are plans in place to work with providers to ensure sufficient capacity for in-patient services in the Yorkshire and Humber region. This will increase the capacity of Local Secure Unit beds in the North of England and mean Yorkshire and Humber will have its own Local Secure Units service. 228. Over the past two years significant work has been undertaken describing the context of the CAMHS Care Pathway, including the inpatient aspect but focussing more importantly and clearly on local and community provision. Publication of the CAMHS Tier 4 Report (2014) and Future in Mind (2015) have led to the development of local 74 See Frith. E, ‘Inpatient Provision for Children and Young People with Mental Health Problems’, (July 2017), Education Policy Institute. 75 See Frith (2017,7, note 7) 76 Data provided in House of Commons written answer. 9 February 2016 in Frith (2017,17) 77 The North East has the highest at 3.0/100,000. 78 Quote from the NHSE report for this SCR. 79 See the NHSE report provided for this SCR. Page 49 of 75 transformation plans in each locality, which articulate how local pathways will work more effectively. 229. NHS England indicates that this future provision for Yorkshire and Humber is based on NHS England’s National CAMHS Tier 4 need and capacity exercise. This supports taking forward key objectives and recommendations in relevant mental health strategy and policy. A key driver has been a lack of capacity in some areas, which has led to out of area placements. The proposed changes in bed numbers aims to address this and ensure that services will include having the right number of General Adolescent Units (GAU) beds and Psychiatric Intensive Care Unit (PICU) beds available to meet demand in each area. As these services are specialist, there is a national oversight of this process, but with a strong emphasis on local engagement. The Yorkshire and Humber region commenced procurement of General Adolescent and Psychiatric Intensive Care Inpatient Services ahead of national timescales. In 2017, Humber NHS Foundation Trust was successful in their bid to provide General Adolescent Service and Psychiatric Intensive Care In- patient Services. This will be a new build, and will be operational in 2019 230. NHS England is collaborating with local commissioners on CAMHS Tier 4 bed changes in the Yorkshire and Humber region to ensure interdependencies between localities which are managed effectively, for example, Psychiatric Intensive Care Inpatient Services provision in West Yorkshire and South Yorkshire. NHS England has now identified and confirmed a new commissioning model for eighteen General Adolescent beds and four Psychiatric Intensive Care In-patient beds within West Yorkshire. Part 7 - Findings, Key Lessons and Current Agency Developments since Clare’s death TORs 1/2/4 Leeds Agencies (LEEDS 0-19, Hospital 3, Clinical Commissioning Group 1) 231. Clare’s physical, emotional and mental health needs and risk issues were appropriately assessed and adequately met by the three Leeds health agencies, although there was an issue about waiting times in with CAMHS 1. Clare’s needs and risks were well met and managed by professionals during her admission at the Hospital 3 in July 2014. 232. Risk issues around potential significant self-harm were effectively considered and appropriately managed internally by CAMHS 1. There was a reasonable balance between working with and managing the risks presented by Clare, addressing her therapeutic needs and being mindful of safeguarding concerns. 233. The delay of nearly five months before the first CAMHS 1 appointment was not to Clare’s advantage. Ideally, and whilst acknowledging the demand pressures on services at the time, it would have been beneficial had she received a quicker and timelier response. 234. A key lesson and improvement action for the Clinical Commissioning Group 1 and the CAMHS 1, identified by this practice episode, is for waiting times for an initial consultation appointment with CAMHS to be within the stated target of 12 weeks, with an aspiration to Page 50 of 75 lower the target time further as resources allow. This SCR endorses the Children Commissioner’s (October 2017) recommendation at Part 2 in relation to Clinical Commissioning Group 180 and suggests that this is implemented. Current Developments with the Leeds/West Yorkshire Local Transformation Plan 235. CAMHS 1 report that over the coming months and as part of the West Yorkshire Mental Health Service Collaborative, they will be working together to improve Child and Adolescent Mental Health Services. This project called ‘New Model of Care’ launched on the 1st April 2018, means that across West Yorkshire agencies will be working together and seeking to make better use of money that pays for inpatient beds for young people. Many professionals believe better support can be offered to young people and their families in communities so as to save money by using less ‘bed days’. From the 1st April 2018, CAMHS 1 was awarded, on behalf of the region’s partners, the budget to manage the local community investment in Children’s Mental Health Services. 236. Work will continue on this new model of care with a plan to invest the money into four main elements: 24/7 care for children and young people achieved through provision of responsive crisis services. Community intensive services working extended hours. Access to non-clinical ‘safe space’ as an alternative to hospital. Care Navigators based across West Yorkshire; to act as children and young person advocates, working with professionals involved in their care. This is to develop strong local relationships and ensure local options for further support are explored before a bed is considered. 237. If a hospital bed is still required, the shared aim is for the child or young person to have the shortest length of stay possible, in a modern, fit for purpose facility. To support this, funding has also been secured to build a new facility in Leeds for children across the region. Inter-agency working and communications 238. Communication and information sharing was effective and of an expected standard in promoting Clare’s safety and welfare and supporting her mother. The agencies liaised appropriately in addressing Clare’s physical, emotional and mental health needs and monitoring her treatment. 239. A key piece of more generalised learning is for CAMHS, the GP service and all other relevant agencies to consider firstly, whether a multi-agency support approach (e.g. an Early Help or a Child in Need assessment) would benefit the child. Secondly, to consider seeking informed consent from both the child or young person (if Fraser competent) and parents to share information with third parties such as a school or a Local Authority Children’s Service. In the event of non-consent, consideration should be given to 80 See page 7/8 of the Children’s Commissioner’s report. Page 51 of 75 dispensing with it in the best interests of the child whilst bearing in mind the need for the young person to exercise control as far as possible in the decision making process, with a view if necessary to interventions at Child in Need81 or Child Protection82 levels, subject to Local Safeguarding Children Partnership threshold and vulnerability frameworks83. School 1 240. School 1 had not been informed by the GP, the School Nurse or CAMHS 1 of Clare’s emotional state, or her self-harming and suicidal ideation84. Although steps had been taken to address Clare’s educational needs through inclusion within the nurture unit, S1 was not in a position to take Clare’s emotional state, self-harming and suicidal ideation into account as a result. It was therefore unable to offer Clare appropriate pastoral support. School 2 241. The transition of Clare’s records from School 1 to School 2 fell far short of excepted and required standards. Formal records were not shared between the schools, a serious shortcoming. 242. Support made available to Clare by School 2 focussed on her academic needs around entry to Year 11. Her social emotional and mental health (SEMH) needs were not considered or assessed by School 2 due to several factors set out previously in paragraphs 63-64. The emphasis was on Clare’s responsibility for her own behaviour, rather than on an effort being made to support her to seek and address the reasons for it. A more structured and supportively pastoral approach from School 2 may have enabled more evidenced based interventions to be undertaken, with greater involvement of outside agencies. 243. There was a missed opportunity for both schools to have made enquiries with Clare’s GP, CAMHS 1 and the North Yorkshire 5-19 Healthy Child Service. Had this been done it may have been possible for School 2 to have re-assessed Clare’s wider SEMH needs in addition to her educational requirements. If necessary, consideration could have been given to making a referral to North Yorkshire Children and Families Service with a view to an Early Help or, if appropriate, a Child in Need multi-agency intervention. 244. Key learning from this episode include: A robust and formally required process for the timely exchange of written records when students transfer between schools. 81 Section 17 Children Act 1989 82 Section 47 Children Act 1989 83 For instance, the North Yorkshire Vulnerability Check list/Threshold document (see NYSCB website www.safeguardingchildren.co.uk) 84 Although a GP letter referring to Clare’s anxiety and depression was sent directly to the exam board in mitigation of her absence of the 16th April 2015 when she missed a GCSE PE assessment. The letter was not made available to the School. This is disputed by Clare’s mother. Page 52 of 75 A robust and equally formally required system of written recording of significant events, conversations and meetings with parents, students and school staff (both within and out with the school), with a record of actions taken to follow up concerns. The need for all staff to be vigilant and to share any concerns with the school’s designated safeguarding lead. All concerns must be followed up in compliance with agreed safeguarding procedures. Systematic use by schools of the ‘Compass Reach Service’ provided by North Yorkshire Healthy Child Service. A more systematic and better informed use by pastoral staff of the statutory threshold document Vulnerability Check List/ Threshold document as per Working Together 2018. A process for schools to support early identification of pupil’s SEMH needs. The development of a school Self-harm and Suicide Prevention Policy that includes the North Yorkshire Pathway of Support for Children and Young People who deliberately self-harm85. Where appropriate, seeking student and parental consent for information sharing with other agencies. Being consistent with the parameters of information sharing, regarding rules of confidentiality, data protection and the circumstances when consent can be overridden in the best interests of the child or young person. Current Social Emotional Mental Health Developments in North Yorkshire 245. There is widespread recognition of the vital role schools play in the mental health and wellbeing of their students86 Schools are well placed to identify the earliest signs of mental health problems and provide appropriate support and counselling to pupils when needed. This SCR would commend and urge the appropriate agencies in North Yorkshire to have regard to the Children’s Commissioner’s Report of October 2017. This recommends that ‘as part of a whole systems approach to the provision of mental health services to children and young people, schools should: Establish a positive environment which promotes children’s wellbeing. Teach children of all ages about mental health and wellbeing. Have a lead professional and a clear mental health policy. Be an access point for early support for children with emerging problems, such as short courses of therapy. Where possible, this should be provided within the school, with local authority and NHS budgets helping to fund these services. Where students have more serious needs, schools should be a referral point into specialised services (e.g. CAHMS)’. 85 See the suicide prevention charity ‘Papyrus’ and it’s very useful, ‘Building Suicide-Safer Schools and Colleges-A Guide for teachers and staff’, ‘Save the class of 2018’, at www. Papyrus-uk.org. Also, see the ‘North Yorkshire Pathway of Support for Children and Young People who deliberately self-harm’, North Yorkshire Children’s Trust. 86 (CQC Report, October 2017; Future in Mind, 2015). Page 53 of 75 246. The Government Green Paper, ‘Transforming Children and Young People’s Mental Health Provision’ December 2017, has set out proposals for consultation around: A designated mental health lead in every school by 2025. Mental health support teams working with schools and colleges offering support to young people with mild to moderate mental health issues such as anxiety, low mood and behavioural difficulties; acting as the link between schools and the NHS. Shorter waiting times with the aim of four weeks for children to obtain treatment.87 247. The Clinical Commissioning Group 3, Local Transformation Plan for Children and Young People’s Emotional and Mental Health 2015-202088 at page 5 sets out its plan to develop a whole school approach at Local Priorities 1 and 2. The aim by 2018 (with a two-year extension) is to have dedicated mental health workers aligned to all school clusters, a named mental health lead in each school and a named link mental health worker for each GP surgery. The stated outcomes include; training staff to recognise and respond to pupils with difficulties (advice/seek help) and supporting pupils through interventions either individually or in groups to feel they can cope and have strategies to do so. In addition, GPs and surgery staff will have direct access to advice about individual patients and strengthened links to schools. 248. The current North Yorkshire Children’s Trust, SEMH strategic cross service implementation plan (2017-2020)89 ‘nests’ within the wider Local Transformation Plan in covering Local Priorities 1 and 2, a whole school approach. Its key priorities include, ‘ensuring that there is a co-ordinated and coherent system for SEMH across, health, education and social care; and that the services commissioned meet the needs identified locally.’ 249. The SEMH strategy in North Yorkshire involves several local initiatives such as: Compass Reach and Compass Buzz, The Thrive Approach, The Academic Resilience Framework and Back on Track. Details of these initiatives and progress regarding implementing of the SEMH strategy can be found in the Local Authority 1 SEMH briefing paper and note of 2017. The strategy is currently being reviewed in order to strengthen it further, particularly with regard to the need to ensure earlier help and intervention. North Yorkshire Agencies 250. There was effective inter-agency co-operation between Police 2, Hospital 4 and Community CAMHS 2 in responding to Clare’s self-harming and suicidal episode as well as promoting her safety and welfare. Clare’s physical, emotional and mental health needs were well met by the staff at Hospital 4. Clare’s parents were well supported. 87 To be piloted in some areas. 88 In line with Future in Mind, 2015 89 This is overseen by the North Yorkshire Children’s Trust Board. Page 54 of 75 251. Clare’s emotional, mental health needs and risks were appropriately assessed and addressed by both CAMHS teams (i.e. CAMHS 2 and CAMHS Inpatient Service 1. Options involving both an in-patient and a community approach were considered. There was effective liaison and information sharing between the two CAMHS teams which promoted Clare’s welfare and safety. Her parents were supported through the episode and informed of the options for the care of their daughter. 252. It is generally to a young person’s advantage to receive in-patient intervention as close to home as possible. Reasons include continuity, ease of contact with family which in Clare’s case was a significant issue, relative familiarity with the young person’s locality, effective communication and liaison with local services, including the local authority, schools and the responsible health agency, particularly in regard to Section 17 home leave and eventual discharge planning and support. For reasons of acuity at CAMHS Inpatient Service 1 in York, it was unfortunate that Clare was not able to be admitted to this local facility as an in-patient. At the very least, her admission would have facilitated family involvement, continuity of schooling and liaison with community social, educational and health agencies. 253. A critical deciding factor for Anne, Patrick and the professionals in opting for an out of area placement was the absence at that time of a crisis/assertive outreach service. 254. Key lessons from this practice episode include: Consideration of the design, development and use of an intensive home intervention service that seeks to maintain them in the community and is consistent with the young person’s safety and wellbeing. Consideration of devising and implementing a robust, early intervention based multi-agency approach that includes: the school, Children’s Services and other relevant agencies within a statutory framework. In the event of an in-patient admission, placement as close to the young person’s home and family as possible. Current Developments 255. CAMHS 2 was identified90 by NHS England within the ‘New Model of Care’ project as one of the selected providers covering both the North East Region and North Yorkshire. This started in October 2016, with an aim to provide the incentive and responsibility to put in place new approaches, which will strengthen care pathways to: ‘Improve access to community support; Prevent avoidable admissions; 90 Information provided for this SCR by CAMHS 2 Page 55 of 75 Reduce the length of in-patient stays and; Eliminate clinically inappropriate out of area placements.’ 256. Early indications are that the additional support offered to children and young people within the community reduces the number of young people requiring admission to hospital and reduction of the length of stay in CAMHS Tier 4 settings. 257. CAMHS 2 now provide a crisis intervention/intensive home treatment91 service for children and young people within North Yorkshire. Had this been in operation in November 2015 it is possible that a place at CAMHS Inpatient Service 1, York may have been found. In the longer term it may have provided favourable circumstances for pursuing a community, multi-agency approach, including children’s services assessing Clare as a Child in Need, enabling professionals to meet Clare’s needs and manage her risks, without recourse to later Out of Area Placements at Sheffield and Norfolk. Indeed, it was the NHS England case manager’s belief in the NHS England report for this SCR that had a home treatment or crisis team been available as an interim support at the time of the referral to CAMHS Inpatient Service 1, this could have provided an alternative to the admission to Hospital 2. Hospital 2 258. There was little evidence to show that any purposive work was done with Clare and her parents on the objectives of the intended four-week admission. Professionals could not engage Clare in assessing her risks, understanding the underlying reasons for her self-harm and suicidal ideation or working towards positive outcomes of re-integration to her home in Yorkshire. That said, the hospital did succeed in preventing her ending her life whilst she was a patient. 259. Multi-agency working was not evident. There was no indication that the NHSE Care Manager or the CAMHS 2 care co-ordinator were present at the Care Programme Approach (CPA) meetings The CAMHS 2 care co-ordinator had a pivotal role in linking Clare, the hospital, the family and home agencies, including the Local Authority Children and Families services92. This was especially important given Clare was compulsorily detained under the Mental Health Act, 1983. 260. Clare’s level of self-harm and suicidal ideation increased along with the attendant risks, leading to the multi-disciplinary team’s decision to seek a transfer to a low secure unit. 261. There were sub-standard internal practice and organisational issues that did not facilitate positive outcomes for Clare, and that this review concludes contributed to her poor and eventually tragic outcomes. These are set out in paragraphs 116-128. 91 Provided between 10a.m to 10p.m 92 There was a legal duty under section of the Children Act 1989 for Hospital 2 and CAMHS 2 to notify Local Authority 1 Children’s Care Services (i.e. the home authority) of Clare’s placement at Hospital 2 once she had been there for three months (i.e. at the end of February 2016) Page 56 of 75 262. There were significant elements of unsafe practice operating on and between the two wards during Clare’s time at Hospital 2. There was an absence of critical fundamental systems and processes, a lack of triangulation of recording systems, no updating of care plans or risk assessments, ineffective intervention by the multi-disciplinary team, and a failure by staff to comply with existing agency policies and procedures, for example in not acting on safeguarding issues. The SCR viewed this catalogue of deficits as unacceptable and concludes that the hospital’s practice and overall care of Clare fell far short of acceptable standards. 263. These matters are cause for serious concern, and raise questions regarding the degree of management grip, and the patchy involvement of senior hospital management, in overseeing the quality of practice and positive outcomes for Clare and the effectiveness of clinical governance oversight and audit. 264. The dysfunctional organisational environment is clear from the reports provided to the reviewer, and was unlikely to have fostered either a developing and necessary sense of security in Clare, or the building of trusting relationships with key staff. Both were essential conditions if she was to be helped to address her emotional state of mind and depression. 265. Many service improvements identified as needed by this SCR are similar to those set out in the CQC reports in 2017. The practice under analysis in this report occurred two years prior to the publication of the CQC report and in the interim period the hospital was subject to a closely monitored service improvement initiative by both the CQC and NHS England. Notwithstanding these regulatory developments, this SCR concludes that Hospital 2 needs to pay particular attention to the following issues and ensure that, if not already addressed, they are now tackled, and improvement in each area listed is proven. 266. These are: Individual care plans should be holistic, comprehensive and address need, treatment, objectives, desired outcomes and risk. They should be wider than just nursing plans and include inputs from the entire multi-disciplinary team. Care plans should be updated regularly, especially after significant events and risk episodes. There should be only one plan for each patient and duplication should be avoided. The hospital should use an electronic recording system that will allow for regular updating, especially after risk incidents, by all members of the multi-agency team. This system should not be enabled to overwrite previous entries. The hospital should ensure that all significant incidents (especially suicidal, self-harm and ligature episodes) are recorded, and clear to all members of the multi-agency team. The hospital should undertake dynamic assessments that recognise the changing nature of risk, as opposed to static assessments that do not. Staff should be trained to see patients’ needs and risks in their historical context so their treatment can be undertaken within a bigger picture of their lives and histories. Page 57 of 75 Ward rounds should include regular reviews of care plans and risk assessments, with the direct involvement of the full multi-agency team and patients. Effective transition arrangements should be put in place between wards (general adolescent ward and PICU), and there should be a system for both better information sharing, and recorded handover meetings. The hospital should ensure better continuity of care and minimisation of disruption to patients, both within a ward, and at any transition points. Recruitment and retention of high-quality staff is needed, to help the hospital to achieve consistency. Less staff turnover and use of agency workers should be the aim. Each patient should have a named key worker. Staff should be trained to be familiar with safeguarding procedures, including any instances where they should be reporting and referring to Children’s Services. The hospital should ensure greater involvement of external agencies, NHS England, commissioning CAMHS and Local Authority Children’s Services in patients’ care. The hospital should commit to, and ensure, greater involvement of parents/carers. The hospital should ensure better recording of the involvement wishes and feelings of subject children and young people in their care/treatment plans and discharge arrangements. 267. There were issues of inter-agency working between Hospital 2 and Hospital 5 that between them dealt with Clare’s self-harming injuries. In addition, there was sub-standard transfer of information from Hospital 2 to Hospital 1. 268. Key lessons from this episode include: The need for effective communication, information sharing and joint service planning by the two providers through the production of a care pathway and protocol regarding treatment and risk management of adolescent patients presenting with self-harming behaviour. Hospital 2 has the responsibility to share information (i.e. mental health issues, presenting behaviours, current risk assessments of self-harm) with the acute agency on admission in order for the provider to ensure the patient’s continuing safety. Documentation in the patient’s medical and nursing care plans should include notes on the triggers and type of self-harm typically demonstrated. All involved should lead to more effective joint provider planning and co-ordination of the patient’s discharge back to Hospital 2. The need for Hospital 2 to ensure that it has a robust patient information sharing and transfer system when young people are discharged from its care. Huntercombe Group 269. The key findings and learning have been set out in the NICHE report which this SCR supports in full. (See appendices 2i and 2ii of this report) Page 58 of 75 CAMHS 2 and NHS England 270. Clear guidance is required and once in place should be followed through, on the role, responsibilities and remit of CAMHS 2 care co-ordinators towards children and young people placed at out of area CAMHS facilities, including links with parents/carers and external agencies (local CAMHS, GPs and the Local Authority Children’s Services) 271. Clear guidance is also required on the role, responsibilities and remit of case managers (NHSE) towards children and young people placed in out of area CAMHS facilities, including links with parents/carers and external agencies (local CAMHS, GPs and the local authority children’s services). N.B. The review was told by the NHSE representative on the 17th September 2018 that clear guidance is now in existence and is being implemented as standard operational procedure in respect of the above learning point. TOR 3 Leeds Agencies 272. There was a mixed record of Clare and her parents having their views heard and included in decision making and actions taken by the three Leeds agencies. 273. The key lesson here is that the agencies involved all need actively to facilitate the maximum possible participation of children, young people and their parents or other legal carers in decisions about themselves, including consideration of their wishes and feelings. The Schools 274. There was a lack of inter-agency information sharing either between, or by other agencies with, the two schools regarding Clare’s self-harming and suicidal ideation. Thus, although there was discussion between Clare, Anne, Patrick, Sue and the schools about her behaviour, motivation and educational development, there was no dialogue regarding her emotional wellbeing and mental health needs. 275. The learning from this practice episode indicates the need for schools to become more aware of their students emotional and mental health needs and having improved their awareness, to respond to them appropriately. Involvement in the North Yorkshire Children’s Trust SEMH strategy and its current review, and in other current local initiatives, should address this issue. (See paragraphs 247-248). North Yorkshire Agencies 276. In general, there was a good record of these agencies listening to Clare and her parents taking on board their wishes and feelings. However, there were questions raised as to how well the parents were informed as to why Clare went to Hospital 2 in Sheffield rather than being offered a place in York, as originally intended. Hospital 2 277. Hospital 2 state that there was generally good communication with Clare’s parents. Conversely, Anne, Patrick and Sue’s view was that communication with staff was very Page 59 of 75 poor. High staff turnover, the use of bank and agency workers and the consequent lack of staff continuity meant that they never saw the same consultant/professional, which they say, was a major factor making for poor communication. Clare’s mother told the lead reviewer that she had no involvement in decision making. 278. The learning from this episode is covered at paragraph 265. Hospital 1 Group 279. There was little effort by Hospital 1 to engage with Anne and Patrick. Anne participated by conference call in the CPA meeting of the 16th March 2017 and her father had no contact. The distance between Norfolk and Yorkshire did not facilitate easy direct contact with the family. Clare was dis-engaged with the staff and chose not to participate in CPAs and ward rounds. Her mother felt that there was poor staff continuity and no named professional to liaise with. In her view, there was a lack of verbal communication and she often felt disconnected. 280. The learning from this episode highlights the crucial importance of every effort being made by hospital staff to encourage the maximum degree of participation and involvement by young people and their careers in the planning and decision making processes. Self-evidently, young people should have a voice in their treatment and post discharge planning though involvement in ward rounds, CPA meetings and other relevant fora’ See also paragraph 303 below. TOR 5 281. Clare was unable to go to CAMHS Inpatient Service 1 in York because of acuity problems at the time of her proposed admission. Due to a lack of capacity of nearby Tier 4 facilities she was found a place at Hospital 1 Sheffield. 282. She was sectioned under the Mental Health Act, 1983 because her escalating self-harming and suicidal behaviour necessitated it in the judgement of the Hospital 2 multi-disciplinary team and NHSE. 283. She was transferred to Hospital 1 in Norfolk because her behaviour in the summer of 2016 required a low secure unit (LSU) facility to safely manage her risk. There were no suitable LSU units in Yorkshire/Humber or the North of England due to lack of capacity which resulted in her going to Hospital 1. Part 8 - Improvements and Challenges 284. All agencies named below are challenged by this SCR to consider what actions are needed to translate the following learning points and improvements into positive outcomes, so as to enhance the safety and well-being of children and young people who have emotional and mental health needs. Page 60 of 75 Leeds Agencies LCH-CAMHS, Clinical Commissioning Group 1, Leeds Safeguarding Children Partnership93 285. Within the context of the, ‘New Model of Care’ the LCH (CAMHS) and Clinical Commissioning Group 1 (as commissioners of CAMHS and GP services) should address: 286. The importance of early recognition, intervention and treatment of children and young people with mental health issues; in the home/locality, or as close to it as possible, ‘The right care at the right time in the right place’. 287. There is a need to reduce waiting times for a first consultation CAMHS clinical appointment to within a realistic stated target date. 288. CAMHS 1 and the Clinical Commissioning Group 1 need to consider the potential importance of a multi-agency approach (Early Help and/or Child in Need), by involving other agencies and in particular, schools, in promoting the safety and well-being of children and young people in their care. 289. There should be annual reporting to the Leeds Safeguarding Children Partnership by the relevant agencies/Boards on progress made on implementing the Local Transformation Plan and New Model of Care. 290. The Leeds Safeguarding Children Partnership should be made aware of this report, especially regarding those agencies mentioned above. North Yorkshire Agencies 291. School 2 and if necessary, all schools in North Yorkshire, should ensure they can prove they are addressing and implementing the nine learning points at paragraph 243. 292. The Clinical Commissioning Group 3 should be made aware of this report. Following consultation, it should take steps to assure the North Yorkshire Safeguarding Children Board that progress is being made on the effective implementation of the Local Transformation Plan, including the North Yorkshire Children’s Trust SEMH implementation plan (2017-2020)94, paying special regard to the development of a whole school approach (see paragraphs 246-248 above). Thereafter, there should be an annual progress report made to the NYSCB. 293. CAMHS 2 should address (through the LTP and NHS E, ‘New Models of Care’ initiative, see paragraphs 254-256 above) the importance of early recognition, intervention and treatment of children and young people, with mental health issues; in the home/locality, or as close to it as possible, as per the ‘The right care at the right time in the right place’, initiative. 294. Through the LTP the need to reduce waiting times for a first consultation CAMHS clinical appointment to within a realistic stated target date. 93 Formerly the Leeds Safeguarding Children Board (LSCB). 94 Overseen by the NY Children’s Trust Board. Page 61 of 75 295. CAMHS 2 and LYPFT should assure the NYSCB by annual reporting that good progress is being made in effectively implementing the New Model of Care agenda, especially the Crisis Intervention/ Intensive Home Treatment initiative. Sheffield Agencies Hospital 2 and Hospital 5 296. In addition to the service improvement initiatives required by the CQC and NHS E, the Hospital 2 Sheffield should address and implement the learning points at paragraph 265. 297. The Hospital 2 and STHFT should address and (where relevant), implement the learning at paragraph 267. 298. The Sheffield Safeguarding Children Board should be made aware of this report, especially in reference to the two agencies mentioned in this section. Huntercombe Group 299. The Huntercombe Group should address and implement the recommendations (see appendix 2ii) of the NICHE report in a timely manner. 300. The Group should report on progress and effective implementation of the action plan to both the NYSCB and Norfolk Safeguarding Children Board within the next six months of the approval of this report. 301. Norfolk Safeguarding Children Board should be made aware of this report and should seek assurance on the safety and well-being of children and young people resident at any Huntercombe Group facility in the county. Police 1 302. A copy of this report should be provided to Police 1 for coronial purposes. All Agencies 303. All agencies involved in this SCR should consider how best to maximise the voices of young people and their parents/carers/ families in decision making processes, especially as regards admission to in-patient care, Care Planning Approach, considerations around Section 17 leave and planning for community discharge. Claire’s Parents Suggestions for Service Improvement95 304. Agencies should give due regard to the following points; Communication between hospitals and parents; professionals need more regular contact with families particularly for those placed out of area. Named Professional to be identified who knows the patient and can liaise with families i.e. Single Point of Contact (SPOC). 95 Obtained from the lead reviewer’s visit to Anne. Page 62 of 75 Connections with families: parental involvement as much as possible. Early Intervention with Schools. CAMHS involvement – more involvement and the opportunity to offer a professional who could visit the home i.e. home care professional. Tier 4 placements: The wards are not homely and felt that they were more like a prison. Needs to be an offer of a nurturing therapeutic environment. Bereavement Support is limited – Anne said that there is limited support for parents and has paid for her own. This is only once a week and is limited due to the cost. Page 63 of 75 Glossary A and E Accident and Emergency APIR Assessment, Planning, Implementation, Review CAMHS Child and Adolescent Mental Health Service CBT Cognitive Behavioural Therapy CC Care Coordinator CGAS Children’s Global Assessment Score CiN Child in Need CPA Care Plan Approach CPS Crown Prosecution Service CQC Care Quality Commission CTL Clinical Team Leader DSH Deliberate Self-Harm GAU General Adolescent Unit GP General Practitioner IPT Interpersonal Therapeutic LTP Local Transformation Plan LSU Low Secure Unit MDT Multidisciplinary Team MHA 1983 Mental Health Act 1983 NiC Nurse-in-charge NHS England National Health Service England NICE National Institute of Clinical Excellence NYSCB North Yorkshire Safeguarding Children Board PICU Psychiatric Intensive Care Unit RC Responsible Clinician SCR Serious Case Review S1 Secondary School 1 S2 Secondary School 2 Page 64 of 75 SEMH Social Emotional Mental Health. SPOC Single Point of Contact SSO School Support Officer STAR Salford Tool Assessment of Risk References Bywaters P and Rolfe A (2002); ‘The Development of Self-Injury as Multi-Functional Behaviour’ PhD, London: University of Greenwich Page 65 of 75 Care Quality Commission; October 2017, The State of CAMHS Children’s Commissioner; 2017; Children’s Mental Health Care in England Frith, E; July 2017; Inpatient Provision for Children and Young People with Mental Health Problems; Education Policy Institute. Furnivall J (2013); ‘Understanding Suicide and Self-Harm Amongst Children In Care and Care Leavers’, Insight 21, July 2013, IRISS, Future in Mind; 2015 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness; May 2016; Suicide by Children and Young People in England NICE, Self-Harm, Quality Standards, 2017 NICHE; September 2017; An Independent Investigation into the Care and Treatment of a Young Person who was a Mental Health Service User in Hospital 1, Norwich. NHS England (July 2014); Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report; CAMHS Tier 4 Steering Group. NHS England, 2015; Five Year Forward Plan for Mental Health IRISS Insights, July 2013, no 21 Papyrus, 2018; Building Suicide- Safer Schools and Colleges- A Guide for Teachers and Staff. Royal College of Psychiatrists (2014); Managing Self-Harm in Young People HM Government; 2017; Transforming Children and Young People’s Mental Health Provision Working Together, 2015; HM Government Appendix 1 Aims, Terms of Reference and SCR Process Aims 1. The overall purpose of this SCR is set out in Working Together to Safeguard Children (2015) namely to undertake a rigorous, objective analysis that will: Page 66 of 75 “Look at what happened in this case, and why, and what action needs to be taken to learn from the Review findings. Action results in the lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm. There is transparency about the issues arising from this case and actions which the organisations are taking in response to them. Including sharing the overview report with the public” (WTSC 15, pg 72) Terms of Reference (ToR) 2. This SCR and the overview report have been undertaken in relation to the following terms of reference, namely; Key Themes Assessment of Clare’s Needs and Risks 1. Critically analyse and evaluate the effectiveness and extent to which Clare’s needs (emotional and mental health, physical health, safeguarding and welfare and educational) and risks of self-harm and suicidal behaviour, were met by agencies. Planning and Service Provision 2. How effective was service planning and provision in addressing Clare’s self-harming and suicidal behaviour and as far as possible, promoting her safety and wellbeing? The Voice of the Child and Parents in Assessment, Planning, Implementation and Review (APIR) 3. How well was the voice of Clare and her parents heard and included in the APIR process? Was the process sufficiently child focussed, if not, why not? Multi-agency working together 4. How effective was multi-agency working together in regard to, Information sharing and communication of concerns Multi-agency meetings Promoting the safety and welfare of Clare Supporting her parents Impact on multi-agency working Support to schools Compulsory Intervention and Out of Area Placements Page 67 of 75 5. Why was compulsory intervention under the Mental Health Act 1983 and Out of Area placements necessary? How well did they promote Child MT’s safety and well-being regarding risk management from harm and meeting her emotional and mental health needs? Scope of SCR 3. The time-frame under examination is from 01.01.2014 to 30.03.2017. This covers the period from Clare and her mother’s involvement with Leeds CAMHS to just after her tragic death in mid-March 2017. It should be noted that this SCR is an examination into agencies’ involvement with Clare and her family over the above time period and not a determination of who (if anyone) may have had responsibility for her death. This is the job of the police investigation or inquest, in the event that one is held. Methodology 4. The following documents, meetings and events underpinned the SCR; Integrated chronology. Fifteen agency reports from Leeds, North Yorkshire, Sheffield, South Yorkshire and Norfolk agencies involved with Clare and her family. Preparation meeting between lead reviewer and agency authors. Reports from NHS England, Care Quality Commission, NICHE and Norfolk 1. The NICHE report was commissioned by Hospital 1 Norfolk and was used extensively by the Lead Reviewer. Discussion and analysis at four panel meetings. Learning event involving front line practitioners and managers: November 2017. Conversations with mother, father, step-mother. Reference to the five ToRS Liaison with the Police 1 Senior Investigation Officer (SIO) and Crown Prosecution Service (CPS) Sight of all relevant documents The adoption of a broadly,’ Systemic’, approach to the understanding and analysis of the case within an organisational context of professionals’ actions and decision making at the time. A focus on learning and not blame The Panel 5. The Panel comprised of senior representatives from the following agencies; SCR Panel Chairs Ms. Dallas Frank (May 2017- February 2018). Business Manager, North Yorkshire Safeguarding Children Board Page 68 of 75 Mrs. Elaine Wyllie (September 2018 - Publication). Designated Nurse Safeguarding Children and Children in Care, North Yorkshire and York. Lead Adviser, Vulnerable Learners, Education and Skills Local Authority 1 Director of Quality Hospital 1, Norfolk Head of Safeguarding, Children and Families Local Authority 1 Designated Nurse Safeguarding Children CCG 4 Senior Designated Safeguarding Nurse CCG 1 Senior Designated Safeguarding Nurse Hospital 3 Head of Service, Safeguarding CAMHS 1 Detective Superintendent Police 2 Lead Reviewer NICHE Mental Health Lead (Yorkshire & Humber) NHS England Associate Director of Nursing CAMHS 2 Senior Nurse Hospital 2 NYSCB Board Manager NYSCB Leadership Support Officer NYSCB (Non-member) 6. The independent lead reviewer was Mr. Paul Sharkey (MPA)96. He had no previous connection with either the NYSCB or any of its partner agencies, including those involved in the SCR. He has a professional background in statutory and third sector safeguarding of over thirty years at senior management level. He has authored/chaired more than seventeen SCRs since 2002 and has attended several DfE/NSPCC courses on improving the quality of SCRs over recent years. Confidentiality 96 Master’s in Public Administration (2007) from Warwick University Business School. CQSW and M.A ( Keele University) in Child Care Law and Safeguarding. Page 69 of 75 7. In compliance with Government guidance this SCR has respected the right to anonymity of Clare, her family and the professionals involved in the case. All names have been changed. Family Involvement 8. Clare’s mother, father and step mother took part in discussions with the lead reviewer and SCR Chair. Race, Religion, Language and Culture 9. Clare and family are English speakers of white British heritage. Parallel Proceedings For most of the duration of this SCR there was an ongoing police investigation undertaken by Police 1 into the death of Clare. The Crown Prosecution Service decided in June 2018 that no prosecutions would follow her death. An inquest took place in November 2019 with the conclusion of Suicide. Appendix 2i -NICHE Findings (Root Causes) 1. We found it difficult to determine a single root cause and concluded that a number of factors aligned which created the opportunity for failure to occur and resulted in Clare taking her own life. These included: Poor communication between multi-disciplinary team members about information pertaining to risk. Lack of review of Clare’s mental state following her return from leave 12 March 2017 Out of date multidisciplinary reports provided to the CPA meeting 16 March 2017 not containing the detailed information from the support workers 1 and 2 on 13,14 and 15 March 2017 following her return 12 March 2017 from two day’s section 17 leave with her mother. Lack of comprehensive multi-disciplinary review of risk, aligning risk assessment and management with levels of observation. Lack of a documented agreement arising from the CPA meeting 16 March 2017 regarding Clare’s observation intervals and an explanation of the rationale aligned with the escalating risk. Lack of an explicit statement of the timing of the intermittent observations for Clare in her health and wellbeing or risk care plan. Lack of an awareness that ligatures could be a risk for Clare coupled with The Huntercombe Group policy ‘Rescue from Ligature and use of Ligature Cutters Policy’ restrictions list not including dressing gown cords. The lack of consistency between The Huntercombe Group and guidelines, policies and procedures for intermittent supportive observations. The record of engagement form for intermittent observations not allowing for the time of the observation to be recorded and creating the opportunity for human error to occur. Page 70 of 75 Inadequate adherence to the HHN stated ‘custom and practice’ of undertaking intermittent level two supportive observations. The record of engagement form timings not correlating with the shift planner staff allocation timings making it complicated for the systems to work together. Support Worker 3 being allocated the intermittent observations from 01.29am for Clare but attending the emergency at 01.35am on 19 March 2017 with other staff leading to a delay in the intermittent observations for Clare. Support Worker 3 then being asked by Support Worker 4 to take over the allocated two-to-one observations allocated to the agency nurse-in-charge to enable the nurse-in-charge to deal with the emergency on the ward leading to further delay of 44 minutes in the intermittent observations for Clare. The agency nurse-in-charge recording in error that he had undertaken the intermittent observation on Clare at 1.30am when in fact it was at 1.00am according to the CCTV footage. Support Worker 4 taking over the intermittent observations believing that observations for Clare had been completed 14 minutes rather than 44 minutes previously. A further delay of 13 minutes in Support Worker 4 undertaking the intermittent observations due to talking to both the nurse-in-charge and the Support Worker that was feeding back the information about her earlier conversation with Clare. Appendix 2ii NICHE Recommendations 1. The Huntercombe Group must align the current CAMH service inpatient supportive observation policy and the HHN local protocol for supportive observation and review the current template for the record of the engagement reflecting on whether the exact timing of the engagement can be recorded to avoid human error. The revision of the policy must meet the NICE quality standard QS 34 for the monitoring of self-harm and a process for regular multidisciplinary team review of the rationale and the level of supportive observation, recorded in the clinical records and the care plan. The policy must be clear that the staff allocated supportive observations must continue to do so unless instructed otherwise by the nurse-in-charge. 2. The Huntercombe Group must review the risk assessment policy based on current Department of Health best practice guidance and ensure that the critical importance of the family is recognised, the role of the formal mental state assessments, provides guidance on the assessment of cumulative and escalating risk factors and aligns with a review of the supportive observations. 3. To ensure that practice is embedded, HHN must ensure that an annual audit cycle is in place and includes audit of adherence to the supportive observation, CPA and risk assessment and management policies. The audit cycle and subsequent audit reports must be approved and scheduled into the local quality governance arrangements. 4. HHN must ensure that there is a process in place to ensure that NICE self-harm in over 8’s long term management clinical guidance CG 133 for the involvement of carers and Page 71 of 75 family members is in place and includes ensuring the carer is appropriately signposted to the Local Authority for a carers assessment, is provided with information on the management of self-harm and is offered information, including contact details, about family and carer support groups and voluntary organisations. 5. HHN must ensure that the current practice of completion of the shift planner by a Support Worker is reviewed so that the allocation of duties does not limit the responsibility of the nurse-in-charge to discharge their responsibilities effectively. 6. The Huntercombe Group and HHN must review the care planning documentation to ensure that it is clear and that it allows for the alignment of care and risk management plans. 7. Given the culture in the Huntercombe Group and HHN CAMH inpatient services of tying ligatures, risk assessments must always assume that this is a potential risk that requires management. The Huntercombe Group and HHN must consider how best to reflect and balance the management of ligatures risks in the revision of the risk assessment policy both from an individual risk assessment basis and by managing the environment and through having a list of restricted items. Appendix 3 - Suicide and Self-Harm - Definition and Context 1. Suicide can be defined as ‘‘A deliberate intent to end life….. (and)…. attempts to stop distress by ending life’97,( Furnivall 2013). Deliberate non-fatal self-harm can be understood as ‘An intentional act of self-poisoning or self-injury irrespective of the type of motivation or degree of suicidal intent’98.( Furnivall 2013) with adolescent deliberate self-harm understood as ‘A way of managing an underlying distress by a young person’99. Motivations for deliberate self-harm vary with individuals. Furnivall 2013 100 identifies that self-harm is used for the relief of negative emotion, intensively difficult feelings and a desire for punishment. Participants describe overwhelming sadness and frustration before the self-injury followed by a sense of relief and calm afterwards. It may be that the release of distressing feelings in itself, through deliberate self-harm can likely reinforce the behaviour. 2. Bywaters and Rolfe (2002) suggest that the motivations of young people to begin and continue to self-harm fall into three main categories. These are, managing events, managing emotions and contextual factors. Managing events refers to traumatic episodes in the young person’s life such as loss, abuse or family discord. Managing emotions through self-harm can be understood as a means of dealing with stress and regulating painful feelings. Contextual factors such as living in a residential setting where 97 See article by Furnivall. J in the Institute for Research and Innovation in Social Services; IRISS insights, no 21, pages 1 and 2, July 2013 98 This definition is quoted in the Furnivall article cited above and taken from the Royal College of Psychiatrists 2010 definition, IRISS insights, no 21, page 2, July 2013 99 IRISS, July 2013 100 Ibid Page 72 of 75 the young person has little control over events or where other residents regularly engage in self-harming behaviour may also contribute to starting and maintaining the behaviour. 3. It is suggested that ‘responding to underlying distress is more important than focusing on stopping the self-harm (and that) assessment is essential but should focus on the needs of young people as well as their current level of risk’. (Furnivall, 2013, 1) 4. Suicidal intent can increase with the frequency of self-harm and a young person’s motivation for suicidal intent can be located within three core categories (Furnivall 2013). These are: avoidance, where suicide is perceived as a rational and realistic option in avoiding ongoing overwhelming distress or in averting an impending intolerable experience; communication, as a way of signalling to others the very painful feelings being experienced by the young person. Finally, suicide as a means of taking control in a powerless situation, either over others who have power or as a means of the young person themselves regaining control over their destiny. 5. Albeit a relatively rare event with young people, suicide is one of the main causes of mortality101 and the second most common cause of death in this group102.The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Report103 (May 2016) found that there were 145 suicides and probable suicides by children and young people in England between January 2014 and April 2015, of which 66 were under 18 years old. The suicide rate in this age group (under 20 years) is low overall but the highest rate within late teens, with 70% male deaths and 30% female deaths. The majority of the deaths (54%) had indicated their risk through previous self-harm104, and around a quarter (27%) had expressed suicidal ideation in the week prior to their death. Almost two-thirds (63%) of the 145 suicides were by hanging. 6. Risk factors include: mental illness, self-harm and suicidal ideation, drug or alcohol misuse, abuse and neglect, bereavement, bullying (online), academic pressures and social isolation. The most common method of death was by hanging/strangulation for both males and females. People who have self-harmed have a 50-100-fold higher likelihood of dying by suicide in the 12-month period after an episode than those who do not self-harm105. 7. Numerous experiences and stresses contribute to suicide and it is rarely caused by one factor.106 There are likely to be several antecedent risk factors including: long-standing family adversity/dysfunction, difficulties in other areas of life, social isolation and withdrawal; all complicated by mental health problems, especially depressive disorder. A pattern of cumulative risk may then lead to a, ‘final straw’ event, often a broken relationship or exam stress. 101 Source: ‘National Confidential Inquiry into Suicides and Homicide by People with Mental Illness’ (May 2016, p4); Office for National Statistics in the UK, 2014 Registrations, Statistical Bulletin 2016: 1-33 102 See Royal College of Psychiatrists, ‘Managing self-harm in Young People’, October 2014, College Report CR192 103 ‘Suicide by Children and Young People in England’ 104 Cutting and self-poisoning (overdosing) being the most common. 105 (NICE; Self-Harm; Quality Standard, 2017, Published: 28 June 2013 106 Source from note 19. Page 73 of 75 8. The study concludes that ‘Improved services for self-harm and access to CAMHS are crucial to addressing suicide risk but the antecedents identified in this study make clear the vital role of schools, primary care, social services and youth justice’107. Appendix 4 - Children and Adolescent Mental Health Policy: The National Context 1.‘If mental health is the Cinderella service of the NHS, then child and adolescent mental health services (CAMHS) is the Cinderella service of the Cinderella service’108. This comment from Norman Lamb (MP), the then Minister of State for Care and Support in the coalition government of 2010-2015 reflected widespread professional and political opinion at the time. Nationally, the CAMHS service was ‘dysfunctional and crying out for a complete overhaul’109, underfunded and inadequately meeting the emotional and mental health needs of children and young people. 2. The Minister set up a taskforce to shake up the service and make recommendations for change and improvement. At the same time in November 2014, the House of Commons Health Select Committee into Children’s Mental Health found that ’The lack of reliable and up to date information about children’s and adolescent’s mental health and CAMHS means that those planning and running CAMHS services have been operating in a fog’. These developments led to the publication of the seminal report, ‘Future in Mind’ in March 2015 and NHS England’s, ‘Five Year Forward View for Mental Health’ (February 2016), both of which provided a blueprint for the modernisation of CAMHS services, backed up by an additional £1.4 billion over the five years to 2020. 3. The reforms were translated locally by the publication of NHS England ‘Local Transformation Plans for Children and Young People’s Mental Health and Well-being’ in August 2015. This set out guidance for local area Clinical Commissioning Groups working closely with their Health and Well-being Boards and partners from across the NHS (including NHS England Specialised Commissioning), Public Health, Local Authorities, Youth Justice and Education sectors on the development of Local Transformation Plans to support improvements in children and young people’s mental health and well-being. 4. The key themes from, ‘Future in Mind’, that underpinned the National and local plans were fivefold, namely: Promoting resilience, prevention, early intervention and a joined up approach with clear pathways for children and young people to navigate; Improving access to effective support by simplify structures-a system without tiers; Care for the most vulnerable; Accountability and transparency; Developing the workforce. 107 (Ibid at note 21; 2016,16) 108 (Independent newspaper, 19 August 2014) 109 (ibid), Page 74 of 75 5.The Vision set out was that by 2020 children and young people in every part of England would have timely access to clinically effective mental health support when needed. The five-year programme would include a comprehensive set of access and waiting time standards that would bring the same rigour to mental health as seen in physical health. There was to be a step change in the delivery of care moving away from a system based up a ‘Tiered’ model of service provision 110, towards one built around the identified needs of children, young people and their families. The aim was to ensure that they would have easy access to the right support from the right service at the right time. This was to be achieved by collaborative commissioning approaches between Clinical Commissioning Groups, Local Authorities and other partners with the development of a single integrated plan.111 6.Planning includes localities having a ‘one stop shop’ of services that provide mental health support and advice to young people in the community, improving communications and facilitating access to support through every area, having named points of contact in specialist mental health services and schools, including the integration of schools and GP practices. In addition, there is provision for the development of clear pathways for community-based care, including intensive home treatment where appropriate, to avoid unnecessary admissions to in-patient care. 7.The recently published Government Green Paper112 builds on ‘Future in Mind’ and notes that, ‘In some cases, support from the NHS is only available when problems get really serious, is not consistently available across the country, and young people can sometimes wait too long to receive that support. Support for good mental health in schools and colleges is also not consistently available’ (HM Government, December 2017). The Green Paper consultation with stakeholders and sets out proposals seeking to achieve earlier intervention and prevention, a boost in the support for the role played by schools and colleges and better/faster access to NHS services113. 8.It has three key elements: Every school and college to identify a Designated Senior Lead for Mental Health to oversee the approach to mental health and well-being; The funding of new Mental Health Support Teams supervised by NHS CAMHS staff to provide extra capacity for early intervention and ongoing help. The teams would be linked to groups of primary and secondary schools and colleges, providing supportive interventions to children with mild to moderate needs and the promotion of good mental health and wellbeing; Trialling a four week waiting time for access to specialist NHS CAMHS services. 110 Tiers 1 and 2 are provided at Universal and Early Help levels (e.g. through existing school and voluntary sector counselling services). Tier 3 is CAMH’s community based, out-patient service provision and Tier 4 is CAMH’s in-patient hospital service. 111 I.e. The Local Transformation Plan. 112 Transforming Children and Young People’s Mental Health Provision (December 2017) 113 See page 3, Executive summary of above reference at 14 for a list of government commitments and achievements. Page 75 of 75 9. The approach is envisaged to be rolled out to at least a fifth to a quarter of the country by 2022/23, securing funding after 2020/21, depending on future spending review decisions. 10.Criticism from the Children’s Commissioner (October 2017) has highlighted the limited and ‘unacceptably slow’ progress made over the last few years in improving CAMHS services. It notes that nearly 60% of local areas are failing to meet NHS England’s own benchmarks for local area improvement and over 55% of local areas are not meeting those standards on providing crisis care in Emergency Departments in hospitals and other settings. 11.A recent Care Quality Commission (CQC) thematic review (October 2017) on CAMHS services concluded with the following key messages which are relevant to this SCR: The system for CAMHS is complex and fragmented with different parts of the system not always working together in a joined up way. It is highly fractured because of the many organisations that commission and provide services across the four tiers of services; Poor quality data prevents a clear understanding of demand and access patterns across England, although the available data suggests that demand is rising across the system; Early opportunities to provide support are being missed because staff working in primary care settings and schools lack the necessary skills in mental health; This is placing specialist services under increasing pressures and children are having to wait longer for admissions; Most NHS specialist services are rated as good or outstanding, albeit there is variation in the quality of care; Safety remains the CQC’s biggest overall concern about specialist services, followed by staffing matters and a lack of person-centred care approaches in some services. |
NC52306 | Serious non-accidental injuries to an 8-weeks-old infant boy in February 2017. Learning is included in recommendations. Recommendations include: have appropriate training to ensure marks to a non-mobile baby are referred to the Non-Mobile Baby Pathway with due regard to safeguarding, and consider using photographs when identifying any marks or bruises in non-mobile babies; discharge babies in line with the infant feeding protocol, including close liaison between midwifery and the health visitor; review the midwifery visiting regime to ensure that it addresses the needs of babies and families; transfer significant history about the health needs assessment, antenatal and postnatal information to the child's records so that this information is available to health visitors; consider the effectiveness of handheld records and provide guidance about when direct communication and information sharing between professionals is needed; there is a need to provide professional continuity; GPs should record who was present during consultations about a child and whether this involvement was in person or by telephone; make GPs aware of their safeguarding responsibilities and ensure the Bruising in non-mobile children policy is embedded within their practices.
| Title: Serious case review overview report: Ethan. LSCB: Durham Local Safeguarding Children Board Author: Amy Weir Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW OVERVIEW REPORT Ethan Endorsed 20.05.2019 Amy Weir MA MBA CQSW INDEPENDENT REVIEWER 2 | P a g e Contents Introduction ............................................................................................................................... 3 Background ................................................................................................................................ 3 Parallel Proceedings………………………………………………………………………………………………………………..4 The SCR: Process and Methodology ........................................................................................... 4 Independence ............................................................................................................................ 7 Serious Case Review Panel ......................................................................................................... 8 Confidentiality ............................................................................................................................ 9 Family involvement .................................................................................................................... 9 Staff involvement ....................................................................................................................... 9 Race, Religion, Language and Culture ........................................................................................ 9 Summary of Family history ....................................................................................................... 10 Overview of events and agency involvement: 2006 to 2017 .................................................... 12 The SCR Key Lines of Enquiry: Analysis ..................................................................................... 12 Lessons Learned ....................................................................................................................... 20 Summary analysis ..................................................................................................................... 21 Multi Agency Recommendations ............................................................................................. 24 Actions for Single Agencies....................................................................................................... 25 References ................................................................................................................................ 28 3 | P a g e Introduction 1. The Durham Safeguarding Children Board (LSCB) agreed in November 2017 to commission a Serious Case Review (SCR) into the serious non-accidental injuries sustained by Ethan when he was aged 8 weeks. 2. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 sets out the requirement for Local Safeguarding Children Boards to undertake reviews of serious cases where: I. Abuse or neglect of a child is known or suspected; and II. Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board Partners or other relevant persons have worked together to safeguard the child. “Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following: • a potentially life-threatening injury; • serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. Background 3. Ethan is the third and youngest child of his parents. 4. In February 2017, when Ethan was 10 weeks old, his parents called an ambulance after Ethan had become unresponsive. Ethan had bruising to his face and chest which mother said had been caused by Ethan flinging himself against his father’s face and bruising to Ethan’s chest from being winded. Ethan, aged 10 weeks, suffered multiple injuries including swelling and bleeding to the brain and numerous fractures to the ribs and limbs. 5. There had been limited multi- agency involvement with the family prior to these non- 4 | P a g e accidental injuries to Ethan. Parallel Proceedings 6. There has been a criminal investigation by Durham Police and following a criminal trial in 2019, both parents were found guilty of two counts of causing or allowing serious physical harm to a child. The SCR: Process and Methodology 7. The Local Safeguarding Children’s Board (LSCB) agreed in November 2017 to commission an SCR. The scope of this SCR was to cover the period from May 2016 to February 2017 in the review. 8. The SCR Sub-Committee recommended that the LSCB should conduct a proportionate, appropriate and participative SCR with the emphasis upon professional involvement to address how agencies had worked together in this case to identify any learning and aggregate lessons from individual organisations and to ensure that an improvement action plan was put in place. 9. Working Together to Safeguard Children (2015) provides guidance for undertaking a Serious Case Review and sets out the purpose and requirements : To provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; Be written in plain English and in a way that can be easily understood by professionals and the public alike and be suitable for publication without needing to be amended or redacted. 10. The methodology adopted for this review was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). 11. This process facilitates the involvement of practitioners in the review so that they can reflect 5 | P a g e together on the case and the learning from it in an informed and supportive way. 12. A Serious Case Review Panel was convened of senior representatives from local agencies involved with the family. This group provided oversight of the review. None of the panel members had any direct professional involvement with the family. The panel supported the Lead Reviewer in considering the evidence and developing the recommendations. 13. There was limited agency involvement with the family and no specific safeguarding concerns raised prior to the non-accidental injury of Ethan. The following agencies were asked to provide a chronology or brief summary of involvement and these were integrated into a combined chronology. Durham Constabulary Primary Care County Durham & Darlington NHS Foundation Trust Harrogate & District NHS Foundation Trust North East Ambulance Service NHS Foundation Trust Durham Children & Young People’s Services 14. The Lead Reviewer was provided with the combined chronology and agency summaries of involvement so that she could consider in detail the sequence of events and identify any key practice episodes relating to those events. 15. The LSCB SCR Panel agreed the terms of reference for the SCR in addition to the terms of reference set out in national guidance. 16. The SCR panel also commented on the key lines of enquiry included in the terms of reference. The key lines of enquiry were: i. The pattern and frequency of visiting by the community midwives including postnatal review. 6 | P a g e ii. Mother and Ethan’s discharge from the midwifery service including the robustness of the assessment prior to discharge. iii. The robustness of the handover between the Midwifery Service and Health Visiting Service. iv. The reason for the number of changes of key professionals during the scoping period and whether this had an impact on the quality of practice. v. The response and actions following Ethan’s attendance at the GP Practice with a history of marks, specifically: whether the appropriate policies and procedures were followed; the liaison and information sharing with other key professionals; whether the attendances were seen in isolation; whether previous information pertaining to the family were taken into consideration. vi. How effective and timely was the communication and information sharing between key professionals? vii. How Health professionals utilise the handheld baby record when reviewing Ethan’s health and development. viii. The response by professionals to mother’s reported low mood and whether they considered the impact on the children. ix. There was a lack of information in respect of Ethan’s father. 17. The SCR has been carried out following a ‘whole system’ approach involving key front line practitioners who worked with the family in a Learning Event held in November 2018. Throughout the review process Ethan and his experience was the central focus of the review process and particularly in relation to the Learning Event. Independence of The Review 18. The Lead Reviewer, Amy Weir, is an experienced independent safeguarding expert. She has completed more than 20 serious case reviews nationally over the past few years. Amy Weir wrote this report with the support of the LSCB Serious Case Review Panel. 7 | P a g e Serious Case Review Panel 19. The SCR Panel met on a number of occasions between January and December 2018. The overview report was ratified at the Executive Group in May 2019. 20. The SCR Panel members were: Title Organisation Independent Safeguarding Expert Chair & Reviewer Business Manager Durham LSCB Admin Co-ordinator Durham LSCB Detective Superintendent – Force Lead for Safeguarding Durham Constabulary Named Nurse Safeguarding Children & LAC North Durham, DDES CCGs Named Nurse Safeguarding Children County Durham & Darlington NHS Foundation Trust Named Nurse Safeguarding Children Harrogate & District NHS Foundation Trust Named Lead Professional for Safeguarding North East Ambulance Service NHS Trust Strategic Manager – One Point and Think Family Services Children & Young People’s Services – Durham County Council Health & Wellbeing Operational Lead Education Durham – Durham County Council Confidentiality 21. Working Together to Safeguard Children 2015 sets out a requirement for the publication in full of the overview report from SCRs: “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request.” 22. When the report is published it will be fully anonymised to protect the identity of the family and the children. 8 | P a g e Family involvement 23. The parents were made aware that a Serious Case Review was being undertaken and were invited to contribute. They had a meeting with the LSCB Business Manager in January 2018, and a note of the meeting was provided to the Lead Reviewer. 24. Given that there are other parallel proceedings in place – possible criminal proceedings and recent care proceedings - the Lead Reviewer has not been able to seek the views of parents regarding the services they received. Staff involvement 25. The staff who were involved with Ethan and his family participated in a Practitioner Event in November 2018. The Learning Event was attended by twenty professionals in addition to the Lead Reviewer, who facilitated the event, and the LSCB Business Manager and the LSCB Admin Co-ordinator. The Learning Event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012). Notes of the event were taken. 26. The discussion at the Learning Event and the points identified for further action were collated and these were used to inform the Lead Reviewer’s analysis for the overview report. Summary of Family history 27. The timescale for this review is limited to the period during the pregnancy with Ethan in May 2016 to February 2017 when it was identified that Ethan had incurred multiple fractures. 28. Within the review there was limited information ascertained about the wider family history. What has been gleaned from collating the information available is integrated within the body of this report. 9 | P a g e SCR Key Lines of Enquiry: Analysis 29. This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for the LSCB and partners. 30. The key lines of enquiry for the SCR were explored through the process of the Learning Event and considered together with the details submitted in individual agency chronologies and brief summaries of involvement. 31. The analysis also draws upon relevant research and upon findings from other serious case reviews. 32. The Midwifery response to meeting Ethan and his mother’s needs. i. The pattern and frequency of visiting by the community midwives was explored to determine whether it was sufficient and in accordance with good practice given Ethan’s low birth weight. The decision to discharge Ethan from hospital following his birth was based on him being fit for discharge which was discussed at Multi-Disciplinary meeting in the hospital. A meeting was held, and it was acknowledged that Ethan was small, however, it was agreed that he could be discharged. This was communicated to the Community Midwife on the day of Ethan’s discharge and she arranged a home visit the following day. On reflection at the Learning Event, it was agreed that the telephone notification to the Community Midwife was not appropriate in this case and there should have been a verbal handover given Ethan’s vulnerabilities; his birth weight was very low, and he was his mother’s third child in three and a half years. It is apparent from the midwifery records that there was a limited pattern of visiting Ethan by the midwives and one consultation took place by telephone. The Health Visiting and Midwifery Partnership – pregnancy and early weeks guidance for birth visit to 10-14 days – sets out the required activity for a midwife with the number of visits to be made linked to the specific circumstances. In terms of learning there is a need for a greater emphasis on and clarity about how long Community 10 | P a g e Midwifery provide care in the community during the postnatal period, particularly those with vulnerabilities. In this case there were particular vulnerabilities - Ethan was born at 37 weeks and was small and thin for his gestational dates and it is well-evidenced that caring for such babies can be very difficult for parents to cope with especially with other very young children in the household. ii. It appears that the midwifery service discharged mother and Ethan by telephone on Day 18 without challenging why mother had not attended the 13-day and 16-day postnatal review and without any verbal handover to the health visitor. It appears that mother had self-reported that she and Ethan were doing well, but there is no evidence that this was verified prior to discharge by the midwifery service. This was a delimited response which did not evidence any professional curiosity about why mother had not attended. The fact that no follow-up visit was completed meant that an opportunity to check on Ethan and his progress was missed. This led to the parents being the main source of information about Ethan’s weight, how he was feeding and what problems they were raising. Given Ethan’s small size and low weight, this lack of direct confirmation is of concern. iii. There was a gap in Ethan being seen from Day 5 following birth to the home visit undertaken by the Midwife. Ethan was seen by the midwife at home on the third day and the fifth day after birth but not thereafter. There was no professional visit for this vulnerable baby for nine days. This seems a very limited response and not within guidelines. It is of note that father contacted 111 on two occasions in December which suggest that the parents were struggling more than they admitted when seen. iv. There was no record of a handover between the Midwife and Health Visitor. There is no evidence that there was a discussion with the health visitor; this would have enabled consideration between them of Ethan’s small size and low birth weight, lack of engagement by mother and the parents’ caring responsibilities of two other young children at home. Previous Serious Case Reviews in Durham have highlighted that some information including the 11 | P a g e antenatal and postnatal risk assessment is not transferred to the child’s records when born and this information stays on the mother’s records which are only with the midwife and so not available for the health visitor to access directly. The postnatal handover report was not readily accessible to the Health Visitor and was only found during information gathering for this Serious Case Review. National guidance recommends that by day 14 post birth, all women, particularly those with identified vulnerability or need, have received a joint handover/contact visit with their midwife and health visitor; it is recommended that this be a home visit. At discharge of vulnerable women and women who require midwifery input after day 14, the midwife and health visitor to have completed and recorded a verbal handover in addition to a written handover (NICE 37). Ethan was very low in weight and we know that mother and father were seeking advice about his feeding and oral thrush. 33. There are some questions to consider in relation to the Health Visiting Service. v. Would home visits have been more appropriate than clinic visits given Ethan’s low birth weight and Intrauterine Growth Retardation (IUGR)? Suggesting to mother that she took Ethan to the clinic depended on her taking him. Prior to Ethan’s birth mother had attended all the required appointments but after his birth she missed several specific appointments, but this was not followed up thoroughly. Therefore, relying on clinic appointments for Ethan was risky and did not allow for more observation of the care Ethan was receiving. However, there were only two clinic appointments. vi. There were several changes of key professionals during the scoping period and there is a need to consider the reasons for the changes of professionals and whether this had an impact on practice. There were three different health visitors involved. It was apparent from the contributions made by practitioners attending the Learning Event that this happened for a variety of different reasons. Cover over the Christmas period did not seem to be an issue. One health 12 | P a g e visitor change was requested by mother and this was accepted and a new health visitor was allocated. 34. GPs’ contact with Ethan. vii. There is a need to consider the history of marks on Ethan and the GP’s response to these. Three different GPs saw Ethan during the review period. From information gathered at the Learning Event, the parents called the GP between Christmas and New Year December to ask for advice about a purple mark on Ethan and they were advised to bring him to see the GP. It appears that the GP who saw Ethan the day after the telephone call, noted a small red mark on the right side of his forehead which was 4mm and thought to be a spider-nevus and not a bruise. There was also a small spider-nevus noted on his left shoulder. As there was no apparent history of trauma, arrangements were made for this to be followed up four weeks’ later. As the marks were not regarded as suspicious the Bruising to Non-Mobile Babies pathway was not followed. There is no indication that safeguarding was considered which, given Ethan’s young age and immobility, it should have been. viii. Why was the marks seen on Ethan’s face not included within the letter to the Paediatrician for a review of Ethan’s growth following his 6 weeks’ check? Ethan and both parents attended for the 6-8 week check and there were no concerns regarding the interaction between Ethan and both parents. A mark on Ethan’s right check was noted as well as the previous attendance in December. As the main issue was the drop in weight, Ethan was referred to Paediatrics for an urgent growth pattern. On reflection, those at the Practitioner Event felt that the Bruising to Non-Mobile Babies pathway should have been initiated and the body map utilised. Mother reported to the Health Visitors on two occasions that Ethan appeared to mark easily, and these marks would come and go. Mother told the Health Visitors that she had seen the GP about this. The Health Visitors confirmed that they did not observe any marks during her contacts with Ethan. The Health Visitor reviewed the GP records and noted that Ethan had already been seen and assessed and this was positive practice on checking events. The GP referral letter to Paediatrics probably should have included reference to the marks presented to 13 | P a g e the GP and discussed by mother with the Health visitors. Non-accidental injury in a non-mobile baby needs to be considered and not ruled out. None of these professionals involved with Ethan compared notes and spoke directly about what they were seeing and hearing and as a result the possibility of a focus on non-accidental injury was missed. 35. There are issues to consider about the quality and frequency of communication between the health professionals involved and Ethan and his family. ix. How effective was the communication between the Health Visitor, the GP and the Practice Nurse in sharing information about this bruising, Ethan’s weight and other contact with the practice about Ethan’s health? What is the protocol for this and what are the expectations? What, if any, contact did take place in relation to the bruising and Ethan’s weight? Overall, there was little evidence in the records of direct communication between these professionals. As far as the marks on Ethan’s body are concerned, this was perhaps an opportunity when information about this should have been shared. According to the GP records, the Health Visitor completed a body map in mid- on 19th December which showed no mark on Ethan’s body. It was discussed at the Practice Learning Event that there is no consistent template for Health Visitors and GPs to use for body map recording and that this is an area of learning to ensure consistency. It was shared at the Learning Event that families that are vulnerable or where there are safeguarding concerns are discussed at the GP Practice Safeguarding meetings which are attended by GPs, Health Visitors and Midwives. In this case the family was not identified as vulnerable or having safeguarding concerns, therefore, they were not discussed at this meeting. This was a missed opportunity when in fact there were several vulnerabilities particularly Ethan’s low weight. Monitoring Ethan’s weight was not given sufficient focus through the use of shared centile charts to plot progress. The Paediatric discharge letter sent to the GP stated erroneously that Ethan had large birth weight when in fact it was low at 1910g – below the 0.4th centile. 14 | P a g e x. Was communication between them through SystmOne effective and timely? The attendance and presentation for oral thrush needed to be explored. About which there was no communication between the GP Practice and Health Visitor when Ethan was prescribed medication for this. The lack of sharing of information and practice is concerning. Professionals were not directly sharing information with each other either. Whilst the health visitor and, prior to that the midwife, were in touch with family separately so too was the GP practice, three GPs and three Practice Nurses. As far as electronic recording and sharing is concerned, the midwives do not use SystmOne postnatally and they document information in the child’s handheld record. GPs have two electronic systems – SystmOne and EMIS and only Community Health staff have access to SystmOne which causes problems in terms of information sharing. There was little evidence of professional curiosity around the oral thrush and its unusually persistent nature and little evidence of liaison between the Health Visitor, Midwife and GP about this issue and further advice on this issue needs to be considered. It is usual practice for Health Visitors to flag significant events as an electronic task to the GPs in order to maintain an audit trail of communication. Regarding the issues regarding Ethan’s weight, on reflection the Health Visitor should have followed up the task to the GP by telephone to ensure that Ethan was seen in a timelier manner. The Practice Nurse identified oral thrush and worked with mother regarding this issue but there appears to be no contact with the Health Visitor about this. xi. Was the handheld baby record utilised during Health professionals’ contact with Ethan in monitoring Ethan’s weight given his low birth weight. It is the role of the community midwife to explain to parents the way the handheld baby records are to be used but there is no recorded evidence that this occurred. Dependence on these handheld records means that professionals have to rely on the parent to bring and share those records when the child is seen. It is not clear that this happened in Ethan’s case and in the absence of direct communication between professionals this was a further missed opportunity to share information between them. There 15 | P a g e was no evidence that Health professionals were aware that mother had lost Ethan’s handheld baby records. On reflection, the Health Visitor felt that she should have observed Ethan taking a full feed and should not have taken mother’s information that he was feeding at face value. It is not required that feeding is observed but should this be reconsidered for babies of such low birth weight especially when he seemed to be making such limited progress. xii. The response by professionals to mother’s reported low mood and whether they considered the impact of the children Mother reported feeling low in mood during several contacts but in the records, there is a lack of evidence that anyone, except the health visitor, had asked mother how she was coping with Ethan and the other two children and suggested action to support her. The Health Visitor sent a task to the GP. The issues regarding mother’s low mood was discussed at the Learning Event and it was reported that this had been identified just prior to the identification of non-accidental injury to Ethan. On reflection, it was agreed that the Health Visitor should have followed up the task to the GP by telephone, however, in this case it would not have made a difference to the outcome. HV1 used the Edinburgh Postnatal depression scale with mother and she offered her listening visits. Also at the Learning Event it was reflected that consideration should have been given to providing intervention in terms of mother’s low mood. In terms of early help, universal services provided support to the family in terms of housing and Early Years provision. On reflection, it was felt that a more holistic approach was needed in this case. Issues such as the vulnerability of Ethan, the fact that parents had three children under the age of 5 years, and the number of house moves should have been considered. There is comparatively little mention of father in the records. However, he was present for almost all of the contacts between practitioners and mother. It was father who initiated two calls to 111. There is no description in the records of him and the focus is solely on mother and this is a significant gap in practice for understanding all those involved in Ethan’s life. On one occasion mother told the Health Visitor that she found it difficult to talk in front of father and the children about her own feelings and needs. There is no evidence that this cue was followed up. 16 | P a g e Lessons Learned – Positives and gaps in practice 36. From the accounts of the professionals who attended the learning event that there were many positives in the practice with this family identified. i. At booking a vulnerability assessment was completed which was a tool used to identify vulnerabilities. In this case it was felt that there were no vulnerabilities or additional needs identified. ii. Mother was encouraged by both Midwifery and Obstetrics to engage with Smoking Cessation, however, she still declined this. iii. The Health Visitor had reviewed the family’s previous Health Visitor’s records but on reflection she felt she could have also spoken with them as well. iv. An assessment of mother’s mental health using the Edinburgh tool was completed and mother was offered the Listening Service. Mother’s low mood was explored, and mother felt that as she had young children she found difficult to focus on herself but intended to see the GP about this. v. The Practice Nurse identified oral thrush and worked with mother regarding this issue. vi. The Health Visitor and the GP identified Ethan’s continuing weight gain issues. The Health Visitor prompted the GP about this. The GP made an urgent routine referral to Paediatrics. vii. After the 999 call was made, there was an immediate safeguarding referral submitted and notification to the Police by the Ambulance Service. viii. The work of Emergency Department’s staff to address Ethan’s critical medical needs was prompt when he presented at hospital in February 2017. 17 | P a g e Summary Analysis 37. The ante-natal booking process was thorough, but the midwife was not aware that mother had sought an early termination of this pregnancy. This was a system issue and a missed opportunity to explore this further, particularly the reason why she changed her mind. 38. A multi-disciplinary discharge planning meeting should have been convened to consider all the factors, Ethan’s low birth weight and phototherapy and a plan put in place regarding visiting patterns. Ethan would not have been discharged if he was not medically fit for discharge. 39. The level of postnatal visiting by the midwifery service to the home was lower than might have been expected given the child’s circumstances of low birth weight. The postnatal contact should have taken place in the form of a home visit as opposed to a telephone call. 40. There was a lack of thorough and verbal communication between health professionals in terms of Ethan’s discharge from hospital and then from midwifery care to the health visitor. 41. This resulted in a single professional’s approach without appropriate sharing and checking out of information they each had. For example, Ethan’s weight could have been more effectively monitored through shared use of a centile chart so that every time he was seen the situation could be reviewed and updated. 42. The GPs approach to the contact with Ethan was from a medical and clinical point of view as opposed to a holistic assessment and each contact was seen in isolation. 43. There were many positive indicators that the parents were coping and managing Ethan’s care appropriately. i. Ethan’s parents were already parents and there had been only one previous minor concern about the care of one of the other children. ii. The parents were in a long term relationship and father was the biological father of all three children. iii. Father’s interaction with Ethan was observed to be positive and there was no evidence of 18 | P a g e maternal ambivalence between Ethan and his mother. iv. The parents engaged with agencies including Midwifery, Health Visiting and the GPs. v. There were no significant events identified during the Primary health visitor visit. Parents were present during Health Visiting visits and engaged well with the Health Visitor and a positive interaction was noted between Ethan and his parents. vi. Parents sought advice from services such as 111, GP, Practice Nurses and Health Visitor. vii. There were no issues regarding the presentation of the other children. viii. The family had local extended family support. 44. There were also some significant vulnerabilities for Ethan and the family and areas not fully explored with appropriate professional curiosity. Some of these were identified but others were not fully discussed or shared. i. All three children of the family were all born close together. ii. Mother had sought an early termination of this pregnancy iii. Ethan’s low birth weight. iv. Smoking in the household by both parents and by mothers during pregnancy increases the risk of respiratory illness in children under one years of age. v. Smoking during the pregnancy. Mother was offered Smoking Cessation at various points during pregnancy and she declined this. vi. Information about how Ethan was feeding, and his progress relied to a conservable degree on self-reporting by mother. vii. Father was always present at home visits which resulted in little opportunity to explore with mother on her own if there were any issues she needed to discuss including any possible domestic abuse. Mother stated that she felt inhibited to speak when the children’s father was present. viii. Generally, there was a lack of consideration of father as all the focus was on mother. 19 | P a g e 45. Improvements have already been made to service delivery since Ethan was injured. i. The booking process was already improved at the point that Ethan was conceived due to learning from previous Serious Case Reviews. ii. Improvements have been made to the antenatal risk assessment in that relevant history is obtained in respect of both parents. The risk assessment is more in depth in terms of the questioning to facilitate professional curiosity. The risk assessment has also been revised to include the Home Environment Assessment Tool. The antenatal risk assessment is scanned and shared with the Health Visiting Service. iii.Mother had sought an early termination of pregnancy and this was a systems issue and a missed opportunity to explore this further, particularly the reason why she changed her mind. This is now part of the Health Needs Assessment in terms of whether the pregnancy was planned and the views of both mother and father regarding the pregnancy. This is also now part of the antenatal risk assessment and this line of questioning takes place at booking. iv. CO monitoring is now offered to monitor the CO levels of both mother and father. There are now interventions visually in terms of the effects of smoking during pregnancy on the placenta which was found to be extremely impactful. v. There is now a greater emphasis on perinatal mental health which is discussed as part of the postnatal risk assessment and this is an area of improved practice. vi. The Health Visiting Service now has a Vulnerable Parent Pathway. However, in this case the family would not have met the criteria as it only considers current and not historical vulnerabilities. vii. The Family Health Assessment Tool is now more in depth and includes the role of the father. viii. The template for the 8-week baby check has been revised and now includes more information around safeguarding and body maps. 20 | P a g e ix. The Faltering Weight Policy was reviewed and revised by Harrogate & District NHS FT in light of the learning identified from this case. Multi Agency Recommendations for the DSCP 46. DSCP to seek assurance that the relaunch of the Bruising to Non-Mobile Babies Protocol has had an impact and that there is appropriate training in place to ensure that any marks to a non-mobile baby is referred to the Non-Mobile Baby Pathway with due regard to safeguarding, and the use of photographs should be considered when identifying any marks or bruises in non-mobile babies. 47. In terms of Early Help, the support they received focused on Housing issues and Early Years provision rather than support to mother’s and father’s parenting and well-being. A more holistic approach is needed. Advice to be provided to ensure that holistic needs and not just practical needs. Actions for Single Agencies 48. The agencies involved in the review have each developed an individual agency action plan to deliver improvements identified. The delivery of the improvement plans will be monitored through the Serious Case Review Thematic Tool maintained by the LSCB Business Unit. Midwifery 49. The discharge of Ethan was not in line with the Infant Feeding Protocol and there should have been closer liaison with the Health Visitor, so these processes need to be reviewed and updated to ensure that they are effective. 50. The midwifery visiting regime needs to be audited and reviewed to ensure that it is addressing the needs of babies and families. 51. The quality and requirements of postnatal care should be reviewed, and staff reminded of these requirements. 52. The handover process between Midwifery Service and Health Visiting Service needs to be 21 | P a g e reviewed and updated, if necessary, to ensure that it complies with national and local guidance. 53. Significant history, the Health Needs Assessment, antenatal and postnatal information in the mother’s midwifery notes should be transferred to the child’s records so that this information is readily accessible to health visitors. 54. The effectiveness of the use of handheld records needs to be considered and guidance provided about when direct communication and information sharing between professionals is required. 55. Much of this activity was during a holiday period with many different professionals being involved and there is a need provide guidance about the need to seek to provide professional continuity – GP, Health Visitor, Midwifery. 56. The Trust to consider adopting Harrogate & District NHS FT’s Faltering Weight Policy. Primary Care - Health Visiting and GPs 57. Communication and information sharing needs to be improved in terms of liaison around the care of young infants particularly between the GP and Health Visitor but also considering the contact with Practice Nurses. 58. The effectiveness of the use of handheld records needs to be considered and guidance provided about when direct communication and information sharing between professionals is required. 59. Standardisation of documentation and the use of templates such as body maps should be considered to ensure consistency between Health professionals, e.g. GP and Health Visitor. The shared use of centile charts by Health Visitors and GPs should be considered in case of low birth weight babies. 60. GPs need to document who was present or spoken to in consultation with clarity about when 22 | P a g e these were by telephone and when in person with the child being seen. 61. GPs should be made aware of their safeguarding responsibilities and ensure the Bruising in non-mobile children policy is embedded within their practices 23 | P a g e References Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010 Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12: New learning from serious case reviews: a two year report for 2009-2011 Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – 2015 Department of Health – Public Health England – Health Visiting Programme: Pathway to support professional practice and deliver new service offer: Health visiting and midwifery partnership – pregnancy and early weeks. Durham LSCB – Bruising in Children Pathway - adapted with permission from Hampshire LSCB Updated 25/10/13 Final version 24 | P a g e NICE Postnatal care up to 8 weeks after birth: Clinical guideline [CG37] Published date: July 2006 NSPCC 2011 - All Babies Count NSPCC Learning from SCRs 2018 NSPCC Learning from case review briefings - Summary of risk factors and learning for improved practice around working with children aged two and under - November 2017 Welsh Government – Protecting Children in Wales – Guidance for Arrangements for Multi-Agency Child Practice Reviews (2012) |
NC52309 | Death of a 7-year-old boy, in 2018 at his maternal grandparents home where he had been living with his mother and sibling. His mother admitted killing Child R and in January 2019 was found not guilty of murder by reason of insanity. Learning includes: a disconnect between the help provided to adults and help to children in the family; the impact of mothers physical and mental health conditions on her children was not fully explored or understood; indications that the children were being adversely affected by their home situation were not fully assessed. Recommendations: need for practitioners to think family and identify barriers that prevent these principles being implemented in practice; mental health providers should communicate the outcome of their assessments including non-engagement back to GPs; adult mental health services should revise their clinical assessment model and training to include a risk assessment of the impact on children where a parent has a mental illness; child mental health services should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and always consider at the point of triage whether a child may be at risk of harm; need for effective two-way information sharing between statutory and non-statutory providers to facilitate the most effective help to children and their families.
| Title: Serious case review: Child R. LSCB: Essex Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Child R December 2020 Jane Wonnacott Lead Reviewer MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd ESCB SCR Child R Report Page 2 of 32 Contents 1 INTRODUCTION ........................................................................................................... 3 2 THE REVIEW PROCESS ............................................................................................. 4 3 CASE SUMMARY ......................................................................................................... 5 4 REVIEW FINDINGS .................................................................................................... 11 5 SUMMARY OF RECOMMENDATIONS ..................................................................... 24 6 APPENDIX ONE – TERMS OF REFERENCE ............................................................ 27 7 APPENDIX TWO – PRACTITIONER DISCUSSIONS ................................................ 32 ESCB SCR Child R Report Page 3 of 32 1 INTRODUCTION 1.1 Child R, aged seven, died in 2018 at his maternal grandparents’ home in Essex. He had been living in the home with his mother and nine-year-old sibling. Mother was arrested, admitted killing Child R and in January 2019 was found not guilty of murder by reason of insanity. She was given an indeterminate hospital order. 1.2 At the time of Child R’s death, records showed that Mother had a long history of physical and mental health problems and was an open case to mental health services. As a child had died as a result of abuse by a mental health service user the case met the criteria for both a child serious case review and an independent mental health homicide investigation by NHS England.1 1.3 Prior to their move to Essex in November 2016, Mother and the children had lived with her ex-husband in Southend. Much of their contact with agencies had been whilst living in Southend, and Essex and Southend Safeguarding Children Boards discussed who should lead the serious case review process. It was agreed that as the children had resided in Essex at the time of Child R’s death the review would be led by Essex, with Southend agencies contributing to the review and joining the review team. Although some of the learning has general applicability beyond the local area, most recommendations focus on either services in Southend or health trusts that work across both local authority areas. 1.4 The decision to carry out a serious case review took place after new statutory guidance came into force in 20182 and prior to new partnership arrangements for safeguarding children being in place in Essex and Southend. Arrangements for initiating this review and publishing the report have therefore remained with Essex Safeguarding Children Board but it is important that the final recommendations are considered and responded to by both Essex and Southend Safeguarding Children Boards/Partnerships. 1.5 The focus of this serious case review is Child R. Due to the circumstances of his death many of the recommendations of this review relate to the way in which risks to children can be recognised by practitioners working with adults with physical and mental health problems. This may inadvertently result in the voice of Child R being lost within the review process and this is not the intention of this review. The main picture given though records and from discussion with family and practitioners is of a child who was loved by his extended family and was a happy boisterous child within school. There were ways in which family circumstances can now be understood to have had an impact on him and this is explored here relevant in the body of this review report. 1.6 The investigation by NHS England focusses in more detail on the NHS services provided to Mother and can be accessed separately, however it should be noted that 1 NHS England Serious Incident Framework (March 2015) https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incident-framwork-upd.pdf 2 HM Government (2018) Working Together to Safeguard Children ESCB SCR Child R Report Page 4 of 32 the two reviewers have worked closely together in finalising the findings and recommendations of this review. It is therefore important that both reports are considered together when planning a response to this review. Recommendation One This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will be joint planning in response to this report and the NHS England independent mental health homicide investigation. 2 THE REVIEW PROCESS 2.1 An independent lead reviewer was commissioned to carry out the review on behalf of Essex Safeguarding Children Board. An initial meeting was held by the lead reviewer with the family including Maternal Grandfather, Maternal Grandmother, the father of Child R, Maternal Aunt and Child R’s sibling. 2.2 In order to avoid duplication, terms of reference3 were jointly agreed with the independent investigator from NHS England and the independent reviewers worked together throughout the review. This has resulted in two separate reports that have been informed by the other with continuity in the recommendations made for the health agencies concerned. 2.3 The terms of reference stipulated that the start date for the detailed chronology should be the point that Child R started school in September 2015 and finishing on the date of his death. Agencies were asked to identify any significant information prior to this date. This is included in this report and has proven to be important in contributing to the final analysis. 2.4 Agency chronologies were received from: ➢ Essex Partnership University NHS Foundation Trust (EPUT) ➢ Essex Police ➢ Local Council ➢ Southend University Hospital NHS Foundation Trust (SUHFT) ➢ NHS Southend Clinical Commissioning Group - CCG (GP services) ➢ North East London NHS Foundation Trust ➢ Southend Early Help ➢ Southend Education ➢ Open Door ➢ Southend Adult Services ➢ Southend Housing ➢ The Advocacy Service Provider ➢ South Essex Advocacy Services 3 See Appendix One for full terms of reference ESCB SCR Child R Report Page 5 of 32 2.5 Mental Health services also carried out a Serious Incident Review and this was made available to the serious case review. Reports were also received from psychiatrists who provided expert evidence for the criminal proceedings. 2.6 As well as the meeting with family members at the start of the review, the independent reviewers have also met with Mother. The review team are very grateful for the contribution of the family and their views have informed the findings set out in this report. 2.7 The review included discussions with practitioners who had been involved with the family and a list of those who contributed can be found in Appendix Two of this report. A final draft was shared with all those practitioners who had contributed in order to check for factual accuracy and enable a multi-agency discussion of learning from the review process. 2.8 The final report was shared and checked for accuracy with Child R’s family prior to publication. 3 CASE SUMMARY 3.1 Mother reported a long history of physical problems associated with fibromyalgia stretching back to childhood. After her marriage and the birth of her two children she is described as spending two years in bed, being unable to leave the home on many occasions and needing to use a mobility scooter. Mother and Father separated in 2012, Father later returned to the home in Southend to care for his children due to the severity of Mother’s physical impairments. 3.2 The following table summarises key contacts with the family up until the two weeks prior to Child R’s death. This is followed by a more detailed description of the events leading up to the fatal incident Services for Mother Services for Children Feb 2014 Mother was seen by Therapy for You (IAPT)4 and scored high on all three assessment tools but was discharged from the service as she did not attend the next two appointments. A subjective interpretation of the scores noted that she was frustrated with her physical/medical condition and perceived lack of support from medical professionals. Feb 2014 Six days after the IAPT assessment Mother was seen in the Emergency Department of Southend General Hospital having taken an overdose and was referred for a mental health assessment. She was discharged to 4 IAPT is Improving Access to Psychological Therapies and is an NHS service designed to offer short-term psychological therapies to people suffering from anxiety, depression and stress. ESCB SCR Child R Report Page 6 of 32 GP care and referred to outpatient psychiatry and psychotherapy services. She was then assessed by the mental health clinical assessment service and the assessment noted no risk to the children. Mother was referred back to the GP as it was considered that she had appropriate help in place via IAPT. There was no further consideration by the GP of any implications for Mother or the children as a result of her disengagement from IAPT. Oct 2014 Father referred Mother to Southend Adult Social Care due to her physical ill health and mobility problems. He also mentioned depression. This resulted in an occupational therapy assessment which focused mainly on her physical problems and adaptations needed to the home. Jan 2015 Child R’s sibling (age six) was referred to Child and Adolescent Mental Health Services with symptoms associated with anxiety. Following an assessment and five sessions, the symptoms were noted to be improved. The assessment was thorough, included a genogram and noted Mother’s overdose although there was no communication with the sibling’s school. March 2015 The school referred to Family Action5 for family support and a support worker started home visits. The school’s view is that risks at this time were managed by Father living in the home but would increase if he left. April 2015 An advocate was working with Mother and made a referral to Southend Adult Social Care for a holistic assessment. After a home visit the social worker recommended direct payments so that Mother could source her own support, but this was turned down by the allocation panel who advised reablement. After visits by the reablement team Mother reported some improvements. Sept 2015 Father was planning to move out and the case was closed to reablement in September 2015 as Mother was described as “not compliant with the assessment”. The record notes that Mother was given the access teams number for when father moved out as she would need help with the children. Child R started primary school. Family Action liaised with the pastoral support worker at the school regarding concerns about the family and discussed the possibility of the referral to young carers. The school did not feel this was needed whilst Father was at home. 5 A voluntary organisation offering support to families. ESCB SCR Child R Report Page 7 of 32 Mother continued to receive specialist health services for physical health problems. During this period there were further signs that Child R was becoming anxious. Jan 2016 Family Action closed the case. Father was not happy with this outcome, but the school supported the decision and were positive about the children’s behaviour and capacity to form friendships. March 2016 Essex Police received an allegation from a neighbour that she had been assaulted by Mother. The decision was to manage this via a Community Resolution, but this was not progressed as Mother could not be located and engaged with. The case was therefore closed. It is the view of Mother’s advocate that this allegation was part of a pattern of harassment by neighbours and that the assault was precipitated by the neighbour. Mother saw the GP and started taking medication for anxiety. Father also visited the surgery to report that Mother might need counselling for depression and panic attacks. He was given contact details for Therapy for You.6 April /May 2016 In an e-mail to her advocacy worker Mother said that she was worried that Child R’s sibling’s anxiety symptoms had returned. Records from this time indicate that Mother had moved temporarily out of her flat in Southend and was staying with family in Essex due to harassment by neighbours. Her advocate contacted the GP to request support with housing and asked Essex Police (verbally and in writing) to give details of the harassment. After inquiries to establish whether this fell into the category of hate crime the conclusion was that it was not a matter requiring further police attention. Father made a referral to Southend Adult Social Care for another assessment which was passed to the locality team. Father told the school he was concerned about Child R’s “anger issues” in and outside the home and that his sibling was “petrified of him”. The school did not recognise this behaviour as there were no problems in school other than normal boisterousness. The next week Mother contacted the school to say she was keeping Child R off school for the rest of the week after a teacher spoke to her about his behaviour as “she was worried it would exacerbate her illness.” From the school’s perspective they had not raised any significant concerns. A referral was made to Southend Early Help Service with the consent of Father. June/ July 2016 Mother was back in the home in Southend and an assessment by Adult Social Care confirmed that Mother met the criteria for support under the Care Act 2014. A social worker from Southend Early Help Team was allocated to the family. In agreement with Mother the visit was deferred until September. Sept 2016 In September, the early help social worker contacted Mother, but she was living in Essex with her sister. The children were living with their father in 6 Therapy for You is a free NHS counselling and talking therapies service for people in South Essex. ESCB SCR Child R Report Page 8 of 32 Southend. Mother told the social worker that she planned to return to Southend and explained about her mental health problems and being in debt. As Mother was living out of area and Father did not want any support the case was closed to Southend Early Help Service. Oct 2016 Mother’s fibromyalgia improved– she had accessed holistic support via an on-line group. It seems that many of the physical symptoms improved and she was no longer using a wheelchair or in permanent pain. Nov 2016 A Southend Borough Council housing worker interviewed Mother with the advocacy worker to assess whether she was homeless. This decision rested on whether it was unsafe for Mother to return to the flat. After obtaining information from the early help worker and the police, the decision was that Mother was not homeless. Around this time the children moved in with Mother to her parents’ home in Essex. They remained at the same Southend school. Feb-April 2017 Mother made two calls to Essex Police. The first was to report the theft of three vehicle batteries from the side of her parent’s house and the second to report a burglary in progress. On the second occasion, the police call taker noted that mother was not making sense and there were concerns about her mental health. Maternal Grandfather commented to police officers that he thought mother was becoming paranoid. There is nothing in police records to indicate that the welfare of the children was considered at this time. There is a note that a referral was made to “social services” for the “mental health team” to make contact with Mother. Maternal Grandmother took Mother to the emergency department at Southend Hospital reporting hallucinations for three years. Mother was assessed by the Rapid Access Interface and Discharge Team (RAID and a referral was made to the Essex Support and Treatment for early Psychosis Team (ESTEP) for a full assessment. Following this assessment, the decision within ESTEP was to carry out a further assessment in order to establish whether Mother met the criteria for the team. Following further contacts from the family expressing concern that mother’s mental health was deteriorating, an assessment was organised at home with the Consultant Psychiatrist from ESTEP. As a result, Mother was started on anti-psychotic medication. ESCB SCR Child R Report Page 9 of 32 April 2017 Mother was allocated a care coordinator from ESTEP who saw her regularly. The care coordinator told this review that her role was to gather further information, build up a therapeutic trusting relationship and keep medication under review. The care coordinator also worked on relapse prevention. The children were not seen by the care coordinator (at Mother’s request) but there was nothing that alerted the care coordinator to any concerns about parenting. There was also no evidence of fibromyalgia. Maternal Grandmother declined a carers assessment. Father asked the school to keep an eye on the boys as Mother was having problems “hearing things”. July 2017 Mother stopped taking her antipsychotic medication for a short time and her paranoia returned. She commented to her mental health worker that her children were a protective factor influence on her self-harm. Aug /Sept 2017 Mother had resumed medication but did not wish this to be increased – some paranoid thinking persisted. Around this time Mother was declared bankrupt. She was also refused a place on Southend’s housing register as there was information on file that she assaulted a neighbour whilst living in her Southend flat. This was followed up by the advocacy service who pointed out that the information regarding the assault was wrong. Advocacy support then ceased as this was a Southend service and Mother was living in Essex. Mother was given details of a local advocacy service should she wish to access it. Mother mentioned to her care coordinator that Child R (age 7) was wetting the bed. The advice from the care coordinator was to talk to the GP about this issue. Father took Child R to the GP and spoke of his violent behaviour and short attention span during the past year. He was described as punching his sibling in the head leading to an A&E attendance. He was also noted as seeing Mother hit Father, and that Mother had severe mental health issues and was thinking of putting him in foster care. This consultation resulted in a referral to children’s mental health services (EWMHS)7. Following a desktop triage, Child R was deemed not to meet the threshold for a service from EWMHS and advice was given to self-refer to a local counselling service (Open Door) A letter to this effect was sent to the GP and Mother. Oct 2017 Mother told a psychologist about stressors including Child R’s violent behaviour towards his brother and that he was having counselling. Mother referred Child R to Open Door for counselling. Nov 2017 Mother had stopped taking her medication and reported no worsening of symptoms. The plan was for relapse prevention work. Maternal Grandmother was monitoring. Jan - June 2018 Mother was seen regularly by the care coordinator who focused on relapse Child R was seen by the Open Door service for counselling. Mother attended the first session and Father the second. 7 Emotional Wellbeing and Mental Health Service. This part of North East London Foundation Trust. ESCB SCR Child R Report Page 10 of 32 prevention work. In April Mother’s condition was noted in the records to be stable. From the school’s perspective they thought Child R’s behaviour at this time was that of an ordinary boisterous child. 3.3 Mother and her family have described her becoming increasingly unwell in the two weeks before the incident. They describe her pacing up and down at night and saying that “they are all going to kill us”. Around this time, Mother also believed that the brakes on her car had been tampered with by the garage who had replaced her windscreen. Maternal Grandmother telephoned the mental health team and described her concerns including that Mother was having the same thoughts as before in relation to conspiracy theories and thinking everyone was against her. As her usual care coordinator was not in, her call was discussed within the team and a mental health worker attempted to call Mother on three occasions, but she did not answer the phone. Maternal Grandmother was informed, and it was agreed that the usual care coordinator would call as soon as she was back at work. 3.4 Three days later Maternal Grandmother called the mental health team to ask whether a scheduled appointment with the care coordinator the next day would go ahead. When informed that the care coordinator was on holiday but someone else could visit, the records note that Maternal Grandmother said that it was not necessary for anyone else to visit. Maternal Grandmother’s recollection of this conversation is different: she recalls being told that here was no one else available. 3.5 The family recall Mother feeling very unwell in the evening three days later and asking Maternal Grandmother to take her to hospital. They arrived at hospital just after midnight and were referred to RAID (the Rapid Assessment and Interface Discharge service) who see all mental health patients who present in the emergency department. A student mental health practitioner, who was nearing the end of her training, took a full history and concluded that the main need was for Mother to start her anti-psychotic medication again. In their opinion there were no overt symptoms that required immediate referral for a Mental Health Act assessment or to stay in overnight for consultant review in the morning. As it was night-time no consultant was on site to prescribe the required medication and Mother was therefore advised to see her GP in the morning for a prescription. It was not common practice for GPs to be automatically notified of a hospital attendance although in some cases a call was made if medication needed changing. This was not thought to be necessary in this case. 3.6 The following morning (Friday) Mother booked an emergency appointment with the GP and attended an appointment accompanied by Maternal Grandmother at 8.59am. The records show that she asked for sleeping tablets and anti-psychotic medication. The GP had no information from the hospital to confirm what medication should be prescribed. The GPs examination concluded that Mother was objectively not depressed and there was no evidence of formal thought disorder. The GP told the review that they would never initiate anti-psychotic medication without psychiatric ESCB SCR Child R Report Page 11 of 32 advice and in the absence of a letter from the hospital they searched for the most recent letter from her psychiatrist which had been received two months previously. Although some GPs may have refused to prescribe without a letter from the RAID team the GP decided to do so as there was a letter on file describing Mother as having “transient psychosis”. In the light of this he prescribed her usual anti-psychotic medication plus medication for sleep. He agreed to review in four weeks or sooner of she was unwell. The GP told the review that Mother did not appear unwell and he was reassured that she attended with Maternal Grandmother and had a network of social support. 3.7 The hospital mental health liaison team sent an e-mail to the community early intervention team and Maternal Grandmother called the mental health team the same day, told them about the hospital visit and that they had collected a prescription from the GP and the medication. Maternal Grandmother confirmed that Mother had taken the first dose although Mother has told the review that she did not take any as she did not feel it would work. Maternal Grandmother is recorded as confirming with the team that she was willing to wait for a visit from the usual care coordinator when she returned from holiday. 3.8 On Monday morning Mother killed Child R. 4 REVIEW FINDINGS 4.1 The overarching finding of this review is the disconnect between the help provided to adults and help to children in the same family. Some of this is structural, some is linked to the right of adults to confidentiality and some of the issues stem from knowledge and skill gaps in recognising the impact of adult issues on their children. This latter issue applied to practice in both adults and children’s services. In summary: ➢ The impact of Mother’s physical and mental health conditions on her children was not fully explored or understood by those working with her. (Finding One) ➢ Indications that the children were being adversely affected by their home situation were not fully assessed when concerns about their wellbeing were considered by community health services, child mental health services and practitioners providing early help services to the family. (Finding Two) 4.2 There are also specific lessons regarding the management of Mother’s mental health condition immediately preceding the incident. (Finding Three) 4.3 The need for practitioners to “Think Family” cuts across all of the findings. This is an approach which was first articulated in 19988 following a study into fatal child abuse 8 Falcov, A.(Ed) (1998) Crossing Bridges: Training resources for working with mentally ill parents and their children. Brighton: Pavilion Publishing ESCB SCR Child R Report Page 12 of 32 and parental psychiatric disorder9 and has subsequently been updated, developed and evaluated10. It focuses on the dynamic interplay in relationships between adults and their children and calls for joint working between practitioners working with adults and those whose focus is the child. This case demonstrates that challenges remain in putting this into practice from both adult’s and children’s services perspectives as well as the need to think widely about services that need to operate from a Think Family perspective. In this case the findings below identify that adult advocacy services, housing, schools and early help providers are all important elements of a whole family approach 4.4 Within Southend Borough Council a Family First Protocol has been in place since 2015 and contains a common set of principles which include “improves the identification of children in need and in need of protection through increased understanding of the impact of adult problems on a child’s life”. Discussion with practitioners indicates that further work is needed to translate this protocol into day to day practice and decision making. 4.5 Training initiatives such as that planned by Southend Adult Social Care in safeguarding young people and new supervision frameworks in children and adult services as well as the work of the Practice Unit11 could provide a vehicle for developing practice in this area of work. However, given the overarching findings of this review, a thorough appraisal of any barriers to implementing a Think Family across Health, Children’s and Adult’s Services in Essex and Southend would seem necessary. This must include the role of schools and other early help services for children where parents have mental health or physical health problems. Recommendation Two Southend Safeguarding Children Partnership and Essex Safeguarding Children Board should work with practitioners in all partner agencies to: a) Agree the principles of a Think Family approach and disseminate these to all providers through staff development and training initiatives b) Identify any barriers that prevent the principles being implemented in practice and take steps to mitigate their impact. Finding One The safeguarding system needs to support practitioners who work with adults to understand the impact of parental issues on children and encourage appropriate information exchange and joint working across services. 9 Falcov A (1996) Department of Health Study of Working Together Part 8 Reports: Fatal child abuse and parental psychiatric disorder. London: Department of Health. 10See for example SCIE guide (2009) and evaluation report (2012) https://www.scie.org.uk/publications/reports/report56.pdf 11 The Practice unit was launched in January 2019 and provides support and challenge to social work and social care practitioners. ESCB SCR Child R Report Page 13 of 32 4.6 There are examples within the records of those agencies working with Mother of situations where more consideration should have been given as to the way in which her mental and physical health problems were impacting on her children. This should have led to a planned approach across services. Mental Health Issues 4.7 Adult mental health services should have been in a good position to explore whether Mother’s symptoms and behaviour could negatively impact on the children and if necessary, liaise with Children’s Social Care. There is no evidence that this happened even when there were indications that the children were involved in her delusional belief system and Mother was open about her worries about Child R’s violent behaviour, disclosed that he was receiving counselling and that his brother had also been in receipt of help the past. In fact, her children were generally referred to in positive terms as a protective factor. 4.8 When Mother took a significant overdose in 2014 this was six days after her assessment by IAPT (Improving Access to Psychological Therapy) which had noted high scores for severe depression and anxiety, indicating that active treatment was warranted. The mental health assessment by the Rapid Assessment, Interface and Discharge (RAID) team at the point of the overdose identified her children as being a “protective factor” – she loved them too much to attempt suicide again. This assessment concluded that there was no risk to the children although there is little information as to how the impact of her condition on the children was analysed. RAID’s assessment assumed that Mother was being seen by IAPT, but this did not happen as IAPT were not notified of the overdose and discharged her from the service as she did not attend. The GP was not aware that she had been discharged from IAPT so could not assess the implications of the whole picture at this stage. 4.9 Mother again referred to the children as a protective factor when working with her care coordinator in the Essex Support and Treatment for early Psychosis team (ESTEP). Where children are understood to be protective in relation to adult mental health, best practice would be to make sure that the assessment includes a second stage which includes an analysis of what this means for the child and consideration as to whether contact should be made with services for children. The need for a more sophisticated assessment of any potential risk is supported by an overview of lessons from previous serious case reviews which comments: Children should never be considered a protective factor for parents who feel suicidal. In some cases, professionals inappropriately viewed the child as a protective element who could help to reduce the parent’s risk of self-harm. This belief significantly increases the risk to the child.12 12 NSPCC 2015 https://learning.nspcc.org.uk/media/1349/learning-from-case-reviews_parents-with-a-mental-health-problem.pdf ESCB SCR Child R Report Page 14 of 32 4.10 There are indications that Mother’s mental health condition was impacting on her children and that they were involved in her delusional belief system but there is limited evidence that this was considered by practitioners. For example, during the eighteen months before the incident she described to mental health practitioners a belief that her children were being “spiked” and that neighbours were trying to kill her and her family. The investigation report by Essex Partnership University Trust also comments that Mother had referred to her ‘children not being bullied at school because of her’ and that this rather odd statement should have been explored further to assess whether her children were included in her delusional system. It is also of note that Mother told the school that she had kept Child R at home for the rest of the week after a teacher spoke to her about his behaviour as “she was worried it would exacerbate her illness”; again a rather strange comment which might indicate involvement of the children in her delusions and is an indication that Mother’s illness was negatively impacting on Child R’s education. The problem for the school was that they were unaware of Mother’s mental health condition (apart from Father having mentioned that Mother was hearing things) and could not understand this comment in that light. 4.11 One factor that also seemed to have inhibited a fuller assessment of risk to the children was Mother’s diagnosis of acute and transient psychotic disorder. The internal investigation report by the mental health trust comments that the ongoing symptoms and delusions described by Mother should have prompted a review of her diagnosis and the differential diagnosis would have been schizophrenia; a diagnosis that was confirmed after the serious incident. Any possibility of psychosis should have included an assessment of risk to children, particularly as in this case they were involved in Mother’s delusional system. 4.12 The Essex Support and Treatment for Early Psychosis team (ESTEP) is a service designed to offer psychosocial interventions which help people to understand their illness and for the family concerned to understand the impact on their lives. In this case the dominant approach was a focus on the potentially stigmatising impact on the adult of the mental health diagnosis and too little attention was given to the social circumstances and others involved in family life, for example the children’s school. 4.13 Family therapy was offered but the family did not take this offer up and it would have been good practice to reflect on why this was. Reluctance may have stemmed from an earlier experience when Mother first went to the acute hospital with psychotic symptoms. Her sister recalls being very upset as she did not feel that Mother was being honest during the assessment and that the clinician would not listen to her when she said that she believed that mother had paranoid schizophrenia. The notes of the session do record her sisters’ views but also extensive questioning of Mother where she described feeling somewhat better since cutting down on her cannabis use and using natural remedies for her physical problems. Her sister was left feeling that the families views were not important. How best to incorporate the views of families into an assessment that also respects the service users’ position is a ESCB SCR Child R Report Page 15 of 32 challenge for all adult services and further consideration needs to be given as to how the families voice can be heard. 4.14 Mother’s expressed wish for the children not to be seen was not considered unusual or unreasonable by the mental health worker but this should not have precluded an approach which actively considered the potential impact of delusional thinking on the children’s lives. Child R’s sibling has told the review that this behaviour impacted on them on a day to day basis for example, by Mother’s refusal to let them drink tap water because it could be contaminated and driving fast because she believed she was being followed. There could also have been a more proactive approach with the mental health service regarding contact with others involved with the family such as schools. 4.15 The school had asked the school nursing service to see both children, but the school nurse would also not have been aware of any mental health problems. The school nursing service in Southend receives mental health notifications through the Paediatric Liaison Services for parents who have been admitted to an acute mental health unit and have a child in a Southend school. This system did not work for this family in either February 2014 or March 2017 when Mother was first diagnosed with psychosis as she had not been admitted to an acute unit. 4.16 There are two issues relating to the school nurse notification process. Firstly, school nurses need to be clear as to expectations on them when they receive such information as they cannot share it without permission unless there are concerns that a child may be at risk of harm. They can however use this information to guide their responses if a school raises concerns about a parent; either by seeing the child, advising and supporting the school, or considering the need for a referral to children’s social care. Secondly, the review has found that schools may not be aware of this process and would not be prompted to consult the school nurse if they are worried about the mental health of a parent. There are currently plans to provide this information to Southend Schools and its impact will need to be evaluated. 4.17 Adult mental health services are provided by Essex Partnership University NHS Foundation Trust which has an integrated safeguarding adults team. Training is provided to staff aimed at encouraging staff to “Think Family” and consider the impact of adult issues on children. This case illustrates the need to constantly reinforce this message as practitioner discussions indicated that this approach is not consistently embedded into practice. Where there are indicators of an escalation in the severity of mental health, any indicators of delusional thought patterns towards the children, or where a parent expresses thoughts of self-harm, or of harming her or his children, these should be taken seriously and should prompt an urgent consideration of the safety of the child. Also, where parental mental health problems co-exist with other risk indicators, particularly domestic abuse, but also including drug or alcohol misuse, or social isolation, this should prompt a further assessment of the ESCB SCR Child R Report Page 16 of 32 child’s safety13. In this case there were reports of domestic abuse perpetrated by Mother, cannabis use, social isolation and mental health problems. The Trust risk assessment which is a tick box form did not adequately prompt further analysis of these issues using any recognised format; even though policies and procedures set out a clear expectation that this should take place14 . Physical Health Issues 4.18 In relation to adult social care, there is evidence that when Mother was experiencing acute symptoms associated with fibromyalgia her capacity to care for her children was reduced. The response from adult social care was focused on her physical condition for example an occupational therapy assessment noted that she had two children age six and four but there was no further assessment of the impact of Mother’s medical condition on them. Further assessment by a social worker resulted in a plan for reablement but again no consideration of the family as a whole and the needs of the children. There was a reliance on Father as the main carer for Mother and the children but more could have been done to understand the dynamics of the family as a whole and formal joint planning with Family Action when Mother became “non-compliant” with the reablement and it was noted that Father was planning to move out 4.19 An advocacy service for adults provided support to Mother from 2013 to 2017. Much of the focus of this work was support with conflict with neighbours, housing applications, and a referral to adult social care for an assessment. Mother shared information from time to time that should have prompted contact with children’s social care in order to make sure that the children’s needs were being met. It is important to stress that there were no incidents that would have fallen clearly into the category of child abuse by either parent, but in more general terms there was information that indicated children’s emotional wellbeing could be adversely affected including information from Mother that Child R’s sibling was self-harming once more. The advocate who worked with Mother confirmed that they had not received any children’s safeguarding training. 4.20 There is a code of conduct for all advocacy services which does specify knowledge of adult and child safeguarding. The contract issued by Southend Borough Council for advocacy services required staff to have “safeguarding training” but did not differentiate between adults and children’s safeguarding and in practice this training has tended to focus on adults. 4.21 During the process of Mother applying for housing, the housing officer had received long e-mails from Mother mentioning anxiety and saying that she worried about her 13 Sidebotham et al (2016) Pathways to Harm Pathways to Protection: a triennial analysis of serious case reviews 2011 to 2014. London: Department for Education. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf 14 EPUT Safeguarding Children Procedure CLPG37, April 2017. ESCB SCR Child R Report Page 17 of 32 boys and had them with her in the car until nine pm in the evening. As far as the housing officer was concerned these e-mails were not out of the ordinary as the housing officers receive many e-mails which often include threats of suicide or killing others. The housing officer thought children’s services were already involved so would not have considered forwarding the e-mails to them. This episode highlights the challenges of recognising those situations which indicate potential risk and need further action where there is a high volume of similar allegations and staff may become accustomed to worrying information. There is no guidance specifically for housing officers as to when to refer to Children’s Social Care and a housing officer commented on the general need for Children’s Social Care and Housing to understand each other more. Although housing officers are managing a high volume of situations involving adults with a range of vulnerabilities that may affect their children, they currently do not receive any supervision that helps them to reflect on their practice. This is an area for development. Summary of learning and areas for development across services for adults 4.22 A general issue in relation to all adult services is how far staff have the knowledge skills and confidence to speak to children during the course of their work and judge at what point they should engage the adult in a conversation about the possibility of a referral for help for their child. More confidence is needed in assessing who has prime responsibility for care of the child (in this case this varied over time) and when a reluctance to accept help for their children becomes a formal safeguarding concern. 4.23 Staff working with adults with mental health problems are understandably concerned about the possibility of discrimination against people with a mental health condition and parental mental health problems should not be seen in and of themselves as necessarily harmful to children. The same issue might also apply where an adult has a physical impairment. The challenge is to remain open to the possibility that children may be affected in many different ways and prevent the children themselves being discriminated against because they have a parent with a specific diagnosis. This discrimination may manifest itself in children not receiving help early enough, there being an insufficiently coordinated response across adult and children’s services and risks not being addressed. In this case the children did receive some services mainly via the school and counselling services but there is no evidence of any conversation by adult staff with Mother as to whether she would be willing for them to work with the school or that there was any assessment that analysed the impact of Mother’s physical and/or mental health problems on the children. 4.24 Skills and confidence in asking difficult questions can be developed through training and reinforced through a relationship with a supervisor which promotes critical thinking and reflection on the assumptions and biases that may underpin day to day practice. There is little evidence that either the required training or effective supervision was in place. ESCB SCR Child R Report Page 18 of 32 Recommendation Three All mental health providers should communicate the outcome of their assessments including non-engagement back to GPs and mental health trusts must provide assurance that this is now established practice and any barriers to communication are understood and removed. Recommendation Four The provider of adult mental health services (EPUT) should revise their clinical assessment model and related training so that it is in line with information in current procedure documents which requires thorough risk assessment of the impact on children where a parent has a mental illness. Specifically, the tool should: ➢ Move beyond a description of children as a protective factor for the adult and assess what this means for the lived experience of the child including any risks. ➢ Support an analysis of situations where children may become part of the delusional thinking of the parent or carer. Recommendation Five All organisations providing services to adults should review the quality of staff supervision in order to ensure that it provides the opportunity for reflection and critical thinking that enables a focus on the needs of all family members particularly children. Recommendation Six Southend Borough Council should inform schools of the information that may be held by school nurses about the mental health of a parent, clarify expectations on both parties and evaluate the impact of this process on the safety and wellbeing of children. Finding Two Practitioners providing services to children, need to take a whole family approach in order to understand children’s behaviours within the context of their family circumstances. 4.25 Generally in relation to an understanding of Mothers mental and physical conditions practitioners working with children saw Father and Maternal Grandmother as protective factors. Whilst this was true, there could have been a more structured assessment of the impact on the children’s emotional wellbeing and an acknowledgement that at times Mother would be a sole carer. The School 4.26 The school attended by Child R and his sibling has a very strong pastoral support team of seven staff who work with about 100 children in total at any one time. Each child seen by the team has a named pastoral support worker. Child R was one such child although the school were not unduly concerned about him: generally, their ESCB SCR Child R Report Page 19 of 32 perception was that the parents were overly anxious. The school were aware that the children had spoken in the past of seeing “mum hit dad”, and that Mother had physical health difficulties; she had been seen in a wheelchair and Child R’s sibling had reported that he was not allowed into her room. The school did contact Children’s Social Care about an incident where Child R’s sibling was described as having a knife but once they realised the family were not known to them, they decided to refer to Family Action. They were not worried when Family Action closed the case as Father was a supportive figure whom the boys worshipped but the school told the review that the boys would however have been described as young carers if Father had not moved back into the home. This analysis of the situation could have informed thinking when Father was no longer living with the boys after her move back to Essex, although it was assumed that Mother’s family would provide the support needed and in the months before Child R’s death the school had an increase in positive contact with Mother. 4.27 When the older sibling had been seen by child mental health there had been no contact with the relevant school. Current operating procedure within child mental health services15 does provide guidance about issues of consent where there is a need to contact a school or where a school contacts the service. Schools are a vital part of the support system around the child and both guidance and training could be more proactive in positively encouraging a link with schools where a child is being seen by mental health services. Health Provision – child mental health and the GP services 4.28 Child R and his sibling were referred to child mental health services two years apart. 4.29 GP services, theoretically, are in a good position to consider the whole family and to understand children’s behaviour in this light. In practice, all family records are individual, and links may not be made between children’s behaviour, family patterns and parental circumstances. The episode when Child R’s sibling threatened self-harm for example was not linked with later concerns about Child R’s violent behaviour and Mothers physical and mental health problems. 4.30 The referral to child mental health services in respect of Child R had been made by the GP after Father had expressed concern about Child R’s increasingly violent behaviour and that he had witnessed his Mother being violent towards his Father. The referral also notes Mother’s severe mental ill health. At this stage the GP should have considered whether this cluster of factors indicated potential risk to the child and a safeguarding referral was needed. These factors included a report of Mother’s violence towards Father. Within Southend, there are current proposals to develop a general practice based domestic violence training support and referral programme for primary care staff, this includes signposting for male victims and may have been a helpful prompt to the GP in this case. 15 Now known within Essex as EWMHS (Emotional Well-being and Mental Health Service) ESCB SCR Child R Report Page 20 of 32 4.31 This referral was considered (triaged) by the child mental health service and the decision was that Child R did not need a mental health assessment. A letter was sent to the GP and Mother advising self-referral to counselling services. This letter to Mother is an action which did not take account of the whole family circumstances and consider that Child R could potentially be put at risk since Father had described Mother’s violent behaviour. The letter should have been sent to Father as the referrer. 4.32 Child mental health services are now commissioned from a different organisation than the one providing child mental health services at the time Child R’s sibling was seen. This made it impossible to review the records for Child R’s sibling. The previous Trust kept paper records making it a time-consuming process that has not been commissioned from EWMHS as part of the triage process. 4.33 EWMHS also raised the point that automatically accessing a sibling’s records would raise Information Governance issues. Electronic patient record systems used by health providers in Essex do not automatically link family members together so a sibling link would only be known about if the referrer made specific reference to this and permission was given to review these records. These factors mean that there is a lost opportunity to understand children’s behaviour within their family context at the triage stage and to use all available information to make a reasoned decision as to the most appropriate course of action, including whether a full assessment is needed. 4.34 The triage process has been discussed in some detail with EWMHS to understand what it involved and what EWMHS has been commissioned to provide. This has been important to understand as part of the overall concern that risks to Child R were not apparent due to a fragmentation of information and response throughout the safeguarding system in adults and children’s services. It seems that EWMHS have been commissioned to provide an accessible service where professionals and families can refer in a wide range of concerns and the triage process is designed to establish whether EWMHS is the right service or the child’s needs could be best met though being signposted elsewhere. There is no detailed information gathering at this stage and the clinician relies on what is written in the referral. For those making referrals, the quality of the information contained in the referral is of crucial importance since this will determine whether a child mental health service is offered. It is not clear how well this is understood amongst the whole professional community, although EWMHS has provided this information to all stakeholders across a range of forums. 4.35 In the case of Child R, EWMHS did not record a clear rationale as to why the referral was not accepted at the point of triage but the rationale given verbally to this review was that there were no clear signs of mental ill health and there was “a low level need of anxiety and anger which could be managed through a community provider”. It was believed that Child R’s anxiety could be best managed via a community counselling service such as Open Door, a decision in line with commissioning requirements that promote less intrusive intervention at the first stage. ESCB SCR Child R Report Page 21 of 32 4.36 Whatever the decision about access to child mental health services, it is important that any safeguarding concerns are identified, and the necessary action taken. In this respect the triage process should always involve a risk assessment based on the information received. In this case the combination of severe parental mental health problems, the report of Mother’s violence and her wish for Child R to be fostered should have triggered a safeguarding alert and action taken to make sure that a referral to children’s social care was made. In this case the GP would have been the most appropriate person and action taken to liaise with the GP to make sure that this had happened. 4.37 If for any reason it was clear that no safeguarding referral was being made, EWMHS could have made this themselves. It should be noted that EWMHS do have a different view about this and argue that the risk factors were based on third party information (what father had reported about Mother) and was historical rather than current. In these circumstances it is the view of EWMHS that they should not make a referral. This is an issue that needs to be resolved and clarified with the Partnership and action taken to make sure all are content with the procedures and the way they are being interpreted. 4.38 The point of referral to the child mental health service was an opportunity to consider whether any help was needed to support the family in meeting the needs of the children. When the decision is that a community-based service is the most suitable, EWMHS commissioning arrangements are such that they do not make a referral but instead ask the parent to self-refer where appropriate. They also do not ask parents for permission to contact the provider and pass on any relevant information. In this case Mother made a self-referral for Child R but the counsellor had no context for the referral and their own assessment at the start of the counselling sessions was based on self-reported information. They could not understand Child R’s presentation or comments during sessions in the light of the family circumstances including Mother’s mental ill health and there was no reason for them to contact other agencies such as EWMHS for further information. Practice would be improved if procedures within child mental health services included asking parents to inform them when a self-referral had been made and for permission to proactively share relevant information with the provider concerned. 4.39 Since under the current system, the receiving service will only have information given by the parent it is common practice to ask parents’ permission to contact other organisations who may have information that will help them to provide the best possible service to the child. The review has been told by Open Door that most parents are happy to give permission, but other agencies often do not respond to requests for information, even where a parent has given written consent. As this case demonstrates, the opportunity to understand the needs of the child within their family context is lost without a holistic approach. 4.40 A recent report by the children’s commissioner into children’s mental health services commented that where a child suffers from “low level” mental health concerns the ESCB SCR Child R Report Page 22 of 32 response can be simultaneously everyone’s responsibility, and nobody’s.16 In this case, responsibility for responding to Child R’s needs was picked up by Open Door but this operated in isolation from the rest of the network. A holistic approach should have sat within the early help framework which is well developed in Essex.17 The cluster of factors described to the GP should have prompted a referral to children’s services and consideration of the need for an early help plan alongside assessment of possible safeguarding concerns. A team around the family approach could have brought together all the services working with the family and been an opportunity to understand the experience of the children in the family and target help accordingly. Recommendation Seven Southend Clinical Commissioning Group should work with GP practices to ensure that both permanent and locum clinicians have an understanding of the cluster of factors that might indicate the need for a safeguarding referral and that information about how to refer to local Children’s Services is displayed in every GP practice. Recommendation Eight Child mental health services (EWMHS) should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and at the point of triage always consider whether a child may be at risk of harm and a direct referral needs to be made. Recommendation Nine Child mental health services (EWMHS) should work with those who refer into the service to make sure that the quality of information received is sufficient to make a triage decision about emotional and mental health needs based on referral information. Recommendation Ten Child mental health services (EWMHS) should be asked to identify the barriers to checking records for any previous involvement with siblings of the referred child and discuss with commissioners of the service as to how these can be overcome and be required practice in future delivery models. Recommendation Eleven At the close of contact with child mental health services (EWMHS) letters outlining the outcome should be sent to the parents or carers who made the original referral. Information systems should be reviewed in order to facilitate this. Recommendation Twelve Southend, Essex and Thurrock Safeguarding Children Procedures should clarify the need for effective two-way information sharing (with appropriate permissions) between statutory and non-statutory providers in order to facilitate the most effective help to children and their families. 16 Longfield, A (2020) The State of Children’s Mental Health Services, The Children’s Commissioner. 17 https://www.essexeffectivesupport.org.uk/media/1078/early-help-offer.pdf ESCB SCR Child R Report Page 23 of 32 Finding Three The coordination and response of mental health services needs to take account of concerns that a patient with a diagnosed mental health condition is relapsing. 4.41 It is the view of this review that the extent, severity and diagnosis of Mother’s mental health was not sufficiently understood by the Mental Health Liaison Team. 4.42 Although the family have described feeling increasingly worried about mother’s symptoms in the days before the incident. Their care coordinator was away for longer than originally planned due to sickness and although a visit from another team member was offered it is reported that the family preferred to wait. The Early Intervention Team should have been more proactive in undertaking a home visit given the deterioration in Mother’s mental health and missed opportunities to intervene early when there were signs of relapse. This issue is identified in the investigation report from Essex Partnership University NHS Foundation Trust. 4.43 When Mother was taken to the hospital and seen by the Mental Health Liaison Team, it is the view of the internal investigation report that there was an opportunity to recognise the severity of her symptoms and consider admission to a psychiatric unit or request an assessment under the Mental Health Act 1983 to prevent a further deterioration in her illness. Even if this was not deemed necessary there should have been a handover to the Early Intervention Team the next morning rather than relying on Mother to go to the GP and for the GP to prescribe anti-psychotic medication. Procedures do expect that when patients are discharged back to the GP this should be with “a copy of the assessment outcome and personalised advice, information and guidance on re-direction or signposting to other services if required”. There are no timescales within which GPs should be notified, and in this case that notification should have been immediate. Recommendation Thirteen Essex Partnership University Trust should ensure that where a patient with a mental health condition is seen out of hours and assessed to require medication, a consultation with an on-call psychiatrist is be requested. Recommendation Fourteen The Rapid Assessment Interface and Discharge Team (RAID) team systems should ensure that when a mental health patient is seen out of hours, contact is made with any treating team and the registered GP at the start of the next working day. Recommendation Fifteen Essex Partnership University Trust should ensure that Early Support and Treatment in Early Psychosis (ESTEP) protocols and practice in respect of patients who are risk of relapse always includes an urgent face to face consultation with the patient when they have been seen by out of hours services. ESCB SCR Child R Report Page 24 of 32 5 SUMMARY OF RECOMMENDATIONS Recommendation One This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will be joint planning in response to this report and the NHS England independent mental health homicide investigation. Recommendation Two Southend Safeguarding Children Partnership and Essex Safeguarding Children Board should work with practitioners in all partner agencies to: a) Agree the principles of a Think Family approach and disseminate these to all providers through staff development and training initiatives b) Identify any barriers that prevent the principles being implemented in practice and take steps to mitigate their impact. Recommendation Three All mental health providers should communicate the outcome of their assessments including non-engagement back to GPs and mental health trusts must provide assurance that this is now established practice and any barriers to communication are understood and removed. Recommendation Four The provider of adult mental health services (EPUT) should revise their clinical assessment model and related training so that it is in line with information in current procedure documents which requires thorough risk assessment of the impact on children where a parent has a mental illness. Specifically, the tool should: ➢ Move beyond a description of children as a protective factor for the adult and assess what this means for the lived experience of the child including any risks. ➢ Support an analysis of situations where children may become part of the delusional thinking of the parent or carer. Recommendation Five All organisations providing services to adults should review the quality of staff supervision in order to ensure that it provides the opportunity for reflection and critical thinking that enables a focus on the needs of all family members particularly children. Recommendation Six Southend Borough Council should inform schools of the information that may be held by school nurses, clarify expectations on both parties and evaluate the impact of this process on the safety and wellbeing of children. ESCB SCR Child R Report Page 25 of 32 Recommendation Seven Southend Clinical Commissioning Group should work with GP practices to ensure that both permanent and locum clinicians have an understanding of the cluster of factors that might indicate the need for a safeguarding referral and that information about how to refer to local Children’s Services is displayed in every GP practice. Recommendation Eight Child mental health services (EWMHS) should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and always consider at the point of triage whether a child may be at risk of harm and a direct referral needs to be made . Recommendation Nine Child mental health services (EWMHS) should work with those who refer into the service to make sure that the quality of information received is sufficient to make a triage decision about emotional and mental health needs based on referral information. Recommendation Ten Child mental health services (EWMHS) should be asked to identify the barriers to checking records for any previous involvement with siblings of the referred child and discuss with commissioners of the service as to how these can be overcome and be required practice in future delivery models. Recommendation Eleven At the close of contact with child mental health services (EWMHS) letters outlining the outcome should be sent to the parents or carers who made the original referral. Information systems should be reviewed in order to facilitate this. Recommendation Twelve Southend, Essex and Thurrock Safeguarding Children Procedures should clarify the need for effective two-way information sharing (with appropriate permissions) between statutory and non-statutory providers in order to facilitate the most effective help to children and their families. Recommendation Thirteen Essex Partnership University Trust should ensure that where a patient with a mental health condition is seen out of hours and assessed to require medication, a consultation with an on-call psychiatrist is requested. Recommendation Fourteen The Rapid Assessment Interface and Discharge Team (RAID) team systems should ensure that when a mental health patient is seen out of hours, contact is made with any treating team and the registered GP at the start of the next working day. ESCB SCR Child R Report Page 26 of 32 Recommendation Fifteen Essex Partnership University Trust should ensure that Early Support and Treatment in Early Psychosis (ESTEP) protocols and practice in respect of patients who are risk of relapse always includes an urgent face to face consultation with the patient when they have been seen by out of hours services. ESCB SCR Child R Report Page 27 of 32 6 APPENDIX ONE – TERMS OF REFERENCE Serious Case Review Terms of Reference (Child R) 1. Subject of Review Subject: Child R Family Members: Mother Sibling Maternal Grandmother Maternal Grandfather Father: 2. Reason for the Review Child R, aged seven, died in July 2018 at his maternal grandparents’ home in Essex. Child R, his nine year old sibling and their mother had been living at the maternal grandparents’ home at the time of his death. It is understood that the cause of death was that Child R was either strangled or drowned in the bath by his mother. Mother had a lengthy mental health history alongside her physical health issues; she had fibromyalgia and was known to have at times heavily used cannabis to ease the pain. Mother experienced her first psychotic episode in March 2017. There has been an ongoing Police investigation in respect of Child R’s death. In January 2019, Mother was found not guilty of murder by virtue of insanity. She has been given an indeterminate hospital order. 3. Relevant time period for the review 1st September 2015 (month when Child R started school) to 23rd of July 2018. ESCB SCR Child R Report Page 28 of 32 4. Organisations who should contribute to the review 1) Essex Partnership University Trust 2) Essex Police 3) Rochford Council 4) Southend University Hospital Foundation Trust (SUHFT) 5) Southend GP services 6) Southend Early Help 7) Southend Education 8) Open Door 9) Southend Adult Services 10) Southend Housing 11) POhWER (Advocacy Service) 12) South Essex Advocacy Services 13) North East London NHS Foundation Trust (EWMHS) 5. Review Team Representatives 1) Adult Mental Health (EPUT) 2) Essex Police 3) Southend CCG Designated Nurse 4) Southend CCG Designated Doctor 5) Southend Children Social Care 6) Southend Early Help 7) Southend Education 8) Voluntary Organisation – Open Door Counselling Services 9) Southend Adult Social Care 10) NHS England 6. Questions to be considered 1) How comprehensive were the assessments and plans undertaken by services involved in the care of Mother, particularly mental health services, in considering her parenting capacity? What assumptions were made based on Father’s involvement with the children and the protective nature of the extended family? 2) What do we know about Mother’s level of violence during psychotic episodes? Were these so different from what happened when Child R was killed? What, if anything, did the family know and perhaps did not share with agencies? Was there a fear that the children could be taken away from Mother? 3) The children had mentioned to their school that the family had been involved with Adult Social Care; this needs to be further clarified …was this followed up by the school at any point? Was there a “think family” approach to co-ordinating care for Mother and her children? What levels of support were offered by Adult Services, and was this appropriate? ESCB SCR Child R Report Page 29 of 32 4) What was the school’s understanding of both the professional support network and the family support network, especially given Mother’s ongoing mental health issues? 5) Were the assessments of Mother’s mental health thorough and responses appropriate in the days leading up to the incident? Mother alluded to not being in control of her mental health issues; did professionals involved in her care ask Mother what she meant by that. What did the Continuing Care team make of Mother’s presentations and the potential level of risk she posed? 6) What was the quality of the multi-agency safeguarding arrangements in respect of the practitioners working with the family (information-sharing, integrated working, communication between agencies, assessments of risk etc.)? 7) Were attempts made to bridge the gap between Mother’s physical health needs and her mental health needs? Mother did not appear to have a big uptake of GP services; were Mother’s physical needs being met by the acute trusts? 8) The review should gather information about the housing situation for the family, what priority was given / should have been given to this vulnerable family, given mother’s mental health and physical health issues? 9) School referred to the children as young carers; what was meant by this, and how were the children supported as “young carers”? 10) Voice of the children; what was it like to be a child in this family? What was the lived experience of these two children? 11) What significant steps did the family take to manage their situation? The Lead Reviewer is to explore this through family contributions to the review. 12) What was the level of domestic violence in the family? Did professionals ask the relevant questions around domestic abuse; did they get answers; or did they not ask? 13) What was the impact of Mother’s relationship with her new partner and the trip to Jamaica? 14) What was the impact of the stresses Mother experienced around the family’s housing situation and her reported £50,000 debt; were agencies aware of the debt and was this discussed with Mother? 15) How do we work together to provide families with adequate support in circumstances where Children’s Social Care thresholds have not been met? 16) What was the role of MIND with Mother? ESCB SCR Child R Report Page 30 of 32 17) Were there any multi-agency meetings to co-ordinate support for the family, and if not why not? 18) What, if anything, could agencies have done differently which may have made a meaningful difference? 7. NHS England Terms of Reference The investigation is to be conducted in partnership with the Children’s Serious Case Review into the death of Child R Terms of Reference. The investigation will examine the NHS contribution into the care and treatment of Mother from her first contact with specialist mental health services following the birth of Child R up until the date of the incident. • Critically examine and quality assure the NHS contributions to the Children’s Serious Case Review • Examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother • Review and assess compliance with local policies, national guidance and relevant statutory obligation • Examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family • Examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services • Review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway • To work alongside the Children’s Serious Case Review and Chair to complete the review and liaise with affected families • To provide a written report jointly with the Serious Case Review report to the Safeguarding Board and NHS England that includes measurable and sustainable recommendations that may be published either with the multi-agency review or standalone ESCB SCR Child R Report Page 31 of 32 8. Methodology The review process is designed to ensure an open and collaborative approach which includes the perspectives and views of practitioners and family members. that there is a focus on what happened and why practice decisions were made. The review seeks to move beyond a focus on individual practice to an understanding of lessons for the safeguarding system the as a whole. The process of the review will be: 1. Gathering and analysing written information via chronologies and other relevant reports. 2. Agreeing key practitioners who should be offered an opportunity to contribute. Meeting with family members. 3. Meeting with family members. 4. Meeting with practitioners either individually or in small groups. These meetings will be led by the lead reviewer along with a panel representative with professional expertise in the area bring discussed. 5. Key themes and learning to be agreed with the Review Team. 6. Production of a draft report to be agreed by the Review Team. 7. Sharing of the final draft with all those who have contributed. 8. Production of final report agreed with the Serious Case Review Sub-Committee and presented to LSCB. ESCB SCR Child R Report Page 32 of 32 APPENDIX TWO – PRACTITIONER DISCUSSIONS ➢ Care Co-ordinator, ESTEP (Early Support and Treatment in Early Psychosis) ➢ Psychiatrist - EPUT ➢ Mental Health Practitioner - RAID (Rapid Access Interface and Discharge) ➢ GP - Southend CCG ➢ Adult services social worker - Southend Adult Social Care ➢ Advocacy worker - PoHwer ➢ Headteacher and Pastoral Worker - Primary School ➢ South Essex Advocacy Service commissioner ➢ Locum GP ➢ Southend Housing worker ➢ Named nurse for safeguarding EWMHS ➢ Head of Children’s Services EWMHS 1 NHS England independent investigation into the NHS care and treament of Mother in Essex To be read as an appendix to the Serious Case Review (Child R) First Published: December 2020 2 Contents 1. NHS England independent investigation ........................................ 3 Approach to the investigation ..................................................... 3 Structure of the report ................................................................ 4 2. Arising issues, comment and analysis ........................................... 5 Quality assurance of internal investigation report ....................... 5 Referral, assessment and discharge procedures ....................... 9 Care planning and risk assessment ......................................... 19 Family communication/responsiveness of services .................. 26 3. Overall analysis and recommendations ....................................... 28 Findings and recommendations ............................................... 28 Appendix A – Terms of reference ............................................. 31 Appendix B – Internal report analysis ....................................... 32 3 1. NHS England independent investigation Approach to the investigation 1.1 The independent investigation follows the NHS England Serious Incident Framework (SiF, March 2015)1 and Department of Health guidance on Article 2 of the European Convention on Human Rights and the investigation of serious incidents in mental health services.2 The terms of reference for this investigation are given in full in Appendix A. 1.2 The main purpose of an independent investigation is to ensure that mental health care related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to services might be required which could help prevent similar incidents occurring. 1.3 The overall aim is to identify common risks and opportunities to improve patient safety and make recommendations about organisational and system learning. This investigation was commissioned to support the work of the independent lead reviewer of the Serious Case Review (SCR) which was commissioned by Essex Safeguarding Board, and the terms of reference were agreed jointly. This investigation should be seen as an addendum/appendix to the SCR. 1.4 Following the homicide of Child R by his Mother in July 2018, NHS England Midlands & East commissioned Niche Health and Social Care Consulting (Niche) to carry out an independent investigation into the care and treatment of a mental health service user, called Mother for the purpose of this investigation. Niche is a consultancy company specialising in patient safety investigations and reviews. 1.5 The decision to carry out a SCR took place after new statutory guidance came into force in 20183 and prior to new partnership arrangements for safeguarding children being in place in Essex and Southend. Arrangements for initiating this review and publishing the report have therefore remained with Essex Safeguarding Children Board but it is important that the final recommendations are considered and responded to by both Essex and Southend Safeguarding Children Boards/Partnerships. 1.6 The focus of the SCR is Child R. Due to the circumstances of his death many of the recommendations of this review relate to the way in which risks to children can be recognised by practitioners working with adults with physical and mental health problems. 1.7 This investigation commissioned by NHS England focusses in more detail on the NHS services provided to Mother, however it should be noted that the two reviewers 1 NHS England Serious Incident Framework (March 2015). https://www.england.nhs.uk/patientsafety/serious-incident/ 2 Department of Health Guidance ECHR Article 2: investigations into mental health incidentshttps://www.gov.uk/government/publications/echr-article-2-investigations-into-mental-health-incidents 3 HM Government (2018) Working Together to Safeguard Children. 4 have worked closely together in finalising the findings and recommendations of this review. This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will joint planning in response to this report and the NHS England mental health homicide investigation. 1.8 The independent mental health homicide investigation was carried out by Dr Carol Rooney, Associate Director for Niche, with specialist advice from Dr Lucinda Green, consultant psychiatrist. The investigation team will be referred to in the first person plural in the report. The report was peer reviewed by Kate Jury, Partner, Niche. 1.9 The investigation comprised interviews carried out with the SCR lead author, and a review of clinical records and documents. 1.10 We met with Mother in May 2019. Mother’s family and Child R’s father did not wish to meet us, but the final report was shared with the family. Structure of the report 1.11 This addendum focusses on an analysis of the care and treatment provided to Mother by NHS services in line with the additional health terms of reference. Mental health services were provided by South Essex Partnership University NHS Foundation Trust (SEPT) until the new Trust was established in April 2017. Mental health services across Essex are now provided by Essex Partnership University NHS Foundation Trust (EPUT). Child mental health services are provided by North East London NHS Foundation Trust (NELFT) and are called the Emotional Wellbeing and Mental Health Service (EWMHS). We have not reviewed the care provided to the children concerned but have included the recommendations made in the SCR as they are recommendations for NHS services. The detailed issues regarding the children’s care are discussed in the full SCR. 1.12 Section 2 provides a review of the EPUT internal investigation report and examines the issues arising from the care and treatment provided to Mother against the health terms of reference (see appendix A). 1.13 Section 3 sets out our overall analysis and recommendations. The SCR has made eight recommendations for health services which we endorse (SCR recommendations 3,4,5,7,8,9 and 10) and we have made three individual recommendations. 1.14 Where we have come to a conclusion we have included these in a ‘summary statements’ box at the end of discussion sections. 5 2. Arising issues, comment and analysis 2.1 The terms of reference for this investigation are to: • critically examine and quality assure the NHS contributions to the Children’s Serious Case Review; • examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother; • review and assess compliance with local policies, national guidance and relevant statutory obligation; • examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family; • examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services; and • review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway. Quality assurance of internal investigation report 2.2 The internal investigation was described as a ‘Root Cause analysis investigation report’ but does not reference the definitions in the NHS England SiF. 2.3 The report is written in a root cause analysis format and lists clear terms of reference. A team was established including a Consultant Psychiatrist, a Non-Executive Director, an external investigator, the Head of Safeguarding Children and the Director of Mental Health Services. 2.4 Mother’s previous care in EPUT/SEPT was summarised, and a detailed chronology is provided. Care and service delivery problems were identified against the terms of reference, exploring the care provided in detail. 2.5 The efforts to involve the family are described, and detailed responses to the family’s questions are listed. The process of the investigation is clearly described, including those interviewed and materials accessed. 2.6 Contributory factors were identified, which were patient factors, individual factors, task factors and system factors. 2.7 The patient factors identified were: • the children were identified by Mother as protective factors, although she had ‘made some reference to them while sharing psychotic beliefs’; • Mother had a long-term diagnosis of fibromyalgia4 and used cannabis to manage pain; • her psychotic symptoms had responded well to antipsychotic medication, although this exacerbated her chronic pain; 4 Fibromyalgia is a long-term condition that causes pain all over the body. 6 • she had a preference for holistic approaches to her health and was reluctant to take antipsychotic medication; • she went on holiday to Jamaica with her partner and reportedly consumed cannabis, although showed no psychotic symptoms when reviewed after her return, although her mental state deteriorated a week later; • Mother lived in her parent’s house, sharing a room with both children; and • Grandmother was very supportive. We consider that there was a missed opportunity to clarify who is caring for the children when there are several adults in the house, as highlighted in previous child serious case reviews.5 2.8 The system factors identified were: • Mother and Grandmother attended A&E on 19 July to obtain antipsychotic medication, but the mental health liaison team do not prescribe out of hours; and • there was a delay in prescribing antipsychotic medication. In our view a further system factor was that the mental health liaison service did not have a protocol for informing the GP and the early intervention in psychosis service (ESTEP) of the out of hours consultation, and the advice given. 2.9 Task factors identified were: • some of the staff involved had not completed mandatory refresher training • some staff were not compliant with mandatory supervision The report does not specify whether the mandatory training included child or adult safeguarding, and whether the supervision was safeguarding supervision. 2.10 In the section entitled ‘root cause’ the report states that ‘the incident was not predictable’, with ‘no past history of aggression towards others or children, and in the absence of overt risk factors for violence’. It does state however that the ‘likelihood of the incident could have been significantly reduced’. The factors contributing to the incident include ‘Mother’s psychotic symptoms, inconsistent engagement with the services, use of cannabis and lack of timely treatment interventions’. 2.11 The omission of previous aggression attributed to Mother is not noted i.e.: there was a history of aggressive behaviour, sibling told a teacher in 2015 that ‘Mum hurts Dad’. Also, in 2016 Mother allegedly grabbed the neighbour and attempted to drag her into the flat. The Trust has clarified that this history was noted in the submission to the SCR, so was not repeated in the internal report. 2.12 The report does not explicitly state whether these was considered to be a root cause or not. In patient safety terms, the root cause of a serious incident is the earliest point at which intervention could have prevented the incident, and in our view this aspect should have been explored further. The terms of reference for the internal 5 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report, Department for Education May 2016. 7 investigation did not in fact require a determination about predictability, so it is unclear why this was included. 2.13 We tested the internal report against our standard ‘credibility, thoroughness and impact’ framework (see appendix A). The score was 21/25, and the areas where the investigation did not meet accepted standards were: The investigation should have been completed within 60 days. 2.14 The finalised investigation report was supplied to the SCR lead author in September 2019. This is 14 months after the homicide, which is well outside the policy expectations in the SiF. The Trust have commented that the incident was ‘stop-clocked’ in agreement with the CCG for a significant period of time pending conclusion and outcome of Police investigations. Further time was used to source and appoint an independent investigator. Once underway, the investigation was extended, in agreement with the Commissioner. Further witnesses and lines of enquiry were also requested which it was stated was not unusual for a complex investigation of this nature. Summary statement 1 The internal report was not completed within expected timeliness standards, and the delay was not explained in the internal report. There was no discussion regarding root cause. 2.15 In the section entitled ‘root cause’ the report states that ‘the incident was not predictable’, with ‘no past history of aggression towards others or children, and in the absence of overt risk factors for violence’. It does state however that the ‘likelihood of the incident could have been significantly reduced’. The factors contributing to the incident include ‘Mother’s psychotic symptoms, inconsistent engagement with the services, use of cannabis and lack of timely treatment interventions’. 2.16 The report does not explicitly state whether there was considered to be a root cause or not. The terms of reference for the internal investigation did not in fact require a determination about predictability, so it is unclear why this was included. Recommendations do not all relate to the findings and lead to a change in practice, are measurable and outcome focused. 2.17 There were three recommendations made. In order for recommendations to be measurable and outcome focussed there should be a clear statement of what the action is intended to achieve (the outcome) and a statement of what would indicate that it had been achieved. All three of the recommendations use aspirational language and encourage an ‘exploration’ of the issues, rather than actions to address the care and serve delivery problems identified. 2.18 The three actions are for ESTEP to ‘consider the RAG rating for patients’, ‘explore full psychiatric symptomology …in order to fully understand the nature and degree of 8 illness’, and for the psychiatric liaison service to ‘explore developing a process of informing ESTEP if one of their patients is assessed at A&E’. These recommendations are not linked directly to the care and service delivery problems identified. 2.19 The first of these recommendations suggests that a system of rating (red/amber/green: RAG) rating be used to monitor patients who are relapsing. It is not clear whether there is already a system/protocol in place for this, and the liaison team did not use it, or whether this would be a new system. 2.20 The clinical risk assessment and safety management procedure6 already in place does not make any reference to a RAG rating procedure. Summary statement 2 Recommendations made in the internal serious incident investigation report were not outcome focussed or measurable. Summary statement 3 The clinical risk assessment and safety management procedure does not include a RAG rating protocol to identify heightened need or risk. 2.21 The second recommendation expects that ESTEP should make a thorough mental state examination and take a detailed history. It is then anticipated that the team could ‘better understand the risks and formulate an appropriate risk management plan’. 2.22 The taking of a detailed history is already a clear requirement of the CPA procedure,7 with a list of all the areas that should be explored, including psychiatric and psychological functioning, personal circumstances, social functioning and physical health needs. A thorough assessment should include review of previous health records and requesting previous records from the GP, and the taking of collateral history from a family member. 2.23 Under the heading ‘personal circumstances’, there are prompts related to assessment of family and parenting issues which are ‘family including genogram’, ‘caring responsibilities’, ‘childcare issues’, ‘relationship issues’. The internal report does not comment on the lack of assessment of Mother as a parent, or the potential impact of her mental health issues on the children. If the history taking had identified the extent of her previous lack of functioning in 2014 and the need for Father to move back in as she couldn’t cope in 2015, the assessing clinician might have wanted to find out more about all this in terms of considering parenting capacity and risk to the children. 6 Clinical risk assessment and safety management procedure, CLPG 28, July 2017 7 Care Programme Approach procedure, CLPG30, July 2017 9 2.24 The expectation that CPA assessments include reference to children has been in place since 2008.8 We were informed that the Trust has implemented a ‘Think Family’9 approach which was intended to help services improve their response to parents with mental health problems and their families. Summary statement 4 The ‘Think Family’ approach did not influence direct clinical practice in ESTEP in this case. There is no ‘child risk screen’ included as part of the assessment process. 2.25 The final recommendation was that the psychiatric liaison service should ‘explore developing a process of informing ESTEP if one of their patients is assessed at A&E’. 2.26 We suggest that this wording should have a clearer outcome focus, for example setting a standard for communication to a team where the patient is already open to an EPUT service. We would also suggest that this standard should include communication back to the patient’s GP. Summary statement 5 When an existing service user is assessed out of hours, there is no standard for communication back to the relevant clinical team and their GP Referral, assessment and discharge procedures 2.27 The GP records show that Mother’s first prescription for nerve pain was in 2001. Mother has told professionals that she suffered from fibromyalgia since the age of 13, which would have been in 1994. GP records from 1994 do not confirm this. There are records showing that amitriptyline10 was prescribed in 2001, which is the first prescription for nerve pain in her records. In these historic records there is reference to her experiencing migraines, but no detailed explanation for this prescription, or referral for specialist input. There is no reference to fibromyalgia until 2007. 2.28 She had a history of asthma which was treated with inhalers. There is also a history of gynaecological problems dating back to 1998. 8 Laming (2003) Recommendation 12 in The Victoria Climbie Inquiry; Summary and Recommendations http://www.victoria-climbie-inquiry.org.uk/finreports/summary-report.pdf 9 SCIE Report 56: Think child, think parent, think family: final evaluation report, March 2012. https://www.scie.org.uk/publications/reports/report56.asp 10 Amitriptyline is an antidepressant medication used in lower doses to treat pain. It is especially good for nerve pain such as back pain and neuralgia. It can also help prevent migraine attacks. https://www.nhs.uk/medicines/amitriptyline-for-pain/ 10 2.29 Early GP records note her first pregnancy was in 2008. There are no entries which describe her antenatal care, although her older son was born by caesarean on 9 September 2008. The postnatal GP examination was completed without problems. 2.30 In 2007 the GP records state that she was ‘adamant’ that she had fibromyalgia, and she said she had done a lot of research. Consequently she was referred by her GP to the rheumatology department at Broomfield Hospital. The diagnosis of fibromyalgia was made in 2007, and she was found to have chronic back pain, with limitation of movement in her spine, but with no evidence of rheumatoid arthritis. In 2008 she was treated with depomedrone11 injections but had no pain relief. 2.31 Between 2000 and 2017 she moved GP surgery three times, as she changed addresses. One of the changes in August 2014 was, according to her, because the previous surgery did not provide the services she expected for her pain. Her GP notes were visible at each new practice and she was referred for physiotherapy, and to rheumatology for back pain and joint pain over many years. She was prescribed pregabalin,12 duloxetine,13 tramadol,14 folic acid and inhalers. She also had a prescription for ‘as required’ diazepam.15 2.32 As well as widespread pain, people with fibromyalgia may also have: • increased sensitivity to pain • extreme tiredness (fatigue) • anxiety and depression • muscle stiffness • difficulty sleeping • problems with mental processes (known as ‘fibro-fog’), such as problems with memory and concentration • headaches • irritable bowel syndrome (IBS), a digestive condition that causes stomach pain and bloating 2.33 We consider that it is possible that prodromal or negative symptoms of schizophrenia may have been missed because some of the symptoms were attributed to fibromyalgia. 2.34 Although there is currently no cure for fibromyalgia, there are treatments to help relieve some of the symptoms and make the condition easier to live with. 11 Depo-Medrol (methylprednisolone acetate) is an anti-inflammatory glucocorticoid used to treat pain and swelling that occurs with arthritis and other joint disorders. https://bnf.nice.org.uk/drug/methylprednisolone.html 12 Pregabalin is used to treat epilepsy and anxiety, and is also taken to treat nerve pain. https://www.nhs.uk/medicines/pregabalin/ 13Duloxetine is an antidepressant medicine. It's used to treat depression and anxiety. It's also used to treat nerve pain, such as fibromyalgia. https://www.nhs.uk/medicines/duloxetine/ 14 Tramadol is a strong painkiller. It's used to treat moderate to severe pain, and is also used to treat long-standing pain when weaker painkillers no longer work https://www.nhs.uk/medicines/tramadol/ 15 Diazepam belongs to a group of medicines called benzodiazepines. It is used to treat anxiety, muscle spasms and fits (seizures). https://www.nhs.uk/medicines/diazepam/ 11 2.35 Treatment tends to be a combination of: • medicine, such as antidepressants and painkillers. • talking therapies, such as cognitive behavioural therapy (CBT) and counselling. • lifestyle changes, such as exercise programmes and relaxation techniques. • exercise in particular has been found to have a number of important benefits for people with fibromyalgia, including helping to reduce pain. 2.36 On 4 February 2010 the GP records note ‘severe depressive episode with no psychosis’, and that she was referred to ‘improving access to therapies’ programme. According to GP records she was seen by a counsellor in March 2010, but there is no detail provided. Child R was born on 30 September 2010. There are no notes of antenatal or postnatal care, and no further reference to mental health until September 2013. At this time Mother attended the GP surgery with Father, saying she was unable to cope, that she had depression since she was a child, postnatal depression after Child R and was again awaiting pain management help. 2.37 Mother was referred by her GP to the pain management clinic at Southend in 2013. On assessment she reported memory and sleep problems, pain, fatigue and irritable bowel symptoms. Mother also said she had suffered from depression since she was eight years old. She reported having benefited from a pain management programme at Broomfield Hospital. Mother admitted to smoking one ‘joint’ of cannabis every evening and was willing to abstain while undergoing a pain management programme. A referral was then made to the clinical psychologist for chronic pain management. There are no reports back to the GP of what treatment she received. 2.38 She was referred to ‘therapy for you’16 which is an ‘improving access to psychological therapy’ (IAPT) service in Essex. This was an appropriate referral for exploration of Mothers’ mental health issues. The service attempted to contact her by phone on the day she was referred, due to the concerns she expressed. She did not reply, and this was followed up by a letter, as required by the local assessment protocols for IAPT. Mother did not respond to the letter either, and was removed from the waiting list in October 2013. IAPT did not communicate this back to the GP, which would have been in line with expected practice. 2.39 She was allocated to a high intensity IAPT therapist in January 2014, although it is not clear from the records how this referral was followed through. 2.40 Mother was seen in February 2014 ,and as part of the assessment she undertook a Patient Health Questionnaire (PHQ-9).17 Her score was 27, which is the maximum score, and according to the guidance, indicates ‘severe depression, and warrants treatment for depression, using antidepressants, psychotherapy and/or a combination of treatment’. She also completed a General Anxiety Disorder-7 16 https://www.therapyforyou.co.uk/ 17 The Patient Health Questionnaire-9 (PHQ-9) is a nine item questionnaire designed to screen for depression in primary care and other medical settings. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med2001;16:606-13. 12 questionnaire (GAD-7),18 and the total score was 21, which again is the maximum and indicates severe anxiety. According to the guidance, this indicates that ‘active treatment is probably warranted’. 2.41 The IAPT notes on 6 February 2014 record that her scores reflect her ‘frustration that the extent and impact of her physical health condition is not appreciated by professionals’. She was reported to be stressed by money and benefits issues, and the focus was on anxiety/panic symptoms, although she was thought to ‘need further assessment for pain management and depression’. It was noted that she did not feel suicidal at that point, nor had any urge to self-harm. There are undated GAD-7 and PHQ-9 score sheets that show some improvement in scores, but it is not clear when they were completed. She did not attend the second planned session, and she made no further contact at that time, so the plan was to discharge her from ‘therapy for you’. 2.42 Meanwhile Mother had taken an overdose of her prescribed medication and presented at A&E on 12 February 2014. This was a serious overdose: 34 tramadol, 72 pregabalin and 25 duloxetine. When seen by mental health liaison staff in February 2014 she expressed regret at her actions, and said it was impulsive due to stress and frustration, and there had been a family argument that day. There were no psychotic symptoms observed. No child risk assessment was undertaken, there is no evidence of any attempts to clarify her day to day responsibility for the children and whether they were witnessing regular arguments, or whether this was a one-off. 2.43 She was referred to the Rapid Assessment Interface and Discharge team19 (RAID) and seen for an assessment by mental health services on 3 March 2014, and told the assessing team that she had recently started at ‘therapy for you’ and said she felt that would help her. Her GP was written to stating she would not be taken on by secondary mental health services, as she was not actively suicidal and was under the care of IAPT, which seemed the most appropriate service for her. She was also written to advising her of this outcome, and reminding her that it was agreed she would attend her IAPT appointments. It was noted her children were ‘protective factors’ and she cared too much for them to consider a further overdose. There was no record of attempts to explore whether she was actually attending IAPT appointments. 2.44 She was not seen again, and was in process of being discharged by IAPT when the letter from the RAID service arrived, which recommended that she continue with IAPT. 18 Generalised Anxiety Disorder Assessment (GAD-7) is a self-administered patient questionnaire used as a screening tool and severity measure for generalised anxiety disorder. https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7 19 Rapid Assessment Interface and Discharge (RAID) team provided an in-reach psychiatric liaison service to prevent avoidable admissions to inpatient wards and mitigate longer lengths of stay associated with mental illness as a co-morbidity to physical conditions. 13 Summary statement 6 Mother was referred by the GP to appropriate primary care mental health services. Summary statement 7 Mother’s statement about ‘postnatal depression’ is not explored by either the GP or IAPT. Summary statement 8 After the overdose in February 2014 it is not clear whether this information was conveyed directly back to IAPT, and a joint plan agreed. The outcome of her IAPT contact was not communicated back to the GP. Summary statement 9 After the overdose there was no reassessment offered by IAPT. 2.45 In March 2016 Mother saw a GP and presented as upset and anxious, talking of problems with her neighbours She attended again three days later, and asked to see a GP who knew her, which was facilitated later that day. Mother asked the GP for a letter of support with regard to housing. She reported being attacked by the house manager and people were ‘talking about her’. Neither GP appears to have explored this in any depth, and the outcome was a prescription for diazepam at her request. Father saw Mother’s GP in April 2016 to report that she may need counselling for depression and panic attacks. He was given the contact information for ‘therapy for you’. 2.46 Mother changed GP surgery again in April 2016, saying someone had recommended a GP there. 2.47 Mother was referred to the Essex Chronic Fatigue Service in May 2016 after a reported ‘nervous breakdown’ (sic).20 These were Mother’s words, and she was seen with Father and her advocate. She described having depression, anxiety and panic attacks all her life. She was taking diazepam but reported trying to cut this down. She said her neighbours were harassing her and this was now affecting her children. The plan agreed was to support her with a letter to housing, and refer to fibromyalgia clinic, then review. 20 This is the phrase used in the GP records, and does not refer to any recognised mental health disorder. 14 Summary statement 10 The issues in the GP consultation were seen as her reaction to social stressors and chronic pain and fatigue. While this was a reasonable assessment, there could have been an exploration of any thoughts of self-harm or of harming others, or whether the beliefs about the neighbours were delusional beliefs, and if so whether this meant the children were featured in these delusional beliefs, and whether there were any other psychotic symptoms given what she described. It appears there was diagnostic overshadowing in relation to fibromyalgia. The statement about the effects on her children should have been explored. 2.48 In July 2016 the GP noted the feedback from the Chronic Fatigue Service, Mother was now off her pain medication and was gradually increasing her activity, and she was encouraged to access the council’s ‘active women’ programme. 2.49 Mother was seen by the GP in July, September and October 2016 for minor physical health issues with no note of any mental health concerns. 2.50 On 6 March 2017 Mother was brought to A&E at Southend University Hospital by Grandmother. Mother was assessed by the rapid assessment interface and discharge (RAID) mental health team. Grandmother stated that Mother had been paranoid, suspicious and hallucinating for the last three years. Mother thought people were after her, and reported a long history of paranoia and visual hallucinations. The overdose in 2014 was noted, and she denied any thoughts, plans or intent to harm herself. She was not asked about potential harm to others. 2.51 The clinical impression was a 35-year-old lady with a three-year history of paranoia and visual hallucinations, with delusions that were not fixed but constantly returning. It was stated she requires further assessment of psychosis and appropriate intervention. The assessment noted that she had two children (ages six and eight) living with her at Grandmother’s but made no other observation. The GP should have provided ESTEP with information about previous concerns re children and ESTEP should have asked the GP for information about whether children’s services were ever involved and whether there had been any concerns re the children. 2.52 The plan was ‘refer to ESTEP ; appropriate intervention/treatment taking her fibromyalgia into account, and discharge from RAID’. 2.53 Mother was assessed by ESTEP on 18 March 2017 and attended with her sister. The assessment was structured to draw out Mother’s perceptions and understanding as well as any psychotic symptoms. Mother described constant anxiety for many years with some increase since stopping cannabis recently. When she was asked if she was afraid of people her sister interrupted and encourage her to be honest. Mother said she no longer felt that people were following her or plotting against her and said this must be due to the effects of cannabis wearing off. Her sister clearly disagreed and mentioned the neighbours plotting against her. Her sister later became tearful and pleaded with Mother to be honest and open, saying she was 15 worried Mother may have paranoid schizophrenia. Mother insisted she was not holding back and felt better than she did when she came to A&E. 2.54 Regarding her children she mentioned and that she had not been involved in their lives due to being bedridden for so long but was determined to change that. There was no attempt to clarify who was the main carer for the children and to assess the impact of their illness on them. 2.55 The plan was to discuss in the ESTEP team meeting and make a decision about treatment. 2.56 Mother’s parents phoned the RAID team on 5 April to say she was getting worse and asking for a plan. ESTEP tried to call Mother. She was offered an assessment appointment with an ESTEP practitioner and doctor on 21 April 2017. Mother said things were getting worse but did not elaborate, she did say she hoped to be seen sooner. Emergency and crisis numbers were provided. 2.57 Grandmother called NHS 111 on 5 April because Mother was talking of seeing things, saying everything is bugged. Took her to hospital six weeks ago and saw mental health services, and was now waiting for ‘an appointment with a counsellor’. The advice given was to see her GP within 24 hours. 2.58 Grandmother called ESTEP on 7 April 2017 and talked of Mother’s paranoia, how she believed the whole family would be killed by carbon monoxide and she would be dead before the appointment on 21 April. She said Mother would only drink bottled water and goes into Grandmother’s room at night to try to convince her that her beliefs were real. They planned to go to the GP that day to request sleeping tablets for Mother. 2.59 Mother was seen by her GP on 7 April 2017, and was regarded as suffering from a ‘major anxiety disorder’ which also interfered with her sleep. Mother said she had been taking drugs (cannabis) although she does try meditation. She was prescribed zolpidem21 10mg to aid sleep for two weeks. 21 Zolpidem is a nonbenzodiazepine hypnotic prescribed for insomnia. https://bnf.nice.org.uk/drug/zolpidem-tartrate.html 16 Summary statement 11 The assessment letter from RAID is stamped as having been received and scanned in by the GP practice on 15 March 2017. ESTEP later asked for a summary of this GP consultation. This should have been referenced in the consultation on 7 April, and the GP should have considered further information about the children. The history available at this time includes three years of paranoid thoughts, suspiciousness, visual hallucinations and significant delusional beliefs regarding the likelihood that she and her family would be killed and that she was only drinking bottled water due to her fears. She also believes ‘everything is bugged’. The presentation at this point includes: • symptoms which strongly suggest a diagnosis of schizophrenia; • children being involved in delusional beliefs as she believes they will also be killed and poisoned; • a woman with a psychotic illness who has been bedridden to the extent that she has not been involved in her children’s lives. 2.60 This was discussed in the ESTEP team on 10 April 2017 and it was agreed that Mother needed support sooner than the planned appointment. It was agreed that they would ask the crisis team to become involved. The crisis team stated that she would need to have been seen within 24 hours and referred by a GP. ESTEP staff called grandmother back and asked her to ask the GP to make a crisis team referral, which she is noted to have agreed to. There is no mention of this in the GP consultation. 17 Summary statement 12 Mental health services recognised appropriately that Mother needed help before the planned referral. Systems were such that the GP needed to make a referral for this to happen, and the expectation was that family would pass this message on. Both the GP and the Trust missed this opportunity to provide timely mental health assessment and support when the family requested it. Early intervention in psychosis guidance states that ‘if the service cannot provide urgent intervention for people in a crisis, refer the person to a crisis resolution and home treatment team (with support from early intervention in psychosis services). Referral may be from primary or secondary care (including other community services) or a self-or carer-referral’.22 2.61 ESTEP visited Mother at home however on 12 April 2017 to follow up after Grandmother’s calls. Grandmother was present, and Mother reported that things have been worse recently. She described that her family dogs are acting strangely, and believes they are being poisoned. She believed her children were being ‘spiked’ and bullied at school because of her, she had checked their pupils and thought they were ‘different’. Mother believed that songs playing on the radio were directed at her and tell her what to do, people are coming into the house, since a ‘tin of worms’ had been opened, but she would not elaborate on this. She also believed that the sleeping tablets the GP gave her recently had caused lumps on her neck, and her sleep is regularly disturbed anyway because her son has nightmares. She was advised that there would be a discussion in the next team meeting and they would be in touch soon regarding a possible assessment by a psychiatrist. 2.62 Mother was seen at home by the associate specialist psychiatrist and a mental health nurse with grandmother on 19 April 2017. Mother confirmed she was still having unusual experiences but they were no worse. Sleep was still a problem and made worse because her son wets the bed and it wakes her up. The notes do not specify which son or when, although grandmother offered to have him to help out for a few nights. They were informed that a care coordinator was allocated and she would visit on 26 April. Aripiprazole23 5 mg was prescribed, to increase to 10 mg after two weeks, and promethazine24 25 to 50mg as needed to aid sleep. 2.63 The GP was written to, and a diagnosis of unspecified non-organic psychosis ICD10 F2925 was made. The risk assessment stated there was a previous history of 22 Psychosis and schizophrenia in adults: prevention and management, Clinical guideline [CG178] NICE 2014. https://www.nice.org.uk/guidance/cg178 23 Aripiprazole is an antipsychotic medication. https://patient.info/medicine/aripiprazole-abilify 24 Promethazine is an antihistamine medicine that relieves the symptoms of allergies, and can be used as a short term aid to sleep. https://www.nhs.uk/medicines/promethazine/ 25 Unspecified psychosis not due to a substance or known physiological condition. https://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F29-/F29 18 substance misuse, but no self-harm or suicidal ideation at that time. The risk to others was ‘low’; it was noted she had two young children who were not present, but ‘she receives support to look after them from her mother. There is no clarification of what ‘support’ meant, nor mention of children being ‘spiked’ or their pupils being different. 2.64 In our opinion, at this stage the nature and duration of symptoms would meet the diagnostic criteria for schizophrenia. Had this diagnosis been considered, and if staff had appropriate training in child risk, this should have prompted some serious thinking about a woman with significant psychotic symptoms and negative symptoms having caring responsibilities for her children. Whist the diagnosis in itself cannot be used to determine risk, there is a lot of evidence in terms of the potential harms to children when there is parental schizophrenia. Even without this, the impact of the specific symptoms of a parent with a chronic psychotic illness should be considered and so the combination of symptoms described should have raised serious concerns and warranted a referral to Children’s Social Care. Summary statement 13 ESTEP responded quickly after family concerns increased, saw her at home and developed a care plan. Summary statement 14 There is no further exploration of the visual hallucinations that Mother first described.26 The presence of visual hallucinations in psychosis has often been linked to a more severe psychopathological profile and to a less favourable prognosis, and is more usually linked to an organic cause.27 Mother had previously said she had been experiencing these for three years. The children were clearly involved in delusional beliefs and this is an indicator of high risk28 and should have triggered an immediate reassessment, including the exploration of collateral information about childcare with other family members. There should have been an assessment of whether the children were safe in her care. Summary statement 15 The NICE quality statement on early intervention in psychosis29 states that treatment should be started within two weeks of referral, which was achieved. 26 Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease. Waters et al 2014. https://academic.oup.com/schizophreniabulletin/article/40/Suppl_4/S233/1875426 27 The effect of delusion and hallucination types on treatment response in schizophrenia and schizoaffective disorder. Kilicaslan E, et al. The Journal of Psychiatry and Neurological Sciences, (3) 2016. 28 Filicide-Suicide: Common Factors in Parents Who Kill Their Children and Themselves, Friedman S et al. J Am Acad Psychiatry Law 33:496 –504, 2005. 29 Psychosis and schizophrenia in adults. Quality standard [QS80] NICE 2015. https://www.nice.org.uk/guidance/qs80/chapter/Quality-statement-1-Referral-to-early-intervention-in-psychosis-services 19 Care planning and risk assessment 2.65 The allocated care coordinator saw Mother at home a week later with Grandmother. Information about the ESTEP treatment programme and about carer support was shared. Mother stated that the hallucinations she had been experiencing had stopped since taking aripiprazole, and that she had been fearful of people harming her, but they have ‘not done anything’ since she started the medication. She said her pain had increased since taking it, but Grandmother said she had been complaining of increased pain before this. It was noted that Mother was physically sensitive to medication, but was also at risk of stopping it due to her own thoughts about the effects on her fibromyalgia. She said she had stopped using cannabis in March because she could not afford it. Summary statement 16 The recommended therapeutic dose of aripiprazole for adults is between 10 and 30 mg, increasing gradually from 5 mg.30 Mother had taken a sub therapeutic dose for one week when she said her symptoms had gone. There are findings that indicate some people respond more quickly, and early response is a good predictor.31 There is also some evidence that there are gender differences in response to antipsychotics so that sometimes women respond to lower doses.32 This does seem a quick response however, and we consider that professionals should have had more curiosity about this sudden recovery. 2.66 A risk assessment was completed on 26 April 2017. The format of this is a ‘tick-box’ list of possible risk. The risks ‘ticked’ as ‘yes’ were ‘risk related to health/ mental health conditions’, ‘likelihood of disengagement /nonadherence’, ‘risk to self through the use of alcohol/drugs’. The risk of Mother refusing to take antipsychotic medication because of her concerns about side effects was noted, as was the potential use of cannabis. She was frightened to go out because of fear of harm, feeling someone might make her disappear. She was thought to feel safe at home, but there was no discussion about her care of the children. ‘Risk to children’ was ticked as ‘no’ but without exploration. This is difficult to understand in the context of the extent of her psychotic symptoms and her previous poor functioning. 2.67 The plan was for the care coordinator to see her ‘every one to four weeks’ to monitor risk, mental health and medication. Medical reviews would be required at least six monthly, to monitor for use of cannabis and offer support with abstinence, to liaise with social worker if required, and support with healthy eating and debt (by signposting as needed). The contingency plans for her current risk which was listed as ‘my mental health is at risk if I take cannabis. Medication causes me pains and I have stopped taking medication in the past’. Various contingencies were listed, 30 https://bnf.nice.org.uk/drug/aripiprazole.html 31 Agid O, Kapur S, Arenovich T, Zipursky RB. Delayed-onset hypothesis of antipsychotic action: a hypothesis tested and rejected. Arch Gen Psychiatry. 2003;60(12):1228. 32 Seeman MV1. Men and women respond differently to antipsychotic drugs. Neuropharmacology. 2019 May 8:107631. 20 relapse signs were identified as ‘increased pain, hallucinations and paranoia’. Plans to reduce risks were ‘tell my Mum’, ‘call the ESTEP team’. It was noted that her parents needed to be aware of this risk also. Grandmother was offered carer support. 2.68 A formal care plan was written on 26 April, Mother identified being free of pain, hallucinations and paranoia as goals, and also wanting to be able to sleep and go out alone, and cope without taking medication. She agreed to contact the team if her symptoms increased, or if she wanted to stop medication because it caused her pain. She also agreed to accept help with her use of cannabis is she was unable to abstain. 2.69 In early May Mother was seen by the care coordinator with Grandmother. She reported her physical symptoms had increased and she believed this was due to the aripiprazole. She asked if smoking a small amount of cannabis would be helpful and was strongly advised against this. Both Mother and Grandmother reported that Mother had seemed stressed and irritable about debts, housing and impending divorce. There were no psychotic symptoms evident. 2.70 She said promethazine did not help her sleeping, and requested zolpidem, which was later prescribed. She talked of not driving at present but would like to, and was advised that she needed to inform the DVLA of the medication she was taking if she did plan to drive. The children were described by her as alright, and various problems with money, housing and physical heath were discussed. She was apparently spending most of the time at home, with visits to her boyfriend in Chelmsford at the weekends. After some cancelled appointments Mother reported she had been away for a few days in Norfolk with her children and boyfriend which they had all enjoyed. She was tired but denied any psychotic symptoms, and had been able to concentrate on sorting out housing applications. There do not appear to have been questions asked by the team about her boyfriend, in terms of risk to children, given the history of domestic violence and that she was clearly a vulnerable woman. 2.71 In July 2017 Mother called ESTEP, angry and upset, saying the DVLA had suspended her licence for six months, because she had indicated she takes aripiprazole and had taken cannabis. She was angry that she would not be able to drive her children over the holidays, but also said she was being punished. Mother went on to describe her belief that she was being watched inside and outside the house, being followed and being punished, by the “illuminati who run mental hospitals and control everyone’s life”. She said she had stopped taking the aripiprazole the previous week because she was taking antibiotics and felt unwell. She believed the aripiprazole had caused her infection and did not want to restart it. It was agreed she would meet the care coordinator later in July. 2.72 This was discussed with the psychiatrist, it was suggested that Grandmother could be relied upon to call if Mother deteriorated, and a mental health act assessment could be considered. Mother reported starting the aripiprazole again, and when the information from the DVLA was reviewed, it appeared her licence was suspended after she informed them she last used cannabis in March 2017. She was tearful at times but said that restarting the aripiprazole was helping her paranoia. There was 21 no exploration of her statement about being watched, or the ‘illuminati’. There was no consideration of the risk to her children or plan to ensure their wellbeing in the context of a deteriorating mental state. 2.73 In July 2017 there was some discussion about the children; she was sharing a bed with her older (eight year old) son, and her younger son (Child R) slept in a bed above. Mother said it was stressful keeping the children quiet during the day because her father had to get up very early for work, and the house was overcrowded. She said the stress was affecting the children’s behaviour which then affects her physical and mental health. This is not explored further. She spoke of being videoed by strangers while out with her children in Chelmsford, the post man tried to enter the house to steal bikes, and her drink had been spiked. When attempts were made to explore these further, Mother appeared unable to differentiate whether they had happened recently or in the past, becoming vague in her answers. 2.74 The risk assessment and care plans were unchanged. At an MDT review in July 2017 it was noted that her paranoid ideas were ‘very fixed with high conviction’, and it was ‘too soon to commence relapse prevention work’. She had been given information about family work, so it was planned to discuss this again. It was felt that she would benefit from an increase in aripiprazole, but it was uncertain whether she would agree. It was agreed to plan a further MDT review in nine months. 2.75 These symptoms were not evident at the next contact in August, which was by phone. A psychology assessment was arranged for later in August, in line with early intervention standards. In August Mother was agitated about what she said were chemicals in her bedroom, ‘coming through the walls’. She said she has always been sensitive to smells and could now smell that her bedroom smelt ‘dusty’. Mother suggested calling the police and fire brigade as a solution. It appeared there was an increase in family stress, following Child R wetting the bed and her experiencing increased pain. Mother refused to consider an increase in aripiprazole due to side effects. 2.76 This was later discussed with Grandmother by phone; Mother apparently believed the ‘chemicals’ were causing Child R to wet the bed, and they had bought a carbon monoxide monitor. Grandmother clarified that some batteries had been stolen, but there was no concern about bikes or cars. She conveyed that Mother had not said strange things for a while, and it was her belief that Child R wet the bed because he was on a top bunk and couldn’t get to the toilet in time. Grandmother was asked about family therapy but said she was very busy, and was not sure Grandfather would attend. 2.77 In October 2017 Mother spoke of worrying that Child R may have ADHD and being aggressive to his brother. The GP had apparently referred him to Essex Emotional Wellbeing and Mental Health service (EWMHS) ‘and this had helped her’. Her mother and sister were also helping out so that the children did not spend so much time together. There was no communication between the ESTEP team and EWMHS. 22 Summary statement 17 The planned medical review in nine months recognises that she has a chronic psychotic illness but does not consider any risk to the children. A review should also have recognised that the children have been involved in her delusional beliefs. The current Trust risk assessment does not include a framework for assessing risk to children. There was no attempt to offer an OT assessment to clarify her level of functioning - it is clear that she had caring responsibilities for her children and that at times she has not been able to function well enough to care for them. There was no communication from EPUT to the GP about a potential mental health referral for Child R. 2.78 A CPA review was planned for 27 October 2017, in line with policy expectations. Mother was seen for a psychological assessment on 24 October 2017. She still maintained that her physical health had worsened on aripiprazole, including causing lumps in her neck. She apparently had no paranoid beliefs at that time, but acknowledged that had previously believed in her thoughts completely. She believed that her psychotic experiences were caused by cannabis. Mother was able to discuss coping strategies, including diet, exercise and meditation that had been suggested by the Chrysalis Effect33 members. She was encouraged to develop a relapse plan with her care coordinator, and not to decrease medication without discussing with her psychiatrist. Because she appeared to have good coping mechanism it was not felt there was a role for psychology at this time, which Mother agreed with and was noted to feel positive about. 2.79 Mother cancelled the CPA review, and the next contact after that was by phone with the care coordinator in early November. Mother reported being physically unwell due to fibromyalgia, and hyperthyroidism. She said the hyperthyroidism caused her difficulty in swallowing.34 They were awaiting counselling for Child (R) who was said to still ‘take things out’ on his brother but things were ‘alright’. 2.80 The CPA meeting took place on 15 November 2017. She reported an increase in her fibromyalgia symptoms which she attributed to aripiprazole, these symptoms were memory loss, trouble thinking, constipation, cold extremities, weight gain and hair loss. It was noted that she said she suffers from hyperthyroidism which “can cause difficulty swallowing and talking”. The symptoms described in fact sound similar to hypothyroidism. She said she did not want to discuss her physical health with her GP, preferring natural methods. 33 The Chrysalis Effect is a support organisation for people suffering the symptoms of ME, CFS and Fibromyalgia. https://thechrysaliseffect.co.uk/ 34 Mother had not been diagnosed with either hyper or hypothyroidism according to GP notes. 23 Summary statement 18 Thyroid disorders commonly cause significant psychiatric symptoms and it is important to ensure thyroid function is assessed and any thyroid disorder adequately treated. ESTEP should have contacted the GP for further information and to ensure appropriate investigations and treatment had been initiated. There was a lack of curiosity regarding this new physical ailment presented by Mother, and how it might affect her mental health, and ESTEP should have explored this with the GP. She had not in fact been diagnosed with either hyper or hypothyroidism by the GP. 2.81 At the CPA review Mother mentioned that she was still looking after her sons, Child R was still aggressive towards his brother, and she was also looking after her nephew. There was in our view a lack of professional curiosity re potential link with her mental illness, in terms of both her mental illness contributing to behavioural problems in the children, and also that her having to cope with this behaviour was an additional stress which may contribute to relapse. She was noted to be mentally well, but at risk of deterioration if she stopped her medication. A ‘process of recovery’ user reported measure was completed by Mother, which showed she was feeling much more positive and engaged with her life. 2.82 The care plan was updated: to see her every two to four weeks to monitor mental health and medication, to check physical observations and take a drugs test (for DVLA), start relapse prevention work, reduce and possibly stop aripiprazole. The two children were noted to be a ‘protective factor’. There was no further exploration of her care of her nephew. A medical review was planned at six months. Summary statement 19 She was noted to be at risk of relapsing if she stopped her medication, yet there was a plan to reduce and possibly stop. The team could have helped her to manage any physical symptoms, and consider the risks and benefits of reducing and stopping medication. Summary statement 20 Outcome measures were used at the CPA meeting, to provide an objective measure of mental health. There was no objective measure of psychosis symptom reduction completed. 2.83 In November 2017 Mother requested to stop taking aripiprazole. The consultant psychiatrist advised against it but suggested she reduce to 5 mg every second day. Contingency plans were agreed, early warning signs were identified as believing people are looking at her, and coming into the house. It was agreed she would start relapse prevention work, and either she or Grandmother would call the team if they 24 have any concerns about her mental health. There was no review of possible effects in the children. 2.84 On 1 Dec 2017 seen at home, was looking after her three-year-old nephew who was asleep. There was no discussion about this. Mother said she had a urinary tract infection, which she maintained had also happened when she stopped medication earlier.35 2.85 Mother’s initial diagnosis in 2017 was ‘non-organic psychotic disorder’, and there was no differential diagnosis developed as the team became more familiar with her. There is no evidence that this was discussed with Mother or her parents in any depth, to help them understand the diagnosis. The reason why this is so relevant and important in this case is that there is evidence in terms of the implications of a diagnosis of schizophrenia for parenting. If this diagnosis had been made, and if staff had appropriate training in child risk and safeguarding, the diagnosis itself should prompt a thorough assessment of potential risk to children. Also we consider that if she had the diagnosis the family may have been able to give more thought to the impact on the children, and professionals could have considered the emotional impact of the children of living with a parent with a diagnosis of schizophrenia. 2.86 The NICE guidance (2014)36 for the management of psychosis and schizophrenia now focusses on each stage of the person’s psychotic illness: • Preventing psychosis • First episode psychosis • Subsequent acute episodes of psychosis or schizophrenia and referral in crisis • Promoting recovery and possible future care 2.87 The referral to ESTEP provided the opportunity for treatment within national guidance; the NICE guidance for the management of psychosis and schizophrenia recommended these standards for psychological interventions: 2.88 ‘Psychological interventions: CBT should be delivered on a one-to-one basis over at least 16 planned sessions and: follow a treatment manual so that: • people can establish links between their thoughts, feelings or actions; and their current or past symptoms, and/or functioning; • the re-evaluation of people's perceptions, beliefs or reasoning relates to the target symptoms; also include at least one of the following components: • people monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms; • promoting alternative ways of coping with the target symptom; • reducing distress; and 35 Mother has a twenty year history of recurrent UTIs. 36 Psychosis and schizophrenia in adults: prevention and management. https://www.nice.org.uk/guidance/cg178 25 • improving functioning. 2.89 Family intervention should: • include the person with psychosis or schizophrenia if practical • be carried out for between 3 months and 1 year • include at least 10 planned sessions • take account of the whole family's preference for either single-family intervention or multi-family group intervention • take account of the relationship between the main carer and the person with psychosis or schizophrenia • have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work’. 2.90 Mother had regular input from the care coordinator, described as ‘supportive monitoring of her mental health and response to medication’. The interventions documented are of a generally supportive nature, and are not linked to the evidence based interventions as described. Family therapy was offered and refused, and carers assessments were offered and refused. 2.91 The guidance on medication in the 2014 NICE guideline was: ‘The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees. Provide information and discuss the likely benefits and possible side effects of each drug, including: • metabolic (including weight gain and diabetes) • extrapyramidal (including akathisia, dyskinesia and dystonia) • cardiovascular (including prolonging the QT interval) • hormonal (including increasing plasma prolactin) • other (including unpleasant subjective experiences)’ 2.92 There is clear evidence that medication and its effects and side effects were discussed many times with Mother. The GP was not involved however in these discussions. Her physical observations were recorded in May 2017 and again in December 2017. As discussed earlier, her assertions that aripiprazole caused her to have infections and hyperthyroidism were not challenged. Summary statement 21 There was a lack of a structured evidence-based approach that would be expected from an EIP service, which should also consider differential diagnoses. 2.93 It was noted at a review in November 2017 that Mother had stopped taking aripiprazole, and had no psychotic symptoms. A medical review in May 2018 noted that she had remained medication free and had no psychotic symptoms. Her risk to 26 other and to herself was regarded as low, and the contingency plans relied on her telling Grandmother that she was unwell, or either herself or Grandmother calling ESTEP. 2.94 This review stated that she had been ‘symptom free’ since June 2017. We question the accuracy of this: she talked of “illuminati who run mental hospitals and control everyone’s life” in July 2017; in August 2017 she believed chemicals were coming through her bedroom walls which caused Child R to wet the bed and were poisoning the family; and in November 2017 she maintained that her physical health had worsened on aripiprazole, including causing lumps in her neck, and that this had caused difficulty in swallowing and hyperthyroidism. 2.95 It was clear that Mother still believed that her psychotic symptoms were caused by her stopping cannabis abruptly. Part of her relapse prevention plan was to ensure she sought help if she was having difficulty abstaining from cannabis use. Family communication/responsiveness of services 2.96 The family did not agree to meet us as part of this review, therefore our observations are limited to information contained in the clinical records or through interviews with staff and Mother. 2.97 The ESTEP MDT review in May 2018 noted that family therapy was offered and refused, and carers assessments were offered and refused. The care coordinator had contact with Grandmother when she made contact to express concerns about Mother. The coordinator called Grandmother on at least one occasion to ask for more information about Mother’s presentation when there was a concern. 2.98 It is evident from the records that Mothers sister was very concerned about her at the ESTEP initial assessment in March 2017. There is a record of the staff member offering the sister an opportunity to talk more about this, but there is no further reference to gathering collateral information from family members. 2.99 Grandfather does not appear to have been present at any point when staff met Mother. It appears that an assumption was made that Grandmother was seen as a protective factor, however Mother clearly had primary responsibility for the children. Grandmother worked full time so was not at home with the children for much of the time. Grandmother was invited to a carers’ information evening in July 2017, a response was not recorded. 2.100 The coordinator never met either Child R or his brother, apparently at the request of Mother. There does not appear to have been any challenge or curiosity about this.37 Clinicians have documented that there is nothing evident to trigger concern about parenting There were no comments on when concerns might arise e.g. when her functioning deteriorates or when her psychotic symptoms become more florid. 2.101 A 10 day holiday to Jamaica with her partner was planned in June/July 2018. Mother called ESTEP in early July and was then not contactable when staff called her back, 37 Serious case reviews highlight the importance of professionals being able to see the children. 27 Grandmother called a few days later to say she was concerned that Mother’s paranoid beliefs about conspiracy theories were still there, and now thought she was unwell but putting on a front. 2.102 Attempts were made to contact Mother which were unsuccessful. Grandmother called back and asked for her to be seen. Accounts of the details of the communication over the next few days differ: Grandmother has stated that asked for Mother to be seen, but it was recorded that Grandmother said it could wait until her care coordinator was available. 2.103 On 20 July 2018 Grandmother took Mother to A&E at Southend Hospital as she was experiencing a relapse of psychosis with similar symptoms as previously. She was seen by the Mental Health Liaison Team and following the contact it was advised that they request that the GP restarted the antipsychotic medication. 2.104 It is acknowledged in the internal investigation report that the Mental Health Liaison Team missed an opportunity to treat Mother who was clearly showing signs of a relapse of her psychotic illness. The report also states that the Mental Health Liaison Team should have considered admission to a psychiatric unit or requested an assessment under the Mental Health Act 1983 in order to prevent further deterioration of her mental illness. There is no comment on the assessment of risk to children, considering she was presenting with psychotic symptoms, and was the main carer to her children. 2.105 There was no handover to the GP or ESTEP in the morning. We consider that the team should have asked for a clinical review the next morning rather than relying on GP to prescribe antipsychotic medication. As Mother had relapsed, we believe ESTEP should have made arrangements to assess her the next day. This was another missed opportunity to initiate treatment for the psychotic episode. Grandmother contacted the ESTEP team to make them aware of the presentation and that Mother was back on medication. It was documented that Grandmother agreed for the care coordinator to make an appointment the following week, when the care coordinator returned from holiday. We have been informed that Grandmother has told the SCR lead author that she had a different recollection of this conversation. 2.106 ESTEP missed a further opportunity to reassess Mother after being informed that she had restarted medication. Mother told us that she had been smoking cannabis in Jamaica, and described continuing to use cannabis after her return from holiday a few weeks earlier. Summary statement 22 The views of family and carers should have been sought to ensure there was an opportunity for the family to be listened to, and a more holistic assessment made that incorporated their perspectives. Liaison services should routinely ask about caring responsibilities for children and ensure there is a safe plan for the care of the children if sending a parent with a psychotic illness home. 28 3. Overall analysis and recommendations Findings and recommendations 3.1 Mother had been under the care of secondary mental health services since March 2017, after an initial short contact in 2014. 3.2 Her diagnosis in 2017 was ‘non-organic psychotic disorder’, and she was treated by the ESTEP team. There was no differential diagnosis developed as the team became more familiar with her, despite symptoms from 2017 warranting a diagnosis of paranoid schizophrenia. There is no evidence that this was discussed with Mother or her parents in any depth, to help them understand the diagnosis and consider contingency plans if she was in need of urgent support. 3.3 Mother had a diagnosis of fibromyalgia, and was reluctant to take conventional medicines to treat this. This reluctance also applied to taking psychiatric medication, and she continued to use cannabis which she believed helped with pain control. She attributed an increase in physical symptoms to her psychiatric medication, and this was accepted at face value by the ESTEP team, without exploration with either Mother, the family or the GP. This contributed to some diagnostic overshadowing, and a lack of consideration that an assessment of negative symptoms of schizophrenia was needed as well as the impact of these on her daily functioning and ability to meet the needs of her children. The assessment of risk did not include any exploration of the makeup of the household, or potential risks to her children. Her children are noted to be ‘protective factors’ without any depth of assessment, and in our view there was a complete lack of consideration of the children’s need and their safety. The extent to which they were involved in her delusional and paranoid ideas was not explored. 3.4 There are many factors in this case which raise significant concerns that the children were at risk and that a referral to Children’s Social Care should have been made including: (a) The children clearly featured in Mother’s delusional belief system at various times and this alone should have prompted an urgent referral to Children’s Social Care, and a safeguarding alert raised. (b) Mother’s poor level of functioning should have been more thoroughly assessed given her history of being bedridden. Even with the information available this indicated a potential risk to the children of physical and emotional neglect. (c) Her history of aggressive behaviour indicates a potential risk of physical harm which warranted further assessment. (d) The emotional harm caused by living with a parent with significant paranoid and suspicious thoughts needed further assessment. (e) The combination of serious mental illness, substance misuse and a history of domestic abuse in this family should also have raised concerns. This ‘toxic trio’ is commonly a feature of child serious case reviews. 29 (f) assumptions should not be made about other potential carers being protective factors without an assessment of their availability and suitability to meet the needs of the children. (g) the importance of being able to see the children has been highlighted in serious case reviews. (h) the new partner was not assessed which is important when there is a history of domestic abuse in previous relationships. (i) children presenting with aggressive behaviour and bedwetting and reporting concerns to adults suggest the possibility that they are being affected by the situation at home. 3.5 Mother was known to be at risk of relapsing if she stopped her medication, yet there was a plan to reduce and possibly stop this, based on her dislike of taking antipsychotics. The team did not explore her reluctance in any depth, nor try to introduce other medication with a different side effect profile. 3.6 When Mother was reported by family to be showing signs of relapse, there was no structured team approach, such as a traffic light system. In our view the care and risk management plans were not effective in treating her condition or mitigating risk. 3.7 The views of family members were not routinely sought, and actions were not taken on family views where they were provided. 3.8 EPUT has clear policies that include the expectation of a holistic assessment of mental state and risk, a ‘Think Family’ approach, and guidance which encourages staff to consider risk where children are involved in parental delusional systems. 3.9 The internal report into this tragic event was completed in September 2019, 14 months after the death of Child R. The recommendations were not outcome focussed. 3.10 The SCR has made eight recommendations for health services which we endorse (SCR recommendations 3,4,5,7,8,9 and 10) and we have made three individual recommendations. 30 Recommendation 1 EPUT must ensure that Early Intervention Services meet the expectations of best practice guidance and standards. Recommendation 2 EPUT must ensure the community mental health teams have a structure and systems for responding to relapse or increase in risks, such as a clinical ‘traffic light’ rating tool. Recommendation 3 EPUT must ensure that internal investigation reports meet the timeliness standards expected by the NHS England Serious Incident Framework, and that recommendations are outcome focused. 31 Appendix A – Terms of reference This investigation was to be conducted in partnership with the Serious Case Review Terms of Reference. The investigation will examine the NHS contribution into the care and treatment of Mother from her first contact with specialist mental health services following the birth of child up until the date of the incident. Additional health related Terms of Reference: • Critically examine and quality assure the NHS contributions to the Children’s Serious Case Review • Examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother • Review and assess compliance with local policies, national guidance and relevant statutory obligation • Examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family • Examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services • Review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway • To work alongside the Children’s Serious Case Review and Chair to complete the review and liaise with affected families • To provide a written report jointly with the Serious Case Review report to the Safeguarding Board and NHS England that includes measurable and sustainable recommendations to be published either with the multi-agency review or standalone 32 Appendix B – Internal report analysis Standard Present Theme 1: Credibility 1.1 The level of investigation is appropriate to the incident Yes 1.2 The investigation has terms of reference that include what is to be investigated, the scope and type of investigation Yes 1.3 The person leading the investigation has skills and training in investigations Yes 1.4 Investigations are completed within 60 working days No 1.5 The report is a description of the investigation, written in plain English (without any typographical errors) Yes 1.6 Staff have been supported following the incident Yes Theme 2: Thoroughness 2.1 A summary of the incident is included, that details the outcome and severity of the incident Yes 2.2 The terms of reference for the investigation should be included Yes 2.3 The methodology for the investigation is described, that includes use of root cause analysis tools, review of all appropriate documentation and interviews with all relevant people Yes 2.4 Bereaved/affected patients, families and carers are informed about the incident and of the investigation process Yes 2.5 Bereaved/affected patients, families and carers have had input into the investigation by testimony and identify any concerns they have about care Yes 2.6 A summary of the patient’s relevant history and the process of care should be included Yes 2.7 A chronology or tabular timeline of the event is included Yes 2.8 The report describes how RCA tools have been used to arrive at the findings Yes 2.9 Care and Service Delivery problems are identified (including whether what were identified were actually CDPs or SDPs) Yes 2.10 Contributory factors are identified (including whether they were contributory factors, use of classification frameworks, examination of human factors) Yes 2.11 Root cause or root causes are described No 2.12 Lessons learned are described Yes 2.13 There should be no obvious areas of incongruence Yes 2.14 The way the terms of reference have been met is described, including any areas that have not been explored Yes Theme 3: Lead to a change in practice - impact Yes 3.1 The terms of reference covered the right issues Yes 3.2 The report examined what happened, why it happened (including human factors) and how to prevent a reoccurrence Yes 3.3 Recommendations relate to the findings and that led to a change in practice are set out No 3.4 Recommendations are written in full, so they can be read alone Yes 3.5 Recommendations are measurable and outcome focused No |
NC52325 | Death of a 4-week-old infant boy in May 2020. Learning includes: cases of children who have been the subject of a supervision order, should remain open on a multiagency child in need plan for a minimum of 3 months, to ensure they can be stepped down safely; for children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started; all reports submitted to a child protection conference should be formally considered, openly shared, and commented upon during the conferences; issues of non-engagement and self-reporting should be actively addressed during child protection conferences; the summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process; escalation procedures should be easy to use; child in need plans are invariably multiagency, and all partners need to be aware of their importance in safeguarding children; extended family or kinship to be included in child in need planning to explore sources of safety and risk when they have been integral to a child protection plan; it is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance; police attending any incident at homes where domestic abuse has been a feature should interview the parties separately; the safeguarding children partnership should review the child protection categories used for children exposed to domestic abuse; the use of neglect as a category can be misleading for professionals. Recommendations form part of the learning.
| Title: Local child safeguarding practice review (West Berkshire): ‘Bobby’. LSCB: Berkshire West Safeguarding Children Partnership Author: Maureen Floyd Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Berkshire West Safeguarding Children Partnership (BWSCP) Local Child Safeguarding Practice Review (West Berkshire) ‘Bobby’ Maureen Floyd, Review Author 2 1. Introduction This Child Safeguarding Practice Review (CSPR) was commissioned by Berkshire West Safeguarding Children Partnership (BWSCP) following the death of 4-week-old Bobby whilst in the care of his parents in May 2020. Bobby lived with his 4-year-old brother Alfie and their parents. Previously, Alfie had been subject to child protection plans and care proceedings in relation to domestic abuse perpetrated by his father. The family’s case had been closed to Children’s Social Care (CSC) for six months when Bobby died. On 9th June 2020, BWSCP decided that these events met the Working Together 2018 criteria for a local Child Safeguarding Practice Review (CSPR). This decision was agreed by the Child Safeguarding Practice Review Panel. 2. Review Process 2.1 - CSPR Panel A panel was appointed to work with the lead reviewers during the review process. The panel was comprised of the following representatives: • Head of Safeguarding Children, Berkshire West Clinical Commissioning Group (CCG) Chair • Independent Reviewers, Bridget Griffin & Maureen Floyd. • Head of Children and Family Services, West Berkshire Council • Service Manager, Children and Family Services, West Berkshire Council • Emergency Duty Service, Children & Families Service, West Berkshire Council • Detective Chief Inspector, Thames Valley Police • Head of Safeguarding, Berkshire Healthcare NHS Foundation Trust • Deputy Headteacher and Designated Safeguarding Lead, Primary School • Associate Chief Nurse Safeguarding, Mental Health & LD and Designated Professional for Child Death, Royal Berkshire NHS Foundation Trust • Named Midwife, Royal Berkshire NHS Foundation Trust • Partnership Coordinator, Berkshire West Safeguarding Children Partnership • Strategic Partnership Manager, Berkshire West Safeguarding Children Partnership 2.2 - Independent Reviewers Bridget Griffin has extensive experience as an author of Serious Case Reviews and more latterly, author of CSPRs. Bridget recently undertook a thematic review in Norfolk relating to 6 children who died from or sustained serious, non-accidental injuries. Bridget and Maureen were co-authors of the Croydon Safeguarding Children Board Vulnerable Adolescent Review, a thematic review looking at the lives of 60 Vulnerable Adolescents. Maureen Floyd has extensive experience of statutory safeguarding work within Children’s Social Care, from Social Worker to Head of Service, with a consistent specialism in child protection. Maureen is an experienced project manager of Serious Case Reviews, Learning Reviews and Safeguarding Practice Reviews and has been the lead author with supervision provided by Bridget. 2.3 - Methodology A comprehensive Rapid Review meeting provided the CSPR panel with extensive background information and identified initial learning. The agreed methodology for this CSPR was outlined as follows: 3 • Chronologies Agencies were asked to provide background information of their engagement and knowledge of the family with detailed Chronologies of involvement between September 2019 to May 2020 • Key Lines of Enquiry (KLOE) The Terms of Reference noted the KLOEs as: 1. How do we work together as a multi-agency safeguarding team across threshold models, approaches, procedures, and processes to safeguarding children? a) Child in Need – How did the CiN Plan get to the point of being closed without a multiagency decision and why was this not challenged. b) How do we facilitate a culture of respectful challenge? c) Pre-birth assessment d) Vulnerable Women’s Midwifery Team 2. Decision making and risk assessment in cases of long-term Domestic Abuse. a) Dynamic risk assessment 3. What have we learnt from previous reviews and how has this changed the way we work? 4. How did Covid-19 effect the way that agencies were able to safeguard? a) Difficulties in safeguarding children virtually • Emerging Themes The report has also sought to examine the systemic issues, which for the purpose of illustration is shown at Appendix One. Analysis of the information from the composite chronology and agency KLOE documents were used to formulate emerging themes which were shared and agreed by the CSPR panel. • Engagement with Practitioners The practitioner learning event enabled staff who had worked directly with the children and their family to gain an overview of ‘Bobby and Alfie’s Story’; to explore the emerging themes and discuss their experience, views, and perspectives. They were able to contribute to the recommendations and advise of positive changes in practice since. A range of views and reactions emerged, which are considered within this report. • Engagement with Family The boys’ father has recently been charged with murder and inflicting grievous bodily harm with intent. The boys’ mother has also been charged with causing or allowing the death of a child, and assault, ill-treatment or neglect. The panel have taken the view that neither parent should be approached for their views whilst the matter is sub-judice. The BWSCP intend to share the report with relevant family members for comment before publication. • Overview report A final draft of this report was agreed by CSPR Panel before being finalised and presented to the Berkshire West Case Review Group for approval. Final sign-off was given by the Executive of the Berkshire West Safeguarding Children Partnership. 4 3. Impact of domestic abuse on children The Panel were aware of the importance within the review of considering the child’s lived experience. It was decided that this would be extremely sensitive, and the preferred approach was to consider the implications for all children exposed to domestic abuse. The Children Act 1989 Section 311 is the legislation which allows local authorities to ask a court to make a child the subject of a care or supervision order. Such an order can only be made by a court if a child has suffered or is likely to suffer significant harm. Section 31(9) gives definitions of ‘harm’; this was updated in 2002 by the Adoption and Children Act (section 120) to include what was recognised as the very real impact of domestic abuse on children. “harm” means ill-treatment or the impairment of health or development, including, for example, impairment suffered from seeing or hearing the ill-treatment of another. UNICEF in their 2006 Behind Closed Doors report2 note the impact of domestic abuse on children. Their Key Findings include: • Children who live with and are aware of violence in the home face many challenges and risks that can last throughout their lives. • There is increased risk of children becoming victims of abuse themselves. • There is significant risk of ever-increasing harm to the child’s physical, emotional and social development. • There is a strong likelihood that this will become a continuing cycle of violence for the next generation. These two examples acknowledge the long-standing awareness and understanding of the significant and detrimental impact of domestic abuse on children. Barnardo’s 2020 report: Not just Collateral Damage.3 The hidden impact of domestic abuse on children noted: Domestic abuse can have a severe impact on child development, particularly for very young children who are exposed to violence. Research suggests the impact on neurological development can manifest itself in poor health, poor sleeping habits, excessive screaming, and result in disrupted attachment. 4. Alfie & Bobby’s Story All family members are White British and have lived predominantly within Berkshire. Father has a long history of juvenile offences, for drug use, violence, criminal damage, and public order offences. He struggled to control his anger and was known for concerns about his mental health, both depression and self-harm. Concerns were also raised about mother’s depression. She had twice taken an overdose which required hospitalisation, aged 15 and 17 and had taken medication and used counselling services to seek support with her emotional wellbeing. 1 https://www.legislation.gov.uk/ukpga/1989/41/section/31 2 200154_SVITH_report5.qxd (unicef.org) 3 https://www.barnardos.org.uk/Not just collateral damageReport_0.pdf 5 Mother was 19 when Alfie was born, and father was 22. The first recorded violent incident towards mother, perpetrated by father, was when Alfie was 3 months old. When Alfie was 6 months, his father was imprisoned for injuring Alfie and his mother. Mother made it clear that she and father were intending to reunite when father was due to be released, so Alfie was made subject to a Child Protection Plan for neglect, from June 2016 to May 2017 and care proceedings were initiated. Both parents underwent parenting assessments, and it was agreed that father would not be allowed to be a primary care giver to his son. In May 2017, the court made a six-month Supervision Order on the basis that Alfie lived solely with his mother, and as a result the Child Protection Plan ceased. The multiagency partnership was aware of the danger towards mother and Alfie in this relationship, and that risks escalated when father used alcohol. The combination of father living apart from them, with contact taking place supervised at paternal grandmother’s home, was the status quo judged to keep Alfie safe. In November 2017, Children’s Social Care ceased their involvement within days of the Supervision Order expiring. Case analysis The criteria for a Court to make either a Care or Supervision Order, is the same; the child must have suffered or be likely to suffer significant harm. The granting of a Supervision Order requires the Local Authority to work with the family, ‘to advise, assist and befriend the supervised children’. Section 35 Children Act 1989 Care proceedings is the highest level of concern that a local authority can demonstrate about the care of a child. Alfie was on a Child Protection Plan, but the local authority regarded that a more serious level of intervention was required. However, once the Supervision Order expired, the case was closed. It is not clear why this happened. At the subsequent CP Conference, the Chair questioned why the case had closed when the plan had not been achieved. What had father achieved in addressing his anger management, alcohol, and drug use. What did both parents now know and understand of the impact of domestic abuse on children? Father had not undertaken the required Building Better Relationships Course via Probation linked to his conviction. Mother had not attended the associated course for partners. Both cited not liking group work. Alfie’s case had not been presented to either of the borough’s domestic abuse panels, Multiagency Risk Assessment Conference (MARAC) and Domestic Abuse Repeat Incidents Meeting (DARIM). The explanation for this was that it was judged to be a case of medium risk and therefore did not meet the threshold for either of these specialist Domestic Abuse meetings. (See Finding 15) Finding 1 Cases of children who have been the subject of a Supervision Order, should remain open on a multiagency Child in Need Plan for a minimum of 3 months, to ensure they can be stepped down safely. 2018 In December 2018, Police received a dropped call from mother at the family home. It was understood that father was in bed, intoxicated, and became irate with 3-year-old Alfie who had disturbed him. Father took mother’s phone, and she fled the home with Alfie. Despite his intoxication, father had already driven away when Police arrived. Mother denied that they were a 6 couple or that father was living at the property. Concerns were immediately raised for Alfie’s safety and child protection enquires initiated. Later in December 2018 Alfie was made subject to a CP Plan for neglect. The social worker (SW) told the CP conference: ‘the family had been through the Court process, and it was made clear should they be together, and alcohol was involved, then the risk was massive. They were aware of the risk but still placed themselves in that position.’4 Father and paternal grandmother both advised conference that the parents’ relationship was ‘toxic’, and they were not intending to be together. Conference heard that Alfie’s behaviour had deteriorated at nursery of late, he had been swearing and had to be kept apart from other children when playing with sand as he was prone to throwing it in their eyes. The pattern of CP conferences and CP Plans were reinstated; father was not permitted to live at the home and contact with Alfie took place at the paternal grandmother’s home. The focus of the CP Plan was to educate the parents about the impact of domestic abuse on Alfie, explore their respective mental health issues, father’s drug, and alcohol use, and a requirement that they keep to these specific requirements to ensure that Alfie was safe and well. Case analysis This was good practice, the response to safeguard Alfie was swift and decisive. Mother’s suggestion that they were not in a relationship was disregarded as father was at her home, in her bed, intoxicated and Alfie was in danger. She had removed Alfie from that danger and attempted to seek Police help. It was good practice that the Police responded to her dropped call and were able to ensure that mother and child were safe. 2019 The review CP conference in March 2019 heard there had not been any reports of domestic abuse or violent incidents. There was some improvement in Alfie’s behaviour at nursery, and a health visitor developmental review had judged him to be reaching his developmental milestones. Although his score on the social and emotional questionnaire was borderline; it was decided to wait and see how he progressed before making a referral to the child development clinic. The aim being to identify if the behaviours were more environmental than organic. Mother and father were each offered direct support in relation to Domestic Abuse and Mental Health. Father acknowledged that he was taking antidepressants, conference heard he had sought support with low mood and a referral had been made to the mental health team which he had not taken up. Father advised that he had been seeing a private hypnotherapist but could not continue when he lost his job. The Chair stressed that Alfie was unsafe when the parents were together, and he was better when they were separated. If they resumed their relationship, it should be away from Alfie and the social worker should be notified, as their relationship was harmful to Alfie. It was noted that father’s alcohol and cannabis use fluctuated. Father said he did not see it as an issue; because he ‘never drank around ‘Alfie’ and just used cannabis as a social thing. ‘However, Alfie was on a CP plan because of his father’s behaviour towards him and his mother in December when he was intoxicated. 4 CSC Initial Child Protection Notes 20 December 2018. 7 Case analysis This was good practice. The conference recognised all the areas that the parents needed to engage with and did not lose sight of Alfie’s needs. There was acknowledgement that there had been some progress, i.e., that parents were engaging with the CP Plan. Paternal Grandmother was present and was vocal about the ‘toxicity’ of the parent’s relationship and inherent risk to Alfie. At the end of July father went to a bridge with the intention of jumping off and ending his life. He was stopped by a passer-by and an urgent referral was made to the Mental Health Crisis Recovery Home Treatment Team (CRHTT). Eleven contacts were offered by the team, and he engaged with six including a medical and psychological review, he was discharged in mid-August. Father agreed to a referral to Talking Therapies although he never engaged. He was taking antidepressants prescribed by his GP. In early August father told the Domestic Abuse worker of his suicide attempt. ‘he is generally okay but that things had not been good and as a result of his low mood and wanting this feeling to end, he took himself to a bridge to end his life’. A few weeks later the review CP conference made no mention of this mental health crisis. Agency reports were submitted to conference although not all the agency representatives were able to attend. The Police report was referred to in that there was no new information. The GP report on father cited the potential suicide attempt as an issue and a risk: • Talked down from bridge – planning suicide. • Depression/suicide risk, depressed mood for 3 to 4 weeks, and had failed to attend his appointment in mid-August. The only reference that was made to the GP report during conference was that it referred to father but did not provide information on Alfie, despite the GP noting the identified risk factors being specifically related to Alfie. The CRHTT, who provided a crisis mental health response to father following his intended suicide, were neither invited to the CP conference nor asked to provide a report. The SW conference report noted a contact with a CPN (Community Psychiatric Nurse) in early August when father was being seen by CRHTT, but their view or a summary of the information or intervention was not recorded. The SW report noted: Although father’s mental health has been generally stable, there was an incident on 27/07/2019 when he went to a bridge, according to him and on reflection, more of seeking attention than actually attempting to jump. A copy of the assessment undertaken by the mental health service was requested but has not been shared. This matter is addressed later in the report. A summary has since been provided. The Pan Berkshire Child Safeguarding procedure states: It is essential that staff working in adult mental health services and Children's social care work together collaboratively to ensure the safety of the child and management of the adult's mental health.5 5 https://proceduresonline.com/berks/west_berk/p_ch_par_mental_health.html 8 A mental health report was provided to conference which related to the work undertaken with mother, noting mother’s anxiety and issues of self-confidence and self-esteem, particularly in relation to parenting Alfie when he displayed challenging behaviour. Since July, Mother had disengaged and Alfie had not attended Nursery, Alfie had started at school on the day of the conference. Also, it was reported that mother had disengaged from domestic abuse services and her case had been closed. The health visitor acknowledged there had been little contact since the last conference in March 2019. All planned appointments had been missed by mother. Alfie’s audiology and asthma appointments had not been achieved despite requests and the HV had only seen Alfie in communal areas on two occasions. Father was closed to Talking Therapies and had attended less than half of the planned meetings with the domestic abuse worker, who advised there was more work to be done. Father said, ‘It was sometimes hard to get up and out of the house’. Father was supported by a Recovery Worker to address his drug and alcohol use. Although unable to attend conference, their report was submitted, but not referred to during the meeting. The report advised that father had numerous DNA’s and rearranged appointments. The recovery worker advised that father had not been seen since early August and should he miss his next appointment his file would be closed for non-engagement. The noted risks to Alfie related to father’s risk of relapse and his mental wellbeing. The report was reliant upon father’s self-reporting; there was no mention of drug or alcohol testing, the recovery worker noted that father said his cannabis, alcohol and cocaine use had all been reduced. This was the first mention of father using cocaine, as the report was not examined, it passed without comment. Father told conference that his cannabis use was under control, he had reduced it from daily to monthly because he realised it was making him paranoid. If true, that was a remarkable achievement, but it was not commented upon. Both parents acknowledged they were drinking and gave conference details of their usual daily or weekly consumption. It is recognised that alcohol use is invariably under-reported, but from their description, each would have been drinking more than the respective weekly UK guidelines. As the Recovery Worker was not present, nor their report scrutinised it is difficult to judge whether there was a contrary view to any of this self-reported information. Each parent said they wished to gain support but had made only limited use of the support provided. Father said he needed help with his anxiety, ‘but there was a block in him accessing support.’ This was not explored. Both parents assured conference they were not in a relationship, did not want to be in one and that they recognised living separately was a protective factor for Alfie. It was noted that again there were no reports of domestic abuse. 9 The CP conference attendees unanimously agreed that a CP plan was no longer required to keep Alfie safe6 and that he could be made subject to a child in need plan (CiN).7 There appeared very genuine understanding from conference members that the parents would cooperate with a CIN plan. The following were noted by Conference: What we are worried about: • If parents were to get back together and/or live together • If parents do not follow up support, which they have identified they need. Case analysis Finding 2 For children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started. A practitioner at the Learning Event advised this had been tried and this had a positive effect. It is important to gain an understanding of why the conference made the decision it did, when the factual information demonstrated that not only was the parents’ recent engagement and cooperation with agencies much less than at the March conference, but also father had experienced a significant mental health crisis of which there was no formal information or opinion. This was not referred to by any professionals during the meeting, which was an important omission. The conference began with an update from the Chair, recounting their meeting with the parents where they listed what had gone well since the last conference on the whiteboard, which was in the room for attendees to see. The parents identified lots of strengths and acknowledged that they were not, nor should they be in a relationship. This is likely to have influenced the tone of the meeting. The omission of vital aspects in the information is likely to have had a bearing upon decision making and in the absence of this information, parental positive self-reporting was not challenged against the facts given within the reports. Reassurance would have also been taken from no reports of domestic abuse. The conclusion of conference members was that the parents would cooperate with a CIN plan, which would continue to seek to address all the concerns raised. For those reasons attendees would have felt reassured that Alfie was going to continue to be subject to regular oversight and that the steer from all parties was in that supportive direction with the agreement of the parents. The Annual Review of LCSPRs and rapid reviews8 published in March 2021 found: At child protection conferences an incomplete or inadequate assessment could undermine the plans for subsequent protection and support. In these cases, child protection or child in need plans often continued ineffectually without progress being made or, more worryingly, cases could be closed and ‘stepped down’ specifically because of a lack of progress. 6 September Review CP Conference minutes dated 4 September 2019. 7 Section 17 the Children Act 1989 1) It shall be the general duty of every local authority (a)to safeguard and promote the welfare of children within their area who are in need; and (b)so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 8 Annual review of LCSPRs and rapid reviews (publishing.service.gov.uk) 10 The fact that a decision has been made to end a child protection plan does not necessarily mean that all risks to the child have ceased and this may also apply when the case moves out of children’s social care into early help or universal service. Finding 3: All reports submitted to a CP conference should be formally considered, openly shared, and commented upon during Child Protection Conferences. Finding 4: Issues of non-engagement and self-reporting should be actively addressed during Child Protection Conferences. CSC did not ask Mental Health services for a report for conference; therefore, Mental Health services cannot be criticised for not supplying it. No evidence has been provided to suggest this was a one-off isolated incident, therefore, it is vitally important that the BWSCP gain an understanding as to whether this is a systemic issue. As per the local guidelines, this is a basic expectation and is compliant with BWSCP procedures for both services to work collaboratively to ensure children’s safety. Finding 5: The BWSCP should conduct a review of how Mental Health services are engaged in CP conferences including the requests made, and the provision of mental health reports to CP Case Conferences when the parent and/or carer is known to Mental Health services. However, the lack of a report to this Safeguarding Practice Review is an unacceptable anomaly for the SPR Panel. The Safeguarding Children Partnership is comprised of three equal partners, the Local Authority, the CCG, and the Police. Each have responsibility to ensure children are safeguarded in their area. Full disclosure of the information is a requirement and there are no grounds for noncompliance. Finding 6: Attempts to be made by BWSCP to clarify with Mental Health services the evident confusion about the requirement to disclose information to a CSP Review. If the matter remains unresolved, this should be escalated to the Partnership Executive. 9 Practitioners at the Learning Event discussed the challenge of the conference voting system as colleagues may not feel confident to express their views, and how staff were trained or prepared for attending CP case conferences, especially those for whom it was an irregular occurrence. It was reiterated that it is the responsibility of the chair to ensure all views are heard and shared. Additionally, that agencies support their staff to attend, invariably when they ask for support. Although some staff, may not be aware of quite how daunting a CP conference can seem until they have attended. Multiagency training in mock conferences, shadowing colleagues, being supported by a manager, are some examples of how staff can be prepared. It appeared those opportunities would be welcomed. 9Response from Berkshire Healthcare NHS Foundation Trust: Having taken advice from the Trust information governance lead, Berkshire Healthcare NHS Foundation Trust have a duty of confidence to all of our patients and their records, as well as having legal obligations to the personal information held under the UK General Data Protection Regulation (UKGDPR) and Data Protection Act 2018 (DPA18). In order to share information with others there must be a clear and legitimate necessity for this and the information shared must be relevant to the purpose it is being shared for. It is not standard practice for the Trust to share full patient records of third parties for the purpose of practice reviews. The Trust instead, as it has done in this case, provides a summary of relevant information where we hold it. In this case the Trust could not identify a need to work outside of usual information sharing practice and could not see a legal basis for sharing the full health records of a third party. This response has been accepted by the local CSPR Panel. 11 Finding 7: BWSCP should gauge if there is an appetite across the partnership for multiagency case conference training. This could be considered as mandatory training for some agencies. Ten days after the conference decided to end the CP Plan, mother attended for a 12-week maternity booking as the couple were expecting their second child. As a result of the history, the midwife made referrals to the Vulnerable Women’s Team10, the SHaRON service11 and alerted Children’s Social Care. CSC commenced a pre-birth assessment. Case analysis This was good practice, the midwife gained good oversight of the circumstances and made appropriate referrals. The speedy response by CSC to conduct a pre-birth assessment was also good practice. The information that the parents were expecting their second child completely undermined their assertion they were not in a relationship. Decision making thereafter should have continued on the basis that they were in a relationship. Reconvening the CP conference was an option that should have been considered. The Berkshire West Safeguarding Children Partnership Procedures Manual notes review conferences should be brought forward when: There is a significant change in the circumstances of the child or family not anticipated at the previous conference and with implications for the safety of the child. Although Alfie was no longer subject to a CP Plan, that did not preclude re-consideration of his circumstances. Conferences had repeatedly referred to the increased risk to him if the parents resumed their relationship. There was a significant change which required formal examination. There was no evidence to suggest the parents were not in a relationship. Finding 8: The CP Procedures should specify that if there is a significant change within 3 months of the conference that removes a child’s name from a CP plan then a multiagency strategy meeting should be convened, to determine whether a s47 enquiry is necessary to enable the local authority to decide whether it should take any action to safeguard and promote the welfare of the child, for example, a CP conference should be held12. The first multiagency Child in Need (CIN) meeting was held in October as would be expected, although parents did not attend. Despite all their assertions at the CP conference neither parent had engaged with the CIN plan nor completed any of the required actions and were expecting another child together. The conference had raised these two points, not engaging with support, and resumed relationship as the risk factors for Alfie. Father had not engaged with the domestic abuse, mental health, or the recovery workers and mother had not engaged with the domestic abuse worker, adult mental health worker or talking 10 A team of midwives who provide maternity care to women identified with complex social factors across Berkshire west with the aim of ensuring these women receive women centred, specialised care that is individually tailored to their needs. 11 SHaRON is a peer support-based e-health system, available via a mobile phone app and associated website. 12 Child Protection Conferences (proceduresonline.com) 12 therapies. Mother did continue to attend the Family Hub to attend the Boost13 course with Alfie being in the crèche. The SW reported it was difficult to complete visits to see Alfie at home, these were required by the CIN plan and in conducting the pre-birth assessment. Actions for mother to ensure that Alfie had an asthma check, and an audiology appointment remained incomplete. Alfie’s school attendance had reduced to 87.7%. There was recognition by most agencies that the parents were spending a lot of time together, which was confirmed by paternal grandmother. On one SW home visit, father was present having just had a shower. Despite their continued assertions to the contrary, evidence pointed to them being in a relationship. The CIN plan continued and a further CIN meeting was planned for seven weeks later in mid-December. The SW continued with the pre-birth assessment, albeit with considerable difficulty, mother accepted only two of the required five assessment visits. Father did not take part, despite repeated requests. The SW finally spoke to him on the phone in late November when he was in the car outside school waiting for mother who was collecting Alfie. He told the SW: “there had not been domestic incidents since the last reported one and added that all this had 'been dragged out' if he were to be honest. He said that he currently did not want social services involvement which he said was stressing him and (the mother) who was worried about what was going to happen with the baby.”14 The views of six agencies were sought in completing the pre-birth assessment. Apart from midwifery none were able to report any engagement with the parents. A significant number of concerns were reported, these included the increased risks of domestic abuse associated with pregnancy, anxiety that the parents were back in a relationship, parental disengagement with services and school noted unexplained absences for Alfie, whose attendance was just six weeks into the school term recognised as low. Mother, who had previously been attending the Family Hub on a regular basis (daily when Alfie was in nursery), had not been seen and she had stopped attending the Boost course, despite previous good attendance, which ‘was not like her’. Case Analysis This was an important reflection by the Family Hub. They had worked more than a year with mother who had been a regular user (often daily) of their resource. For mother to stop all engagement was highly unusual and should have been followed up. Had she offered any explanation? Had her views been sought? But this issue was not explored within the meeting. She was pregnant with their second child, father voiced his unwillingness to work with CSC and she maintained the clearly false position that they were not in a relationship. This was important information and the possibility that she may be a victim of coercive control should have been considered. Domestic Abuse can typically involve coercive control that traps a victim in the cycle of abuse and in silence; this needed to be considered as the dangers for children in these households are significant. 13 The Boost course is specifically targeted to empower women to address confidence and self-esteem. 14 Pre-birth assessment dated Nov 2019. 13 Women’s Aid define coercive control as: Domestic abuse isn’t always physical. Coercive control is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. This controlling behaviour is designed to make a person dependent by isolating them from support, exploiting them, depriving them of independence and regulating their everyday behaviour. 15 Despite these agency misgivings, in late November 2019 Children’s Social Care concluded their pre-birth assessment with the decision that their involvement could cease. The reasoning given was that: ‘there have been no further incidents of domestic violence since December 2018, father has completed work with the domestic violence Adult Worker, and both parents say that they do not want the ongoing support of Children's Services.’ It is important to note the domestic violence work was not complete. Case analysis The BWSCP procedures note that a pre-birth child protection conference should be held where: • An adult or child who is a risk to children resides in the household or is known to be a regular visitor. Other risk factors to be considered are: • The impact of parental risk factors such as mental ill health, learning disabilities, substance misuse and domestic violence. In seeking to reconcile why practice was so different from these requirements and the recommendation was closure, it is important to consider the circumstances. The family were resisting engaging and were actively challenging when they did engage. Father had reiterated that no incidences had happened recently, and that CSC were themselves a source of stress to the family. In the summary of the pre-birth assessment the December 2018 domestic abuse incident which prompted the CP response was recorded as ‘verbal only’. This is a factually correct quote from the police report, in that no-one was physically hurt, however it minimised the impact on Alfie and his mother and the seriousness of the risk to him as set out in the two previous Child Protection conferences. The incident when father sought to jump from a bridge was noted as ‘more of seeking attention than actually attempting to jump.’ There was no information from Mental Health services to support this interpretation, it was also contrary to the information provided by the DA worker. This perspective was reliant only on father’s self-reporting and suggested the risk posed by father’s mental health difficulties and potential of suicidal intent was minimised. Lord Laming in the Victoria Climbie Inquiry stressed the need for SWs not to passively accept information they are given by their clients, and they should keep an open mind: ‘respectful 15 The Victoria Climbie© Inquiry (publishing.service.gov.uk) page 205 14 uncertainty should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact’. 15 Social workers need to be supported to question, validate, and challenge what is being presented to them. Management and supervision should help facilitate reflection and give guidance and advice in critically examining information. At the Learning Event practitioners advised that: ‘Copies of pre-birth assessment are not shared with them routinely, only the outcome. Midwives noted they can go back and ask for a copy if they have concerns, but the family need to give their consent.’ No evidence has been provided to suggest any agencies were informed of the Pre-birth assessment outcome. Case analysis Positive emphasis was made of previous engagement, but the recent disengagement of parents was not analysed as presenting a risk to Alfie. Father told the SW they did not want to work with CSC, and mother repeated the same comments when she was in the car with father shortly afterwards. It is not known if these were her views, or she was prompted to make them. The pre-birth assessment should have been shared with agencies who contributed to it. By not having sight of it, agencies were not aware of assumptions and decisions and their opportunity to provide informed challenge was diminished. Eileen Munro’s article on Common errors of reasoning in child protection work: 16 ‘It was found that professionals-based assessments of risk on a narrow range of evidence. It was biased towards the information readily available to them, overlooking significant data known to other professionals…A critical attitude to evidence was found to correlate with whether or not the new information supported the existing view of the family. A major problem was that professionals were slow to revise their judgements despite a mounting body of evidence against them. 17’ Finding 9: The summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process. Case analysis When the CP conference stepped the case down to CIN, there were clear requirements that were included within the CIN plan to ensure Alfie’s safety and promote his welfare. Within 2 months the plan had not been complied with and parents were expecting their second child together and it was evident that they were in a relationship. There was a considerable change in the parents’ engagement with agencies, what had formerly been limited, following the step down to CIN, became completely resisted. 16 http://eprints.lse.ac.uk/358/1/Common_errors_of_reasoning_1999.pdf 17 Children and Family Services, West Berkshire Council. Closure letter dated 4 Dec 2019. 15 They were no longer willing to work with CSC, were not engaging with any other agencies that were seeking to support them address the identified concerns. This was an important issue that needed to be explored and reflected upon, and strategies employed to address the disengagement. It appears this acceptance was wholly related to the parents’ consent, i.e., the parents chose not to cooperate, therefore because it was CIN it was judged that nothing could be done. Consent is an important issue but must not be confused. The Duty to Investigate under section 47 of the Children Act 1989 enables the LA to make enquiries of partners about the welfare of a child, about whom there are concerns, without requiring parental consent. Any CP conference and plans are entirely similar to CIN, in that parents can decide to work together with the LA and their partners, or indeed not. The LA must consider what action it may propose should a family not engage, in either circumstance. CIN does not suddenly become a threshold through which parents can opt out because it is ‘consent based’. All engagement with the LA is by nature ‘consent based’ and, is through negotiation between both parties. The skill is to ensure parents engage with the LA to improve safeguarding for their child. Local authorities (LAs) have the option to commence the Public Law Outline, (alert the parents that the LA will be seeking the intervention of the Courts). Family Group Conferences can be helpful in ensuing wider family support to address ongoing issues and contribution towards safety planning. If efforts to engage the family with a CIN plan are unsuccessful, then the concerns need to be reviewed collectively by the multiagency team and considered if it is safe to instigate a Team Around the Child (TAC) approach, which may involve universal services, charities, and the voluntary sector. This is not a free pass for LAs to absolve themselves of engaging with CIN cases, rather the opposite; for LAs to develop their workforce to build skills and recognise disguised compliance. The safeguarding workforce require support to work with resistance and, in cases where resistance is an enduring feature, to recognise the risks this poses to children and take action. For Bobby’s parents, their compliance was no longer disguised, it was openly resistant. The formal process of holding a multiagency CIN meeting before case closure was required to explore this across the partnership. This did not happen. CSC undertake monthly group supervision and have suggested this could be opened on occasion to include the multiagency network. Whilst this may be useful, utilising the already established procedures would seem more appropriate, rather than seeking to create another process. The case was closed to CSC in early December 2019; the CIN Plan ceased, and the December CIN Review meeting was cancelled. Two services who attended the CP conference in September were sent written notification of the case closure (Health visitor (HV), and Family Hub) and the school and midwife were informed. The closure letter asked they get in touch with the team direct if they had any further safeguarding concerns, there was no explanation as to why the case had closed. There is no record of any other agencies being informed of the case closure. The parents were each sent a letter notifying them of the case closure which encouraged them to: continue to seek support from the midwife and health visiting team. Practitioners advised at the Learning Event that they were unclear about the difference between CP and CIN and advised there seemed to be different thresholds applied across the different Berkshire 16 areas. They felt CP was more robust and valued the challenge of an independent chair, and services were more likely to be provided to CP cases. These are some of their comments: ‘Understand CIN means level of risk is lower but could still be significant and chronic.’ ‘CiN not as formal, if family doesn’t meet the plan, then not as significant.’ ‘Major difference is consent. If parents don’t want to engage then difficult to force them.’ ‘The CiN was closed so the implication is that the situation felt safe. The feeling is that it is downgraded by the SW, so the situation is OK. Case analysis The Annual Review of LCSPRs and rapid reviews published in 2021 found: 18 In relationships dominated by domestic abuse and coercive control, it may be very hard, even impossible, for a parent to engage with services…Patterns of engagement and withdrawal should prompt an escalation of concern, and not closure of the case. Refusals of offers of support should be recorded and assessed. There were other examples of cases that were closed too soon when families and/or children did not engage. A key message is that services should consider the reasons for non-engagement – in the family and in the response of practitioners and agencies – and how to engage, rather than close due to non-engagement. Progress should be evidenced prior to closure, the reasons for closure should be clear and closure should not be viewed simply as the end – that is, there should be clarity about what to do if new concerns emerge. There is a formal procedure that CIN cases will not close without a multiagency meeting taking place, but that did not happen. The closure occurred just a week before the next planned CIN review meeting. It remains unclear why the decision was made not to hold the multiagency meeting and to close the case. The perspective from CSC appears to be that professionals were not raising any concerns. However, the closure letter suggests agencies get back in touch with any further safeguarding concerns, which seems to suggest ‘new’ concerns, not any existing ones. But there is no information given about challenging or disagreeing with the closure decision. Finding 10: CP cases which are stepped down to CIN should remain open for a minimum of 3 months. Finding 11: An audit should be conducted to determine whether multiagency meetings are being held prior to the closure of all CIN cases. Finding 12 Escalation procedures should be easy to use. The BWSCP should produce multiagency guidance to ensure it is accessible to all agencies. Future audits will include related questions to determine if the guidance is being used. Management oversight and case supervision should be in place and audited. West Berkshire Local Safeguarding Children Board conducted a Serious Case Review into the death of Child K, a baby of 18 weeks who died of extensive head injuries in 2017. 18 Annual review of LCSPRs and rapid reviews (publishing.service.gov.uk)page 17 17 His father was subsequently convicted of his murder. Recommendations relating to CIN plans and working with resistance were made which are relevant to Bobby’s case, whose death occurred almost 3 years later. Practitioners at the Learning Event were not familiar with the SCR or the recommendations: SCR Child K Rec. 4 The LSCB should ask that the Local Authority Children and Families Services review their Children in Need procedures and how they apply across the service to ensure practice is safe, robust, and consistent and that all staff have clarity and procedures are followed. SCR Child K Rec. 7 The LSCB should request reassurance from partner agencies that professionals are being appropriately supported to recognise disguised compliance and work with resistance, this should include consideration of the impact of domestic abuse, control, and coercion on a non-abusing parent’s ability to work with professionals as required. The SCR Child K Action Plan notes that these actions are not yet complete. The BWSCP was able to share copies of training provided in respect of learning in respect of several Serious Case Reviews, plus a presentation illustrating disguised compliance. It is unclear how far reaching this training has been. There is not a case for suggesting it has been embedded across the BWSCP. The SCR Child K report was not published because of sensitivity, a Learning Report was published. Finding 13: Child in Need plans are invariably multiagency, and all partners need to be aware of their importance in safeguarding children. The relevant action set out in SCR Child K Rec 4 is long overdue. Previous plans had always relied upon paternal grandmother for support, with managing and supervising contact. Alfie had a close, reliable relationship with her, and it begs the question why grandmother was not involved or alerted to the concerns? Grandmother had on occasion minimised the negatives and over-stated alleged positives of her son’s behaviour, which would not be highly unusual. Although at conference she did actively voice her concerns about the parents’ ‘toxic’ relationship in respect of Alfie’s welfare. Her commitment to Alfie’s contact had demonstrated that she was consistently proactive about keeping positive contact with her grandson. She did not attend the CP conference in September 2019 despite being expected to continue with an important role in Alfie’s CIN plan. This was an important omission. Finding 14: Extended family or kinship to be included in CIN planning to explore sources of safety and risk when they have been integral to a CP Plan. In 2017 West Berkshire Council adopted the Family Safeguarding Intervention Programme19 a service to work with the whole family. A team of multidisciplinary staff are available to work on differing family issues, such as social workers, domestic abuse, mental health, and recovery workers, as well as family support workers and psychologists. The ethos is to engage with families using the relationship-based practice model (see Appendix Two) to identify and support changes needed to improve the quality of children’s lives. As part of this approach all staff in the Family Safeguarding Teams are required to trained in Motivational Interviewing (MI) an important tenet in relationship-based practice. Train the trainer MI training was 19 FSM_flyer_families.pdf (westberks.gov.uk) 18 provided so the training could continue to be delivered. It was also provided to CP Chairs, Independent Reviewing Officers as well as some local Head Teachers. Donald Forrester explained: MI is perhaps best thought of as a way of having purposeful conversations about difficult issues…The concept of resistance as an understandable response to the circumstances people find themselves in is particularly helpful. Yet most important of all – and for me the point at which MI and social work converge – is in the concept of self-determination…the right for individuals to make their own decisions and to be treated with respect, is at the heart of both social work and MI. In child protection work this concept of parents (in particular) as active actors often becomes lost: they are treated as if they are problems to be solved rather than partners to be engaged. MI provides one of the best descriptions of how to have more respectful and purposeful conversations with parents, even about difficult issues such as child abuse, alcohol or drug problems or violence.20 In seeking to determine why these previously agreed SCR recommendations have not been achieved it is important to recognise that the statutory responsibility, which previously lay with the LSCB (Local Safeguarding Children Board) no longer applies. Between the deaths of Child K and Bobby there was a significant structural change. LSCBs had statutory responsibilities for safeguarding training and ensuring learning from case reviews. Following the review by Sir Alan Wood21, LSCBs were required to change to develop their own Multi Agency Safeguarding Arrangements (MASA) effective no later than September 2019. LSCBs were separate entities led by an Independent Chair, the Wood Review sought to place responsibility directly with the three statutory partners, the Local Authority, the CCG, and the Police. This was supported by the Children and Social Work Act 2017,22 the legislation which removed the requirement for LSCBs and their statutory duties. Case analysis Parents had agreed at the CP conference that they needed to work on a number of areas. Yet 6 weeks later the compliance and agreement had ceased. Parents seemingly saw social services as the cause of their stress and were no longer willing to engage. Unfortunately for Alfie and then unborn Bobby, the risks had not changed. It could be argued they had increased as there was less likelihood that help would be sought by the parents. Despite the MI training and the multidisciplinary Family Safeguarding team around the family, no solutions were offered to address the parents’ intransigence. Finding 15: It is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance. The relevant action set out in SCR Child K Rec 7 is long overdue. The subsequent Berkshire West Safeguarding Children Partnership covers three authorities of Reading, Wokingham, and West Berkshire. Previously the six unitary councils which make up the county of Berkshire each had their own safeguarding children board. It was felt that the change in these arrangements has resulted in some loss of the impetus and oversight previously provided by the LSCB. The BWSCP has delivered training on Working with 20 https://www.theguardian.com/social-care-network/2016/mar/08/motivational-interviewing-quick-guide-social-work 21 Wood review of local safeguarding children boards - GOV.UK (www.gov.uk) 22 Children and Social Work Act 2017 (legislation.gov.uk) 19 Resistance and on the findings from the most recent SCRs but doubt this has been embedded across the workforce. It is hoped that sessions being offered across the BWSCP will attract greater numbers than previously seen at the individual LSCBs. Also, it is thought the commonality of issues can make a stronger case for mandatory training. Finding 16 The BWSCP should provide guidance as to what multiagency training is to be made available and how Partnership actions disseminating learning and providing training from SPRs is to be achieved. Case analysis The Triennial analysis of serious care reviews published in 2016 noted: The impact of all domestic abuse is harmful to children and a step-change is required in how we understand and respond to domestic abuse. There is a need to move away from incident-based models of intervention with domestic abuse to a deeper understanding of the ongoing nature of coercive control and its impact on women and children, and also on men. 23 The prevalence of using incident-based models means that absence of reporting of any incidents can lead to a false sense of security, in thinking that nothing has happened. Whereas some may see incident disclosure as a potential risk of greater intrusion and escalated intervention, therefore are not reported. This can be used as a threat also, to ensure compliance in an abusive relationship. Both parents knew that professional concerns were heightened when they were together, so it would be reasonable to assume they would have been wary about agencies finding out their circumstances. Finding 17 The BWSCP should review their procedure, risk assessment tools and responses to children living in households which experience domestic abuse. This includes risk ratings and the use of MARAC and DARIM Panels, and the prevalence of relying upon incident-based models. 2020 In early January 2020, Police received a call from a neighbour who reported loud shouting and swearing by father and a child crying. Previous history at the address and a ‘child at risk’ marker was identified, so officers immediately responded and attended the address. Father confirmed that Alfie had been crying, he told Police that Alfie was: ‘kicking his parents whilst they were lying in bed to try to get them up and had been told off which has resulted in the crying.’ Case Analysis It is important for staff to consider what level of noise and distress and length of time would prompt people to call the police to such an event. We are reliant upon such reports to give a real time window into the child’s lived experience. 23https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf 20 Officers tried to speak with Alfie, who was noticeably upset, his parents advised this was because he was scared of Police, although no further explanation was given or requested. Alfie confirmed with nods that he was okay. It is understood that a ‘Welfare Check’ was carried out as Alfie had been noted to previously have a CP Plan for neglect, therefore officers checked the property and established there were no signs of neglect. The Police passed on the information to MASH24 with their view that there were no safeguarding concerns. The caller was not approached by the officers to ascertain if the family’s explanation was consistent with their report. The information was passed to social care where no checks or action was taken. It is understood that the previous team that held Alfie as a CP case were alerted and concurred with the Police that it was not a safeguarding matter. CSC records state: ‘Record incident only, no role for Children Services. The vulnerable women’s midwifery team were working with mother but were not informed of this incident. This incident suggested that father was living in the home which was a known risk for Alfie and a potential risk for the unborn baby. Also, this was at complete odds with the previous response to the December 2018 incident, which prompted a full CP response. Case analysis Police routinely interview those involved in domestic abuse incidents separately, but this incident was not regarded as domestic abuse. There was a history of such and of previous incidents involving harm to Alfie, therefore it would have been helpful to determine the perspectives of each adult. This is particularly important if there are issues of coercive control. Thames Valley Police have provided assurance that the child is always engaged with now, to ensure their wellbeing. Finding 18 Police attending any incident at homes where domestic abuse has been a feature should interview the parties separately. Finding 19 The BWSCP to review the CP categories used for children exposed to Domestic Abuse. The use of neglect as a category is misleading. Six weeks later, in February 2020, Housing alerted CSC to a neighbour reporting that father was living in the property and that Police had attended. The Housing Officer commented: ‘As there have been problems in the past with toxic arguments that Alfie had been exposed to, I felt it necessary to alert CAAS25 with maybe a view to investigate.’ Social Care assumed that this was a reference to the January incident and decided it was not a safeguarding matter and again took no action. Case analysis This was good practice; even if it did relate to the January incident, the Housing Officer had attended the December 2018 and March 2019 CP conferences and knew the risks associated with the father being back in the home and was right to highlight those concerns. 24 MASH, Multiagency Safeguarding Hub 25 Contact Advice and Assessment Service https://directory.westberks.gov.uk/kb5/westberkshire/directory/service.page 21 The assumption by CSC about this report, compounded the poor response to the January incident, were important factors. Evidence was growing about father’s regular presence in the home, father admitted he was in bed and shouting, and Alfie was crying, so the concern was substantiated and needed to be explored. In March 2020 mother (8 months pregnant) contacted Police to complain of a neighbour confronting her and kicking her door at 6.30 a.m. asking why Alfie was crying and making a noise. Initially the Police dealt with this by way of a telephone resolution. When it was passed to the Smarter Resolution Team, they identified the previous CP concerns and neighbourhood police officers were asked to do a welfare check on Alfie, which is good practice. This was treated as a neighbourhood dispute, although despite speaking with the neighbour, they did not establish the reason for their 6.30 a.m. visit. The information about this incident was not shared with any other agency. Case analysis This was an important omission. Police held a history of attending domestic abuse incidents at this address and concerns about the child which had resulted in father’s imprisonment, and CP plans being made. Again, the question arises about whether the use of the neglect category skewed the focus of concern? The other aspect of this incident is that mother had brought it to the attention of the Police. She was complaining about the neighbour, but the original concerns were that Alfie was crying so much at 6.30 a.m. that it prompted a visit from a neighbour to make a complaint. Because the neighbour was not asked about her concerns it is difficult to draw any strong conclusions about whether the neighbour was concerned about Alfie’s wellbeing. And, without any other information, it is not known whether father was present. In March 2020 mother reported to the vulnerable women’s midwifery team that the couple were getting on well. Alfie was released from school the week prior to lockdown because of his asthma and was visited at home weekly with relevant schoolwork and food parcels. At the end of March, mother advised midwifery that father had moved into the home because of the Covid lockdown. Case analysis Whilst previously, there may have been suspicions that father had been living, or at least staying at the home for some time, this was the first formal confirmation of him doing so. Despite this being a known risk to Alfie and the expected baby, this information was not escalated within Health or shared with any other agency. The vulnerable women’s midwifery team were involved specifically because of the safeguarding risks identified when it became known that mother was pregnant in September 2019. In seeking to explore why, despite knowing the history, such significant information was not shared, it seems that by the time the baby was born, it was overlooked. There seems to have almost been a general assumption that everyone knew he was living there. Whilst father had not attended ante-natal appointments, he was said to have attended all baby scans. Mother was stating to those she did see that she and father were ‘getting on well.’ 22 In early April 2020 Bobby was born at full term, his father was present for the delivery. Mother and baby were discharged home the next day. Midwives visited mother and Bobby at home on 3 occasions, on one of those visits, they noted father and Alfie stayed in the bedroom playing. On the 10th day, as is customary when mother and baby are regarded as doing well, Bobby and mother were discharged from midwifery care. The next day the HV was due to undertake a video assessment of mother and Bobby rather than a home visit because of the Covid restrictions. Mother advised that she could not do this, so it was conducted via telephone. Mother reiterated to the HV that she and father were not in a relationship, but they did spend family time together. It is not clear what she meant by ‘family time’ as this was not explored. Case analysis This was at odds with the information held by midwifery who knew that father was living there. This was important information that should have been passed to the Health Visitor, who was aware of the history and risks associated with father being back in the home. When Bobby was 14 days old mother sought advice from the GP as Bobby was not feeding; he also appeared to have conjunctivitis and breathing difficulties due to a blocked nose. The GP called an ambulance, and he was transported to hospital for admission. Bobby was discharged from hospital the same day. The health visitor contacted mother to check up following the hospital visit who confirmed that his feeding had improved. The health visitor asked about mother’s emotional wellbeing and mother said she had no concerns, and all was well. An appointment was arranged for Bobby’s 6-8 weeks check. Case analysis It was good practice to quickly follow up on a hospital admission for such a young infant; also, to use the opportunity to check on mother’s own wellbeing and set the date for Bobby’s development check. It is not clear whether there was any exploration about father’s involvement in Bobby’s care or father’s wellbeing. Mother had told everyone, apart from midwifery who were coming into the home, that father was not living there. Observations of the home would have provided the opportunity to challenge and ask questions about what was seen in addition to directly interact with Alfie. Mother was able to establish, on disclosing that information to midwifery, that seemingly nothing changed, there was no sudden intervention from other agencies. Telephone contact is vastly different from face to face home visits, which were not available to the HV team at that time because of advice with respect to the Covid pandemic. Mother had resisted the video calls, advising that her phone could not be used for them. All such information would have to be taken at face value, as there was no evidence available to suggest anything to the contrary. It would not be unusual for a DA perpetrator to be in the home keeping oversight and control of all conversations, especially those with professionals. As this was during the early stages of the pandemic, there was little in place to guide practitioners in conducting virtual risk assessments and interventions. This has been recognised since as particularly difficult in circumstances of domestic abuse. 23 Two weeks later, in May, at 1.30 a.m. an ambulance was called to the home, 4-week old Bobby was said to have been found unresponsive in his cot, both parents and Alfie were present. Case analysis This was a fast-moving, emotive and difficult situation with the worst possible outcome, that of a young infant losing his life. Within less than 24 hours, a host of agencies and professionals had worked together to try to address all the aspects of the complicated scenario. The ambulance service quickly identified this was a safeguarding issue and Police attended the scene. This was good practice. Following police attendance at the home the CAIU were alerted, and a police detective was able to attend the hospital at the crucial time. This was good practice. Whilst all efforts were made to seek to preserve Bobby’s life, these proved to be unsuccessful. His physical presentation raised concerns and despite his death the hospital response was quick and thorough in undertaking CT scan and x-rays and other tasks in accordance with the ‘Kennedy Guidelines’, the Royal College of Paediatrics and Child Health 2016 guidance on Sudden unexpected death in infancy and childhood. 26 This was good practice. Although the Emergency Duty Service were notified of events in the early hours, they were left somewhat to play catch up. Their speedy contact with CSC alerted them to prioritise the welfare of Alfie. This was good practice. The main area of contention, although subsequently rectified, was the difference of approach from the Police towards to parents to that of CSC. Although the home had been sealed, the Police did not advise EDS they were treating the parents as witnesses, which meant mother and father returned to be with the grandparents and Alfie. For CSC this was a clear risk to Alfie and therefore was not acceptable. As soon as these issues were identified, EDS made arrangements for the parents to be provided with alternative accommodation and mental health support. This was good practice. 26 https://www.rcpath.org/uploads/assets/874ae50e-c754-4933-995a804e0ef728a4/Sudden-unexpected-death-in-infancy-and-childhood-2e.pdf 24 5. Recommendations As some of the findings relate to similar themes, these have been grouped together. Rec. 1 - Supervision Orders (Finding 1) Cases of children who have been the subject of a Supervision Order, should remain open on a multiagency Child in Need Plan for a minimum of 3 months, to ensure they can be stepped down safely. Rec. 2 - Child Protection Case Conferences (Findings 2,3,4,5,8 & 16) a) For children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started. b) All reports submitted to a CP conference should be formally considered, openly shared, and commented upon during the conference. c) Issues of non-engagement and self-reporting must be actively addressed during the conference. d) The BWSCP should conduct a review of how Mental Health services are engaged in CP conferences including the requests made, and the provision of Mental Health reports to CP Case Conferences when the parent and/or carer is known to Mental Health services. e) The CP Procedures should specify that if there is a significant change within 3 months of the conference that removes a child’s name from a CP plan then a multiagency strategy meeting should be convened, to determine whether a s47 enquiry is necessary to enable the local authority to decide whether it should take any action to safeguard and promote the welfare of the child, for example, a CP conference should be held. f) The BWSCP should review the CP categories used for children exposed to Domestic Abuse. The use of neglect as a category is misleading. Rec. 3 - Children in Need (Findings 10,11,13, & 14) a) CP cases which are stepped down to CIN must remain open for a minimum of 3 months and be subject to management scrutiny and review before closure. b) An audit should be conducted to ensure that a multiagency meeting is held prior to the closure of all CIN cases. c) Child in Need plans are invariably multiagency, and all partners should be aware of their importance in safeguarding children. Reference to SCR Child K Rec 4 for a similar ongoing action in relation to regular review and revision (if required) of local Child in Need procedures. d) Extended family or kinship should be included in CIN planning to explore sources of safety and risk. Rec. 4 - Domestic Abuse (Finding 17 &18) a) Police attending any incident at homes where domestic abuse has been a feature should interview the parties separately. b) The BWSCP should review their procedure, risk assessment tools and responses to children living in households which experience domestic abuse. This includes risk ratings and the use of MARAC and DARIM Panels, and the prevalence of relying upon incident-based models. Rec. 5 - Pre-birth assessments (Finding 9) The summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process. If necessary, consultation with agency Data Sharing officers should be undertaken. 25 Rec. 6 - Escalation and multiagency debate (Finding 12) Escalation procedures should be easy to use. The BWSCP have agreed to produce guidance to ensure it is accessible to all agencies. All future audits undertaken will include questions to determine if they are actively being used. Rec. 7 - Learning and development (Finding 7,15, & 16) a) BWSCP should gauge if there is an appetite across the partnership for multiagency case conference training. This could be considered as mandatory training for some agencies. b) Working with resistance and disguised compliance: It is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance. Reference to SCR Child K Rec 7 for a similar ongoing action. c) The BWSCP should provide guidance as to what multiagency training is to be made available and how Partnership actions disseminating learning and providing training from SPRs is to be achieved. Rec. 8 - Agency engagement with the SPR process (Finding 6) Attempts to be made by BWSCP to clarify with Mental Health services the evident confusion about the requirement to disclose information to a CSP Review. If the matter remains unresolved, this should be escalated to the Partnership Executive. A response from Berkshire Healthcare NHS Foundation Trust has been received (noted as footnote 9 on page 10) and this has been accepted by the local CSPR Panel. 6. Conclusion The death of such a young infant is a dreadful tragedy and examining the minutiae of practitioner engagement with Alfie and Bobby’s lives is a difficult undertaking for all concerned and especially for those who knew them. The BWSCP extends their gratitude to all the practitioners and agencies who have taken part in this review with such helpful candour and careful thought. Our deepest sympathy goes to the family and to Alfie for the terrible loss of Bobby. 26 APPENDIX ONE Triennial Analysis of SCRs 2011-2014:27 In this model (Figure 1), it is important to recognise that not all child maltreatment consists of discrete incidents of harm. Thus, there may be ongoing contexts of harmful actions or omissions by carers; and fluctuations in the degree of vulnerability and risk; changes in the background context; and reductions as well as exacerbations of risk. This is illustrated by the curved arrows in the model. Figure 1: Pathways to harm in child maltreatment Preventive and protective interactions between professionals, parents and wider society, along with the underlying systems and processes which may support them, are illustrated in Figure 2. Figure 2: Pathways to prevention and protection 27 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf Pages 25/27 27 APPENDIX TWO |
NC050398 | Death of a three-month-old baby in 2016. An inquest recorded a verdict of death by natural causes. There were indications of drug use, poor home conditions and neglect within the family which included four other children. Children's services had been involved with the family at various times over several years. The mother was arrested and a criminal investigation initiated. Key findings: partner agencies' concerns were often not accepted by children's social care; families do not fully understand the differences between Level 2, Level 3 and Child in Need within the Common Assessment Framework; lack of openness within children's social care to escalate cases; uncertainty as to the appropriate response when the mother refused access to the health visitor and other workers; no consideration given as to why the mother was neglectful or what levels of support she had in the community. Recommendations include: the need to develop a broader agreement amongst partner agencies on the application of thresholds; to review the effectiveness of the escalation policy and its application locally; children's services should develop clear practice guidance on the use of announced and unannounced visits; professionals leading on a Level 3 Common Assessment Framework (CAF) should ensure that GPs are fully informed of CAF activity in line with existing procedures.
| Serious Case Review No: 2018/C7321 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Page | 1 Baby L Serious Case Review Findings and Recommendations Report Page | 2 Introduction 1. This overview report was commissioned by a Safeguarding Children Board as a Serious Case Review (SCR) following the death of baby L in 2016. He was a three-month old baby who died after he was found lifeless early in the morning by an older sibling. He was taken by ambulance to hospital but resuscitation attempts by ambulance crew and hospital staff were unsuccessful. 2. The subsequent inquest recorded a verdict of death by natural causes, 3. At the time of his death there were indications of drug use in the family home, poor home conditions and neglect within the family. The family were open to children’s social care services at the time of the baby’s death and a formal child protection investigation had been initiated the previous day. Children’s services had been involved with the family at various times over several years. 4. Mother was arrested the day after baby L’s death and a criminal investigation was initiated. 5. The Safeguarding Children Board was concerned to establish whether previous contacts with services had correctly identified and assessed the risks for this family and taken appropriate action to mitigate the issues during a three year period up until baby L’s death. 6. Felicity Schofield was appointed to chair the SCR process and Daryl Agnew was commissioned as the Independent Author to complete the SCR overview report. Both are independent of any services involved in this case. 7. A panel of senior managers from each of the agencies involved was appointed to support the review process. 8. At the initial scoping meeting, a three year timeframe was agreed for the review. The SCR sub-committee also identified a number of issues for consideration by all the agencies involved. They included: the quality of assessment; thresholds for intervention; family engagement and the voice of the child; multi-agency working; and staff supervision and management. Page | 3 Summary and Conclusion Thresholds 9. The use of two levels within the Common Assessment Framework is complicated. Level 3 is similar to family support (Children in Need: Section 17) in many other local areas. Practitioners at the practitioner event expressed the view that families do not fully understand the differences between Level 2, Level 3 and Child in Need. Views were also expressed that significant efforts seem to be made by Children’s Social Care to keep cases away from children’s social care. This case also shows that partner agencies’ concerns are often not accepted by children’s social care. 10. When the case was accepted by children’s social care, the earlier work of their colleagues within the Children and Families First service went largely unrecognised so that the Child in Need plan replicated rather than built upon the work done within the earlier Common Assessment Frameworks. This is not a good use of resources and is hard for families to understand. 11. The child protection threshold was reached, but not recognised, sooner than the date when the strategy discussion was requested. This is because the concerns, which were well known to professionals, were much more significant when applied in this case to a very young baby. Escalation 12. Practitioners understood the concept of escalation and why it was important. However, a view expressed by practitioners is that the culture within children’s social care services was not open and escalation within the lower levels of organisations had simply no effect. Practitioners with experience of working across local authority boundaries described a greater openness in neighbouring areas. Consent 13. There was uncertainty amongst practitioners about what was the most appropriate response when the mother refused access to the health visitor and refused to let workers see parts of the family home. The LSCB should offer some practice guidance to enable practitioners to address such issues. Assessments 14. Assessments at all levels did not consider why the mother was neglectful, her own background or the levels of support that were available to her from her extended family or within the local community. 15. GPs and other relevant partners, such as housing, were neither involved in nor advised of the outcome of assessments. 16. The lived experience of each of the children did not always feature. In particular, when the mother was pregnant with baby L the assessments did not consider either the impact on the mother in caring for a 5th child singlehandedly or the particular impact of unhygienic conditions on a new born baby. Resources 17. There was agreement amongst all agencies at the practitioner event that there were more resources (i.e. time and capacity) available to help families within Children and Families First than when a case transferred to children’s social care. Page | 4 Therefore it would seem, as need increases a family can actually expect less input. Use of the Graded Care Profile 18. There has been no leadership offered to the partnership with regard to the use of the important but also intrusive and very time consuming process of a Graded Care Profile (GCP). As a result, the GCP is used in an ad hoc way and the outcomes are not used to good effect. Unannounced visits 19. Whilst unannounced visits may be built in to either a child in need plan or a child protection plan it is difficult to understand why they would be appropriate at a Common Assessment Framework level. When the mother was not at home for unannounced visits, it seemed to be held against her. This is neither logical nor fair. Page | 5 7. Recommendations The LSCB: Recommendation 1: the LSCB should offer practice guidance to enable practitioners to address the issue of the lack of parental consent within the context of voluntary family support. Recommendation 2: the LSCB should review the multi-agency training on neglect to enable the development of a shared understanding about the cumulative impact of neglect on children and the ways in which professionals can challenge adults in such circumstances. In addition, such training should be linked to practice regarding the use of Signs of Safety and guidance on when and how to use the Graded Care Profile. Recommendation 3: the LSCB should review the effectiveness of the escalation policy and its application within the local context. Recommendation 4: the LSCB should develop broader agreement amongst partner agencies on the application of thresholds. This should involve commissioning follow-up work to a previous threshold audit in order to establish how effectively the thresholds are being applied. Children’s Services: Recommendation 5: Professionals leading on a Level 3 Common Assessment Framework (CAF) should ensure that GPs (and where relevant, other partners) are fully informed of CAF activity in line with existing procedures. In addition, all multi-agency assessments should involve GPs. At Level 2 CAF, consideration should also be given to informing other agencies, where relevant. Recommendation 6: Children’s social care staff should respect and build on the earlier work done by Children and Families First colleagues and partner agencies when a child transfers to social care. Recommendation 7: Children’s services should develop clear practice guidance on the use of announced and unannounced visits. |
NC047020 | Overdose by a 17-year-old female leading to a profound brain injury. Review examines services provided to Child N between the ages of 14 and 17-years-old across two local authorities. N was a 'Child in need' at the time but children's services lost contact after she left supported lodgings to move in with her boyfriend. He was 5-years her senior and they had met in a sexual exploitation hotspot. A police search of his house after the overdose found young females under the influence of alcohol and drugs but there was insufficient evidence to bring charges against him for the supply and possession of controlled drugs. In the 10-weeks prior to the incident, N went to Accident and Emergency twice following overdoses, saw her GP, attended mental health services and was seen by police following concerns of domestic abuse. N had a troubled adolescence with issues of self-harm, substance misuse and going missing. Mother sought professional help to cope with N's behaviour. An allegation of physical assault against N's mother led to a S47 investigation and subsequently a referral for parenting support. Highlights good practice including the support provided by N's senior school. Missed opportunities include: social workers should have worked to repair family relationships; greater consideration should have been made relating to child sexual exploitation; and N should have had treatment and assessment from child and adolescent mental health services following her first overdose. Recommendations include: early help services must be proactive in working with families with adolescents; local authorities must exercise their legal duties relating to homeless adolescents; and that a clear pathway of mental health services for 16 to 18-year-olds is created and disseminated to all agencies.
| Title: Serious case review report: Child N. LSCB: Salford Safeguarding Children Board Author: Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Salford Child N Final 20 March 2015 Page 1 of 47 Serious Case Review Report Child N This report will be published in line with statutory guidance. In order to preserve anonymity as far as is possible, the author has: Used abbreviated letters to reflect each child and adult made limited reference to the gender of person, other than where not to do so would compromise the readers understanding of the report avoided the use of exact dates not used any details about local services which could lead to recognition of individuals Salford Child N Final 20 March 2015 Page 2 of 47 1. Introduction 1.1 This Serious Case Review (SCR) concerns services that provided a service to a young woman, Child N, who at the time of writing this report is now an adult. Child N requires 24 hour nursing care after sustaining a profound brain injury. Child N lives in a minimally conscious state; she cannot communicate, eat or drink without medical assistance and has a tracheotomy in place. 1.2 The Review predominantly considers the activities of agencies across two Local Authority areas; Local Authority 1, where Child N spent the majority of her adolescent and formative years, and Local Authority 2 where Child N lived from the age of 16 years and 11 months for three months until the incident which precipitated the convening of this Serious Case Review some three months later. Child N attended senior school in a third Local Authority area. 1.3 During her high school years, Child N lived with her mother MN, step-father SFN and three younger siblings. Information from the school and MN indicates that throughout Child N’s school years, she was a child that was well supported by her family and had aspirations for her future. 1.4 Child N attended the same senior school for five years. She was an academically bright and capable pupil academically who also needed additional periods of emotional, social and behavioural support. Child N at times struggled to ‘fit in’ with her peers, and it is evident she felt the need to present herself as exciting and interesting at times. Those who knew Child N best at this time consider that this need sometimes led her to fabricate stories and events in order to canvass the attention of her peers. Child N was considered to react well to the additional support of a Learning Mentor and successfully completed her senior education. 1.5 In additional to the pastoral support from school based staff, Child N also regularly accessed a counselling service provided within the school by Relate. During these sessions, Child N predominantly discussed friendship, low level bullying issues, and latterly some references were made to relationship issues within her family. Salford Child N Final 20 March 2015 Page 3 of 47 1.6 MN recalls Child N’s last two school years as a particularly difficult time. MN recalled that she spoke very regularly with the Learning Mentor who she considered provided very helpful support to Child N and herself. MN described times of feeling desperate in trying to understand Child N’s behaviour and keep her focussed on achieving in education. 1.7 On reflection, MN considers that once Child N left school, family life was becoming unbearable, with a great deal of focus on keeping track of Child N. MN feels strongly when Local Authority 1 became involved with Child N, there was little understanding of their family or attempts to rebuild family life and that the support was wholly inadequate. 1.8 Child N was provided with a Supported Lodgings Placement aged 16 years and 9 months and stayed at this address for approximately two months. It is believed that Child N formed a relationship with a male she considered as her boyfriend, TT, shortly before moving into this housing arrangement. At 16 years and 11 months, Child N moved home to live with TT in Local Authority 2. TT was five years older than Child N and an adult. 1.9 Within one month of moving to live with TT, Child N registered with a local GP. In the ten weeks that followed, leading up to the critical incident, Child N visited the GP on four occasions. Whilst living with TT, Child N presented to the local hospital Accident and Emergency Department on two occasions prior to the critical incident, each occasion related to an overdose of drugs/medication, none of which was prescribed for Child N and one of which she described as a deliberate overdose attempt. 1.10 The critical incident occurred eight weeks after Child N had presented at hospital with an overdose of TT’s prescribed insulin. Child N described this at the time as a ‘stupid thing to do’ but admitted that it had been with suicidal intent. On the date of the critical incident, an ambulance was called for Child N by TT at 9.51 am. Child N was described as unresponsive with her eyes rolled into the back of her head. The Ambulance arrived within eight minutes and undertook emergency procedures prior to transporting Child N to hospital. TT stated that Child N had fitted the previous evening; that she was put to bed after staggering about the house, but found to be Salford Child N Final 20 March 2015 Page 4 of 47 unresponsive the following morning. At the hospital Child N was found to be in a coma with an early prognosis that she was unlikely to survive, but if survival occurred, than she most likely would remain in a vegetative state. Twenty months on, Child N has never regained any consciousness. 2. Serious Case Review Process and Methodology 2.1 The case was first discussed at the Salford Safeguarding Children Case Review Subgroup (CRSG) in June 2013 following which discussion commenced with the Safeguarding Children Board in Local Authority 1 as to which Board should lead on considering the case. Negotiations then proceeded over which LSCB should lead on consideration of the referral for review. Legal advice was sought, and seven months later that a joint meeting took place with representatives from Area 1 and Area 2 Case Review Group. This meeting recommended that there should be a joint learning event to review the issues and involving practitioners and front line managers familiar with the case. 2.2 The Salford CRSG then recommended that a screening panel took place in Salford to better reflect the level of concerns raised by the information shared at the joint meeting. Members of the CRSG agreed that the alleged victim had been seriously harmed and that the circumstances of the case merited further consideration as to whether a Serious Case Review should be recommended. The screening panel took place in April 2014 and agreed that serious harm amounting to abuse and neglect had occurred to Child N and that concerns existed about the following issues: information sharing across and within Local Authority boundaries recognition and referral of causes for concern relating to incidents of domestic abuse, self-harm and possible exploitation in Child N’s relationship with TT assessment and escalation of need listening to the voice of the child, including recognition of Child N as a child and not simply as a young adult who had the capacity to consent. 2.3 A decision was then taken on 10th April 2014 by the Interim Chair of the LSCB that a Serious Case Review would be undertaken. Salford Child N Final 20 March 2015 Page 5 of 47 2.4 The Salford Safeguarding Children Board made the decision to appoint three professionals to oversee the Review process, to work alongside a Review Panel made up of Senior Officers from the contributing agencies. The three professionals each had a nominated role as Panel Chair, Independent Author and Independent Facilitator. During the process of the Review, due to unforeseen circumstances, the Independent Author also adopted the role of Independent Facilitator. 2.5 The Review has followed the guidance set out in Working Together 2013, to ensure the following was achieved: a recognition of the complex circumstances in which professionals work together to safeguard children; to establish where possible precisely who did what and the underlying reasons that led individuals and organisations to act as they did; an openness to understanding practice from the viewpoint of the individuals and organisations involved at the time to avoid the over influence of hindsight bias Careful consideration was given to the fact that information was to be collated from across three Local Safeguarding Board areas, and to this end a decision was made to collate data using two principal approaches. In the first instance, each agency that had worked with Child N or had particular information known to be relevant to the scope of the Review was asked to complete a Single Agency Analysis Report (SAAR). Following receipt of the majority of agency SAARs and all agency significant events timeline a Learning Event was undertaken with practitioners directly involved with the case. This approach was taken in order to promote single agency accountability whilst also placing an emphasis on the practitioner’s perspectives of how services responded to Child N in order to reach a deeper understanding of what happened specific to this case and what can be learnt about from this to maximise the safeguarding of young people. 2.6 Through the SAARs, each contributing agency was asked to address the following questions: How well information was shared between agencies, within Local Authority 1, within Local Authority 2 and across the boundaries of the two areas Salford Child N Final 20 March 2015 Page 6 of 47 How well risk assessments were carried out in respect of the circumstances of Child N Whether Child N was recognised as: a child with safeguarding concerns; a young person with vulnerabilities; a young person with mental capacity to make reasonable decisions about her welfare The impact of factors such as domestic abuse and sexual exploitation on Child N’s welfare and safety How well the voice of Child N was heard and listened to Whether the local authorities gave appropriate consideration to Child N’s homelessness and the potential for ‘looked after child’ status It was agreed the outline timeframe for the Review would be 1st January 2012 to 27th April 2013. This timeframe was chosen to reflect the point from which Child N became significantly known to additional services. 2.7 Information has been provided to the Review from many services. This includes: From Local Authority 1: Children’s Social Care Early Help Service Positive Steps College Sexual Health Services Hospital 1 From Local Authority 2 this has included: NHS Clinical Commissioning Group (CCG) Hospital 2 NHS Foundation Trust (provider services) Children’s Social Care Integrated Youth Service City West Housing From Regional/national Services: Greater Manchester West Mental Health NHS Foundation Trust Greater Manchester Police North West Ambulance Service NHS Trust Relate Counselling Service Additional: Senior School Pennine Care Foundation Trust - School Nursing Salford Child N Final 20 March 2015 Page 7 of 47 2.8 In addition to the above, the Panel identified a need to seek an objective expert medical opinion to review the medical interventions for Child N and comment upon whether the outcome of assessments were appropriate to her history and presenting behaviour. In order to reach confident judgements on specific aspects of medical care, specific comment was requested in the following areas: the robustness of a mental health assessment of Child N that took place 6-7 weeks prior to the critical incident given that the mental health assessment was conducted by an adult mental health practitioner (and Child N was 17 years old), was it likely that an assessment conducted by a child and adolescent mental health practitioner would have resulted in a different outcome the appropriateness of Child N’s prescribed anti-depressant medication to what extent Child N was considered a child when reaching clinical judgements about services were safeguarding concerns identified and acted upon appropriately 2.9 The methodology adopted, in particular the opportunity to be an integral and direct part of a multi-agency review process, was new to many of the practitioners who attended the Learning Event. This event was considered to a powerful reflective event from which practitioners were genuinely consulted and invited to share their own learning. 2.10 The Review was committed to developing an understanding of Child N’s life but sadly Child N was not medically fit to make a direct contribution. In order acquire some understanding of Child N’s thought and feelings, the Independent Author accessed notifications made by Child N on face book and twitter. MN kindly provided the Independent Author with many photographs of Child N taken over her adolescent years. 2.11 The Independent Author met with MN who was provided a view about the services that she had access with. The Independent Author also met with TT to try to get a sense of Child N’s day to day life prior to the critical incident. Salford Child N Final 20 March 2015 Page 8 of 47 3. Overview of what was known to Agencies 3.1 Seventeen months prior to the timeframe of this Review when Child N was 14 years, MN contacted Children’s Social Care in Local Authority 1 and requested support. MN advised that Child N would frequently lie and that MN had sought privately funded counselling which had not helped. MN was advised to access a ‘Surviving Teenagers Course’ with no further action taken by the Department. 3.2 Ten months later, Child N was 15 years when she contacted the Out Of Hours social worker in Local Authority 1. Child N was upset and stated that everyone wanted her to leave the family home after she had told a lie about a boyfriend which had caused trouble at school. MN confirmed to the social worker that she had told Child N to make the call because she was stealing and lying. MN became upset stating that she had telephoned Children’ Social Care several times but there was nothing anyone could do to help her. One week later, in response to the referral, MN was advised that the circumstances did not meet the threshold for a service by the Department but that she could self-refer to the Family Intervention Service. 3.3 Two weeks later, Child N alleged at a friend’s house that MN had physically assaulted her. A joint police and Social Care Section 47 investigation was undertaken. Both Child N and MN wanted to work through an argument that had occurred. Following this, Children’s Social Care made a referral to the Youth and Family Team, which stated that Child N was ‘pushing the boundaries, drinking, lying, and arguing a lot’. The referral asked for support with parenting strategies and a Youth Worker was allocated. After three months the case was closed. The closure summary states the family had made no contact after letters and telephone calls; however, there was no record of any contacts made with the family or any other involved professional in the case notes. It cannot be substantiated that the family were ever contacted by the Youth and Family Team. During this period, Child N was seeing the Relate Counsellor through school. 3.4 When Child N was 15 years and 11 months, a pupil at school reported that Child N had confided in her that she had taken an overdose of paracetamol tablets. A senior Learning Mentor spoke with Child N who denied saying this to the pupil or that she Salford Child N Final 20 March 2015 Page 9 of 47 had taken the tablets. Child N did say that there had been an argument at home about Facebook because she had sent postings indicating that she was gay although this was not true. The school spoke with MN who advised that she had also discovered an email to Brook Advisory Centre which Child N initially said she had sent on behalf of a friend but later stated she thought she might be pregnant. 3.5 Shortly after Child N’s sixteenth birthday, MN contacted the police. MN reported that that Child N had returned from school with a swollen face and that she was reporting this because in the past Child N had made allegations about MN physically harming her and she wanted it documenting. As a consequence, a police officer spoke with Child N who said the visible slight swelling was due to putting on make-up and rubbing it off. The chronology shows that Child N fought with another child in school that day. 3.6 In preparation for Child N’s transition to college, the school had shared information with the college that Child N was a pupil who needed support. The college met with the school who shared that Child N had a history of fabricating stories and had stolen from home. 3.7 Shortly before the GCSE exam period, Child N told staff in school that she had discovered the existence of a paternal half sibling on Facebook by chance. Child N said she felt unsettled by this as she wanted to get to know the half sibling without establishing any contact with her birth father. The day following this disclosure there was a dispute at the family home which was attended by the police. The dispute did not involve Child N or any other child. Information was shared with Children’s Social Care, the health visitor and school nurse. The school nurse shared the information with Child N’s Learning Mentor. 3.8 Child N successfully finished her senior school. MN shared with the independent Author photographs of Child N taken on the day of her school leaving prom which show a vibrant young girl for whom leaving school was being celebrated as an important milestone by her family. 3.10 During the school holidays, aged 16 years and 8 months Child N was reported as missing to the police for the first time by SFN at 2.45pm. SFN reported that Child N Salford Child N Final 20 March 2015 Page 10 of 47 had been seen leaving the family home that day at 1pm with a bag of clothes and that earlier she had been challenged about smoking and checking her Facebook page. Child N returned home the following day safe and well, however, when a police officer went to speak with her, she refused to say who she had stayed with, only giving the general area. 3.11 Child N began college to study engineering after the school holiday. A Pastoral Mentor was assigned to establish a support plan with Child N, and it was agreed that Child N could access 1:1 weekly support and would also benefit from careers advice. A week into college at the first 1:1 session, Child N indicated that she was settling into college and had aspirations to go to university. At the second 1:1 session, Child N talked about her aim to join the army as an officer in the Engineering Corps and about her family life. The Mentor described Child N in her recording of the meeting as very gregarious and happy with her life just now. They agreed that keeping to a weekly timetable for sessions was not necessary but that Child N could access the Mentor whenever she needed the service. 3.12 During the first four/five weeks of college, all indications were that Child N had settled in well and managed the transition better than had been anticipated. She represented the college as a student ambassador, a position for which she was successfully interviewed, and was seen as having done this exceptionally well. Child N did express an interest in changing course to photography but as this was over-subscribed, agreed it best to remain where she was. 3.13 Five weeks into the term, Child N did not attend college without notification. Child N’s Personal Tutor tried to make contact with Child N, and after failed attempts to do so, copied MN into an e-mail sent to Child N. MN subsequently contacted the Personal Tutor and advised her that Child N had run off after stealing money from her parent’s company bank account. MN stated that she thought Child N was with a group of people from a specific place in Manchester who were into smoking cannabis. MN said that the family were very anxious about MN but from monitoring her Facebook activity they did not believe her to be at serious risk. MN explained that this had become a pattern of behaviour and they expected she would return home shortly. Salford Child N Final 20 March 2015 Page 11 of 47 3.14 One week later, Child N did re-attend college but left after the morning session before the Personal Tutor could get to see her. The following day, MN contacted the Personal Tutor to say that Child N had not been seen in over a week. The Mentor contacted MN and asked for any contact details for Child N. The following day, Child N met with the Mentor. The Mentor asked that she contacted MN which she agreed to do but stated that she had an appointment with Connexions the following day to discuss temporary accommodation. Child N agreed to continue with college and restated her desire to transfer to photography when possible. 3.15 That same day, Child N attended Positive Steps, the Connexions Service in Local Authority 1. Child N stated that she left the family home after an argument and had remained estranged staying with friends and boyfriends family for a week. Child N said she had no money or food and no one with whom she could permanently stay. It was established that Child N could stay with a friend that night and an arrangement was made for a food parcel to be delivered. Child N was advised to present at Housing Advice the following morning and to call back to Connexions after that to review the financial benefits entitlement. Also that day, Child N attended the local Centre for Sexual Health. After hearing Child N’s circumstances, the Vulnerable Young Person’s Support Worker contacted Positive Steps and was advised of the plan in place for Child N. 3.16 Child N went to Housing Advice as agreed and stated that she did not want to return as MN had ‘thrown her out’ and assaulted her, so she needed support with accommodation. MN was contacted and stated that there was an issue over money going missing and it was recorded that MN advised that Child N could not come home at that time. (Note that MN told the Independent Author that this call came as she was en route to a trade fair some distance away, and that her family income relied heavily on attendance at the bi-annual trade fair. MN said she told the caller that she would be available on Monday as she believed that Child N was aware of the significance of that weekend). A Supported Lodgings placement was arranged for Child N for the weekend. Child N then went back to Positive Steps and updated the service on what had happened. The Service tried to make an application for a Crisis Loan but Child N did not return to complete this process. Salford Child N Final 20 March 2015 Page 12 of 47 3.17 A meeting was arranged by Children’s Social Care for the Monday morning which was attended by Child N and MN. It was agreed that Child N would return home that day with support to be put in place by the Families First Outreach Team. The Family First Team attended two meetings with Child N just over a week later. Firstly with college, where despite an e-mail stating that she was considering taking a year out of college, Child N agreed to continue with the engineering course with support to catch up on missed work. Secondly with Positive Steps Child N asked for support to complete a C.V. and finding part time work. 3.18 Sixteen days after returning home, MN contacted the police to report Child N missing. MN expressed concern that Child N was naïve for her age and might be at risk of crime or sexual exploitation. A police officer attended the home and spoke with FN and SFN who stated that Child N had previously been missing for a period of nine to ten days by staying with various friends and refusing to return home and that this had not been reported to the police as the family had known where Child N was. On this occasion however, they reported that Child N had taken clothes and emptied her school bag onto the bed leaving a packet of 32 paracetamol of which two had been used, and a bottle of 20 paracetamol of which only 6 remained. The police officer recorded that there was no evidence to suggest, or concerns being raised, that Child N had either taken the tablets or threatened to do so. The police officer completed a risk assessment which was determined as being low. 3.19 The day following the police report Child N attended the Centre for Sexual Health. Child N told the staff that she was homeless and would not disclose any address. The Nurse passed this information on to Positive Steps who contacted the Families First Team but was unable to get a reply. The Positive Steps Worker also left a message on Child N’s mobile phone number to make contact. 3.20 Child N was found by police in a park four days after the missing report in the company of a young person who was three years younger, missing from care, and about whom there were concerns of risk of sexual exploitation. The police ascertained that both girls had been hanging about the Urbis area of Manchester which is a known hotspot for sexual exploitation. The information given to the Police Officers resulted in a multi-agency strategy meeting in respect of the accompanying child eleven days after the girls were found. This meeting was attended by the social Salford Child N Final 20 March 2015 Page 13 of 47 worker for the accompanying child and also the social worker that was allocated to Child N the day after being located. The social worker for Child N stated that she had spoken to Child N about taking the accompanying child into Manchester, and that Child N accepted it was not right and would not do this again. It was agreed from the meeting that Child N’s social worker would need to speak with her again regarding going to the URBIS and potentially putting herself at risk. 3.21 Child N stated that if she was taken home she would run away again. Children’s Social Care determined that Child N was a ‘child in need’ by definition of the Children Act and arranged for her to stay at a semi-independent accommodation whilst a supported lodgings placement was secured. Child N was allocated to a social worker. Child N advised that she intended to take a year out of college. The Positive Steps Team tried to counsel Child N into education, employment or voluntary work, but Child N struggled to commit to a particular plan. The service continued to support Child N. A Core Assessment was conducted by Children’s Social Care which concluded that Child N should remain in supported lodgings until such a time as she was able to live independently as MN was not open to reconciliation. Child N was also located with a child missing from care the following day, a child who was at known risk of Child Sexual Exploitation and frequented the Urbis area in the City Centre. 3.22 The social worker contacted MN to arrange to collect Child N’s belongings. Social work records indicate that MN said she wanted nothing to do with Child N. Child N was placed in Supported Lodgings aged 16 years and 9 months with a first time Supported Lodging Provider. During the time that Child N lived in the Supported Lodgings Placement she attended different Accident and Emergency departments at three different hospitals. The first occasion was in Local Authority Area 1 and was for treatment for a foreign body in the eye, the second occasion was the following day at a city centre hospital with an ankle injury, and the third occasion was in Local Authority Area 2 with a cut to an arm sustained on New Years Eve whilst intoxicated. 3.23 The Supported Lodgings Scheme had in place an agreement whereby young people were permitted to stay out up to three nights per week without permission being necessary. Seven weeks into the placement, Child N left the property after an Salford Child N Final 20 March 2015 Page 14 of 47 argument and the Provider alerted the social worker that she had refused to return. The following week, Child N advised the social worker that she was moving to live with TT in Local Authority area 2. Although the social worker warned Child N of the potential pitfalls of this plan, no further actions were taken by the social worker to establish any information about the person Child N was going to live with, to discourage this course of action, to ensure Child N was safe and supported after this conversation. Child N left the supported lodgings placement aged 16 years and 11 months and there was no further contact between Child N and the allocated social worker. 3.24 TT’s home was the tenancy of his grandmother who had been in hospital for a substantial period of time. The day after Child N moved to this property an ambulance was called just before midnight, Child N was taken to hospital and presented with an accidental overdose of LSD. Child N informed medical staff that she had a diagnosis of bi-polar disorder and also that she thought she may be pregnant which was not confirmed after a test. TT attended the hospital with Child N, and she was reluctant to remain for assessment without him. It is noted that TT was escorted from the hospital by security although the reason for this is not recorded. The hospital undertook routine safeguarding screening with Child N who stated she was safe living with TT. Child N was offered a referral to a Substance Misuse Service but declined this. 3.25 Approximately three weeks later, Child N attended a GP new patient consultation with a Practice Nurse. The consultation provided was a thorough physical health check however her more general welfare circumstances were not established. The following day, Child N attended an out of hours GP service with back pain. Child N told the GP information that was not shared in the consultation the day previous, namely that she had been taking TT’s antiemetic medication for three weeks because of vomiting. 3.26 Two days later Child N saw a GP at the surgery she had registered. This consultation discussed three issues, contraception, depression and a suspected urinary tract infection. Child N stated she had low mood, and was tearful at night. The GP record noted that Child N stated she had a ‘previous medical history of bipolar’. The GP Salford Child N Final 20 March 2015 Page 15 of 47 established that Child N had no thoughts of self-harm and began a course of anti-depressant medication - citalopram, a course of antibiotics and further urine analysis. The GP also made a referral to a primary care psychology service. An appointment was made for Child N with psychology service at the surgery, this was however cancelled when the practitioner was off sick and the appointment was not rearranged prior to the critical incident. Child N returned to the surgery the following week and saw a different GP. Child N explained that the urinary tract symptoms had not dissipated and that she was not feeling any benefit from the anti-depressant medication. Child N was advised to continue with both courses of medication. 3.27 Approximately one month after Child N moved to live with TT; TT received a visit from a Young Fathers Project Worker. TT was engaged with the service as he had a child to a previous partner who was subject to a Child Protection Plan. The Worker met with Child N during this visit and did not observe anything to cause concern. Child N had presented as chatty and supportive to TT. A second visit was made one month later. It is clear from the descriptions of the property that the home was being used by various young people and it presented as untidy and unclean. The worker was however reassured by a second observation of Child N and TT that there were no obvious signs of domestic abuse or unhealthy relationship dynamics. 3.28 One week after the second GP consultation an ambulance was called to the address of TT; it was reported that Child N had taken an overdose of TT’s prescribed medication. Child N was just 17 years old. The ambulance crew made a referral to Children’s Social Care in Local Authority Area 2. The ambulance service advised that Child N has tried to kill herself after an argument with her boyfriend and she stabbed herself with his insulin pen. The crew had noted that Child N had a large bite mark on her arm that she said had been caused by her boyfriend, along with evidence of old cuts to her forearms and when asked about this stated that she and her boyfriend cut each other. 3.29 Child N was taken to hospital and admitted to the Emergency Assessment Unit for treatment. TT attended the hospital. The Unit requested that the Mental Health Liaison Team (MHLT) assess Child N once she was deemed medically fit for assessment. Child N remained in hospital overnight and then left the hospital Salford Child N Final 20 March 2015 Page 16 of 47 without being formally discharged the following afternoon. The hospital contacted the police to report that Child N required an urgent mental health assessment, and that having spoken to her by telephone she was at the home of TT but refusing to return. 3.30 A Police Officer attended the address; Child N agreed to return to hospital and was accompanied by the Officer. It was noted that the address was the tenancy of TT’s grandmother who was in hospital but appeared to be being used by all of his friends. Child N chatted to the Officer and said that she had been in a relationship with TT for nine weeks and that she had taken the overdose following an argument about money. The argument resulted in TT refusing to take his Insulin medication and attempting to leave the house. Child N stated that she had tried to stop him and a struggle ensued during which TT had bitten her on her upper left arm, Child N punched TT on the back, and he then slapped her face before leaving. When Child N realised that what she had said to the Officer would lead to TT being arrested for assaulting her, she refused to provide a statement of complaint to the Police or allow her injuries to be photographed. Child N did, however, allow the officer to see the bite mark, which was described as a 3 cm bruise to her arm. Child N told the Officer that this was the first time that ‘anything like this’ had happened between them and she did not want anything else like it to happen again. Child N was adamant that she wished to stay in a relationship with TT and continue to live at his grandmother’s address as she ‘had nowhere else to stay’. Child N described TT as suffering from schizophrenia, depression and bi polar and a person who also smoked cannabis on a regular basis. The Officer completed a child concern risk assessment which was graded as medium risk and a crime report was created. The Police incident log recorded this incident as both a domestic incident and a concern for a person under 17 years. Following a discussion with the Multi-agency Safeguarding Hub, the Police made a referral to Children’s Social Care in Area 2. 3.31 During the assessment by the MHLT, Child N reported two previous incidents of self-harm in the past two years both following arguments with her mother, firstly an overdose of paracetamol and ibuprofen, and secondly an attempt to hang herself. Child N reported that neither incident resulted in medical intervention. Child N further stated that she had a previous history of deliberate self-harm via self-Salford Child N Final 20 March 2015 Page 17 of 47 laceration as a means of managing her emotions. With regard to the presenting issue, Child N stated that she had suicidal intent ‘at the time’ but on reflection stated that it was a ‘stupid’ thing to do. The assessment concluded that Child N had good insight into her mood and mental state. Child N disclosed some questionable lifestyle choices with regard to aspects of her relationship with TT but it was concluded that she had capacity and is fully aware of the consequences of their actions. The MHLT agreed that Child N could be discharged to the care of the GP, with advice to attend follow up planned appointments at the surgery and for the Emergency Duty social work Team to liaise with the previous social worker team with a view to transferring support now she has moved. 3.32 The Emergency Duty Team in Local Authority 2 had been in liaison with the hospital throughout the incident. Liaison with the Emergency Duty Team in Local Authority 1 revealed that Child N remained an open case. The overdose and alleged assault was discussed at the Multi-Agency Safeguarding Hub in Area 2 once usual business hours resumed. The referral from the Ambulance service to the Emergency Duty Team was the first occasion that Children’s Social Care in Local Authority 2 knew that Child N was residing in their area. Local Authority 2 advised Local Authority 1 that they needed to make a formal referral. Despite Child N remaining an open case, Local Authority 1 took no action in relation to the information that Child N had taken an overdose and was a suspected victim of assault. No contact was made with Child N and no transfer arrangements to Local Authority 2 were put into motion. The case was closed one month after the incident with no consultation with other agencies and no attempts to establish Child N’s current welfare. Local Authority 2 closed the contact without establishing that Child N’s needs had been pursued and met. 3.33 TT was arrested by the Police on suspicion of assault. TT conducted a no comment interview in relation to the suspected assault. Whilst TT was in Police custody, Child N was visited again by a police officer to establish if she would make a statement of complaint which she refused to do. TT was released later that day after the Duty Inspector decided that the case did not meet the threshold for referral to the Crown Prosecution Service for a charging decision to be made. No further police action was subsequently taken. Salford Child N Final 20 March 2015 Page 18 of 47 3.34 Following discharge from hospital, Child N was contacted by the GP practice and asked to attend a GP appointment. Child N saw the GP she had seen at her second GP appointment at this GP surgery. The citalopram dosage was doubled and an analgesic was given for back pain with 100 tablets prescribed. The GP record does not indicate that the attempted overdose and attendance at hospital was discussed. Later that evening, an ambulance was called for Child N by TT because of chest pains. Child N was taken to hospital and discharged. 3.35 Ten days after hospital discharge, Child N was visited by a member of staff from the Vulnerable Young Person’s Team (VYPT) following a referral from the hospital at the last admission. The remit of this team is to provide public health, social and emotional advice and/or interventions to young people up to the age of 19 years who may not be accessing mainstream services. A health assessment was conducted which agreed that Child N would be referred to a counselling service for young people. A referral was made to this service however; the VYPT Nurse was advised that the waiting list was 8-10 weeks for an initial meeting. 3.36 Three weeks after the hospital discharge, Child N attended the GP surgery and saw a third GP. Child N was accompanied by a male friend; this is likely to have been TT. Child N explained that she was low in mood and crying herself to sleep every night, that she had thoughts of self-harm but no plans. The GP asked Child N about her social history, and Child N described TT as her ‘carer’. The GP noted that a previous psychology appointment had been cancelled by the service and made the decision to refer Child N to the adult mental health team. In response to this referral, a Community Mental Health Nurse tried to telephone the GP but as the GP was on holiday requested a return call once the GP had returned. A letter was sent to the GP by the Adult Mental Health Services advising that a full mental health assessment had been undertaken by the MHLT after Child N presented with an overdose and that an appointment would be offered if the GP felt that Child N’s circumstances had changed in which case the GP should re-refer. 3.37 Child N attended a further GP appointment six weeks after hospital discharge. On this occasion, Child N saw a different GP to any she had seen previously. A citalopram prescription was re-issued and it was noted that Child N had a forth coming Salford Child N Final 20 March 2015 Page 19 of 47 physiotherapy appointment to review her back pain. A further visit by the VYPT Nurse two days later noted that Child N remained concerned about her mood and it was agreed that a referral would be made for counselling to an alternative provider. Child N did not attend the scheduled physiotherapy appointment. 3.38 The Housing Provider who had responsibility for the property that TT was living in was contacted by the police and neighbours expressing concern about people staying at and visiting the address. The Housing provider had no knowledge that the tenant had been in hospital for several months or that TT was living at the address. A joint visit was undertaken by a representative of the Housing Provider and the police. The property was in an unsatisfactory condition and TT was advised that this would need to be rectified with a further check being made in a few days. TT advised that she would like to take over the tenancy and was advised that this was highly unlikely. The Housing Provider followed this visit by trying to establish contact with the grandmother’s social worker and TT’s parents. 3.39 Three days later the critical incident occurred, Child N was 17 years and 2 moths old. The ambulance was called on a Saturday morning. The information that was subsequently gathered by the police established that TT had attended at the hospital shortly after Child N’s arrival. TT told hospital staff that he had found a packet of pain killing tablets were missing from his bedroom and he suspected that Child N had ingested 15 tablets. He stated that Child N had ‘fitted’ the previous evening so he had put her to bed where they both slept. TT stated that he woke the following morning to find Child N fitting, foaming at the mouth, drenched in urine and had vomited. TT called an ambulance and asked a friend to help carry Child N downstairs. On this occasion, the ambulance crew did not raise a safeguarding concern. 3.40 During the subsequent police investigation, it was established that TT’s address had been used as a haven for disaffected young people. A police search was conducted and two young females were discovered at the address, both were believed to be under the influence of alcohol and drugs and one reported as missing from home. Drug taking, both illegal and prescribed drugs was described as common place and it was discovered that another vulnerable young person had been taken to hospital with an overdose four months earlier having taken drugs and alcohol supplied and Salford Child N Final 20 March 2015 Page 20 of 47 prescribed to TT. This matter was referred to the Crown Prosecution Service for consideration of criminal charges to be brought against TT in respect of supplying or possession of controlled drugs. A decision was made that there was insufficient evidence to charge him with either offence. 4. Analysis The examination of single and multi-agency working leading up to the precipitating incident of this Serious Case Review has identified several aspects of single and multi-agency learning. Where an issue of single agency practice is identified as an issue of concern and the relevant single agency has made a recommendation to address this, the recommendation is referenced in bold typeset. The table of single agency recommendations is referenced at the end of the report. 4.1 From the information known to agencies and supplemented by the contribution of MN, it is clear that Child N experienced a turbulent adolescence which at times overwhelmed her family’s ability to cope. Child N had no relationship with her birth father following a separation with her mother before she was born. MN described how her next partner was aggressive and how she, Child N and her second child experienced fearful occasions when he would harass them at their home after their separation. MN recalled that Child N became very protective of her and struggled, feeling somewhat misplaced when after some years alone she met Child N’s step-father. MN recalled how around this time, and still in primary school, Child N stole something from a shop and MN tried to deter her from doing this again by taking her to a police station to underline the seriousness of what she had done. 4.2 As Child N entered adolescent years, MN described aspects of her behaviour that caused her to become exasperated. MN described how Child N fabricated stories to make herself ‘interesting’ to her peers, stole money – small amounts at first leading up to amounts of £50, pushed boundaries from an early age with make-up, cigarettes and alcohol and would then swear it was not her when they both knew it was. MN said that the school were extremely supportive and that she worked closely with the Leaning Mentor to keep Child N on a safe pathway. To this end, MN considered, and the information from agencies would suggest, that once Child N lost Salford Child N Final 20 March 2015 Page 21 of 47 the structured environment of school her risk taking behaviour became much more erratic. 4.3 Child N was extremely well supported by her senior school, who worked in a close partnership with MN on both educational and welfare issues. During her school years, Child N frequently accessed a counselling service provided by Relate which was commissioned by the school. The information from Relate shows that Child N used the service during each school year and generally talked about friendships, bullying and her family life. Child N did talk in one session about a family dispute; this information should have been shared with other agencies. The SAAR report from Relate states that ‘it was safe to believe that the police would have referred the case to Social Services for assessment in the event that a risk of harm was identified’. The recognition and response to domestic abuse has been a progressive issue in child protection over the past 20 years. In 2008, witnessing domestic abuse for children became a specific category of significant harm as defined by the Children Act 1989. The extent of the problem is now overwhelming agencies, and there is a danger of practitioners becoming de-sensitised to the issue by perhaps seeing as a norm of behaviour in working with families at a high threshold of need. Successive Child Protection Enquiries and Serious Case Reviews have driven home the point that no agency should assume the actions of another, and should always share information that could be suggestive of risk to a child. In this case, although the police did share the information with Children’s Social Care and health, the information was provided to the school several weeks later by the school nurse. Significantly, the information told to the counsellor was the only information that confirmed that Child N knew of the incident and that it had an impact on her. Sharing this information at an earlier stage could have provided an opportunity to discuss the impact on Child N with MN. SCR Recommendation to Relate: To ensure all counselling staff have a complete understanding of the need to share information that could have safeguarding implications for children and never to assume that responsibility has been adopted elsewhere within the safeguarding systems. 4.4 The senior school had a good understanding of Child N and recognised an emotional vulnerability which they shared with the college she was planning to attend. The Salford Child N Final 20 March 2015 Page 22 of 47 college attended a meeting with the school to establish the areas of vulnerability in order to plan for her support needs. When Child N began college two things became significantly different to the support she had benefited from in school. Firstly, that the school had worked in partnership with MN and secondly that the Mentor, pleased with Child N’s initial settling in period, was reassured that the structure of support could be removed at very early stages. The college have recognised through the SAAR that at the point attendance deteriorated for Child N, they could have been more questioning and contacted agencies to advocate on behalf of Child N and seek their assistance in keeping Child N in college. For parents, the transition from school to college is significant, not least because far more emphasis is placed on the young person to share information and there is far less direct contact from the staff. The loss of a well-established partnership with the school would in itself have had an impact on MN’s ability to work through the difficulties of Child N without a network of support. 4.5 MN stated that she had frequently contacted Children’s Social Care in Local Authority 1 and two contacts are recorded in their records to this effect, seeking help with the management of Child N. When a Youth Worker was allocated to the family after a Section 47 investigation, the case was closed with no contact having been established. Significantly the case closure details no specific attempts either by telephone or letter at contacting the family or other agencies such as school if this could not be achieved. See Area 1 Early Help Service Recommendations 1,2,3,4 4.6 The next substantial contact with Children’s Social Care occurred after Child N had been reported missing for a second time by the police. On this occasion, Child N returned home with the addition of a service from Families First Team. MN recalled this meeting and considered that as a family they were made promises about support that did not materialise. The records show that a worker from Families First supported Child N to attend two appointments, made one visit to the family home to see both Child N and MN, and had approximately ten telephone contacts with MN. Ultimately, just over two weeks later, Child N became missing again. MN is honest in stating that at this point she was overwhelmed by the stress that Child N’s behaviour was having on family life, and that the three younger children were now suffering Salford Child N Final 20 March 2015 Page 23 of 47 because their parents were constantly distracted by Child N. MN described being at the end of her tether, and considered that she had tried many different strategies to support Child N but to no effect. On this basis MN did not oppose Child N when she said she would not return home and hoped that over time their relationship would repair. 4.7 When Child N presented as homeless to Local Authority 1, she was provided with temporary accommodation and then introduced to a supported lodgings placement. At this point, Child N and her family were adrift, she had stopped attending college was therefore NEET (not in employment, education or training). Children’s Social Care undertook a Core Assessment which stated that Child N needed supported accommodation until she was ready to live independently. Although Child N had had difficulties throughout adolescent, in the space of only six weeks she had gone from being a young girl with some noted degree of vulnerability, but who was considered to be happy and prospering in college, to a young girl who became highly vulnerable with no support network, no structure and no economic means. The Core Assessment that was completed in respect of Child N had significant limitations and it is difficult to see how the assessment sat within the overall approach to the case, it did not address Child N as a child of her wider family and failed to reach an understanding of the family functioning from which social work intervention could have addressed what was needed for Child N to live with her family again. Specifically the assessment focussed on homelessness as being the presenting issue of concern. In 2009, an appeal upheld in the House of Lords (G vs Southwark) changed previous case law and as such became a landmark ruling when considering the circumstances of children presenting as homeless. Effectively the ruling affirmed that if a child meets the criteria for accommodation in Section 20 Children Act 1989, that the accommodation should be provided under that provision and Local Authorities may not choose to provide accommodation for lone children under other powers unless the child themselves have been appropriately advised of their entitlements and being capable of making an informed choice, refuses such provision. It is clear that Child N was assessed at that time as having no person prepared to exercise parental responsibility and as such a duty had arisen and the Local Authority was not entitled to side step that duty by simply providing accommodation under Salford Child N Final 20 March 2015 Page 24 of 47 another process. Giving due regard to the implications of this judgment, Child N was entitled to support under Section 20 of the Children Act 1989 but she was never advised of this entitlement. There is no indication throughout all the information that was known about Child N that Children’s Social Care ever considered the possibility of using Section 20 of the Children Act to alleviate Child N’s circumstances, or that any other agency challenged their decisions not to do so. See Area 1 Children’s Social Care Recommendation 3 4.8 The impact of not recognising Child N to be entitled to receive services under Section 20 of the Children Act 1989 was compounded by the fact that although she was determined as having a Child in Need status, no usual Child In Need Processes were followed. No multi-agency meeting was ever convened and no Child In Need Plan was drawn up for Child N. In addition, there is no indication of any social work interventions at this stage other than assisting with the move to a supported lodgings placement. Had Child N become formally looked after under Section 20, a number of processes would have occurred which would have enhanced her welfare. This includes the appointment of an Independent Reviewing Officer, the requirement to have a looked after children care plan and a greater emphasis on understanding the circumstances that led to her becoming looked after which may have assisted any potential for reconciliation with her family. The absence of adhering to established multi-agency procedures resulted in each agency working with Child N in isolation and missed opportunities to share information about Child N’s whole circumstances. 4.9 The effect of the move to supported lodgings without any multi-agency process in place was that Child N was left to do her own thing at 16 years and 9 months and find her own way through an early transition to independence. Effectively she went from a situation where a parent was struggling to exert control and boundaries to one where there was very little. The supported lodgings scheme was a provision that was managed in the main through one worker. Access to information kept on Providers suggests that the recruitment of Providers was focussed on the physical provision of accommodation as opposed to the availability of emotional support and guidance. Although it was stated that all Providers had checks completed as part of the assessment, no police check was on file for one of the Providers in Child N’s case. Salford Child N Final 20 March 2015 Page 25 of 47 The assessment to become a Provider was a very limited document and focussed on the health and safety aspect of the accommodation. Child N was the first placement that the Providers experienced. It was agreed from the outset with the social worker that Child N was permitted to stay out overnight three times per week with no expectations of dependencies in place to oversee this arrangement. The Supported Lodgings Providers have provided information for this Review which states that they had no issues with Child N’s behaviour other than untidiness and a tendency to leave rotting food in her bedroom and wardrobe, but they were concerned about her increasing tendency to stay away with TT. In an effort to get to know TT they allowed him to stay for tea and even stay overnight on a couple of occasions. A substantial sum of money went missing about two weeks before Child N left the placement which they believe was taken by Child N. Although there was telephone contact between Child N’s social worker and the Providers, the social worker did not visit the placement after Child N moved there. Since the beginning of the Review, no further Supported Lodgings placements have been made in Local Authority 1. The Local Authority intends to revise the procedures for assessing, approving and reviewing Supported Lodgings Providers. See Area 1 Children’s Social Care Recommendation 4 4.10 MN stated that she had hoped that the social worker would help facilitate a resumption of the relationship between Child N and herself once the heat of the situation had calmed down. MN said that the day that Child N left there had been a disagreement about social media. MN had gone shopping and rang Child N to ask about an item of clothing she was buying her, Child N said at this point not to bother as she was leaving. MN said she was frantic, they had just enjoyed a weekend in London and she hoped that this was a turning point. MN recalls that she rang the Families First Team to tell them what was happening and had wanted someone to go out to see Child N but this did not happen. MN said she felt very let down by a service that had promised a responsive service when Child N had returned home. MN said that once the social worker became involved, she felt judged as a mother who was withdrawing from her daughter without any appreciation as to what the family had gone through and the fact that she had four children to consider. Salford Child N Final 20 March 2015 Page 26 of 47 4.11 It seems that TT had been known to Child N for some time. They had met each other whilst hanging around the Urbis Centre in Manchester. MN said that Child N started frequenting that area whilst she was in her last year at school. MN noticed certain changes in Child N’s demeanour; she became anti-establishment, and voiced her belief that rules had no place in Society. The police SAAR notes that the Urbis area of Manchester is an area that was frequented by Child N, the associate who was missing from care when found with Child N, and TT. It has been known to the Police for a number of years that this and the area surrounding are locations which attracts a large number of young people, some of which have been identified as being vulnerable from across the whole of the Greater Manchester area. Statistics for 2014 show that 25% of all known returned missing from home children in Greater Manchester have told the Police that they have been to these areas whilst missing. As a result there is presently ongoing police and multi-agency activity which is being supported by local charities in these areas on most evenings and they are subject of enhanced regular police patrols. Further partner led multi-agency initiatives are being planned as part of a long term review of vulnerability in the centre of Manchester. See Greater Manchester Police Recommendation 1 4. 12 Child N was at risk of child sexual exploitation although thus was not identified as a risk in the core assessment. Her circumstances were suggestive of a number of risk factors; that she was using illegal substances, that she had associations with other young people known to be at risk, that she had little adult controls on her whereabouts and that she was isolated with minimal support. Child N may well have felt trapped by her circumstances, she had stated to the police when discussing the bite mark to her arm that she wanted to stay with TT and had ‘nowhere else to go’. The Review Panel was advised that older children presenting as homeless is a growing area of concern in both Local Authority 1 and Local Authority 2. Concern was expressed about the adequacy and availability of supported accommodation options, and there was a sense that each new presentation to intake services presented a challenge to resolve. In Local Authority 2 between March 2014 and January 2015, there have been 29 assessments on older children who have presented as homeless. This represents an increase from the previous year and Salford Child N Final 20 March 2015 Page 27 of 47 increasingly children are presenting at a point of crisis. A similar picture is painted in Local Authority 1 and for this reason a recommendation is made to the Boards to achieve a greater understanding of the whole vulnerability issues for older children who need accessible support and accommodation. See SCR Recommendation 5.5.5 4.13 Child N was able to make the decision to move to live with TT without challenge. When Child N told the social worker what she was doing, there is little evidence that the social worker made any realistic attempts to dissuade her. No consideration was given to informing MN and whilst it could be argued that there was no legal requirement to do so and Child N may not have wanted this, there are occasions when determination about a child’s best interest should override a child wishes, and where concern for welfare means that all possible sources of support are reconsidered. Child N was still the subject of a Child in Need plan and this significant change did not alert the convening of a child in need meeting nor was Local Authority 2 alerted to the fact that a Child In Need was moving into their area as would be expected in accordance with the North West Children in Need moving across Local Authority Boundaries 2013 guidance. The social work approach to the management of Child N as a Child in Need in Local Authority 1 is passive at best and disinterested at worst. One can only form the impression that Child N was simply perceived and responded to as having an accommodation problem which was met first through Supported Lodgings and then by TT rather than as a vulnerable child whose circumstances were extremely precarious. Given that Child N had met TT at a known CSE hotspot, he was older and offering her a home, the social worker for Child N should have been alerted to dig deeper, in particular with sceptical approach to whether Child N was being coerced, groomed or simply felt she had no better alternative before her. The approach of the social worker also raises questions about the management oversight of the case through case work supervision and assessment counter signatory. The need to improve systems and practice in respect of Children in Need has been identified by Local Authority 1 during this Review, and this has also been identified by another recent Serious Case Review in that area. 4.14 After Child N left the Supported Lodgings placement the social worker made no attempts to contact her. Such a lack of interest in a vulnerable 16 year old who was Salford Child N Final 20 March 2015 Page 28 of 47 actually a Child in Need to the Authority raises fundamental concerns about the case holding social worker, and it does feel as though Child N’s circumstances were ‘processed’ rather than seeing the child and her life. No checks were made as to the suitability of the arrangement, no forward safety planning took place and contact became lost with Child N from Children’s Social Care in Local Authority 1. Had Child N had received genuine social work intervention, there was every likelihood that she could have been supported to remain in college and regain a relationship, even if not to live, with her family. Child N received a very poor social work service which may well have contributed to her ongoing choices. 4.15 Given what is now known, it is likely that Child N had started to use illegal substances in her last school year and this increased to a greater need/dependency from the summer holidays onwards. Moving to TT gave Child N greater access to illegal substances and an environment to use without the knowledge or challenge of a responsible adult. TT is known to have longstanding physical and mental health issues and from moving to live with TT her increased access to health services suggested a similar pattern was emerging. The first hospital presentation for Child N was the day after she moved. Child N was 16 years; she advised that she had been living with her boyfriend who she had known for two weeks and had accidentally overdosed on LSD. During the assessment, Child N was asked three routine safeguarding questions which are: Do you look after anyone at home How often do you drink 6 units or more of alcohol Have you ever been hurt of felt frightened by anybody you know The answers to the above questions raised no concern and once medically fit Child N was discharged to TT’s address. The questions are generically applied to help assess vulnerability, in Child N’s situation however, the information she gave outside of the questions should have raised greater concern about her vulnerability. There is a danger of relying too greatly on prescribed processes which are general when a greater reliance should be placed on bespoke situations. It would have been proportionate to refer a concern for welfare for a 16 year old who presents with a drug overdose but refuses a referral to a drug service, states she is living with a Salford Child N Final 20 March 2015 Page 29 of 47 boyfriend she had known for only two weeks and reported a non-medicated bi polar diagnosis. 4.16 The Review Panel and Practitioners meetings have spent considerable time in trying to understand how Child N spiralled into increased vulnerabilities in particular given the attempts by various medical services to reduce them. Having already stated that Child N became lost to Children’s Social Care Services at the point she moved, she did become increasingly visible to medical services for both physical and emotional health issues. Child N’s health screening when she registered with a GP was thorough from a heath perspective, yet although she was still only 16 years old, her domestic circumstances were not considered. The presentation at hospital and the initial Heath consultation both beg the question as to whether Child N was being perceived by professionals as a child. On both occasions, she was still 16 years, yet she appeared to be viewed as a young adult whose circumstances were private with no right to question. Child N is described as a child who was very articulate by those who knew her best; however, they also stated that her verbal articulation masked an emotional immaturity. This suggests that Child N presented as older than her years, but functioned at younger than her years. 4.17 When Child N first attended a GP appointment at the surgery where she registered, she was prescribed an anti-depressant medication, citalopram, initially being given a two week supply, and also referred to a primary care psychology service. Both courses of actions are more recommended for adult patients, again suggesting that Child N’s child status was not a dominant factor in the consultation. Current National Institute for Clinical Excellence (NICE) Guidance 28 advises that for those under 18 years, citalopram should not be used as a new therapy, and favours an alternative drug of fluoxetine. The guidance goes on to state that citalopram should only be used when: That child and their parents/carers have been fully involved in discussions about the likely benefits and risks and have been provided with written information The child’s depression is sufficiently severe and/or causing serious symptoms to justify a trial of another anti-depressant There is clear evidence that there has been a fair trial of fluoxetine and psychological therapy Salford Child N Final 20 March 2015 Page 30 of 47 There has been a re-assessment of the likely causes of the depression and of treatment resistance There has been advice from a senior child and adolescent psychiatrist – usually a consultant The child and/or someone with parental responsibility for the child has signed an appropriate and valid consent form. Both citalopram and fluoxetine are drugs that selectively inhibit the re-uptake of serotonin in the body, and they are termed SSRIs (selective serotonin re-uptake inhibitors) however, through clinical trials, only fluoxetine has been shown to be effective in treating depressive illness in adolescents, whilst citalopram have actually shown an increase in harmful outcomes. A GP attending the Learning Event from the GP practice was confident that citalopram was an appropriate prescription, however, the opinion of the NHS Commissioning Group SAAR and the independent psychiatric opinion commissioned for this review was at odds with that perspective. The Independent Psychiatrist provided an opinion that the prescription of anti-depressants was not appropriate when Child N was also presenting with physical symptoms that could have affected her mood and therefore should have been treated before considering medication. See NHS Salford CCG Recommendation 1 4.18 The referral to primary care psychology services did not proceed because the worker was unavailable, nor was it re-established prior to the critical incident. Given Child N’s age however, a more appropriate route for referral would have been the Child and Adolescent Mental Health Service. This Service is designed to meet the needs of adolescents and would have been in a better position to consider Child N’s whole circumstances and offer challenge about her support needs to Children’s Social Care. 4.19 Child N did have a mental health assessment when she stated she had deliberately overdosed on TT’s insulin medication and showed some signs of physical injury. This was approximately eight weeks before the critical incident. The hospital acted robustly by contacting the police to seek Child N’s return to the hospital when she left without assessment and this was achieved by the intervention of the police. Greater Manchester West Mental Health Services have responsibility for the MHLT that undertook the mental health assessment. During the Review the Trust found the Salford Child N Final 20 March 2015 Page 31 of 47 assessment to be very comprehensive and this is supported by the view of the Independent Psychiatrist. The Independent Psychiatrist comments however that even a robust assessment in Accident and Emergency is of limited efficacy in terms of both mental state examination and risk assessment without adequate community follow up and that given Child N’s reported previous significant attempts of self-harm and the evidence of early relationship difficulties, very close monitoring and intensive follow up arrangements in the community setting should have been established. The Independent Psychiatrist concludes that the robust mental health assessment could not stand alone as a comprehensive assessment of Child N’s needs and that an urgent referral to the CAMHS service should have been made with a multi-agency approach and Care Planning Approach. See NHS Salford CCG Recommendation 2 4.20 The risk management plan put in place by the MHLT included a referral to the Vulnerable Young Person’s team and a discharge to the care of the GP. The Team could have referred Child N to a CAMHS Team EMERGE who work specifically with 16 and 17 year olds and follow up assessments within seven days on an Accident and Emergency attendance, but it is stated that they were not aware of this specific service. The attempt by the GP to refer to the Community Mental Health Team was never resolved through discussion between the two services, and given that this was four weeks before the critical incident this was a missed opportunity to discuss in depth the needs of Child N and how they could be best met. 4.21 The police SAAR considers that the police activity in returning Child N to hospital and initiating an investigation of assault to Child N provided an opportunity to take a firmer protective stance. Whilst vulnerability in two areas was recognised, that being a concern about a young person under 17 years and a domestic incident, and the triage of this incident went through standard police processes, the process failed to consider what was known about TT’s history or the total safeguarding history in relation to both Child N and TT available from police systems. This happened because the concern about a young person under 17 took precedence, as was standard police procedure at the time, which meant that risk assessment procedures in relation to domestic abuse was not completed. Had this incident occurred four weeks later, the police response to the domestic incident coding would have Salford Child N Final 20 March 2015 Page 32 of 47 reflected the fact that the Home office definition of a domestic violence incident was changed so that young people aged 16 and 17 years would be included and the definition was changed in order to capture coercive control. The police SAAR concludes that the oversight of the Public Protection Unit did not comply with police procedure for two reasons, that the totality of the risk assessment was not adequate because it did not consider all available information and secondly that no supervisor review was completed before the incident was signed off. In short, although faith was placed in the fact that a referral was made to Children’s Social Care, information available to the police that suggested the presence of particular risk factors for TT was not considered or analysed. Had a complete risk assessment been undertaken, then this could have led to the convening of a Strategy Meeting where information would have been shared and analysed across agencies. See GMP Recommendations 2, 3 4.22 The Vulnerable Young Persons Team made two visits to Child N after her hospital discharge. The team was however working in isolation from other services who either were or should have been working with Child N. The service had no contact with the GP and two referrals for counselling services at the same time as the GP surgery was seeking a further mental health assessment. On the first visit, Child N stated that she did not want her social worker to be contacted and the Nurse respected this although understood from hospital records that Local Authority 1 had been informed. There is no specific comment in the records about Child N’s living conditions, although the police and Housing Provider found them to be unsatisfactory only days after the second visit. See Salford Royal Foundation Trust Recommendation 1 4.23 No agency or professional grasped the need to work together for Child N and ensured that this happened. There can be no doubt that Child N’s circumstances were deteriorating, and despite having had direct contact with the hospital, GP, Vulnerable Nurse Team, and her circumstances becoming known to Children’s Social Care in Local Authority 1 and 2 no firm intervention was taken to assess and plan for Child N’s needs. 4.24 Agencies were asked to consider whether and how well the voice of Child N was heard. Without Child N’s contribution, it is difficult to know what she wanted from Salford Child N Final 20 March 2015 Page 33 of 47 her life and whether that changed over time or whether she considered herself to be trapped into certain decisions for some reasons not known. Generally agencies felt that in individual issues, Child N’s voice was present in their decisions and actions, but there are some significant omissions. Child N was not advised that she was entitled to services under Section 20 of the Children Act 1989 and what this might have meant for her, she was therefore denied this opportunity. When Child N was discharged from hospital after the stated overdose she wanted to see a counsellor but a service could not be accessed for her in a timely way. On occasions, Child N was permitted to make life changing decisions without any guidance such as leaving college and moving to live with TT. We should not forget that sometimes children need a professional to care enough to say no and not support their choices. One of the things that MN described as very important to Child N was a long standing desire to join the armed forces. MN described how she wanted to avoid labelling Child N through earlier potential medical processes because she did not want any barriers to stop Child N achieving her goal. 4.25 Child N’s last presentation at hospital was in a critical state; it was anticipated that Child N would not survive. Although there are a number of factors in relation to this incident that give cause for concern about what happened to Child N prior to being taken to hospital, at the time the hospital did not appear to have any cause for concern and focussed on Child N’s acute medical needs. The hospital contacted Children’s Social Care in order to trace Child N’s parent. On the third day of Child N being in hospital, SFN contacted the police to report concerns about what had happened to Child N, and a police investigation ensued. The investigation is ongoing and once this is concluded, it is intended the police will submit a further report to the Serious Case Review Panel and consideration will be given as to whether there is additional learning and if so, the Overview report will be amended to reflect this. 5. Findings 5.1 The Review of how services were provided to Child N and her family has resulted in some very salutary realisations for agencies who would have wanted to do better and this is reflected in many of the SAAR reports. There are a number of critical points where services should have been more responsive to the needs of the family Salford Child N Final 20 March 2015 Page 34 of 47 and Child N and other points where deviation from established procedures and guidance had a profoundly negative effect on Child N’s welfare. 5.2 This Review highlights a critical pathway of missed opportunities to provide better and more protective services to Child N which could have made a difference to the ongoing life choices that she made. The critical opportunities can be summarised as followed: Early help services should have created a multi-agency approach from which the needs of Child N and the whole family could have been considered; The Families First Team should have taken a more interventionist approach and ensured that Child N was better supported through the transition to college, and identified the indicators of substance abuse; Consideration should have been given to Child N’s entitlement to become a looked after child at the point it was determined she could not live with her family; Determined social work intervention should have worked with Child N and MN to repair relationships to enable Child N to remain a member of her family; Given that Child N was determined as Child in Need by Children’s Social Care in Local Authority 1, multi-agency Child in Need Processes should have been initiated and, if she was determined to move to Local Authority 2 this should have been as part of a support plan that established how her safety and welfare needs would be met; Child N’s circumstances should have triggered greater consideration of risk of sexual exploitation from the point she was known to frequent hotspots for CSE activity, stated she was moving to live with an older male that she had met there and presented as a victim of domestic abuse shortly after moving to live with him; Child N’s substance misuse and refusal to accept support services should have triggered cause for concern to her welfare; Child N should have received clinical treatment for depression in accordance with NICE guidelines; Following the stated overdose, both Local Authority 1 and Local Authority 2 should have been dogged in ensuring she was receiving appropriate support; Salford Child N Final 20 March 2015 Page 35 of 47 Following the stated overdose, Child N should have had follow up community treatment and further assessment from a child and adolescent mental health service. 5.3 It is important to note the particularly positive experiences and good practice that Child N experienced. This includes: A senior school that understood her as a person and worked in partnership with her parent to good effect; Nursing staff that acted robustly when she took hospital discharge without consent in order to ensure here needs were assessed. 5.4 The Learning Event was attended by ten different organisations that had worked with Child N in the year leading up to the critical incident; some did not know of each other’s existence and no one person knew the whole history of what had happened to Child N in that year. What is remarkable though is that at no point did any one agency initiate or question why there was no multi-agency plan for Child N despite the fact that this was clearly needed from the summer she left school. Practitioners undoubtedly understood the need for this and the benefits of doing so, but still there is a tendency to work alone, or at best, in contact with one other organisation. All agencies report a continual mismatch between resources and demand which has an impact upon competing priorities for time. Knowing this to be true, the Learning Event in relation to this case focussed on how resources could be used both efficiently and effectively when a multi-agency approach is taken and why this is necessary to optimise outcomes for children. The event also helped practitioners to consider that challenge and support are not exclusive concepts in multi-agency working and that all agencies need and should welcome challenge as part of maintaining best practice. Many Practitioners found the day to be extremely valuable, commenting that although they receive supervision, time pressure dictates that the accountability aspect takes precedence over any opportunities for reflective case management. Some of the lessons that practitioners stated that they took from the event are highlighted below: To be persistent and have tenacity Whole systems working is vital “no man is an island” Salford Child N Final 20 March 2015 Page 36 of 47 Share information with all agencies no matter what organisation it is and promoting the organisation I work for and what information I can share To consider more thoroughly consequences of inaction To not presume people know information, better hear it twice than not at all Heightened awareness of need to listen, respond, build relationships, signpost and advocate for children Today I will take away thinking of someone under 18 as a child 5.5 The following paragraphs describe the key points of learning from this Review from which audits against current services and actions should be formulated: 5.5.1 The provision of early help services must take a pro-active approach to working with children and families and to preventing adolescent children becoming harder to help through unstructured interventions Child N attended her senior school for five years, during this time a good working partnership was developed with MN. Given that it was the remit of Families First to work with families to prevent family breakdown, the team was not successful in working with Child N and her family. It is disappointing that there is no concrete evidence of any attempts to work with the family at the point of emergency when Child N returned home. The Biennial Analysis of Serious Case Review 2005 -2007, considered 10 Serous Case Review of young people aged 11-17 years. The report noted that the older children subject to reviews were well known to agencies and had profiles characterised by risk taking behaviour, substance misuse and sexual exploitation. The struggles of the young people were examined as a case study, which identified the key issues as follows: That early preventative intervention can prevent later entrenched problems; That when children’s behaviour becomes a way of speaking, they need to be heard; The need for a holistic assessment which incorporates an understanding of the child and family functioning; The need to mobilise specialist services and ensure that they are coordinated; Salford Child N Final 20 March 2015 Page 37 of 47 The need to ensure that information was shared across agencies, with plans better coordinated and reviewed. There is a danger that support services that fall below statutory children’s services are too ready to place emphasis on the parent to steer the service as a way of gate keeping or ‘leaving well alone’ after a crisis has passed over. However, long term sustainable change can only be achieved through a programme of planned intervention which should be led by the service. 5.5.2 That agencies working with children who are at risk of becoming NEET take affirmative action, and work together to prevent this occurring Generally speaking, the education, training or work opportunities that disaffected children receive is possibly the most crucial aspect of engagement. From a purely practical basis, children attending and engaged in education or work are less likely to turn to other forms of stimulus, and education will provide life chances that give young people aspirations for their own future. Child N was able to leave college too easily without any other form of education or employment to go to. Whilst the college knew that she had been missing from home, they never knew that she left home. At this point three agencies were involved with Child N, Families First, Positive Steps, and the college. A multi-agency approach that sought to work with Child N and MN should have been deployed to maintain her occupied position. Increased unstructured time allowed Child N to develop an unhealthy and anti-social lifestyle. The SAAR from the college of Area 1 made stretching recommendations for the college to implement their learning form this review, to initiate and maintain contacts with external agencies involved with pupils, and to continue attempts at re-engagement once a pupil has left the college without forward provision. 5.5.3 That to protect vulnerable adolescents, Local Authorities must exercise their duties in accordance with Section 20 the Children Act 1989 and in compliance with the ‘Southwark’ ruling Local Authority 1 could not explain why this was not exercised for Child N, but were clear that the duty was known. During the Learning Event, practitioners spoke of a perceived and latent pressure not to accommodate older children. It was agreed Salford Child N Final 20 March 2015 Page 38 of 47 however that completing good quality assessments and risk assessments was the pathway to ensuring sound decisions were made for children, and to enabling a practitioners to advocate for a child with confidence. At a time when Local Authorities have significant budget pressures, it is vital that practitioner’s assessments of need focus on identifying that need are not fundamentally influenced by the pressure to rationalise resources. Other agencies also agreed it was their role to challenge on behalf of children if they consider their welfare needs remained unmet. 5.5.4 Where safeguarding agencies receive information that suggests a child could be at risk of child sexual exploitation, robust and affirmative multi-agency responses must be initiated to ensure all information is shared to maximise protection and options of services. Supporting children at risk of sexual exploitation, requires acute awareness of indicators on behalf of families and professionals, robust multi-agency systems that support information sharing, a tenacious approach from professionals to provide pathways of services for children and disruption of activity of offenders. This case is a salutary reminder of how quickly a child’s vulnerability can heighten, and just how devastating the outcomes can be. Time is of the essence, agencies need to be able to respond quickly and firmly to protect children. 5.5.5 The LSCBs need to be satisfied that there is a range of provisions suitable to meet the needs of children who present with homeless and support needs There is a danger that assessments of older children’s circumstances will be overly influenced by the professional awareness of limited resources. The Review must serve as a constant reminder of the true extent of vulnerability of older children even when their personal presentation does not necessarily indicate this. Homelessness is a symptom of a difficulty experienced by a child, it requires the meeting of a very basic need for shelter, which should not detract agencies form understanding the holistic needs of a child and providing the support needed to navigate the transition to adulthood. Salford Child N Final 20 March 2015 Page 39 of 47 5.5.6 Any child who is an open case to Children’s Social Care should have a multi-agency plan and team around the child, and that all open cases of 16-18 years olds are audited against this standard Every child who is an open case to Children’s Social Care under current threshold arrangements if likely to be either a Child In Need, subject to a Child Protection Plan or Looked After. In all of these circumstances, the child should have a multi-agency plan. Management oversight and case work practitioners must ensure that the plan is active, relevant and commonly understood by agencies working with that child. Similarly all agencies must take responsibility for multi-agency working, and where it is expected that a social worker would be the Lead Professional to challenge in instances where this does not happen. 5.5.7 No Children’s Social Care Service should close a case or sign off a contact until they can be satisfied that all outstanding needs have been considered This statement seems so obvious that it should not need stating, Child N’s needs however were known by two Children’s Services, one to whom she was an open case and to whom she was a resident child, yet neither ensured an appropriate safety plan was in place following her first stated overdose. See Salford Children’s Social Care Recommendation 1, Area 1 Children’s Social Care Recommendation 1 5.5.8 That a clear pathway of mental health services for 16-18 year olds is created and disseminated to all agencies that work with this age group This case has shown that there has been real misunderstanding amongst medical professionals about the services and treatment available and most suited to the 16-18 age group. There is no reason to believe that the misunderstandings in this case would not happen again without substantial activity to educate practitioners and clarify the established pathways of care. 5.5.9 That NICE guidelines on anti-depressant medication for children is re-affirmed across all GP surgeries and acute mental health services Salford Child N Final 20 March 2015 Page 40 of 47 The issue of appropriate anti-depressant treatment for adolescents is a matter that has divided practitioners during this Review. The NICE Guidance is however unequivocal and should be reinforced for all GPs and other mental health professionals as appropriateness of the medication was not identified by the mental health assessment. 5.5.10 That the Board ensure every opportunity is taken through procedure, strategy and line management structures to re-enforce the message that all young people must be treated as a child in accordance with the Children Act 1989 until they attain the age of 18 years At the very heart of this Review has been the extent to which Child N was seen as a child. The years between 16 and 18 years present many dilemmas for professionals working with this age group. At 16 a child can marry with parental consent, can apply for state benefits in their own right and to all intents and purposes are seen as capable of making their own decisions. Under the Children Act 1989, a child is a child until they have passed 18 years, and concerns and questions about vulnerability should be responded to from this perspective. Child N was perceived as capable by most professional she met, but her choices and vulnerabilities belied the fact that she was a child growing up faster that she was emotionally able to cope with. Salford Child N Final 20 March 2015 Page 41 of 47 Appendix 1: Recommendations Area 1 & Area 2 LSCBs 1. The provision of early help services must take a pro-active approach to working with children and families and to preventing adolescent children becoming harder to help through unstructured interventions. 2. That agencies working with children who are at risk of becoming NEET take affirmative action, and work together to prevent this occurring. 3. That to protect vulnerable adolescents, Local Authorities must exercise their duties in accordance with Section 20 the Children Act 1989 and in compliance with the ‘Southwark’ ruling. 4. Where safeguarding agencies receive information that suggests a child could be at risk of child sexual exploitation, robust and affirmative multi-agency responses must be initiated to ensure all information is shared to maximise protection and options of services. 5. The LSCBs need to be satisfied that there is a range of provisions suitable to meet the needs of children who present with homeless and support needs. 6. Any child who is an open case to Children’s Social Care should have a multi-agency plan and team around the child, and that all open cases of 16-18 years olds are audited against this standard. 7. No Children’s Social Care Service should close a case or sign off a contact until they can be satisfied that all outstanding needs have been considered. 8. That a clear pathway of mental health services for 16-18 year olds is created and disseminated to all agencies that work with this age group. 9. That NICE guidelines on anti-depressant medication for young people is re-affirmed across all GP surgeries and acute mental health services 10. That the Board ensure every opportunity is taken through procedure, strategy and line management structures to re-enforce the message that all young people must Salford Child N Final 20 March 2015 Page 42 of 47 be treated as a child in accordance with the Children Act 1989 until they attain the age of 18 years LA1 Children’s Social Care 1. When a Child in Need moves out of the borough, the Greater Manchester Child in Need transfer process must be followed prior to case closure. 2. Children’s Social Care should always take account of significant history and impact on children when responding to Domestic Abuse notifications received from police. 3. 16-17 year olds presenting as homeless should always be considered in relation to the primary duty under Section 20 accommodation, pending a further assessment. 4. Supported Lodgings arrangements for 16-17 year olds who are deemed Child in Need should be subject to regular management oversight and review. 5. The voice of the child should still be heard when dealing with 16-17 year olds. LA1 Early Help Service 1. All staff follows Step down procedures and allocation procedures. 2. Record keeping policy adherence needs to be monitored closely and regularly audited. 3. A clear engagement policy is required for early help. 4. Cases cannot be closed until management oversight has been completed. 5. Take good practice of recording referral information into the multi agency HUB. LA1 Positive Steps 1. More emphasis could have been put upon checking and recording the emotional state of a client who is in such challenging circumstances Salford Child N Final 20 March 2015 Page 43 of 47 2. When it is identified that a vulnerable young person leaves the local authority area and becomes the responsibility of a new local authority, we should be actively ensuring that information is sent to the new LA so that the young person can immediately be supported rather than waiting for them to present at an agency 3. Liaison with other supporting agencies has been effective and we need to ensure that staff, especially new members of staff, are fully aware of the range of agencies available and how to make effective referrals to them 4. CAPIR completed with vulnerable clients; Positive Steps guidelines are made explicit to staff. LA1 College 1. Review the process for gathering transition information from schools and ensure that references to other agencies alluded to in such information are contacted as a matter of course 2. Review procedures for information sharing and notification with other agencies. 3. Develop better understanding of the term “vulnerable young person” and expectations of service delivery. 4. Establish a procedure which ensures that attempts are made to maintain contact with vulnerable young people when they have left the organisation in order to provide a channel for re-engagement, even when communications is only possible by another agency. LA1 Sexual Health Services 1. A review of the process for addressing the issue of homelessness in relation to young people aged 16 – 18yrs both within the Trust and across partner agencies. LA1 Hospital 1 1. To improve documentation when action is taken to safeguard children LA2 NHS Clinical Commissioning Group Salford Child N Final 20 March 2015 Page 44 of 47 1. Local guidance to be issued to GPs reinforcing the NICE Guidelines CG 28 ‘Depression in children in young people: “Identification and management in primary community and secondary care” and cascade via the GP Safeguarding Leads Forum meetings 2. Guidance to be distributed about the pathways for assessment of 16-18 year olds who present at A & E with mental health issues or self-harm 3. GP Safeguarding Children training to include; a. -The voice of the child in general practice consultations b. -record keeping following an SCR 4. Standards for GP Patient Registration 5. Increased awareness of these issues through SCR Training events within both local authority areas LA2 Hospital 2 NHS Foundation Trust 1. The VYPT are to strengthen current information sharing processes, both within SRFT and other relevant agencies to include across boundaries. 2. The VYPT to further develop processes to formulate a chronology of attendances to the ED dept. This is to enable the practitioner to gain an oversight of individual cases to ensure a comprehensive assessment can be undertaken. For young people who meet the criteria for referral to the VYPT. 3. In order for all SRFT staff to access the safeguarding children’s team consideration is to be given to extend the hours of service to include out of hours. 4. For SRFT ED registration documentation to accurately complete all demographic details to include, GP, school, religion and the ethnicity of patients attending the ED on every attendance. LA2 Children’s Social Care 1. Where young people move across boundaries the responsibility is for the Local Authority from which the child has left to supply all relevant information both verbally and in terms of documentation. However, consideration should be given to Salford Child N Final 20 March 2015 Page 45 of 47 a process for escalating where there is a lack of compliance with the regionally agreed procedures. 2. Ensure that arrangements for management oversight of assessments are robust. 3. Ensure that screening processes cross-reference significant adults and any related child protection concerns. LA2 Integrated Youth Service 1. The Young Fathers Project should inform Salford’s After Care Team if it comes into contact with any young people aged under 18, who are looked after/or present as being looked after, by a borough other than Salford, and appear to living permanently in Salford. City West Housing 1. A review to be undertaken internally of City West Housing Trust s’ procedure (Vulnerability Matrix) and procedures, whereby a new household member is identified as residing at the property and how we can risk assess and provide support and intervention to those customers. 2. ‘Privileged Position’ Housings’ position in Safeguarding. Greater Manchester West Mental Health NHS Foundation Trust 1. All members of staff in the Salford Mental Health Liaison Team must be made aware that when patients present at A&E who are age 16/17 years old they should consider in their assessment whether referral to the CAMHS EMERGE for 7 day follow up 2. That wherever possible and when clinically indicated in order to inform risk assessments and the management of; the Salford Mental Health Liaison Team should complete a risk assessment on patients that are referred by the acute hospital trust prior to medical clearance. 3. That following a referral when attempts are made to contact a GP by the CMHT this is followed up. Salford Child N Final 20 March 2015 Page 46 of 47 Greater Manchester Police 1. A fully documented policing plan to address vulnerability and CSE in the city centre is to be implemented. 2. Mandatory refresher training package to all specialist public protection staff (Triage function) 3. Mandatory refresher training package to all PPIU supervisors (Roles and responsibilities) 4. Design and deliver a training package to all front line staff and supervisors. (Safeguarding / Vulnerability / CSE) 5. Victims / offenders / Crimes to be flagged for CSE. North West Ambulance Service NHS Trust 1. Develop guidance for EMD’s in relation to identifying children during domestic abuse incidents (and other incidents) who may be vulnerable requiring a safeguarding child referral. 2. Review the Safe Transportation of Children Policy and Procedure and the Rapid Response Vehicle Handbook to ensure the safety of children is paramount and staff responsibilities are clear. 3. Provide a training document to highlight vulnerabilities of children aged 16-17 (including self-harm). Relate Counselling Service 1. In this new experience for Relate GMN, to provide training for our YP counsellors, about learning about SAAR and any implications for our work. 2. To meet with the Senior School to share any joint learning 3. SCR Recommendation to Relate: To ensure all counselling staff have a complete understanding of the need to share information that could have safeguarding Salford Child N Final 20 March 2015 Page 47 of 47 implications for children and never to assume that responsibility has been adopted elsewhere within the safeguarding systems. Senior School 1. With heightened awareness in the light of the SCR, ensure that we sign-post and offer high-quality Care, Guidance and Support to all pupils, not least the most vulnerable Pennine Care Foundation Trust – School Nursing 1. To review the process of transition of health records for 16- 18 year old to enable access to records. Review roles and responsibilities in Oldham for 16- 18 year old school nursing provision 2. To review the provision of school nursing across the region for 16-18 year olds |
NC52549 | Incidents of rape and sexual assault by a 16-year-old looked after child, referred to as C80, in the nursery where he was an apprentice. A sibling of C80 subsequently disclosed past experience of rape by C80. Learning includes: a trauma informed approach could be further developed across the partnership; a child's experience of sexual abuse should form an integral part of care plans and assessments even where this is not the primary reason for protection or intervention; it is not deemed necessary or appropriate that a child's experience of sexual abuse, or other ACEs should be shared with employers; therapy should form part of ongoing care planning to ensure continuity, particularly when placements are disrupted; life story work with all children in care should be mandatory and timely; practitioners should be confident to identify and respond to sexual abuse indicators and to differentiate between 'normal' behaviour and that of concern or risk; there should be a timely transfer of information regarding vulnerable students between pre and post 16 education and training providers; there is no statutory guidance regarding the level of suitability assessment required for students attending placements as part of childcare studies; information that may be of safeguarding concern should be shared by referees with potential employers; CCTV should not replace in person observation; need for clarification regarding the layout/ design of toilet facilities in nursery settings; when sexual abuse is suspected, a single point of contact should be established that signposts to appropriate support services. Makes recommendations to improve procedures for care experienced children and to strengthen approaches in the areas of recruitment, apprenticeship, supervision and safeguarding practice in early years settings. Includes recommendations for the Department for Education, regarding a review of the Early years foundation stage (EYFS) framework.
| Title: Child safeguarding practice review: Child ‘C80’. LSCB: Torbay Safeguarding Children Partnership Author: Sarah Lawrence Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Child ‘C80’ Independent Reviewer: Sarah Lawrence Date Completed: August 2021 This report was produced for and is owned by Torbay Safeguarding Children Partnership (TSCP). It should not be disclosed or copied, prior to publication, either as a whole or as extracts without the agreement of TSCP. Torbay Council Children’s Services Devon and Cornwall Police NHS Devon CCG 2 Contents INTRODUCTION AND CONTEXT FOR THE REVIEW .............................................................. 3 Summary of the case .......................................................................................................................................3 The Review ......................................................................................................................................................3 Review Themes .................................................................................................................................................. 4 C80’s Background and Experiences ............................................................................................................... 4 Recruitment & Apprenticeship ...................................................................................................................... 4 Supervision & Oversight................................................................................................................................. 4 Safeguarding Practice .................................................................................................................................... 4 Response to Alleged Incident/s ..................................................................................................................... 4 Local / National Learning ............................................................................................................................... 5 Methodology ...................................................................................................................................................... 5 Timeline ......................................................................................................................................................... 5 Review Panel .................................................................................................................................................. 5 Engagement with Practitioners and Organisations involved ......................................................................... 5 Engagement with Families of Children Attending Nursery ............................................................................ 6 Engagement with C80 and Family .................................................................................................................. 6 Document Review .......................................................................................................................................... 6 Time Period .................................................................................................................................................... 7 Review Context .............................................................................................................................................. 7 Reviewer Experience and Independence ........................................................................................................... 7 KEY EVENTS AND ANALYSIS .............................................................................................. 8 Summary of Key Events ...................................................................................................................................8 Pre Torbay .......................................................................................................................................................... 9 2014.................................................................................................................................................................... 9 2015.................................................................................................................................................................. 10 2016.................................................................................................................................................................. 12 2017.................................................................................................................................................................. 13 2018.................................................................................................................................................................. 14 2019.................................................................................................................................................................. 18 2020.................................................................................................................................................................. 32 LEARNING SUMMARY ..................................................................................................... 33 C80’s Background and Experiences ................................................................................................................ 33 Recruitment & Apprenticeship ...................................................................................................................... 41 Supervision and Oversight ............................................................................................................................. 44 Safeguarding Practice .................................................................................................................................... 45 Response to incidents .................................................................................................................................... 47 Good practice in C80’s case history. ............................................................................................................... 52 RECOMMENDATIONS ..................................................................................................... 53 3 Introduction and Context for the Review This Child Safeguarding Practice Review was commissioned by Torbay Safeguarding Children Partnership (TSCP) in response to the requirements of statutory guidance issued by HM Government; “Working Together to Safeguard Children: A guide to inter- agency working to safeguard and promote the welfare of children.” (July 2018) 1. Summary of the case On 29th July 2019 at the age of 16 years old, a Torbay looked after child2, known for the purpose of this review as ‘C80’, was arrested on suspicion of rape of a 3-year-old. This incident took place at the nursery that C80 worked as an apprentice. Police carried out a detailed review of CCTV footage from the nursery and found evidence of further sexual assaults by C80 towards children within the nursery. A sibling of C80 subsequently disclosed past experience of rape by C80. On 25th October 2019 C80 was charged with 3 counts of rape and 13 of sexual assault by touching. A trial took place in May 2021 and C80 was found guilty of all charges. C80 was given a 14.5-year sentence in July 2021. The Review Following the incidents a referral regarding this case was made to Plymouth and Torbay Safeguarding Children Partnership (PTSCP) for consideration of a case review. The National Child Safeguarding Practice Review Panel were notified and PTSCP carried out a rapid review on 28th November 2019. Following this and further debate with the National Panel regarding the type and level of review that should take place, it was agreed that a Local Child Safeguarding Practice review should take place led by the newly created Torbay Safeguarding Children Partnership (TSCP) which replaced the previous joint arrangement with Plymouth. Working Together 2018 recognises that child protection in England is a complex multi-agency system involving many different organisations and individuals. It states that reflecting on how well the system is working is an important part of the collective effort to improve responses to children and families, including when serious harm or death is experienced, to identify lessons that can be learned at local and national levels. Child Safeguarding Practice Reviews such as this provide a way that this can be achieved. The intention of this review therefore is to identify learning for local and national systems to prevent future similar harm, and to further safeguard and promote the welfare of children in similar situations to this case. The purpose of this review is not to apportion blame on individuals or organisations or to hold them to account. As Working Together states: “Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, 1 See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 Under the Children Act 1989, a child is legally defined as ‘looked after’ by a local authority if he or she: • gets accommodation from the local authority for a continuous period of more than 24 hours • is subject to a care order (to put the child into the care of the local authority) • is subject to a placement order (to put the child up for adoption). 4 including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings”. The circumstances that led to this review are complex and, while of no consolation to the victims and their families, ultimately very rare. Serious sexual harm has been experienced by children that are most vulnerable by their young age. Sexual abuse is immensely traumatic for victims and their families, in this case those who had entrusted their children to the care of a nursery that they put their trust and faith in to nurture and protect them. The right and primary purpose of this review is to identify learning that could potentially prevent similar future abusive situations occurring. In the process of delivering this review, careful consideration has been given throughout to keep to this purpose while at the same time avoiding any unintended consequences that may impact negatively on the outcomes for young people that are care experienced and also victims of past abuse themselves. Review Themes This review is based on a number of thematic areas agreed by TSCP. These were drafted reflecting on the range of complex factors and perspectives involved in this case, the concerns and questions raised by parents of children attending the nursery and findings of previously undertaken local reviews of the case. The themes that follow aim to encompass the range of systematic issues involved in this case: C80’s Background and Experiences - To review multi-agency case record relating to C80 to identify any pre-existing information and learning relevant to this review. - To consider what information relating to C80 could or should have been shared with his employer from other organisations. - To identify examples of good practice as appropriate in C80’s case history. Recruitment & Apprenticeship - To identify if safe recruitment practices were in place and undertaken in the nursery and for an apprenticeship. - To establish whether the nursery identified or were made aware of any concerns about the employment or work of C80 and if so, the effectiveness of responses. Supervision & Oversight - To evaluate the nature and quality of supervision and management oversight provided to all staff in the nursery. - To establish whether there were particular supervision arrangements for apprentices in the nursery including access to individual children. Safeguarding Practice - To establish how matters of concern were identified, recorded, and responded to in the nursery, including CCTV oversight and monitoring. - Review this response against local and national guidance regarding; whistleblowing, safeguarding policy / procedure, designated safeguarding lead responsibilities and safeguarding training. Response to Alleged Incident/s - To evaluate the work that was undertaken following the allegations in this case first coming to attention by local statutory partners and national regulators. - Establish the quality and timeliness of responses and whether all relevant lines of enquiry were properly and fully pursued 5 - To understand and evaluate the response of the Day Nursery’s Regulator (Ofsted) to being informed of the allegations that centred on the setting. - To identify and assess the timeliness and effectiveness of the actions Ofsted took following being made aware of the allegations, whether local safeguarding agencies were properly involved and how they impacted upon the safety of children. - To evaluate the timeliness and effectiveness of information sharing with parents and carers, giving due consideration to any legal constraints that prevent communication. Local / National Learning - To identify all points of learning arising from this matter and highlight any implications they have for national and local policy and guidance, strategic or operational management and front-line practice. - To evaluate the local safeguarding partnership’s response to the alleged incident, identify what immediate actions have been taken to identify local learning and how this has been implemented across the partnership. - To identify any learning in relation to the timeliness of decision making in relation the type of review to be commissioned. Methodology This review uses statutory guidance and best practice models for reviews in its methodology. There were limitations to the activities undertaken for this review given it coincided with the Covid-19 pandemic, national lockdown and while varying levels of social distancing guidelines were in place. This meant that there had to be significant adaptations. The review consisted of: Timeline A comprehensive multi agency timeline was created covering the time period of review, summary information was also provided for any significant events outside the agreed time period. This document formed the foundation of the review and enabled the reviewer to explore and analyse key events and responses relating to them. Review Panel A multi-agency review panel was convened to support and guide the progress of this review as well as to implement any learning as swiftly as possible once identified. The panel comprised: • Independent Reviewer • Independent Chair • Torbay Council Children’s Services (incorporating Children’s Social Care, Education and Early Years) • Devon and Cornwall Police • NHS Devon CCG • Torbay Safeguarding Children Partnership Business Unit. Engagement with Practitioners and Organisations involved The Independent Reviewer sought to engage a wide range of practitioners with direct case involvement with C80 and his family in Torbay. This included practitioners from all safeguarding partner agencies (local authority, police, health) as well as those involved in C80 care, education, apprenticeship, and employment. Ofsted engaged in this review, sending detailed information relating to the case, input to the review timeline and via meetings with the reviewer. This related to their direct involvement as the regulatory authority for childcare providers. While the process for engagement with practitioners and organisations took a different approach to that which would have been ideal in a ‘non covid’ situation, the information provided has been of great value to the review process. It was often difficult for those invited to participate given the 6 circumstances and emotions attached to the case. It is of credit to Torbay as a partnership that all those invited to did participate in an open, transparent, and learning focussed way. Engagement with Families of Children Attending Nursery Parents and carers of children that attended the nursery, including parents that were directly impacted as a result of the abuse to their children, were notified of this review by TSCP (via Police). Parents were invited to engage in the review process once the trial was concluded given some were called as witnesses. The reviewer met with 12 parents / carers; this took place online in 8 meetings including meetings with more than one parent present. Parental insights on the case and in particular their perspectives on learning for safeguarding partners in terms of responses to the abuse and support given to them, has been of immense value to the review. Given the extremely difficult circumstances surrounding this case the value of this should not be underestimated. Their insights have informed the analysis in relevant sections of this report. Engagement with C80 and Family C80 and family members were notified of the review taking place via their lead social workers. All were invited to contribute following the conclusion of the trial. C80’s eldest two siblings were keen to meet with the reviewer and did so with their foster carer present. Their views and engagement have provided a number of hugely valuable insights into learning that have been included in this report. The reviewer sought to engage C80 in the course of this review. Initially, the review process and purpose was outlined in writing and discussed with C80 via his key worker, pre-trial. Following the trial, C80’s contribution and engagement was sought via his key worker/s again, and a number of options for ways to engage were presented. Unfortunately, engagement was declined by C80. Similarly C80’s mother and aunt were offered opportunities to engage in the process but declined to participate. Where records of independent advocacy meetings with C80 were apparent and recorded in case files, these are reflected in relevant sections of this report with the aim of reflecting C80’s voice in the review. Document Review Relevant documentation was provided to the reviewer, this included: - A comprehensive multi agency timeline based on time period of review - Local partnership case records and information - Meeting records - Local safeguarding policies, procedures, and processes relevant to the time period of review, including within the nursery - Ofsted early years criteria and procedure e.g. serving welfare and suspension notices relevant to time period - Communications between TSCP and the National Child Safeguarding Practice Review Panel Two quality assurance reviews had previously taken place within TSCP and the Local Authority to identify any immediate learning to action from this case. These were carried out by independent people prior to the commissioning of this CSPR, a summary report of one of these has been provided. 7 Time Period It was agreed that the review would focus on the period of 1st December 2014, the date that C80 and family move to Torbay, until 17th June 2020, the date that the national panel agreed a local review should take place. The reviewer also requested summary background and contextual information outside of this period in the course of review to analyse as relevant. Review Context In person, face to face meetings with the reviewer were not possible because of the Covid 19 pandemic and subsequent restrictions. This meant that those directly impacted and traumatised by the circumstances of this case, including parents of children from the nursery, practitioners and family members had to be approached in less ideal ways. It was also not possible to have ‘in person’ group meetings with practitioners to discuss practice and learning. Much of the engagement activity was carried out with individuals and remotely due to the pandemic, using secure online meetings, telephone, and email exchanges. A decision was made by the Review Panel with advice from the Police Senior Investigating Officer, not to approach those that may have been called as witnesses in the criminal trial until it was completed. This was to ensure no interference with evidence. The trial was delayed for a number of reasons including related to the pandemic and this affected the timescale for conclusion of the report. Reviewer Experience and Independence Sarah Lawrence is an independent safeguarding and domestic abuse consultant with experience of case reviews concerning children and adults. She has no previous involvement with the case under review or the services involved. 8 Key Events and Analysis The table below gives a brief outline of the key events reviewed for this case. An analysis of these events follows. Summary of Key Events Year Key Event 2007 C80 disclosed experience of rape by mother’s ex-partner. Alleged perpetrator found not guilty. 2014 C80 family move into Torbay area, children subject to Child Protection Transfer in conference details neglect, maternal mental health, domestic abuse, C80 experience and indicators of past sexual abuse also described. C80 abuse of sibling occurs (disclosed in 2019) 2015 C80 abuse of sibling occurs (disclosed in 2019) C80 and siblings become looked after (first foster care placement) following a police protection order. Initial Health Assessment for C80 takes place Referral for physical and mental health services support C80 alleged to have added bleach to foster carers shampoo and toothpaste bottle, concerns regarding continued influence of mother. Full care order granted. Court psychologist recommendations made Placement change 1; move to second foster care placement. 2016 Therapy started with private therapist with foster carer in attendance Risk management meeting – following disclosure of experiences of abuse and entering other children’s rooms. Placement change 2; as result of concerns for carer health, return of male carer to home and C80 behaviour issues Therapy suspended due to placement change Placement change 3; C80 request as a result of allegations against foster carer regarding assault to C80 2017 Missing episode results in mothers arrest / caution under Child Abduction Legislation Series of short missing episodes C80 mother gives birth to fourth child Placement Change 4; move to residential care setting 2018 C80 employed part time in a bar / restaurant C80 finished school, applied, and enrolled in college course “Introducing Caring for Children and Young People Level 2”, includes placement at preschool setting A needs assessment takes place following C80 asking for sleepover at a younger girl’s house and disclosure of massage being paid for by an older woman College concerned about attendance, attitude and completion of work and commence disciplinary procedures Multiple missing episodes occur Section 47 meeting occurs as a result of concerns relating to behaviours & risk posed to C80 C80 regularly intoxicated, an ambulance is called on one occasion due to him being nonresponsive 2019 C80 leaves college following disciplinary procedures relating to behaviour and attitude to learning Placement supports C80 with applications for work based childcare apprenticeships. C80 attends trial session at a nursery and then becomes employed as an apprentice DBS is completed and returned satisfactorily Apprenticeship commences Missing episodes occur C80 describes a behaviour management concern with a child in nursery IRO concern raised ref lack of allocated social worker and plan 4 references requested by nursery – 1 satisfactorily returned C80 nursery probationary period extended due to incomplete references Further missing episodes occur 9 Abuse in nursery reported to nursery and police by victim’s family Police investigation commences Ofsted visit nursery and issue ‘improvement notice’ C80 sibling discloses experiences of rape by C80 at a younger age, to his foster carer Local ‘Gold’ and ‘Silver’ command meetings begin to take place Police investigation and review of CCTV reveals further incidents of abuse by C80 in nursery A helpline is set up by partners to coordinate enquiries Rough handling by 2 additional members of staff, with witnesses, identified on CCTV Ofsted & nursery staff review CCTV. Relevant members of staff are suspended Ofsted serve a ‘welfare requirement notice’ to the nursery Further incidents of sexual abuse by C80 are identified in CCTV footage by Police Ofsted suspend nursery registration C80 arrested for further offences C80 charged with 3 x rape and 13 x sexual assault offences C80 placement change Ofsted interviews with staff raise further concerns regarding safeguarding culture of the setting Independent review of partnership responses takes place National Child Safeguarding Practice Review (CSPR) Panel discuss case Local Rapid Review of case occurs, CSPR agreed Parents raise questions relating to the case via a self-organised parent group Ofsted interview with nursery directors raises further concerns 2020 (to June) Ofsted notifies the owners of the nursery of their intention to cancel registration Nursery owners resign their resignation National CSPR panel notify of intention to deliver national review of case Support offer to parents is reviewed by partners Police respond to parent group questions C80 pleads not guilty at crown court National CSPR panel notify of a change in decision re national review due to Covid. Pre Torbay 1. A summary of information was requested from Gloucester Children’s Services who had worked with C80’s family in his earlier years. This information indicated details of anal rape experienced by C80 shortly after turning 5 years old. This is alleged to have been perpetrated by C80’s mothers’ ex-partner who was also the father of C80’s sibling. Health and Children’s services information from this time indicates evidence of physical harm concurrent with C80’s experiences of the sexual abuse that is described, the impact of this on C80’s health, including bowel incontinence and soiling is also detailed. Following a trial, the alleged perpetrator was found not guilty. 2014 2. C80’s family moved to Torbay late in 2014 and within a month, a transfer in Child Protection Conference took place with input from Cornwall (the preceding local authority) children’s services department. Records from this conference detail a number of issues of concern including mother’s mental health, the children’s low school attendance, concerns regarding children’s safety in the home and neglect. C80’s experience of sexual abuse (while in Gloucestershire) and the health impacts of this were described as part of the handover of information. It was decided that the family should be placed on a Child Protection Plan. Plan review meetings took place over the coming months and the children remained subject to child protection planning with neglect as the primary reason. Records suggest at this time that there was a poor relationship between C80 and his siblings, who reportedly felt threatened and bullied by him. C80’s siblings contributed to the review process describing violent assaults by their brother at this time. C80 experiences of soiling are also reported, as are declines in C80’s behaviour at school. Bullying of C80 at school is also referenced as a factor. A 10 referral for Intensive Family Support to address issues was made however there is no evidence of interventions taking place. 3. Advocacy records suggest that C80 was concerned about his home environment and his dissatisfaction with services involvement in his life. C80 also describes his ambition to be a marine biologist at this time. 4. The abuse of C80’s sibling, by C80, took place during 2014 and 2015. In a victim statement his sibling describes the impact of this: “Whilst I was being abused, I felt nervous and embarrassed as I was being humiliated in the worst possible way by someone I trusted. I felt I had no power or help. I was isolated and alone and felt like I was living in a cage and unable to get out. During the entirety of this time, I lived in a constant state of fear from abuse and rape everyday. I wasn’t allowed to go to school or socialise as I was unable to leave the house. I felt scared of [C80] as he had a temper and was violent towards me, both physically and emotionally. I feel let down by the adults and professionals who were in my life during that time. My days would consist of waking up in the same bed as [C80]. I would spend the days in a haze and then every single night for years, I would have to endure this abuse by my brother. All of my days were the same, and I would always dread what was to come at the end of the day. My trauma has caused me to block out a lot of memories from this time in my life, but what I do remember vividly is a constant feeling of shame and embarrassment about what was being done to me; this is something I still carry with me today and probably always will. I would consistently have nightmares which led to me waking up, feeling unable to breathe and in a state of anxiety”. 5. The abuse was not known or suspected by practitioners or carers involved with the family until 2019, after abuse at the nursery was reported, when it was disclosed by the sibling to his foster carer. 2015 1. C80 and his siblings were removed from mother’s care following an Emergency Protection Order being granted, this was as a result of a visit which found the children padlocked in the home. There were also further multi agency concerns regarding neglect and unsafe home conditions. C80 was placed in foster care with his siblings. C80 is regularly described at this time as in ‘low mood’ and expressing feelings of anger and anxiety. He continually protested the need for care and expressed a strong feeling that he and his siblings should return home to their mother. Case records reference C80’s continued and recurring bowel incontinence. 2. An Initial Health Assessment (IHA) was carried out by a specialist doctor in child health. C80 did not attend all of this assessment, leaving at the start of the appointment. Records from this IHA describe lack of knowledge in terms of C80 past health history. Because C80 was reported to be having issues with soiling and hygiene a referral was made to the Bladder and Bowel service by letter. In this letter, the doctor describes soiling as well as ‘long standing difficulties in the past of neglect and adverse home situation’, it does not refer to C80’s alleged sexual abuse experiences, suggesting this was not known by the doctor. Searches of medical records at this time do not indicate this information was used in the IHA. The letter also suggests that the Bladder and Bowel Service should contact C80 social worker for more details of his experiences. This also indicates a letter had also been written to a worker from the Child and Adolescent Mental Health Service (CAMHS) to enable a joint approach. 3. An appointment was made with the Bladder and Bowel Service. The service describes that at this appointment, also attended by C80’s foster carer, they were unable to gain any history of C80’s issues and as a result ‘advised the foster carer to ask the social worker to contact the clinician for further information’. It is not clear if any follow up was carried out or attempts to gain this 11 information were made by the service, by the doctor, or the carer, and C80’s referral was subsequently closed two months later. It is the view of panel members and the reviewer that this was not an appropriate course of action, or good practice and should have at least led to written follow up by the health services involved. No further specialist interventions took place in relation to this issue, and the problems continued in the following years as demonstrated in this timeline, until 2018. A later psychologist report (at the time of a Full Care Order being granted) describes this issue and its impact. The report refers to a possibility that C80 ‘unconsciously chooses to ignore this area of his body as a post traumatic response to anal penetration’ which leads to ‘both the incontinence and his difficulty in accessing treatment’. 4. At the point of the IHA, a letter was also written to a CAMHS worker seeking advice for C80’s foster carer regarding his soiling, alluding to an ‘emotional cause’. The letter states that C80 had already been referred to CAMHS by another route. The referral led to some initial support for C80 and his foster carer, however the intervention was not of a therapeutic nature as the CAMHS practitioner was not clear this was the right time for therapy and indicates that they were also aware that other therapy was in process. 5. In advocacy, C80 presents at this time again as frustrated and angry about being in care, describing a wish for more contact with his mother and a dislike for the placement that he is in. 6. Shortly after this, C80’s placement changed following an incident where C80 had placed bleach in the foster carers toiletries, in particular their shampoo bottle. This incident caused injury to the foster carer. The influence of C80’s mother in this was discovered after C80’s foster carer read messages between C80 and his mother seeming to influence C80 to disrupt the placement. Records therefore linked this incident to continued contact with his mother and highlight concerns about mothers ongoing influence over C80. There is no evidence that this then informed risk assessments or further contact arrangements. 7. A Full Care Order was subsequently granted for C80 and his siblings. A psychologist report produced as part of this process suggested that long term psychological therapy was required for C80 given it was “quite likely he has a level of PTSD as a result of the sexual abuse he experienced” and indicating that C80 “should be assessed for difficulties such as Conduct Disorder”. There is no evidence that this assessment was undertaken. The psychologist in her report also suggested that C80 behaved “as if he has been in charge of the two younger children” and that C80 would benefit from “singleton foster care placement in a family where there might be older children only and with an experienced carer”. 8. C80 was subsequently separated from his siblings, with supervised contact in place. At the following CLA (Child Looked After) Review it is reported that C80 had settled in well at the placement, and the plan was for C80 to remain there as a long term foster care placement. 9. At this time C80’s sibling explained he had thought that their separation was due to knowledge of the abuse C80 had perpetrated against him rather than any other incidents such as bleach in shampoo, or instructions from court. He’d felt at the time that professionals had discovered the abuse, however there is no evidence that this was the case at this time and he recognises that this was not the case describing to the reviewer; “If I’d been asked, I’d have told them, I thought it was normal. I didn’t know how to lie and would have said”. 10. In his victim statement, C80’s sibling describes clearly his feelings at this time as: “Once [C80] and I were separated and placed into foster care, the trepidation I had been suffering for the past years had finally subsided and I felt a level of relief”. 12 11. C80 was reported to have been regularly attending school at this time. School reports many behaviour issues involving C80 throughout the period, described as disruptive and anti-social behaviour, rudeness, bad language, and physical fights with other students. Sanctions were used as a result including periods of isolation and detentions. 12. C80’s siblings also moved placement at this time. Both siblings and their foster carer describe a level of physical fighting between siblings at this point, that they explained to the carer had been the way they had also been treated by C80. 2016 13. Therapy was arranged for C80 via Children’s Services as a direct result of the psychologist recommendation, and this commenced. C80’s experience of sexual abuse was not communicated as part of the referral to the therapist. In engagement with this review, C80’s therapist suggested this was unknown until he disclosed his experience within the sessions to the therapist, and to his foster carer. Shortly after this disclosure, the carer raised concerns to Children’s Services regarding C80 posing a ‘sexual risk’ (this is the language recorded in files from the time). Information available to the reviewer indicates that this related to C80 entering other children’s bedrooms and removing items. There is no indication in information presented to this review, that any other behaviour was present or that C80 presented a risk of sexual harm at this point. 14. A meeting was held as a result, described in records as a ‘Risk Management Meeting’. The meeting concluded that there were unfounded concerns, and no sexual risk was present. Despite this conclusion, the foster carer proceeded to place sensors on all bedroom doors and the term ‘sexual risk’ remained on C80’s case file in relation to this incident. 15. Further analysis of this event has taken place including discussion with practitioners, reflections from partners and a further review of records. It is evident from this that concerns followed on from C80’s disclosure of sexual abuse in therapy (with the foster carer present) rather than any indicators being present of harmful sexual behaviour from C80. 16. Approximately 6 months after this event, C80’s placement with the same foster carer ended. Information submitted to the review suggests that the sole female carer had developed additional health needs and had put in a request for additional funding to enable the male carer to become a joint carer for C80, this request was refused. At this point the carers had described “difficult behaviour [by C80] that had not been seen or raised before” to social workers, including shouting, swearing, and stealing money from another foster child. C80 had also become distressed as a result of being told he was not going to be returning to the care of his mother. Case records from Children’s Services suggest that the level of disruptive behaviour reported at this time did not warrant the resources requested for an additional carer. Carers served notice of their intention to end care for C80, shortly after and prior to a permanency panel at which it was expected C80 would have been permanently matched to these carers. It is not clear what support package, if any, was offered at this time to the carers. 17. This placement had offered a level of stability in C80’s life and that the sudden placement breakdown that occurred had a detrimental impact on C80’s wellbeing. C80 is described as ‘tearful and confused’ when being told by a social worker that his placement had ended. Therapy was suspended at this point due to the placement ending, it was not restarted. 18. In advocacy records from this time, C80 is reported to be feeling very low in mood, frustrated and angry, stating he is not interested in talking to anyone. C80 continued to harbour the wish to have more contact with his mother. 13 19. At C80’s next placement, allegations were made by C80 against the carer regarding a physical assault that took place on a holiday abroad. This resulted in a police and a Local Authority Designated Officer (LADO) investigation, and section 473 enquiries also commenced. C80, and another foster child, were subsequently moved to new placements. No further action was taken against the carers due to the incident taking place outside UK jurisdiction. Section 47 enquiries also concluded that physical abuse was unsubstantiated. 2017 20. Early on in this year C80 was reported missing by his foster carer. C80 had been taken to school by taxi but never entered school on that day and instead was taken by his mother to a train station where he took a train to stay with his maternal aunt in another county. C80 was found two days later at this address. C80’s mother was arrested and cautioned under the Children Act 1989 – abduction of children in care legislation4. Two further short episodes of going missing took place at this time, both related to arguments with foster carers about freedoms while on holidays away from the home. 21. C80’s placement changed once more and C80 was placed with a residential care setting that provided intensive 1-2-1 support for children. Records from this time do not evidence the rational for this move to a higher level of support, nor is there an assessment of need evident that led to this. Records do indicate however, that this was not a planned move and was considered only once C80’s current foster carers had given notice of the previous placement ending. A number of participants in this review suggest this was more based on the need for a placement of some kind rather than C80 having any specific individual care or support needs that warranted this level of support. 22. Throughout this year, C80 again demonstrated his distress at his care arrangements and a wish for increased contact with his mother and siblings. He again reiterated a desire to return to the care of his mother. In advocacy C80 describes feeling settled in the 1-2-1 placement, suggesting some things were better than foster care, however, is concerned about the level of ‘rules’ in place, lack of freedom and a wish to go out more. 23. Termly Personal Education Plan (PEP) meetings took place for C80. Generally, records of these reflect a positive picture of C80 in terms of attainment and behaviour. C80 was credited with work regarding food technology, and it is referenced that he had won a local award for this. C80 views were fed into initial PEP meetings, indicating that he found school rules more difficult to keep to and that he preferred practical lessons. He later went on to describe how he ‘likes nothing about school’. C80 suggests at this time thoughts about his future career being marine biologist. Later this changes to Chef and then more recently a primary school teacher or career in health and social care. 24. Information in files held by school from this time indicates an increase in negative behaviour episodes. Episodes are described by school as; damage to property, dangerous behaviour, failure to cooperate, disruption in lessons, fighting with other students, kicking, and hitting doors and making inappropriate remarks. Sanctions are carried out for C80 in school including attending the school’s behaviour centre. It is evident that school were aware of the links between C80 behaviour escalating and key negative events, such as C80 being told he couldn’t return to his mother’s care. School representatives participated the PEP meetings, however there is no indication in the information reviewed that the full range of behaviour episodes recorded by school were discussed, noted, or 3 Section 47 of the Children Act 1989 (reasonable cause to suspect a child is suffering or likely to suffer significant harm) 4 Section 49 of the Children Act 1989 Abduction of children in care etc. 14 actioned as part of these meetings and therefore these do not feature in multi-agency plans that may have identified ways to work restoratively with C80 to address his behaviour. 25. At this point, C80 started part time employment at a pub / restaurant near to his placement. This was seen as a positive influence in C80’s life at this point. 2018 26. In the early part of this year, C80’s mother gave birth to C80’s youngest sibling. Case files show that consideration was being given to C80’s return to mothers care at this time. C80’s mother then advised practitioners that she could not look after C80 due to the new baby. It is not clear how this potential option for C80’s care was being assessed, and there is no evidence that describes how information about this situation was communicated to C80 at this time. It is clear from previous indications of reactions to this topic that not being able to return to his mother would have been devastating to C80. 27. Life story work5 with C80 was discussed, with his Community Care Worker (CCW) during this year, while C80 was 15-16years old. Attempts to carry this out were not commenced until later in the year given C80’s preparations for GCSE exams. C80 later refused to engage in any exploration of his Life Story work. The need for this intervention is referenced a number of times from 2015 onwards within the timeline for this review, including alongside referrals for therapy or CAMHS interventions but was never completed. Information suggests that C80 did not want to engage with practitioners at all on this topic, particularly in his adolescent years. At times throughout the timeline of this review it is evident that professionals deemed it was not the right time for this intervention to be carried out, it is unclear when the right time would have been deemed correct to pursue this further with him. NSPCC describes the importance of Life Story Work: “Children and young people who are in care or adopted may have little understanding of why they don’t live with their birth parents, the reason for them entering care and events that took place in their early lives. This can have a negative impact on their emotional wellbeing and self-esteem. Life Story Work aims to help children in care begin to understand and accept their personal history”. Ofsted describes the issue of timeliness in its inspection report of Torbay in 2018, stating; life story work starts too late in the process for children to learn and understand about their birth family and history”. 28. This experience of lack of life story work was echoed to the reviewer by C80’s sibling and their foster carer. Importantly, it was felt by both the sibling and carer that had this been undertaken in a timely way it may have given opportunity for his abuse to have been disclosed to a practitioner much earlier. 29. Information within the timeline for this review suggests there were 5 different social workers allocated to work with C80 in the year 2018/2019. This followed a period of 2 years of relative stability in terms of his lead professional. Some consistency remained in place during this period because of a male Community Care Worker (CCW) that was also engaged in support, providing welfare visits and consistent ‘role model’ to C80. The CCW describes a positive relationship with C80 up until later in 2018, when the relationship changed following delivery of Return Home Interviews (RHI’s) by the CCW. RHI’s are a statutory requirement where children go missing from care6, it is 6 For more details see statutory guidance page 14 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/307867/Statutory_Guidance_-_Missing_from_care__3_.pdf 15 recommended in national guidance that these are delivered independently. The workers perception was that completing multiple RHI’s shifted C80’s perception of him from providing a supportive role to a more punitive / statutory intervention. 30. The context of services for children in Torbay, including care experienced children, are reflected in findings from Ofsted inspections. It was at this time that an Ofsted inspection revealed deep rooted and long-standing problems across the Children’s Service, leading to a second consecutive judgement that the services overall effectiveness was inadequate. Ofsted findings demonstrated serious and widespread concerns, including about child protection. Their report from this time states: Children’s services in Torbay are inadequate. Some improvements have been made, but not enough, and all judgements from the 2015 Ofsted inspection apart from the adoption judgement are unchanged. The quality of practice ranges across and within services, from areas showing serious weaknesses, such as fostering, to pockets of strong, focused work, such as early help. Overall, the pace of change has been too slow and some recommendations from the previous inspection are not met. Fundamental weaknesses remain in management oversight and supervision and in identification of and response to risk, as well as workforce development and capacity….. ….The quality of social work practice is adversely affected by frequent changes of social workers, all of whom are dealing with a range of complex cases. For example, visits to some children do not adhere to recommended timescales…. ….Too many children in Torbay do not enjoy meaningful and consistent relationships with social workers due to the considerable turnover of staff….. 31. Inspectors subsequently also reported in monitoring visits on 1 February 2019 and 8 May 2019 that while subsequent restorative actions were showing some signs of progress, improvements were fragile, and children were still not considered to be consistently safeguarded. They documented findings of continuing serious weaknesses in management, practice and quality assurance arrangements and expressed concern for the (lack of) pace of change and the debilitating impact of staff turnover which led to social workers having to ‘fire fight’ rather than use their skills to work intensively and constructively with children. 32. During this year and on turning 16, C80 was eligible to receive the support of a Personal Advisor (PA). There is no evidence that this was offered to C80 until he reached the age of 18 and after the abuse took place. There is also no evidence that any challenge was made regarding the lack of PA at any point during this year by those involved in his care. Statutory guidance7 states: “The PA acts as a focal point for the young person, ensuring that they are provided with the practical and emotional support they need to make a successful transition to adulthood, either directly or through helping the young person to build a positive social network around them. All care leavers should know who their PA is and how to contact them. Throughout their transition to adulthood and independent life, care leavers should be able to rely on consistent support from their PA, who is the designated professional responsible for providing and/or co-ordinating the support that the young 7 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/683701/Extending_Personal_Adviser_support_to_all_care_leavers_to_age_25.pdf 16 person needs. This includes taking responsibility for monitoring, reviewing, and implementing the young person’s pathway plan”. 33. Pathway plans were in place for C80 during this year however there is no evidence to detail how these were being implemented or monitored as part of care planning or within other multi agency arrangements. There is a possibility that the reason for this is linked to the instability and changes of social worker for C80. A challenge was made in terms of the lack of Pathway Plan in 2019, via a Dispute Resolution Procedure from the Independent Reviewing Officer (IRO) to Children’s Services however it is unclear what action this resulted in. 34. Part of a PA role, if in place, would have been to “aid in support and advice on a range of issues relating to leaving care including access to training and employment opportunities”8. A PA could have therefore provided further support to C80 in deciding future career and education plans. 35. C80 was in his final year at school, and he applied to a local college to study “Introducing Caring for Children and Young People Level 2”. At this point, a regional careers service became involved in assisting C80 with next steps as a care experience child. Information contained in the timeline for this review from this service suggests that C80 stated he would be interested in employment or university and possibly becoming a Primary School Teacher. 36. Following his application a ‘Risk Assessment’ meeting was held by the College. The purpose of the assessment meeting was to consider students’ needs where necessary because they are care experienced or require further pastoral support. In this meeting C80 was recorded as ‘LAC’ indicating his care experience was the reason for the meeting rather than any concern about his behaviour and being enrolled on a course of a childcare nature. This is reflected in the actions which relate to ensuring support from College and attending the next PEP meeting for C80. There are some headline discussions regarding C80’s course choice and behaviour noted in the meeting records, this does not lead to any further analysis. It is stated that C80 is “adamant he wants to do the childcare course….He has done really well with food at [school]”. It is noted that “staff believe he chose a course that may allow him to somehow move home”. An incident of behaviour issues is raised by the school pastoral lead at this meeting, relating to a chair being thrown across a classroom, linking this to C80 recently being told that he couldn’t return to the care of his mother. No concerns are raised at this meeting regarding any risks in terms of his enrolment on the course. 37. Records of a PEP meeting that followed this assessment notes good transition work between school and college and discusses C80’s plan for college. At this point in time, C80 also attended his Review Health Assessment, and it is reported at this that he is generally well engaged, his wish to study childcare is noted. 38. In the autumn term, C80 was enrolled on to the childcare course. As part of enrolment, college advises that it is a requirement for students to complete a DBS (disclosure and barring service)9 check to enable their attendance at a childcare placement later in the term. C80 did not complete this within the correct timescales and as a result this was logged as stage 1 of the College 8 IBID. 9 The Disclosure and Barring Service helps employers make safer recruitment decisions 8by processing and issuing DBS checks for England, Wales, the Channel Islands and the Isle of Man. DBS also maintains the adults' and children's Barred Lists and makes considered decisions as to whether an individual should be included on one or both of these lists and barred from engaging in regulated activity. 17 Disciplinary Procedure. During this term a PEP meeting took place. This noted that the DBS had since been completed successfully, with no indications of any concerns coming from the check. 39. In this same PEP meeting, the course tutor suggests C80 is challenged by time management skills and planning. A worker from C80’s residential setting contributed to the meeting referencing concerns about C80’s recent behaviour and his contact with mother. It is noted in the meeting that there was a discussion about whether childcare was the right course for C80 given his “love of cooking and his part time work in the hospitality industry”. The instigation of disciplinary procedures at college was not noted as being discussed at the meeting. No coordinated multi agency action is described to respond to the issues raised in this meeting, and there is no evidence of monitoring actions taken or how this would be communicated to influence C80’s plans. 40. Shortly after, C80 and his residential care worker discussed a relationship that C80 had with the younger sister of a college friend. This was first discussed in terms of some friendship issues that had come about as a result of the relationship. C80 told the worker that the girl was 14, at this time C80 had turned 16. C80 later requested to stay overnight at the friend’s house. The worker discussed this in detail with C80 explaining issues that may arise with sleeping over, given his girlfriend would be there and her being under the legal age of consent and the impact this could have if there were any concerns. C80 suggested he would be staying with both of the siblings as friends only. As a result of this being raised, a number of detailed conversations took place between the placement worker, C80, his social worker and CCW. A parent of the girl was also contacted, and it was agreed that this sleepover would not take place. The parent later suggested they were happy for C80 to sleepover as long as on the sofa downstairs, it is unclear if any such stays occurred. The consensus of practitioners at the time was that this episode related to C80 struggling to move between childhood and adulthood and to understand the complexity of sleeping over. There is no evidence that any sexual intention was indicated by C80 or suspected at this point. 41. C80 also suggested later, to his residential placement staff, that he had an older female friend, aged 23, that he met at his place of part time employment. He suggested that this female had given him a full body massage that he had paid for. The detail of this was shared with C80’s social worker and subsequently followed up with the female friend that had been mentioned. On investigation, it was established that C80 had overheard a conversation regarding massages between the female and an older male member of staff at C80’s place of work. Case records indicate this incident, along with the earlier discussions regarding relationships and friendships, was recorded as a ‘potential sexual risk’. On exploration of this terminology in case files, it is clear that this refers to risk posed to C80 relating to his suggestions of paying for a massage with the older female, rather than risk he posed to others. 42. Following this, partners continued to be concerned for the safety of C80 given reports of behaviour decline and an increase in episodes of C80 going missing from care and college. C80 behaviour is said to have further declined at this point. He is described to have been vaping, consuming alcohol and being generally reverting to being ‘non-compliant’. C80 is reported at this time to be working long hours at his part time job resulting in him often falling asleep in class, and not attending some classes at college. As a result of this, the college move him to stage 2 of their disciplinary procedures. Within disciplinary meetings C80 is offered alternative options for learning which he is reluctant to engage with. 43. As a result of recent events with C80, a multi-agency strategy meeting then took place to discuss escalation in concerns. In this meeting C80’s social contacts, work and attitude to college life are explored in detail. Contacts with, and the influence of his mother are noted within this. C80’s potential vulnerability to exploitation by other is noted as this had been flagged following police analysis of missing episodes. His behaviour is described as being linked to transition to adulthood and adolescent development. A number of actions are listed as a result of this meeting to respond to 18 the concerns, however there is no evidence that these were followed up or that they informed pathway or care plans for C80 beyond this meeting. 44. Shortly after this strategy meeting, C80 started his college placement at a local pre-school setting. This involved attending one day per week for 6 weeks. C80 attended the setting as an induction, presented his DBS and was shown around in his first visit. In subsequent weeks C80’s attendance was described as sporadic. When in attendance at the setting, C80 is described as acting like ‘a child himself’ . The setting advises that on occasion they used similar disciplinary measures to manage C80’s behaviour as they would have the young children in the setting, this is described as very unusual. C80’s behaviour is said to be of an immature nature rather than anything that would indicate any risk to children at the setting and no concerns of a sexual risk were apparent to the staff. It is not clear if behaviour concerns were feedback to C80’s course leader from the setting or how this was assessed as part of his course. The setting leader advised they had at this time, placed responsibility for safe recruitment procedures for students on placement with the college, requesting sight of DBS only as a result. 45. C80’s safeguarding file was sent from his school to college approximately 2 months after he enrolled on his course, and after he had begun his placement. School and college advise that this was usual procedure at the time, and that files were transferred only on request. Contributors to the review suggest that improvements to this process have now been made, and that transfer of information where there are safeguarding concerns, students require additional support or have identified needs is much more timely. 46. C80’s missing episodes continued throughout this period, with some extending overnight, occasionally taking place following shifts worked at a local pub / restaurant. C80 is noted to have returned to his placement on multiple occasions “visibly under the influence of alcohol”, advising that he had been out with friends and then had gone to his mother’s house. On repeat occasions C80 refused to disclose his whereabouts while he had been missing leading to suspicion about his mother’s involvement. Descriptions of these episodes suggest that practitioners were concerned about his mother’s influence, specifically in terms of his alcohol use. On one occasion, the placement worker directly contacted C80’s mother to warn of consequences of C80 not returning home, resulting in his immediate return. Return interviews regularly took place between C80 and the CCW as described previously, however no evidence suggests how information from these then informed the future planning for C80. 47. College soon moved C80 to stage 3 of their disciplinary procedures for behaviour and attendance. This is the final level of disciplinary. C80 was then absent for further class sessions is reported to not be regularly attending his childcare placement at the preschool setting. 48. Missing episodes continued, again with C80 regularly said to return intoxicated. Staff at the pub C80 worked also reported a noticeable change in behaviour advising placement staff that C80 was not always turning up for shifts at work. On Christmas day of this year C80 is reported was as missing after not returning from his workplace. C80’s placement staff were advised by the pub C80 was asked to leave as he had been taking drinks from the bar. C80 had then presented at another residential care setting and been refused entry due to being drunk. C80 was collected by a worker and is described as being heavily intoxicated. An ambulance was called due to him being nonresponsive. C80 recovered once paramedics arrived. 2019 49. The early part of this year commences with further missing episodes and C80’s dismissal from his childcare course at college following final disciplinary procedures. C80 did not attend the final disciplinary meeting however it was attended by a care worker from his residential setting. College suggest that they would be in contact C80 to discuss his enrolling in a ‘Courses to Careers’ course to 19 enable a lower-level childcare qualification and to complete Maths and English courses. This was refused by C80, stating a preference to begin a work-based apprenticeship. C80 was subsequently withdrawn from college. 50. A CLA review took place shortly after C80 withdrew from college, C80 was not in attendance. A summary of this meeting suggests concern regarding a change in C80’s behaviour, use of alcohol and missing episodes alongside the end of his time at college. Concern was raised that C80 may be at risk of CSE as it is unclear who he is spending time with. Despite concerns there is no evidence that actions were agreed including any plans to assess this risk further. It was noted that the Pathway Plan was out of date with a completion date set of one week. An IRO dispute resolution was raised regarding absence of a Pathway Plan however this was not followed up and remained out of date for at least a further 6 months. 51. C80 was provided support with next steps in his career by his placement and the regional careers service supporting with interview preparation and requesting updates on progress. C80 expressed a wish to continue with a career in childcare that was more practical than academic, and an apprenticeship was agreed as the best option. 52. Workers at C80’s residential placement assisted him to make speculative approaches to approximately 8 childcare settings in the Torbay area. C80 was subsequently offered two interviews and attended both. C80 expressed a preference to his placement worker for the setting that had a smaller number of children and that was not part of a larger chain. As a result, C80 was invited to attend a trial shift at the smaller setting, and to visit to the nursery to size up a uniform and carry out ID checks. C80 is said to have commenced employment at this nursery 4th March 2019, as evidenced in C80’s employment contract. 53. In terms of a suitability assessment for the role, nursery advise that this was delivered via the above trial shift / ‘second interview’ that included members of the wider staff team. Nursery advises this review that C80 impressed them at this first interview stage because of his personable approach and experience of caring for his younger siblings. C80 is said to have spoken of his aspiration to become a primary school teacher and his hope that the apprenticeship was a pathway to this. At recruitment stage it was unknown to the setting that C80 was a care experienced child, and this would not have been expected to have been disclosed by C80, as explored in later sections of this report. Nursery expressed to the reviewer that they had held a keenness to employ male members of staff to enable a gender balance and positive role modelling for the children at the nursery. Male applicants were described as rare, and this meant they were pleased when C80 approached the nursery for employment. 54. The nursery safeguarding children policy states that: “we abide by the requirements of the EYFS10 and any Ofsted guidance in respect to obtaining references and suitability checks for staff…..to ensure that [those] working in the setting are suitable to do so”. 55. The EYFS statutory guidance details the requirements for providers to check suitability of those present in the setting stating that: Providers must ensure that people looking after children are suitable to fulfil the requirements of their roles. Providers must have effective systems in place to ensure that practitioners, and any other person who is likely to have regular contact with children 10 EYFS: Statutory framework for the early years and foundation stage, see: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/596629/EYFS_STATUTORY_FRAMEWORK_2017.pdf 20 (including those living or working on the premises), are suitable…and…..Registered providers other than childminders must obtain an enhanced criminal records check in respect of every person aged 16 and over (including for unsupervised volunteers, and supervised volunteers who provide personal care). This statutory guidance does not require any further checks in terms of suitability or pre-employment checks, nor does this detail any statutory duty on settings with regards to obtaining references. 56. Local TSCP guidance on Safer Recruitment suggests pre appointment checks and references should be undertaken and an offer of employment should be conditional upon, among other items, receipt of at least two satisfactory written references, where possible confirmed by telephone, as well as a satisfactory DBS disclosure. 57. References were requested by nursery from C80’s part time employer and his college. The nursery’s ‘safe recruitment of staff’ policy states that “successful candidate[s] will be offered the position subject to at least two references from previous employment or in the case of a newly qualified student, their tutor and a personal or professional reference. These references will be taken up before employment commences”. 58. A reference was sought from C80’s part time role in a pub / restaurant on 8th March 2019, this was returned on 20th March 2019 satisfactorily. Nursery advise that this detailed C80’s “good work ethic and reliability”. This was positive about C80’s suitability for work in a position of trust and with children. Information available to the review suggests a reference from the college was requested on 21st May 2019 via email. This is two months after C80 is said to have commenced employment and is therefore outside of the statement made in the settings safeguarding policy and also is not within the spirit of TSCP’s local guidance. The email from the setting to the college states: The above-named has recently started an apprenticeship at [X X Nursery] as a Trainee Nursery Practitioner and has given us your details as a referee. We would appreciate your views on his suitability for this position. We would be grateful if you could complete the attached form and return it to within the next week. References are a statutory requirement for working with children and young people, so we really appreciate you taking the time to complete the reference request. If you wish to discuss this request further please contact us on the number below. 59. On 13th June 2019 college responded to the reference request to say that they are “unable to give a character reference for [C80].. however with [C80’s] permission could confirm dates enrolled at the college. If you have any further questions, please do not hesitate to get in touch”. It is not evident that any contact was made between the nursery and the college to follow up on the reasons for this lack of character reference. College representatives have advised the review that they declined to complete a full reference due to C80’s immaturity and attitude to learning rather than any risks they had identified or were concerned about in terms of his suitability to work with children. 60. On 15th July 2019, over 4 months after C80 commenced his employment, a reference was requested from C80’s secondary school via email. This was responded to on 18th July 2019 with school returning an incomplete reference form and C80’s attendance and academic record. Sections on this form relating to C80’s suitability to work with children were left blank. The form was signed and dated. According to the school, the reason for this was twofold. Firstly, a key part of the reference form asked them to comment on their willingness to employ / reemploy the candidate, the school representative has indicated being unable to respond to this due to C80 being a student rather than a previous employee. School also advise that the reason much of the remaining form was left unanswered was due to the time that had passed since C80 was a student (having left the previous academic year) as well as their experience of C80’s previous behaviour and attitude. They indicate this was not in relation to concerns regarding any kind of sexual risks more a concern based on his behaviour record while in school. 21 61. School also acknowledged that it had been some time since C80 had left school and that a reference would have been better taken up with C80’s further education provider, it was unknown to them that this had been previously attempted. 62. Concerns regarding C80’s behaviour and attitude to learning were not communicated by the school or college as referees. Nursery were therefore not made aware of this. In explanation for this to the reviewer, School express concern about giving negative references and how this may be in contravention of data protection legislation including GDPR. It is also not evident, that any follow up took place to explain this gap, and therefore concerns expressed by school to this review were not highlighted to nursery at the time. 63. The reviewer is aware that nursery also attempted to gain a reference, by phone, from the preschool that C80 had attended for placement while in college. A number of missed calls / answer phone messages are reported between the two settings however a direct conversation did not take place and a reference was not completed. Had this contact been successful, the setting indicates a similar reflection as given by college and school, regarding C80’s behaviour as well as his immaturity would have been given. 64. C80’s probation was extended on 31st May 2019 due to the lack of a satisfactory second reference. Notes from that meeting and nursery records suggest this was the only reason for the extension. 65. C80’s apprenticeship training was arranged by the nursery with a private provider that they had previously used. This provider was not part of a Local Authority ‘approved’ apprenticeship provider list. The apprenticeship involved coursework, testing and tasks as well as a number of visits by an assessor to observe practice and child interaction. C80 reported in a meeting with his assessor that he preferred to be more practical and struggled with coursework. In the time that C80 was employed at the nursery the assessor visited on site on 4 occasions between 23rd March 2019 and 16th July 2019. 66. C80 is recorded as having supervision within the nursery on 3 occasions during his employment, with a probationary meeting also taking place. Nursery policy states that apprentices would be offered supervision every month. Supervision is recorded in C80’s personnel file as first taking place on 25th March 2019. Records show a discussion regarding C80 sitting on the floor with legs outstretched, a comment that C80 should `...say where you are going before leaving the room', as well as a need to not encourage children to get ‘hyped up’. In further supervision dated 14th June 2019 there is a comment that C80 had' completed all training', and that observations and a change of room / age group had been very positive. The third supervision is undated, with little detail of issues discussed or action to be taken. 67. During this time, C80 is alleged to have threatened a member of placement staff before leaving for work one morning. This was reported to C80’s social worker at the time, with follow up related to an allegation made by C80 against a member of placement staff rather than this. In a further incident two months later, C80 is reported to have shown threatening behaviour relating to frustration that a game with a higher rating to his age had been taken away. This report indicates use of a shovel to attempt to open doors and break into the placement office and also the smashing of a glass. C80 is reported to have become distressed and emotional following this incident. C80’s social worker was informed of this at the time. No records have been presented to this review to suggest follow up , risk assessment or any detail as to how this was responded to. 68. During this period C80 continued to have missing episodes, on one occasion spending time with his maternal uncle at his mother’s home. The uncle is said to have been known by services to be an unsafe adult. C80 suggested his uncle was “off his head on coke” in a text message that was later 22 found by staff, to his mother. This information was passed to C80’s social worker, subsequent action taken involved discussion with C80’s mother to prevent further unsupervised contact. A request was made for C80 to have contact with his maternal aunt which it was suggested would be assessed. Concerns regarding alcohol use continue to be apparent in records from this time. 69. On 9th May 2019, C80 was asked by a placement worker about how he was finding his role in the nursery. In discussion, C80 described that on that day, a child he did not like so much had jumped on him and that he had pushed the child off. The pushing action was demonstrated by C80. The worker explained consequences of this kind of reaction and C80 was advised he should speak to senior staff at the nursery if he felt overwhelmed or frustrated, as he needed to ask for assistance and ‘time out’ to get back to positive practices. 70. The issue was discussed with safeguarding leads at the residential placement the next day. It was decided that the nursery should be told C80 was “struggling with the behaviour management of one child” and also that the social worker should be contacted. The placement worker then contacted the nursery to discuss behaviour management without mentioning the act of ‘pushing’ of a child. Nursery advised that behaviour management would be discussed with C80, and support would be put in place. C80’s Social work team (via the duty line) were also contacted, they were advised that another conversation would take place with C80 that evening. The placement worker suggested it was possible that C80 may not have ‘pushed’ the child. The social worker suggested that the nursery should be told the full information once the next conversation with C80 took place, particularly if the conversation identifies that pushing had taken place. 71. The following evening a different placement worker discussed the issue with C80 explaining potential seriousness and impact. C80 reacted angrily and became verbally abusive to the worker, stating he did not know why this would get him into trouble and that he would never hurt a child. C80 stated that he had not actually ‘pushed’ this particular child but instead that he would sometimes ‘like to push’ this child. No follow up information is available to suggest any further assessment of this incident, or discussions with nursery or social worker occurred on this matter. 72. On 31st May 2019 C80 discussed his probation review with his placement worker, suggesting that this went well and that he needed to improve one point only which was to gain a second reference, given the nursery had not heard back from his previous college. 73. On 4th June 2019, C80’s Independent Reviewing Officer (IRO), raised a concern within the Dispute Resolution Procedure regarding the lack of an allocated social worker, progress of assessments relating to C80’s contact with mother and lack of Pathway Plan. 74. On 5th June 2019 during an advocacy appointment, C80 discussed the above concerns in terms of being allocated a social worker, but decided not to raise a complaint. C80’s engagement with health assessments and reviews was encouraged and noted to be also out of date. C80 states to his advocate that “it feels like they’ve given up on me”, referring to the local authority. 75. A number of missing and absent episodes occurred at this time. On 10th July 2019, which is the day that the first incident of abuse by C80 is recorded as taking place, C80 is reported as missing given he did not return to his placement after working at the nursery that day. C80’s mother is contacted by the placement to check his whereabouts, they are informed that C80 is in mothers home, and he will return. C80 did not return that evening and attended work the next morning, 11th July 2019, the date of a further incident of abuse at the nursery. On collection from work that day, C80 is reported to have been hyperactive having drunk energy drinks. Placement also report concerns about his diet, smoking habit and hygiene. C80 is also reported to have been working at his part time job immediately after his nursery work, often arriving home late at night. It is not clear how these 23 concerns were raised with children’s service or partners involved in his care planning, or what follow up action to resolve these issues was agreed. 76. At this time, C80 is said to have requested a move to more independent placement which was said to be in progress at this time. C80 is said to have been frustrated at the pace of this change in care. 77. On 22nd July 2019, C80 fell ill at work and was collected from work at the nursery early. On this date C80 was advised that he would be moving to the more independent placement. C80 returned to work on 24th July 2019, on this date, 4 incidents of abuse in the nursery by C80 are recorded. C80 also spent his first night at his new placement on this date. 78. A CLA review took place on 25th July, C80 did not attend this meeting. A summary of the review suggests that C80 is more settled however C80 is described as ‘not looking after himself’ and again, wanting more contact with his family. It is not clear what actions were agreed as a result of these points. 79. On 28th July 2019, C80 advised his placement worker that he has received a written warning from his part time job following what he describes as “a few days of sick and haven’t been putting enough effort in”. 80. On 29th July 2019 at approximately 4.30pm, a parent of a child attending the nursery telephoned to report an allegation of alleged abuse against their child. This report named C80 as the perpetrator, advising the child had disclosed he had changed the child’s clothes that day and put his nipple in her mouth. The parent stated that the word ‘nipple’ was used instead of penis in their household. 81. One of the directors of the nursery took the call and asked for this information to be repeated to C80’s room leader. Both Designated Safeguarding Leads (DSL)’s, including the co-owner of the nursery were also notified. C80 was suspended in the light of this. At this point he was advised of the details of the allegation, including the detail regarding the use of the word ‘nipple’. C80 then returned to his placement and advised them of his suspension. 82. The nursery owners attempted to contact the Local Authority Designated Officer (LADO) for advice on the matter, however the LADO was not available due to the time of day being after working hours. Nursery reported to the reviewer that no other advice was available and that they were not aware of what should happen in this situation, therefore a report to police was not made at this point. 83. At approximately 6pm both parents and a grandparent of the victim attended the nursery to seek further information about what had and would be done. The family were advised that C80 had been suspended. The parents requested sight of the location of the incident and were shown the toilet facilities. Reflections on this meeting suggest there was a level of understandable tension between the nursery owners and the family. There was a sense of disbelief from the owners that this could have happened. 84. A grandparent of the victim then reported the abuse to Police at approximately 7:15pm. This was the first report to the Police. Police subsequently attend C80’s previous placement address, not being aware of C80’s recent move, followed by attendance at his new placement address, arresting C80 at approximately 10:15pm. C80 was then taken to a Police station where he was assessed by health and mental health practitioners, no concerns were identified. Evidence was gathered from C80 and later from his placement. An ‘Appropriate Adult’ for interviews was identified from a local service that was independent from the case. 24 85. Ofsted records suggest they were notified of the allegations made by the nursery director / DSL on 30th July 2019. Ofsted contacted the LADO and were advised that a strategy meeting was to take place. The LADO raised a concern to Ofsted about the settings management of the allegation. 86. On the same day, a multi-agency strategy meeting took place to consider next steps, all safeguarding partners were represented at this meeting. The actions agreed included planning for the victim to attend the Sexual Abuse Referral Centre (SARC11) and for an Achieving Best Evidence (ABE) interview to take place with an intermediary. 87. It was also agreed that liaison with the nursery should occur, and that contact should continue with the LADO. Police also requested that C80’s mother should be notified of the sexual element to the allegations without full details being disclosed, this was suggested with a view to ceasing any contact between C80 and other children in the family. In addition, it was agreed that a risk assessment and management plan would be undertaken with C80 at his placement. 88. At this meeting the nursery became aware of the full details relating to the issues that were discussed on 9th May 2019, particularly that this had indicated C80 had pushed a child. Nursery were surprised at this detail coming to light, confirming that this information had not been passed to them within conversations that were had at this time. 89. On this date, the nursery sent a communication to parents of children that attended the nursery. This stated the incident involved one person and was believed to be an isolated incident, that this person was arrested and was in police custody. The communication also indicated that ‘safeguarding remains our highest priority’, indicating a police log number and that families could contact the Police non-emergency number should they have any concerns. This also asked that families refrain from posting any details of the case on social media or online to prevent any speculation having a detrimental impact on evidence for any potential case. 90. A number of parents advise that they sought further information from nursery regarding this and particularly with regard to the reference to ‘safeguarding’. As would be expected, nursery was unable to provide them with any further details given this was a live investigation. Parents expressed to the reviewer that this left them with a difficult dilemma in terms of whether to continue to leave their children in the care of the nursery. Some parents suggested that the ‘isolated incident’ message was reinforced which led them to feel reassured about the safety of the childcare at the setting. 91. All parents engaged with this review recognised the need for careful management of information and the need to ensure no evidence was contaminated as part of the response. Parents suggested that potential learning on this would be to ensure in future that there was one single point of contact outside of the nursery, perhaps police led would have provided a more appropriate source of information in the very early days of this case coming to light. 92. On 31st July 2020 an Ofsted Early Years Regulatory Inspector (EYRI) liaised with the LADO as described earlier, followed by contact with the nursery. This discussion confirmed action taken by the nursery. They described suitable procedures taken to recruit, support and supervise C80. They also described that as C80 was an apprentice, he was never left unsupervised with children. The EYRI discussed what steps the providers had taken following the allegation and they confirmed that they 11 https://sarchelp.co.uk/sarcs/what-is-a-sarc/ 25 had refreshed staff’s knowledge of safeguarding, they had reviewed their procedures and they had considered increasing CCTV coverage in key areas. 93. The next day the EYRI spoke to the Police lead for the investigation at the time to confirm that a visit to the nursery would not interfere with the police investigation. This was agreed and the EYRI subsequently visited the nursery on 2nd August 2019. Prior to this the EYRI spoke to a lead officer in the Local Authority who confirmed that there were no concerns with the setting. The purpose of this visit is described as not to carry out an inspection, but to enable the EYRI to gain ‘a clear picture of how the setting operates, to consider their safeguarding procedures and how these were implemented’ and to ‘assess staff awareness of safeguarding and how management support and review’ this. The visit is also described with the purpose of assessing how the setting managed safeguarding issues, incidents and allegations made against staff as well as staff deployment and procedures for monitoring staff practice. 94. The EYRI is described to have observed that staff were deployed effectively and interactions with babies/children and staff were positive. The staff ratios were observed to be high, and this was evidenced to the EYRI within the nursery’s attendance records for the day of the incident. The EYRI reviewed the area where the incident occurred and concluded that the bathroom area would be within sight and/or hearing of other staff. The nursery leaders suggested that they were regularly in the rooms with staff and confirmed that they were completely confident that no staff member is ever left on their own with children. In addition, the EYRI was advised that all staff were aware of the nursery policy to never be on their own with children. 95. Staff recruitment, supervision, monitoring of staff practice, safeguarding issues and procedures were also discussed. The EYRI is reported to have viewed evidence of this including a sample of other staff files, evidence of staff suitability, policies and procedures and safeguarding records. The leaders of the nursery indicated that supervision takes place every month for apprentices. The EYRI was unable to see supervision records to test this and analyse the quality of supervision, as this had been removed by the police. There is no evidence to suggest that this file was directly requested from police by the EYRI. 96. The EYRI was advised that C80’s probation period had been extended due to incomplete references. The EYRI was aware that C80 had started in employment on 4th March, but it is not clear if dates of reference requests for C80 were checked, possibly due to concern about interfering with the Police investigation. Nursery confirmed to the EYRI that C80 was never left unsupervised with children. In addition it was confirmed that apprentices are not assigned as a key person for individual children and could not undertake intimate care (as this was the responsibility of a key person). Parental contributions to this review suggest that C80 was introduced to them as their child’s key worker. 97. The EYRI spoke to other staff during the visit and describes that they displayed a suitable understanding of safeguarding. The EYRI identified some gaps, specifically in terms of responding to the allegation and the details of this being disclosed to C80. In addition nursery leaders had not contacted the Police when the allegation was first made. This resulted in a ‘notice to improve’ being issued to the nursery to address these issues by 23rd August 2019 to ensure that all staff understood local safeguarding procedures, specifically regarding the management of allegations against staff. 98. Following this visit, the EYRI discussed issues with their line manager, an Early Years Senior Officer (EYSO). This considered the option of bringing forward an inspection of the nursery in the light of the concerns raised. It was noted that the nursery had not received its post registration inspection as this takes place 30 months after registration. The nursery had registered in December 2017 and so was within this timescale. The EYSO confirmed that Ofsted should wait until the police had concluded their investigation prior to conducting a full inspection particularly if this was within the 30-month expected timescale. C80’s recruitment and supervision were also discussed. The EYRI was 26 able to confirm exploration of these issues with the nursery owners, noting that C80’s recruitment file had not been viewed due to being in the possession of the police. The EYRI described that the owners had also confirmed C80 was never left unsupervised and had also had probation extended due to the non-return of a reference. 99. According to Ofsted, all actions set as part of the ‘notice to improve’ were concluded by the setting by 12 August 2019. The EYRI remained in contact with local partners and later attended multi agency partnership meetings. 100. Gold and Silver12 command meetings that took place between September 2019 and February 2020, led by police with local safeguarding partners and Ofsted involved. The Gold commander “holds ultimate responsibility for the handling and outcome of the incident and sets the strategy for dealing with it” whereas Silver “is responsible for producing the tactical plan following the strategy set out by the Gold Commander”. For this case the Gold and Silver meetings were multi agency including all relevant safeguarding partners. 101. Records from very early Gold and Silver group meetings suggest that partners were content at this point with the plan for the Nursery stay open, stating ‘children are safeguarded’. The CCTV review by police at this point had identified further possible incidents involving C80 which were being investigated. 102. C80’s sibling advises it was at this point that he disclosed abuse by C80, to his foster carer, that had taken place a number of years previously, stating; It was only after some time of us being apart- nearly three years after being placed into care -that I finally felt safe and therefore able to speak about the abuse I had suffered. 103. In response to the disclosure partners discussed and agreed strategies for responding in Silver meetings. This included gathering evidence in relation to the abuse. C80’s sibling describes this experience as ‘humiliating and degrading’ in his victim statement. 104. Discussions also took place at this time regarding the strategies in place for media and communications, managing the impact of the case and concerns about C80 and sibling’s safety. It was agreed that the Silver group should coordinate engagement, and they discussed setting up a helpline. It is referenced that the review of CCTV would continue and there would be a need to agree communications once this had happened. Ofsted were represented at the first Silver Group meeting by the EYSO, requesting contact with local partners for information regarding any other premises or additional staff involvement should this come to light. 105. It was also agreed that a helpline would be set up in MASH (Multi Agency Safeguarding Hub), operating Monday to Friday and that this would be resourced by the partnership. It was also suggested that a script would be drafted to guide the helpline operators, and that they would pass information to relevant organisations when appropriate. Support for parents was suggested via the SARC (sexual assault referral centre) and also the local ISVA (independent sexual violence advisor) service. 12 See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/736743/critical-incident-management-v12.0ext.pdf 27 106. It was around this time that C80’s siblings and foster carer were made aware of C80’s arrest and allegations, despite bail conditions stating no contact with children including siblings, this was not communicated to the carers of the children. Instead, the foster carer reports being advised of this by the Head Teacher at the youngest child’s primary school on return for the Autumn Term. 107. On 3rd October 2019, partners were advised that further enquiries and review of the nursery CCTV records by police investigators identified further sexual offences perpetrated by C80 along with other serious concerns within the setting. Both Gold and Silver group were convened to discuss and coordinate relevant action. At the meetings, the footage identified incidents of rough handling of children by two other members of staff. In addition, it is said to have also indicated ‘no evidence of supervision of staff’. The LADO advised that no reports of the rough handling incidents had been made to them. Members of the groups were clearly concerned about risks to children being cared for at the setting and that they considered best course of action to address this. 108. Given the concerns, there was a consensus from local partners that nursery registration should be suspended by Ofsted while investigations took place. Multi agency plans to respond to a suspension notice were discussed in both groups including communications to parents and media statements. 109. Ofsted’s representatives at the meetings were clear that there was a need to view the footage and then to speak with the nursery owners to seek clarification about the incidents, specifically those involving other staff. This was to identify any action that had already been taken by the nursery to address this, and to allow appropriate action to be taken, prior to any suspension. This was in line with the Early Years Compliance Handbook13 which sets out Ofsted’s approach with providers. Ofsted’s representatives indicated that it was their view that the provider had acted appropriately through ought the investigation and that they had no reason to believe this would not continue to be the case. It was agreed that due process should be followed and that Ofsted representatives would travel to the police station to review the relevant CCTV footage as soon as possible and prior to their visit to the nursery. 110. An EYRI from Ofsted later reviewed the CCTV footage and identified that this did raise concerns about the handling of a child, however it was agreed with a Senior Her Majesty’s Inspector (HMI) that the information should be shared with the provider to give them the opportunity to identify the staff and take action that was deemed necessary. This was because up to this point the view of Ofsted was that the provider ‘took appropriate action when concerns were bought to their attention’. 111. The next day on 4th October, a further incident relating to another member of staff rough handling a child came to light following police review of CCTV. A decision was made that the nursery owners would view both sets of footage with Ofsted representatives at a police station. The group again discussed likelihood of the suspension of registration, and partners again discussed planning to respond to this. 112. The viewing took place and the members of staff that were responsible for the rough handling as well as those that witnessed it were immediately suspended pending an investigation. Following later discussions within Ofsted it was decided that as the risk relating to the members of staff 13 See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/935665/Early_Years_Compliance_Handbook_161120.pdf 28 involved in further incidents had been removed, because they had been suspended by the nursery, the risk had therefore been removed and removed the sense of urgency regarding suspension / closure of the setting. Ofsted inspectors visited the setting on the same day, the purpose of this was ‘to explore the culture within the setting in terms of safeguarding and staff understanding of behaviour management’. Inspectors spoke with members of staff that were present discussing safeguarding awareness, whistleblowing procedures and supervision processes. Inspectors viewed the staff files of those that had been recently suspended and observed practice. Ofsted advise that this raised ‘no cause for concern’ during the visit, but that a case review within Ofsted would take place to review evidence collated so far and agree next steps. 113. On 7th October 2019, local partners convened in a gold group meeting. The decision not to suspend the nursery registration was discussed in detail and there was a consensus across all organisations represented that there were ‘lingering concerns and questions’ in relation to reassurances of children’s safety at the setting. It was also of concern that the LADO had not yet received a referral from the nursery in relation to the suspended staff. The group discussed what best course of action could be taken and agreed this would be to escalate their collective concerns within Ofsted. The chair agreed to do this on behalf of the group. 114. The EYSO from Ofsted attended part of the gold meeting and advised the group that a case discussion would be taking place later that day. The level of concern regarding the safety of children in the nursery was discussed with the EYSO. Local partners were particularly concerned about the lack of supervision and oversight within the setting, concerns were also raised about the culture of the setting in the light of the incidents viewed on CCTV and how this highlighted a lack of whistleblowing practice and LADO referral. The EYSO reiterated the framework within which they operated and that their visit had not highlighted any additional causes for concern. The EYSO advised that the case discussion would discuss what action was needed and it was agreed that the group would be advised of the outcome. The chair felt the escalation of concerns to regional level within Ofsted should be held off until this point. 115. Suspension of the settings registration was considered at Ofsted’s (single agency) case review meeting. Suspension of registration thresholds are explained in the Early Years Compliance handbook as: “We suspend registration generally or only in relation to particular premises when we reasonably believe that the continued provision of childcare by the registered person to any child may expose such a child to a risk of harm.” “We suspend to allow time for an assessment into the grounds that give rise to our belief that a child may be exposed to a risk of harm, or for any necessary steps to be taken to eliminate or reduce the risk of harm. 116. In their case review meeting on 7th October 2019, Ofsted representatives decided that as the provider had taken steps to eliminate or reduce risk of harm by suspending staff involved on all occasions, the threshold of suspension was not met. A Welfare Requirement Notice (WRN)14 was 14 A WRN sets out the actions that a provider must take by a certain date to meet one or more requirements of the ‘Statutory framework for the early years foundation stage’ 29 agreed because of the identified issues in relation to behaviour management in the setting. This required the provider to meet relevant requirements that are set out in the EYFS statutory framework. Following this, it was agreed that a WRN monitoring visit would take place and that Ofsted would continue to liaise with the LADO and police should any further information come to light during the investigations for this case. 117. The local partners met again later the same week for a further gold meeting. They heard from the EYSO regarding the WRN being served, including what action would be specified within the notice. This addressed concerns relating to supervision and monitoring of staff practice, children’s behaviour management and physical interventions and staff roles and responsibilities. The EYSO advised they would re visit the setting following the deadline for the requirements to be met. In the same meeting there were discussions about supporting the setting with reduced staffing following suspension as well as with appropriate levels of information about the investigation. 118. A multi-agency silver meeting took place later that month, on 24th October 2019. At this meeting partners and Ofsted were informed that the police review of 250 hours of CCTV footage had identified further incidents of sexual abuse by C80 within the nursery. Meeting notes from this suggests police had “significant concerns with the extended period of time [C80] was unsupervised and this is when the incidents occurred” This, along with other (non-sexual) concerns relating to other members of staff use of, or witnessing of, physical interventions was the trigger, Ofsted advise, that bought further in to question the adequacy of safeguarding arrangements and evidence of concerns regarding the safeguarding culture at the setting. The threshold for suspension of registration is described as being met at this point, and following a case review meeting within Ofsted, it was decided to suspend the nursery registration on this date. In line with Ofsted procedures, parents of children attending the nursery were notified of the suspension. 119. C80 was arrested on 25th October 2019 and was later formally charged with 3 x rape offences and 13 x sexual assault offences. He was released on conditional bail with the trial date was initially set as 23rd November 2020. Risks to C80 safety were considered in silver meetings throughout this period and on 31st October 2019, C80 placement was changed due to concerns regarding risks. C80 is reported to have been “emotional and upset” on hearing the news of this planned move. 120. A gold group meeting took place on 29th October 2019. Ofsted’s EYSO advised they were expecting an appeal by the provider and felt information should be shared with the owners regarding the information that had come to light regarding additional offences and that had led to their suspension. It was agreed that this could be shared. 121. At the same meeting communications with and support for nursery parents and those directly impacted was confirmed. The group expressed concern for the welfare of the families and also that all nursery parents should be engaged with regarding recent developments. The group heard that plans had been put in place via the silver group, for police and social workers to engage with parents and carers – prioritising victims and their families first, with all parents of children at the nursery following. Follow up welfare visits were also discussed. 122. On 5th November 2019, a police communication to parents of children impacted by the case described that a system of email notification had been set up to deliver important news on the case. In addition parents were made aware of press coverage that day that would likely be covered 30 in news. Parents advise that the news had broken at this point, in particular because of an interview a director of the nursery with a national newspaper, followed by a filmed press statement by a police lead. Parents received further updates on the police investigation and progress beyond this. For example on 20th November 2019, 21st January and 22nd April 2020 advising progress around charges and what may be published in the press. Communications also requested that parents do not engage in social media activity in relation to the case as this may undermine the court processes. The purpose of these communications was clearly stated in emails, for example: “Our position is and will remain that wherever possible, we will tell you, as the parents of children who attended the Nursery, before news reaches the media”. 123.The communications also aimed to provide reassurance to families regarding concerns they may have about abuse of their child, advising; “Police have made personal contact with those parents of children on whom the above charges are based. If you have not been contacted, please take reassurance that the fact remains we have not uncovered evidence that would raise concern for your child”. 124. A further silver meeting on 12th November took place, multi-agency actions to coordinate responses were again discussed and agreed. The group were updated that the helpline had been busy the previous week and that this should continue to be offered. Ofsted’s representative advised that the setting was planning to appeal their suspension at a tribunal however the providers had notified that they no longer intended to continue with their appeal on 11th November. Ofsted and partners were not aware of the reasons for this. Ofsted also advised they’d been notified of a parent forum that had been set up with circa 40 parent members and a lead parent involved, it was agreed that relevant information could be shared with partners to ensure a coordinated response. Ofsted also detailed arrangements to interview nursery staff and next steps in terms of their investigations. 125. Ofsted Inspectors carried out interviews with nursery staff between 12th November 2019 and 3rd December 2019 as part of their evaluation of the providers suitability and ability to meet the requirements of the EYFS. The findings of this indicated concerns to Ofsted regarding practice in the setting beyond those identified in earlier visits to the nursery. Ofsted have summarised their findings from the meetings to this review and this is explained as follows: - Staff talked of concerns with C80’s behaviour related to his ‘tendency to get children over excited’, and winding children up for example throwing them in the air. Concerns were raised related to the time he spent in the nursery ‘sleep room’. - They were aware that senior staff had taken the behaviour related concerns to the provider. The response was that C80 had always be with a senior or qualified member of staff and couldn’t be left alone with children in a room, “as noise levels would become too high”. - Staff advised inspectors that on occasions when C80 was working with only one other member of staff, that they would send him to change children or take them to the bathroom rather than leave him with a group of children because of the concerns about his behaviour. Ofsted have advised that this contradicted what they had been told by the nursery owners that apprentices were never left unsupervised. - The Inspectors were advised that the owners gave a list of concerns that had been raised about C80’s practice to the leader of the room in the nursery that C80 was working in. These were to be discussed with C80 during a supervision meeting. - Staff interviewed indicated that this was a reason C80’s probation was extended - however records show the reason was as Ofsted were advised by the nursery, relating to the incomplete references that were awaited. - Staff also confirmed to inspectors that, when the bathroom door was in place, children did use the cubicle behind the door suggesting they were out of sight. 31 - Staff demonstrated a general awareness of safeguarding issues, but not all had a strong understanding of particular issues such as grooming. They spoke about whistleblowing procedures, but evidence showed they did not implement this in practice. - Staff were able to demonstrate an understanding of appropriate behaviour management strategies, but not all were aware of suitable procedures regarding managing the use of physical intervention. - Staff described two incidents where children had been left unsupervised, Ofsted advise they did not have records of these. - Staff describe some occasions where observations of staff practice took place and feedback was given, Ofsted found little evidence to support effective monitoring of practice. - Some staff had a poor understanding of whistleblowing. A member of staff had observed poor practice of a colleague who lifted a child just by hands/arms, confirming that she had not realised at time she should have reported this. - Other staff had also observed/heard a staff member shouting at a child. Discussions with staff suggested that the directors also had concerns about this staff member shouting however there was no evidence of action being taken and no records had been kept on the staff member’s supervision files. - Staff spoke of checks being taken up for their appointment, some saying if DBS was not back, they were identified by not wearing uniform, but might be left unsupervised at times. Some staff felt the induction they received was helpful and it had included completing safeguarding training. However, until the recent dismissal of other staff, they had received no refresher training. - Staff in baby room appeared to be organised and well supported by their senior member of staff. - After staff were dismissed due to the rough handling identified on CCTV, Ofsted advise that the directors had confirmed they would contribute personally to ensure safe staffing levels and that they would work alongside staff much more, so they had a better understanding of day-to-day practice. Staff confirmed that the directors did this for a few days after which they returned to being back in office for the majority of their time. 126. Following these meetings, a case review took place within Ofsted, and it was agreed that the suspension of the registration should be extended by six weeks while considerations were ongoing. This was communicated to nursery owners and parents of children attending. Ofsted’s representatives continued to liaise with Police and relevant partners via the silver group meetings to share information about this and gain updates as relevant. 127. Parents of nursery children had continued to engage (via a representative) with Ofsted and questions that had been raised were fed into the multi-agency silver meetings in November and December 2019. It was agreed that local partners should be involved in answering their questions and a police lead was identified to take this forward via the silver group, who would liaise with the lead of the parent group. 128. During October 2019, the local partners begin to discuss a number of partnership learning review mechanisms. Communications on this were also taking place with involvement of the National Child Safeguarding Practice Review Panel. Torbay Council had forwarded a serious incident notification to the relevant national bodies on 23rd September 2019. This triggered a review of the case at a National Panel meeting on 29th October 2019. A decision not to instigate a national review was made at this meeting and communicated to the local safeguarding partners in Torbay. The panel advised there was a need for a rapid review to take place by TSCP. This rapid review took place on 28th November 2019 where it was agreed that this case met the threshold for a local CSPR. The rapid review was also considered by the Nation Panel which took a decision to reverse their previous advise that a National review was not required. However, the complexities caused by the 32 Government response to the Covid-19 pandemic meant that the National review was set aside in favour of a local learning review. 129. In the meantime, a brief review was underway, entitled ‘Independent Review of the Response of the Torbay Safeguarding Partnership’ to check responses were in line with good practice and expectations. This review was commissioned by the DfE appointed Children’s Commissioner under the terms of Torbay’s statutory notice. It was intended that this review would assure the commissioner that the safeguarding activity and the actions taken by partners were robust. this review was presented to Torbay’s improvement Board that was attended by DfE and all relevant partners. In addition it was made available to the Gold commander. Subsequently an independent consultant reviewed the recent file records and verbally feedback his findings to the commissioner. 130. On 16th December 2019, Ofsted met with the directors of the nursery to follow up their lines of enquiry. Ofsted have shared their analysis of this meeting for this review and a summary is below. - Directors denied that anything like this could have happened in their setting. - They were not aware of the majority of the concerns raised from the CCTV footage and accounts given by staff in interviews. - Accurate records were not kept relating to all incidents nor had notifications been made to Ofsted of significant incidents, including where a child had been left alone in the garden unsupervised. - Directors did not recognise the weaknesses in safeguarding practice within the setting including confidence in use of physical interventions or following whistleblowing procedures. - They were not aware of the EYFS requirement to ensure staff under 17 were not left unsupervised with children. - One director shared information they had been told about, regarding knowledge of C80’s behaviour in the past. 131. Following the meeting, Ofsted representatives liaised with police and the LADO regarding the information shared by one of the settings directors, and also to gain further clarity on matters that impacted on their investigation. This included the use of CCTV in evidence when assessing the suitability of registration of the nursery. 2020 132. Once this was confirmed, a case review took place within Ofsted on 7th January 2020 to review evidence gathered and identify next steps. It was decided that given evidence of significant and wide-ranging breaches of the EYFS and responses to these by the provider, that Ofsted would proceed to cancel the registration of the nursery. The significant concerns were explained to the nursery owner along with the decision to cancel their registration. The provider was also notified that the documentation would be drafted and sent as soon as ready, and that this may take a few days. The following day, on the 8th of January 2020 the provider emailed Ofsted to advise they wished to resign their registration. Ofsted advise that it would not have been possible for the provider to resign their registration once formal notice had been served. 133. At this time partners were aware of a number of questions raised by parents of children at the nursery relating to the case and circumstances of C80’s employment. At a silver meeting on 10th January 2020 police representatives advised that they were leading on attempts to answer as many of the parent queries as possible within the parameters of the current investigation, and that some may need answering by Ofsted or other parties. Police leads fed back progress to group and advised that parent engagement with responses to the questions had taken place in April 2020. There were some gaps in answers to these questions where local partners could not respond as indicated above. 33 134. At this time, parents had raised questions about the support that could be provided to them and their children in relation to this incident. This was discussed by partners in the same silver group, specifically to ensure that support services that families had been referred to were appropriate and meeting the parents identified needs. Services currently offered were discussed in detail with representatives from the SARC and a local sexual violence advocacy service in attendance. They gave an overview of the services that they could provide and relevant referral routes in and out of their provision where relevant, for example due to the age of the children or specific needs. It was apparent that at this point, four families had accessed SARC support in relation to this case and that two had had contact with the sexual violence advocacy service. 135. Records of the partnership silver meetings that followed indicate that those directly affected or identified as potential victims were offered support via SARC or had been referred there, however not all took up this offer. This was an area of focus for the partnership at this time specifically as it was apparent that wider support needs of parents and children may not have been met via this route. Partners considered options available to parents and a letter was sent to parents TSCP giving the options for support that were available on 23rd April 2020. This included signposting to Victim Support, Health Visitors and GP’s. This also gave more detail about specialist services that could be offered by the SARC and a local ISVA service where this was appropriate for parents. 136. On 3rd February, the National Child Safeguarding Practice Review Panel wrote again to Torbay partners suggesting that on detailed review of case information, they felt there would be significant opportunity for national learning and advised they would be delivering national single case review. Torbay partners responded to request further detail of the reasons for this. A set of preliminary terms of reference for the review were drafted. 137. On 2nd June 2020 C80 attended a virtual crown court hearing and pleaded not guilty to all charges. 138. On 17th June 2020 a change of decision from the National Panel was communicated to Torbay, given Covid restrictions, Torbay agreed to undertake local CSPR incorporating previously agreed TOR. Learning Summary C80’s Background and Experiences 139. On review, it is clear that C80 experienced a chaotic and traumatic childhood. C80’s experienced serious adverse childhood experiences (ACE’s) including sexual abuse, neglect, domestic abuse, adult mental health and substance use in his early life. The impact of this is evident in the behaviour demonstrated in his childhood and adolescence. C80’s trauma was compounded by the instability caused by multiple placement breakdowns, regular changes of carer and lead worker during the period of this review. 140. C80’s experience of trauma is not uncommon for a care experienced child. Neither is the expressed behaviour that was clearly demonstrated as a result of this. As the National Institute for Health and Care Excellence (NICE) states; “The rates of emotional, behavioural and mental health difficulties are 4 to 5 times higher amongst looked-after children and young people than the wider population”. 141. It is, however, uncommon for those experiencing this go on to abuse or commit crime. Research and evidence suggest that most looked after children are not involved in offending behaviour with 94% 34 of children in care in England not proceeding to commit crimes15. For those who do offend, it is likely that their behaviour results from a complex interaction between; their experiences in care, involvement with different professional systems, individual characteristics and resilience, and the familial and environmental risk factors that led to their entry into care (Schofield et al 2014). 142. C80 experienced much instability in his life as a looked after child, the impact of this can be seen in his own words through advocacy and input to his looked after child reviews. This is also evident in the key events described in the timeline for this review, and in conversations with practitioners from all partner agencies. At points during the period of review, C80 identified he did not have a social worker and on one occasion he described that the person that was his social worker, lived in a distant place. C80 described his frustration with this in the information provided to this review. Local Authority representatives have advised the reviewer that plans have been implemented since this time to improve placement suitability assessments as well as to increase stability of allocated social worker for looked after children. These plans as well as those to improve recruitment and retention of social workers are being implemented and monitored by the local children’s services improvement board. 143. This case demonstrates the need for further development of a trauma informed and restorative approach to addressing the care and support needs of care experienced children. In C80’s case it is particularly evident that responses to his behaviour and attitude to learning in education settings (pre and post 16) were not trauma informed and there is no evidence that the sanctions used, such as disciplinary measures, were influenced by a restorative approach. This meant they had minimal impact on improving his educational or behaviour outcomes. Similarly the volume of care placement changes experienced by C80 demonstrates there could have been a lack of understanding by carers regarding his childhood experiences and/or a limited understanding about how to care for a child with the level of behaviour and support needs that C80 demonstrated. This could also indicate a lack of appropriate suitability assessment each time that C80 was placed with carers. A number of these placement breakdowns related to behaviour issues and in one case, C80’s own experience of sexual abuse as a child, indicating a possible lack of knowledge of his history and also limited understanding of the impact of such adverse experiences and how to respond. 144. It is evident in the records considered as part of this review that C80’s mother had negative influence on C80’s behaviour throughout this period, however consideration of this does not seem evident in the arrangements made for contact or in later care planning. Examples of mother’s negative influence in this case include: - disruption of C80’s placements (e.g. C80 adding bleach to his carers toiletries). - escalation of C80’s negative behaviour post contact with his mother - mothers central role in a number of missing episodes, including C80 returning under influence of alcohol 15 “In Care, Out of Trouble” Lord Laming, 2016. Learning Point: Care experienced children are more likely to experience emotional and behavioural difficulties. Almost all care experienced children do not engage in any offending behaviour, let alone sexually motivated offending and there is no evidence to suggest that being care experienced as a child leads inevitably to offending. It is not therefore deemed evidential or appropriate that a child or adult should be mandated to share their care experience or that of the ACE’s that led to their care, with employers. 35 145. C80 regularly demonstrated his frustration regarding being separated from his mother through his behaviour and also in advocacy and other discussions with practitioners. C80 was determined to be reunited with his mother and siblings throughout his childhood and adolescence which clearly impacted on his progress and recovery from trauma. There were at times mentions of plans to review contact arrangements however no action is evident to adjust these or consider contact further. In addition concerns raised by C80’s foster carers regarding contact between siblings were not fully assessed or responded to. 146. C80’s own experience of sexual abuse at the age of 5 was discussed at his transfer in child protection conference in 2014; where details of the physical and emotional impact of this were given. Sexual abuse was then not explicitly stated in the future work or interventions with C80. This was not communicated to a number of C80’s carers 147. This is evident given one foster carer concerns that are recorded as unfounded ‘sexual risk’ in 2016 following C80’s disclosure of sexual abuse. This demonstrates that it was unlikely that the foster carer was aware of C80’s specific adverse childhood experiences of abuse prior to therapy being undertaken and also highlights a potential issue with placement suitability assessment at that time. The feeling that there was a need expressed by the carer for sensors on doors reinforces this. 148. C80’s sexual abuse history was not apparent in crucial assessments and planning by partners after the transfer in conference, including in terms of initial and review health assessments, onward specialist health referral to bladder and bowel services (linked to physical consequences of the abuse) or in referral for mental health and therapeutic interventions. 149. This led to very little direct intervention to respond to C80’s complex and specific physical and emotional needs that were linked to his experience of sexual abuse. Why this was not communicated is possibly linked to the lack of transfer of key information between practitioners / services for example when carrying out the Initial Health Assessment for C80, which led to limited information being passed to specialist onward health intervention referrals. A further explanation given to the review is that the alleged perpetrator of C80’s abuse had been found not guilty and this could have impacted on practitioner’s confidence to refer to and respond appropriately to the abuse. Another explanation relates to the fact that the serious neglect of C80 and his siblings was the primary reason for protection, which was then the issue that was communicated in future multi agency plans and assessments. Learning Point: The impact of trauma and adverse childhood experiences is evident in the timeline for this case. A trauma informed approach was not in place in Torbay, this is now beginning to form in Torbay led by the Local Authority. Given the role of partners in care experienced children’s lives, this could be further developed within wider the partnership. A trauma informed / restorative approach can also be considered in terms of behaviour management and disciplinary approaches in education settings (pre and post 16). 36 150. Therapy was indicated as a necessary intervention for C80 by the doctor carrying out the IHA and a Clinical Psychologist at FCO stage. Therapy was commissioned and C80 was said to have been engaging well. This was interrupted by a placement change at what is described by the therapist as a crucial point and was never restarted indicating that therapy was not an ongoing feature in C80’s care plans. In addition, the Clinical Psychologist carrying out the assessment at FCO stage recommended further assessment of C80 for difficulties such as Conduct Disorder. There is no evidence that this subsequently happened. C80 is often described as in low mood, ‘blocking things out’ and refusing to engage in work that would have looked at his traumatic experiences including his life story work. Had these further assessments been done, and therapy or life story interventions been successfully delivered it is possible that this could have had a more positive and lasting impact on C80’s emotional well-being and future life. 151. In addition, C80’s sibling has expressed a view that exploration of his ‘life story’ may have been an opportunity in which he would have disclosed his experience of abuse by C80 much earlier than was the case. 152. Of the records presented to this review that related to the time period prior to 2019, there are none that indicate C80 demonstrated any obvious indicators of harmful sexual behaviour, either to practitioners or carers, until the abuse reported. Practitioners involved in this case and contributing to the review described shock regarding this tragic outcome. The review panel communicated to the reviewer that this in itself could denote a need for further learning on this topic, given the abuse that was perpetrated by C80 both in the nursery and to his sibling. 153. The abuse of C80’s sibling was disclosed once the allegations of abuse in the nursery had come to light, 5 years after the abuse took place. There are no indications that this was known or suspected by practitioners previously to this point in time. There are many complex reasons why a child in the siblings’ position will not have been able to disclose their experience of abuse any earlier including shame, embarrassment and fear of being believed. This is demonstrated in the Governments Tackling Child Sexual Abuse Strategy (2021), which gives some insight in to the barriers that exist for children (and later adults) in coming forward about their experiences of sexual abuse, the most Learning Points: C80’s experience of sexual abuse, and the responses to this, are relevant factors in this review. Partners should ensure that a child’s experience of sexual abuse forms an integral part of care plans and assessments even where this is not the primary reason for protection or intervention. Referrals for specialist support as a result of abuse should be explicit about the reasons for this so that appropriate interventions can be delivered. Protocols within Health services should be reviewed in the light of this review, to ensure sufficient guidance to practitioners where care experienced children are referred for specialist support. Experiences of sexual abuse can contribute to a child displaying harmful sexual behaviour; however this is not a definite outcome by any means. It is therefore not deemed necessary or appropriate that an adult or child’s experience of sexual abuse, or other ACEs should be shared with employers. Learning Points: Where commissioned, therapy should form part of ongoing care planning to ensure continuity, particularly when placements are disrupted. Where further assessments are recommended for looked after children in family court processes, this should be followed up and monitored as part of multi-agency care planning. Life story work with all children in care should be mandatory and undertaken in a timely way. 37 common being that children feel they will not be believed. The report also highlights that boys are less likely to report sexual abuse than girls. 154. In his victim impact statement, C80’s sibling describes his own reasons for disclosure as follows: “It was only after some time of us being apart- nearly three years after being placed into care -that I finally felt safe and therefore able to speak about the abuse I had suffered” 155. Clearly, professionals working with children have a responsibility to raise concerns and identify children who are at-risk of, or experiencing, sexual abuse. However, this can be difficult. In 2015, the Children’s Commissioner for England reported that just one in eight children who are sexually abused are identified by professionals. There is concern that professionals do not have a good enough understanding of the signs of child sexual abuse and lack the confidence and skills to talk about it16. The crucial role practitioners play in identifying abuse is best demonstrated in the clear and impactful words C80’s sibling stated to the reviewer: “If I’d been asked, I’d have told them [about the sexual abuse], I thought it was normal. I didn’t know how to lie and would have said”. 156. Abusive behaviour is often hidden from plain sight and may not visible until a disclosure from a victim is made, as was the case in this situation. It is crucial therefore that practitioners and carers of children are confident in recognising harmful sexual behaviour and distinguishing between ‘normal’ age-appropriate behaviours and those of concern. Research tells us that around half of young people who have displayed harmful sexual behaviour have experienced sexual abuse themselves17. In the light of this case, it is crucial that the practitioners working with children and young people in Torbay fully understand the context and indicators of Harmful Sexual Behaviour. 157. As reported earlier the terms ‘sexual risk’ and ‘potential sexual risk’ are recorded in C80’s case history in 2016 and 2018. On review, neither seems to have been recorded as such for an evidenced or substantiated reason, the latter event may have referred to risks posed to (rather than from) C80. While a strategy meeting took place, there is no evidence of specific assessment or consideration of how practitioners could robustly identify if this related to 'normal' age-appropriate relationships/friendships, or if this was behaviour which causes concern - and was not therefore considered in future multi agency work or planning. 158. There are a range of frameworks and checklists to locate children and young people’s sexual behaviours at various levels of seriousness or concern that could be utilised in such circumstances. TSCP itself has an agreed Harmful Sexual Behaviour procedure18 and Brook has an online sexual behaviour ‘traffic light’ tool19 for professionals which distinguishes between three levels (green, amber, red) of sexual behaviour in children and young people. 16 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/973236/Tackling_Child_Sexual_Abuse_Strategy_2021.pdf 17 https://www.stopitnow.org.uk/concerned-about-a-child-or-young-persons-sexual-behaviour/preventing-harmful-sexual-behaviour/ 18 https://www.proceduresonline.com/swcpp/torbay/p_sexually_harm_behav.html 19 https://www.brook.org.uk/training/wider-professional-training/sexual-behaviours-traffic-light-tool/ 38 159. The TSCP procedure also explains that; “there are no diagnostic indicators in personal or family functioning that indicate a pre-disposition towards sexual offending, although the following characteristics have been found in the background of some young people who sexually offend: • Attachment disorders - poor nurturing and parental guidance. • Domestic violence and abuse. • Previous sexual victimisation - a younger age at the onset of the abuse is more likely to lead to sexualised behaviour. • Social rejection and loneliness. • Poor empathy skills. Many of these factors exist alongside typical family environments where other forms of abuse are present”. 160. C80 experienced multiple missing episodes during the period that this review covers. These increased in frequency in the period leading up to the abuse perpetrated by C80. At times, the episodes seem to have been linked to disruption in C80’s life or to be linked to contact with his mother. 161. Partnership information in relation to missing incidents was well shared, for example with C80’s education providers (pre and post 16) so that concerns could be raised should he not attend college. There is however limited evidence of coordinated activity to respond meaningfully once this point had passed and to identify strategies to prevent future episodes. A strategy meeting took place in late 2018 which included discussion about the growing number of missing episodes. Actions were agreed here however there is no evidence of how these actions were implemented or how they influenced future plans or work with C80 by any of the partners that were present. Return Home Interviews (RHI’s) were at this time being delivered by C80’s social worker or the family support worker from the local authority, rather than an independent practitioner. This was not concurrent with expectations set out in national guidance. It has been reported to this review that this had a negative impact on C80’s relationship with one of his closest positive influences (male support worker) as it changed the relationship from a supportive to a more punitive one. There is no evidence of how findings from RHI’s influenced future actions or care / pathway plans with C80 and his carers. 162. Child Sexual Exploitation (CSE) risks to C80 are recorded in case records around the time of the increase in missing episodes, largely due to this increase and some concerns as to who C80 was spending time with. There is no evidence that an agreed partnership risk assessment took place at any point relating to CSE risk and this therefore did not inform future planning for C80. The reviewer has been advised that the Local Authority has since developed approaches to missing children, including: o return home interviews are provided by an independent person, and that findings inform assessments of risk, care, and planning o where risk of child sexual exploitation is identified and recorded, relevant assessment takes place to identify risk and inform future planning. Learning Point: Abusive behaviour is often hidden from plain sight and may not be visible until a disclosure is made. It is crucial that practitioners across TSCP, as well as carers, are confident to identify and respond to sexual abuse indicators and to differentiate between ‘normal’ age-appropriate behaviour and that of concern or risk, so that this informs their planning and work with children. 39 163. C80 was not offered a personal advisor until July 2020 (age 18), a year after the abuse perpetrated by C80 was reported. This is clearly outside of legal duties of the local authority20. At this time there were also multiple changes to the social worker for C80 and at one point he was left ‘unallocated’ in this period. C80 is reported to have said at this point to his advocate that it had felt “as if everyone has given up on me”. Torbay Council’s website states that a Personal Advisor is offered at the age of 16 and supports care leavers with the following: • practical help (e.g. helping secure a tenancy, paying for certain things in your home • emotional support (e.g. being there when you need us, keeping your motivation up) • advice and information (e.g. helping you go through your housing options, choosing the right course and college). 164. Where Pathway Plans do exist for C80’s ‘care leaver’ period in the time covered by this review, they are incomplete, do not include input from C80 and do not show actions or demonstrate how these were monitored and progress evaluated. 165. As corporate parent for C80 the local authority did not meet its statutory duties at this time. It is not possible to predict whether C80 would have taken up the offer of a Personal Advisor at age 16 as he had by this point often found it difficult to engage or trust practitioners following the long period of instability he had experienced. Residential placement worker/s seem to have stepped in to provide parts of this role and coordinated many of the activities that would have been expected of a PA, for example assisting C80 with his search for work after ceasing college. 166. Virtual school involvement with post 16-year-old care experienced children in Torbay at this time was also limited, contributors to the review suggest that this was reactive, stepping in if any issues were highlighted as part of post 16 Personal Education Plan (PEP) meetings or concerns raised by education providers. It is said that this related to the level of resources and time within the virtual school team. A PEP took place shortly after C80 started college highlighting concerns about his progress and submission of work. Concerns were raised at this meeting regarding his attitude and behaviour in the care setting at this meeting, and also if the childcare course was the right one for him. There is no indication of follow up on this latter point. C80 very rarely engaged in his PEP’s, and it is not obvious how actions that were agreed for him to progress were communicated with him, monitored, or followed up by partners. No further PEP records are available for C80, there is no evidence that these took place for C80 once he had been subjected to college disciplinary procedures in the months that followed. 167. A regional careers service also provided some support regarding C80’s options, specifically once he had been dismissed from his college course and was deemed to have been Not in Employment, Education or Training (NEET). They had been notified of this by C80’s carer and met with C80 to assist with preparation for interviews. No further contact is apparent in terms of recording C80’s success with interviews or employment in the next two months. Had C80 been offered, and engaged with, a Personal Advisor a coordinated level of support for C80 could well have been in place including further careers advice. This may in turn have influenced his preparation for independence and decisions regarding his future options for career and employment. This is not 20 Section 3 of the Children and Social Work Act 2017 requires Local Authorities to provide personal advisors to care leavers from the age of 16 up until they reach the age of 25 40 however to suggest this would have been an intervention that would have altered C80’s choice of employment or indeed had any influence on his perpetrating abusive behaviour. 168. In contributing to this review, practitioners gave some context of what was happening at this time, particularly in terms of the challenges faced by Torbay, and indeed, all Councils in recruiting and retaining social work staff. This clearly impacted directly on Torbay’s ability to deliver consistent social work services to C80, and to deliver expected roles and plans to assist in his next steps as a care leaver. 169. At points in 2018 the lack of pathway planning is noted by partners – for example in CLA (Child Looked After) review. There is, however, limited evidence of how or when this was followed up or concerns escalated, and the situation and quality of plans remained the same. It is not clear if partners were aware of potential escalation routes beyond the IRO dispute resolution procedure which took place but resulted in little action. This was instigated but unsuccessful. Use of the TSCP “Escalation Policy21” does not seem to have occurred indicating a lack of awareness of this as a route to achieve a more positive outcome in this situation. 170. The Local authority has advised that improvement plans are currently being implemented that have altered or will positively influence practice in this area, specifically as a result of improvements to: - Sufficiency strategy for looked after children - Support for post 16 looked after children, specifically relating to the quality of pathway planning, actions and follow up - Personal advisor allocation as set out in the Child and Social Work Act - IRO dispute resolution procedure and appropriate escalation points / routes - Role of the virtual school is clarified in terms of post 16 education employment and training 171. C80’s student file, which contained essential information about his care experience, family history, school behaviour and safeguarding issues, was passed to his college two months after his enrolment in a childcare course, and some six months after the college held a ‘risk assessment’ meeting (held for all vulnerable students) relating to his application to attend the college and this course. This meeting is discussed later. 172. In addition, it would be pertinent to review the timing of such information exchange between schools and post 16 education or training provider to ensure that the full range of information is considered when assessing student’s suitability for their chosen courses. 21 https://www.proceduresonline.com/swcpp/torbay/p_escalation.html Learning Point: Personal Advisors and Pathway Plans form the foundation of post 16 support for care experienced children. This is essential and a statutory requirement for the Local Authority as corporate parent. Virtual school coordinate PEP plans for those in post 16 education, this is particularly important where there are concerns or a care experienced student enters disciplinary procedures. Partners can ensure that this support is in place and effective and where there are gaps, consider linking to the IRO to utilise the dispute procedure and / or refer to TSCP’s Escalation Policy to assist in supporting and challenging to ensure the needs of the child are met. 41 173. The file transfer coincided with the onset of college disciplinary procedures being launched (for reasons related to his behaviour and lack of motivation for study). GDPR and poor relationships between settings has been referenced to this review as a barrier at that time to the automatic transfer of files for students. School representatives describe improvements to this process since the period of the review with better relationships with some but not all post 16 education settings and training providers in the Torbay area. Work on this does continue, with suggestions that this approach mirrors transition for looked after children between primary and secondary education. 174. Following C80’s disclosure that he was struggling to manage behaviour of one child at the nursery, it is clear that full details of this should have been shared with the nursery. Specifically, the suggestion from C80 that he had used a physical intervention and ‘pushed’ a child. This crucial detail of this event was not given to the nursery. The reason this was not shared is said to have been because C80 had subsequently denied he had actually pushed the child and stated he’d sometimes felt that is what he might do. Nevertheless, this detail, even his intention that he might carry out such physical intervention, could have been shared to enable the nursery to be fully informed to decide about the correct course of action at that time. It was good practice that the Local Authority social work duty team were consulted about this matter and that the detail was shared initially. There is no evidence to suggest however that there was any follow up on this matter by the care provider or C80’s social worker at the time, to ensure that C80 was being supported with the behaviour management issues that this raised. 175. There is a possibility that in this case the LADO may have been consulted for advice. The LADO and other contributors to the review have advised that local settings were at this time, aware of the role and support offered in this kind of scenario. Given subsequent events related to this nursery and more serious issues that required reporting to the LADO it is not obvious if nursery procedures would have led to this. It is also very unlikely that any formal LADO investigation would have been progressed whoever had contacted them, as a result given the circumstances of the disclosure. It is, however, the view of the LADO that had this information been shared with them, it would be most likely that this would have led to proactive contact with his lead worker / IRO in terms of coordinating support for C80 for example, and the nursery on the issue. 176. Feedback in wider practitioner meetings for this review indicated a lack of clarity regarding application of allegations management procedure for under 18’s including looked after child working or volunteering in position of trust. The LADO in Torbay has indicated to the reviewer that they have action underway with early years settings and others in relation to awareness that the relevant procedure applies where staff, apprentices or volunteers are under 18. Recruitment & Apprenticeship 177. Safe recruitment is central to the safeguarding of children and young people. All organisations which employ staff or volunteers to work with children and young people have a duty to safeguard and Learning Point: It is essential that there is a timely transfer of information regarding vulnerable students between pre and post 16 education and training providers. This is to ensure that relevant suitability / risk assessments are fully informed and that an appropriate level support is in place for the student. Learning Point: While information about C80 struggling to manage the behaviour of a child was shared with his employer, a crucial detail regarding his alleged use of physical intervention (or intention to use this) was not. This should have been shared by those responsible for C80’s care to enable informed assessments and decisions to be made. Where a child under 18 discloses issues relating to a position of trust that they hold, whether as an employee, apprentice, or volunteer this should follow the same procedure as for an adult. 42 promote their welfare. This includes ensuring that the organisation adopts safe recruitment and selection procedures which prevent unsuitable persons from gaining access to children22. 178. The EYFS Statutory Framework suggests that all providers should ensure staff are ‘suitable’, this seems to be broadly based around processes relating to DBS. There is no further detail to guide carers or settings on other essential safety and suitability checks, for example references. In comparison, the statutory guidance for schools and colleges, KCSIE (Keeping Children Safe In Education23) describes safe recruitment requirements in detail and gives very clear guidance regarding pre appointment checks, including references that are required for any individual working in or visiting schools. The EYFS suggests that childcare providers may “find it helpful to refer to this [KCSIE] guidance” but there is currently no statutory duty for them to meet the requirements within it. Ofsted’s Early Years Compliance Handbook as a result describes only DBS processes in relation to safe recruitment, although the regulator states clearly that it can act where it feels the welfare of children is not safeguarded. 179. Given the vulnerability of the babies and young children that are within early years settings, it is not clear why less specific safe recruitment statutory guidance is currently in place in EYFS compared to KCSIE. 180. Suitability to work with children could also be examined more closely where students wish to study childcare, in particular where they include placements in settings or a pathway through qualification to roles in childcare settings. This would be equitable to the requirements to study for a teaching qualification. While the college C80 attended did hold a ‘risk assessment’ meeting, this happens only for students with additional or complex needs rather than specifically for those studying to work with children. The meeting did cover some aspects of ‘suitability’ of C80 to attend this course and did not identify any issues that deemed him to be unsuitable. 181. Representatives of the college advised the reviewer that a letter is now sent to previous education settings for all students enrolling to study childcare, to ask about suitability. 182. Information submitted to this review suggests that the nursery was not adhering to it’s safeguarding policy in terms of ensuring that two satisfactory references as part of pre-employment checks for C80 were in place, prior to his start date and work with children. The DBS was carried out within 12 days of start date and one reference (from C80’s part time job) was received 16 days after start. Evidence held in C80’s personnel file and gained from school and college suggests requests for a second references were taken up some time after C80 commenced employment, at 2 months (college) and 4 months (school) after his start date. 22 https://www.proceduresonline.com/swcpp/torbay/g_safe_rec.html 23 https://www.gov.uk/government/publications/keeping-children-safe-in-education--2 Learning Point: There is no statutory guidance regarding the level of suitability assessment required for students attending placements as part of childcare studies. This differs from expectations for trainee teachers, as KCSIE applies. Post 16 education and training providers offering childcare courses, especially those that involve placements, should carry out pre-enrolment checks, references, and suitability assessment procedures in the light of this review. Particularly to ensure that these are as robust and thorough as those within higher education courses offering teaching qualifications. 43 183. The nursery owners recalled to the reviewer that C80 was acting as a work experience student, wearing different clothes to staff to distinguish that fact, during a period in which a DBS was awaited. His contract of employment states a start date of 4th March 2019, subject to satisfactory DBS checks being returned. Delays to start dates are not evidenced in the case of lack of references however C80’s probation had been extended for this reason. Staff from the nursery spoke to Ofsted (post suspension of registration) regarding the issue of checks being taken up for their appointment, stating that if their DBS was not back before they started work, they were also identified by not wearing uniform. Nursery explain that this would indicate that they were not yet employed and were working as work experience. It is not clear if these non-uniformed staff would then be included in the nursery ratios. It is also unclear if this was known to Ofsted prior to the suspension of the nursery registration. 184. It is important to try to understand the context for why setting may allow staff to commence employment prior to satisfactory pre-employment checks and references being gained. In the course of the review it has been suggested that this may be linked to a need to swiftly recruit and employ staff due to high turnover of staff and recruitment and retention issues in the sector. In this case, the nursery has indicated a particular keenness to recruit male members of staff given the relative rarity of male applicants, this could have also impacted on decisions made in this case. 185. Having consulted with all three potential referees as part of this review it is apparent that there were no concerns or indicators visible to them of the sexual risk that C80 posed, and this would not have been identified in any of the references had they been completed. All three did describe C80’s behaviour and attitude to work and learning very negatively, albeit with hindsight given the events that have since occurred. Separately they suggested that had they completed the full reference or been contacted by the employer by phone, they would have not recommended him for employment for this role. 186. The reasons for not communicating this proactively to the nursery are mixed. In conversation with one of the potential referees, it is apparent that they considered the reference document format unsuitable for education referees. The representative at the school also advised that they are also concerned about the legalities of providing a negative reference, there were concerns that they could be challenged. They also reflected that on the very few previous occasions where a reference for a student had not been fully completed, they would have had proactive contact or a phone call following up on this from the employer, and that this didn't happen in this case. School was not aware that a failed attempt for a complete reference had been made to the college prior to the request to them. The college also shared a view that they had expected follow up from the nursery to ask further questions, and this would have been in line with TSCP guidance on the matter. The setting that provided a placement to C80 and was contacted for a reference seems to have not been followed up because of missed calls and answerphone messages. Learning Point: Pre employment suitability checks, including successful references, are an essential part of safe recruitment practice in all settings working with children. TSCP guidance gives the local framework for this. There is no legal reason for information that may be of safeguarding concern to not be shared by referees with potential employers. Referees should proactively communicate all concerns to employers relating to a prospective employee. Learning Point: The EYFS does not provide a detailed statutory framework for safe recruitment (beyond DBS) that guides settings on this topic and enables HMIs in Ofsted to hold them to account. Keeping Children Safe in Education does offer this for schools and colleges, and therefore Ofsted, but it is not mandatory for childcare settings to follow this. 44 187. C80s apprenticeship was arranged by the nursery with a training provider they had previously used. In a recent safeguarding visit to the training provider, Ofsted found insufficient progress in relation to safeguarding and the report from this visit demonstrates poor quality safeguarding practices there. There is no evidence that suggests the training provider quality assured the safe recruitment or suitability assessment carried out by the nursery prior to commencing work with C80. 188. It is evident that the apprenticeship training provider was aware of C80’s care experience given their invitation to a CLA meeting in the period of C80’s apprenticeship. It is not clear if additional bursaries were accessed for C80 as a result by the provider or if this could have instigated additional support. There was no system for arranging apprenticeships for looked after children in Torbay at that time and given the lack of personal advisor and pathway planning, the local authority and partners involved in C80’s care did not have oversight of the apprenticeship arrangements that were taking place. Local Authority apprenticeship leads have advised the reviewer that they can offer a role for coordinating and oversight of arrangements for apprenticeships for care experienced children and care leavers which would ensure providers are of a good quality. Supervision and Oversight 189. Throughout the entire time of his employment at the nursery, C80 was aged 16 years old. The EYFS framework states; “Only those aged 17 or over may be included in ratios (and staff under 17 should be supervised at all times)”24. This indicates that C80 should not have been included in staff ratios at the setting. 190. In initial visits to the nursery by Ofsted the owners of the nursery presented very positively that this had always been the case. The owners were adamant that this abuse could not have happened in the setting because C80 was always supervised. They describe to the review that C80 was always in ‘sight or sound’ of a supervisor and that they always ensured staffing levels were above the recommended numbers. 191. CCTV footage collated for the police investigation is said to indicate that C80 was seen to be left unsupervised on a number of occasions for periods of time that enabled the abuse to occur, for example Police suggest a period of 39 minutes in relation to one incident, where C80 was effectively left unsupervised. C80 was taking children to the toilet unsupervised, demonstrated by the location of the rape that was committed. While the often-hidden nature of sexual abuse is a possible explanation for the discrepancy in accounts and evidence, it is difficult to comprehend how this could have happened had he been in sight or sound of other staff while taking children to the toilet. In the course of meetings with parents of children that attended the nursery for this review, the reviewer was frequently told that nursery owners had assured parents that children would not be taken to the toilet by individual members of staff as detailed in their policies and this had reassured parents enough to choose this as a setting they would want to use. 192. This is compounded by the information staff of the nursery later reported in meetings with Ofsted inspectors. Here they suggest that they had been told by setting leaders C80 could not be left unsupervised. This was thought to be linked concerns of immaturity and behaviour, rather than any safeguarding risks, and it is possible also to the issue raised by his placement. Staff indicated that because of deployment issues it was not possible for him to be constantly supervised. Staff indicate he would often be asked take children to the toilet or to change individually rather than be left with 24 The guidance goes on to state that Staff that work in ‘early education’ as apprentices (aged 16 or over) can be included but only if the provider deems they are ‘competent and responsible’. 45 a bigger group of children to manage. This is not to say C80 would have been ‘out of sight and sound’ on each occasion that he did so. However it seems possible that the level of supervision and oversight at the nursery did allow the opportunity for C80 to abuse children. 193. Ofsted detail that while investigating nursery practice as part of their registration suspension, some observations of staff practice were apparent with feedback given in the setting but there was limited evidence of how the setting were monitoring practice as a result, to measure how well improvements were made. EYFS Statutory Guidance states: “Providers must put appropriate arrangements in place for the supervision of staff who have contact with children and families. Effective supervision provides support, coaching and training for the practitioner and promotes the interests of children. Supervision should foster a culture of mutual support, teamwork and continuous improvement, which encourages the confidential discussion of sensitive issues”. 194. The nursery supervision policy states, “supervision meetings are be carried out every month for apprentices” and that “supervision is carried out by the line manager”. Monthly supervision is not recorded each month for C80. Evidence from Ofsted records suggests that the nursery owner/s completed supervision for senior staff and senior staff completed supervision for all other staff. Ofsted were told by staff that C80’s room leader had been given a list of concerns that had been raised about his practice, specifically regarding his behaviour by the owners. These concerns influenced the choices made about how to deploy C80 as stated earlier and were to be discussed with C80 during a supervision meeting. On review of supervision notes, there is very little noted in meetings to demonstrate that this happened, and to then track progress C80 may have made relating to concerns raised. 195. It is evident that the nursery owners ensured all staff read and understood their policies and procedures, and that this formed part of their induction. Staff, including apprentices such as C80, had to sign to confirm they had read these. There is no evidence that leaders at the nursery then ‘tested’ application of this knowledge through observation and their oversight of practice. Safeguarding Practice 196. The EYFS states: “Providers must have and implement a policy, and procedures, to safeguard children. These should be in line with the guidance and procedures of the relevant Local Safeguarding Children Board (LSCB). The safeguarding policy and procedures must include an explanation of the action to be taken when there are safeguarding concerns about a child and in the event of an allegation being made against a member of staff and cover the use of mobile phones and cameras in Learning Point: In order to ensure children are safeguarded it is vital that settings adhere to the guidance set out in EYFS regarding supervision of 16-year-olds, and their inclusion in staff ratios. Staff in settings should be confident to report situations internally and then to escalate this, where these requirements are breached. The terms ‘competent and responsible’ are open to local interpretation and could be further clarified in EYFS guidance. Learning point: Safeguarding children should be a formal part of supervision and observation of practice. Application of key safeguarding policy and procedures in practice, for example the use of physical intervention and whistleblowing, should be measured as part of this. Managers / owners of settings should ensure ‘leadership by example’ in terms of linking observation, supervision, and tracking practice improvement. The EYFS could be expanded in the light of learning from this review, to give further clarity to settings and Ofsted on these expectations. 46 the setting”. The nursery adhered to this requirement and policy regarding key safeguarding issues relevant to this review detail all the right and proper principles and procedures to follow. 197. The application of these in practice is however not always evident in the information gathered. Meetings held by Ofsted inspectors with nursery staff suggest that there were gaps in some significant areas, for example Ofsted state that staff were not confident in managing the use of physical intervention or following whistleblowing procedures. 198. Staff also seem to have had a poor understanding of whistleblowing and were not aware of or implementing the duty to report physical interventions or behaviour concerns even where this was witnessed, as demonstrated by the evidence found on CCTV. Contributors to the review suggest that when issues had been flagged there was very limited follow up which led them to no longer feel confident that their concerns would be acted upon. A further explanation given to the reviewer by parents and other contributions to the review is that there were some strong friendships within the staff group which could have affected the likelihood of reporting incidents because of a fear of losing social networks. In any event, there is no evidence of staff having knowledge of wider local procedures25 in terms of whistleblowing or of the possibility of reporting concerns to the LADO or Ofsted. There also seems to have been no awareness of national helpline run by the NSPCC that is available to all. This is despite the Designated Safeguarding Lead (DSL)’s regularly engaging in Safeguarding Forum meetings held by the Local Authority, indicating a lack of communication of issues learned at that forum to staff. In addition, staff reflected that they felt the induction they received was helpful and it had included completing safeguarding training. However, until the recent dismissal of other staff, they had received no refresher training. 199. The setting had two DSL’s rather than the statutorily mandated one. This role is said by EYFS to be responsible for; “liaison with local statutory children's services agencies, and with the LSCB. They must provide support, advice, and guidance to any other staff on an ongoing basis, and on any specific safeguarding issue as required. The lead practitioner must attend a child protection training course that enables them to identify, understand and respond appropriately to signs of possible abuse and neglect”. The settings safeguarding policy describes the correct process for reporting concerns to the DSL, for them reporting to the correct statutory authorities, and the recording procedures within the setting. 200. CCTV was in use at the setting, footage from this provided essential evidence for the investigation and criminal trial of C80. At the time of the first report of abuse the setting discussed the angles 25 For example TSCP Whistleblowing Procedure: https://www.proceduresonline.com/swcpp/torbay/p_whistleblowing.html Learning Point: Policies alone do not safeguard children; it is crucial that these form a part of a whole setting approach to safeguarding. Settings should ensure that the principles and processes that policies reference are implemented every day in practice and through regular training, awareness raising and monitoring of practice. Learning Point: Staff in the nursery were not confident about whistleblowing procedures. It is this vital for children’s and adult’s safety that staff feel safe and listened to and that action is taken when appropriate when they raise concerns about practice/s in their setting. There is a national Whistleblowing Advice Line available that offers free advice and support to professionals with concerns about how child protection issues are being handled in their own or another organisation. 47 covered by the CCTV with investigating police officers and agreed that there were some areas, including the toilets, that were not covered by the cameras. The nursery had a clear CCTV policy in place, stating the details of the purpose and process for the use of this. The lack of cameras in the toilets and changing areas is said in the policy to have been deliberate in order to protect the dignity of children. This lack of coverage would have provided further opportunity for the abuse to happen. 201. The EYFS does not detail any statutory framework in relation to the use of CCTV in early years settings, simply stating that if CCTV is in use it should be covered by a policy. CCTV use therefore does not form part of the Ofsted inspection framework handbook. The setting policy states, “CCTV is monitored centrally from the nursery office”, and that CCTV footage may be used for training purposes “including staff supervisions”. As with other policies referred to in this report, it is not clear how this was evident in practice. Evidence of multiple episodes of abuse committed by C80, and later others physical interventions was found on the CCTV footage by police investigators, however this was not seen as part of routine monitoring by the owners of the setting. In addition there is no evidence to suggest that footage was used to address concerns regarding C80’s behaviour in supervision as the policy suggests it could be. 202. A nursery policy states that “No…. intimate care routines take place behind closed doors”. It is the view of a number of parents that engaged in this review that the toilet facilities were not appropriately laid out for a childcare setting and that these provided a further opportunity for the abuse to take place. This is because at the time of the rape incident the toilets were contained within a room that had a closable door. This door opened in a direction that partially blocked sight of some of the room. This door was later removed by the owners. The EYFS does not indicate any guidance on visibility of toilet areas, it only states that “Providers must ensure there is an adequate number of toilets and hand basins available. Except in childminding settings, there should usually be separate toilet facilities for adults”. Parents also questioned how the set-up of toilets is considered in Ofsted inspections of settings, it is clear that the layout in terms of safeguarding is not considered however Ofsted have advised that inspectors may discuss how settings ensure the privacy and dignity of children for example where there are no doors. Response to incidents 203. At the point that the parents of the victim of abuse reported to the nursery it is evident that there was confusion in the setting about how to respond to the allegation. The police did not immediately receive a report from the nursery, instead they attempted to seek advice from the LADO, who was not available at that time. C80 was told details of the allegation in the process of suspending him from the nursery. This included details about the language used by the child (the term ‘nipple’ was used by the family instead of penis), which could have affected evidence gathering. A family member of the child later reported the abuse to the police and C80 was arrested This created a delay in arrest of C80 and a potential that crucial evidence could have been lost. 204. This approach within the setting is possibly due to the rare, unthinkable, and shocking nature of such abuse. Sadly abuse in a nursery setting has happened before and could happen again, consideration Learning Point: There is no reference in EYFS statutory guidance relating to the use of CCTV in settings, simply a requirement that there is a setting policy regarding their use. This should be considered in the light of this review, particularly to ensure it does not replace in person observation and to encourage proactive use of this to monitor practice where improvements have been Learning Point: There is a need for clarification regarding the layout / design of toilet facilities in nursery settings. National guidance (and settings policies) should address the need for balance between safeguarding children from harm and ensuring their dignity - both in terms of CCTV coverage where this in use, and in ensuring the design and layout of toilets prevents the opportunity for abuse. 48 could be given to ensure settings have ‘critical incident’ procedures that are used in such cases. It is evident that there was a feeling of disbelief and a sense that “this could not have happened here” from the nursery owners from this point on. Parents reflected to the reviewer was that it felt as if nursery owners were suggesting it was impossible, because of CCTV, supervision, and staffing levels. This was also the view of the owners when communicating with partners and crucially Ofsted inspectors in their early visits to the setting when they attended shortly after the incident. Tragically this was not the case. It is clear that many perpetrators of abuse, whatever their motivation, will seek out opportunities to abuse regardless of how well guarded non abusive individuals or organisations feel they are against this. 205. An independent review into how local safeguarding partners responded to this case was reported in 2019. This stated that, “based squarely on evidence collected, that Torbay’s response as a safeguarding partnership to safeguarding issues at the [nursery] was outstanding”. Two recommendations were made as a result of this review that are included in the recommendations section of this report. The Terms of Reference for this subsequent CSPR has led the reviewer to undertake a more in-depth analysis of the response from partners, identified learning is summarised below. 206. It is thankfully extremely rare that safeguarding partners would need to respond to a case as complex and difficult as this. It is evident that as the circumstances of the abuse unfolded, local partners worked together to share information and respond appropriately, echoing the positive findings of the earlier review. Given the rarity of the events there are some learning points that have arisen that can be actioned should similar cases come to light in future in Torbay or other local authority areas. 207. Parents of children that attended the nursery and contributed to the review provide helpful suggestions for learning from the response to this incident. There were mixed comments made about communication throughout this process. On the whole, communication from Police in later stages (from Autumn 2019 onwards) was seen as positive. All parents reflected positively how well police and the Crown Prosecution Service (CPS) had enabled the outcome via criminal proceedings. There was however a general feeling by parents that they were ‘left in the dark’ in the immediate days / weeks after the first reporting of concerns. Parents that were not directly involved in the initial reports knew that something major had happened but had no information about the nature of the allegations or how it impacted on their child’s care. One parent described a connected group of parents that they felt ‘knew everything’ while there were others that new very little. 208. Clearly the level of appropriate communication was influenced by a need to ensure protection of evidence as part of the investigation, this was acknowledged and understood by parents. It is also evident that police were reviewing 250 hours of CCTV footage and it was not until later in the process that the details of the abuse that was carried out were uncovered, while this was not known by parents at the time, it does provide an explanation for this. There was much speculation and hearsay in the community about the abuse at this time, which is not uncommon in a case of this nature. The lack of factual information given to parents seems to have fuelled this further. 209. Early communications to parents of children attending nursery regarding this case were sent by the owners of the nursery. The earliest communication was sent by email and suggested that ‘all safeguarding process are in place’, it was an ‘isolated incident’ and advised against discussing on social media. The mention of safeguarding highlighted the nature of allegations and subsequently Learning Point: Childcare settings should view safeguarding through a lens of ‘it could happen here’ in the light of this review. There is a crucial period for evidence gathering when sexual abuse is suspected. Consideration should be given to developing critical incident procedures within settings to respond to such cases in future. 49 this caused anxiety. When enquiries were made about this to the nursery, parents were told they couldn’t be given any further details and therefore felt that they were being asked to make their own decisions about continuing to send their child in to their care. It was difficult therefore for parents to make informed decisions about their children’s future care arrangements in these early days given limited information that came from the provider. 210. Later in the investigation, communications were organised via the Police investigation team. Feedback from parents indicates these were viewed more positively given the factual information that was then sent from a more neutral position. 211. Communication with the carers of C80’s siblings was also an issue, with the main carer discovering the details of allegations and arrest of C80 once the children had returned from school. This meant there had been no preparation work with the siblings in terms of what may happen once they returned to school. One of the siblings attended primary school opposite the nursery site and, given the area their school was based, many of both siblings fellow students and teachers had links to the case. The reviewer is aware also that there were bail conditions restricting C80’s access and contact with siblings at this point, which the foster carer was not aware of and feels rightly that this should have been included in the multi-agency response in these earlier stages. 212. Parents input to this review demonstrated an ongoing need for practical and emotional support related to theirs and their children’s wellbeing. The level of need varied for individuals according to their level of involvement in the case, including those directly impacted by abuse, those unable to identify if their children were victims and more generally for those who felt a level of anxiety related to their association with the nursery. 213. It is evident in the information passed to this review that support needs were discussed in detail and actioned within the partnership silver and gold command groups and the local SARC was suggested as the key supporting specialist service. This came relatively late in the process and there was some mixed understanding about what could be offered by local specialist services which added further delay. Therefore this did not translate as support to parents in a way that met their needs at that time. 214. The evidence considered for this review clearly explains the actions of Ofsted as regulator of the nursery setting once the allegations of abuse had come to light. Inspectors use the Ofsted Early Years Compliance Handbook, which is in turn, based on the EYFS statutory guidance. Following thorough review of the actions of the regulator it is clear that all statutory guidance and handbook thresholds were applied appropriately in this case. 215. However, local partners have expressed a sense of frustration with the time taken between notification of concerns to suspension of the registration of the setting. This was rightly centred around concerns for the safety of the remaining children in the care of the nursery. As identified earlier in the report, it was the view of the that the owners of the nursery that the abuse ‘couldn’t have happened’ in their setting. This positivity was communicated to an Ofsted EYRI in their initial visit, and this was tested to the level expected by their handbook. The setting adhered to all Learning Points: Where police investigations relate to abuse within a childcare or similar setting, communications to parents and carers should be delivered by a member of the safeguarding partnership, rather than through an interested party or witness. A single point of contact should be established from the outset for this type of investigation specifically for proactive contact with concerned parents and carers in situations such as this, that signposts to appropriate support services. In line with the recommendations from an earlier independent review, this should be overseen by a lead senior officer. 50 requests made and were able to demonstrate the improvements made to specific actions that were agreed, for example in terms of inviting in the LADO. They responded to concerns regarding additional staff by suspending and investigating them promptly which in the Ofsted inspectors and senior officers view had removed the risk. All of this added to the positivity felt by Ofsted that the setting was reacting and responding appropriately. It is for these reasons that the setting was viewed optimistically by inspectors up to the point that the registration was suspended. An Ofsted representative contributing to this review reflected also that settings can and do challenge decisions relating to suspension of registration legally through tribunal. This means that inspectors are required to adhere to the framework that determines this should happen. 216. In visits to the nursery, the EYRI spoke at length the owners of the nursery, observed practice, viewed a number of staff files, and met with practitioners. Practitioners did not disclose anything of concern, and observations of practice did also not raise any further concerns. C80’s personnel file was not available at the nursery at any point, as it had been taken by police as evidence. The file was not requested by the EYRI as they had been concerned that this would have interfered with the police investigation. Viewing the file may have highlighted issues with the timing and details of reference requests, which may have led to further probing and questioning. 217. Once concerns were raised regarding further staff members at the setting, regarding physical interventions, others witnessing this and the lack of awareness of this by owners, local partners explicitly raised concerns about the safeguarding culture and practice in the setting to Ofsted representatives. Ofsted Inspectors that had viewed CCTV footage and subsequently visited the nursery to explore the culture of the setting are noted to also have carried these concerns. The visit at this time focussed on observations and staff discussions, these gave no cause for further concern. Ofsted have identified that the time spent at the setting was limited (as Inspectors had also spent time reviewing CCTV nearby) which could have impacted on their ability to carry out their investigations. The suspended members of staff were not approached by Ofsted at this time, which could have provided vital information to enable Inspectors to probe further. Members of staff were much more open and descriptive about the culture of the setting once its registration had been suspended. 218. It is clear that Ofsted Inspectors were required to follow the due processes relating to their own guidance, and this, at times was in conflict with local partner expectations and concerns regarding children in the setting. Partners regularly challenged and questioned decisions made by Ofsted inspectors through their attendance at gold and silver command meetings, and on most occasions partners presented as concerned but satisfied with next agreed courses of action. It is not clear if Ofsted representatives were invited to every part of every meeting or if they were able to attend all of the sessions, perhaps due to their own limited resources. It is clear that at key points in this case there was a continued level of dissatisfaction from some of the local partners. Escalation of concerns to a more senior / regional level within Ofsted was considered at times, although not actioned or completed. Ofsted representatives held internal case discussions at appropriate stages in the management of this case, these were single agency. Consideration of a including a lead partner (in Learning Point: Regulators and inspectors can adopt an ‘it could happen here’ approach when visiting settings following safeguarding incidents or concerns being raised. Learning Point: Criminal investigations and evidence gathered as part of this, are not a barrier to seeking essential information that is required by regulators, this should be clarified and reinforced to inspectors. Learning Point: Appropriate time is needed in such serious cases to ensure full investigations can take place to inform decision making by regulators. Past employees may offer a more open and descriptive view of settings where there are concerns about safeguarding practices. 51 these cases the police SIO), particularly where there is remaining concern about the thresholds and actions being taken may enable a stronger sense of working together to safeguard children. 219. The National Child Safeguarding Practice Review Panel and TSCP leads had communicated regularly regarding the type and level of review to undertake at points within the period of this review. It is evident that there was a change in direction communicated by the National Panel over the course of that period in terms of the type of review that was being suggested. The eventual decision that this should be a local review was due to practicalities related to the onset of the Covid 19 pandemic. Torbay partners had undertaken other activities to quality assure responses including an independent review of partner responses to the allegations and a local Rapid Review. The latter took place later than the statutory timescales that are detailed in Working Together 2018. This, and the need for a Serious Incident Notification was prompted by the National Panel in one of their communications to TSCP. Local leads asked for clarification on regarding thresholds for these and both then took place. The reasons for this delay were linked to interpretation of statutory guidance and criteria for notification / review, but are also explained by partners as potentially due to a change in local partnership arrangements from a regional safeguarding children partnership to one more local to Torbay. Learning Point: In order for children to be fully safeguarded in responses to such complex cases, local partnerships and regulators need to work together, sharing appropriate levels of information to inform their work and aid in decision making. Where concerns are raised and responses deemed unsatisfactory to achieve this, escalation of these concerns, between appropriate senior leaders, should occur. Learning Point: The combined learning from previous reviews has been included in this CSPR and is presented as part of this report. Decision making related to the nature and type of review required by the National Panel and TSCP caused some delay in the commencement and completion of this CSPR. 52 Good practice in C80’s case history. 220. Safeguarding Partnerships can learn as much from good practice as it can from practice requiring improvement. In the course of this review examples of positive practice have been demonstrated, including the following: • There were timely multi agency interventions to protect C80 and his siblings once in Torbay area. Therapeutic work was commissioned and was making good progress prior to it ceasing. • C80’s voice was represented well at times, because of the contacts he had with the advocacy service, and this was fed in regularly. A male CCW from children’s services provided consistency and role modelling for C80 at a time when there was high turnover of social workers. • There is evidence of shared multi agency knowledge regarding C80’s missing episodes, particularly relating to C80’s mother’s role in these. • Safeguarding work by the Local Authority with early years providers is regularly evident including termly Designated Safeguarding Lead (DSL) meetings, training, and self-assessment safeguarding audits. LADO work has developed well with early years settings to build relationships and awareness. • An open and engaged partnership approach to safeguarding has been demonstrated in the engagement in this review, demonstrated by panel and also by the positive input of practitioners to the process. There is clear evidence of improvements in leadership and practice in Torbay since this time. • Partners coordinated responses to the incident well while protecting evidence, through regular and well attended gold and silver command meetings. 53 Recommendations The following recommendations are made in the light of the learning from this review. Unless otherwise stated, these recommendations are for the Safeguarding Partners as TSCP: 1. Develop a partnership wide restorative / trauma informed approach in systems for care experience children, specifically: • Education (pre and post 16) relating to behaviour / disciplinary approaches • Placements and suitability assessments • Working with hostile and coercive parents • Language used and recording concerns 2. Raise awareness of the impact and indicators of child sexual abuse with practitioners and carers of care experienced children. 3. Seek assurance of partners responses to sexual abuse particularly the communication of a child’s experience in referrals, plans and assessments. 4. Ensure timely delivery of Life Story Work with care experienced children, and that where therapy is commissioned for a care experienced child that: • It is completed when there is placement disruption • Recommended assessments take place • Progress of this informs care planning 5. Consider ways to improve the confidence of local practitioners in distinguishing between ‘normal’ age-appropriate relationships and behaviour that may cause concern. 6. Ensure that consideration is given to implement best practice tools for assessment (incl. Brook Traffic Light Tool) within TSCP’s current review of HSB policy / procedures. 7. Seek assurance of the implementation of improvements to the post 16 offer to care experienced children – specifically personal advisor provision, pathway planning and virtual school. 8. Request assurance of quality and timeliness of handover of safeguarding information between secondary and post 16 education providers. 9. Seek assurance that robust commissioning processes are in place for independent residential care providers and that this includes requirements of the placing LA to meet needs of child in standard operating procedures as well as use of the TSCP Allegations Management Procedure. 10. Ensure all practitioners, including early years and childcare settings, understand how to respond to concerns relating to under 18’s / apprentices working in positions of trust, and the role of the LADO. 11. Ensure ‘out of hours’ access to LADO related advice and support 12. The Department for Education (DfE) should provide statutory guidance for post 16 education providers relating to safer recruitment procedures for students enrolling on childcare courses. 13. Ensure all early years and childcare settings aware of TSCP Safe Recruitment procedures specifically in relation to standards relating to seeking pre-employment references 14. Seek assurance from schools and colleges to ensure there is proactive contact with employers when references are refused or sent incomplete as a student is deemed as not suitable for work in a position of trust with children or other vulnerable people. 15. Provide clarity to education settings and other partners regarding GDPR and what can be included in references relating to students 16. DfE should review the EYFS framework in the light of this review, specifically in terms of: a. Providing statutory guidance on safe recruitment requirements and pre-employment checks to mirror expectations in KCSIE for schools and colleges 54 b. Defining further what is meant by ‘competent and responsible’ in terms of those under 17 working in early years settings c. Clarity of use and purpose of CCTV in early years settings d. Identifying safeguarding concerns relating to the layout and design of toilets and areas used for intimate care. 17. Early years settings and childcare providers should reflect on the learning points highlighted in this review, evaluating their safeguarding practice, and setting culture, through a lens of ‘it could happen here’ 18. Raise awareness of whistleblowing procedures and the national Whistleblowing Advice Line specifically targeting frontline, early years practitioners. 19. Consider ways develop safeguarding assurance work with EY settings, such as ‘deep dive’ audit work and practitioner involvement to address themes from this review and adherence to safeguarding related elements of the EYFS guidance, specifically regarding: • Inclusion of under 17’s in staff: children’s ratios • Supervision of under 17’s • Safeguarding within supervision and observation of practice • Staff feedback and monitoring of practice (including CCTV) • Record keeping where physical intervention used / process for informing parents • Whistleblowing practices including record keeping and Ofsted notification where statutory criteria met. 20. Develop a framework for responding to complex and high-profile safeguarding issues that includes from the outset. • assigning a single officer to take a ‘helicopter or balcony’ view of the process • providing a single point of contact for parents / stakeholders • ensuring communication is sent from an independent organisation • Sending proactive, coordinated communication that reaches all stakeholders • Providing specialist support to those affected. 21. Ensure practitioners and leaders are aware of and utilise TSCP escalation policy, and that this and other escalation routes are used as necessary to safeguard children 22. Ofsted should use the lessons learnt from the independent review to influence regulatory policy and practice, and to brief inspectors inresponding to serious incidents and/or allegations in regulated settings. 23. Ofsted and the National Police Chiefs' Council should develop a joint protocol to support working together when responding to serious incidents in regulated settings, including: • Opportunities for joint work within parameters of investigation • Contact points for both parties • Information sharing to enable full consideration of thresholds for interventions • Participation in local multi agency meetings • Escalation routes for local partners within Ofsted. |
NC50682 | Death of a 16-month-old boy in March 2017 due to a non-accidental head injury. Child Ns father assaulted him and seriously injured his female twin, Child O. Family had moved from Haringey to Hackney a fortnight before the incident. Fathers workplace raised concerns about the amount of time he was taking off work. Father contacted Hackney Childrens Social Care alleging mother had had an affair and assaulted the children. Mother reported paranoia and controlling behaviour by father. Call to emergency services by member of the public reporting incident. Father pleaded not guilty to murder, admitted manslaughter on the grounds of diminished responsibility. Sentenced to indefinite detention in October 2017. Family had limited involvement with universal services. Father arrived in UK on a student visa and served papers as an over-stayer, with no recourse to public funds. Father of Bangladeshi origin; Mother is Romanian. Learning includes: practice should be sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family; communication, information sharing or service delivery, should be fluid between those working normal office hours and others providing out of hours services. Recommendations include: promote the learning from this SCR, ensuring that issues relating to faith or culture do not dilute safeguarding responses for children exposed to domestic abuse; audit the use of interpreters at new birth/new contacts and the extent to which the health history of involved fathers (mental health, substance misuse, other impacts upon parenting) is being captured.
| Title: Serious case review: Child N and O. LSCB: City of London and Hackney Safeguarding Children Board Author: Fergus Smith Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CITY OF LONDON & HACKNEY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD N & O FERGUS SMITH Published May 2018 Contents 1 INTRODUCTION 1 1.1 Event triggering this serious case review & known background 1 1.2 Purpose, scope & process of the review 2 2 SIGNIFICANT EVENTS 4 2.1 Use of universal services prior to review period 4 2.2 Review period 5 3 POST INCIDENT RESPONSE 11 3.1 Introduction 11 4 ANALYSIS / RESPONSE TO TERMS OF REFERENCE / LEARNING 13 4.1 Introduction 13 5 CONCLUSIONS & RECOMMENDATIONS 17 5.1 Conclusions 17 5.2 Recommendations 17 6 GLOSSARY: ABBREVIATIONS / PROFESSIONAL ROLES 19 CAE 1 1 INTRODUCTION 1.1 EVENT TRIGGERING THIS SERIOUS CASE REVIEW & KNOWN BACKGROUND 1.1.1 On 18.03.17 child N (a 16 month old male) was assaulted by his father. His female twin (child O) sustained serious injuries in the same incident. Child N was brought to Royal London Hospital in full cardiac arrest by the Helicopter Emergency Medical Services (HEMS) and pronounced dead. His twin was transported to the same hospital then via the Children’s Acute Transport Service (CATS) to Kings College Hospital for further treatment. Father subsequently pleaded not guilty to murder, admitted manslaughter on the grounds of diminished responsibility and in October 2017 was sentenced to indefinite detention. 1.1.2 The family had limited involvement with universal services in Haringey and had only lived in Hackney for about a fortnight before the children were assaulted. 1.1.3 Father, who originates from Bangladesh had first arrived in the UK (possibly via Romania) on a student visa on 22.01.10. He was served papers on 03.10.14 in respect of him being an ‘over-stayer’ and in consequence, had no recourse to public funds (NRPF)1. He initiated an appeal on 12.01.17 which remains outstanding. The twins’ mother, who is of Romanian origin, has a right to reside in the UK. 1.1.4 Mother and the children (and latterly father) were registered with a GP in Haringey. Father was not (so far as is known) in receipt of any other public services and he had no criminal record in the UK. CONSIDERATION OF A SERIOUS CASE REVIEW 1.1.5 The independent chairperson of the City & Hackney Safeguarding Children Board (CHSCB) made an immediate decision on 20.03.17 that the required criteria for completing a serious case review (SCR) (reproduced in paragraph 1.2.1) were satisfied for both children. 1.1.6 The Department for Education (DfE), regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE)2 were informed of the above decision and this review was undertaken between April and October 2017 in accordance with the terms of reference (reproduced in section 4). 1.1.7 Following approval by the CHSCB, a copy of this report is being sent to the NPIE and to the DfE. 1 No recourse to public funds (NRPF) is a condition imposed on someone due to her/his immigration status. S.115 Immigration and Asylum Act 1999 indicates that a ‘person has no recourse to public funds’ if s/he is subject to ‘immigration control’ e.g. a visa ‘over stayer’ such as child N&O’s father 2 The NPIE was established by central government in 2013 in order to advise LSCBs on the initiation and publication of SCRs. CAE 2 1.2 PURPOSE, SCOPE & PROCESS OF THE REVIEW 1.2.1 Regulation 5 of the Local Safeguarding Children Board Regulations (LSCB) 2006 requires LSCBs to undertake reviews of ‘serious cases’ in accordance with the statutory guidance in Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and either the child has died or has been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local, or if relevant, national services. A SCR is not concerned with attribution of culpability (a matter for a criminal court), nor (when that is relevant), the cause of death (the role of a Coroner). 1.2.3 The period of review was agreed as being from the birth of the twins (November 2015) to the date of their assault. It also considered issues of relevance emerging from the dates of the parents’ respective arrivals in the UK and the post-incident responses by local agencies. 1.2.4 An independent report was commissioned from www.caeuk.org so that on the basis of material supplied (a merged chronology of agencies’ contacts and self-critical individual management reviews), the lead reviewer would: Collate and evaluate it Conduct consultation / learning events with relevant professionals and Develop for consideration by the SCR review team a narrative of agencies’ involvement and an evaluation of its quality, conclusions and recommendations for action by the CHSCB, member agencies and (if relevant) other local or national agencies 1.2.5 A consultation event with relevant professionals was planned for a point when the sequence of events and issues arising from them were sufficiently clear. The aims of such involvement were to ensure the accuracy of information within the report, to justify or amend provisional conclusions and to encourage acceptance and application of the learning that was emerging. 1.2.6 The SCR review team was comprised of representatives from: The City & Hackney Safeguarding Children Board (CHSCB) The City & Hackney Clinical Commissioning Group (CCG) Hackney Children’s Social Care The Metropolitan Police Service (MPS) CAE 3 AGENCIES’ CONTRIBUTIONS 1.2.7 The following agencies supplied information to the SCR: Haringey CCG (GP Services for mother and children) Whittington Health NHS Trust (midwifery & health visiting services) Hackney Children’s Social Care (First Access & Screening Team) London Ambulance Service (LAS) NHS Trust (responding to the incident) Metropolitan Police Service (MPS) (responding to the incident) FAMILY INVOLVEMENT 1.2.8 The parents were informed that a review was being completed though the need to avoid undermining the criminal investigation necessitated postponement of their involvement. TIMETABLE FOR COMPLETION OF SERIOUS CASE REVIEW Event Target date Decision to initiate serious case review & formal notifications 20.03.17. Initial scoping meeting 11.04.17 SCR review team meeting 1: planning the review process 05.05.17 SCR review team meeting 2: consideration of individual management reviews & a ‘preliminary’ overview 18.09.17 Submission of ‘draft 1’overview 29.09.17 Meeting with mother of child N & child O 30.10.17 Staff learning event 31.10.17 Submission of final ‘draft 2’overview 31.10.17 Quality assurance with SCB Professional Adviser 13.03.18 & 10.04.18 STRUCTURE OF CHILDREN’S FAMILY Father Mother Child N Child O CAE 4 2 SIGNIFICANT EVENTS 2.1 USE OF UNIVERSAL SERVICES PRIOR TO REVIEW PERIOD CONSULTATIONS WITH GP PRACTICE 2.1.1 Mother is known to have been registered with a GP Practice and on occasions consulted doctors there for routine reasons unrelated to this SCR. Father was not at this time registered with any GP. ANTE-NATAL CARE 2.1.2 In late April 2015 a GP referral for ante-natal care was made to Whittington Hospital Maternity Service. The referral contained no grounds for concern about mother or her unborn child/ren. At her initial appointment the estimated date of delivery (EDD) was the end of December. 2.1.3 Mother reported having a supportive partner and although asked, made no reference to past or current domestic abuse. She reported no history of mental health conditions in either parent. Mother’s ethnicity was recorded as a Romanian Christian and father’s as a Bangladeshi Muslim. 2.1.4 The pregnancy was initially evaluated as ‘low risk’ though subsequently raised to ‘high’ when a scan was completed 18 weeks into the gestation and a revised EDD calculated. In July 2015, anti-natal care was appropriately transferred to a specialist ‘Twin Clinic’ and routine medical needs of mother addressed. Mother engaged well with ante-natal care, attending 12 appointments in total. Records do not indicate whether father was present on any of those occasions. BIRTH & IMMEDIATE MIDWIFERY SUPPORT. 2.1.5 It is known that father was present at the birth of the twins (which for medical reasons had been induced). The GP Practice received a routine confirmation of the event. Comment: Ante-natal and labour-related documents should capture the presence of a partner. 2.1.6 The day after the discharge of mother and babies (day 6 post-birth), when they were accompanied by father, the midwife completed a home visit. The babies were overdressed and advice was offered. Mother described her partner as ‘supportive’, although records do not make it clear if he was present. 2.1.7 A further visit was made at day 11 when both babies were seen to be thriving. Routine advice was offered and a formal handover from the midwife to the Health Visiting Service was completed. CAE 5 2.2 REVIEW PERIOD NEW BIRTH VISIT & PLANNED FOLLOW-UP 2.2.1 At the new birth visit completed by a ‘bank’ health visitor HV1 both parents, babies and the maternal grandmother were present. Reportedly because he was working ‘nights’, father was asleep throughout the visit. The accommodation (a studio flat) was described as spacious and well organised. The kitchen and bathroom facilities which were shared were clean and well maintained. It was reported that the family was due to move to larger accommodation. 2.2.2 No interpreter was used for the visit and in HV1’s view, mother’s command of English was ‘reasonable’. No family history of mental health difficulties or substance misuse was identified. Discussion of the possibility of domestic abuse was prevented by the presence of father and the maternal grandmother (who was reportedly going to remain for two or three months). 2.2.3 Mother said that both she and her partner had come from Romania and was advised to encourage her partner to register with a GP. 2.2.4 At a GP / health visitor liaison meeting a couple of weeks later (attended by a different health visitor HV2), the birth of the twins and a consequent need for additional support was noted. Father’s need for a GP was not discussed. Comment: such liaison is good practice; the proposed ‘enhanced’ level of health visiting did not imply any specific grounds for concern. 2.2.5 Because the twins weighed less 2.5Kg, a follow-up visit was agreed and completed in late November 2015. The twins were gaining weight. Both parents were present and HV1 informed them of local sources of support such as Home Start and Children’s Centre Outreach. Grandmother was reported to be due to return to Romania in March 2016. The issue of father’s lack of a GP was not discussed. Comment: it seems that HV1’s stated intention of further contact in January 2016 (whether at home or in clinic is uncertain) was not followed through; there is no record to confirm that HV1 sent the family any details of local sources of support. 2.2.6 In early December 2015 father did register with a GP and confirmed his ethnicity viz: his mother was Romanian and father from Bangladesh. 2.2.7 At a post-natal check-up completed just before Christmas 2015 mother was accompanied by her partner. About 2 weeks later the twins’ routine 8 week check revealed no concerns and included a reference to the support being offered by their maternal grandmother. The children were given their first immunisations on this occasion. Mother’s anxiety which was observed by a now retired nurse, was assumed to reflect only the additional demands of twins, remained unexplored and resulted in no additional action. CAE 6 REFERRAL TO PAEDIATRIC CLINIC 2.2.8 Prompted by a minor skin anomaly detected by HV1 at the time of her visit at the end of November 2015 (though not at birth or the initial baby check), the GP referred child N to a paediatric clinic. At a further presentation by both parents of child N in January 2016 it was noted that the family had not received an offer of a hospital appointment. A re-referral was initiated and child N subsequently examined a week later by a paediatrician. S/he in turn referred child N to a dermatologist. Records do not specify whether both parents were in attendance on these occasions. 2.2.9 When treatment of child N began a few days later both parents were present and shown how to administer the prescribed medication. There were two further appointments associated with child N’s condition in early February 2016. Treatment administered by parents continued for some months and proved effective. 2.2.10 The second immunisations of both children had been administered on in early February 2016 but the children were not presented for their third 4 weeks later. The children eventually received them in November 2016 when this anomaly was recognised. GP CONSULTATIONS 2.2.11 Child O and child N were presented to the GP Practice by both parents in late February 2016. No concerns about the care of the children or the parents’ behaviour were noted. 2.2.12 In April 2016 mother consulted her GP over a minor medical matter. This was the last occasion on which she was seen in her own right before the assault on the children a year later. Comment: though father had almost always been present at the twins’ various health appointments, he was not present on this occasion. 2.2.13 By August 2016 parentally-administered treatment of child N was successful enough to enable discharge from the dermatology clinic. 1 YEAR DEVELOPMENTAL REVIEW 2.2.14 The family was not followed up in January 2016 as intended by HV1 and the next contact with the Health Visiting Service was in December that year when the standard 1 year developmental review was completed by a community paediatric nurse. A 14 month ‘Ages and Stages’ questionnaire was completed with mother. Both children were noted to be progressing well and to have a loving and secure relationship with their mother. Mother was regarded as engaging positively with health advice offered. Records do not confirm the presence or absence of father. CAE 7 2.2.15 The case was at this point allocated for universal health visiting service and the next routine contact would have been a 2 year developmental review. 2.2.16 Though records do not confirm which parent presented them, both children were seen by a GP in late December 2016 and reassurance offered about a minor childhood condition. No further contact with health agencies took place until the developments in March 2017 described below. 2.2.17 It is understood that the family moved on 01.03.17 from address 1 in Haringey to address 2 in Hackney. AN ALERT FROM FATHER’S WORKPLACE 2.2.18 On 13.03.17 the same bank health visitor (HV1) who had completed the initial birth visit received a call from the manager of the hotel at which father was understood to be an employee. The manager reported concerns about how much time father was taking off work. She also referred to father’s claim that he needed to be at home so as to keep the children safe. Father was thought to be present during this conversation. 2.2.19 HV1 agreed that the manager would encourage father to contact Children’s Social Care and if he did not, then the manager undertook to do so. HV1 confirmed the family’s new address in Hackney and offered advice about the nearest Health Centre. The health visitor planned to complete a transfer summary and meanwhile provided a verbal handover to the Health Visiting Team at the relevant Health Centre. Comment: in response to an unusual situation, HV1’s responses were sensible and proportionate to the known facts. FATHER’S CALL TO HACKNEY CHILDREN’S SOCIAL CARE & FOLLOW-UP First Access & Screening Team (FAST) 2.2.20 On Monday 13.03.17 father made a phone call to Hackney Children’s Social Care First Access & Screening Team (FAST)3. He confirmed the family’s move on 01.03.17, which he said had been prompted by his partner having an affair with one of the male residents in the shared Haringey house. He reported mother had been having sexual intercourse with this individual with the twins present in the bed. Father claimed to have a recording of such behaviours on his mobile phone. 3 FAST (comprising co-located Police, Health, National Probation and Children’s Social Care staff) was established in October 2015 and screens all incoming referrals to establish whether they meet the threshold for ‘statutory social work intervention’, ‘early help support’, ‘advice and guidance’ or just information. CAE 8 2.2.21 Father made generalised comments about mother shouting and slapping the children though offered no dates or times. He thought she was not ‘normal’. He said that he had raised these issues with his partner since January 2017 but matters remain unchanged. Father also reported (inaccurately) that the children were not registered with a GP though (correctly) that they had received their standard immunisations. Initial response 2.2.22 The social worker to whom the referral was passed noted her concern about father’s reported response to his partner’s behaviour and recommended further checks as follows: ‘Is the mother in a sexual relationship with another male and who is he?; does she understand the risks if she is having sex with the children present?; does the mother find the children’s behaviour challenging and does she need support to manage them: - establish the nature of her relationship with the children’s father and screen for any concerns around domestic violence’ 2.2.23 The record indicates a need to check whether a health visitor had recently seen the children, whether they were registered with a GP and ascertain whether there were any concerns about the family whilst in Haringey. A visit by ‘Early Help’ was recommended if efforts to contact the mother were unsuccessful. The case was held in FAST for completion of initial checks and a discussion with mother. Comment: the response to the referral was thoughtful, and appropriately drew on management advice; records do not indicate whether the father’s affect or speech patterns were noteworthy. First follow-up 2.2.24 Phone contact was established with mother on Wednesday 15.03.17. Via an interpreter, a shocked mother responded to the allegations made by her partner and said that they were ridiculous. She described a relationship of some five years duration which, although not perfect, was ‘OK’. Mother described differences of view about women’s roles rooted in their differing religious allegiances. She spoke of her partner’s suspicious and restrictive conduct as ‘stressing her out’ e.g. calling her a slut and thought her mother’s imminent arrival would help. Comment: apparent cultural sensitivity / relativism should never diminish the unacceptability of domestic abuse. 2.2.25 Mother reported that she had persuaded her partner to attend the GP the next day (16.03.17) to seek advice on what she perceived to be his cannabis-induced distorted thinking and occasional hallucinations. Mother expressed confidence that father would not hit her or the children (though acknowledged her siblings’ concern that he might). CAE 9 2.2.26 Mother explicitly denied ever hitting her children and reported that her partner had not raised his concerns with her. She referred to him initially using cannabis at a time when (feeling unwell in the early stages of pregnancy), she had returned to spend time with her mother. 2.2.27 The social worker confirmed with mother that she knew what to do if she felt unsafe, discussed a referral to the ‘Domestic Abuse Intervention Service’ DAIS (to which mother agreed) and undertook to liaise with the Health Visiting Service. Arrangements were subsequently made for a ‘transfer-in visit’ by the local Health Visiting Service who were briefed about the referral, concerns about domestic violence and the current absence of a local GP. Second follow-up & acknowledgement of domestic abuse 2.2.28 On Friday 17.03.17 the social worker learned in a phone conversation with father that he had not, as planned, attended the GP Practice. He repeated his allegations, admitted current use of cannabis and referred to the use of cocaine some five years previously. The social worker described this conversation as being frustrating because father kept repeating his sense of helplessness without being able to elaborate. Comment: responses continued to be cautious and proportionate. 2.2.29 The social worker contacted St Anne’s Hospital in Haringey and was advised on how to seek confirmation of any prior contact by the father of child N and O with its Mental Health Service. Liaison with the Police Public Protection Unit revealed only a one-off contact with father some five years earlier at an address believed to be a brothel. On the same day, the social worker had a second phone conversation with mother (a different interpreter assisted). She laughed at the suggestion her partner had recorded her infidelity and spoke of waiting seven years to have children and that she would do nothing to harm them. 2.2.30 Mother spoke of her partner’s growing jealousy over the past two months, ‘often’ coming home during the day to check up on her (e.g. checking the cupboards, fridge and pantry apparently looking for men). She revealed that her partner had tied them together in bed with shoelaces so that he would know if she got out. She also disclosed that two weeks previously, father had slapped her in the face. She had not informed the Police and had accepted his apology. She described her partner’s stated wish to be helped, a reluctance to consult a doctor and his acute fear she will leave him. She said he was not in touch with any mental health services. Comment: the term ‘jealousy’ was recorded but the conduct attributed to father sounds more controlling and paranoiac than the jealousy a father might feel if a baby is consuming a disproportionate quantity of a mother’s time; it should be noted that the social worker at this point had no knowledge of father’s previous conversations with, or any concerns expressed by, his employer. CAE 10 2.2.31 The FAST social worker later again consulted her ‘screening and referral manager’. It was agreed that she should explore with mother her partner’s mental health and check with Mental Health Services in Haringey. The social worker was also tasked with undertaking a further discussion with mother about safety planning. Referral on to Domestic Abuse Intervention Service 2.2.32 Mother assured the social worker that she had no concerns about her personal safety. She reported that her brother was aware of the situation and held a key to the property. She was also confident that her partner would do nothing to harm the children whom, she said ‘he loved more than her’. Mother reported that her partner’s brother and mother had referred to previous depressive moments and fits of anger. 2.2.33 The twins’ maternal grandmother was due to arrive on Sunday of that weekend and mother said that they would work on persuading father to consult a doctor. Following Friday’s conversation, the social worker again consulted the screening and referral manager and initiated a late afternoon referral to DAIS. Comment: the responses were all justified and timely; nothing suggested the level of immediate risk that events next day demonstrated. TRIGGER INCIDENT 2.2.34 At 23.12hrs on Saturday 18.03.17 a member of the public made a 999 call and alerted Police to an incident at address 2. A female could be heard screaming. The caller also requested an ambulance for a ‘sick baby’. Two further calls were made by the same person and another caller rang to report that ‘someone is trying to kill their own children’ – the wife is screaming’. That caller indicated that the victims were twins and that they had been punched. 2.2.35 Officers arrived at 23.22hrs and within a minute placed an urgent call to London Ambulance Service (LAS). Two minutes later they requested helicopter transport and confirmed that there were two children with bleeding head injuries. At 23.24hrs the LAS declared the incident ‘critical’. 2.2.36 The children were transported to hospital as summarised in section 1 of this report. At 23.53hrs father called Police to offer his location and said that he had killed both children. Officers attended the location provided and completed an unsuccessful area search. Father was later detained. 2.2.37 LAS informed Hackney’s Emergency Duty Team of the events at 04.30hrs on 19.03.17 and on Monday 20.03.17 the case was allocated to the Service’s consultant social worker. On the same day Haringey’s Safeguarding Children Adviser (SCA) liaised with Hackney Safeguarding Children Team (Health) and received confirmation that the latter’s Children’s Social Care had accepted a referral the previous week. CAE 11 3 POST INCIDENT RESPONSE 3.1 INTRODUCTION 3.1.1 In an attempt to identify all possible learning, the CHSCB has sought to understand responses that followed immediately after the assaults on the twins. The ‘rapid response meeting’4 convened after the incident was informed that: A St. John’s Ambulance5 rather than a London Ambulance Service (LAS) vehicle has been dispatched to the incident A ‘year 1’ paramedic student made up half the crew The Royal London Hospital, to which the vehicle with child O was directed was only informed of an ‘unwell’ toddler, ahead of the vehicle’s arrival 3.1.2 Initial and supplementary reports supplied by the LAS were triangulated with those of the MPS and indicate the following detailed time-line: 23.12hrs – member of public (caller 1) made a 999 call and sought ambulance attendance at the home address for a ‘sick baby’ and Police attendance with respect to a screaming female. Caller 1 made two further calls repeating that request 23.15hrs – call received at the LAS Emergency Operations Centre (EOC) from attending police officers relaying what they had been told i.e. the need for an ambulance to attend a ‘sick baby’ 23.19hrs – A ‘caller 2’ phoned 999 to report that ‘someone is trying to kill their own children; the wife is screaming’; this caller specified that the children were twins 23.22hrs – police officers arrived on scene 23.23 – police officers sought urgent LAS attendance 23.24 the police officers sought Helicopter Emergency Medical Services (HEMS) and advised that there were two children with bleeding head injuries 23.24hrs The LAS EOC declared this to be a ‘critical incident’ 23.25hrs – A Fast Response Unit (FRU) of a paramedic and a student operating together constituting a ‘Joint Response Unit’ JRU6 ‘self-dispatched’ 23.30hrs - on the arrival of the above JRU, the crew were directed by police officers to the two patients and consequently alerted the EOC to this being a ‘high priority’ and confirming the need for the dispatch of a ‘duty officer’ and the HEMS 4 A ‘rapid response meeting’ is held after the death of any child in a local authority area. 5 The LAS currently contracts a small number of private ambulance providers to assist at times of peak demand. ‘St. Johns Ambulance’ was on duty as a paid contractor working alongside the Joint (with Police) Response Unit CAE 12 3.1.3 The LAS report acknowledges that a further (untimed in its submitted report) message had been received after the 23.15hrs alert by Police and indicated that ‘2 babies were bleeding from the head and that a male had attacked his family’. This may refer to the Police report of 23.24hrs from which time it was clear that the LAS had been informed of the presence of 2 injured infants. By 23.30hrs (18 minutes after the first call by a member of the public) LAS staff had been able to see the actual situation for themselves. Wholly understandably, the bereaved mother has described those minutes as feeling like hours and still struggles to come to terms with the fact that her son’s injuries were too serious to survive. 3.1.4 In consequence of the initial 999 call referring only to a sick baby and screaming female, there was a delay before accurately briefed and sufficiently skilled paramedical staff were on scene and able to help. Following application of extensive efforts to address the urgent medical needs of the children, the advance briefing offered by the JRU crew conveying child O to the Royal London Hospital was incomplete. 3.1.5 No evidence has been located to indicate that the above response made a material difference to the less severely injured surviving child (child O). The LAS has confirmed that its post-event de-briefing addressed the personal learning needs of the crew who responded as best they could in a rare and especially traumatic situation. 3.1.6 CHSCB is satisfied that the responses do not suggest any systemic weakness in the ability of the LAS to respond to such critical incidents. CAE 13 4 ANALYSIS / RESPONSE TO TERMS OF REFERENCE / LEARNING 4.1 INTRODUCTION 4.1.1 The ten elements of the agreed terms of reference have been reproduced below and the performance of each relevant agency evaluated. The broader learning that emerges is outlined in section 5. Were practitioners aware of and sensitive to the needs of the child in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? 4.1.2 The services provided by midwives and doctors prior to the birth of the twins appear to have fully satisfied respective professional standards. No cause for concern (other than the fact of mother expecting twins) was discerned. 4.1.3 After the twins were born, the responses of the midwife and subsequently the health visitor were timely and reasonably thorough. Father’s presence at the health visitor’s initial and follow up visits served to deny mother the opportunity for sharing any account or fear, of domestic abuse. The inability to address this issue should have been recorded by the health visitor. Furthermore, seeking and recording a response to the possibility of mental health difficulties or substance misuse was overlooked. 4.1.4 Mother had been asked about domestic abuse on three occasions during her ante-natal period though not at the point of discharge to health visitor care (current midwifery practice is reported to be that the issue is raised in accordance with NICE guidelines, at every maternity visit and the result recorded). HV1 should have captured her inability to address the issue in her records so that the need to raise it could be recognised and addressed at a future contact. 4.1.5 Nothing untoward had emerged from the family’s contact with local agencies until some two weeks before the incident. The health visitor’s response to the unusual and difficult call from father’s manager was a well-informed and proportionate one (though she could have agreed to pass on the concerns if neither the father nor manager did so). 4.1.6 The responses of Children’s Social Care staff in the week immediately preceding the death of child N were (in relation to the apparent urgency) prompt and logical. They recognised the possibility of father’s mental health and/or domestic abuse being a feature of the reported situation. 4.1.7 No formal assessment had begun and as such, the understanding of the children’s needs was based solely upon parental accounts and network checks. CAE 14 4.1.8 Mother’s confidence in her partner’s love of his children, reinforced by the imminent arrival of her mother served to indicate that there was little or no imminent risk of significant harm to the children. The social worker’s conversations with mother usefully served to increase her appreciation that she was experiencing some form of domestic abuse. When, and in what way, were the child’s experiences ascertained and taken account of when making decisions about the provision of services? Was this information recorded? 4.1.9 The records maintained by the health visitor confirm that she justifiably believed that mother was receptive to health-related advice. Observations of a consistently positive relationship between mother and her babies were captured. To the more limited extent that father was seen with the children, their degree of attachment or affection toward their father is less apparent. 4.1.10 The community paediatric nurse who completed the year 1 development check made good use of developmental instruments and recorded her observations of how the twins played and interacted. 4.1.11 Events overtook the responses being set in place by staff from Hackney Children’s Social Care, although the records maintained by the social worker make it clear that she was alert to the emotional impact on the twins arising from the levels of domestic abuse emerging from the initial accounts. What were the key relevant points / opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did you agency liaise / engage appropriately with other agencies? 4.1.12 The limited number of key points for assessment and decision–making were at: Ante-natal presentations of mother The birth of children N and O Peri-natal contact by midwife and health visitor Consultations with GP Practice in respect of mother or her babies Hackney Children’s Social Care response to father’s referral of 13.03.17 4.1.13 During the first four opportunities set out above, any additional level of need quite understandably reflected the fact of there being twins, rather than any perceived inability or deficit with respect to parenting. 4.1.14 The response by the FAST to father’s referral recognised the need and specified what should be assessed. The killing of child N occurred before that planned assessment commenced. CAE 15 4.1.15 Inter-agency liaison was also unremarkable. When the health visitor was alerted by father to his perceptions of the twins’ mother, she made an immediate oral link with the local Health Visiting Service provider. The assessment being planned by Children’s Social Care quite properly anticipated liaison with health visitors and GP. 4.1.16 The only recurring sub-optimal practice (amongst health practitioners) was the failure to capture the presence or otherwise of the children’s father or to explore his influence and impact on the children. Father’s failure to register with a GP was an entirely lawful choice and did not of itself, offer justification for action by any in the professional network, although HV1 could usefully have pursued the issue at her follow up meetings and formal liaison with the GP liaison. Did actions accord with assessments and decisions made? Were appropriate services offered / provided, or relevant enquiries made, in the light of assessments and was the family signposted to appropriate support? 4.1.17 All recorded actions by health professionals and Social Care staff accorded with the needs perceived at the time. The FAST worker was contemplating the involvement of ‘Early Help’. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 4.1.18 The above issue was of no relevance in this case. All communication and information sharing prior to the incident, was undertaken during office hours and without difficulty. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? 4.1.19 There were differences of opinion with respect to the question of how good mother’s command of English might be. Midwives, doctors and the health visitor regarded it as sufficient for their respective purposes. The FAST staff determined it to be necessary to communicate via an interpreter. 4.1.20 The above difference does not imply any insensitivity on the part of those whose judgements had been that mother’s understanding was sufficient. The approach taken by FAST was a cautious one, in the knowledge that an in-depth assessment was to be completed and likely to explore sensitive issues. 4.1.21 The potential implications for parents from such significantly differing cultures remained unexplored by the health professionals with whom mother (and to a much less extent father) had contact. CAE 16 Were senior managers or other organisations and professionals involved at points in the case where they should have been? 4.1.22 The liaison between midwives, health visitors, hospital staff and GPs appears to have worked well. In formulating a response to the contact by father the FAST worker appropriately sought and obtained management direction. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 4.1.23 Other than the issues identified in respect of poor recording, nothing has been seen that implies any significant departure from the professional expectations or procedural requirements of involved professionals. 4.1.24 The Children’s Social Care IMR identified some minor delays in an otherwise effective response to the presenting circumstances and the recommendations in section 5 reflect the organisational responses now required. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? & was there sufficient management accountability for decision-making? 4.1.25 Because the family had moved out of Haringey without notifying the Health Visiting Service in that borough, a local Hackney health visitor had not been allocated until the responses of the FAST social worker triggered the allocation process. 4.1.26 None of the involved agencies has identified any staffing or resource-related issue that impacted upon the services provided and nor has any evidence been found to suggest any lack of management accountability. CAE 17 5 CONCLUSIONS & RECOMMENDATIONS 5.1 CONCLUSIONS 5.1.1 Few if any events or observations that might hint at what was to come emerge from the period prior to or after the births of the twins. Until father’s call to the health visitor in early March 2017 nothing distinguished this couple from the many thousands of others in comparable circumstances. 5.1.2 Although there exists no grounds for supposing that even optimal responses would have made a decisive difference to the tragic event of March 2017, the case does reinforce the importance of: Identified or unidentified fathers in terms of potential value or risk Routine enquiries with respect to the possibility of domestic abuse The relevance of cultural / linguistic barriers to mutual understanding 5.1.3 The evidence from the records evaluated is that intra and inter-agency communication (whilst limited in quantity) was clear. 5.1.4 The additional pressure that twins impose on any relevant parent was recognised by health professionals and responded to appropriately. Whilst questions were beginning to form in the minds of health visitor and social workers about the mental health needs of father and mother, no differences with respect to risk is evident. 5.1.5 No agency or individual was able to (nor could be reasonably expected to) anticipate or prevent the actions taken by father within so few days of him raising his concerns about his partner. 5.2 RECOMMENDATIONS CITY & HACKNEY SAFEGUARDING CHILDREN BOARD 5.2.1 In its commissioning or delivery of training, the CHSCB should promote the learning from this SCR, with a specific focus on ensuring that issues relating to faith or culture do not dilute the safeguarding response for children or adults exposed to domestic abuse. WHITTINGTON HEALTH NHS TRUST 5.2.2 The Trust should: Audit the use of interpreters at new birth / new contacts Audit the extent to which the health history of involved fathers (mental health, substance misuse, other factors impacting upon parenting) is being captured CAE 18 CHILDREN’S SOCIAL CARE 5.2.3 An oversight mechanism is required in FAST so as to ensure timely completion of tasks and transfer of case for assessment. 5.2.4 Staff should be reminded that DAIS is able to contact those experiencing domestic abuse on the day of referral if requested to do so by phone. HARINGEY CLINICAL COMMISSIONING GROUP (CCG) 5.2.5 Haringey CCG should by means of its IRIS7 training, dissemination of NICE guidance and development of a ‘post-natal exanimation template respectively, encourage: Practice nurses to act on any concerns and escalate them appropriately Practitioners to ask depression-related screening questions at 6-8 week post-natal consultations GPs to see mothers alone at 6-8 week post-natal consultations 7 IRIS – (Identification and Referral to Improve Safety) is a general practice-based domestic violence and abuse training support and referral programme that has been evaluated in a randomised controlled trial. Core areas of the programme are training and education, clinical enquiry, care pathways and an enhanced referral pathway to specialist domestic violence services. It is aimed at women who are experiencing domestic violence / abuse from a current partner, ex-partner or adult family member. IRIS also provides information and signposting for male victims and for perpetrators. CAE 19 6 GLOSSARY: ABBREVIATIONS / PROFESSIONAL ROLES Agency / Abbreviation Meaning A&E Accident and Emergency Department EDD Estimated date of delivery DAIS Domestic Abuse Intervention Service EMIS EMIS Health, formerly known as Egton Medical Information Systems supplies electronic patient record systems and software used in primary care in England FRT First Response Team IRIS IRIS – Identification and Referral to Improve Safety LSCB Local Safeguarding Children Board MPS Metropolitan Police Service NICE National Institute for Health & Care Excellence NPIE National Panel of Independent Experts SCR Serious Case Review Hackney Children’s Social Care SW1 SW2 GP Service GP1 GP2 Hospital Trust Health Visiting Service HV1 HV2 Medical Services Addresses Address 1 Haringey Address 2 Hackney |
NC51230 | Review of the partnership response to child sexual exploitation (CSE) over two sites in January 2019. Commissioned following an Ofsted inspection of children's services and subsequent monitoring visits. Focuses on the current policies, procedures and practices, with a view to improving the outcomes and responses for children who had been or were at risk of CSE. Review included a literature review of policies and procedures relevant to CSE, analysis of seven case audits, focus groups with professionals, and conversations with young people and their caregivers. Identifies 14 areas for consideration representing issues which are national areas for development. Ethnicity and nationality not stated. Observations include: there was evidence of good recording and record keeping throughout the case audits; six out of the seven cases audited involved children in care, and the relevant statutory processes and CSE process observed worked well together; social workers welcomed moves towards reflective practice within children's services; professionals wanted further support to apply their existing skills to the online context to enable them to respond to online abuse and exploitation. Key areas of focus going forward include: consider reviewing training to ensure that it provides staff with the relevant knowledge and support they need to complete CSE risk assessments to quality assurance standards; ensure that professionals are aware that where there are safeguarding risks, consent is not required prior to making a referral; enhance work with children at 'low risk' of CSE to ensure an effective pathway and escalation process.
| Title: Child sexual exploitation review. LSCB: Kirklees Local Safeguarding Children Board Author: Phil Ashford, Kevin Murphy, Steve Baguley, Kay Wallace and Maria Cassidy Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Kirklees LSCB child sexual exploitation review Review Team Phil Ashford Kevin Murphy Steve Baguley Kay Wallace Maria Cassidy February/March 2019 NWG HQ Suite1, Innovation House East Service Road Raynesway Derby DE21 7BF CONTENTS: PAGE: Introduction: 1 Timescales and Methodology 1 Acknowledgements 2 The Reviewing Organisation 3 Overview 4 Observations 5 Key Areas of Focus Going Forward 8 Appendices 12 Nomenclature: KCS Kirklees Children’s Services KSCB CSE RAV team CE CCE NRM Kirklees Safeguarding Children Board Child Sexual Exploitation Risk and Vulnerability team Criminal Exploitation Child Criminal Exploitation National Referral Mechanism Introduction The NWG CSE Response Unit was commissioned by Kirklees Safeguarding Children Board (KSCB) to carry out a review of the current partnership response to child sexual exploitation (CSE). The review was commissioned following an OFSTED inspection of children’s services, and subsequent monitoring visits that have illustrated an improving picture. This review sits alongside a review of Historical cases and an overview of the current Contextual safeguarding strategy. It is intended that all the work will report together to give the Board a fuller picture of assurance. The main focus of this review was to examine the current policies, procedures and practices, with a view to improving the outcomes and responses for children who had been or were at risk of CSE. Terms of reference were established in liaison with KSCB which identified the following key lines of enquiry: 1. To provide independent specialist opinion into the current practice in regard to Child Sexual Exploitation, to include but not limited to current pathways into support. 2. To determine what steps have been taken to ensure practitioners are equipped to identify children and young people who are potentially at risk of being exploited and consider how effective these measures have been. 3. To review transition into Adult services, as well as considering how effective these measures have been in protecting children and young people through that transmission phase. 4. To consider the effectiveness of current CSE governance structures in Kirklees in relation to both operational practice and strategic oversight – with particular focus on the current Strategy, Action Plan and Risk and Vulnerability strategy alongside considering the multi-agency arrangements and information sharing. 5. To provide independent specialist opinion into the impact of the current support provided to the workforce regarding CSE including induction, training, supervision and case management. 6. To provide independent specialist opinion into the impact of partnership work carried out to raise the awareness of Child Sexual Exploitation with communities, businesses and non-safeguarding organisations. 7. Ensure that current practice learns from the past and has a strong strand of research evidence. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 1 8. To support the Board in developing new ways to hear the voice of victims and to use this to influence policy, practice and procedure. Review Timescales and Scope: • The review took place over two sites visits with the case audits held between 29th and 30th January 2019. The focus groups took place between 28th February and 1st March 2019. • The review covered the area for which Kirklees Council has responsibility for children and young people. • The review only considered live cases in the audit in order to ensure a focus on current practice. Methodology: • The review included a literature review of policies and procedures relevant to CSE, prior to the two site visits conducted by the CSE Response Unit. • KSCB initially provided the CSE Response Unit with an anonymised list of children known to be at risk of or have been victims of CSE in order to randomly select 10 cases. However, issues with gaining the consent of children and their parents led to the audit involving 7 cases. • Initial findings from the case audits were feedback to KSCB and contributed to the discussions facilitated by the focus groups. • As part of the focus groups, the CSE Response Unit had the opportunity to speak with the CSE Strategic Group, as well as three other groups of professionals, representing a diverse range of agencies and roles involved in tackling CSE in Kirklees. (See Appendix 2 for details of the focus groups) • The CSE Response Unit also had the opportunity to speak with a number of young people and parents and carers to gain their views on the current response to CSE. Acknowledgements: The CSE Response Unit would like to thank Kirklees Safeguarding Children’s Board for inviting the unit to undertake the review. We would like to extend our thanks to all participants who contributed to this work, for taking time out of their busy schedules and providing the unit with useful and relevant information to inform our conclusions and enable the writing of this report. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 2 We would like to particularly commend the open approach professionals took to the review, despite the current additional pressures facing practitioners working within the field of CSE in Kirklees. The CSE Response Unit would like to make specific reference to the tireless work of Sharon Hewitt, KSCB Board Manager, without whom the review would not have been possible. The Reviewing Organisation: The NWG has been assisting agencies and professionals with their responses to child sexual exploitation since 2009 and during that time has developed a wealth of knowledge and experience in the field. In 2015 the organisation’s CEO was involved in roundtable discussions which led to the formulation of the government’s Tackling Child Sexual Exploitation Action Plan. Since 2016 the NWG has hosted the government’s CSE Response Unit, specifically tasked with supporting practice. The NWG have previously supported national inquiries into child sexual exploitation in Scotland and Northern Ireland – four members of the response unit have contributed to the current Independent Inquiry into Child Sexual Abuse. In the past two years the CSE Response Unit has assisted over 20,000 professionals and has visited agencies across England to develop a broad understanding of both the issues and approaches to addressing it. During that time the unit has been commissioned to carry out seven strategic reviews of either individual agencies or partnerships’ responses to child sexual exploitation. These reviews have addressed a broad range in terms of lines of enquiry and have been co-designed in consultation with the commissioning organisation. Four members of the unit are experienced report writers, having written reports in relation to some of the work detailed above, as well as experience gained elsewhere in their careers – one member of the team is an LGA peer reviewer. . www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 3 Overview: Throughout the CSE Response Unit’s time in Kirklees the reviewing team spoke with a passionate workforce and observed a determination to tackle CSE and other forms of exploitation. Kirklees should be commended for taking the decision to adopt a contextual approach to safeguarding and will hopefully benefit from the ongoing support of Dr Carlene Firmin and the Contextual Safeguarding Network. Many of the areas for consideration are challenges which are not unique to Kirklees, representing issues which are national areas for development. The CSE Response Unit was encouraged to hear about the positive steps already taken by Kirklees in regard of the development of a response to wider forms of exploitation and a trauma-informed approach. This clearly demonstrates Kirklees’ recognition of issues and an openness to discuss them critically, as well as a desire to be amongst the best. This was demonstrated by the decision to commission this, and other reviews and the commitment to ensure practice is informed by evidence-based research. The reviewing team were also reassured by the swift response by senior managers to a concern raised by health staff regarding CSE notifications. This was dealt with immediately, suggesting that the system can respond with pace. The cases considered by the CSE Response Unit demonstrated a good standard of recording and excellent multi agency work in regard of children who are looked after and at risk of exploitation or those who have been victims of abuse, evidenced through the case audits and in discussion with the case holders and other professionals. KSCB’s ongoing quality assurance procedures should provide reassurances to a broader range of CSE cases than was possible in this review and this is clearly a part of the safeguarding system. Staff approached the focus groups with refreshing honesty and an openness to the challenges they currently faced and the opportunities to build on the progress already made as a result of local authority’s improvement plan At all levels professionals demonstrated a commitment to learning from previous local experiences as well as that from national experts. There was also a strong focus on putting children and young people at the centre. Kirklees is on a journey of continuous service improvement, which has been recognised by OFSTED in their monitoring visits. There has been an acknowledgement of need for swift action to get Kirklees into a ‘safe place’ so that further progression can be implemented. This has necessitated Leadership that is robust and directive. We heard of plans to increase opportunities to engage the front line more. There are clear plans for engagement of staff from all agencies in place as part of the shift to a safeguarding partnership. These plans also include the engagement of the CVS sector and of young people . This is intended to ensure the voice of children and young people contributes to strategic vision and operational service provision. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 4 Observations: Throughout the case audits here was evidence of good recording on Liquid Logic, children’s services’ electronic recording system, as well as clear analysis and evidence of management oversight of all the cases. The CSE Response Unit acknowledges that the Liquid Logic system has only recently been implemented and is not yet fully embedded, however feedback from social workers regarding the system and its ease of access was positive. Six of the seven cases audited involved children who are looked after, with the relevant statutory processes and CSE process observed to work well together. Social workers who contributed to the audit welcomed a move towards reflective practice, which is currently being embedded within children’s services – a move to adopting this approach universally for all staff would be encouraged by the CSE Response Unit. Reflective practice is the ability to reflect on one's actions so as to engage in a process of continuous learning. Those practitioners spoken to reflected that further support to apply their existing skills to the online context, as well as additional skill and knowledge development would be beneficial to assist them to respond to the issue of online abuse and exploitation, as well as being supported to take a more trauma-informed approach to their practice. . From the evident recording, it was not always clear that professionals had a clear understanding of consent or were applying it consistently in regard of children and young people. It should be recognised that the case audit sample size was small, however further concerns were raised in the focus groups regarding this issue. It is recognised nationally that there are tensions around consent in the case of exploitation, where individuals may not see what is happening to them as abuse. This issue has been picked up by the KSCB in both the decision-making Framework and as part of the CSE training. The Authority has invested in considerable work at the front door with Prof David Thorpe to ensure a clearer understanding amongst professionals. Transition arrangements were clear from the audits in cases involving looked after children and those children with special educational needs. However, attendees at the focus groups identified transition arrangements for other children as they moved into adulthood, including police responses and mental health support as an area that would benefit from further development. It was recognised as a positive step that the RAV team keep cases open for three months after children turned 18. The recording of information accurately is an issue identified by managers and is being addressed www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 5 Multi-agency feedback from the focus groups and police input to the case audit process identified the need to ensure consistent application of risk and need, considering information from a range of agencies. The assessment arrangements are still new and The CSE Response Unit expects KSCB will be able to address this, and the timely sharing of information between partner agencies, through existing quality assurance processes. Risk assessment meetings were often bolted onto statutory meetings, which is not necessarily an issue in itself, however it was not always clear from the recording that the purpose of the risk assessment meeting was met taking this approach. Young people spoken to by the CSE Response Unit were knowledgeable about CSE as a result of awareness raising campaigns which they accessed through schools and colleges. Young people identified a number of locations of concern for them and their peers – Kirklees’ adoption of contextual safeguarding should help address such locations. The CSE Response Unit had the opportunity to speak with a limited number of parents and carers who were complimentary of the services available to them and for children and young people. This is a strength. Professionals welcomed the recognition of the need as set out in the contextual work, to move towards a more trauma-informed response to supporting children affected by exploitation. A number of teams represented at the focus groups had benefited from trauma training and were keen to see this rolled out to colleagues. Trauma informed practice requires an organisational structure and framework of support that involves understanding, recognising, and responding to the effects of all types of trauma. Health professionals raised concerns that CSE notifications were no longer being sent to the local Accident & Emergency Department. This matter was raised with senior management by the CSE Response Unit and addressed immediately. Both professionals and young people spoken with lamented the loss of the youth service, with young people keen to see centre-based provision. Kirklees has already begun work to look at youth provision across the Borough and is undertaking this work with the CVS. The issue of budgets and the non-statutory nature of youth work has made this a national concern and it is positive that Kirklees is taking a proactive approach. A review has been commissioned to capture the voice of young people in regard of youth provision. The social worker focus group discussed concerns regarding the support of children identified as ‘low risk’ and the need to intervene at the earliest possible opportunity to prevent harm. The www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 6 development of the Early support strategy and its roll out to localities will assist in this regard as part of a preventative offer . Police officers and social workers engaged with as part of the focus groups raised concerns about children being placed in Kirklees from other areas. Staff recognised the value of Kirklees striving to avoid placing its children out of area. Professionals also recognised the good work carried out by care providers in Kirklees and identified one specific home, Ruby Lodge, as demonstrating excellent practice. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 7 Key Areas of Focus Going Forward: 1. Use of the Assessment Tool The review team recognised Kirklees' existing use of audits as an area of strength, which could support the embedding of work to look at the use of the assessment tool within the existing audit timetable. KSCB may consider it beneficial to undertake regular audits of the new ‘CSE risk assessment tool’ process, which was implemented in August 2018. 2. Review of Training Offer There is a comprehensive training offer in Kirklees which offers multi agency training including sessions on trauma-informed practice and an understanding of wider forms of exploitation. KSCB may consider reviewing the training which has been put in place for those workers in locality teams, who now complete CSE risk assessment tool. This will help to ensure that the training is providing staff with the relevant knowledge and support that they need, to complete CSE risk assessments to the quality assurance standards of the KSCB. A review of training compliment work underway within the KSCB to consider the impact that training has on outcomes. Kirklees staff stated they would welcome further training. 3. Consent to Referral The review team noted that there had been recent changes and improvements to 'The Front door' including the consideration of the need to gain of consent prior to making a referral. The KSCB has also reviewed thresholds for making decisions in safeguarding. While it is clear that where there are identified safeguarding risks, consent is not required, a consistent message from across the partnership at the focus groups was the need for greater consistency around the interpretation and implementation of this issue. We are aware training has been delivered to staff around consent and referrals, however it may be beneficial to review the impact of the training. 4. CSE Notifications to Accident & Emergency Due to recent changes in Kirklees it was noted that CSE notifications to Accident and Emergency (A&E) were no longer being effectively sent. It is our understanding that this issue had not been raised with the strategic exploitation group. As soon as this issue was raised by the review team with the strategic lead from Kirklees, this was immediately resolved. This pace of the response is to be commended. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 8 5. Contextual Safeguarding Kirklees has approved through the KSCB a contextualised approach to exploitation, which has built on the work of the University of Bedfordshire. This approach is welcomed by Kirklees staff and is recognised as an extremely positive development by the review team. This is not as advanced in other authorities in the country as it is in Kirklees. 6. Trauma-Informed Practice Staff who participated in the focus groups were enthusiastic and welcomed the ‘Trauma Informed’ approach to exploitation, which Kirklees is committed to developing. KSCB are Working to examine the 'Adverse Childhood Experience' (ACE) model and how it will support embedding the contextual safeguarding work. 7. Implementation of Learning KSCB is responsive and promotes a culture of learning evidenced by reassurance given to the review team by KSCB, that the points for consideration from this review will be implemented through the contextual safeguarding strategy. The strategy is complete and is in the process of being shared with operational staff across the partnership. The review team welcome this, as this will give a shared understanding of Kirklees' vision to which all professionals operate. 8. Staff Engagement The review team recognise that Kirklees’ improvement journey for Children’s Services has required swift executive action, this has necessitated acting with pace, resulting in opportunities to engage with staff in discussion and developmental dialogue not being as extensive With the improvement now evident, the CSE Response Unit observed a commitment to a more inclusive approach. The review team noted that a practitioner forum has been developed under the new safeguarding arrangements. This forum will provide a line of sight from strategic management to frontline practitioner, allow staff consultation to take place and ensure that the voice of operational staff is heard at the highest level, influencing strategy and service provision within Kirklees. The review team welcome this approach. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 9 9. Youth Provision Kirklees like other areas across the country have had to implement substantial reductions in funding which have impacted upon service delivery. This is felt particularly in non-statutory services such as youth provision. Throughout the focus groups undertaken by the review team, there was a recognition that the loss of the youth service within Kirklees had had a significant impact, particularly on the engagement opportunities for adolescents. The review team noted that KSCB had undertaken a defined piece of work to consider the voice of young people and that with the new Director this was being expanded to consider youth engagement more broadly. This is will play a key part in Kirklees' development of their contextual safeguarding strategy. 10. Transition Arrangements Exploitation and the transition between Child and Adult Services is a national issue. The review team noted Kirklees’ commitment to improving existing transition arrangements for those affected by exploitation. Kirklees' approach to transition was apparent through their attendance at the NWG transition workshop held in September 2018. It is also encouraging that Adult Services within Kirklees are keen to develop a transition process and a potential adult services response to victims of exploitation. From the work we have undertaken during the review, Kirklees staff and The NWG review team would welcome this. 11. Online Exploitation During the focus groups staff gave feedback that they would welcome additional training and support in ensuring consistency when safeguarding and supporting children who were at risk of or being exploited online. The NWG recognises that Kirklees has developed a number of online tools, which could be further utilised to support this concern. The work on youth engagement will also support the development of young people as scrutineers in the new safeguarding partnership, sitting alongside the practice group referred to, this will ensure that the voice of workers and young people is at the heart of safeguarding practice. 12. Early Intervention The review team found evidence to support Kirklees’ self-assessment that working with children at ‘low risk’ of CSE, needs to be further enhanced. The review team also welcome Kirklees’ decision to embed Risk and Vulnerability (RAV) workers into locality teams to support staff in this area. The development of the Early Support Service and the accompanying strategy will provide an opportunity to ensure an effective pathway and escalation process for children assessed as ‘low risk.’ www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 10 13. Out of Area Placements The review team noted concerns from practitioners in relation to 'out of area' placements into Kirklees, with the availability of cheaper housing there are a growing number of private providers - this is a national challenge. The review team endorses and commends the steps Kirklees has taken to address this issue, including action by the Director of Children’s Services and KSCB’s independent chair to contact every placing authority regarding Kirklees’ expectations. The development of a ‘provider network’, which will promote consistency, enhancing the return home interview process including the sharing of intelligence. Kirklees have requested practice examples relating to the management of planning applications and supporting documents from other areas who are attempting to respond to this challenge. 14. Enhanced Parental and Family Engagement The review team heard from parents and carers who spoke highly of the support services available to both them and their children. Emerging responses to adolescent vulnerabilities and threats, external to the family home can support parents, carers and families to be involved in the safeguarding of their children. This is a national area for development in which Kirklees has an excellent springboard from which to enhance its engagement of parents, carers and families as it moves to a contextual response to safeguarding children. The new local safeguarding arrangements could provide an excellent vehicle for further developing dialogue and support for families affected by child exploitation. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 11 Appendices: Appendix 1 - The Review Team Phil Ashford is the Operational Lead for the CSE Response Unit – a Department for Education funded programme responsible for providing operational and strategic support for professionals and agencies tackling child sexual exploitation. Phil previously managed a multi-agency CSE service in Sheffield for 3 years, overseeing the integration of a range of agencies and professionals into the co-located service. Phil’s professional background is community safety, having spent 7 years working with police safer neighbourhood teams. Kevin Murphy is the NWG Response Unit’s Sport and Communities Lead. He was previously Head of Service for a local authority and held responsibility for 3 multi-agency teams, 6 Children Centre's and the Youth Service delivering services within a diverse and multi-cultural environment. He was also the Principal Education Welfare Officer and the strategic lead for missing children and chaired a monthly missing children MARAC. Steve Baguley is the NWG Response Unit’s Education lead, who specialises in services for this cohort. Steve has previously been a Head of Service for a local authority and helped to pioneer a project delivering integrated working across the children’s workforce, this received national recognition of delivering “change” across the children’s workforce. Steve has also managed a Connexions Service delivering support to vulnerable post 16 students which also included specialist health provisions and the leaving care team. Steve has visited over 80 areas in the country and has gained a national picture of working with vulnerable adolescents, especially in an exploitation context and the transition into adult services. Kay Wallace is the NWG Response Unit’s Police and Justice lead. She worked as a police officer for 30yrs, and investigated and managed child abuse investigations for over 26yrs of her 30yr police service. She was also a senior investigating officer and has managed many serious and complex child abuse and CSE investigations. She has managed CSE teams online and on street. In 2003 Kay implemented the Lord Laming recommendations for West Midlands Police, following the Inquiry into the death of Victoria Climbie. The changes were wide reaching and changed the culture of child abuse investigation in the police service. In October 2015, Kay took up the post of CSE regional coordinator for the West Midlands region and gained considerable knowledge about approaches to investigating and disrupting CSE, from shared learning throughout the UK. Maria Cassidy is the NWG Response Unit’s Parental Engagement Lead, working alongside organisations to highlight how they can work with parents as safeguarding partners. Maria is a www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 12 qualified Youth and Community Worker and has been a Senior Training and Curriculum Lead for Bristol Youth and Play Services and most recently led on substance misuse for Derbyshire Health Promotion. Maria provided valuable assistance in reviewing the documentation sent prior to the review by NCS. Appendix 2 – List of Focus Groups CSE Strategic Group - Strategic direction of Kirklees’ response to CSE and learning from previous cases. Social Care Focus Group - Front door staff, area teams, looked after team and specialist team. Health Focus Group - CAMHS, school nurse service, drugs and alcohol service, GPs, health visitors. Young Person’s Focus Group - Kirklees to arrange for appropriate group of young people to discuss CSE. Police Focus Group - CSE Team, Missing officers, local policing team and other police staff. Parents and Family Focus Group – Parents/carers and family members to discuss CSE. Multi-Agency Focus Group - YOS, education, housing, licensing, residential care providers, adult services, early help. www.nwgnetwork.org www.stop-cse.org @NatWorGroup fb:NWG Network 13 |
NC52342 | Death of a 3-year-old girl by drowning in Autumn 2017. Child A's mother was charged in connection with her death and subsequently found guilty of murder. When Child A was 4-months-old, Mother self-referred to counselling for low mood, possibly post-natal depression, after her diabetes consultant had raised the issue with the family GP. No safeguarding concerns were identified during counselling which Mother attended with Child A. When Child A was aged 2-years-old, her parents expressed an interest in adopting a child but their application was not taken forward. In the six months before her death, the nursery suggested referring Child A for speech and language help but had no other concerns. Health visitor checks and assessments showed normal development and there was very little involvement with the family by external agencies. Child A's parents separated shortly before her death. No learning was identified but highlights that there was discussion among the health professionals about the impact of long-term-medical conditions and the value of considering the impact on parenting, to promote the well-established think family message. Makes no recommendations.
| Title: Serious case review Child A. LSCB: Hampshire Safeguarding Children Partnership Author: Karen Tudor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW CHILD A INDEPENDENT REVIEWER Karen Tudor November 2018 updated March 2020 V2 010419 Page 2 INTRODUCTION 1. This Serious Case Review (SCR) concerns a three-year old girl who died from drowning in the Autumn of 2017; the child is known as Child A. Her parents are a professional, couple who had separated shortly before her death. Child A’s mother was charged in connection with her death and subsequently found guilty of murder. Child A’s parents are referred to as Ms AM and Mr AF. 2. The SCR was commissioned by the Hampshire Safeguarding Children Board (HSCB) in Autumn 2018; the reason for the delay was because Child A’s mother spent time in hospital immediately after the child’s death, this delayed the criminal investigation into the cause of Child A’s death. 3. An Independent Reviewer was appointed, and chronologies were requested from the agencies who knew the family; the Reviewer held two meetings, one with the chronology authors and one with the practitioners. As there had been relatively little professional involvement prior to Child A’s death, only three practitioners attended the meeting. The process was overseen by the SCR sub-group. 4. The Review covers the period from Ms AM’s pregnancy with Child A, June 2014, to Child A’s death in October 2017. SUMMARY OF AGENCY INVOLVEMENT Wiltshire Health and Care - diabetes service Ms A had been diagnosed with Type 1 diabetes as a child and was insulin dependent. She was well known to the diabetes service with which she engaged well. Her condition was described as “well managed.” She had experienced some hypoglycaemic episodes, one of which occurred when she was driving, and this led to the temporary loss of her driving license. The fear of further attacks was reported to have caused her anxiety. Salisbury NHS Foundation Trust Maternity Services 2014 Child A was born by emergency Caesarian Section after a traumatic labour. Ms AM recovered well and there was nothing unusual or notable about the pregnancy or post-natal period. Health Visiting (4 home visits and 2 clinic appointments) Health Visiting provided a Universal Service to Child A. The usual assessments were carried out and Child A’s one- and two-year development checks showed she was developing normally. Health Visiting’s most recent contact with Child A was a year before she died. The service had no concerns about her care. V2 010419 Page 3 GP Child A and her family were registered at the same GP practice who had known the family for many years. They attended occasionally with minor conditions; Child A’s immunisations were up to date. When Child A was four months old, a letter to the GP from Ms AM’s diabetes consultant referred to the possibility of Ms AM being depressed. Following a consultation with the GP Ms AM self-referred for counselling. Apart from this, practitioners had no concerns about Child A or her parents. Private Counselling Service When Child A was 4 months old (2014) the diabetes consultant, during a routine appointment, questioned whether Ms AM’s low mood might be post-natal depression. A letter was sent to Ms AM’s GP who discussed the matter with her and she self-referred for 10 sessions from a private counsellor. The counsellor worked with Ms AM on some marital issues. Child A was present during most of the sessions and the counsellor described Ms AM as a “good and loving mother.” There were no safeguarding concerns identified during the counselling process. Children’s Social Care - Adoption Team In October 2016, when Child A was aged 2 years, her parents expressed an interest in adoption, the records indicate they wanted another child but Ms AM was reluctant to go through another pregnancy. An assessing social worker visited them at home and their application was not taken forward, primarily because of the couple’s limited appreciation of the challenges of adoption. The assessing social worker observed the couple with Child A and described her as “much loved.” Nursery Child A attended a private nursery, two days a week, for 6 months before her death. The nursery had suggested referring Child A for some speech and language help but had no concerns about her health, wellbeing or care. FINDINGS AND ANALYSIS 5. It is inevitable that the degree of scrutiny involved in a Serious Case Review will highlight practice which could have been better and in this case the Health Visiting service have indicated that the routine assessments of post-natal depression and possibility of domestic abuse could have been more robust. There were no indications that either of these factors were a feature of family life and the V2 010419 Page 4 assessments were superficial. It appears that neither Ms AM or Mr AF were asked about domestic abuse. 6. The key practice issue was Ms AM’s management of her diabetes which meant she had regular appointments with medical practitioners, she engaged well with the services offered and communication between the hospital and community was appropriate. The possibility that Ms AM might be suffering with post-natal depression was picked up, communicated to the GP and promptly addressed with Ms AM. 7. The diabetes service had the most contact with Ms AM and, after Child A’s birth, it appears that she was present during most of Ms AM’s appointments; this is not made explicit in the records and the service has indicted that in the future they will make a more detailed note. 8. In general, all the work carried out with Child A and her family was proportionate, focused and to an expected standard. 9. The adoption service in particular, although they only carried out one interview, provided sensitive insight into this family’s life. 10. Child A was observed to be well cared for, her one- and two-year developmental checks showed she was healthy and developing normally. The nursery were planning to provide some additional speech and language input but there were no concerns about her care. 11. Child A’s death came as a great shock to all the practitioners who knew her. LEARNING AND CONCLUSION 12. During this Review there was some general discussion among the health professionals about the impact of long-term medical conditions and the value of considering the impact on parenting, to promote the well-established “think family” message. 13. However there was no indication of any warning signs or indicators of risk which might have prompted further assessment or intervention. 14. Despite the tragic death of Child A, this Review concludes that, at this stage, there is no learning to be taken forward by the Hampshire Safeguarding Children Partnership. V2 010419 Page 5 Family Involvement in the Review Following conclusion of the criminal investigation both Father of Child A and Mother were invited to meet with the Independent Reviewer. Father accepted the invitation and met with the independent Reviewer. Mother declined the opportunity to contribute to the review. Following the meeting with father no additional learning was identified in this case. Karen Tudor Independent Reviewer November 2018, updated March 2020 |
NC52244 | Death of a 15-year-old boy in June 2017. Child B's father found him unconscious in woodland near their family home. Child B died at hospital having suffered severe brain damage. Child B had reported anxiety and admitted self-harming behaviour and was referred by his GP to the child and adolescent mental health service (CAMHS). Multiple agencies were involved with Child B over the previous eight months before his death. Child B had a history of going missing and had four overdoses between November 2016 and February 2017 resulting in hospitalisation. Child B reported an inexplicable and implausible incident of assault which lead to professional concerns of possible psychotic presentation. Police called out several times to the family home and school. Ethnicity and nationality not stated. Learning includes: practitioners across the multi-agency network face challenges when charged with responsibility for safeguarding children in mid-adolescence; effective plans for risk-taking, tolerating uncertainty, risk-minimisation and promoting safety rely on robust risk analysis; the principle of understanding behaviour as communication is as relevant for children in mid-adolescence as for younger children. Recommendations include: ensure that specialist mental health services engage in effective collaboration and co-working with the team around the child, the child's parents, and the child's informal network of care throughout their involvement with children; ensure that staff throughout the service are aware of and consider a range of potential sources of early help for children and families while waiting for specialist assessment or input.
| Title: Learning review: Child B. LSCB: Surrey Safeguarding Children Partnership Author: Fiona Mainstone Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final 12.10.2020 (revised for publication 05.01.2021) Page 1 of 49 Learning Review Child B Report Author Fiona Mainstone MSc MA CQSW AASW PgCert HE Associate of In-Trac Training and Consultancy Ltd Final 12.10.2020 (revised for publication 05.01.2021) Page 2 of 49 Contents 1 INTRODUCTION ........................................................................................... 3 2 THE REVIEW PROCESS .............................................................................. 3 3 FAMILY BACKGROUND .............................................................................. 5 4 KEY EVENTS AND PRACTICE ISSUES ARISING FROM THE TERMS OF REFERENCE ................................................................................................ 6 5 FINDINGS ................................................................................................... 26 6 RECOMMENDATIONS ............................................................................... 39 7 APPENDIX 1 THE LEAD REVIEWER ........................................................ 43 8 APPENDIX 2 – TERMS OF REFERENCE .................................................. 44 9 APPENDIX 3 - TIMELINE ........................................................................... 45 10 APPENDIX 4 – REFERENCES ................................................................... 49 Final 12.10.2020 (revised for publication 05.01.2021) Page 3 of 49 INTRODUCTION This case review has been carried out because of the death of Child B at the age of 15 years and 10 months. On 28th May, Child B’s father went out to search for his son. Child B’s father found him in woodland near their family home. Child B was found, unconscious, sitting in a hollow, with a washing line attached to a branch, around his neck. Child B died in a Paediatric Intensive Care Ward having suffered severe brain damage on 28th May 2017. He died soon after breathing apparatus was withdrawn on 5th June 2017. The medical causes of death were hypoxic ischaemic encephalopathy and hanging. Following an inquest into Child B’s death in February 2020 the Coroner recorded her conclusion as to his death “(Child B) was a 15 year old boy with no history of mental illness until October 2016 when his family began to have concerns that he was isolating himself. In November 2016 he admitted to some self-harming behaviour and thereafter he was referred via his GP to the [Surrey Child and Adolescent Mental Health Service] and he remained under their care, and later under the care of the [specialist mental health service for young people with complex needs] until the time of his death. He did not have a formal mental health diagnosis at the time of his death although the clinical team worked with a case formulation that identified difficulties with emotional regulation, relationships, anxiety, and low mood. During the period from December 2016 to February 2017 he took four overdoses which resulted in hospitalisation. On 28th May 2017 he deliberately hanged himself from a tree, using a piece of rope as ligature. His intentions in doing so remain unknown. Thereafter he was taken to St. Georges Hospital where he was diagnosed with a brain injury, which resulted in his death at the hospital on 5th June 2017”. The period for this review is September 2016 when he entered Year 11 of his school education, to 5th June 2017, the date of his death. THE REVIEW PROCESS Multiple agencies had been involved with Child B over the previous 8 months, and it was decided at a Post Child Death Review Meeting held on 18th July 2017 to refer the Case Review Panel. The Case Review Panel held on 19th September 2017 determined that a practice learning review should take place. Following prolonged delay, the lead reviewer initially appointed withdrew from the process. Fiona Mainstone1 subsequently replaced them in January 2019 and met with the Surrey Wide Associate Director of Safeguarding for initial briefing in March 2019. 1 For details of the lead reviewer please see Appendix 1 Final 12.10.2020 (revised for publication 05.01.2021) Page 4 of 49 The lead reviewer met with Child B’s parents and younger brother at their home on 17th July 2019. During this meeting Child B’s parents articulated numerous concerns about professional intervention in the months leading up to their son’s death. The questions underlying their concerns were congruent with the terms of reference already determined by the Case Review Panel and related to: ➢ How risk assessments were conducted ➢ Whose voices were heard in those assessments ➢ How decisions about risk were made ➢ How the treatment plan and interventions to reduce risk were determined The lead reviewer attended the first four days of the five-day Coroner’s Inquest conducted in February 2020. This case review is therefore informed by oral evidence given to the Coroner together with three bundles of documented evidence. An integrated chronology was completed on 24th February 2020. Thereafter a timetable for the review process was agreed, and a panel was appointed to oversee the review. An initial panel meeting was held on Monday 30th March 2020. This meeting was conducted on-line using Microsoft Teams under special arrangements made because of the Covid-19 pandemic. The chair of the review panel is the Surrey wide CCG Designated Nurse for Looked After Children / Deputy Designated Nurse Safeguarding Children, NHS Guildford and Waverley Clinical Commissioning Group. The review panel consists of representatives from the Surrey and Borders Partnership NHS Trust; Surrey Police; the Named GP; Surrey County Council Children’s Services and the Area Schools Officer. The lead reviewer has accessed and reviewed the following documents: ➢ An integrated multi-agency chronology ➢ The three bundles of evidence compiled for the Coroner’s Inquest ➢ The Safety Investigation Report (sic) prepared by the NHS Trust with responsibility for CAMHS services. ➢ The Case Record held by the above NHS Trust ➢ The specialist mental health service for young people with complex needs Operational Policy 2016 and 2019 ➢ The Coroner’s Inquest Conclusions ➢ Minutes of Post-Child Death Review Meetings held on 18th July and 19th September 2017 Under the direction of the panel and as part of the formal review process the lead reviewer conducted a series of interviews with relevant staff. Between 3rd April and 21st May 2020, the lead reviewer held meetings by phone or using Microsoft Teams with: Final 12.10.2020 (revised for publication 05.01.2021) Page 5 of 49 ➢ The Student Support Officer / Deputy Designated Safeguarding Lead at Child B’s School (no longer in post) ➢ The Designated Safeguarding Lead at Child B’s School ➢ The Head Teacher at Child B’s School ➢ The Consultant Child and Adolescent Psychiatrist, Child and Adolescent Mental Health Services (CAMHS) ➢ The Crisis Assessment Nurse, Child and Adolescent Mental Health Services (CAMHS) ➢ The Team Manager, School Nursing Service ➢ The Service Manager, specialist mental health service ➢ The Mental Health Nurse – specialist mental health service ➢ A group of three Service Managers from Surrey Children’s Services. This final report has been discussed at each stage with the panel and has been shared with Child B’s parents. Child B’s parents welcomed the report and formally requested that it should be published in full. FAMILY BACKGROUND The integrated chronology poignantly documents the commitment of both his parents to securing the best possible treatment for Child B and their persistence in trying to safeguard him from self-harm. Child B presented a complex picture of troubled behaviour and unmet needs in the 8-month period leading up to his death. However, his family background is uncomplicated. His family household consisted of Child B’s parents and his younger brother. The integrated chronology refers to his grandfather’s death as a recent source of sadness, and the family had regular contact with his bereaved grandmother. There was no professional involvement with Child B, or his family and no concerns are noted in relation to either his physical and mental health, or his educational progress until October 2016. There is no known family history pre-dating the sudden emergence of Child B’s distress in the autumn of 2016. Child B’s parents discussed his distress, troubled behaviour and disconcerting changes in his mood and thought processes with many professionals. They were open about their uncertainties about how to respond to his difficulties, and about their impact on life at home. The integrated chronology poignantly documents his parents’ fears for Child B, their unquestioned commitment to him, their desire to protect him from harm, and their dedicated pursuit of help and guidance. They sought above all to understand, respond to, and meet his needs and to keep him safe from harm. Final 12.10.2020 (revised for publication 05.01.2021) Page 6 of 49 KEY EVENTS AND PRACTICE ISSUES ARISING FROM THE TERMS OF REFERENCE This section of the report should be read in conjunction with the timeline set out in Appendix 3 How effectively did agencies work together to safeguard Child B in response to his increasing anxiety and deteriorating mental health? By all accounts, until the autumn of 2016, Child B was physically active, intelligent and enjoyed good long-standing friendships. He was described by the Student Support Officer / Deputy Designated Safeguarding Lead at his school as “a radiant child with a great, cheery personality”. It was anticipated that Child B would perform well in his GCSE’s and no problems were reported in his family life. Difficulties associated with poor sleep and anxiety were not remarked upon in the family until October 2016. Child B first spoke with school staff about feeling anxious in early November. From that point on his moods changed at pace and were marked by extreme fluctuations in behaviour at home and at school. Child B’s anxiety and deteriorating mental health manifested in several different ways and across the contexts of school, family, and friendships. The integrated chronology documents 21 separate entries describing destructive, erratic or uncontained emotions or behaviour within the first two months between mid- November 2016 and mid-January 2017 including two attempted overdoses. It is easy to trace both the frequency, and the escalation in intensity of “meltdowns” in the 5 months leading up to Child B’s death. When talking to professionals, Child B explicitly and consistently described his mood as low. This self-assessment was echoed by those who knew him well (parents and school staff) as well as those who encountered him only briefly e.g. Police Officers called out to specific incidents. Child B appears to have experienced unremitting emotional pain, although his behaviour fluctuated between extremes and the manifestation of this distress was intermittent. Working together was significantly compromised by fundamental disagreements. The difficulties affecting purposeful collaboration were perceived differently by contributors to the multi-disciplinary network, as well as by Child B’s informal network. To a significant extent these different perceptions persist so that differences of opinion and perspective remain unresolved. Sadly both “sides” feel their view is vindicated by the specific circumstances of Child B’s death. The fact that conflicted views persist despite opportunities for reflection and resolution in the intervening three years suggest persistent structural problems within some parts of the service and across the system interfered with professional capacity to achieve meaningful collaboration and work together to protect Child B from harm. Final 12.10.2020 (revised for publication 05.01.2021) Page 7 of 49 Staff at Child B’s school were surprised when they became aware of his distress in early November 2016 because they knew him only as a lovely boy, who was always smiling, had lots of good friends, and was an able student who worked hard. Within days of Child B first speaking about his low mood and anxiety the Student Support Officer / Deputy Designated Safeguarding Lead encouraged his parents to ask the GP surgery to refer Child B to CAMHS for assessment. She also shared information about several potential sources of help such as Young Minds, Kooth, Headspace and Childline. As concern for Child B grew during December 2016, she undertook a risk assessment and kept in regular contact with Child B and his parents. From the perspective of school staff, the rapid deterioration in Child B’s mental health in late December 2016 to mid-January 2017 was shocking. The behaviour they observed at school seemed to them to be out of his control. His extreme distress, anger and confusion bore no resemblance to their routine experience of pupils who are ill-disciplined or behave badly in school. They were in no doubt that he was unwell and in need of psychiatric treatment. Following his second overdose a comprehensive, timely and achievable support package was put in place to enable him to return to school safely on a reduced timetable. As the indicators of Child B’s evident distress continued to escalate the Student Support Officer / Deputy Designated Safeguarding Lead sought guidance from the specialist mental health service about a risk management plan, and on 22nd March asked for him to be signed off from school and a referral made to Access to Education (A2E) on medical grounds. When Child B first came to CAMHS’ attention in mid-November 2016 with concerns about low mood, anxiety and sleep difficulties the children’s health referral portal efficiently directed him towards a counselling service for individual counselling. Given that there was no prior history of mental health problems this was an appropriate and timely response to his apparent needs at that time. The school subsequently alerted the children’s health referral portal to the escalation of Child B’s self-harming behaviour on 22nd November and again the response was immediate and appropriate: he was provided with an emergency face to face appointment for assessment of his mental health needs. Thereafter until mid-January services were provided both from the counselling service’s charity workers who had already engaged with Child B and by CAMHS Community Team practitioners. On 10th/11th January Child B repeatedly reported an experience of being chased and assaulted by a group of unidentified assailants. His account at the time was considered completely implausible by both his parents and the police in attendance. When he talked subsequently about this incident in counselling with the counselling service’s practitioner on 24th January, they too described him as agitated, distressed and experiencing paranoia. The Student Support Officer / Deputy Designated Safeguarding Lead was similarly impressed by the intensity of Child B’s anxiety and concluded that Child B was describing an event that did not in Final 12.10.2020 (revised for publication 05.01.2021) Page 8 of 49 fact take place. His parents and professionals from these three different settings all formed the view that Child B himself fully believed that this chase and assault had happened and was genuinely upset and frightened. They have described his behaviour and physical presentation both immediately after returning home from “the chase” and in the days that followed as congruent with panic and terror. From their perspective, and from their lay understanding of psychiatric illness, they all worried that this event represented an episode of psychosis. Child B was admitted to hospital for the second time on 17th January less than a week later. Child B was hospitalised and received 1:1 nursing care for three nights following an attempted overdose of approximately 35 paracetamols. Soon after taking the overdose Child B retreated into a locked toilet cubicle and it was with some difficulty and the help of Child B’s father as well as Police Officers in attendance that he was taken to hospital. The Mental Health Nurse attached to the Community CAMHS team already working with Child B met with him while he was still receiving medical treatment (Parvolex), recommended psychiatric hospital admission for further assessment and was supported in this advice by the consultant on duty. Child B therefore remained on a paediatric ward for further assessment from a Psychiatrist and the specialist mental health service. This was in accordance with the pathway indicated where there is concern about risk and the need for psychiatric in-patient assessment or treatment. Subsequent assessment by the Consultant Child and Adolescent Psychiatrist attached to the CAMHS Community Team and the specialist mental health service recommended discharge home. Child B was offered medication but declined this. The input from the counselling service continued until 24th March 2017. Responsibility within the CAMHS Community Team transferred to a Psychiatrist in training who met with Child B weekly from late January onward. The Consultant Child and Adolescent Psychiatrist attached to the CAMHS Community Team and the specialist mental health service retained medical responsibility and remained the Clinical Lead for Child B until his death. Crucially involvement of the specialist mental health service marks the point at which Child B’s mental health problems met the threshold for Tier 4 psychiatric services. The specialist mental health service’s remit is to support cases of significant mental health difficulties with significant risk. The planned intervention consisted of several interwoven threads: ➢ A Mental Health Nurse, recently qualified and still within her preceptorship period from the specialist mental health service team, was assigned to conduct outreach work with Child B and his family in their home ➢ This outreach work was supported by the Extended specialist mental health Service that provides support outside of normal working hours until 11 pm. ➢ A trainee Psychiatrist then on placement in the CAMHS Community Final 12.10.2020 (revised for publication 05.01.2021) Page 9 of 49 Team began a programme of Cognitive Behavioural Therapy with Child B in accordance with Nice Guidelines for persons presenting with anxiety and depression. ➢ The counselling service agreed to continue their offer of counselling and family mediation The Consultant Child and Adolescent Psychiatrist did not make a diagnosis of Child B’s mental health status, preferring to use an ongoing process of case formulation to inform the treatment plan. During the final four months of Child B’s life the risk he posed to himself was assessed as low. Child B repeatedly assured both the Consultant Child and Adolescent Psychiatrist and the trainee Psychiatrist that he was not intending to self-harm and that he had no suicidal intention. When he talked about suicidal ideation this was interpreted as unplanned and impulsive. It seems that the evaluation of risk rested on Child B’s account of his thoughts, feelings and actions being taken at face value. The Mental Health Nurse providing the outreach service usually had weekly contact with Child B and his family at their home and her case notes provide a thorough narrative description of her conversations with them. Her case records describe many phone conversations and include details of email exchanges. These demonstrate frequent communication and evident goodwill flowing between the Mental Health Nurse, the Student Support Officer / Deputy Designated Safeguarding Lead in school, and Child B’s parents. Child B’s voice is reported in this record alongside information provided regularly by Child B’s parents and the school. Their information painted a picture of continued distress and repeated, often prolonged events of extreme crisis when Child B appeared to be in a profoundly altered state. In addition to Child B’s initial superficial self-harm and subsequent overdoses there are repeated references throughout the Coroner’s documentation to notes that Child B wrote and sent multiple texts to peers in which he spoke of plans to harm himself. There were also offensive posters decorating his room, sinister drawings, writing, symbols and slogans, aggressive and angry outbursts, and website searches relating to methods of suicide including hanging and overdose. The integrated chronology indicates a dynamic between Child B’s contact with mental health professionals and his episodes of self-destructive behaviour. This pattern was first seen on 29th November 2016 when Child B assured a CAMHS Mental Health Nurse that his mood was improved, and that he had no thoughts of self-harm, but took an overdose of paracetamol the following day and did not disclose this until another day later. Although it was recognised in this, as in many cases, that Child B’s behaviour should be understood as communication, it seems that this pattern went unremarked even as Child B’s mental health continued to deteriorate during the late winter and spring of 2017. Final 12.10.2020 (revised for publication 05.01.2021) Page 10 of 49 The Police were called out by Child B’s parents on ten occasions between 19th December and 28th May 2017. At each of these attendances the police officers involved took every immediate step to safeguard Child B from harm. The integrated chronology demonstrates that his safety and protection were at the forefront of decisions made and action taken. Several police reports highlight how baffled they were by Child B’s erratic and sometimes aggressive behaviour. Police officers deemed it necessary to use physical restraint on three separate occasions. The referrals they made to Surrey Children’s Services demonstrate that police officers saw serious grounds for intervention to secure Child B’s safety, were very concerned for the well-being of his parents, and noted the impact of Child B’s distress on his younger brother. Child B’s parents have articulated the challenges they faced, and have continued to encounter since his death, because of the apparent discrepancies between agencies. They feel that whereas some professionals clearly understood the significance of the breakdown of his mental health, the intensity of his distress, and the challenges they faced in trying to fulfil their parental responsibility to keep him safe from harm, others did not. As well as feeling baffled by the apparently inconsistent approaches to Child B’s needs and vulnerability by practitioners from different professional disciplines, his parents found it especially hard to make sense of how different parts of the safeguarding system conceptualised risk. Police officers, Child and Adolescent Mental Health Service and Children’s Services all use different vocabulary and measures to describe risk. The meaning of risk scores and the rationale behind them are not readily understood by anyone who does not work within those specific contexts. Both the school and Child B’s parents asked members of the specialist mental health service team for a risk management plan, and guidance about how to respond in moments of crisis. The Consultant Psychiatrist has said both at the time and more recently that no risk management plan or guidance offered could anticipate every possible contingency and that those involved would need at times to make their own judgements based on common sense. This, of course, is true. However, in the absence of a shared inter-professional understanding of Child B’s needs, and of any agreed multiagency risk minimisation plan and management strategy his vulnerability increased and the capacity of his parents and of professional practitioners to keep him safe was compromised. Was information sharing between agencies sufficient and timely in light of escalating concerns to understand Child B’s support needs? The integrated chronology indicates that information was shared appropriately between professionals during the period between November 2016 when Child B’s support needs became apparent and his death in May 2017. A few lapses in Final 12.10.2020 (revised for publication 05.01.2021) Page 11 of 49 information sharing were of minor significance but did not interfere with agencies’ understanding of Child B’s support needs. Crucially, however, although information was generally passed between the professionals involved and was recorded appropriately, there is little evidence of transparent debate about differing professional perspectives and the challenges of supporting Child B. A shared understanding of his needs and of the presenting risks was not achieved. Although there were phone conversations and some inter-agency meetings, nowhere in the record is there evidence of the whole professional network coming together to formulate a shared holistic understanding of Child B’s complex needs. The fluctuations, inconsistencies and ambiguities in Child B’s communication, behaviour and demands were not explored fully. Without full exploration of the various and conflicted views no consensus could be reached. An agreed and shared understanding of Child B’s difficulties and needs was never achieved. This compromised the treatment plan and meant that no effective plan was in place to protect him from the risk that Child B would either come to harm unintentionally or enact his declared intention to kill himself. One meeting that came close to achieving this was on 27th April 2017 and attended by Child B, both parents, the trainee Psychiatrist, the Mental Health Nurse assigned to the case, the youth support worker, and the Student Support Officer / Deputy Designated Safeguarding Lead. Its focus was on crisis management within the home. It confirmed the intervention plan already in place, but it did not generate a purposeful risk management strategy or risk minimisation plan. When the youth support worker, trainee Psychiatrist, Mental Health Nurse and Student Support Officer / Deputy Designated Safeguarding Lead met again on 25th May 2017 a general sense of optimism was shared. The diagnosis / case formulation was discussed but no exploration of the ambiguities and differences of perspective was recorded. The specialist mental health service intervention plan relied on case formulations and judgements about the level of risk based on the observations and judgement of the whole specialist mental health service team but ultimately determined by the lead clinician. The integrated chronology indicates that the Consultant Child and Adolescent Psychiatrist attached to the specialist mental health service met with Child B in hospital on 20th January 2017 and spoke on the phone with his father. The case record provided by the Consultant Psychiatrist to the Coroner verifies that from this time onward he held medical responsibility and was the Clinical Lead by virtue of his dual roles in the CAMHS Community Team and the specialist mental health service and through supervision of the trainee Psychiatrist. There is a record of a review conducted on 12th February, but it is not clear what form that took. The Consultant Child and Adolescent Psychiatrist led a “network meeting” on 28th February. Was the school response to Child B’s emerging and escalating needs in November 2016 sufficient? Final 12.10.2020 (revised for publication 05.01.2021) Page 12 of 49 Child B first asked to speak with the Student Support Officer / Deputy Designated Safeguarding Lead on 3rd November 2016. Until that point there had been no indicators of any concern for or about him. The integrated chronology demonstrates that the school took appropriate and timely steps in response to the evidence of Child B’s escalating distress in school and to the concerns expressed by his parents. A parents evening on 8th November provided an opportunity for Child B and his father to talk about their worries. The Head of year 11 followed this up with a request that the Student Support Officer / Deputy Designated Safeguarding Lead speak with him and circulated an email alerting all staff to the difficulties that had been shared. The Student Support Officer / Deputy Designated Safeguarding Lead was available to and frequently saw Child B throughout November 2016. The integrated chronology records specific meetings with Child B on 9th, 22nd and 23rd November. She provided him with information about a range of relevant on-line resources that he could access for further help. The Student Support Officer / Deputy Designated Safeguarding Lead liaised with Child B’s father on 9th, 15th, 22nd and 23rd November. She actively encouraged and supported Child B and his father to secure a referral to and help from CAMHS and undertook to make additional contact herself if needed. The Student Support Officer / Deputy Designated Safeguarding Lead liaised with CAMHS on 21st and 23rd November, shared relevant information and contributed to the intervention plan. Throughout the remaining months of Child B’s life, he made frequent use of opportunities to share his worries with the Student Support Officer / Deputy Designated Safeguarding Lead and she gave him practical help and support. The Head Teacher and Head of Year supported her to create a risk management plan to ensure Child B’s safety and the safety of others within school. They also worked creatively to support Child B completing his GCSE studies. Other services could have been enlisted by the school when the first signs of Child B’s difficulties emerged. The Early Intervention Team could have engaged with the whole family at home at this early stage but might still have been superseded by the involvement of the counselling service and CAMHS as the extent of Child B’s mental health difficulties became apparent. Similarly, the School Nursing Service could have complemented the help given by the Student Support Officer / Deputy Designated Safeguarding Lead by bringing relevant expertise to understanding and managing Child B’s established sleep problem, low mood, and his growing anxiety. Could more have been done to support Child B? Child B’s school were consistently helpful to him and everything possible was done to ensure that he could attend school despite his escalating difficulties. His Final 12.10.2020 (revised for publication 05.01.2021) Page 13 of 49 temporary exclusion in late January was immediately followed by a meeting that put a plan in place to help him manage his anxiety in school with a view to resuming his studies. When it became clear in March that Child B simply could not manage the pressures of school life it was agreed with his parents that he need no longer attend. The school believed that this step could and should be supported on medical grounds. He was enabled to sit GCSE exams in the week before his death. Consideration was given to deferring GCSE exams to 2018 but Child B was keen to progress to sixth form. He was still enrolled at the school when he died. The initial CAMHS referral to a counselling service in mid-November 2016 was appropriate to the difficulties known about at that time. When, within days, it became clear that he needed further assessment, CAMHS put appointments in place and began a parallel process of direct work alongside the contact already established by the counselling service. This level of service was similarly appropriate to the difficulties known about at that time. Child B was admitted to hospital following his three attempted overdoses during the winter of 2016 / 2017 in accordance with the appropriate guidance (NICE, 2013). He received full nursing care and the correct safeguarding procedures were followed. On each occasion he was assessed within the hospital by an experienced Mental Health Nurse from the CAMHS crisis team. It seems that Child B found this process supportive since he subsequently asked to meet with him again. Thereafter, the focus of crisis intervention by the specialist mental health service practitioners was to calm and “manage” the situation. Although therapeutic sessions with the trainee Psychiatrist addressed some of Child B’s unhelpful thought patterns, the records do not indicate that Child B’s stated intention to harm himself or end his life were addressed. Child B often disparaged the support he received. He is recorded as saying “nothing is helping, and nothing is changing”. He disliked having to repeat his story to different professionals. Child B often voiced his criticism of his parents, school, therapist, and support workers to other parts of the system but not directly to the person concerned. For example, he complained to his therapist about his father being critical, demanding and heavy handed, to specialist mental health service workers about being rejected by his school, and to his parents about the CAMHS therapist being unhelpful. These unfavourable comments were not examined as an expression of his bleak state of mind and catastrophic thinking processes. In the absence of constructive collaborative relationships between professionals this process seems to have gone un-noticed. When taken at face value, his complaints were open to misinterpretation, reinforced differences of opinion held between organisations, and fuelled a culture of blame and criticism. Surrey Children’s Services offered to assign an Early Help practitioner in February 2017. The integrated chronology indicates that CAMHS Community Team, the Final 12.10.2020 (revised for publication 05.01.2021) Page 14 of 49 specialist mental health service and Child B’s parents reached an agreement that this was unnecessary and could create “overload” while specialist mental health service workers were still involved. The specialist mental health service team includes Social Workers, but they were not involved with Child B or his family. This may have led to an erroneous assumption that the multi-disciplinary specialist mental health service Team was engaged in meeting all the needs of the whole family. The case was closed and an early opportunity for collaboration between Surrey Children’s Services and the mental health professionals, working together to design and provide a holistic family intervention was lost. As described elsewhere, the specialist mental health service undertook an assessment from late January 2017 and subsequently provided a comprehensive package of intervention for Child B. The service offered by CAMHS and the specialist mental health service has been examined by The Surrey and Borders Partnership NHS Trust and explored in evidence to the Coroner. The specialist mental health service Manager believes that the intervention fully met Child B’s presenting needs. There are several support and treatment strategies that were or may or may not have been considered but were never provided: ➢ School nursing service involvement at initial indicators of concern ➢ Help at the initial stages from Surrey Children’s Services Early Intervention Team ➢ A child protection conference, plan, and intervention as the outcome of the Section 47 Enquiry undertaken by Surrey Children’s Services ➢ Opportunities to revisit and reconsider recommending and prescribing appropriate medication ➢ Active encouragement to explore the benefit of prescribed medication targeted at helping to reduce his anxiety, raise his low mood, improve his sleep, potentiate psycho-therapeutic interventions. The specialist mental health service Mental Health Nurse recognises with hindsight that she could have provided more information to encourage Child B to reconsider his decision ➢ A period of respite from family life whether by calling on family and friends, using a foster placement or overnight stays in the specialist mental health service House ➢ Voluntary admission to psychiatric hospital for assessment ➢ Voluntary admission to psychiatric hospital to provide emotional containment ➢ Alternative psycho-therapeutic intervention when Child B proved unable to engage fully with the Cognitive Behavioural Therapy approach ➢ A working diagnosis, so that Child B could be helped to understand his disturbed thoughts/feelings/behaviour as mental illness, and Final 12.10.2020 (revised for publication 05.01.2021) Page 15 of 49 differentiate these from his core identity/sense of self ➢ Active support to restrict his engagement with social media and manage on-line communication with peers ➢ A risk minimisation or child protection plan that was agreed, “owned”, and acted upon by all the key adults who supported him across different contexts ➢ A risk minimisation or child protection plan that provided a consistent workable strategy to promote Child B’s well-being during periods of calm, and contain his anxiety during episodes of acute distress ➢ Certificated exemption from education on medical grounds, explicit encouragement to focus on recovery, and support to consider postponing his GCSEs. Were police referrals into the MASH appropriately responded to against a background of an increasing frequency of missing episodes, concerns about possible psychosis and the impact social media could be having, as a factor affecting Child B’s mental well-being? When the police first referred Child B to the Multi-agency Safeguarding Hub on 20th December 2016, it had recently processed two earlier referrals from the Hospital on 2nd December 2016 arising out of Child B’s first overdose of paracetamol, and from the Emergency Duty Team on 15th December 2016 because his father reported him missing. The police referred Child B to the Multi-agency Safeguarding Hub on ten separate occasions: ➢ 20th December 2016 ➢ 11th January 2017 ➢ 17th January 2017 ➢ 5th February 2017 ➢ 10th February 2017 ➢ 17th February 2017 ➢ 24th February 2017 ➢ 23rd March 2017 ➢ 9th May 2017 ➢ 27th May 2017 Crucially, none of these police contacts were perceived as child protection referrals and so none led to strategy discussions or to Section 47 Enquiries. The integrated chronology indicates that decisions to take no further action were generally based on the assumption that the existing involvement of the Community Child and Adolescent Mental Health Team, specialist mental health service and / or the Early Intervention Team already met all Child B’s needs. It names 68 different staff within Surrey Children’s Services who became involved in this case between December 2016 and May 2017 and suggests that 14 different managers took Final 12.10.2020 (revised for publication 05.01.2021) Page 16 of 49 responsibility for oversight of decisions made in Surrey Children’s Services during this period. It is highly probable that discontinuity contributed to the service not recognising the complex interplay of factors affecting Child B’s well-being as well as disregarding the escalating intensity and frequency of episodes reported by the police. When the police referral was received on 9th May it represented the 3rd report of Child B as a missing person within a 90-day period. This triggered a protocol requiring a strategy discussion and the case was assigned to the Area Assessment Team. The Multi-agency Safeguarding Hub had, at that point, recently processed a referral from the Child and Adolescent Mental Health Team reporting an incident where Child B’s father was believed to have used physical force to restrain him resulting in a fight between father and son. A timely assessment was completed but again concluded that there was no need for additional intervention and there was no further outcome from that referral. Should agencies have explored further the nature of the use of physical restraint and force, both in terms of the possibility of physical abuse and Child B’s state of mind and the impact of this incident on his mental health and well-being? The integrated chronology highlights how, when these multiple police referrals were received, social workers and the team managers with oversight of practice not only assumed that the mental health provision precluded the need for safeguarding intervention but also determined that Child Protection protocols need not be used because the parents were not a source of risk and were committed to protecting Child B. This interpretation of the Multi-agency Safeguarding Hub’s responsibility to take the lead role in assessing and managing risk meant that repeated opportunities were missed. As a result, the many complex and enduring factors affecting Child B were never fully understood as a source of harm or danger to him and to his family. The Youth Support Worker and Social Worker continued with a remit to support Child B within a preventative framework long after the Initial Child Protection Conference (ICPC) Threshold 4 had been reached and a Child Protection Plan could have been in place. (The Surrey Safeguarding Children Board operational guidance in place in 2016 – 2017 defined Level 4 as “Children and families requiring specialist support in order to meet their needs, led by Children’s Services, risk of significant harm. Children who require intensive help and support from a limited range of specialist services led by Children’s Services. Agencies provide specialist services that are underpinned by wrap-around support services to help children ‘step down’) How did agencies respond to “Child B’s voice” and anxieties about delays in support, and his family’s concerns? Agencies witnessed and recorded Child B speaking in two distinct voices. Final 12.10.2020 (revised for publication 05.01.2021) Page 17 of 49 ➢ Before the autumn of 2016 Child B was intelligent, articulate, increasingly mature and self-aware. In 2017 he was still, at times “his old self”, and was able to present as competent to make his own decisions and choices when not in states of acute anxiety and distress. ➢ Child B persistently articulated low mood; catastrophic thinking; Intention to harm himself; morbid pre-occupations; plans to end his life; distrust of and growing anger towards family, friends, and all the professionals engaged with him; despair that “nothing is helping, nothing is changing”. The mental health professionals delivering his treatment prioritised the “competent” first voice. The case formulation promoted by the Consultant Psychiatrist and adopted by the specialist mental health service and the trainee Psychiatrist understood Child B’s difficulties as emotional dysregulation especially in respect of relationship difficulties. His self-destructive and hostile behaviour was interpreted as a mechanism he learned to use to attract care and support in situations where he felt distress and lacked the capacity to self-soothe. This meant that his dips into extremely low mood, growing anger, and continuing suicidal intention were taken seriously as dysfunctional learned behaviour but were discounted as evidence of mental illness. The impact of this case formulation meant that mental health professionals prioritised the “competent” first voice and Child B’s right to self-determination was privileged over his need for protection. Child B’s parents voiced their fears for his mental health and for his safety from November onwards to every agency with whom they had contact. Working together, they took action to safeguard Child B by instructing local pharmacists not to supply him with over-the-counter medication; locked knives and sharps away; confiscated ropes; tried to restrict his use of social media; monitored his internet searches; changed their working arrangements to be a continuous presence at home; searched for him whenever he went missing; and at times physically restrained him to prevent self-harm, destroying objects at home, or aggression towards family members. Some agencies encouraged and endorsed these steps, but they remained uncertain that their interventions would be supported. The absence of an agreed Child Protection Plan or risk management strategy left them with sole responsibility for determining how to behave, what to say, and how to seek the help of professional agencies during Child B’s recurrent episodes of acute distress. At least 187 different personnel are named in the integrated chronology. Child B’s parents explained their situation and concerns repeatedly to Police Officers, Social Workers, support workers, and mental health professionals in various roles. His father resorted to preparing their own document that summarised all agencies’ involvement and key contacts. When he gave this to the police officer in attendance on 27th May it was described as “easy to read”. Notwithstanding the services provided and the agencies involved it is understandable that his parents spoke of themselves as “as a family in crisis, crying Final 12.10.2020 (revised for publication 05.01.2021) Page 18 of 49 out for the help that never came”. How effective was family mediation and support for the family in coping with child B’s increasingly violent behaviour and missing episodes? In the early stages of Child B’s difficulties, the counselling service offered him individual counselling and a series of family mediation meetings. These initial meetings were not difficult but nor, it seems were they especially helpful. Child B’s parents voiced the extent to which they felt out of their depth and overwhelmed many times. Several opportunities to consider the parents’ need for support as carers of a child with mental health problems were missed by the Community CAMHS team, by the specialist mental health service and by Surrey Children’s Services. The Student Support Officer / Deputy Designated Safeguarding Lead at Child B’s school listened, heard, gave due weight to their concerns, and worked closely with his parents. She shared the parents’ sense that the sudden onset and rapid escalation of Child B’s increasingly violent behaviour and missing episodes, as well as his apparent suicidal intention were driven by serious mental health problems. This affirmation of their worries by someone they trusted and who knew their son well was helpful, but it was no substitute for the effective support they needed. Similarly, the Mental Health Nurse assigned by the specialist mental health service made regular home visits during which she listened to the parents’ worries and fears. However, her apparent empathy for their struggles did not translate into treatment interventions that made a difference or effected sustained improvement in Child B’s mood, thinking and ideation. She or her colleagues responded when the parents called for their help during emergencies, but ultimately their roles and responsibilities did not encompass the help the parents felt they needed from the psychiatric profession. On 11th April 2017 Child B spoke with the trainee Psychiatrist about an incident two weeks earlier where his father had physically restrained him. This was not a one-off occurrence: his father had already been open with several professionals about other occasions when he had taken similar action to contain aggressive behaviour or prevent Child B from leaving the home. Indeed, the police had also made the judgement to use physical restraint several times and recorded their rationale for this course of action. In consultation with the Clinical Lead it was correctly agreed that this incident fitted the protocol for referral to the Multi-agency Safeguarding Hub as a child protection matter. But protocols, guidance and indeed the law prescribe what professionals can or sometimes must do, they do not determine how they should do it. In this case, the referral focused on the relationship between Child B and his father, and the father’s use of force as a source of risk to Child B. Enquiries by the Social Worker within the Multi-agency Safeguarding Hub did not Final 12.10.2020 (revised for publication 05.01.2021) Page 19 of 49 lead to a strategy meeting and concluded that neither safeguarding intervention nor further additional services was required. However, the parents were left with the impression that physical restraint was prohibited. From then onwards they felt profoundly uncertain about how to manage those moments when Child B seemed likely to harm himself or go missing. The process deprived them of confidence in their own judgement and in their capacity to protect to Child B without being blamed or criticised. Child B’s parents repeatedly articulated their need for specific guidance about how to contain Child B’s crises. There was a “Safety Plan” in place that was agreed, regularly reviewed, and updated. However, it was intended as a plan for Child B to follow when in distress. It was designed by him and did not serve as guidance for the parents who still held day-to-day responsibility for their son’s well-being and safety. Child B’s parents had the contact details of extended specialist mental health service and were provided with a list of potential sources of help out-of-hours. The overarching advice they were given by the lead clinician was that each emergency should be judged as it arose, and ordinary common sense should determine the correct course of action in each instance. This advice is not in itself wrong or misleading. However, as their anxiety for Child B deepened, their trust in professional judgement was compromised, and their confidence in themselves was undermined. Although a Youth Support Worker and Social Worker were assigned to work preventatively with Child B and his family, the Integrated Chronology suggests that they played only peripheral roles in the case. The Youth Support Worker was rightly concerned that Child B’s parents needed help to construct an agreed plan focusing on how they should support Child B through crises and keep him safe. This had not been achieved by the time he died. There is no evidence that their contributions had any positive impact on Child B’s well-being or on his family’s capacity to cope with his distress. In January 2017 at the time of Child B’s second paracetamol overdose in a six-week period, was there sufficient assessment of Child B’s increasing risk of suicide? The correct protocol for treatment and assessment was followed at the time of Child B’s second paracetamol overdose in accordance with appropriate guidance (NICE, 2013). The integrated chronology and documents prepared for the Coroner convey a strong sense of Child B’s intense emotional distress on the day of his second paracetamol overdose. The events leading up to his hospital admission on 17th were highly charged: Child B’s friends, his father, school staff, and police officers all tried without success to calm him, contain the situation, and prevent him from Final 12.10.2020 (revised for publication 05.01.2021) Page 20 of 49 harming himself. Those involved at the time believed that this incident represented a serious intention to kill himself. Child B received medical treatment and 1:1 nursing care following admission to hospital. He remained on the ward for three nights. Child B was assessed by a CAMHS crisis nurse who already knew him. This assessment was robust, systematic, and comprehensively recorded. It concluded with a recommendation for hospital admission. Child B was subsequently assessed by the Child and Adolescent Consultant Psychiatrist attached to both CAMHS and the specialist mental health service. This assessment concluded with the recommendation to discharge him home and engage the specialist mental health service in community-based support. Neither the integrated chronology, the oral and written evidence given to the coroner, nor the lead reviewer’s discussion with the Consultant Child and Adolescent Psychiatrist offer a detailed account of the risk assessment process and defensible decision making. It seems that the decision rested on Child B’s vivacious presentation suggesting that he was “not particularly depressed”, and on the score from his own response to the Child Depression Scale. The Consultant Child and Adolescent Psychiatrist has acknowledged that “it was all a bit unclear”. In his clinical judgement Child B’s presentation precluded a diagnosis of major depressive disorder, the likelihood of successful suicide was low. He concluded that hospital admission was contra-indicated. The record of the Child Death Review Meeting held on 19th September shows the Consultant Child and Adolescent Psychiatrist stating that “Child B did not meet the criteria for admission to a psychiatric hospital and there was clear professional consensus around this”. He later asserted in evidence to the Coroner that “hospital was never a serious consideration because we had a comprehensive range of services in the community”. Was the response to Child B’s deteriorating mental health appropriate and timely? Child B’s school responded effectively to his initial request for help and engaged in respectful communication with his parents so that they were able, to reach the conclusion together, and with Child B’s agreement that he needed CAMHS support. The CAMHS Community Team contribution to assessment when Child B’s mental health problems first came to their attention was both appropriate and timely. The children’s health referral portal triage intervention, and referral for individual counselling to a counselling service took place the same day that the GP’s letter arrived. This immediate response was congruent with the very recent concerns about anxiety and poor sleep presented at that time. Within the week following the referral to a counselling service information shared with the children’s health referral portal, both by Child B’s parents and the school, Final 12.10.2020 (revised for publication 05.01.2021) Page 21 of 49 led to a swift reappraisal of need. Following triage by a Mental Health Nurse from the Community CAMHS team on Friday 25th November she offered him an emergency appointment on Tuesday 29th November. Child B took an overdose of paracetamol the next day and was assessed in hospital by a Mental Health Nurse who was a colleague from the same team. The Community CAMHS team put in place a revised treatment plan involving ongoing appointments with the CAMHS Mental Health Nurse alongside the counselling appointments already agreed with the counselling service. When Child B took a second overdose on 17th January 2017, he remained on the hospital ward for three nights. Once medical treatment was completed, the crisis assessment worker, a Mental Health Nurse attached to the Community CAMHS team already working with Child B, went out of his way to meet with him outside of his on-duty period rather than have him seen by his colleague who had no prior knowledge of Child B or of the treatment already under way. This was the same nurse that had met with Child B following the 1st overdose in December. Child B had, in fact asked to work with this same nurse rather than the practitioners assigned to his case. The written report resulting from this assessment indicates that it was approached in a thorough, systematic way. The report demonstrates that the practitioner has reflected on the whole story and brought robust analytical skills to bear on the complexity of Child B’s troubled presentation. It reached the conclusion that Child B’s mental health difficulties needed further investigation. Given the continued escalation of these difficulties throughout a period of planned community-based assessment and intervention, it recommended further assessment should at this stage take place in the context of a psychiatric in-patient ward. It was therefore appropriate that the Consultant Child and Adolescent Psychiatrist for CAMHS Community Team and the specialist mental health service should conduct the next stage of assessment. The specialist mental health service is intended for young people experiencing complex mental health, emotional, social, and behavioural needs that could require a Tier 4 hospital admission. Its goal is to prevent or shorten hospital admission by meeting those complex needs while supporting the young person in their own home. The Consultant Child and Adolescent Psychiatrist recommended that Child B’s assessment and treatment be transferred to the specialist mental health service. This decision represents a crucial watershed moment in the decision-making process. As discussed in paragraph 4.73-74 this was a judgement made by the Clinical Lead with medical responsibility. Its rationale is not entirely transparent. There followed a period of assessment by the specialist mental health service but there is no formal record of its conclusion other than a letter confirming that the specialist mental health service would continue to work with Child B and his family. Final 12.10.2020 (revised for publication 05.01.2021) Page 22 of 49 Oral evidence to the Coroner and interviews conducted in the preparation of this report indicate that subsequent intervention by the specialist mental health service and CAMHS practitioners rested on a case formulation that Child B did not suffer from mental illness and that his presentation arose out of maladaptive behaviour intended to attract care and support. It was anticipated that this maladaptive behaviour would take time to “unlearn”. Nowhere in the record is this case formulation set out, nor is there any evidence to suggest that its implications were explained to other professionals or to Child B’s parents. Indeed confusion arose out of letter from the trainee Psychiatrist to Child B’s GP on 20th February 2017 that led those outside of the mental health professional network to believe that a formal diagnosis of ‘Mixed Anxiety and Depression’ had been made. The specialist mental health service provided an intense intervention package from 24th January 2017 until Child B’s death consisting of several threads: ➢ A recently qualified Mental Health Nurse was assigned to provide intensive community outreach with Child B and his family. She generally made planned visits to the family home at least once a week, liaised with his school, and responded to any specific requests for support in moments of crisis. ➢ Child B was offered cognitive behaviour therapy with a trainee Psychiatrist on placement within the CAMHS service. ➢ Child B’s parents accessed the extended specialist mental health service if they needed help or advice during the evening or weekend daytimes. ➢ Once withdrawn from school in late March Child B was able to access the specialist mental health service Day Programme. Although there is reference to a timetable of 2 days each week, the calendar provided by his parents and the specialist mental health service case records both indicate that he attended on eight days during March and May. ➢ It is evident that the specialist mental health service provided a range of services to Child B intended to meet his needs from several angles. It is less evident that this strategy met his needs and addressed the continued deterioration of his mental health. The CAMHS Community Team and specialist mental health service practitioners asserted both in evidence to the Coroner and at interview that Child B’s mental health improved as their intervention progressed. However, recurrent episodes of acute distress, repeated references to killing himself by various means, and growing anger were documented and shared both by his parents and school records throughout March, April, and May 2017 with only a brief period of relative calm reported in mid – late April. The fact that Child B met the criteria for specialist mental health services means that his treatment needs outstripped what could be offered within the CAMHS community services at Tier 3. It implies that his needs could best be met, and risk safely managed within the community, whilst recognising that he reached the Final 12.10.2020 (revised for publication 05.01.2021) Page 23 of 49 threshold criteria for Tier 4 services i.e. assessment or treatment in a hospital setting. Within this context at the “edge” of Tier 4, the specialist mental health service differentiates between Low, Medium, and High risk. It also uses the colour coding “traffic light” metaphor to articulate risk. Risk assessment is always a dynamic process. Inevitably it is also highly subjective. In the context of children’s safeguarding the multi-agency network usually manages this in three distinct but interwoven ways: ➢ the use of explicit measures to describe risk ➢ multi-disciplinary discussions where different understandings of risk can be shared, compared and consensus agreed ➢ evidence-based and transparent threshold criteria to determine the fit between individual need and professional intervention The integrated chronology indicates that these processes were not implemented effectively during the final 4 months of Child B’s life. Despite the accumulation and escalation of indicators from February onwards that Child B’s mental health continued to deteriorate, the specialist mental health service persevered with the original treatment plan. During their involvement with Child B he was mostly categorised as Low Risk. Although the service responded to crises as and when they arose, because escalations in risk were seen as sporadic, sudden and relatively short-lived his escalating needs were not re-evaluated. In the context of their work with children with significant mental health difficulties, and their extensive experience of working with self-harm, specialist mental health service practitioners need to guard against becoming desensitised to self-destructive behaviour in the same way that practitioners in Surrey Children’s Services need to avoid internalising high thresholds for intervention. Having declined medication in January 2017, Child B was not offered this option again. The question of whether Child B’s symptoms met the criteria for a diagnosis of major depressive illness and whether medication should therefore have been recommended was rehearsed at length before the Coroner. Those who knew Child B well (his parents and teachers) and spent time with him every day believe that he did manifest the requisite symptoms of Major Depressive Disorder. We will never now know whether his difficulties would have responded to the evidence-based pharmaceutical interventions indicated for the persistent anxiety, low mood, sleep problems, and anger he experienced. From February 2017 Child B attended a series of meetings with a trainee Psychiatrist under the supervision of the Consultant Child and Adolescent Psychiatrist. The minutes of the second Child Death Review Meeting together with the trainee Psychiatrist’s evidence to the Coroner indicate that Child B was unable to benefit from the Cognitive Behavioural Therapy approach followed in these sessions. Crucially, he did not complete the tasks assigned to him between sessions that serve as the lynchpin of this form of therapy. It seems that as these Final 12.10.2020 (revised for publication 05.01.2021) Page 24 of 49 sessions progressed Child B continued to report low mood, couched his thinking in “black and white”, catastrophic terms, and articulated angry feelings about both his school and his family. The structure of the specialist mental health service is designed around the principle of multi-disciplinary collaboration. There are frequent and regular opportunities for case discussion within the team, and for different perspectives to be heard. The Mental Health Nurse’s case notes record that Child B was discussed within the specialist mental health service team on 29th March 2017. Although the notes name various issues the process of this discussion is not on record. In the case of Child B, effective multi-disciplinary collaboration did not extend beyond the specialist mental health service team. Each agencies’ records report information-sharing by phone, via email and in some face to face meetings. However, these records convey little sense of purposeful collaboration. Referrals were made to Children’s Services but there is no evidence that the Consultant Child and Adolescent Psychiatrist in his role as Clinical Lead sought to integrate the social work assessment and subsequent intervention with the mental health service plan. The school’s prior knowledge of Child B, engagement with his parents, insights into his relationships with peers, and direct experience of his acute distress were not harnessed to inform the assessment. Education professionals who had worked with Child B for five years felt that their information and perspective were not heard, acted upon or respected by the mental health professionals. Their view of the dynamic between the school and the psychiatric services has been borne out in the process of this review. The view of the Clinical Lead was, and is still, that the treatment plan for Child B was the optimal approach to meet his needs, and that his mental health improved accordingly during the spring of 2017. His thinking during that time shifted towards the view that the source of Child B’s distress lay within the family dynamic. An incident where Child B’s father physically restrained him prompted referral to Surrey Children’s Services as a child protection matter and resulted in a Section 47 Enquiry. An internal referral was made for family therapy within CAMHS and this was due to start in late May 2017. These are telling examples of Child B’s account of family life being taken at face value without due reference to context. Review of the integrated chronology offers another interpretation of this period. There were indeed fewer episodes of acute distress during April. This period partly coincided with the school holidays. Child B stopped attending school in late March 2017, when the Safeguarding Leads and parents together took the view that being in school put unmanageable pressure on Child B. They were united in their concern that performance anxiety, a sense of failure and troubled dynamics within his peer group at school were important components of Child B’s distress. They Final 12.10.2020 (revised for publication 05.01.2021) Page 25 of 49 hoped that being out of school would remove the pressures that previously served as triggers for Child B’s “meltdowns”. He was not excluded from school or removed from the school register. Child B’s parents were still extremely worried throughout the spring. They continued to express urgent concern about his low mood, possible substance misuse, his trips to the woods with ropes, the impact of contact with friends via social media, and his research on suicide websites. These were shared with the mental health professionals as well as voiced to social workers conducting the Section 47 Enquiry. His parents acknowledge the relative calm of this period when there were fewer dramatic episodes and “meltdowns” but did not feel that Child B’s difficulties were resolved or even diminishing. Despite there being significant multi-agency support for Child B, was there an agreed co-ordinated care plan in place? There was no agreed multi-agency co-ordinated care plan. No child protection plan was put in place to guide the multi-agency network’s input to keeping Child B safe. The integrated chronology highlights several missed opportunities for Surrey Children’s Services to step into a lead role to drive a co-ordinated plan that could promote a constructive treatment plan, address the parent’s need for ongoing support with the challenges of safeguarding Child B, and oversee a jointly agreed inter-agency strategy for minimising risk and managing crises. Was a lead professional identified? The case notes of the Consultant Child and Adolescent Psychiatrist within CAMHS Community Team and also attached to the specialist mental health service clarify that he held medical responsibility and was the Clinical Lead for Child B. From late March 2017, a worker from the Youth Support Service had some involvement with Child B and his family. In April 2017, a brief assessment resulting in no further action was carried out within the Multi-agency Safeguarding Hub in response to the only safeguarding referral made by CAMHS. On 10th May 2017, the case was allocated to a newly qualified Social Worker in the Assessment Team. Since she was unable to begin this work it was re-assigned to a Senior Family Support Worker on 24th May. There is no record within the Integrated Chronology of any Strategy Meeting, Child Protection Conference, or Child in Need in meeting. It is not clear therefore what formal mandate underpinned the work of Surrey Children’s Services during this period. Child B’s parents have stated that they did not know who to go to as the key professional with oversight of his care. Final 12.10.2020 (revised for publication 05.01.2021) Page 26 of 49 Neither the Consultant Child and Adolescent Psychiatrist nor any personnel within Surrey Children’s Services enacted the role of lead professional. The integrated chronology gives no indication of a lead professional being identified. Was there appropriate clinical supervision? Clinical supervision is only applicable to health professionals, nursing and medical staff. There is insufficient detail within the Child and Adolescent Mental Health Service and specialist mental health service contributions to the Integrated Chronology to afford insight into the quality of clinical supervision in this case or analyse how clinical supervision influenced practice and decision-making. The Terms of Reference and scope of the Safety Investigation Report prepared in September 2017 by Surrey and Borders NHS Trust made no mention of clinical supervision. The Safety Investigation Report makes neither comment nor recommendations in respect of clinical supervision. It has not been possible to examine records of the supervision process in this case nor review the quality of supervision received by CAMHS and specialist mental health service practitioners. Interviews with the Service Manager and the Mental Health Nurse within the specialist mental health service assigned to Child B and his have clarified the supervisory arrangements within the specialist mental health service as follows: ➢ The Mental Health Nurse received both line management and clinical supervision from the Lead Nurse on a one-to-one basis ➢ Cases could be raised for discussion at weekly local team meetings led by the team manager ➢ Each of the professional disciplines met for monthly group discussion led by one of the therapists ➢ Each team met for monthly group discussion led by an independent therapist ➢ The Team managers met for monthly group discussion led by an independent therapist Witness evidence given to the Coroner by the Consultant Child and Adolescent Psychiatrist and the trainee Psychiatrist indicated that they met weekly for supervision but did not always discuss Child B. The trainee Psychiatrist could also discuss Child B informally with colleagues in the hub area. FINDINGS Child B’s experience highlights how the multi-agency network’s responsibility to safeguard children in mid-adolescence is affected by ambiguity and subjectivity. It is inevitable that each individual practitioner’s approach to these ambiguities is Final 12.10.2020 (revised for publication 05.01.2021) Page 27 of 49 influenced by their core beliefs; professional values; personal and professional experience; training background; practice context; team culture; organisational practice and policy; and supervision. Each of these factors varies from individual to individual both within each profession and across the different professional disciplines. Decision-making and practice were affected by unresolved differences of opinion between professionals within the multi-agency safeguarding network. The experience of Child B and his family was determined by differing perspectives in relation to the following themes that commonly arise in similar situations: Competence: UK statute is profoundly confusing regarding children’s rights and responsibilities. The age at which children become responsible for their own decisions varies in relation to criminal responsibility; consent to sexual activity; marriage; health choices; leaving home; the right to vote. The Mental Capacity Act, 2005 provides frameworks to empower and protect adults who may not have capacity to make certain decisions for themselves, but it does not apply to children under 16. Self-determination and personal growth: Practitioners across the multi-agency network face challenges when charged with responsibility for safeguarding children in mid-adolescence. Achieving the right “fit” on the continuum between taking necessary steps to protect a vulnerable child placing themselves in danger and affording them opportunities to understand and manage risk for themselves is the central challenge of safeguarding practice throughout the secondary school years. Safeguarding Responsibility: The Children Act, 1989 determines that parents retain parental responsibility to the age of 18: read alongside the statutory guidance contained in Working Together to Safeguard Children the powers and duties of the multi-agency network include safeguarding children to the age of 18. All parents and professional practitioners recognise that these responsibilities must be enacted differently as children grow and develop. However, the detail of when and how children should be afforded opportunities to exercise freedom and learn to look after themselves varies from child to child, parent to parent, family to family, across cultures. Inevitably, in adolescence all children assert their need to choose their own friends and ways of spending time and every parent must decide how to manage this while still making sure that their child is safe. These dilemmas are compounded by ambiguity about the relationship between the individual, family and state that lies at the heart of safeguarding practice. Hospital Admission and Treatment: Most people make a rational choice to avoid being admitted to hospital until or unless necessary. Nursing practice and treatment processes in hospitals can leave people feeling disempowered (Department of Health, 2001). For many patients there is a risk that they will become “institutionalised” and soon feel unduly dependent on medical care. These Final 12.10.2020 (revised for publication 05.01.2021) Page 28 of 49 risks apply regardless of whether patients are admitted to hospital for physical or mental health problems. Nevertheless, most people take rational decisions and follow medical advice to go into hospital when they need to. In the UK our mental health legislation emphasises professional responsibility to ensure that, regardless of age, treatment for mental health problems is provided using the “least restrictive alternative” and sets out safeguards to ensure that psychiatric patients are only assessed or treated compulsorily in hospital according to strictly prescribed criteria. Hospital care for children with mental health problems carries known risks, should never be recommended lightly, but is sometimes necessary for their safety, and can serve as the threshold for recovery in the same way for children as for adults. Risk assessment. Theories of risk are complex and hotly contested (Power, 2004; Webb, 2006). Within the field of safeguarding children, it is widely acknowledged that actuarial risk assessment methods and clinical judgement are both useful, but both are also flawed. Reaching a consensus about risk is difficult because risk analysis is highly subjective. Risk assessment is a dynamic process that considers fluctuations across time and different contexts. Sometimes assessments fail to discuss families’ needs because safeguarding procedures align with scarce resources to drive practice into responding primarily to specific incidents where harm was perpetrated by person(s) who abused the child. Professional practitioners with responsibility for assessing and analysing risk assessment need to bring skill, knowledge and experience, and an open mind. Risk analysis should address all foreseeable sources of potential harm. No professional practitioner can be expected to predict and prevent every possible danger to a child but must be able to demonstrate defensible practice. Practitioners across different services may take quite different approaches to risk assessment. Talking about risk, how risk is perceived and respective approaches to risk assessment is therefore fundamental to effective collaboration. There is always ambiguity but all professional practitioners can be expected to articulate how they have gathered and examined information, explored, and weighted different opinions, drawn on the professional evidence base and guidance, formed their judgement and reached their conclusions. Risk Management: Effective plans for risk-taking, tolerating uncertainty, risk-minimisation and promoting safety rely on robust risk analysis. Outcomes are easier to predict when risk is low than in high-risk situations (Hayes and Spratt, 2009; 2012). Risk management like risk assessment is an inexact science, never fail proof and therefore must be completely transparent in process and content. It is appropriate that practitioners working to minimise risk of harm to a child should feel anxiety since complexity and uncertainty are inevitable, but their burden can be shared across the multi-agency safeguarding network: ‘a trouble shared is a trouble halved’. Understanding and communicating with children: The principle of understanding behaviour as communication is as relevant for children in mid-Final 12.10.2020 (revised for publication 05.01.2021) Page 29 of 49 adolescence as for younger children. As with adults, what they say cannot be taken at face value but must be weighed against what they do. Difficult behaviour in mid-adolescence is often best understood as an indicator of distress, just as it is in earlier childhood. When children place themselves in the way of danger, whether intentionally or unintentionally, their behaviour is always a safeguarding concern. Social media and on-line communication: Adolescence is a period of fundamental and sometimes rapid physical, neurological, psychological, and intellectual change in preparation for adulthood. It is also therefore a period of potential susceptibility (Stein, Ward and Courtney, 2011 cited by Brown and Ward, 2012). The fact that young teenagers are second only to babies in suffering untoward death is testament to their vulnerability (Brandon, Bailey and Belderson, 2010). There is little discussion or consensus about the kind of care adolescents need within families and from the state. The increased incidence of self-harm and child sexual exploitation have exposed the detrimental impact that technological advances have had on some young people. The significance of social media for young people’s physical and mental health in the short and longer term is not yet fully understood. The evidence for both positive and negative impact is sketchy and further research is needed. Anecdotally, some parents are thought to be learning from difficult experience with their own teenagers that they need to restrict the access they afford younger children to computers, tablets, and phones. Bullying, body-shaming, rumourmongering, manipulating, shifting loyalties, questioning gender identity and sexual experimentation are all familiar aspects of early teenage life but are now conducted on-line within the family home and in classrooms as well as in the playground and streets. The pressure of continuous contact with peers via messaging is increasingly recognised as a potential source of anxiety and distress for some children, especially when they stay on-line at night and sleep patterns are interrupted. The rule of optimism: The work of professional practitioners in the multi-agency network is primarily directed at creating change and enabling development. The contemporary emphasis on strengths based / recovery models across many fields of practice mirrors this expectation. However, in the safeguarding arena it is necessary to guard against naivety. In the context of danger, the presence of strengths does not necessarily represent safety. Skill, knowledge, and experience: Public, voluntary, and not-for-profit organisations working with children and families find it increasingly difficult to recruit and retain experienced and professionally qualified staff. The multi-agency network has become reliant upon employing inexperienced unqualified staff and newly qualified practitioners to fill vacant posts and sustain the establishment needed. To engage purposefully with complex cases practitioners in all the different roles across the safeguarding network need depth of knowledge, breadth of experience, refined emotional literacy, and flexible interpersonal skills. They must be able to Final 12.10.2020 (revised for publication 05.01.2021) Page 30 of 49 access knowledge that is often highly specialised and understand the significance of evidence from research. They must be able to do this while simultaneously holding in mind the unique experience of each child and their family. Only a few new recruits bring this capacity with them when they start out. It also takes time to integrate the personal, professional and role authority that underpin professional practice. Practitioners cannot exercise authoritative practice with children and families until these have been assimilated. The ability to debate, challenge, understand, negotiate, and resolve differences of opinion across the multi-agency network relies on practitioners having overcome all these developmental challenges. They must find a way to internalise their early practice experience to form a personal / professional identity that will sustain them through their working lives as instruments of change and positive role models. Professional education, in-house training programmes, and individual commitment to independent learning are not enough to enable practitioners to achieve these transitions. Workplace learning is and always has been the cornerstone for professional development that equips practitioners with the diverse range of skills demanded in work with children and families where needs are complex and risks uncertain. The role of experienced work colleagues and practice leaders in creating purposeful teams cannot be underestimated. At best, where work-based learning is neglected the development of good practice is likely to be compromised and at worst, opportunities are created for poor practice to take root. The multi-agency network shared information about Child B and his difficulties well-enough. The difficulty lay in making sense of that information. Differences of opinion arose between professionals as to the meaning of his distress and behaviour. These differences were mirrored within the informal network that Child B turned to for help. All the issues outlined in paragraph 5.2 (above) played a part. Essentially a split developed whereby the same information was interpreted differently. The school and Child B’s parents believed that he suffered rapid onset of mental illness that should be diagnosed and treated. Their awareness of his morbid preoccupations and repeated insistence that he would die soon led them to believe that he planned and intended to take his own life. The mental health professionals formed the opinion that Child B was unable to regulate his emotions and lacked the ability to self-soothe when he experienced stress. Relationships between practitioners were friendly and constructive. This meant that the extent to which they disagreed was not understood, issues were not challenged, and differences of opinion went unresolved. Because the differing perspectives of the various agencies involved with Child B were not exposed they never informed an agreed and integrated assessment of risk. Opportunities were missed to convene Strategy Meetings and a Child Protection Case Conference, either of which could have afforded a forum to explore and get to grips with the safeguarding issues in this case. This in turn affected the planning process. The “safety plan” spelt out Child B’s chosen strategies for Final 12.10.2020 (revised for publication 05.01.2021) Page 31 of 49 managing his emotions, and the “care plan” described interventions to be made by the mental health services. Neither was intended to help the parents or school perform their responsibilities. There was no multi-agency risk-minimisation plan, risk management strategy, or child protection plan put in place to enable the safeguarding network to help his parents protect Child B from placing himself at risk of harm. These missed opportunities indicate a whole-system problem. The climate of the multi-agency network caring for Child B seems not to have afforded opportunities for constructive challenge. Disagreements became embedded as conflicts and gave rise to distrust between agencies. Far from achieving a sense of working together to meet the needs of Child B, the School Safeguarding Leads, the professionals who had the most long-term understanding of Child B and who knew his personality and behaviour well came to feel unheard and misunderstood by decision-makers in the mental health services. The fact that differences of opinion were not explored suggests that a lack of professional curiosity served as a counterpoint to and reinforcement of the systemic difficulties around constructive challenge. Every time different perspectives were voiced between members of the team around Child B there were missed opportunities to examine meaning. For example, with the benefit of hindsight it is clear that numerous questions were not asked such as: ➢ Did the agencies involved with Child B hold different information about him? ➢ Did the agencies hold the same information but understand or interpret it differently? ➢ Did some professionals hold specialist expertise that could be shared with a view to enhancing the interventions of others? ➢ Did any general organisational objectives interfere with meeting the individual needs of Child B? Had these and other questions been explored, new insights could have informed the plan to address and manage Child B’s deteriorating mental health in the months leading up to his death. Several entries into the integrated chronology indicate that the practice of the many police officers that became involved with Child B and his family was clearly described and explained. The account provided of the work undertaken by the Student Support Officer / Deputy Designated Safeguarding Lead is detailed and explicit. The crisis assessments undertaken immediately after Child B’s first two hospital admissions for overdose were exemplary. The specialist mental health service’s Nurse’s case notes provide a full descriptive narrative of her contact with Child B, his parents, and other agencies. The trainee Psychiatrists records and letters to Child B’s General Practitioner outline the content and process of his therapeutic sessions with Child B. Final 12.10.2020 (revised for publication 05.01.2021) Page 32 of 49 The key practitioners interviewed for this case review have been able to articulate how and where they reflected on what they observed and heard. However, their reflective and analytical process is not contained in the record, nor is it evident in the documents that were shared across the network. Whereas professionals and parents may have thought they were all working together and “on the same page” Child B’s death has exposed how little they had developed a shared understanding of his distress. Profoundly different perspectives on the meaning of his distress inevitably led to different ideas about the best way to intervene, treat and manage Child B. The Surrey and Border Partnership Trust’s case record does not clarify how the Consultant Child and Adolescent Psychiatrist formed his opinion of Child B’s mental health status and planned his treatment. The Child and Adolescent Consultant Psychiatrist’s records of his direct contact with Child B are very brief: they describe Child B’s presentation and summarise his clinical judgements in note form. The Child and Adolescent Psychiatrist’s view that Child B did not suffer from a diagnosable mental illness and was at low risk of actual self-harm or suicide informed the mental health service intervention plan even though it was repeatedly contradicted by parents and school staff who perceived Child B as seriously ill and a real source of danger to himself. Several clinical decisions were queried within the Safety Investigation Report prepared by the Surrey and Borders Partnership in the early autumn of 2017 and in their medical review of the serious incident, dated 30th October 2017. In particular this report highlights that on 2nd December 2016 and 12th May 2017 it would have been more appropriate to rate Child B’s risk as High / Red or at least Medium / Amber (behaviours have escalated) rather than Low / Green (engaging with services, attending school, placement intact).The reasoning behind these decisions has not subsequently been made transparent in the evidence provided to the Coroner or in the interviews conducted for the purpose of preparing this report. Child B’s story exemplifies how essential it is that all practitioners across the whole safeguarding network articulate how and why they reach the judgements on which subsequent actions rest. Every intervention should be evidence-informed, and every decision should be defensible. Responsibility for transparency and accountability is a matter of professional ethics. It requires more than simple compliance with guidance and procedures. Whether in case notes, within minutes of meetings or within supervision records whenever practitioners do not commit critical reflection to the written word opportunities for explicit examination of meaning and shared understanding are lost. Child B and his family struggled to live with his sleep difficulties; low mood; anxiety; his self-harm and risk-taking behaviour; morbid interests; and episodes of bizarre or aggressive behaviour. Initially his parents offered unconditional love and support Final 12.10.2020 (revised for publication 05.01.2021) Page 33 of 49 matched with clear boundaries and expectations. As his distress escalated and his behaviour became more shocking and difficult to contain, they openly shared their sense that something was seriously wrong with Child B. They repeatedly asked for advice and most importantly explained that they no longer knew how to keep him safe from harm. They locked away all sharps and household medication, attempted to minimise the impact of social media and on-line communication, asked local pharmacies not to supply over-the-counter medication to Child B, confiscated knives and ropes, and on occasion physically restrained him to prevent him from causing material damage, injury to himself or others and from leaving the home in an agitated state. They were candid about the stresses this placed on them, their concerns for their younger son living alongside Child B, the disruption to everyday family life, and changes in their employment that they felt compelled to make in order to be continuously available. As his distress deepened their love and support met with his anger and sometimes open hostility. Once Child B was demonstrably in serious emotional and psychological distress, suffering sleep problems, continuous low mood, and frequent episodes of acute anxiety they could and should have been regarded as his carers. The involvement of the specialist mental health service marks a recognition that Child B’s second overdose brought him to the threshold of admission to hospital. When it rapidly became clear that the parent’s responsibilities towards Child B exceeded those of a healthy 15 – 16-year-old their needs as carers should have been assessed under the provisions of the relevant legislation. Had the parents’ requests for support been understood as the consequence of their role as carers their need for advice, guidance, and services (including respite care) could have been framed very differently. The Child in Need plan for Child B missed the mark because its frame of reference was mis-directed. The Child and Adolescent Mental Health Service should have been there to meet Child B’s need for effective treatment. The proper role of Surrey Children’s Services was to identify a package of care to meet his parents’ need for guidance, practical help, and emotional support and to co-ordinate a multi-agency plan. Since Child B’s difficulties escalated sharply in November / December 2016 to meet the threshold for CAMHS Tier 3 services and continued to escalate towards the threshold for Tier 4 (hospital admission), reasonable adjustments to meet his educational needs should have been managed on medical advice. In late January, after his second overdose and the traumatic context in which it arose, the Designated Deputy Safeguarding Lead put in place a risk management plan to be used when Child B returned to school. In the weeks that followed it became clear that Child B’s anxiety and distress could not be contained safely within school. Consequently, Child B’s parents and school staff improvised a plan to relieve him from the pressures of school, he stopped attending altogether, individual tutorial home visits were arranged, and the specialist mental health service day programme stepped in with part-time provision. Sadly, Child B persistently misconstrued this arrangement as a rejection and directed much anger towards the school staff. These arrangements could and should have been supported with Final 12.10.2020 (revised for publication 05.01.2021) Page 34 of 49 exemption from education on medical grounds and referral to Access to Education (A2E). Having been out of school through March, April and early May he went back into school to sit GCSEs only in the week immediately before he hanged himself. Child B’s parents and the professionals who knew him well shared concerns about his use of social media, and the negative impact of communicating with his friends and peer group by text. The Student Support Officer / Deputy Designated Safeguarding Lead were shown texts by his friends that described his despair, thoughts of self-harm and plans to end his life. Child B’s parents worried that they witnessed his mood plummet or anger rise in response to text messages that upset him. His parents often had to rely on his friends to alert them when Child B put himself in danger. When his parents attempted to monitor Child B’s on-line activity, they discovered visits to websites about suicide and specifically death by hanging. It is difficult to know, even with hindsight, how Child B’s on-line activity affected his sleep and mood. Its contribution to his mental illness, fluctuating presentation and rapid deterioration will never be fully understood. It was difficult for Child B’s parents and school staff to make sense of his rapidly escalating anxiety and episodes of intense emotional distress. As discussed above, opinions differed across the network as to the severity of his problems and risk of suicide but there was broad agreement that the causes of his distress were uncertain, and his needs were complex. With an evolving set of interlocking issues and constraints and no definitive solution, Child B and his family needed the multi-agency system to adopt a collaborative and inclusive approach if they were to find a purposeful way forward (Grint, 2005). Although it has become commonplace for case reviews to identify the challenges of working together as a root cause of child deaths the issue is not trite and still needs to be addressed. Detailed examination of Child B’s experiences and the fact that he took his own life (whether intentional or not) suggests the need for a transformational approach to collaborative practice in similar cases. Current research across diverse academic subjects indicates that interdependence is a powerful asset when allied with social intelligence. The various practices and disciplines across the multi-agency network draw on similar concepts, ideas, and words. Understanding how these migrate and move from one to the other is vital to how professional groups communicate knowledge to one another. It is now widely recognised across all fields of endeavour that creativity flourishes most readily between existing disciplines, calling for an openness of mind that is best fostered by sharing a common goal with people of contrasting approaches. Child B’s death highlights the significance of contextual safeguarding where the primary source of danger is the child himself. Practice innovation is needed to ensure that the multi-agency network come together to plan holistic constructive intervention and treatment as soon as such safeguarding concerns are raised in any part of the system. Final 12.10.2020 (revised for publication 05.01.2021) Page 35 of 49 Over time Child B was at risk of harm in several different contexts and in several different ways. The many ways in which Child B placed himself intentionally and unintentionally in danger were not construed as safeguarding concerns. This suggests a difficulty across the whole system in recognising the need for a risk assessment and child protection plan in Child B’s case. When the Multi-agency Safeguarding Hub conducted a Section 47 enquiry it was unclear whether the focus should be the general context of risk or the specific concern that Child B’s father was known to use physical restraint. The fact that Child B’s parents were committed to keeping him safe was understood as a strength, but the extreme difficulties they faced that ultimately prevented them from achieving this goal were not recognised as a risk factor. The Signs of Safety model had been adopted across the multi-agency network at that time. This model enabled these strengths and risk factors to be named, but the fundamental principle that “safety is strengths demonstrated as protection over time” was overlooked (Turnell and Edwards, 1999). That Child B’s behaviour placed him at risk of harm but was not recognised as a safeguarding issue is particularly significant for the roles and responsibilities of Surrey Children’s Services. Since the Section 47 enquiry concluded there were no concerns about risk to Child B from within the family, no further Child Protection processes were undertaken. The danger Child B posed to himself and clear statements from the parents that they no longer felt confident to protect him were not considered to meet the threshold for continuing child protection intervention. Subsequent input by the (local) Assessment Team did not include a risk minimisation plan that enabled a helpful distribution of roles so that CAMHS and the specialist mental health service could focus on treating Child B’s mental illness, while Children’s Services helped his family to keep him safe. This raises fundamental questions about the role of Surrey Children’s Services in cases where other children are in a similar position i.e. receiving treatment from The Child and Adolescent Mental Health Service, at risk of making decisions / taking actions that place them at risk; not at risk of harm within the family, and the family commit to day-to-day responsibility but are unable to ensure safety. Structures and practice within Surrey Children’s Services have changed in the intervening three years. The Adolescent Safeguarding Teams include CAMHS practitioners and now routinely assess and continue working with similar cases. In principle this enables co-working arrangements whereby the Child and Adolescent Mental Health Service focuses on the child’s mental health needs, while the Adolescent Safeguarding Team support the family in the challenges of keeping the child safe. The use of a range of different risk assessment protocols was profoundly confusing for Child B and his parents. It also gave rise to misunderstandings across the multi-agency network. For example: ➢ The various agencies across the network used different frameworks for assessing risk at different points in time and in different contexts. Final 12.10.2020 (revised for publication 05.01.2021) Page 36 of 49 ➢ Organisations working at low thresholds for concern might deem a particular risk to be high while the same behaviour could score as low in a system that routinely works with a higher threshold ➢ Different assessment frameworks used various terms and metaphors to describe levels of risk e.g. low / medium / high; scales of 1 – 10; red / amber / green so that it was not always possible to discern whether assessments had yielded discrepant accounts ➢ It was sometimes unclear which risk factor was under assessment e.g. child to parent violence, physical abuse, domestic abuse, self-harm, harm to others, suicide ➢ The purpose of the child safety plan, the care plan and the child in need plan were unclear The impact of these confusions on Child B and his family highlights the importance of systems that ensure risk assessment documents integrate all the information available to the child, the family and the whole multi-agency system so that they can inform an effective risk-minimisation plan. The various plans in place in this case did not address all the contexts in which Child B was likely to experience harm and did not make sense to the child, the family, and all the professionals involved. Each organisation generated and worked to various kinds of safety plans, risk management plans and plans to meet Child B’s needs. This was confusing and unhelpful. Child B’s death highlights the need to build on recent service improvements achieved by the Adolescent Safeguarding Team’s current approach to similar situations. Safety planning and risk management approaches will be further improved by adopting a collaborative multi-agency approach to the preparation of comprehensive risk-minimisation plans. A collaborative risk-minimisation plan should: ➢ be worked towards at first point of referral and generated as soon as possible e.g. as an outcome of strategy discussions ➢ complement and include the “Safety Plan” written and owned exclusively by the child, ➢ be prepared in close consultation with the child’s parents, and informal network of carers, extended family, or friends as appropriate ➢ be drawn up by the whole network of relevant organisations involved with the child ➢ make sense as a holistic strategy so that each organisation’s interventions are congruent with the plan and support its overall goals ➢ consider all the different contexts in which the need for it are likely to arise ➢ be explicit about the different kinds of danger, risk or harm that is anticipated ➢ name and outline the purpose of the different risk assessments that have been completed Final 12.10.2020 (revised for publication 05.01.2021) Page 37 of 49 ➢ if actuarial risk assessment procedures have been used, explain the meaning of scores, how they have been interpreted, and spell out their implications ➢ be pragmatic and anticipate the challenges that those with responsibility to enact the risk minimisation plan are likely to face in practice ➢ co-exist with, complement, and carry the same weight as any Child Protection Plan in place ➢ carry the same weight as a Child Protection Plan where none is needed ➢ incorporate contingency planning to anticipate foreseeable problems ➢ be distributed to all relevant organisations involved with the child ➢ be provided in hard copy to the child, parents and any other people in the informal network that have accepted a role within it ➢ be made available (as appropriate regarding confidentiality) to other organisations that might become involved e.g. the Ambulance Service, Surrey Children’s Service Emergency Duty Team ➢ be subject to regular multi-agency review meetings in close consultation with the child, parents, and the informal network for updating, amendment or revision. Child B’s presentation was indeed complex and fluctuated between extremes of apparent distress and calm. It was sometimes hard to understand. Various meanings were attributed to his behaviour by different parts of the multi-agency safeguarding network. The most telling feature of professional practice and decision-making in this instance is that treatment and intervention plans rested on an evaluation of Child B’s difficulties and needs that did not change. A fixed view was sustained within the lead agency. Even though risk assessment, the safety plan and the care plan were reviewed, the support and treatment programme initially offered in late January was still in place in late May. This plan included appropriately intense service provision by mental health professionals but did not demonstrably improve Child B’s mental health and safeguard him from intentional or unintentional harm. This was especially detrimental because the fact that Child B was offered this highly specialist and intensely resourced service perhaps led other professionals to step back. It is not clear from the documentation available why or how a fixed view came to affect the work with Child B. The perpetuation of a fixed view sometimes arises out of systemic difficulties that can affect the work of any team e.g. “groupthink”, bullying or coercion, closed working alliances, poor boundaries, rigid hierarchies, rivalries, inappropriately low or high confidence, misplaced loyalties. Child B’s experience of the specialist mental health service’s input underlines the need for continuous meaningful collaborative working even where highly specialist and well-resourced services take the clinical lead. It is important that the specialist Final 12.10.2020 (revised for publication 05.01.2021) Page 38 of 49 mental health service inter-disciplinary team should work holistically alongside services with long-term knowledge and understanding of the child and family. The work undertaken by the specialist mental health service should from the outset anticipate how other services will pick up the thread once their intensive input achieves change and their treatment outcomes have been met. For example, Child B ardently hoped to re-join his peers in the school’s sixth form in September 2017. However, with his school attendance interrupted, uncertainty hanging over his GCSE outcomes and concern that he might not be well enough to progress to A-level studies in the autumn, Child B’s plans for the future were in jeopardy. At this important watershed in his school career there was a particular need for the specialist mental health service to support him in working constructively towards his plans. The interdisciplinary team working with Child B and his family from late January to May 2017 was mostly made up of relatively inexperienced staff. The record shows that individuals meeting regularly with Child B and his family made well-intentioned and conscientious contributions to the overall care plan. Child B’s presentation of distress was difficult to understand, his needs were complex, and his parents found it overwhelmingly difficult to keep him safe. It is not clear whether the practitioners charged with responsibility for direct work in this case were able to process the ambiguous information they held, negotiate the contradictions, and make sense of uncertainty to provide the support and guidance Child B and his family needed. This team may not have had the knowledge and experience needed to be sufficiently open-minded, authoritative, skilful, flexible, and containing. Several lapses of procedure and technical errors should be noted although they may not have contributed directly to Child B’s death: ➢ The concurrent input of a counselling service (from 23rd December 2016 to 24th March 2017) initially with the CAMHS Community Teams and latterly alongside the specialist mental health service was well-intentioned but incongruent with the threshold criteria for these services. It was already evident by 2nd December that the risk was too high for the counselling service and psychological therapy should have remained with the CAMHS Community Team ➢ There was no formal re-evaluation of risk recorded by CAMHS in spring and early summer of 2017 when concerns about Child B’s self- harm and attempts to take his own life escalated. ➢ Surrey Children’s Services did not provide feedback from the Section 47 Enquiry in late March 2017 to reassure the parents that no further action would be taken ➢ The Integrated Chronology suggests that Surrey Children’s Services did not clarify the outcome of referrals made by the police about call outs ➢ The rationale for involving the Youth Support Worker was unclear Final 12.10.2020 (revised for publication 05.01.2021) Page 39 of 49 RECOMMENDATIONS Recommendation One Surrey and Borders Partnership should ensure that the specialist mental health services engage in effective collaboration and meaningful co-working with the team around the child, the child’s parents, and the child’s informal network of care throughout their involvement with children. This will require not only exchange of information but also full and frank exploration of the meaning attributed to information so that collaboration and co-working rest on shared understanding and agreement about each child’s needs, risk of harm, intervention strategies, and intended treatment outcomes. Agreements and plans should be shared not only with the formal team around the child, the child’s informal network but also with organisations likely to become involved at points of crisis e.g. police, ambulance and acute hospital services. The Safeguarding Lead for Surrey and Borders Partnership should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Two Surrey and Borders Partnership should ensure that specialist mental health service engages with the team around the child, the child’s parents and the child’s informal network of care to pro-actively plan for the end of their involvement and transition back into engaging with the CAMHS Community Team and all other relevant services. The Safeguarding Lead for Surrey and Borders Partnership should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Three Each partnership organisation should review risk assessment procedures and reports to ensure that they are transparent, that risk is articulated clearly in a way that can be understood by practitioners in other settings and explained by practitioners to the child, parents and informal network supporting the child. This recommendation should be considered in conjunction with the review and the Suicide Prevention Toolbox that has recently been completed within Surrey Safeguarding Children Partnership: “Thematic Review: Deaths of children and young people through probable suicide 2014 - 2020”. The Safeguarding Lead for each partnership organisation should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Four Final 12.10.2020 (revised for publication 05.01.2021) Page 40 of 49 Each partnership organisation should ensure that staff throughout the service are aware of and consider a range of potential sources of early help for children and families while waiting for specialist assessment or input. This recommendation should be considered in conjunction with the review and Suicide Prevention Toolbox that has recently been published by Surrey Safeguarding Children Partnership: “Thematic Review: Deaths of children and young people through probable suicide 2014 - 2020”. Safeguarding Leads of each partner organisation should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Five Each partnership organisation should review and rationalise plans that are drawn up on behalf of children with a view to ensuring that planning contributes to integrated, coherent and consistent holistic multi-agency working to manage both need and risk. This recommendation should be considered in conjunction with the review and Suicide Prevention Toolbox that has recently been published by Surrey Safeguarding Children Partnership: “Thematic Review: Deaths of children and young people through probable suicide 2014 - 2020”. Safeguarding Leads of each partner organisation should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Six Surrey Safeguarding Children Partnership should consider the use of risk-minimisation plans as outlined in paragraph 5.32 (above). Recommendation Seven The Safeguarding Children Partnership should seek assurance that difficulties which arise frequently do not continue to compromise working together: ➢ CAMHS practitioners engaged in work with a child do not always contribute to or attend meetings called by other agencies ➢ Expectations about confidentiality and data protection between partnership agencies are unclear. Each partner should re-issue guidelines or consider further training on confidentiality and data protection so that partners have confidence to share information where appropriate and necessary in accordance with the guidance in Working Together, 2018. ➢ Communication between agencies when children have been treated and are discharged from hospital sometimes fails ➢ Child in Need meetings and plans do not routinely involve General Practitioners and outcomes are not shared with them ➢ CAMHS routinely notify General Practitioners about mental health interventions with children and young people. These are not currently copied to Surrey Children’s Services. Final 12.10.2020 (revised for publication 05.01.2021) Page 41 of 49 Recommendation Eight Each partnership agency should ensure that practitioners across the multi-agency network know, understand and are confident to use the agreed processes set out in the “Professional Disagreement Escalation Policy” approved by the Surrey Safeguarding Children Partnership in April 2020 in situations where there are intractable differences of opinion as well as where there is a need to escalate safeguarding concerns. Recommendation Nine Surrey Children’s Services should ensure that the Initial Child Protection Conference (ICPC) threshold relating to children who have attempted serious self-harm or suicide is implemented consistently so that they are always managed with a team around the child, regardless of whether they are subject to a Child in Need or a Child Protection Plan. This recommendation should be considered in conjunction with the review and Suicide Prevention Toolbox recently published by Surrey Safeguarding Children Partnership: “Thematic Review: Deaths of children and young people through probable suicide 2014 - 2020”. Surrey Children’s Services Safeguarding Lead should overview progress and provide evidence to assure the Surrey Safeguarding Children Partnership that this recommendation has been fulfilled. Recommendation Ten Surrey Children Safeguarding Partnership should consider implementing a robust process for audit and quality assurance. This process should support and promote consistently transparent, fully accountable, and defensible practice and decision-making across the whole multi-agency network so that the rationale for decisions made and action taken is clear in all written communication i.e. e-mails, letters, case notes, plans, agreements, supervision records, and reports. . Recommendation Eleven Surrey and Borders Partnership should ensure that the specialist mental health service engages with the team around the child, to include school and / or college representatives, the child’s parents and the children’s informal network of care to actively plan for reintegration into education (wherever that might be). Recommendation Twelve The Surrey Safeguarding Children Partnership should explore how to support and promote work-based learning and evidence-informed practice especially in relation to creating a culture of authoritative challenge, effective collaboration, and creative discourse both within and between the partnership organisations. For example: Final 12.10.2020 (revised for publication 05.01.2021) Page 42 of 49 ➢ Experienced practitioners and practice leaders should be supported to contribute to staff development and the promotion of best practice across the multi-agency network, so that they can help colleagues learn to be assertive, advocate for the child and family, elicit other’s expertise, be authoritative, challenge others, hear and accept challenge, listen for all relevant voices, exercise empathy, work collaboratively, engage in critical reflection with others. ➢ Opportunities should be created for skills development / workplace learning between the partner agencies such as direct observation, co-working with colleagues, action learning sets, structured approaches to reflective group supervision, special interest groups, reading groups. Final 12.10.2020 (revised for publication 05.01.2021) Page 43 of 49 APPENDIX 1 - THE LEAD REVIEWER Fiona Mainstone worked in local government social work settings from 1977 until 2003. She completed her post-graduate qualification as a Social Worker in 1983 and subsequently achieved the Advanced Award in Social Work in 2007. Between 1978 and 1997 she provided community social work services to children at risk of harm, children in care, adults with mental health problems, disabled adults, adults with sensory and intellectual impairments, and with older people. In 1985 she qualified to perform the duties of an Approved Social worker under the Mental Health Act 1983, retaining these functions until 1997. From 1997 to 2003 Fiona Mainstone occupied a senior consultancy role within a child protection team working with families where there was severe and complex risk of harm. From 2003 to 2010 she was employed as a Senior Lecturer within the Faculty of Health, Brighton University, contributing to both undergraduate and masters-level teaching across the Faculty. She secured post-graduate qualifications in Child and Marital Therapy in 1991, Child Protection in 1993, Solutions Focused Psychotherapy in 2002, and an MSc in Child Forensic Studies in 2009. She has worked as an Independent Social Worker, and as an Associate of In-Trac since 2005. Final 12.10.2020 (revised for publication 05.01.2021) Page 44 of 49 APPENDIX 2 – TERMS OF REFERENCE The following terms of reference were initially set out in 2017 and subsequently confirmed by the Case Review Group in February 2020 1. How effectively did agencies work together to safeguard Child B in response to his increasing anxiety and deteriorating mental health? 2. Was information sharing between agencies sufficient and timely in light of escalating concerns to understand Child B’s support needs? 3. Was the school response to Child B’s emerging and escalating needs in November 2016 sufficient? 4. Could more have been done to support Child B? 5. Were police referrals into the MASH appropriately responded to against a background of an increasing frequency of missing episodes, concerns about possible psychosis and the impact social media could be having, as a factor affecting Child B’s mental well-being? 6. How did agencies respond to “Child B’s voice” and anxieties about delays in support, and his family’s concerns? 7. How effective was family mediation and support for the family in coping with child B’s increasingly violent behaviour and missing episodes? 8. In January 2017 at the time of Child B’s second paracetamol overdose in a six-week period was there sufficient assessment of Child B’s increasing risk of suicide? 9. Was the response to Child B’s deteriorating mental health appropriate and timely? 10. Despite there being significant multi-agency support for Child B, was there an agreed co-ordinated care plan in place? 11. Was a lead professional identified? 12. Was there appropriate clinical supervision? Final 12.10.2020 (revised for publication 05.01.2021) Page 45 of 49 APPENDIX 3 - TIMELINE November 2016 Child B talks with Student Support Officer / Deputy Designated Safeguarding Lead about anxiety for the first time Father shares concerns with school and GP School advises father to see GP with a view to referring to CAMHS GP refers to CAMHS The children’s health referral portal conduct triage and refer to a counselling service Concerns escalate within a week of referral CAMHS complete crisis assessment and plan for continued intervention by mental health nurse 1st paracetamol overdose CAMHS crisis assessment in hospital plans for continued intervention by mental health nurse December 2016 Continued distress and agitation at home reported on six separate nights mid-month Parents lock away medicines and knives Close friend shares multiple text messages about self-harm etc. with Deputy Safeguarding Lead Community CAMHS continue to assess and offer support Deputy Safeguarding Lead actively supports child and parents The counselling service input begins Police attend 1st call out to home and notify MASH January 2017 Child B reports inexplicable / implausible incident of chase and assault Police attend 2nd call out to home and notify MASH Community CAMHS and the counselling service both continue to assess and offer support The counselling service report concerns about chase incident and possible psychotic presentation to CAMHS Child B takes 2nd overdose. Final 12.10.2020 (revised for publication 05.01.2021) Page 46 of 49 Police attend 3rd call out, intervene at school with physical restraint, transport to A & E, and notify MASH Crisis assessment in hospital recommends Tier 4 assessment and intervention in hospital setting CAMHS / specialist mental health service Psychiatrist assesses in hospital. Case closed to Community CAMHS and transferred to specialist mental health service The counselling service continue to offer support Child B returns to school with support plan February 2017 Continued distress at home Parents find suicide note Child B goes missing from home and school Intervention team offers support but withdraws because of specialist mental health service involvement Police attend 4th call out to home and notify Mash Family mediation meeting called by CAMHS Child B goes missing and takes 3rd overdose Police attend 5th call out to home, locate Child B transport to hospital and notify MASH CAMHS / specialist mental health service psychiatrist carries out follow up review Child B goes missing? 4th overdose Police attend 6th call out, transport to hospital, and notify MASH Deputy Safeguarding lead conducts risk assessment and creates school’s management plan Child B talks about plans for suicide Child B goes missing Police attend 7th call out, liaise with CAMHS / specialist mental health service Psychiatrist, and notify MASH Child B creates suicide DVD Specialist mental health service continues to support with weekly appointments Final 12.10.2020 (revised for publication 05.01.2021) Page 47 of 49 CBT sessions begin March 2017 The counselling service withdraw Child B returns to school but has extreme difficulties with peers within first two days Parents decide, with school’s agreement that Child B should not attend school School asks for medical sign off so that Child B can be referred to A2E Child B goes missing Police attend 8th call out notified to MASH CAMHS internal referral for family therapy Early Intervention worker operates watching brief Specialist mental health service continues to support with weekly appointments April 2017 Child B discusses earlier incidents at home where father physically restrained him CAMHS make safeguarding referral to MASH S47 Enquiry quickly resolved with no further action Early Intervention worker operates watching brief, Early Intervention worker offers Child B 1:1 meetings and advice to family ref de-escalation to avert physical restraint Specialist mental health service Day Programme arranges timetable of twice weekly attendance Specialist mental health service continues to support with weekly appointments CBT sessions continue May 2017 Surrey Children’s Services allocate case to local Assessment Team Child B goes missing, and carries/ drinks / intends to drink bleach Police attend 9th call out, report as RED and notify MASH Missing episode triggers Child and Family Assessment by local Assessment Team Child B refuses return home interview with Social Worker Final 12.10.2020 (revised for publication 05.01.2021) Page 48 of 49 Family Support Worker allocated Specialist mental health service Day Programme timetable continues specialist mental health service continues to support with weekly appointments CBT sessions continue Social worker begins process of Child and Family Assessment CAMHS Family Therapy appointment offered Child B expresses worries about feeling manic to Deputy Safeguarding Lead Prolonged crisis over 3-day bank holiday weekend culminates in Child B found unconscious in woods Police attend multiple call outs during 3-day period Specialist mental health service nurse visits home and meets with Child B as well as parents Extended specialist mental health service nurse visits home and meets with Child B as well as parents June 2017 Child B on life support in intensive care Child B dies without regaining consciousness Final 12.10.2020 (revised for publication 05.01.2021) Page 49 of 49 APPENDIX 4 – REFERENCES Brandon, M., Bailey, S., and Belderson, P. (2010) Building on The Learning from Serious Case Reviews: A Two-Year Analysis of Child Protection Database Notifications 2007 – 2009. London: Department for Education. Brown, R., and Ward, H. (2012). Decision-Making Within a Child’s Timeframe: An Overview of Current Research Evidence for Family Justice Professionals Concerning Child Development and The Impact of Maltreatment. Working Paper 16. London: Childhood Wellbeing Research Centre. Carers (Recognition and Services) Act 1995. Carers and Disabled Children Act, 2000. Carers (Equal Opportunities) Act 2004. Department of Health (2001) Your Guide to the NHS Grint, K. (2008) Wicked Problems and Clumsy Solutions: The Role of Leadership. Clinical Leader, 1, 2, 11 – 15. National Institute for Health and Care Excellence (2013) Self-Harm Quality Standard QS34 Stein, M., Ward, H., and Courtney, M. (eds.) (2011) Special Issue on ‘Young People’s Transitions from Care to Adulthood’ Children and Youth Services Review, 33, 12, 2409 – 2540. Surrey Safeguarding Children Board (2019) Effective Family Resilience Surrey. Every Child in Surrey Matters. Surrey Safeguarding Children Partnership (2020) “Professional Disagreement Escalation Policy” Turnell, A., and Edwards, S. (1999) Signs of Safety: A Solution and Safety Oriented Approach to Child Protection. New York: Norton. |
NC047191 | Death of a 21-month-old boy from serious injuries in June 2011. Following the child's death, the mother's boyfriend was sentenced to eight years for manslaughter and the mother to 15 months for child cruelty. Mother had recently moved out of maternal grandmothers home into her own tenancy, and her new partner spent significant amounts of time there. Mother had a history of: mental health problems, childhood sexual abuse and abusive relationships. Partner had a history of substance misuse. Issues identified include: the failure of GPs to consider safeguarding issues when treating parents of vulnerable children and inadequate screening of referrals of concern to childrens social care. Identifies a number of improvements to practice since the interim findings of the review were published, including: improved GP engagement in the child protection process and the development of the Multi-Agency Safeguarding Hub. Recommendations include: that the Safeguarding Board should routinely evaluate measures taken by Childrens Social Care to improve the screening of referrals and that the Mental Health Trust should promote guidance on protecting children and young people for doctors who treat adult patients. Includes Birmingham Safeguarding Children Boards response to the review, their judgement that the report was unfairly unbalanced and their decision not to fully accept the reviews findings and recommendations.
| Title: Board Response to Case Number BSCB 2011-12/1: overview report LSCB: Birmingham Safeguarding Children Board Author: Alan Ferguson Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Birmingham Safeguarding Children Board has chosen to include identifying details of the children and the perpetrators as this information has been in the public domain. Final Overview Report BSCB 2011-12/1 1 Birmingham Safeguarding Children Board Response to Case Number BSCB 2011-12/1 Final Overview Report BSCB 2011-12/1 2 Case Number BSCB 2011-12/1 The tragic death of Kieron Barley 23.06.2011 Birmingham Safeguarding Children Board Response Introduction 1.1 As Independent Chair, I am responding to, and commenting on behalf of Birmingham Safeguarding Children Board, regarding a Serious Case Review (SCR) into the tragic death of Kieron Barley, in June 2011, when he was aged 21 months. Due to the circumstances of Kieron’s death, the Birmingham Safeguarding Children Board commissioned a Serious Case Review in September 2011, in order to establish what could be learnt from this tragedy. 1.2 The covering report has been agreed by the Board. In addition the Board has agreed a publication process designed to minimise additional distress for Kieron’s extended family whilst ensuring the learning is made publically available. It is also quite clear that the Board accepted the learning that emerged at the time of the original review, and has acted accordingly. There is good evidence this has generated changes in practice for the better. 1.3 The review has taken nearly five years to be published. Much of what it addresses relates to services and practices that have significantly changed during that unacceptably long period of time. The reasons for the delays are set out below and relate to three key factors: • A very long and complex criminal investigation by West Midlands Police; • The delay in the release of crucially important facts about Kieron’s death as part of the criminal investigation until the trial, necessitating a second stage to the review which took nearly a year; and • Significant and extensive efforts to improve the analysis and identification of learning in the report in the interests of natural justice, balance and objectivity. Final Overview Report BSCB 2011-12/1 3 1.4 It is important to recognise that Kieron’s death was neither predictable, nor preventable. Despite this, and despite the fact that the agencies involved with Kieron and his family, did not contribute to his death (as is established by the Review on the basis of the evidence available, there is undoubtedly considerable learning for all agencies, which was applied by them after the first stage of the review, and which is still very relevant. 1.5 The most important and relevant message from this review, is that professionals must assess and understand the nature of parenting relationships from the point of view of both (or all) the adults involved, rather than focussing solely on the mother of a child and her capacity to parent. The other relevant message is that collusion between adults can be very convincing, and successful, when there is no evidence to indicate such collusion is taking place and no reason to be concerned. 1.6 In addition, as we understand more about the nature of coercion and control within relationships, largely through work and research relating to domestic violence, we can use the learning to inform the work we do with families where there are concerns about how well a child is being cared for. The report 1.7 This summary report and response from the Board is intended to explain the delays and inform the public about what has happened to improve things, where required, since June 2011. 1.8 We wholly agree that Kieron’s death was a tragedy and are clear his death was caused by his mother’s boyfriend. We know that Kieron was a much loved child within his family and for the first 20 months of his life, he lived with his mother and maternal grandmother. His mother formed a relationship during this period with the man who was found guilty in April 2014 of the manslaughter of Kieron. In the last six weeks of his life, Kieron and his mother were living in their own house. His mother’s boyfriend spent significant amounts of time at that house Final Overview Report BSCB 2011-12/1 4 and during that period, Kieron received a series of significant injuries leading ultimately to his untimely death. 1.9 Unfortunately his family have not been able to see the eventual Serious Case Review, until now. This is for a number of complex reasons. The first stage of the SCR process was completed in November 2012 and presented to the Board as an ‘interim SCR’, as it could not be finalised or published until the court case was concluded. Despite the barrier to publication, each of the agencies involved completed their own action plans after it had been agreed as an interim report. 1.10 The court case did not conclude until April 2014 (nearly three years after Kieron’s death). During the long and complex criminal investigation, the police were unable to provide significant pieces of information about the case to the lead reviewer relating in particular to Kieron’s injuries. This information was also not known to any of the agencies involved with Kieron and his family. 1.11 It would be fair to say that as a consequence, the interim report drew conclusions based on partial, erroneous and inaccurate information. Significant progress was however made in implementing the learning from individual agency reports and the interim report. During this period Birmingham City Council, and its partners, also went through a very turbulent period of change and transition as it worked to improve services. 1.12 After the trial, where it was established that Kieron had sustained a fracture to his back as well as the injuries previously known, it was clear that the interim SCR needed to be fully reviewed and consideration needed to be given to whether there were further lessons which could be learnt from the new information available to the SCR panel. It was also important for the SCR to be informed by the fact that culpability for Kieron’s death was clearly to be attributed to the man found guilty of manslaughter. His mother was found guilty of criminal neglect, relating to her failure to recognise the degree of harm Kieron was experiencing, and her failure to be honest when he presented to the hospital with injuries in the first of two visits just before he died. Final Overview Report BSCB 2011-12/1 5 1.13 The second stage of the review took place and the final report is published with this covering report and response. It was considered by Birmingham Safeguarding Children Board in November 2015 and further discussed until finalised for publication in March 2016. 1.14 Regrettably the Board were unable to fully accept the report’s findings and recommendations. The Board takes the view the report is unfairly unbalanced in the emphasis it places on the role of Birmingham and Solihull Mental Health NHS Foundation Trust. It also does not meet the required standards in terms of accuracy, the presence of clear hindsight bias and objective analysis based on evidence. 1.15 This does not negate the very real fact that there was much to be learnt from why and how Kieron died In addition, how professionals from a range of organisations worked with and responded to Kieron, his family and his mother’s boyfriend. The Board is very clear that much of the practice set out in the report was undoubtedly poor quality, and that action to improve was clearly required; including the learning in relation to what happened when the child was presented at Birmingham Children’s Hospital NHS Foundation Trust and to why the referral made to children’s social care was not acted on. 1.16 The Board has concluded that: • There is no doubt that some things could have been done differently, in order to improve Kieron’s life experiences, but this would have had no direct bearing on his death; • There is valid and important learning for the Board and its partners as a result of the review; • That much of the report demonstrates hindsight and author bias, is not well evidenced and, in places, is inaccurate • There is good evidence all the Individual Management Reports (IMR) recommendations have been implemented and learning achieved; Final Overview Report BSCB 2011-12/1 6 • There is external assurance from both Birmingham Cross City Clinical Commissioning Group (CCG) and the Care Quality Commission (CQC) about practice improvement in relation to safeguarding at the Birmingham and Solihull Mental Health Foundation Trust (despite the fact that poor practice had no impact on Kieron’s death); • That the review is now very old and there has been significant change since it took place; and • There is a need to move on and publish the report. 1.17 Because the learning is important, the Board has taken steps before this publication of the SCR to assure itself on the actions taken in response to the findings and recommendations in the report. A set of reports has been received clearly stating what each agency has done, how they monitor this activity and assure themselves of its effectiveness and how they have applied the learning to improve current practice. This has informed the Board’s final response to the report recommendations as follows Recommendation 1 That Birmingham Women’s Hospital NHS Foundation Trust (BWH) take actions to satisfy itself and BSCB that: its staff are adequately skilled and knowledgeable about safeguarding children procedures; procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children and; that safeguarding referrals are made when necessary. The Board now has robust assurance mechanisms in place to monitor how well the BWH addresses its safeguarding responsibilities. Close relationships with their lead safeguarding staff are supplemented by the work on their section 11 audits. In addition, they are partnering with the Birmingham Children’s Hospital NHS Trust and sharing professional knowledge and support. We are satisfied that the BWH understands what it has to do, and is addressing areas for improvement on a Final Overview Report BSCB 2011-12/1 7 consistent basis. The Board is satisfied that the reasons for this recommendation have been addressed. Recommendation 2 That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate measures taken by Children's Social Care to improve the screening of referrals of concern about children. There has been significant work over the last two years in terms of referral practice and the development of the Multi-agency Safeguarding Hub (MASH). A monthly multi-agency audit of referrals takes place and is reported to the Board. The Board is satisfied that the reasons for this this recommendation have been addressed. Recommendation 3 and 4 That BSCB carry out a thematic audit of Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems. That BSMHFT robustly promote the GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness. The Board does not accept this finding. Whilst BSMHFT has identified the need to address a range of issues arising from the SCR, there was and remains no evidence that Kieron’s mother’s poor mental health had any direct causal relationship with Kieron’s death. The impact of her mental health problems made it harder for her to parent, but she recognised this and lived with her mother for most of Kieron’s life so Final Overview Report BSCB 2011-12/1 8 she did not compromise his well-being as a result of her ill health. There is evidence that her vulnerability made her more likely to be coerced by her boyfriend. However, the role of staff at BSMHFT would not have had any impact on this either through commission or omission. The Board is satisfied that this finding was ill informed, not sufficiently well evidenced and irrelevant to our learning. Recommendation 5 That BSCB and (now South Central and Cross City CCG’s) robustly launch and promote the above General Medical Council (GMC) Guidance to all GPs in their locality. Whilst engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally. The Board recognises that GP’s are one of the hardest professional workforce groups to engage with. This is reflected in national analysis of SCR’s, as well as in this one. Since this recommendation was drafted, major changes have taken place with regard to GP practice in Birmingham. The three Clinical Commissioning Groups have driven a coordinated, well led and assertive programme for supporting GP’s to understand their roles as regards safeguarding. A combination of well led and well managed organisational activities, including financial incentives or penalties for non-compliance, has substantially and significantly changed GP practice in the city. A well evidenced improvement plan is in place and regular monitoring and assurance of practice takes place. An inspection by the Care Quality Commission reinforces this position and the Board is assured much has changed. Recommendation 6 That Birmingham Community Health Care NHS Trust issues a practice directive to health visitors on the need to liaise with BSMHFT about the parents of vulnerable children, in order to inform assessments of need for them. Such guidance to include information on issues related to consent/confidentiality. Final Overview Report BSCB 2011-12/1 9 Since the review began, there have been significant changes in the way health visitors and mental health professionals work together. The Board is satisfied these changes significantly mitigate against similar failures occurring now, although there is much still to do. Recommendation 7 That Birmingham Children’s Hospital NHS Foundation Trust place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S Maguire 2011) in strategic locations within the hospital. The Board is satisfied this recommendation isn’t relevant, nor will it have a direct or real impact on practice. In addition, the Board is also satisfied that there was no reason to be suspicious about a bruise given the plausible presentation by Kieron’s mother and her boyfriend at the time. In those circumstances, and given the fact that Kieron was not displaying any physical indications that would lead to suspicion about a serious back injury, there were no clinical or social reasons to trigger a skeletal x-ray. There are very detailed protocols governing practice at the BCH in relation to the potential for concern and what is required of clinicians. BCH is clear that the learning is important in relation to how busy professionals understand, and are more curious about parental behaviour, and has regular training available to staff. They also understand the importance of regular monitoring and case work audit activity to mitigate the risk of professionals missing important triggers for concern. The Board will prepare a learning bulletin focussing on the learning in this SCR that remains relevant and important. It will be disseminated through every agency to front line staff for use in team and staff briefing, as well as training courses. Final Overview Report BSCB 2011-12/1 10 Conclusion Kieron’s death was a tragic result of the behaviour of his mother’s partner towards him, and her collusion with it (however willing or unwilling). Professionals could not have identified there was a risk to him however effective their practice. However, his death has provided us with learning, which we are committed to using to improve the experiences of children and their families in similar circumstances and to better ensure similar circumstances do not arise again. Final Overview Report BSCB 2011-12/1 11 SERIOUS CASE REVIEW BSCB 2011-12/1 In respect of the death of Kieron Barley Dob 22.08.2009 Dod 23.06.2011 Report of the Birmingham Safeguarding Children Board following the consideration of a Review written by: Alan Ferguson Final Overview Report BSCB 2011-12/1 12 Author's Details I am a qualified Social Worker and registered with the General Social Care Council. In March 2009 I retired from the post of Service Development Manager (Safeguarding & Quality Assurance) within Worcestershire County Council after a career in child care stretching back 35 years. Within that role I had written numerous management reviews on behalf of Children's Services as well as overview reports on behalf of the Local Safeguarding Children Board. Since retirement I have become the Director of an Independent Social Work Consultancy offering a range of services including consultancy related to Serious Case Reviews. In this period I have served on numerous Serious Case Review Panels as both Panel member and Chair and, in recent months, have taken advantage of Regional and National events to further extend my knowledge in this area and to keep abreast of recent developments. At the time of commencing this report, I had written twelve Overview Reports for various LSCBs in the West Midlands Region. I have no professional or personal connections with Birmingham Safeguarding Children Board. Alan Ferguson Director Three Towers Consultancy Limited Final Overview Report BSCB 2011-12/1 13 INDEX OVERVIEW REPORT 1. Introduction 2. Conclusions and Recommendations 3. Reasons for Serious Case Review 4. Term of Reference (Précise) 5. Methodology 6. Summary of Family Circumstances 7. Summary of Key Events 8. Key Issues Arising From Review 9. Conclusion and Key Learning Points 10. Recommendations Appendix 1 - Term of Reference Appendix 2 - Agencies Participating in this Serious Case Review Appendix 3 - Quality Assurance of Individual Management Reviews Appendix 4 - Action Plans (From Individual Management Reviews) Final Overview Report BSCB 2011-12/1 14 INTRODUCTION 1.1. The purpose of a Serious Case Review is as outlined in Chapter 8 (8.5) of the Working together to Safeguard Children 2010 (hereafter referred to as Working Together) guidance, namely to: • establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; • identify clearly what those lessons are, how they will be acted on and what is expected to change as a result; and • as a consequence, improve inter-agency working and better safeguard and promote the welfare of children. NB. The above document, which was the statutory guidance in place at the time of the Kieron’s death, was updated in April 2013 and this report also takes account of the revised guidance. 1.2. The guidance goes on to describe two criteria for undertaking a Serious Case Review i.e: • when a child dies and abuse or neglect is known or suspected to be a factor in the death, the Local Safeguarding Children Board (LSCB) should always conduct a Serious Case Review; or • where a child has been seriously harmed as a result of being subject to sexual abuse, the LSCB should consider whether to conduct a Serious Case Review (Para 8.11). 1.3. The subject of this Serious Case Review is a child aged 21 months who died in the early summer of 2011. Due to the circumstances of Kieron’s death Birmingham Safeguarding Children Board (BSCB) commenced a Serious Case Review in September 2011 and the interim findings of that enquiry were reported to the Serious Case Review Sub-Group on 16th November 2012. Final Overview Report BSCB 2011-12/1 15 1.4. The reasons for these findings being described as ‘interim’ are as a consequence of a long and complex criminal investigation into the circumstances surrounding the Kieron’s death, during which the author was unable to access certain information about the death of Kieron nor was he able to contact the family to invite their participation in the Serious Case Review process as required by the guidance. NB. There is no suggestion that this information was inappropriately held back by West Midlands Police, it was done to prevent the complex investigation being compromised in any way. 1.5. Presenting the interim report to the Serious Case Review Sub-Group was deemed to be an appropriate action at that time as, despite the author’s inability to make contact with the family, it was considered that the information that was already available to him indicated a number of areas where urgent action was necessary to improve local services for safeguarding children. 1.6. It was not until 1st April 2014 that the criminal aspects of the case were finally resolved i.e. on that day Louise Barley (mother) and Craig Lewis (mothers partner) received significant prison sentences for their roles in the Kieron’s death (see section 3 for details). I can now confirm that Louise Barley, Maternal Grandmother and Craig Lewis have all been interviewed by members of the Serious Case Review Panel and have made contributions to this Review. All parties will also receive feedback on the Review’s findings from the Author. 1.7. In the wake of their sentencing, the Chair of BSCB commissioned the completion of this Serious Case Review which was then considered to be a two part task i.e: • a review of how the recommendations of the interim report presented on 16.11.12 had been implemented; and Final Overview Report BSCB 2011-12/1 16 • consideration of whether further lessons can be learnt by partner agencies of BSCB from the additional information that could now be released by the Police (primarily related to the last five/six weeks of the Kieron’s life). 1.8. This report is the final report into the circumstances surrounding the death of Kieron and the role of the various agencies involved in his short life. Final Overview Report BSCB 2011-12/1 17 2. SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS 2.1. First and foremost it is the judgement of the Serious Case Review Panel that the death of Kieron was not predictable or preventable by staff in the partner agencies of BSCB who were involved in his life. 2.2. In reaching this judgement the Serious Case Review Panel has considered Kieron’s short life in two phases i.e. • the first 20 months of Kieron’s life during which there was mounting concern in respect of developmental delay exacerbated by home and environmental conditions; and • the last six weeks of Kieron’s life during which he suffered a number of serious physical assaults which ultimately led to his death. 2.3. In respect of those first 20 months, the Serious Case Review Panel has received considerable evidence to suggest that Kieron was a much loved child within his family and, while there was ongoing concern about home conditions and a lack of opportunity for stimulating play, no professional at any time considered that there was any risk to Kieron’s physical safety. 2.4. During the vast majority of this period Kieron and Louise Barley lived in the home of Maternal Grandmother, an environment that caused increasing levels of concern to the Health Visitor involved and which led her eventually to make a safeguarding referral to Children’s Social Care in March 2011 with a recommendation that Kieron be made the subject of a Child Protection Plan. The failure of Children’s Social Care to adequately assess the situation in response (and the Serious Case Review Panel’s judgement in respect of the longer term implications of that decision) are covered in detail later in this report i.e. would subsequent actions by health personnel have been different if Kieron had been subject to a Child Protection Plan when presented at Birmingham Children’s Hospital in May 2011. Final Overview Report BSCB 2011-12/1 18 2.5. In the interim Overview Report presented to BSCB on 16th November 2012 the Serious Case Review Panel identified a number of weaknesses in the services provided to Kieron and his family in this period, and these findings (and accompanying recommendations) are listed in paragraphs 2.20 – 2.24 below. 2.6. The Serious Case Review Panel wishes to record at this point that significant progress has been made over the last two years in implementing these recommendations and there is confidence that services for safeguarding children locally are greatly improved as a consequence. These remedial actions are described in more detail later in the report. 2.7. Notwithstanding these weaknesses in service provision, it can be repeated here that no professional involved with the family in the first 20 months of Kieron’s life had any reason to be concerned for Kieron’s physical safety e.g. no suspicious injuries or bruising were ever reported and there were no concerning attendances at Hospital. 2.8. One of the concerning factors identified in the history of this family was Louise Barley’s vulnerability in respect of her relationships with men e.g. Kieron’s Father was a violent sex offender, and at least two relationships during Kieron’s short life were with men described as ‘controlling and exploitative’. No assessment was ever undertaken to address the impact of these frequently changing relationships upon Kieron’s life but it can be surmised as significant. 2.9. Louise Barley’s relationship with the man who would eventually be convicted of her son’s manslaughter began in January 2011 and initially caused no concern to family and friends who describe him as a ‘kind and caring person’ or to professionals when he attended various health appointments with Louise Barley and Kieron. Had a Police check been undertaken at this time (which would only have happened if Kieron had been subject to a Child Protection Plan) it would have revealed nothing of concern. Final Overview Report BSCB 2011-12/1 19 2.10. In May 2011 Louise Barley and Kieron moved out of the home of Maternal Grandmother and into her own tenancy. Louise Barley had made application for separate housing in March 2011 following a significant and violent family row involving her brother who suffers from cerebral palsy and epilepsy. 2.11. While both Louise Barley and Craig Lewis deny that he actually moved in with her, it is clear that he spent significant periods of time staying there from the very beginning and that he played a significant part in caring for Kieron. It would appear that Kieron suffered physical injuries within days of this arrangement commencing i.e. • on 17th May 2011 a doctor at Birmingham Children’s Hospital observed bruising on Kieron’s back; and • on 28th May 2011 Kieron was seen at Birmingham Children’s Hospital with an injury to his shoulder but it later transpired that he was also suffering with fractured vertebrae at this time (this was not identified until after his death). 2.12. The Serious Case Review Panel has addressed both these Hospital attendances in some detail later in this report and has concluded that the doctor involved on 17th May 2011 made an error of judgement in not seeking safeguarding advice from senior colleagues in respect of the bruising, but that staff involved with the consultation on 28th May 2011 could not be blamed for failing to identify the fractured vertebrae. 2.13. Although other professionals were involved with Kieron and his family in the six week period prior to his death i.e. the Child Development Centre who diagnosed him with cerebral palsy only two weeks earlier, the Health Visitor and the Children’s Centre who were trying to engage Louise Barley in a range of activities to promote Kieron’s development, it is the two attendances at Birmingham Children’s Hospital in May 2011 that offered the most realistic opportunity whereby the immediate and serious risk to his life could have been identified. Final Overview Report BSCB 2011-12/1 20 2.14. In the opinion of the Serious Case Review Panel there is no doubt that staff at Birmingham Children’s Hospital would have reacted differently had Kieron been the subject of a Child Protection Plan at the time of the Hospital attendances on 17th and 28th May 2011 i.e. the circumstances of Kieron’s attendance would have been shared with Children’s Social Care. On both occasions it can safely be assumed that safeguarding action would have followed. 2.15. However, he was not subject to such a plan and later sections of this report detail the Serious Case Review Panel’s conclusions in respect of the actions of Children’s Social Care following the Health Visitor referral in March 2011 i.e. our judgement is that the screening of the referral was inadequate. 2.16. Examination of the available information indicates that Kieron’s status changed in a matter of days once he and Louise Barley moved out of Maternal Grandmother’s home and formed a family unit with Craig Lewis i.e. from being a toddler whose developmental delay was a matter of concern (and more recently of concerted action) to a child whose very existence was threatened. None of Kieron s extended family considered Craig Lewis to be anything other than a benign and supportive figure in his life based upon his engagement and relationship with the Kieron in the preceding four months. 2.17. In these circumstances the Serious Case Review Panel had little hesitation in agreeing that Kieron’s death could not have been predicted. The issue of preventability was more balanced but the Panel took the view that there were too many uncertainties in any sequence of events that might have led to safeguarding action to say unequivocally that Kieron’s death was preventable. 2.18. The Interim Overview Report presented to BSCB on 16th November 2012 contained six recommendations for remedial action based upon the findings of the Serious Case Review at that time. These findings and recommendations are summarised below. As stated earlier in this section there has been Final Overview Report BSCB 2011-12/1 21 significant progress in implementing these recommendations and further detail in respect of that progress is provided later in this report. 2.19. A summary of additional findings arising from the reactivated Serious Case Review in 2014 and the one additional recommendation is included at the end of this section. 2.20. The first finding of the Interim Overview Report was that staff at Birmingham Women’s Hospital paid insufficient attention to Louise Barley’s troubled history, including her poor mental health and history of overdoses, when assessing the appropriate level of care during her pregnancy. Recommendation 1: That Birmingham Women’s Hospital take actions to satisfy itself and BSCB that its staff are adequately skilled and knowledgeable about safeguarding children procedures and that those procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children, and that safeguarding referrals are made when necessary. 2.21. The second finding was that Children’s Social Care’s screening of two referrals of concern in respect of Kieron were inadequate and based on presenting information only rather than a scrutiny of their own agency records and those of partner agencies. A thorough assessment following the Health Visitor’s referral of March 2011 may have resulted in Kieron being the subject of a child protection enquiry which would have significantly changed the focus of Hospital staff when he was presented there in May of the same year. Recommendation 2: That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate Final Overview Report BSCB 2011-12/1 22 measures taken by Children's Social Care to improve the screening of referrals of concern about children. 2.22. The third finding was that staff in the Mental Health Trust missed a number of opportunities to promote the safety and welfare of Kieron by not considering the impact of Louise Barley’s mental health problems upon her capacity to parent him safely. Recommendation 3: That BSCB carry out a thematic audit of The Mental Health Trust’s compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems. Recommendation 4: That Birmingham and Solihull Mental Health Trust robustly promote the GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness. 2.23. The fourth finding of the original Overview Report was that Louise Barley’s GP missed a number of opportunities to consider various risk factors that compromised her capacity to safely parent Kieron, and failed to maintain regular liaison with the Health Visitor who was having on-going contact with the family. Recommendation 5: That BSCB and NHS South Birmingham robustly launch and promote the above GMC Guidance to all GPs in their locality and, while engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally. Final Overview Report BSCB 2011-12/1 23 2.24. The final finding of the original report was that the Health Visitor failed to liaise with mental health professionals who were providing services to Louise Barley and therefore she was never in a position to understand whether those mental health problems could have a detrimental effect upon her capacity to provide safe and nurturing care for Kieron. Recommendation 6: That the Community Health Care Trust issues a practice directive to Health Visitors on the need to liaise with the Mental Health Trust about the parents of vulnerable children in order to inform assessments of need for them. Such guidance to include information on issues related to consent/confidentiality. 2.25 A further finding from the updated Serious Case Review was that an opportunity to safeguard Kieron was missed on 17th May 2011 when a Doctor at Birmingham Children’s Hospital failed to implement child protection procedures after identifying bruising on his back. The recommendation below is intended to promote greater awareness of suspicious bruising in young children by Doctors in similar situations. Recommendation 7: That Birmingham Children’s Hospital place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S Maguire 2011) in strategic locations within the Hospital. Final Overview Report BSCB 2011-12/1 24 3. REASONS FOR SERIOUS CASE REVIEW 3.1. In early summer 2011 a 999 telephone call was made to West Midlands Ambulance Service Emergency Control Room at 1832 hours, requesting an ambulance for a child said to be in cardiac arrest. 3.2. On arrival at the given address, the ambulance crew found a small male child on the floor of the living room, not breathing, no sign of any pulse and with his mouth and airways full of vomit. After administering immediate first aid to clear his airways, the child was transported to Birmingham Children’s Hospital and admitted to their Paediatric Intensive Care Unit. 3.3. A CT scan revealed bleeding in Kieron’s brain (an indicator of non-accidental injury) which prompted a referral to the Duty Social Work Team and West Midlands Police. Further scans showed a fracture of the eighth vertebrae, and examination of Kieron’s eyes revealed bleeding therein, again giving rise to concern that he had been the victim of physical abuse. 3.4. For the next four days every effort was made to save Kieron, but he failed to respond to any treatment and the intensive care support was withdrawn on the fourth day on grounds of futility whereupon he died. Kieron was only 22 months of age at the time of his death. 3.5. In view of the circumstances of his death, the matter was referred to Birmingham Safeguarding Children Board (hereafter referred to as BSCB) for consideration of undertaking a Serious Case Review. 3.6. In addition to the information provided by Birmingham Children’s Hospital (see 3.2/3.3 above) BSCB sought information from partner agencies to inform their decision regarding the threshold for a Serious Case Review. This revealed that: Final Overview Report BSCB 2011-12/1 25 • Kieron was a child with developmental delay who had recently been diagnosed with cerebral palsy i.e. two weeks before his death; • Louise Barley had a history of mental health problems stretching back to her childhood; • Louise Barley was a victim of sexual abuse in childhood and again in adolescence; • Louise Barley had previously come to the attention of Children's Social Care as a victim of domestic abuse (from one of her partners but also from her brother who suffered from epilepsy and cerebral palsy); and • Kieron’s birth father was a convicted sex offender, although he was known to be in prison at the time of the Kieron’s death. 3.7. In view of the above and the available medical evidence, the Serious Cases Review Group of BSCB met on 9th September 2011 and made a recommendation that the threshold for undertaking a Serious Case Review was met. The recommendation was formally endorsed by Eleanor Brazil (then the Chair of BSCB) on 19th September and a Serious Case Review commenced on that date. 3.8. The criminal proceedings were not completed until April 2014 when Kieron’s mother was found guilty of child neglect and Craig Lewis of manslaughter. Both received significant prison sentences i.e. Louise Barley was sentenced to 15 months in prison for ‘child cruelty’ (this was later halved on appeal) while Craig Lewis pleaded guilty to manslaughter and was sentenced to eight years. 3.9. Following completion of these criminal proceedings the Serious Case Review was reactivated by the current Chair of BSCB, Jane Held, who authorised the drafting of this Overview Report using a new format and template approved in the intervening months. Final Overview Report BSCB 2011-12/1 26 4. TERMS OF REFERENCE 4.1. The original Terms of Reference for this Serious Case Review were agreed at a meeting of BSCB’s Serious Case Review Group on 9th September 2011, and these comprise two elements i.e. • generic issues, as set out in the Working Together guidance, which should be addressed in all Serious Case Reviews; and • specific issues that have been identified by the Serious Case Review Group as pertinent to this case. 4.2. A full list of these Terms of Reference is included in this report as Appendix 1. 4.3. When the Serious Case Review was reactivated in April 2014 the Terms of Reference were also updated and the changes are listed below: • examine what subject child’s life and experiences were like on the basis of the contact agencies had with him, his birth Mother, his extended family and his Mother’s partner; • pay particular attention to what was known about Mother’s partner and considered in terms of his impact on subject child’s life and why the fact that he was a cocaine and alcohol user was not apparently taken into consideration by any agencies; • address exactly why Mother and subject child did not appear to have any consistent early help or family support given that his Mother was a very vulnerable adult with mental health problems and he had clear developmental delay; • establish whether organisational cultures and behaviours affected the degree to which professionals were alert to subject child’s life and experiences; • establish whether the context in Birmingham impacted on the degree of, and quality of, professional responses and whether a clear consideration Final Overview Report BSCB 2011-12/1 27 of appropriate interventions ever took place on a multi-agency basis and, if not, why not?; • establish how well the process of assessment for cerebral palsy also took into account subject child’s social and economic as well as emotional circumstances; • establish whether anyone considered the accumulation of risk factors apparent retrospectively and if not, why not?; • examine in depth the last six weeks of subject child’s life and experiences and what that can tell us about how agencies were working together to support the whole family and improve his life chances; • explore the degree to which Mother and Mother’s partner were able to manipulate and deceive agencies, why this was able to happen and whether anything additional for frontline practitioners and professionals can be learnt from this or not; and • review whether the changes to practice in Birmingham in the last nine months addressed any of the key learning from this case already, and make any key over-arching recommendations to build on practice learning as a consequence of the case. Final Overview Report BSCB 2011-12/1 28 5. METHODOLOGY 5.1. Paragraph 8.5 of the Working Together guidance requires LSCBs to establish Serious Case Review Panels to ‘manage the process’ of the Review. The guidance also requires that this Panel be independently chaired i.e. not by a member of the LSCB involved, an employee of any of the agencies involved or the overview report writer. 5.2. The Chair appointed for the Serious Case Review Panel is Nicola Pettit, an Independent Social Work Consultant. Ms Pettitt is an Independent Social Worker and Manager with 22 years’ post qualifying experience, the majority of which she has spent employed by local authorities in London and the South East, working in Children's Services. She is an experienced Chair of Serious Case Reviews and the Author of both Individual Management Reviews and Overview Reports. She is independent of all agencies represented on BSCB. 5.3. The author of the Overview Report, is Alan Ferguson, a Director of Three Towers Consultancy Ltd. A brief summary of his career can be found at page 2 of this report. 5.4. The ‘Working Together’ (2010) Guidance requires that the members of the Panel as nominated by local agencies, should be identified by their designation and agency only. For this Serious Case Review the original Panel members were: • Detective Chief Inspector – West Midlands Police; • Designated Nurse, Birmingham and Solihull NHS Cluster; • Head of Children Protection and Review Service, Children, Young People and Families Directorate; and • Designated Doctor, Birmingham Community Healthcare NHS (Foundation) Trust. Final Overview Report BSCB 2011-12/1 29 5.5. However, due to staff movement it proved necessary to convene an almost entirely new Panel once the case was reactivated in April 2014 and the composition of this new Panel is as follows: • Designated Doctor, Birmingham Community Health Care NHS (Foundation) Trust; • Deputy Designated Nurse (Safeguarding Children), BSC CCG; • Head of Child Protection Services, Birmingham Children’s Hospital; • Head of Service, South Birmingham Children’s Services; • Lead Nurse for Safeguarding Children, BCHC; • Named Nurse for Safeguarding Children, Birmingham & Solihull Mental Health Trust; • Detective Chief Inspector, West Midlands Police; • Representative from voluntary sector, Midland MENCAP; and • two lay members. 5.6. In order to carry out its function of ‘managing the process’ the original Serious Case Review Panel met on five occasions between January and August 2012, while the later Panel met on four occasions between June and October 2014. 5.7. The Serious Case Review commenced on 19th September 2011, when the Chair of BSCB wrote to all agencies advising them of her decision to undertake a Serious Case Review and requesting that all agencies research their records about the family and complete an IMR (Individual Management Final Overview Report BSCB 2011-12/1 30 Review) for submission by 9th November 2011. In all cases extensions to this timescale into the New Year were requested and agreed. 5.8. Agencies were required to look critically and openly at individual and organisational practice to ascertain whether changes could and should be made and, if so how this should be achieved. It was a requirement that a designated Senior Manager who had no previous involvement or line management responsibility for the case should complete the review and the Serious Cases Sub-Group is satisfied that this standard has been complied with by all agencies. Guidance notes with a template were provided to all agencies, including the requirement for them to implement any internal recommendations in a timely way. Agencies were also required to send a nil return if they could find no trace of involvement with the family. 5.9. To assist agencies in this task the letter also included: • up-dated guidance on completing IMRs; • an updated template for the IMR and the Genogram; • a template for the Action Plan and the Chronology; • guidance on interviewing staff in connection with an IMR; • an anonymisation code; • a quality assurance checklist; and • Ofsted’s grading descriptors. 5.10. BSCB were aware of Ofsted evaluation feedback that had previously highlighted inconsistencies in the quality of IMR reports. In response, the Board agreed to deliver IMR training for Authors and Senior Managers in December 2009, May 2010 and June 2010. The training launched new IMR guidance, the IMR template and instructions on the interviewing of staff, together with exemplars of good practice aimed at enhancing the quality of reports. Further quality assurance measures have been incorporated within the Serious Case Review process, with all agencies receiving evaluation Final Overview Report BSCB 2011-12/1 31 feedback on the quality of IMRs and areas for further clarification and analysis. 5.11. A Health Overview Report has been produced by one of Birmingham’s Designated Doctor for Safeguarding. This is in line with guidance contained in Working Together to Safeguard Children (2010) which focuses upon “How health organisations have interacted together”. (Para 8.30) 5.12. For this Serious Case Review, IMRs were received from the following agencies on the dates shown: West Midlands Police 19th January 2012 Children, Young People and Families Directorate 1st December 2011 Birmingham Children’s Hospital 18th January 2012 Community Healthcare NHS Trust 19th January 2012 University Hospital Birmingham Birmingham Women’s Hospital 16th January 2012 20th January 2012 NHS South Birmingham (GP) 16th January 2012 Children’s Centre 30th March 2012 Mental Health Trust 30th March 2012 NB. When the Serious Case Review was reactivated in April 2014 all the above agencies were asked to update their IMRs to take account of the previously undisclosed information and to reconsider their involvement with Kieron in the last five/six weeks of his life. These updates have all been received and taken into account by the Serious Case Review Panel. 5.13. Nil returns were received from the following agency on the dates shown: CAFCASS 18th July 2011 Education Welfare Service 20th July 2011 Birmingham & Solihull Women’s Aid 21st July 2011 Royal Orthopaedic Hospital 28th July 2011 Final Overview Report BSCB 2011-12/1 32 Family Action 4th August 2011 NSPCC 24th August 2011 Sandwell and West Birmingham NHS 14th October 2011 Staffordshire and West Midlands Probation Service 1st November 2011 West Midlands Fire Service 8th November 2011 The Sweet Project 26th March 2012 5.14. In addition to the IMRs listed on 6.6 above, the Serious Case Review Panel had the benefit of helpful information reports from the following agencies: Connexions, Birmingham NHS Foundation Trust (Orthoptist) West Midlands Ambulance Service NHS Direct Barnardo’s Amazon Project Salisbury Hospital Homeless Service, Birmingham City Council 5.15. It is a requirement of BSCB procedures that all IMRs produced by partner agencies for a Serious Case Review are ‘signed off’ by a Senior Manager within that agency who, in doing so, is confirming that: • he/she has used the BSCB quality assurance tool to ensure that the report is accurate, of good quality and reflects that agency’s acceptance of its findings; and • that all recommendations contained within the IMR will be subject to timely implementation. 5.16. Those agencies that had significant involvement with the family, and therefore were asked to complete IMRs about that involvement, are identified at paragraph 5.12 above. The following paragraphs give a brief summary of that involvement. Final Overview Report BSCB 2011-12/1 33 West Midlands Police 5.17. West Midlands Police had limited knowledge of the family prior to Kieron’s death, and Louise Barley in particular was only known to them as a victim of sexual abuse. Kieron’s birth Father was well known to Police but he has played no role in his son’s life. There was no Police involvement with Craig Lewis prior to the death of Kieron. 5.18. A criminal investigation lasting nearly three years was undertaken into the circumstances surrounding Kieron’s death and resulted in a successful prosecution of Louise Barley and Craig Lewis. Children, Young People and Families Directorate (BCC) 5.19. Prior to the death of Kieron, Children's Social Care had three contacts with the family i.e. July 2009, September 2010 and March 2011. The last referral was from a Health Visitor suggesting that Kieron’s circumstances warranted him being made subject to a Child Protection Plan, but the assessment by Children's Social Care was that the threshold for a child protection enquiry (Section 47 Children Act 1989) was not met, and the case was closed. It remained closed at the point of Kieron’s death. 5.20. Subsequent to Kieron’s death Children’s Social Care was involved with the child born to Louise Barley and Craig Lewis, and this child is now placed within the paternal family. Birmingham Children’s Hospital 5.21. Kieron attended this Hospital on ten occasions in his life for a variety of medical reasons. Prior to his final attendance with fatal injuries, he had been seen four times in the preceding month, once for an MRI scan as part of ongoing assessment related to his developmental delay, and three times following a fall where he had apparently only suffered minor injuries. Final Overview Report BSCB 2011-12/1 34 Community Healthcare Trust 5.22. This Trust provided a health visiting service to Louise Barley and Kieron throughout his life. From March 2011 a range of specialist services were provided via the Child Development Centre, in order to investigate and assess the nature and extent of Kieron’s developmental delay. 5.23. These assessments eventually led to a diagnosis of cerebral palsy (about two weeks before Kieron’s death) and the Trust were currently involved in helping the family access a range of services appropriate to this diagnosis at the time of his death. University Hospital Birmingham 5.24. This Trust had no contact with Kieron whatsoever, but did have a number of contacts with Louise Barley in the period set for this Serious Case Review, notably when she attended their Emergency Department in December 2008 having taken an overdose of a drug prescribed for her epilepsy. NHS South Birmingham (GP) 5.25. This Trust provided GP services to all family members identified as relevant to this Review. Louise Barley was registered with the same GP for 16 years and Kieron was registered at the same practice throughout his short life. Craig Lewis was registered with a different practice that had no knowledge of his role in Kieron’s life. Children’s Centre 5.26. Louise Barley and Kieron were first referred to the Family Support Team of this Children’s Centre in March 2011 and they had remained involved for a Final Overview Report BSCB 2011-12/1 35 short period beyond the time of Kieron’s death in order to provide ongoing advice, support and bereavement counselling to Louise Barley. 5.27. The intention of the original referral by the Health Visitor had been to get Louise Barley and Kieron engaged in the groups and activities run by the Centre. The Health Visitor had become concerned at Kieron’s developmental delay and the lack of stimulation he received at home. Mental Health Trust 5.28. This Trust provided Mental Health Services to Louise Barley between November 2003 (when she was aged 16 years and displaying self-harming behaviours) until late 2011 when she was discharged back to her GP. Louise Barley re-engaged with the Neuro-Psychiatry Service and Obstetric Service in March 2012 as she was again pregnant. • In the period designated for this Serious Case Review Louise Barley had contact with a range of disciplines within the Trust i.e: the Neuro-Psychiatry Service and the Perinatal Liaison Psychiatry Service. Final Overview Report BSCB 2011-12/1 36 6. SUMMARY OF FAMILY CIRCUMSTANCES 6.1. Kieron lived his whole life in the care of Louise Barley who was aged 20 years at the time of his birth. 6.2. His biological Father had never lived with Kieron indeed, according to Louise Barley, he has only seen his son on two occasions. Information provided by West Midlands Police describes Father’s background as concerning (including offences against children) and suggests that ‘he could have been anticipated to pose a serious risk to Louise Barley and Kieron’ had they ever cohabited. 6.3. From the time of his birth (August 2009) until March 2011, Kieron and Louise Barley resided in the home of Maternal Grandmother. This home was also shared with Maternal Uncle, a young man who suffered from cerebral palsy and epilepsy, and who was unable to live independently. 6.4. In March 2011 Louise Barley and Kieron left the family home following a reported heated argument involving Maternal Uncle. Kieron was said to have become hysterical at this time and was removed by Louise Barley for his protection. Louise Barley and Kieron spent one night in a hostel (leaving because Louise Barley felt unsafe there) and a short period with a Maternal Aunt before moving back to Maternal Grandmother due to the Aunt having personal problems of her own. 6.5. At this time Louise Barley registered herself as homeless with the local authority and was quickly allocated a tenancy to which she moved in early May 2011. Louise Barley’s partner soon joined her there (although both state he was not living there full time) and this address is the location of the assault upon Kieron that led to his death only six weeks later. 6.6. It is a matter of record that Louise Barley had a troubled adolescence and was regularly engaged with local mental health services as a young adult. She Final Overview Report BSCB 2011-12/1 37 also struggled with personal relationships and had a number of brief and unfortunate relationships with men during Kieron’s life. 6.7. Louise Barley’s relationship with the man who would eventually be responsible for the death of Kieron began in January 2011 and developed to the point that he effectively moved in with her once she obtained her own tenancy in early May of that year. Louise Barley described him as a kind and caring man who was very fond of Kieron and enjoyed playing with him. To this day she continues to claim that she never saw him mistreat Kieron or behave in any way towards him that caused her concern. 6.8. Louise Barley gave birth to this man’s child in 2012 but, following intervention from the local authority, the child is now living in the care of paternal family members under the legal protection of a Care Order (Section 31 Children Act 1989) in favour of Birmingham City Council. 6.9. Maternal Uncle constantly struggled with frustration at his restricted lifestyle as a consequence of his medical condition, and his occasional violent outbursts were a source of stress for the family. A number of the IMRs submitted to this Serious Case Review comment that disability issues were a significant factor in the family’s life but, for reasons that cannot be established, insufficient attention was paid to them at the time of various family crises. 6.10. All agencies involved with the family had identified that they were white British, English speaking and non-practicing Church of England. Local practice in identifying and recording the ethnicity of their clients is well-embedded in the practice of partner agencies of BSCB, and this was confirmed in the findings of this Review. Final Overview Report BSCB 2011-12/1 38 7. SUMMARY OF KEY EVENTS 7.1. This section of the report will provide a summary of key events in this family’s history i.e. events that the author considers have been significant in shaping Kieron’s life and, of course, subsequently his death. 7.2. Attention will be drawn to matters of concern or interest by use of a box entitled ‘Author’s Note’ and this will highlight issues that will receive greater attention in later sections of this report. 7.3. Although the original Terms of Reference for this Serious Case Review set a timeframe of November 2008 to June 2011, a number of agencies have helpfully provided information from earlier in Louise Barley’s life which they consider relevant. This included a history of Louise Barley taking an overdose of prescribed medication on three occasions and subsequently receiving psychological counselling and support. 7.4. By February 2009, Louise Barley was pregnant with Kieron and had returned to live with Maternal Grandmother after a short period of living with her now ex-boyfriend. The GP’s letter to Birmingham Women’s Hospital requesting maternity services included reference to Louise Barley’s history of involvement with Mental Health Services, but this failed to prompt any further assessment. Author's Note The IMR completed on behalf of Midwifery Services acknowledges that ‘more should have been done to assess Louise Barley’s vulnerability’ in the context of her history of involvement with Mental Health Services. It cannot be acceptable practice that this vulnerable woman was allowed to take this baby back to the family home (where the two others adults resident there were known to have significant personal problems of their own) without some assessment of the risks to the child. Final Overview Report BSCB 2011-12/1 39 7.5. Despite a threatened miscarriage late in February 2009, the pregnancy was still viable in May when the GP received a letter from the Psychiatric Clinic that was treating Louise Barley. The letter listed a number of concerns in respect of Louise Barley’s condition e.g: • Louise Barley had a history of depression and three overdoses; • the pregnancy was unplanned and not welcomed by Louise Barley’s family; • home conditions are overcrowded (Louise Barley sleeps in same room as Maternal Grandmother); and • Maternal Uncle (also resident in household) suffers with epilepsy as a consequence of cerebral palsy. 7.6. There is nothing documented in the GP’s records to suggest he considered this information in the context of Louise Barley’s capacity to safely care for a baby. 7.7. A further letter to the GP from a Consultant dated 18th May 2009 suggested that Louise Barley’s seizures may not be as a result of epilepsy but ‘a manifestation of distress and difficulties in coping’. Again the GP appeared not to have considered this in the context of safeguarding the unborn child. Author’s Note While the GP may have been confident in respect of Louise Barley’s capacity to safely parent her expected child (based upon his knowledge of his patient and her family) it would have been reassuring to read that he had actively considered all the risk factors in this situation. 7.8. In the same month Louise Barley was asked to provide a witness statement regarding domestic abuse allegedly perpetrated by Father. He was at that point on bail in respect of a serious sexual assault against an adult female. Final Overview Report BSCB 2011-12/1 40 On 23rd May 2009 Father was given a verbal warning in respect of witness intimidation and told to stay away from Louise Barley and Maternal Grandmother (there is no record of a specific incident of intimidation). 7.9. Louise Barley was referred by CAFCASS (Family Courts) to Children's Social Care in July 2009. CAFCASS were involved with Father’s latest partner (although they were separated at that point) who was alleging sexual assault by him. In interviews with the CAFCASS worker, this ex-partner reported that she was aware of Louise Barley and her pregnancy by Father, and CAFCASS were anxious that the local authority knew of the potential risks to her and the unborn baby. 7.10. In response Children's Social Care clarified that Louise Barley had permanently separated from the baby’s Father and decided to take no further action other than record the referral in their records in case the parents chose to reunite at some point in the future. 7.11. Kieron was born in the summer of 2009 while Louise Barley was on holiday in the south of England. As a consequence of his prematurity (born at 33 weeks’ gestation) he suffered significant health problems and spent time in a number of intensive care units and neo-natal units in three specialist Children’s Hospitals. It is reported that Kieron and Louise Barley would have had significant periods of separation during these early weeks and correspondence in the GP’s case records makes reference to ‘poor bonding’. 7.12. Shortly after Kieron’s birth Children’s Social Care were contacted by West Midlands Police as Louise Barley had disclosed that his father had been convicted of offences against children and there was some concern that he may try to abduct the child. The response of Children’s Social Care to this referral was similar to their response to the referral by CAFCASS one month earlier, i.e. they believe that: • Louise Barley was acting appropriately; Final Overview Report BSCB 2011-12/1 41 • it was only a problem if she attempted to make contact or resume her relationship with father; and • the Police are the appropriate agency to deal with any threat of abduction. Author’s Note This appears to the Author to be an inadequate response in respect of promoting Kieron’s safety and welfare. Scrutiny of Children’s Social Care case records and a trawl of partner agencies would have revealed a range of concerning information about the family’s circumstances and should have prompted further enquiries. 7.13. On 5th September 2009 Louise Barley discharged herself from Hospital (against medical advice) leaving Kieron on the ward. It was commented in this Trust’s IMR that mothers of pre-term babies are encouraged to stay in Hospital so they can access appropriate support in caring for a child with additional needs. However, Louise Barley said that she was feeling depressed and insisted on leaving. By 9th September 2009 Kieron was well enough to be discharged home where he was seen by a Health Visitor at her primary visit on 2nd October. No concerns were identified. 7.14. Between September and December 2009 the Kieron was seen regularly by health personnel who expressed no concerns for his health and development. It was noted that Louise Barley had ended one relationship (with a 53 year old man who was described as controlling) and had commenced a new one. The details of this partner were obtained by the clinic nurse and appropriately recorded in the Kieron’s case record. 7.15. On 15th October 2009 the Nurse Practitioner Epilepsy (NPE) wrote to Louise Barley’s GP with a range of concerning information e.g: Final Overview Report BSCB 2011-12/1 42 • Louise Barley had been suffering panic attacks; • she was again suffering from low moods; • she had not bonded with the baby; • she needed to be prompted to feed the baby at nights; • Kieron was sleeping poorly, not eating and crying persistently; • Louise Barley was said to be ‘actively suicidal’; • she was still in a difficult relationship with a ‘controlling’ man; • she had been re-started on anti-depressants; and • they had both been referred to a Mother and Baby Unit. 7.16. However, Louise Barley was seen by her GP on 16th October 2009 for post-partum care and gave a very different story to that reported by the NPE above (NB: the GP had not received the NPE’s letter at this point). Louise Barley acknowledged feeling low and that she had been prescribed anti-depressants again but said she was coping well with the help of Maternal Grandmother. She also said that she was bonding well with Kieron which was again in direct conflict with the information given to the NPE a few days earlier. Author’s Note There is nothing in the chronology to indicate how the GP responded to this letter or whether any consideration was given to Kieron’s safety in this situation. The discrepancy between this interview with the GP and the letter from the NPE is striking, but is not picked up or addressed. 7.17. Between January and April 2010 Kieron was seen by health personnel on a number of occasions with minor childhood ailments e.g., coughs, sticky eye, ear infection and upper respiratory tract infections. In early April he was admitted to Hospital with dehydration following a bout of gastro-enteritis, but made a good recovery and, after rehydration, was discharged the next day. Final Overview Report BSCB 2011-12/1 43 7.18. At a consultation with her GP on 28th April Louise Barley’s mood was reported to be very low. She acknowledged thoughts of an overdose the previous night but reported that Maternal Grandmother, having reminded her that she had a baby to look after, also persuaded her to see the GP. The GP completed a patient health questionnaire for depression and recorded a score of 22/27 which was a ‘moderately severe’ outcome. He prescribed anti-depressants and referred Louise Barley to a local Mother and Baby Unit. Author’s Note This appears to have been a missed opportunity by the G.P. to refer Louise Barley and Kieron to the Health Visitor for targeted support, particularly in relation to Louise Barley’s contemplation of overdosing. 7.19. A letter from Louise Barley’s Neuro-Psychiatrist was sent to her GP on 20th July 2010, commenting that her attacks/seizures ‘were suggestive of a non-epileptic aetiology with psycho-social factors contributing’. The Psychiatrist recommended cognitive behavioural therapy. Author's Note There is no consideration in the letter or the GP’s notes as to any implications for Louise Barley’s care of Kieron as a consequence of either her current mental health or her physical health e.g. the risk of seizures. 7.20. On 30th July 2010 a further letter was received by the GP from a Psychiatrist, this time at a Mother and Baby Psychiatric Unit where Louise Barley had been referred for further treatment and support. This letter repeated Mother’s history of complex social problems (already well known to the GP) and concluded that ‘she has had a number of difficult life events that have made Final Overview Report BSCB 2011-12/1 44 her vulnerable to episodes of low mood’. It also described her as ‘socially isolated’ but able to care for Kieron i.e. there are no child protection issues. Author’s Note The evidence for saying there were no ‘child protection issues’ seems limited. In fact there were many indicators of potential concern for Kieron’s welfare and safety. 7.21. By August 2010 it was clear that Kieron’s development was significantly delayed in a number of areas. Other concerns identified by the Nursery Nurse involved at that time included his failure to put on weight, poor physical conditions within the family home and the unusual number of adults who seemed to be regularly present in the household. No action under safeguarding proceedings was considered necessary at that time. 7.22. No improvement was noted by the Nursery Nurse at a visit on 3rd September 2010 when the family were warned that home conditions must improve or Kieron will be referred to Children’s Social Care for consideration of safeguarding action. This appears to have prompted a positive response as conditions were noted to be better at a further home visit by the Nursery Nurse on 15th September. 7.23. At a home visit by the Health Visitor on 9th February 2011 it was recorded that Louise Barley had a new partner but that he did not live with her in the home of Maternal Grandmother. The conditions in the home are again described as ‘cluttered’ and advice was given on keeping alcohol and cleaning products out of Kieron’s reach. A referral to a Parenting Support Project was discussed and Louise Barley gave her consent to the referral being made. Author's Note Final Overview Report BSCB 2011-12/1 45 Louise Barley and Maternal Grandmother have been warned many times by the Health Visitor/Nursery Nurse about the state of the home and its impact upon Kieron’s safety and general development. In September 2010 they were warned that failure to improve would result in a referral to Children's Social Care. With the added risk factor of ‘hazardous substances’, why was this threat not acted upon? 7.24. On 28th February 2011, the Health Visitor received a telephone call from Louise Barley’s Counsellor advising that she was meeting with Louise Barley fortnightly regarding her symptoms of low mood associated with previous trauma. The Health Visitor agreed to re-visit the household and explore Louise Barley’s concerns. 7.25. Following a delayed 12 month developmental check Kieron was referred to the Community Paediatric Team to assess his ongoing developmental delay. Although he was referred in December 2010 he was not seen by a Paediatrician until 29th March 2011 at which time the full extent of his problems had become more evident i.e. • global developmental delay; • motor delay; • speech and language delay; • visual concerns; and • microcephaly. 7.26. Shortly before the above paediatric assessment was undertaken there had been a serious and violent incident within the family home. It was reported that Maternal Grandmother’s partner and Maternal Uncle had got into an argument which developed into a physical confrontation. Kieron was reported Final Overview Report BSCB 2011-12/1 46 to be hysterical, leading to Louise Barley removing him from the family home and moving to stay with a friend over the weekend. 7.27. The incident was reported by Louise Barley to the Health Visitor the following day, when she was reassured that Kieron would be safe over the weekend (this was a Friday). On the following Monday, the Health Visitor liaised with the brother’s GP (for information about his behaviour and the level of risk that he might pose to those around him) and made a referral on the appropriate multi-agency referral form to Children's Social Care. It was noted that the Health Visitor now believed that the threshold was met for a Child Protection Plan to be made in respect of Kieron. 7.28. This referral was screened in Children's Social Care and passed to a Senior Practitioner for action. The Senior Practitioner contacted the Health Visitor and Louise Barley by telephone to update and clarify the referral information but, although identifying some risk as a consequence of the volatile relationship between Maternal Grandmother’s Partner and Maternal Uncle, and the stress of coping with Maternal Uncle’s condition, the Senior Practitioner concluded that: • Louise Barley had a good insight into Kieron’s needs; • she could ensure his safety; and • the significant factor in this situation was not Kieron’s safety or welfare but Louise Barley’s need for housing. 7.29. The Senior Practitioner’s recommendation was that there was no need for further action under child protection procedures and that other agencies could support Louise Barley with her housing application. This recommendation was supported by the responsible Team Manager and the referral was signed off on 22nd March 2011. Final Overview Report BSCB 2011-12/1 47 Author's Note This referral, which started with the Health Visitor suggesting that Kieron should be made subject to a Child Protection Plan, was not assessed robustly. The IMR author for Children’s Social Care suggests a number of weaknesses in the assessment e.g., •••• failure to consider Kieron’s vulnerability in the light of his developmental delay; •••• a failure to consider Louise Barley’s history of mental health issues; •••• there was no strategy discussion with Police colleagues or contact with them to request any information; •••• no risk assessment particularly in respect of Louise Barley’s various partners (of whom there have been at least four since the birth of Kieron); and •••• no risk assessment in respect of any further contact between Kieron and Maternal Grandfather/Maternal Uncle. The Senior Practitioner appeared to believe that if Louise Barley obtained her own accommodation then all risks/concerns will be reduced to manageable proportions, but this appears a massive leap of faith. Louise Barley would be moving into her own accommodation for the first time at age 22 years with a background of concerning factors, not least having to care for a toddler whose health problems and developmental delay were only just beginning to be clarified. The Senior Practitioner’s assessment was superficial at best and grossly optimistic in terms of Louise Barley’s capacity to safeguard Kieron, while the Team Manager’s authorisation of this piece of work is less than robust. Also disappointing was the failure of the Health Visitor to consider using the escalation policy that was developed for just such situations i.e. she had referred the matter suggesting that a Child Protection Plan was necessary to Final Overview Report BSCB 2011-12/1 48 safeguard Kieron, but Children's Social Care simply close the case after two phone calls. It is the opinion of the Author that the Health Visitor’s concerns merited a challenge to that decision. N.B. The SCR Panel were advised that the BSCB escalation policy has subsequently been updated and re-launched. Review of its’ on-going effectiveness is now embedded in BSCB’s Business Programme. 7.30. On 3rd May 2011 Louise Barley’s latest partner (and the man later convicted of Kieron’s manslaughter) attended his GP with Urticaria, a red itchy rash more commonly referred to as hives, for which he was prescribed anti-histamines. He also reported a continuing history of cocaine use which he was struggling to cut down. The GP gave him the telephone number of Birmingham Drug Line. At this stage Craig Lewis and Louise Barley were not known to be living together so the GP had no reason to be concerned for Kieron or for any other child. 7.31. On the same day (3.5.11) Louise Barley attended her latest therapeutic counselling session. The key issues discussed include: • Louise Barley and Kieron were currently living with a friend but expected their own accommodation to be available within two weeks; and • the ‘whole session’ was focused upon Louise Barley’s anxiety about Kieron’s possible diagnosis which she knew may include cerebral palsy. Author's Note Given what was known about Louise Barley’s history of mental health problems, should the Counsellor have considered Louise Barley’s anxiety in the context of safeguarding Kieron from potential significant harm. Final Overview Report BSCB 2011-12/1 49 This appears to be a missed opportunity to facilitate a multi-disciplinary discussion on safeguarding children issues. The focus appears to be exclusively on Louise Barley’s needs/problems. 7.32. Kieron attended Birmingham Children’s Hospital on 17th May 2011 as a day patient for a range of tests to determine the nature and extent of his developmental delay. The examining Doctor documents four bruises on his back that Louise Barley and Craig Lewis say were caused by the straps on his high chair. Despite this explanation lacking credibility, the Doctor does not discuss the bruising with senior colleagues or seek other safeguarding advice. 7.33. The Health Visitor contacted Louise Barley on 20th May and was advised that she now had her own tenancy and was in the process of furnishing and decorating it. An appointment was arranged for the Health Visitor to visit on 9th June 2011. 7.34. At about 1700 hours on the evening of 28th May 2011 Louise Barley called an ambulance because Kieron had fallen, struck his head on the corner of a settee and has gone ‘floppy and crying’. He was taken to Birmingham Children’s Hospital but discharged at approximately 2050 hours. An x-ray had revealed no fracture to his shoulder and advice was given to Louise Barley. Medical staff had wanted to keep him in for a further two hours observation but Louise Barley requested early discharge for the following reasons: •••• Kieron seemed well again; •••• Craig Lewis had to go to work; and •••• a sibling was being looked after by a neighbour. Author’s Note It is clear with hindsight that Louise Barley deceived the Hospital on this Final Overview Report BSCB 2011-12/1 50 occasion i.e. there was no sibling being cared for by a neighbour. However, Hospital staff had no reason to doubt or query this story. It is possible that the parents were anxious to prevent further investigation into Kieron’s health and wellbeing (it is now accepted that he had fractured vertebrae at the time of this examination) but if so that failed to work as he was taken back to Hospital a few hours later still vomiting and very distressed. 7.35. Later the same evening (at 2337 hours) Louise Barley telephoned NHS Direct for advice as Kieron had been vomiting since their return from Hospital. The advice was that Kieron should be taken back to A&E as soon as possible. He was, in fact, seen there again very quickly i.e. at 0016 hours on 29th May. On this occasion he remained for several hours observation eventually being discharged home at 0845 hours. 7.36. Kieron was still unwell two days later when, at 1631 hours on 30th May, Louise Barley called NHS Direct again. She reported that Kieron was not eating or drinking but continued to vomit and was very distressed. Louise Barley was advised to take Kieron to A&E via her own transport, however, some three hours later (at 1949 hours) a 999 call was made to West Midlands Ambulance Service requesting an ambulance for him. He was again taken to Birmingham Children’s Hospital where he was admitted to the Observation Ward for 12 hours during which time he tolerated oral fluids and opened his bowels after being administered a suppository. 7.37. On 6th June 2011 Louise Barley and Kieron were seen by the Community Paediatrician. At this time, Louise Barley was advised that, following the extensive investigations including a detailed brain scan, the Paediatrician had concluded that Kieron does have cerebral palsy. It was not recorded how Louise Barley reacted although it was noted that the CDC Co-ordinator was also present, to offer support and advice. Final Overview Report BSCB 2011-12/1 51 NB. Kieron was not subject to any physical examination that might have identified the fractured vertebrae that we now know had been inflicted upon him. The meeting was arranged solely to share the diagnosis and to consider ongoing support for Louise Barley. 7.38. An indication of Louise Barley’s reaction to the news of Kieron’s diagnosis can be found in the recording of a telephone conversation between her and her Counsellor, the Nurse Therapist, on the following day (7th June). In it Louise Barley advised that: • she felt shocked, upset and pre-occupied; • she had been tearful and emotionally labile; and • for a while ‘she couldn’t be around Kieron’. 7.39. However, she also reported that she was starting to come to terms with the news and that her partner Craig Lewis was being very supportive. 7.40. The Health Visitor made a visit to the family on 9th June 2011, but did not see Kieron as he was asleep. Louise Barley advised the Health Visitor that she was coming to terms with the diagnosis of cerebral palsy and confirmed that she had a realistic picture of what to expect as her brother had been living with the condition for many years. Welfare benefits and local resources were discussed, and Louise Barley agreed to the Health Visitor referring Kieron to the Family Support Service and to the Sweet Project (this was never taken up). 7.41. The final chapter in Kieron’s life began at 1832 hours on 19th June 2011 when a 999 call was made to West Midlands Ambulance Service requesting an ambulance for a child said to be in cardiac arrest. An ambulance arrived within five minutes and, after some basic life support input, Kieron was transported to Birmingham Children’s Hospital. Final Overview Report BSCB 2011-12/1 52 7.42. On arrival Kieron was confirmed as being in cardio-respiratory arrest, but was revived following cardio-pulmonary resuscitation. He was admitted to the Paediatric Intensive Care Unit where a CT brain scan shows bleeding in the brain. Further scans quickly revealed fractured vertebrae and an optical examination showed some bleeding into the eyes. In view of the potentially suspicious circumstances, the Hospital Social Work Team and West Midlands Police were notified of Kieron’s admission to Hospital and current condition. 7.43. At one point on this day (19th June) the Police were notified that Kieron had died but a pulse was detected just as Hospital staff were about to turn off the life support systems. Kieron remained on life support until 22nd June although he was critically ill with no voluntary responses throughout this period. After discussion with the family a decision was taken to withdraw intensive care the following day on the grounds of futility. 7.44. Kieron died at 1342 hours on 23rd June 2011 following the agreed withdrawal of intensive care support – he was aged 22 months. 7.45. Initially there were no grounds for considering that his death had been other than by natural causes i.e. there were no obvious injuries or marks upon his body that would suggest non-accidental injury. 7.46. It was only following a painstaking criminal investigation, supported by complex forensic evidence, that the truth emerged i.e. that Kieron had been the victim of at least one serious assault by Craig Lewis in which fatal injuries were inflicted. Final Overview Report BSCB 2011-12/1 53 8. KEY ISSUES AND ANALYSIS 8.1. Any Review which considers a case with the intensity that comes with a Serious Case Review will inevitability uncover areas where individual practice fell below optimum standards and this Review is no exception. However, as stated earlier in this report the purpose of a Serious Case Review is not to target or scapegoat individual practitioners, it is to learn lessons about how partner agencies of the LSCB can create an environment in which poor practice is less likely to occur. This report will now consider what agencies have learnt from undertaking their own IMRs and what additional learning has been derived from an overview of all submissions to the Panel. Children's Social Care 8.2. The author of the IMR submitted to this Review on behalf of Children's Social Care has identified a number of key learning points i.e.: • the need to strengthen screening processes to ensure judgements are made about the need for an initial assessment taking into account previous referrals and knowledge about the family; • a need to improve case recording systems in order to make it easier and quicker for practitioners to access this information; • a need to continue to improve quality assurance measures in respect of referrals and initial assessments to ensure that, as far as possible, individual practitioner errors as identified in this review are identified and addressed; and • a need to provide specific training and regular updating briefings for staff responsible for screening referrals on relevant research and the findings of Serious Case Reviews. 8.3. The original Serious Case Review Panel considered that these were reasonable and proportionate responses to the issues raised in the IMR, but remained concerned that all these issues had been raised in previous Serious Final Overview Report BSCB 2011-12/1 54 Case Reviews conducted by BSCB. Clearly there were issues here about the sustainability of learning from those Reviews that presented BSCB with a significant challenge. 8.4. The response of Children’s Social Care to the Health Visitor’s referral dated 17th March 2011 can only be described as inadequate. In response to a safeguarding referral, in which the referrer indicates her belief that the threshold for making a Child Protection Plan is met, the Senior Practitioner makes two telephone calls (one back to the Health Visitor and one to Louise Barley) and then closes the case having decided that the only issue is one of housing and that can be dealt with by other agencies. 8.5. A check of her own and partner agency records would have revealed Louise Barley’s troubled history and concerns for Kieron’s development delay, and should in the opinion of the Serious Case Review Panel have led to a strategy discussion with the Police and a child protection enquiry under Section 47 Children Act 1989. It is entirely possible that this in turn would have led to a full multi-disciplinary discussion at a Child Protection Conference (in which mental health services would have been expected to contribute) and to concerns for Kieron’s safety and welfare being managed under a Child Protection Plan. 8.6. The Serious Case Review Panel accepts that this sequence of events is in part speculative but a thorough review of the available evidence at that time does support our position that such an outcome was likely had there been a robust child protection enquiry in response to the Health Visitor’s referral. 8.7. The implications of Kieron being subject to a Child Protection Plan in the wake of the Health Visitor’s referral seems to the Serious Case Review Panel to be significant e.g. • the role of Craig Lewis in Kieron’s life would have been a matter of greater scrutiny; Final Overview Report BSCB 2011-12/1 55 • this is particularly relevant to the period following Louise Barley obtaining her own tenancy when Craig Lewis effectively moved in with her i.e. there would have been greater focus by the allocated Social Worker upon Kieron’s safety in the changed living arrangements; • Birmingham Children’s Hospital would have reported the bruising noted on Kieron at his attendance there on 17th May 2011 to Children’s Social Care; and • more robust safeguarding action (certainly involving a report to Police/Children’s Social Care) would have been taken by Birmingham Children’s Hospital following Kieron’s attendance there on 28th, 29th and 30th May 2011. 8.8. It is possible that action under any one of these bullet points might have changed the tragic outcome in this case but in particular the identification of fractured vertebrae on 28th May would have resulted in immediate safeguarding action (certainly his detention in Hospital and probably removal from his Louise Barley’s care). 8.9. In trying to identify why the referral was not progressed through the child protection process, the Serious Case Review Panel has investigated the possibility that Children’s Social Care were going through a phase in which the prevailing culture was to manage cases outside that process wherever possible (possibly due to workload issues) and, if so, whether that culture posed a wider risk to the safety of children in Birmingham. 8.10. The Serious Case Review Panel has looked at rates of children (per 10,000 of population) being made subject to Child Protection Plans in Birmingham and compared this with other similar authorities (accepting that Birmingham is very difficult to make comparisons with). Extracts from those figures for the last four statistical years are as follows: Final Overview Report BSCB 2011-12/1 56 • at 31.03.10 Birmingham had 48.9 per 10,000 children subject to Child Protection Plans compared to an average of 40.1 for their statistical neighbours and 31.7 for the whole of England; • at 31.03.11 the respective figures were 51.4, 45.5 and 38.3; • at 31.03.12 the figures were 46.3, 40.1 and 37.8; and • at 31.03.13 they were 37.2, 42.1 and 37.9. 8.11. From this information there seems no reason for concern at low levels of Child Protection Plans in 2010 and 2011 i.e. in the months before Kieron’s death. The figures are consistently higher than Birmingham’s statistical neighbours and the England average which, in the view of the Serious Case Review Panel, is likely to be entirely appropriate given local demographic features. 8.12. BSCB may wish to investigate the figures recorded as of 31.03.13 which has seen Birmingham fall below both the statistical neighbours and the England average, but this issue is outside the remit of this Review. 8.13. However, the Serious Case Review Panel is satisfied that there is no obvious pattern of non-compliance with child protection processes in 2010/11 leading to an inappropriately low number of Child Protection Plans being in place at that time, and does not consider this issue to be a factor in the decisions taken following the Health Visitor’s referral in March 2011. 8.14. In the absence of any cultural or systemic failure (or indeed any concerns about the quality of information provided by the Health Visitor), it can only be surmised that the reasons for the inappropriate response to that referral are linked to poor decision making by the practitioners concerned possibly exacerbated by workload pressures. It is acknowledged in the IMR submitted on behalf of Children’s Social Care that ‘neither the Team Manager or the Senior Practitioner exercised good, evidenced professional judgement’ in Final Overview Report BSCB 2011-12/1 57 screening this referral but, in mitigation, it also comments that there were significant pressures within the Duty Screening Team at that time due to an unprecedented volume of new referrals (also identified within an Ofsted Inspection in July 2010 that led to further re-structuring of services locally). 8.15. In 8.3 above I refer to the challenge that faces BSCB in ensuring the sustainability of learning from Serious Case Reviews particularly in respect of the screening of new referrals. Over the last two years BSCB has met that challenge by developing a Multi-Agency Safeguarding Hub (MASH) which was launched on 24th July 2014. The MASH is a multi-agency team which integrates and co-locates key safeguarding agencies with a view to better identifying risks to children and improving decision making, interventions and outcomes. The MASH enables the multi-agency team to appropriately review their information systems, share all appropriate information in a secure environment, and ensure that the most appropriate response is provided to effectively safeguard and protect the child. 8.16. Current plans for this service are that the Birmingham MASH will continue to evolve and see agencies across all sectors represented by over 60 professionals from Social Care, Police, Health, Education and the Voluntary Sector co-located at Birmingham City Council offices. The proposed involvement of the Mental Health Trust in MASH will greatly help in the assessment of risk where parents of vulnerable children are known to practitioners from that Trust. 8.17. The MASH will be the first port of call for anyone with a child safeguarding concern and is seen as a significant development in addressing what had been a perennial problem i.e. inadequate or superficial screening of such referrals within Children’s Social Care. As with any new development on this scale it will need time to bed in but the Serious Case Review Panel shares BSCB’s confidence that it will successfully address the concerns identified in this and previous Serious Case Reviews. Final Overview Report BSCB 2011-12/1 58 Mental Health Trust 8.18. The IMR for this Trust has robustly considered their involvement with Louise Barley and concluded that there was ‘excellent liaison between services and other agencies around the general management of Louise Barley’s case’. 8.19. However, the author of the IMR has also identified that there had been a failure to follow the Trust’s policy on safeguarding children, as well as a failure to implement the BSCB inter-agency procedures and best practice guidance. The key learning points from the IMR are: • a need to ensure that all relevant practitioners have undertaken training on safeguarding children issues in line with the Trust’s mandatory policy on this subject; and • the need to improve record management in the Perinatal Psychiatric Service. 8.20. In the course of their enquiries, the Serious Case Review Panel has identified at least six previous Serious Case Reviews where the mental health of the parent was a factor in the death of a child, and where the recommendations called upon the Mental Health Trust to improve training and practice in respect of safeguarding the children of their patients. The most high profile of these cases was presented to the BSCB in April 2010 (then known as Case 14) which, due to the unusual and horrific nature of the child’s death, received significant attention from national media. 8.21. Birmingham and Solihull Mental Health NHS Foundation Trust submitted an IMR to that Review which contained the recommendation: ‘to take account of the learning identified from the IMR for all Trust clinical staff’. Final Overview Report BSCB 2011-12/1 59 In the Action Plan attached to the Review, the Trust has added the words ‘action completed’ to this recommendation. 8.22. Given that, in the twelve months following this Serious Case Review, practitioners within the Trust failed on six occasions to identify and address safeguarding concerns in respect of Kieron, the Serious Case Review Panel has to challenge the effectiveness of the Trust’s follow up to this recommendation. 8.23. On the evidence of this case, safeguarding practice within the Trust has not improved despite the learning derived from the previous Serious Case Reviews, and there is an urgent need for Senior Managers within the Trust to ascertain why their public commitment in this area has not been translated into effective practice at the frontline. The IMR author has been robust in his identification of the issues and the Trust now needs to see that the lessons learnt really are the catalyst for change and improvement. 8.24. It has been drawn to the attention of the Serious Case Review Panel that the Mental Health Trust is commissioned to offer secondary mental health care and that much of the primary mental health care provided in the community is diagnosed, recognised and treated by GPs. The use of the generic term ‘mental health’ in this report needs to be read in that context. None of this however diminishes the Panel’s concerns about the role of the Trust where their patients are also parents of vulnerable children, and the proposed audit is still seen as a valid intervention. 8.25. In July 2012 the GMC published new guidance for all Doctors who provide care for adults who are also parents. This was implemented on 3rd September 2012, and this comprehensive document could be used by the Mental Health Team as a catalyst for education and change. 8.26. For BSCB the issue is one of great importance. The mental health of parents has long been identified as a significant factor in child protection work Final Overview Report BSCB 2011-12/1 60 particularly in cases where children have died or suffered serious injury. Reviews of Serious Case Reviews undertaken by Ofsted in recent years confirm that in 2003/05 past or present mental health issues for either parent was a factor in 61% of the 161 cases considered while the corresponding figure for 2005/07 was 63% of 189 cases. 8.27. It should be of concern to BSCB that one of their partner agencies appears unable to implement and sustain necessary changes to their practice despite the sometimes disastrous impact that this is having upon the lives of children. 8.28. The Serious Case Review Panel is recommending that BSCB undertake direct work with the Trust, preferably informed by a thematic audit of current cases in the safeguarding system, to identify the barriers to achieving full compliance with safeguarding procedures. Such an audit should identify children subject to safeguarding enquiries and/or Child Protection Plans where one of their parents is receiving a service from the Trust, and then analyse the Trust’s contribution to that work e.g. the quality and frequency of information sharing, attendance at Child Protection Conferences and Core Group Meetings, provision of written reports to Conference, etc. 8.29. Anecdotally the Panel has received information suggesting that practice has improved since 2011 so the suggested audit should give added weight to that perception. Community Healthcare Trust 8.30. The IMR written on behalf of this Trust identifies the learning points as: • a need to ensure that staff make appropriate contacts/referrals if they see a vulnerable adult with unmet needs within the household of a family with young children; Final Overview Report BSCB 2011-12/1 61 • a need to develop analytical case recording skills to ensure that issues of developmental delay can be recognised through consistent observation and recording; and • the use of the Common Assessment Framework by Health Visitors can give a structure to work with children who have complex health problems or developmental delay, and a way of addressing the child’s needs holistically. 8.31. The Panel considers these points to be well evidenced in the IMR but feels there is further learning to be derived from the Health Visitor’s failure to clarify the nature of Louise Barley’s contact with Mental Health Services. It should be acknowledged at this point that, as described earlier in the report, practitioners and clinicians from the Mental Health Trust did not share information appropriately with various agencies including the Health Visitor. However, Louise Barley’s contact with the Trust was known to the Health Visitor in March 2011 if not earlier but she chose not to make further enquiries, which would have helped her understand whether Louise Barley’s mental health issues could be having a detrimental impact upon her capacity to provide safe and nurturing care for Kieron. 8.32. Such an enquiry might also have had the effect of alerting the Mental Health Trust of the need to consider Kieron’s safety and welfare in the light of Louise Barley’s mental health. 8.33. In her referral to Children's Social Care in March 2011, the Health Visitor described Louise Barley as having a ‘tragic past’ and the Serious Case Review Panel believes that contact with the Mental Health Trust at this time would have enabled the Health Visitor to better understand the impact of her earlier experiences on her present life, her ability to form appropriate adult relationships and, of course, her attachment to Kieron. 8.34. Notwithstanding the above point, the Serious Case Review Panel considers that the Health Visiting Service provided a good standard of care to Kieron Final Overview Report BSCB 2011-12/1 62 and strong support to Louise Barley, but it will make a recommendation to the Trust concerning the need to liaise with the Mental Health Trust in cases where targeted intervention is required or, as the Health Visitor believed in March 2011, the threshold for a Child Protection Plan was met. Birmingham Women’s Hospital 8.35. The IMR for this Trust considers that the learning points arising from the Review are all linked to issues of domestic abuse i.e. the awareness of staff about the issue and the consistency in patients being routinely questioned on the subject when presenting for ante-natal appointments. 8.36. Two recommendations are made by IMR author i.e.: • all Midwives to attend mandatory training on domestic abuse issues; and • routine enquiries to be made of patients, and documented in case records (or the reasons why the questions were not asked). 8.37. Both these recommendations are supported by robust arrangements for monitoring their effective implementation but again the Serious Case Review Panel believes there is further learning to be derived from the failure of Midwives to assess Louise Barley’s vulnerability during pregnancy in the context of her involvement with Mental Health Services and her recent overdoses. 8.38. It is of some concern to the Panel that despite a range of concerning information being available to the Midwifery Service, no-one apparently thought to ask the obvious question i.e. in view of Louise Barley’s history, is it safe for her to take a baby back to this family home where the other adults resident there had a range of personal problems of their own? Final Overview Report BSCB 2011-12/1 63 8.39. The answer may well have been in the affirmative but the issue remains that a risk assessment was not even considered let alone a safeguarding referral to Children's Social Care. 8.40. This report will contain a recommendation that the Trust reviews its policies and guidance in this area to satisfy BSCB that staff are alert to the circumstances where risk assessments are required and that they are competent to carry them out or to refer them to other agencies as necessary. Update: September 2014 8.41. The current Serious Case Review Panel recognises that the above concerns date back to 2009 and is reassured by the updated IMR submitted to the reactivated Review earlier this year. This report describes improved screening of newly pregnant women (i.e. attention to any report of domestic violence, substances misuse, mental health issues, etc) to ensure any vulnerability is identified and acted upon, as well as improved training on safeguarding children issues for a wide range of staff according to their assessed need. Other than robust oversight of the impact of these measures, the Serious Case Review Panel is satisfied that their concerns have been addressed. Birmingham Women’s Hospital 8.42. This Trust had limited contact with Louise Barley in the period set for this Review – she was last seen in September 2009 when she was in the care of the joint Obstetric and Epilepsy Clinic. There was no contact between the Trust staff and Kieron. 8.43. The IMR author believes that Louise Barley received appropriate care and follow up support when she attended the Trust and has identified no specific learning points. Staff did identify Louise Barley’s vulnerability, particularly in the light of her earlier overdoses, but considered that her relationship with her Mother was a protective factor. Final Overview Report BSCB 2011-12/1 64 8.44. The Serious Case Review Panel has not identified any other issues in relation to this Trust. NHS South Birmingham (GP) 8.45. The IMR author for this Trust has identified that Louise Barley’s GP failed to consider a number of risk factors that compromised her capacity to safely parent Kieron and also failed to liaise with the Health Visitor who was having regular contact with the family. 8.46. This learning is addressed by a recommendation that ‘when a parent is identified with mental health problems the GP should always discuss with the Health Visitor in order to ascertain the likely effect on parenting capacity…’ 8.47. It is pointed out in the IMR that a recommendation was made in a recent Serious Case Review conducted by BSCB (2011/12-2) that ‘encourages’ GPs to have regular scheduled meetings with Health Visitors to enable discussion about families of concern. The Serious Case Review Panel was pleased to note that a recent (2014) audit undertaken on behalf of BSCB demonstrated improved practice in this area. There is confidence within BSCB that this area of work is now embedded in ongoing audit work/staff training and policy development and, as a direct consequence, these actions will make a positive difference to the safety and welfare of children in Birmingham. 8.48. Of concern to the original Serious Case Review Panel was the IMR author’s finding that the GP missed a number of opportunities to identify potential safeguarding issues for Kieron and does not appear to have ‘considered at all the impact of Louise Barley’s mental health upon her ability to parent Kieron’. In mitigation it has been suggested to the Serious Case Review Panel that: • the GP would see many parents with low level mental health issues and neither Mother or her partner would stand out as a risk to children; and Final Overview Report BSCB 2011-12/1 65 • he may well have assumed that specialist services involved with Louise Barley would have made appropriate safeguarding referrals as and when necessary. 8.49. However it is the view of the Serious Case Review Panel that making assumptions in child protection matters can never be defended, and this raises concerns about the quality of safeguarding training accessed by the GP. 8.50. The IMR author has confirmed that safeguarding training in the practice was up to date but this appears to have had only a limited impact upon practice. Scrutiny of previous Serious Case Reviews conducted by BSCB confirmed that this is not a new issue. In addition to the Serious Case Review mentioned above, the issue of GPs failing to identify and report safeguarding concerns, and their compliance with safeguarding training, has been mentioned in at least five other Reviews between 2007 and 2009. 8.51. BSCB needs to understand why so much work and so many well intentioned recommendations appear not to be having the desired impact. The Serious Case Review Panel also recommends that BSCB take advantage of the timely publication of the GMC Guidance ‘Protecting Children And Young People – A Guide For Doctors Who Treat Adult Patients’ (published July 2012) in order to promote sustainable change in this area. 8.52. Some of the key messages from this guidance are: • when Doctors care for an adult patient, that patient must be their first concern but they should also consider whether the patient poses a risk to children or young people; • Doctors must be aware of the risk factors that have been linked to abuse and neglect and look out for signs that the child or young person may be at risk; Final Overview Report BSCB 2011-12/1 66 • Doctors should have a working knowledge of local procedures for protecting children in their area; and • Doctors must develop and maintain the knowledge and skills to protect children and young people at a level that is appropriate to their role. 8.53. The guidance document is comprehensive (64 pages) and contains a wealth of practical guidance with extensive links to research. The GMC had set an implementation date of the 3rd September 2012 and it was a strong recommendation from the original Review report that BSCB engaged with the Birmingham and Solihull PCT Cluster to ensure that it receives an appropriate high profile launch in Birmingham. More recently (July 2014) the NSPCC, in collaboration with the Royal College of General Practitioners, has published an overview of policy, practice and research, which local practitioners and managers would benefit from studying. 8.54. It was the opinion of the original Serious Case Review Panel that only through a commitment to robust implementation and ongoing monitoring of GPs’ compliance could BSCB hope to finally resolve this perennial flaw in local services for safeguarding children. Update: September 2014 8.55. The new Serious Case Review Panel has been given updated information which suggests that, over the last three years, there have been a number of new developments which give greater confidence about the engagement of GPs in the child protection process i.e. • all GP practices now have arrangements to meet and regularly liaise with Health Visitors to consider cases where children may be at risk; • the CCG has safeguarding champions who can support and give advice to GPs on safeguarding issues; • GP training in respect of safeguarding children (extended now to all practice staff) is of greatly improved quality; and Final Overview Report BSCB 2011-12/1 67 • there has been significant improvement in the engagement of GPs in the Child Protection Conference process following meetings with Children’s Social Care staff at which the ‘strengthening families’ model was explored. Children’s Centre 8.56. Although the Children’s Centre was only involved with Kieron and his family for the last twelve weeks of his life, the IMR author has taken full advantage of this Serious Case Review to identify a number of learning points that will inform their future work. 8.57. The IMR confirms that practice will be strengthened in the following areas: • induction and training on safeguarding issues will be reviewed and further developed for staff; • information sharing and case recording issues will be enhanced to ensure a consistent approach to identify developmental delay or safeguarding concerns; • the use of the Common Assessment Framework will be embedded into service delivery; and • supervision processes for staff will be improved to reflect the need for objectivity and challenge. 8.58. The Serious Case Review Panel considers this IMR to be robust and its learning has been reflected in the recommendations. West Midlands Police 8.59. Until the evening that Kieron was admitted to Hospital with fatal injuries, West Midlands Police had only two contacts with the family in the period set for this Review. Final Overview Report BSCB 2011-12/1 68 8.60. Neither of these contacts raised any concerns about the practice of individual officers or about force policy and protocol. The report makes only one recommendation and that is in relation to how West Midlands Police contribute to future Serious Case Reviews. This recommendation, which the Serious Case Review Panel fully endorses, arose from the failure of West Midlands Police (for reasons that cannot be identified) to share information with partner agencies about Kieron’s fractured vertebrae when first identified. That information would have influenced judgements about the safety of Craig Lewis’s two children from his previous marriage during their regular contact sessions. Birmingham Children’s Hospital 8.61. Birmingham Children’s Hospital had contact with Kieron ten times in his life of which five contacts were in the six week period preceding his death. 8.62. The significant contacts prior to Kieron’s admission with fatal injuries on 19th June 2011 were: • 17.05.11 – when a junior member of the medical team failed to consider bruising noted on Kieron under the Hospital’s child protection procedures; and • 28th, 29th and 30th May 2011 – when medical staff treated Kieron for injuries following an alleged fall but failed to identify that Kieron had suffered a number of fractured vertebrae. 8.63. Birmingham Children’s Hospital have considered both these events most carefully and recognise that, in respect of the attendance on 17.05.11 the junior member of the medical team failed to follow appropriate safeguarding procedures. As a consequence there was no adequate scrutiny of the bruises (the explanation that it was caused by straps in a high chair lacked credibility) and an opportunity to intervene under safeguarding procedures was missed. Final Overview Report BSCB 2011-12/1 69 8.64. The IMR goes on to consider why an otherwise competent doctor (who had undergone child protection training) failed to even seek advice from senior colleagues on this occasion but, other than workload issues leading to personal error could identify no other specific reason. As with the later Hospital attendance on 28th May 2011, the response of the Doctor was likely to have been very different if Kieron’s safety was being monitored by a Child Protection Plan in the wake of the Health Visitor’s referral in March. The doctor in question has subsequently been given further guidance and instruction in respect of his performance on safeguarding children matters. 8.65. Whether a safeguarding referral at this stage would have made any difference to the final outcome is of course speculative. A safeguarding referral from Birmingham Children’s Hospital less than two months after one from the Health Visitor could have prompted a child protection enquiry which in turn may have led to safeguarding action that could have prevented the fatal injuries suffered by Kieron later that month. However, the Serious Case Review Panel cannot be certain that this would have been the sequence of events and the outcome of any referral at that time. 8.66. Kieron’s attendance at Birmingham Children’s Hospital on 28th, 29th and 30th May raises two issues: • should Hospital staff have been alert to the deceit of Louise Barley when she fabricated a story in order to facilitate Kieron’s early discharge home; and • were Hospital staff negligent in failing to recognise that he had been the victim of a serious assault in which he suffered a number of fractured vertebrae? 8.67. In respect of the first bullet point, it is not thought that any Hospital protocols were breached. At that stage there were no suspicious circumstances in respect of Kieron’s condition and the story told (a sibling being cared for by a neighbour and Craig Lewis needing to go to work) was entirely plausible. Final Overview Report BSCB 2011-12/1 70 While Hospital staff would have preferred Kieron to remain for two hours more, the decision to allow Louise Barley to take him home (with clear guidance on observing his progress) appears entirely reasonable. It is also noted that Louise Barley returned Kieron to Hospital within a few hours in response to his continued vomiting and in line with the guidance on head injuries provided to her. 8.68. The author and the Serious Case Review Panel have paid particular attention to the second bullet point having been made aware of comments attributed to family members that have appeared in the media e.g. a newspaper article dated 14.07.14 quotes Kieron’s birth father as saying ‘Every part of Kieron should have been checked that day, not just his shoulder’. 8.69. Kieron was taken by ambulance to Birmingham Children’s Hospital on the evening of 28th May 2011 when his Louise Barley reported that he had fallen while trying to walk, struck his head and shoulder and then had a ‘floppy’ episode. Medical staff noted an abrasion to his shoulder and a swelling to the bridge of his nose. The shoulder was x-rayed but no injuries were observed. 8.70. As described above, Kieron was discharged earlier than medical staff would have wished but was returned by his Louise Barley later that evening and again on 30th May with symptoms of vomiting and general distress. 8.71. The IMR is clear that the practice of medical staff on all three occasions was in line with Hospital policy in respect of the management of minor head injuries in children. Indeed the practice of the doctor who saw Kieron on his first admission was described as ‘above the minimum expected standard of practice’ as he undertook a full top to toe examination which included checking the spine manually. The examination of the spine revealed no tenderness and gave the doctor no reason to request a further x-ray. 8.72. If it is accepted that the medical staff involved acted appropriately and within the Hospital’s guidelines for such situations then the next question is whether Final Overview Report BSCB 2011-12/1 71 those guidelines are ‘fit for purpose’, in particular should all children who visit the Emergency Department at Birmingham Children’s Hospital with minor injuries (or those in certain age groups or with certain conditions) automatically be subject to top to toe examinations including full skeletal surveys. 8.73. This point was put to the Named Doctor for Safeguarding at Birmingham Children’s Hospital by the Chair of the Serious Case Review Panel and elicited the following responses: • mandating that all young children presenting with minor injuries have a full head to toe examination has ‘huge implications for the treatment time of these children and also for all other children attending the emergency department’; • the existing guidance to doctors prompts them to consider non-accidental injury at many stages in their assessment of the child, particularly in the range of injuries associated with child abuse (which includes head injuries); and • any indication or impression that the history is ‘inconsistent, implausible or indicates a lack of appropriate care of supervision’ would prompt a response under safeguarding procedures. 8.74. The letter also points out that Kieron did have a top to toe examination and this gave rise to no concerns that suggested a need for a full skeletal survey, and it concludes by saying that the Hospital cannot support a recommendation making such examinations mandatory for all children seen in the Emergency Department. 8.75. The Serious Case Review Panel has clarified with the Hospital that had Kieron been subject to a Child Protection Plan at the time of his attendance there on that occasion (and on 17th May 2011 also) there would have been greater focus upon the safeguarding concerns but not necessarily a full skeletal Final Overview Report BSCB 2011-12/1 72 survey. The Serious Case Review was advised by Birmingham Children’s Hospital that whether or not he was subject to such a survey would be a clinical decision and not influenced by his child protection status. 8.76. Given that formal safeguarding arrangements were not in place did Hospital staff have any reason for singling out Kieron from the many other children presented there with minor injuries, and implementing child protection procedures? Certainly Louise Barley and Craig Lewis did not give them any particular cause for concern and, other than three Hospital presentations in three days, there was nothing sinister or worrying about this case based on the knowledge of those members of staff involved in his care. 8.77. The Serious Case Review Panel has taken separate medical advice in reaching the following conclusions about the performance of medical staff on the four occasions that Kieron attended Birmingham Children’s Hospital in May 2011 i.e. • the bruising noted by a junior doctor on 17th May 2011 should have been considered as non-accidental in line with the available evidence and discussed with a senior colleague or safeguarding professional to decide upon the need for action under safeguarding children procedures; • no blame can be attached to staff members on 28th May 2011 for failing to realise that Louise Barley had lied to them in order to facilitate Kieron’s early discharge home; • all medical staff involved in Kieron’s attendances on 28th, 29th and 30th May 2011 acted appropriately and within Hospital guidelines when treating him and there was no negligence in the failure to identify his fractured vertebrae; and • a recommendation to make top to toe examinations compulsory in respect of all minor injuries is considered to be disproportionate and unworkable. 8.78. The Serious Case Review Panel supports the recommendation contained in the IMR of Birmingham Children’s Hospital i.e. to revise the guidance for Final Overview Report BSCB 2011-12/1 73 managing children who present at Hospital frequently (including improved liaison with community based health staff) and to incorporate the lessons of this Serious Case Review into future training, particularly for junior staff. 8.79. It is likely that the family of Kieron will find it difficult to accept that any child can be presented at Hospital with fractured vertebrae and not have this problem identified but, in the context described above (and where the child is non-verbal and has already been diagnosed with developmental delay) the Serious Case Review Panel considers that no blame can be applied to the staff involved. 8.80. As stated at the very beginning of this report the task of the reactivated Serious Case Review Panel in 2014 was twofold i.e. • a review of how the recommendations of the interim report presented to BSCB on 16th November 2012 had been implemented; and • consideration of whether further lessons can be learnt by partner agencies of BSCB from the additional information that could now be released by the Police (primarily related to the last five/six weeks of Kieron’s life). 8.81. The first bullet point has been addressed throughout the preceding paragraphs of this section of the report, and overall the Serious Case Review Panel is satisfied that partner agencies of BSCB have responded robustly to the concerns raised in the interim report. The development of the Multi-Agency Safeguarding Hub is viewed with particular interest as it suggests an innovative, and hopefully effective response to a perennial problem i.e. superficial and inadequate screening of safeguarding referrals within Children’s Social Care. 8.82. In addressing the second bullet point above (and recognising that there is inevitably some overlap between the two) the Serious Case Review notes that Kieron was seen on eight separate occasions in the period 16.05.11 to Final Overview Report BSCB 2011-12/1 74 19.06.11 and, with one exception, all these contacts were with health personnel i.e. •••• once at clinic by a Community Nursery Nurse; •••• once with a Family Support Worker from the local Children’s Centre; •••• twice at the Child Development Centre (physiotherapist and neuro-development clinic); •••• four times at Birmingham Children’s Hospital (once for an MRI scan as part of the CDC assessment and three times in the emergency department following his alleged fall on 28th May 2011) 8.83. In addition the Health Visitor made a visit to the new family home (good practice in circumstances where there are concerns for the development of a child) but did not see Kieron who said to be asleep at the time. 8.84. No contact was made by Children’s Social Care who were unaware of the family’s change of address, having closed their case after addressing the Health Visitor’s referral in March 2011. 8.85. In conducting his analysis and identifying the key issues from this period, the Author has used the revised terms of reference (see section 4) as the framework for this work and the following paragraphs should be read in conjunction with that section. Kieron’s Life Experiences 8.86. Considering Kieron’s daily life experiences needs to be addressed in two parts i.e. his life while living with Louise Barley in the home of Maternal Grandmother, and the final six weeks of that life when Louise Barley obtained her own tenancy. Regrettably very little can be ascertained in respect of that life in those final weeks as the only person who saw him at home was the Family Support Worker, and she was simply there to collect Kieron and Louise Barley for an introductory visit to a toy library. The Health Visitor however had Final Overview Report BSCB 2011-12/1 75 considerable knowledge of his life experiences while living in the home of Maternal Grandmother and, despite clear evidence that Kieron was a much loved child by all the family, concerns were regularly expressed in respect of the home environment and the impact upon Kieron’s development i.e. •••• the home was frequently noted to be ‘cluttered and untidy’ restricting the amount of safe play space available to Kieron; •••• hygiene conditions were regularly unacceptable thereby posing risks to his health; •••• on occasion the atmosphere was described as ‘smoky’ and there was a persistent smell of cigarette smoke in the home; •••• Kieron was noted to spend inappropriately long periods in a baby bouncer or a pushchair rather than being free to develop age appropriate gross motor skills; •••• there was a lack of age appropriate toys to stimulate Kieron’s learning and development; and •••• although Maternal Uncle was cared for ‘lovingly’ by the family his regular outbursts, some violent were a constant source of stress for the family (and in fact one was the trigger for Louise Barley seeking her own accommodation). Craig Lewis 8.87. Very little was known by partner agencies about Craig Lewis during the relevant period. Craig Lewis was seen by health professionals on a number of occasions but his presentation and behaviour caused no concern at this time. He did visit his GP on 3rd May 2011 and during the consultation acknowledged using cocaine twice a week that he was finding difficult to reduce. Appropriate advice was given by the GP who, at that time, had no knowledge of his relationship with Louise Barley and Kieron. No other agency involved with the family was aware of this habit and he was not engaged with any drugs agency. Craig Lewis advised the Author in interview that his occasional use of cocaine and alcohol was not a factor in Kieron’s death and, in the absence of Final Overview Report BSCB 2011-12/1 76 evidence to the contrary, the Serious Case Review Panel can draw no conclusions from this. No agency involved with Kieron was aware that Craig Lewis had children from a previous relationship. Early Help 8.88. The IMR from the Community Health Care Trust describes in detail the range of early help made available to Louise Barley and Kieron throughout his life. From the very beginning the Health Visiting Team maintained ‘a constant level of targeted intervention’ which included a referral to the local Children’s Centre (at ten weeks old), and the ‘Flying Start’ programme (a home visiting service) but this latter service was not taken up by Louise Barley. In addition it was the Health Visitor who, in noting Kieron’s developmental delay, referred him to the Child Development Centre for assessment. Louise Barley did not take up all the support offered but the Serious Case Review Panel do not consider that her failure to do so should have prompted any safeguarding action by the Health Visitor. The IMR does suggest that better co-ordination of services to Louise Barley and Kieron in those early days could have been improved if a CAF assessment had taken place. There is confidence that the response to a similar referral in 2014 would be more robust but it is recognised also that still more could be achieved with the allocation of additional resources. Organisational Culture and Behaviour 8.89. None of the IMRs submitted in this Serious Case Review suggested that organisational culture played any role in their agency’s performance while providing services to Kieron and the Serious Case Review Panel have not identified any evidence to suggest otherwise. Where performance fell below the required or optimum standards it is attributed more to individual error than organisational issues. Final Overview Report BSCB 2011-12/1 77 Context/Multi-Agency Response 8.90. It is clear from the available information that there was never any ‘multi-agency consideration of appropriate intervention’ in respect of any risks to Kieron’s safety and welfare. There were a number of points at which such consideration might have been undertaken had individual practitioners demonstrated greater professional curiosity and made enquiries among partner agencies of BSCB e.g: • prior to Kieron’s birth, when midwifery staff failed to assess Louise Barley’s vulnerability in the context of her history and mental health problems; • shortly after Kieron’s birth when Louise Barley reveals concerning information about his biological Father; • on 15th October 2009 when the G.P. received a letter of concern from the Nurse Practitioner (Epilepsy): • in October 2010 when Louise Barley was not responding to the Health Visitor’s advice about home conditions and Maternal Uncle was displaying aggressive behaviour; • in March 2011 when Children’s Social Care closed a safeguarding referral from the Health Visitor after making two telephone calls; • on 17th May 2011 when a junior doctor at Birmingham Children’s Hospital noted bruising on Kieron’s back (the explanation for the bruising was later described as ‘not credible’); and • on 30th May 2011 when Kieron was presented at Birmingham Children’s Hospital for the third day running which (the IMR suggests) should have prompted a review of the parents’ capacity to promote Kieron’s safety and welfare and an attempt to ascertain why the Hospital appeared unable to meet his health needs. 8.91. All these events are discussed earlier in this section of the report, as is their potential impact upon the tragic outcome for Kieron. The Author and the Serious Case Review Panel have made it clear that they consider formal child Final Overview Report BSCB 2011-12/1 78 protection procedures should have been commenced on at least three of those occasions which would have led to multi-agency consideration of Kieron’s safety, probably via a Child Protection Conference. 8.92. The reasons why they did not progress in that way is also considered earlier in this report and can be summarised as a lack of professional curiosity and individual errors of judgement. There are no obvious weaknesses in safeguarding procedures but in the above circumstances no-one considered the need to implement them (other than the Health Visitor in March 2011 whose referral was promptly closed down by Children’s Social Care). Assessment of Cerebral Palsy 8.93. It is clear that the Child Development Centre undertook some enquiries into Kieron’s home circumstances (social, economic and environmental) but there is insufficient information available for the Serious Case Review Panel to draw conclusions about any impact upon the reasons for this Serious Case Review. There is nothing to suggest that the assessment process was anything other than robust. Identification of Risk Factors 8.94. Only the Health Visitor considered the accumulation of risk factors in Kieron’s life (to the extent that in March 2011 she felt the threshold was met for a Child Protection Plan) while other professionals either failed to recognise the significant of information before them (errors of judgement) or failed to make appropriate checks of partner agency records (poor practice). Last Six Weeks of Kieron’s Life 8.95. As stated earlier in this report the only professionals involved with Kieron in the last six weeks of his life were from health disciplines i.e. the Child Development Centre, the Health Visitor and Birmingham Children’s Hospital, Final Overview Report BSCB 2011-12/1 79 plus one contact from the Children’s Centre. While all these professionals were working individually to promote Kieron’s life chances, there is no evidence of their working together in this short period to achieve that outcome. 8.96. An example of where inter-disciplinary liaison may have made a difference was raised in the IMR written by Birmingham Children’s Hospital i.e. the decision of the Paediatric Liaison Health Visitor not to contact Kieron’s community based Health Visitor on the occasion of his three attendances there on 28th, 29th and 30th May 2011. In the first instance such a referral would have ensured that Kieron’s progress and recovery was monitored by the local Health Visitor (and she would certainly have insisted on seeing him at her home visit on 9th June if she had been aware of his recent Hospital attendance) but a secondary benefit would have been that Birmingham Children’s Hospital had access to the range of concerning factors that had led the Health Visitor to make a safeguarding referral only two months earlier. That additional information, when shared with medical practitioners, may have occasioned a more detailed examination of Kieron. Whether it would have prompted a full skeletal survey (the only way that the vertebral fractures would have been discovered) is less clear. Deceit of Louise Barley and Craig Lewis 8.97. There are only two proven incidents where Louise Barley and Craig Lewis deceived professionals although it can reasonably be presumed that there were others, particularly in the last six weeks of Kieron’s life e.g. was he really asleep when the Health Visitor visited on 9th June or was Louise Barley hiding him because of obvious signs of assault/abuse. 8.98. The first known incident of deceit was at Birmingham Children’s Hospital on 28th May 2011 when, in order to facilitate Kieron’s earlier discharge, Louise Barley told staff that a neighbour was caring for his sibling. This issue is considered earlier in this section of the report and no blame has been apportioned to any Hospital staff for failing to spot such an innocuous lie. Final Overview Report BSCB 2011-12/1 80 8.99. The IMR submitted to this Review by West Midlands Police clearly demonstrated that, from the moment that the Police first made contact with the family following Kieron’s death, both Louise Barley and Craig Lewis began to manipulate and deceive officers and this continued right up to the trial in 2014’. Clearly their motivation for doing so was to try and prevent their arrest, conviction and imprisonment for serious offences against Kieron, but thanks to the persistence of the investigation, supported by forensic evidence, their plans were ultimately unsuccessful. 8.100. While it is likely that there was further deception by both Louise Barley and Craig Lewis, there is no evidence to suggest that any individual professional failed to identify and address obvious inconsistencies in any information provided by Kieron’s carers. Final Overview Report BSCB 2011-12/1 81 9. CONCLUSIONS, KEY LEARNING POINTS AND COMMENTS 9.1. Kieron was clearly a much loved child within his family and, despite increasingly obvious evidence of developmental delay, was described as happy, contented and ‘bubbly’. 9.2. It is likely that this delay in development was partly as a consequence of being born at 33 weeks’ gestation, but there is also ample evidence within the Health Visiting records that his home environment was a contributory factor e.g. • cramped and cluttered conditions that inhibited his ability to explore his environment and learn new skills (e.g. pulling himself up, walking, etc); • he spent long periods of time strapped in a buggy; • a lack of opportunity for stimulating play with age appropriate toys; and • limited opportunities to mix with other children whereby he could learn to socialise etc. 9.3. These issues were identified and raised with the family who, in fairness, did try to respond to the advice offered by the Health Visitor although sustaining that compliance proved difficult and this eventually led to the Health Visitor advising Louise Barley that she would have to refer Kieron to Children’s Social Care if things did not improve. 9.4. The previous sections of this report have clearly set out the problems that beset Kieron’s development while living in the home of maternal grandmother and how these problems were influenced by issues of disability, parental mental health, poverty and the numerous father figures that came and went in his life. However, nothing that the Serious Case Review Panel has read or heard in the course of this Review suggests that his life was at risk prior to his Louise Barley moving into her own tenancy in early May 2011. Final Overview Report BSCB 2011-12/1 82 9.5. It is at this point that Louise Barley’s partner becomes a significant feature in Kieron’s life, a role which clearly involved some level of direct care for him. The relationship between Louise Barley and Craig Lewis had begun in January of that year but now intensified. Both advised the Author that he had not fully moved into the flat to co-habit with Louise Barley but was spending significant periods of time there (the Health Visitor noted male clothing around the home). 9.6. What is clear retrospectively is that Kieron was subject to physical abuse within days of Louise Barley moving into her new home i.e. bruising was noted during a Hospital appointment on 17th May 2011 and the parents’ explanation is, with hindsight, accepted as ‘lacking credibility’. In the first 21 months of his life Kieron’s development was increasingly a matter of concern but at no point until now had indicators of physical harm been noted. 9.7. The violence towards him increased significantly in the days following that incident to the point that, when seen at Hospital on 28th May 2011 (allegedly having suffered a fall while trying to walk), he had actually suffered vertebral fractures, injuries that were highly unlikely to have been caused accidentally. The circumstances surrounding the failure of medical staff to identify those fractures is considered at length in the preceding section of this report and concludes that no blame can be apportioned to those staff. 9.8. Much attention has been paid to Louise Barley’s deceit on the occasion of this Hospital attendance i.e. she lied to staff in order to facilitate Kieron’s discharge home earlier than staff wished, the implication being that she wished to avoid further investigation that might have revealed the true extent of his injuries. However, this suspicion is undermined by the fact that Kieron was returned to Hospital by Louise Barley on 29th and again on 30th May as he continued to present as unwell. Overall the Serious Case Review Panel thinks that no great significance can be attached to Louise Barley’s behaviour in this respect on 28th May. Final Overview Report BSCB 2011-12/1 83 9.9. The IMR prepared on behalf of Birmingham Children’s Hospital suggests that two courses of action were indicated following Kieron’s attendance there on those three successive days i.e. • action by medical staff under the ‘frequent attendee’ protocol to identify how the Hospital were failing to meet the child and family’s needs; and • liaison between the Paediatric Liaison Health Visitor and the community based Health Visitor to share information about Kieron’s treatment and to ensure appropriate follow up. 9.10. Action under the second bullet point would have been particularly helpful as the Health Visitor knew nothing of this Hospital attendance when she made a home visit on 9th June 2011. At this visit she was denied contact with Kieron who was said to be sleeping, but there was little doubt that she would have insisted upon seeing him had she been aware of his recent visit to the Hospital. Whether she would have seen anything of significance that required safeguarding action is now only known to Louise Barley and Craig Lewis. What is known is that this was the last occasion he might have been seen by any professional prior to his admission to Birmingham Children’s Hospital with fatal injuries on 19th June 2011. 9.11. The Serious Case Review Panel was greatly shocked to note the speed at which Kieron moved from a child whose developmental delay was the subject of concern (and concerted action) by professionals, to a child whose very life was threatened and ultimately ended. It can only have been a matter of days after Louise Barley moved out of the comparative safety of Maternal Grandmother’s home before Kieron was subject to physical abuse, abuse which escalated over the coming days/weeks leading to his death approximately six weeks later. 9.12. Given that Kieron’s situation deteriorated so quickly in this period, the Serious Case Review Panel has considered carefully whether any professional missed Final Overview Report BSCB 2011-12/1 84 an opportunity to safeguard him and have concluded that there were two occasions when liaison between Birmingham Children’s Hospital and partner agencies of BSCB (notably the Health Visitor and Children’s Social Care) might have prompted a more robust response i.e. • on 17th May 2011 when a junior doctor did not discuss bruising noted on Kieron with senior colleagues; and • on 28th May 2011 and the two following days when a failure to liaise with community based personnel meant that a history of concerning information about Kieron and his family (which had led the Health Visitor to make a safeguarding referral only two months earlier) was not obtained and taken into account. 9.13. While such enquiries may have prompted a more robust examination, the previous sections of this report document the Serious Case Review Panel’s view that the response of Birmingham Children’s Hospital, and indeed of all the agencies involved with Kieron at this time, would almost certainly have been very different if he had been the subject of a Child Protection Plan following the Health Visitor’s referral in March 2011 i.e. their questioning would have been more rigorous, their investigation of the presenting symptoms more robust and their overall intervention would have been equally focused upon safeguarding as upon attention to the reported injuries. 9.14. In such circumstances there is considerable confidence that the true nature of Kieron’s injuries would have been identified which in turn would have led to immediate safeguarding action. 9.15. However, Kieron was not subject to such a plan and the failure of Children’s Social Care to progress the Health Visitor’s referral into a child protection enquiry under Section 47 of the Children Act 1989 is considered earlier in this report. It is impossible for the Serious Case Review Panel to say with certainty that any such enquiry would have led to a Child Protection Conference and to Kieron being made the subject of a Child Protection Plan, Final Overview Report BSCB 2011-12/1 85 but a comprehensive assessment picking up on all the concerns identified in the course of this Serious Case Review make it a strong possibility. 9.16. The Serious Case Review Panel was asked to consider whether there was a prevailing culture in Children’s Social Care at that time involving a reluctance to use the formal child protection process as means of managing caseloads (children subject to Child Protection Plans have a range of statutory responsibilities attached to their cases e.g. home visits at specified intervals, core group meetings, etc.) but no evidence was found to support this. 9.17. The numbers of children subject to Child Protection Plans in Birmingham in 2010/11 is detailed earlier in this report and gives rise to no concern about practice in that period i.e. as would be expected the numbers are higher than both Birmingham’s statistical neighbours (similar authorities) and the England average, and there are no unusual variations (i.e. significant drops) in this period. 9.18. It is the opinion of the Serious Case Review Panel, that the decision not to instigate a child protection enquiry following the Health Visitor’s referral was not influenced by any prevailing culture but was as a result of poor practice by the Senior Practitioner and poor decision making by the Team Manager. 9.19. Given that Louise Barley’s partner had been convicted of the manslaughter of Kieron (following a guilty plea) the updated terms of reference for this Serious Case Review required the Panel to consider Craig Lewis’s role in the family, particularly the impact of his cocaine and alcohol use. 9.20. Again this is fully explored in the preceding sections of this report and the conclusion of the Serious Case Review Panel is that there was no evidence to suggest that any professional who had contact with Louise Barley’s partner in the last six weeks of Kieron’s life should have viewed the partner as a threat to his safety or welfare. He was seen several times by health professionals when attending appointments with Louise Barley and Kieron, and never gave Final Overview Report BSCB 2011-12/1 86 any cause for concern in respect of his behaviour or presentation. Craig Lewis was not engaged with any drugs agency and the only reference to his use of cocaine was at a GP consultation on 2nd May 2011 when he acknowledged using it twice a week and said he was finding it difficult to cut down. The GP had no knowledge of his involvement in Kieron’s life and, quite appropriately, signposted him to a drugs agency (guidance which he chose not to follow). 9.21. Louise Barley and Maternal Grandmother both describe Craig Lewis as a kind and caring man who interacted well with Kieron and seemed genuinely fond of him. Both claim to be thoroughly shocked at the assaults upon Kieron, never suspecting for a second that he was capable of such behaviour. Certainly the IMR from West Midlands Police confirms that he has no history of violent behaviour. 9.22. In interview with the Author, Craig Lewis either could not or would not give any explanation as to why this apparently ‘kind and caring’ man should commit such terrible offences but whatever his motivation the Serious Case Review Panel is confident that this behaviour could not have been predicted based upon his previous presentation. 9.23. As in most enquiries of this nature it has been relatively straight forward to establish what actions and decisions were taken by the professionals involved and to understand their impact upon the life of Kieron. More difficult is to try and understand why those actions and decisions were taken. The following paragraphs will consider what the Serious Case Review Panel believes to be the key moments in this case i.e. the moments that might have changed the course of events, and will briefly give the Panel’s observation on the ‘why’ question. 9.24. At the very beginning of this chronology the midwives and obstetricians involved with Louise Barley when she was pregnant with Kieron failed to identify her vulnerability and to factor this into her ante-natal care. The Final Overview Report BSCB 2011-12/1 87 author of the IMR for that Trust suggests that this happened because in 2009 local procedures in respect of safeguarding children were not robust and there was no culture of awareness in this area that would have supported the practitioners involved to take appropriate action. The Serious Case Review Panel has received assurances and some evidence that practice (and procedures) are very different now, significantly reducing the risk of such a similar situation developing today. 9.25. Once Kieron was born, why did staff from the Mental Health Trust fail on several occasions to consider Louise Barley’s capacity to provide safe and nurturing care for Kieron in the light of her mental health problems the ‘Think Family’ message? In the view of the Serious Case Review Panel the answer lies in the failure of the organisation (over many years and through a number of Serious Case Reviews) to give adequate priority to safeguarding children whose parents were accessing their services. This is reflected in procedures, front line practice (lack of engagement with the child protection process) and training. The Panel received anecdotal information that there has been a significant improvement since 2010/11 but still considers that this should be evidenced via a themed audit of practice. 9.26. Why did Louise Barley’s GP Practice not consider the safety and welfare of Kieron in the light of the concerning (and sometimes contradictory) information that was shared with them in respect of Louise Barley’s engagement with mental health services? It has been suggested to the Serious Case Review Panel that GPs have many patients with symptoms similar to Louise Barley and that, in the context of their heavy workloads, there was nothing exceptional about this case that should have caught his attention from a safeguarding perspective. The Author is not satisfied with this explanation, particularly in the light of comments about the practice of GPs in previous Serious Case Reviews and the many recommendations that have accompanied those Reviews. However, the Author and the Serious Case Review Panel were reassured by developments over the last three years in which significant improvements in training, protocol and improved liaison with Final Overview Report BSCB 2011-12/1 88 Health Visitors feature highly. This improvement was facilitated by a ‘task and finish group’ within BSCB on GP engagement issues. 9.27. Why, in response to the Health Visitor referral in March 2011, did the Senior Practitioner fail to make robust enquiries of partner agencies (or interrogate her own agency records) before closing this referral after making only two phone calls and without seeing Kieron? This action cannot be explained in terms of culture or procedure and can only be considered to be poor practice by an individual, possibly under significant workload pressure. 9.28. A similar question has to be posed in respect of the Team Manager’s decision to counter-sign this recommendation and approve closure of the referral. No explanation is offered in the IMR presented by Children’s Social Care and the Serious Case Review Panel has again concluded that this was poor decision making by an individual made in the face of prevailing workloads. However, the Serious Case Review Panel was pleased to note positive developments in respect of the screening of safeguarding referrals i.e. the launch in July 2014 of the Multi-Agency Safeguarding Hub, and sincerely hopes that this will be the answer to a problem identified in numerous Serious Case Reviews over recent years. 9.29. One further question has to be posed in respect of this safeguarding referral. Why did the Health Visitor (who said in her referral that she believed the level of concern for Kieron now met the threshold for a Child Protection Plan) fail to implement local ‘escalation’ procedures when the referral was closed so abruptly after only two telephone calls? No clear answer is available in the IMR presented on behalf of the Community Health Care Trust but the Serious Case Review considers that the Health Visitor (whose work with this family was otherwise excellent) either lacked knowledge of those procedures or, more likely, lacked the confidence to implement them. Final Overview Report BSCB 2011-12/1 89 9.30. The Serious Case Review Panel also considers that the Health Visitor should have liaised with the Mental Health Trust to obtain information about Louise Barley’s health, information that would have informed judgements about her capacity to promote Kieron’s safety and welfare, and has considered why this did not happen until March 2011. While acknowledging that there was a reciprocal responsibility upon the Mental Health Trust, the Panel believes that, as concerns rose in respect of Kieron’s developmental delay and the impact of environmental factors upon that became a significant factor, then the Health Visitor’s assessment was incomplete without the knowledge of Louise Barley’s diagnosis and treatment by the Mental Health Trust. Again no explanation is offered by the IMR author for the Community Health Care Trust so Panel has reached the conclusion that this was a practice/training issue for the individual concerned and has recommended wide circulation of further guidance in this area. Update: August 2015 It has subsequently been brought to the Author’s attention that the Health Visitor believed that Louise Barley was receiving counselling in respect of an alleged historical sexual assault which she considered to be different from someone receiving intervention or support in respect of a diagnosable mental health condition e.g. depression. The Manager providing this information also considers that the Health Visitor would have made appropriate enquiries of the Mental Health Trust had she had any evidence of a mental health disorder that may have impacted on her parenting capacity. The SCR Panel is happy to acknowledge this but considers that there is still value in the recommendation for action by the Community Healthcare Trust (see also paragraph 8.31 regarding the need for practitioners to clarify the role of the Mental Health Trust with vulnerable parents). 9.31. The next question raised by the Serious Case Review Panel was why, on 17th May 2011 the examining doctor at Birmingham Children’s Hospital failed to discuss bruising noted on Kieron with senior colleagues. This issue Final Overview Report BSCB 2011-12/1 90 was considered at length at Section 8 of this report and the Panel agree with the IMR’s conclusion that this was an error of judgement by an otherwise competent junior doctor who has since been given further guidance in respect of future practice. In considering how this Doctor, and others faced with similarly difficult judgements, could be helped to reach better conclusions, the Serious Case Review Panel was deeply influenced by an article published by Doctor S. Maguire in April 2011 (Which Injuries May Indicate Child Abuse?). The article includes a chart with summary guidance and body maps that the Serious Case Review Panel believes would be advantageous to hard pressed practitioners if they could be laminated and placed strategically within the Hospital’s examination rooms. A recommendation to that effect will be made in this report. 9.32. Kieron attended Birmingham Children’s Hospital again on 28th May 2011 (and followed this with two further attendances on 29th and 30th as he continued to present as unwell) and a significant question posed in this Serious Case Review is should the medical staff responsible for his care have identified fractured vertebrae that a subsequent forensic examination confirmed were present at the time. Again this was debated at length by the Serious Case Review Panel and their deliberations are detailed in the preceding sections of this report. The conclusion of the Panel is that the staff involved acted within the agreed guidance for minor head injuries and their examination of Kieron gave them no grounds for undertaking a full skeletal survey. The Serious Case Review accepts entirely that a full ‘top to toe’ examination of all children attending the Emergency Department at Birmingham Children’s Hospital is a disproportionate response to this issue. 9.33. A recent research study on the methods of learning lessons from Serious Case Reviews (Sidebottom 2010) suggests a number of problems regarding their effectiveness, including: • an overwhelming sense that there is too much emphasis on getting the process right than improving outcomes for children; and Final Overview Report BSCB 2011-12/1 91 • shallowness and sustainability of learning. 9.34. Others will judge how well the balance implicit in the first bullet point has been achieved in this Review, it has certainly been Serious Case Review Panel’s intention to keep Kieron at the heart of our deliberations while at the same time working to local and national guidelines in respect of Serious Case Reviews. 9.35. However, the findings of this Serious Case Review fully support the second bullet point in relation to sustainability of learning. There are three major issues arising from this Review that have cropped up repeatedly in Serious Case Reviews undertaken by BSCB i.e.: • the failure of GPs to consider safeguarding issues when, in the course of treating the parents of vulnerable children, they receive information that suggests either immediate referral to Children's Social Care or discussion with a designated safeguarding professional in respect of thresholds; • superficial, sometimes inadequate, screening of referrals of concern to Children's Social Care i.e. decisions made on presenting information only rather than a scrutiny of internal case records for evidence of previous concerns and obtaining information from partner agencies about their current and past involvement; and • the failure of Mental Health Trust staff to ‘think family’, in particular their failure to consider the capacity of those patients who are also parents to provide safe and nurturing care to their children and to what extent their poor mental health inhibits that capacity. 9.36. These earlier Serious Case Reviews make compelling reading and were well evidenced. The reports presented in those Reviews concluded with comprehensive and pertinent recommendations that were intended to enhance training, improve procedure and practice and make children safer. Despite this another child has died and these same three issues are identified yet again as significant factors in that death. Final Overview Report BSCB 2011-12/1 92 9.37. The Social Care Institute for Excellence (SCIE) in its 2009 publication ‘Learning Together To Safeguard Children – Developing A Multi-Agency Systems Approach For Case Reviews’, suggests that the findings of Serious Case Reviews tend to be familiar and repetitive, raising questions about their value for improving practice. Such a criticism could be levelled at this Review as, in addition to the three issues highlighted above, some other familiar issues were identified i.e. • failures to communicate and share information across agencies and, in some cases, between different departments of the same agency; • poor record keeping, making it difficult to understand or evaluate intervention by practitioners; and • inconsistent/inadequate training for professionals who come into contact with children and young people. 9.38. Good practice in each of these domains is essential for the provision of an effective service for safeguarding children, but this Review found weaknesses at different points in Kieron’s story. However, evidence was also received that these issues are now robustly and routinely monitored by BSCB and current quality assurance measures so the Serious Case Review Panel will make no further recommendation in this respect. 9.39. There have been many difficulties in undertaking a Serious Case Review that, for perfectly understandable and acceptable reasons, has been spread across three years however one significant benefit is that the Author and the Serious Case Review Panel have been able to consider how the partner agencies of BSCB responded to the Interim Overview Report presented to them on 16th November 2012. 9.40. Overwhelmingly the Panel has noted this response to be positive as evidenced throughout this report, with the improvements to GP engagement in the child protection process and the development of the Multi-Agency Final Overview Report BSCB 2011-12/1 93 Safeguarding Hub being the stand out achievements. Guidance on thresholds for intervention under child protection procedures (another issue that crops up regularly in Serious Case Reviews including this one) has been updated, and the BSCB publication ‘Right Services Right Time’ launched in May 2013 is a valuable new working tool for practitioners in all partner agencies. 9.41. While the impact of the Multi-Agency Safeguarding Hub (which only commenced operations in July 2014) has still to be evaluated, the early signs are positive. Combining the resources of partner agencies to ensure effective screening of safeguarding referrals is, in the opinion of the Author, the most significant single development in this area for many years and will make children in Birmingham safer. 9.42. At the conclusion of this report the Author and the Serious Case Review Panel are required to reach a judgement about whether the death of Kieron was predictable and/or preventable. The judgement in respect of predictability is much easier to make and the Panel is clear that, although there were ongoing concerns about his developmental delay (exacerbated by home conditions) no-one could have predicted that within six weeks of Kieron and Louise Barley moving into their own home he would be dead. 9.43. The question of preventability is slightly more difficult and is clouded by speculation i.e: • staff at Birmingham Children’s Hospital would have been more focused upon safeguarding issues when Kieron attended there on 28th May 2011 if he had been subject to a Child Protection Plan; • Kieron may have been the subject of such a plan if staff at Children’s Social Care had processed the Health Visitor’s referral of March 2011 through the child protection system; and Final Overview Report BSCB 2011-12/1 94 • the failure to progress the referral through the child protection system may have been reversed if the Health Visitor had implemented the escalation policy, etc. 9.44. However, no certainty can be applied to any of these points and the Serious Case Review Panel has concluded that Kieron’s death was neither predictable nor preventable. 9.45. A recent review of Serious Case Reviews undertaken in Northern Ireland comments: ‘The majority of cases subject to a case management review are very similar to lots of other cases known to GPs, Health Visitors, Teachers and Social Workers. Therefore trying to predict which children are at greater risk of dying or suffering serious injury is ultimately a futile exercise. However, providing families with early, sustained and co-ordinated support does reduce the likelihood of children suffering unnecessarily’. 9.46. Ironically in Kieron’s case that support was in the process of being put into place following the diagnosis of cerebral palsy but sadly, given his sudden and violent death, it never had the opportunity to improve his life chances. Final Overview Report BSCB 2011-12/1 95 10. RECOMMENDATIONS 10.1. The Interim Overview Report to be BSCB on 16th November 2012 made six recommendations i.e: • That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate measures taken by Children's Social Care to improve the screening of referrals of concern about children. • That Birmingham Women’s Hospital NHS Foundation Trust take actions to satisfy itself and BSCB that its staff are adequately skilled and knowledgeable about safeguarding children procedures and that those procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children, and that safeguarding referrals are made when necessary. • That BSCB carry out a thematic audit of The Mental Health Trust’s compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems. • That The Mental Health Trust robustly promote the recent GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness. • That BSCB and NHS South Birmingham robustly launch and promote the above GMC Guidance to all GPs in their locality and, while engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally. Final Overview Report BSCB 2011-12/1 96 • That the Community Health Care Trust issues a practice directive to Health Visitors on the need to liaise with the Mental Health Trust about the parents of vulnerable children in order to inform assessments of need for them. Such guidance to include information on issues related to consent/confidentiality. 10.2. The preceding sections of this final Overview Report confirm that significant progress has been made in implementing these recommendations and the Serious Case Review Panel is satisfied that services for safeguarding children in Birmingham are better as a consequence. 10.3. The Serious Case Review Panel makes only one further recommendation i.e. • that Birmingham Children’s Hospital place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S. Maguire 2011) in strategic locations within the Hospital. Alan Ferguson Independent Author |
NC050437 | Death of a 17-year-old British/Caribbean mixed heritage boy in February 2016. Child D and Brother D had consumed significant amounts of alcohol and illegal drugs before returning home in early hours of the morning, where after an argument Child D was fatally stabbed by Brother D. Brother D charged with murder and sentenced to life imprisonment with a minimum tariff of 11 years and three months. Family was previously known to childrens services as well as police. Learning includes: the crucial importance of building relationships when working with families where there are both needs and challenges; the need to develop a constructive practice model with young men and boys who may not engage with services; the need for improved responses to domestic abuse in families in situations when it is not intimate partner abuse. This is a joint Domestic Homicide Review (DHR) and Serious Case Review (SCR). Recommendations include: Children's Social Care and Youth Offending Team to draw on the learning from this review to improve joint working; Bristol Safeguarding Children Board to consider working with adolescent boys as a thematic priority in its strategy. Please note that this report was written in November 2017 but was published in 2018.
| Title: Child D: serious case review and domestic homicide review. LSCB: Bristol Safeguarding Children Board Author: Sian Griffiths and Deborah Jeremiah Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD D SERIOUS CASE REVIEW AND DOMESTIC HOMICIDE REVIEW Report into the death of Child D aged 17 Died February 2016 Independent Reviewers: Sian Griffiths & Deborah Jeremiah November 2017 LIST OF CONTENTS 1 Introduction Page 1 1.1 The circumstances leading to the review. Page 1 1.2 Purpose of the Review and methodology. Page 2 2 The Circumstances of Child D’s death Page 4 3 Chronology of key events Page 5 3.1 Summary of what is known about the family history and circumstances. Page 5 3.2 The significant events and involvement of agencies for the main period under review (April 2013-February 2016) Page 7 4 Contribution of Child D’s family and friends Page 13 5 Analysis and appraisal of Agencies’ Practice Page 15 5.1 What this case tells us about the multi-agency response to domestic abuse which is not intimate partner abuse. Page 15 5.2 What this case tells us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria. Page 24 5.3 What does this case tell us about the effectiveness of safeguarding in relation to older children. Page 33 5.4 Concluding remarks. Page 34 6 Recommendations Page 35 Appendix A Page 37 Bibliography Page 48 1 1. INTRODUCTION 1.1 The circumstances that led to undertaking this Joint Review 1.1.1 This Review was commissioned jointly by the Bristol Safeguarding Children Board and the Safer Bristol Partnership, following the death of a 17 year old boy, Child D, in February 2016. Child D died after being stabbed by his half-brother, who subsequently pleaded guilty to Child D’s murder and was sentenced to life imprisonment in October 2016. 1.1.2 The Bristol Safeguarding Children Board’s Serious Case Review Sub Group concluded that the case met the criteria for a Serious Case Review (SCR), as outlined in Working Together to Safeguard Children 20151, in that Child D was a child at the time of his death and there was information that: a) abuse or neglect of a child is known or suspected; and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.1.3 The Safer Bristol Partnership also identified that the circumstances of Child D’s death met the criteria for undertaking a Domestic Homicide Review (DHR) under Section 9(3) of the Domestic Violence, Crime and Victims Act 2004. A DHR is: a review of the circumstances in which the death of a person aged 16 or over has, or appears to have resulted from violence, abuse, or neglect by: (a) by a person to whom he was related and who was a member of the same household. (b) A member of the same household as himself, With a view to identifying the lessons to be learnt from the death2 1.1.4 The Review takes as its starting point the government definition of domestic abuse as follows: Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members, regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: • Psychological • Physical • Sexual • Financial • Emotional 1 Working Together: HM Govt March 2015 2 Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews: Home Office (December 2016:5) 2 Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim 1.1.5 A decision was made by the Chairs of the Bristol Safeguarding Board and the Safer Bristol Partnership to convene one Review combining the requirements of both a Domestic Homicide Review and a Serious Case Review. Advice was sought from the Home Office as to the methodology that would be used given the joint nature of this report and the approach to be adopted was subsequently agreed by the Home Office by e-mail on 5th December 2016. 1.2 Purpose of the Review and Methodology 1.2.1. The key purpose in undertaking this joint SCR and DHR is to ensure that learning can be identified following the death of this individual child3. Most importantly the purpose is to ensure the Review achieves the fullest understanding possible both of what happened but also why, in order to identify improvements and contribute to the prevention of future similar tragedies. 1.2.2. The methodology and format required of Serious Case Reviews and Domestic Homicide Reviews are different in some ways. This combined Review has been structured so as to balance the requirements of both. In particular the methodology was underpinned by a systems approach and unusually for a DHR did not include the use of Individual Management Reviews for each agency. The methodology and processes adopted are described in more detail in Appendix A of this report. 1.2.3. This Review examines the responses of all the relevant agencies that had contact with Child D and his family and considers whether there were gaps in services or wider learning about domestic abuse and the safeguarding of children. The main timeframe for the Review was identified as beginning with the first recorded incident which indicated the possibility of conflict or domestic abuse within the family and ending at the point of Child D’s death, that is: April 2013 – February 2016 1.2.4. This timeframe was identified as it was agreed it represented the period that would provide the greatest learning. Nevertheless, where there was significant relevant information prior to this point, which could improve our understanding of the family’s experience, particularly in relation to any history of violence within the home, this was requested and has been included in the report. 3 The word ‘child‘ is used in this Review to refer to Child D in order to clearly identify his legal status and the resulting duties of agencies to protect him. It is recognised that as a 16 year old, this is not how Child D may have described himself and should not be taken as a wider comment on his maturity. 3 1.2.5. The full Terms of Reference are to be found in Appendix A. In particular these include three specific areas for focus within the Review A: What does this case tell us about the multi-agency response to domestic abuse in families in situations when this is not intimate partner abuse? Are agencies equipped to recognise potential adolescent to sibling or parent abuse and is the professional response effective? How well do agencies recognise whole family working and the risks and needs of different family members, where there is domestic abuse taking place? How effective is the interface between the frameworks for children’s safeguarding and domestic abuse services? B: What does this case tell us about the effectiveness of safeguarding in relation to older children? For safeguarding children does the age of the child impact on the response of agencies? How do professionals balance the older child’s need for autonomy with the duty to safeguard a child? C: What does this case tell us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria? How can professionals’ best gain an accurate understanding of a family who may be demonstrating multiple risk factors, e.g. early sexual activity of a child; drug and alcohol abuse, criminal activity. What role does community intelligence properly play in gaining this understanding? How effective is the single and multi-agency early intervention for families with multiple risks? Are the risks associated with young people using or carrying knives fully understood by all agencies? How do agencies understand the significance of non-resident fathers in the lives of young people and what is the impact for young people. How can professionals work with families who do not engage? 1.2.6. In line with the expectations both of the SCR and the DHR, full consideration was given to the involvement and potential contribution of key family members and friends, including Brother D, within this review. With the exception of Child D’s father, none of those contacted wished to be involved in this Review. The steps taken to seek their involvement are outlined in more detail in Appendix A. 1.2.7. Both of Child D’s parents were asked their views as to choosing a pseudonym for Child D and other family members. Child D’s mother initially said that she would wish to choose a name, but ultimately decided that she did not want to 4 use alternative names but preferred the style that has been adopted in this report. The Review considered it proper to follow the Mother’s wishes in this regard. Individual Anonymisation Age at February 2016 Race (as identified in service records) Subject of Review Child D 17 years old Dual Heritage: Black Caribbean and White Half Brother of Subject 4 Brother D 19 years old Dual Heritage: Black Caribbean and White Half Brother of Subject Brother D2 Adult (not in living household) Information not available Half Sister of Subject Older Sister Adult (not in living household) Information not available Half Sister of Child D Younger Sister 4years old White British Mother of above Mother Adult White British Father of Child D Father of Child D Adult Black Caribbean Father of Brother D Father of Brother D Adult Black Caribbean 2. THE CIRCUMSTANCES OF CHILD D’S DEATH 2.1. 17 year old Child D lived in Bristol with his mother, his 19 year old brother, Brother D, and his 4 year old Younger Sister. The family lived in settled accommodation and were established in their community. Prior to his death Child D had made plans with his local college to re-enrol in September to undertake a course he had previously been unable to complete. His girlfriend was expecting their child. 2.2. One night in February 2016 both Child D and Brother D had been out at clubs and bars in the city with their friends and had also spent time with Brother D’s father. They had both consumed significant amounts of alcohol as well as illegal drugs. The two brothers returned separately to their home early in the morning, Child D accompanied by one of his friends. Child D arrived home first and became involved in a verbal argument with his mother who was angry that he had driven home in her car. 2.3. Shortly afterwards Brother D returned and a fight started upstairs between the two brothers. The fight continued onto the stairs during which time Brother D 4 Child D, Younger Sister and Brother D were half siblings, but will be referred to as brother and sister during the report reflecting their family situation as it was lived. 5 stabbed Child D a number of times. Brother D then left the house. The Mother immediately called 999 and both police and ambulance attended. The police and subsequently paramedics undertook CPR at the scene, and Child D was then taken by ambulance to hospital. However shortly after arriving at hospital he was declared dead. The Post Mortem identified that several of the stab wounds were comparatively superficial but one wound to his chest was more serious and was the cause of Child D’s death. 2.4. Brother D subsequently handed himself in to the police and was charged with murder. He pleaded guilty at Crown Court and was sentenced to Life Imprisonment with a minimum tariff of 11 years and 3 months. 2.5. Information was provided to the Review by a number of different professionals with knowledge of the family’s local community that there was an ‘outpouring of grief’ following Child D’s death. The local Youth Club was opened specifically following his death and there was a collection for the family. A ‘big parade’ took place in his memory and his funeral was attended by a very large number of friends and family. 3. CHRONOLOGY OF KEY EVENTS Full chronologies were provided by all the agencies5 known to be involved with the family. The resulting combined chronology was considered in detail within the Review and the relevant information is summarised here. The information available to this Review is almost totally reliant on the records of the various agencies who were involved at different times with the family. Inevitably this means that the picture provided will be an incomplete one and cannot effectively describe Child D’s experience from his perspective. 3.1 Summary of what is known about the family history and circumstances. 3.1.1. Child D had lived all his life in Bristol, the family having moved to their current address some years earlier. Child D’s father lived separately from the family and had occasional contact with his son. The wider family included 2 older siblings (Brother D2 and Older Sister) who had previously left home, Brother D’s father, who it is understood had limited routine contact with Child D, and also Brother D’s wider paternal family. The level of involvement of the older siblings with the family is not known. It is understood that the Mother had been the main or sole carer for her children, with some contact but no regular involvement from the fathers of her children. Her brother was a regular visitor to the home and appeared to have a good relationship with Child D. There is very little information as to whether the Mother had employment outside of the home but it is known that she was reliant on benefits for much, if not all, of the time. 3.1.2. The Mother is recorded as being White British. Child D and his brother are both recorded as Black Caribbean and White. There is no information that 5 The agencies concerned are listed in Appendix A 6 identifies faith as a significant feature in the family. There is also no information to suggest that any of the family members had any disabilities. Whilst there is evidence to suggest that the family were settled in their locality, in the absence of their own perspective the Review has little information about how either the mother or the boys experienced their world, family and community. One of the few insights is that the Mother was described by some as quite protective about the two boys and told staff at the college that she thought Brother D in particular was picked on, some of which she believed was due to racism. 3.1.3. Child D’s Mother had herself been in the care system as a child and later had a history of involvement with drugs and possibly drug dealing, and was therefore known to the police. Following Child D’s death it was discovered that cannabis had been grown in the house which, irrespective of who initiated this, could not have been without the knowledge of the Mother. The level and seriousness of the Mother’s personal drug use is not properly understood, but it did not appear to have had a debilitating effect on her daily life. 3.1.4. Both Child D and Brother D had problematic school attendance, with Child D having a number of changes of school and for a period of a few months being described as home educated. In 2011 Brother D was excluded from school and received support from the Local Authority for his learning at home. They also both had some involvement with the criminal justice system as young teenagers. Throughout their childhoods there was a repeating pattern of not responding to appointments or letters with health services and on one occasion the Mother discharged 20 month old Child D against medical advice after he had been admitted for possible meningitis. In 2000 the family were noted by the GP surgery as a ‘family of concern’, which is an internal note that is kept on the GP System. The GP believes that this was triggered by the concern about health appointments being missed. 3.1.5. There is some information to suggest that the relationship between Child D and Brother D was not always easy. The Review has had a consistently positive picture of Child D from those professionals and other individuals who had contact with him. He has been described as ‘a lovely, pleasant lad, very polite’ ‘easy going and not one to get into fights’. There were more expressed concerns about Brother D, particularly in relation to his use of violence. One of the professionals described him as a bright boy, who was very stern, unwilling to open up and who could be ‘quite intimidating’. The Mother is recorded as being friendly and pleasant, she had previous experience of social work, and came across as considered and helpful when she spoke to professionals. The Mother also had a history of depression and previous experience of domestic abuse. Information from the GP was that she used cannabis to help her sleep and when she was low in mood and there is some suggestion that she also used other prescription drugs. 3.1.6. Very little is known about the Younger Sister. Younger Sister was a premature baby, as a result of which she was under the neonatal team to monitor her development. Health professionals recorded concerns from the outset about her not being brought in promptly for checks ups and immunisations, as well as health visitors being unable to see her. The 7 housing provider had not been told when Younger Sister became a member of the household and they remained unaware of this until after Child D’s death. 3.1.7. The significant key events known to agencies prior to the main timescale identified for this Review are as follows: DATE BRIEF SUMMARY OF EVENT June 2001 2 year old Child D attends A&E with fractures to fingers. June 2002 3 year old Child D attends A&E with injury to lower body. July 2003 Referral to Children’s Social Care (CSC) by Mother, allegation that an 11 year old had assaulted 5 year old Child D. Initial Assessment. Case closed September 2003. March 2004 5 year old Child D attends A&E with burn to arm from inhaler caused by brother. June 2006 9 year old Child D seen by GP with ‘superficial’ injury to face. October 2010 12 year old Child D seen by GP with minor head injury having been punched in the face – not known by whom. Referred by school nurse. June 2011 12 year old Child D seen by GP with mother who asked for him to be given an STI test. Information sought but not given re partner. Test negative. Referral made to CSC. Advice given by CSC, no further action March 2011 Brother D receives 6 month Referral Order for Burglary of a dwelling October 2011 Child D charged with Affray. Sentenced in November 2012 to 12 month Youth Rehabilitation Order Feb 2012 Brother D receives Youth Rehabilitation Order for robbery/criminal damage April 2012 Child D receives a Referral order for Handling Stolen Goods. Completed August 2012 April 2012 Education Welfare planning to take action re non-school attendance August 2012 Child D receives Conditional Discharge for Possession Class B Drugs January 2013 Brother D’s Youth Rehabilitation Order revoked, replaced with Attendance Centre Order. 3.2 The significant events and involvement of agencies for the main period under review (April 2013-February 2016) 3.2.1. In April 2013 Child D was living at home and attending school. Information about Brother D at this time is limited, although there a record to say that he did have periods of time being educated at home following the exclusion in 2011 and also received individual support from the Local Authority with his learning. 3.2.2. The first significant event was an argument between the two brothers and their Mother in early April 2013 which led to the Mother calling the police. 8 Police Officers attended the house, but did not identify any offences and subsequently sent a Domestic Incident notification to Children’s Social Care (CSC). The Police safeguarding unit also made a referral to the Victims Advocate Unit as had been requested by the Mother. However, there was no record that the Victims Unit did in fact call the Mother or that this was followed up either by the Mother or by any professional concerned. It was noted in the CSC Records that this was a domestic incident and there was recognition that the perpetrator, Brother D was a child. CSC concluded that no further action was required as the incident did not meet the threshold for involvement. The Mother was considered to have acted appropriately and had received advice about seeking support from the police. 3.2.3. The Police received an anonymous call on a second occasion in the early hours of the morning in April 2013 reporting that there was fighting and shouting at the house. Police attended and both Brother D and their older brother (Brother D2) were present, as was the Mother, but it is not recorded which other family members were in the house. There had been an argument but none of those present were willing to speak about what had happened. The Police gave words of advice and this was recorded as Anti-Social Behaviour. 3.2.4. The following month an abandoned 999 call was made to the Police who went to the address provided and found that a 15 year old boy, who was drunk, was in charge of his own 9 year old brother as well as 2 year old Younger Sister. Nearly an hour later the boy’s parents and Child D’s Mother returned to the house, which was the home of the boy’s parents. A referral was made by the Police to CSC as a result. Child D’s mother acknowledged that she should not have left Younger Sister with the 15 year old, but stated that they had only left because of an emergency in relation to other family members and the boy had not been drunk when the adults went out. The Mother told CSC that there had been social work involvement with her two older children, but there was no information about this on the computerised records. CSC concluded that given the Mother had acknowledged their concerns and as there had been no referrals for the family since the records were computerised there was no need for further action. 3.2.5. Child D had been subject to a Youth Rehabilitation Order since November 2012 as a result of an offence of affray. In August 2013 his Mother spoke to his YOT worker about Child D having recently disclosed another occasion when he had been subject to an assault as a young child which was causing him flashbacks. She was concerned about this and wanted to access some support for Child D. The YOT worker made a referral to CSC and a Strategy Discussion involving Children’s Services and the Police took place. The conclusion was that no further action would be taken as Child D did not want the issue pursued. Child D also spoke to his GP about the assault and told the GP about the Police involvement. Although Child D was distressed, no referral for counselling or other support was made by the GP. It was suggested that he return to see the GP again in a few weeks, but did not do so and there was no follow up by the surgery. Neither is there evidence of any contact between CSC and the GP. Child D told his YOT worker that he did not want any support. 9 3.2.6. In September 2013 Brother D enrolled at South Gloucestershire and Stroud College. 3.2.7. In October 2013 a further referral was made by the Police to Children’s Social Care, as a result of information that both the brothers were regularly using drugs, possibly in the presence of 2 year old Younger Sister. The Police subsequently also provided information that the brothers had been in a fight with each other and both attended hospital. Information from the A&E department of the local hospital was that Brother D had attended with a cut mouth following an alleged assault, although it is not clear if this related to the same incident. Further enquiries were made and subsequently due to the Police’s ‘significant concern’ about drug use and difficulties in making contact with the Mother, CSC decided that an Initial Assessment should be undertaken. 3.2.8. Enquiries for the Initial Assessment began in early November 2013 and were underway when 2 further referrals were made. The first was by a neighbour who reported that 2 year old Younger Sister had been seen walking alone in the street without a coat or shoes. The second referral was from the YOT team less than a week later informing CSC that Brother D had been remanded in custody following an alleged offence of Wounding with Intent6 in which he was said to have stabbed someone at a party. Because of his age (17 years old), this meant that Brother D was now classed as a Looked After Child7. A Looked After Child Plan was initiated, but Brother D was bailed and returned home three days later. The Looked After Child Plan was not completed and there is no evidence that Brother D was seen by social work staff. Brother D was suspended from his college course due to the potential risk to other students given the nature of the charge against him. 3.2.9. The Initial Assessment was completed in December 2013 taking into account all three referrals. Brother D had been looking after Younger Sister when she was found walking alone in the street having got out of the house because the back door had been open. It was accepted that both Brother D and his Mother used cannabis recreationally, with the Mother stating that she would have one or two joints an evening which she said was never in Younger Sister’s presence. She also said that Younger Sister shared a bed with her, which was the approach she had taken with all her children and which she was unwilling to change. The assessment’s conclusion was that there were no significant concerns about the children or their mother’s parenting capacity other than that Brother D should not be left in sole care of Younger Sister. A ‘Partnership Agreement’ was put in place, signed by Brother D and his Mother and this information shared with the Health Visitor. The agreement was as follows: “Brother D is not to have sole care of Younger Sister at any point, including if (mother) just ‘pops to the shops’”. The case in relation to all three children was then closed. 6 Wounding/causing grievous bodily harm with intent, contrary to section 18 Offences Against the Person Act 1861 7 All children who are remanded into custody become ‘Looked After’ by the Local Authority under Legal Aid Sentencing and Punishment of Offenders Act 2012. 10 3.2.10. The Social Worker had spoken to the Health Visitor during the Initial Assessment. The Health Visitor had no specific worries about Younger Sister’s health or development but had not seen the family much during the year and recent appointments had not been kept. The Health Visitor was told by the Social Worker about the Mother’s use of drugs and linked dangers of co-sleeping with Younger Sister and the Health Visitor agreed she would attempt to visit again and discuss this with her. On 11th December 2013 the Health Visitor contacted the Social Worker asking her to visit. She was informed that CSC had no concerns and that the case was about to be closed after a final visit. 3.2.11. At the end of December 2013 there was a further referral from the Police after an anonymous complaint about a party at the family home. It was said that people were under the influence of drugs and alcohol and that Younger Sister was present into the early hours of the morning. The referral was considered by CSC in relation to Child D and Younger Sister, although there was no apparent consideration of any impact on Brother D. No further action was considered necessary. 3.2.12. The Health Visitor recorded concerns about Younger Sister not being taken to her neo-natal team appointments. She discussed this in Child Protection Supervision and it was agreed that she should liaise with the Social Worker. The Health Visitor called the Social Worker concerned asking what the situation was in the home, particularly in relation to Brother D. The Social Worker said she would make enquiries and get back to her, but did not do so. 3.2.13. During the first 3 months of 2014 the Mother presented to health professionals on three occasions with injuries, or what might have been symptoms of injuries. She was seen first by paramedics following a 999 call in relation to having had ‘bangs on the head’, on another occasion at A&E with pain in her wrist and thirdly with an accidental scald to her wrist. In April 2014 she reported to the housing department that Child D had been assaulted, although there is no record as to who had assaulted him, and that there had been threats made towards her from someone in prison. However, she did not follow up these concerns and later could not recall some of the information she had given. There were other occasions across the three year period when the Mother attended, predominantly the A&E department, as a result of minor accidents. 3.2.14. In early summer of 2014 the Health Visitor again recorded that Younger Sister had missed her neonatal team appointments. She made several attempts to contact the Mother both by telephone and home visits without success, as well as contacting CSC to see if they were aware of the family situation, including that Brother D was still living in the home. The Health Visitor specifically asked for any information about safeguarding concerns or risks. CSC wrote back to say that they had no new information about the family but that the Partnership Agreement remained in place. Then in August the Health Visitor contacted the CSC First Response team, but was told that her concerns would not meet their threshold for involvement. The Health Visitor continued to attempt to make contact with the Mother and Younger 11 Sister and again in October 2014 discussed the case with her Child Protection supervisor. In November 2014 the Health Visitor again contacted the First Response team, with no outcome and finally wrote to the GP outlining the lack of contact since December 2013 and the involvement of CSC. CSC found no records of this contact from the Health Visitor but all contacts are well documented in the health visiting records. 3.2.15. Brother D re-enrolled at College in September 2014, but his attendance that year was very poor and when he reapplied to enrol in July 2015 his application was declined. 3.2.16. In February 2015 the Mother contacted the Housing Provider asking for a transfer following alleged threats to her and Child D from someone in prison as well as an incident when the Police were called when two boys were said to have kicked her door. The Housing Provider undertook a risk assessment and agreed an action plan with the Mother. However, she did not ultimately pursue the application which was therefore eventually cancelled. 3.2.17. The next significant event took place in May 2015 when Brother D was given an Adult Caution after an unprovoked attack in which he had punched a man in the face. A few days later Brother D himself attended A&E with a broken nose which he said had happened when he had tried to split up a fight. 3.2.18. During 2015 the Mother also sought help from her GP as a result of depression and was prescribed anti-depressants and advised to consider counselling, but did not take up this option. 3.2.19. In June 2015 the Mother called Police to the house when a verbal argument with Brother D escalated and she became worried he would cause damage to the house. There were no offences disclosed, but the Mother was given information about the support available from Lighthouse8 who contacted her the following day, but she declined their offer to refer her to Domestic Abuse support services. The Mother had also declined to take part in a DASH (Domestic Abuse) risk assessment, although this would not have prevented the Police completing one without her direct input. A routine referral was sent by the Police to CSC and the Health Safeguarding Children Team, but it was not considered to meet the threshold for joint intervention between Police and CSC. The information provided was reviewed by CSC, but no further enquiries made and no further action taken given the information provided to them. In August the Police were also alerted when Child D was found with a facial injury which was suspected to have been the result of an assault. Child D would not confirm what had happened and no further action was therefore taken. 3.2.20. In August 2015 Brother D had an operation for an open fracture on his hand. 3.2.21. Later in August 2015 another significant event took place in the home. The Police were again called to the house during the night, on this occasion by Child D. When the Police arrived Brother D and his mother were initially 8 Lighthouse is a commissioned witness and victim support service working within Avon and Somerset Constabulary. 12 found motionless on the kitchen floor, both of them with some visible injuries. Child D also had what was described as a severe cut to his arm, which he said had been caused by Brother D when he had tried to stop him taking his Mother’s car. The Mother was described as intoxicated, but Brother D less so. Child D and Brother D then began arguing, with Child D telling his brother that ‘he was an idiot to himself, but he cared about him and didn’t want him to ruin his life by doing something stupid’. Child D was described by attending officers as frustrated with his brother rather than angry with him. Brother D was arrested, but not ultimately charged as neither Child D nor the Mother was willing to make a complaint. During the incident, Child D was seen by one of the officers to be attempting to wash two knives in a child’s paddling pool in the back garden. The knives were taken as potential evidence. 3.2.22. An emergency ambulance also attended and paramedics treated the Mother and Child D at the scene. A referral was made by the Police to the CSC First Response team and the Health Safeguarding Children Team. The Mother stated that she did not want Brother D to return to the address and it was said that he would go to stay with his Older Sister. The Police view was that the Mother would probably allow him home and that ‘nobody appears to be in fear of him’. A DASH (domestic abuse risk assessment) form could not be fully completed for Child D who refused to co-operate with the assessment. The Police Officer therefore recorded this as a standard risk and stated that it was believed the incident was ‘drug and alcohol fuelled’. The Custody Sergeant and Inspector made the decision that this would not reach the CPS threshold for charging. Consideration was also given to the making of a Domestic Violence Protection Notice, the purpose of which is to prevent the perpetrator returning to the address. However, this was not pursued and the incident itself was mistakenly classified as an abduction offence, not domestic violence. Despite this Child D was offered support by Lighthouse, but he did not wish to take this up. 3.2.23. It is uncertain whether Younger Sister was at home at the time of the incident, as the attending Police Officers had not been told, and had not considered the possibility that there might be any other children in the house. With hindsight the officer who was dealing with Child D and the Mother reflected that this was a mistake, but at the time no one had said another child lived in the house and the Police’s focus was on dealing with a potentially violent situation. On receipt of the referral, CSC made inquiries with the nursery attended by Younger Sister and were informed that she presented as a bright, happy child who had a good bond with her mother. She was about to start at the local infant school. The CSC records state that Younger Sister had not witnessed the incident as she was staying with Older Sister, information which they were given by Mother a week after the event. As Younger Sister was said not to have been present and because Mother had said that Brother D would not be welcome back in the house, CSC concluded there should be no further action. Information about previous contacts and referrals was also obtained and concerns about Brother D’s violence and use of knives, drug and alcohol in the house, non-engagement with the Health Visitor for Younger Sister and concerns over the Mother’s supervision of each of the children when younger were all noted. 13 3.2.24. The Social Worker also had a telephone conversation with the Mother who ‘presented as concerned, appropriate and knowledgeable about the risks to her younger children around Brother D’. On the basis that the Mother was believed to be acting in a protective manner; that Younger Sister was said not to be in the house at the time of the incident; that the mother had called the Police and that Brother D was said to be no longer welcome in the family home, it was decided that there would be no further action. 3.2.25. In September 2015 Child D enrolled at college on a bricklaying course, having previously undertaken an apprenticeship. The college concerned was the same one which Brother D had previously attended, but it was not known to the college that the two boys were related. However, Child D’s attendance was poor from the outset and in October 2015 he was withdrawn from the course. Despite this, when Child D attended college unannounced at the end of November asking to see the Team Leader, he was given both time and advice by the team leader. Child D explained that his girlfriend was pregnant and there had been a lot going on at home. The Team Leader offered him a careers interview and gave him the option to return in March 2016 in order to begin the process of enrolment for September. 3.2.26. In November the Mother had a GP review in relation to depression and was restarted on anti-depressants which she had previously stopped taking. 3.2.27. In the early hours of the morning during February 2016 the police were called to attend the house where Child D had been stabbed several times by Brother D following an argument. The Police and then paramedics conducted CPR and Child D was taken to hospital. However, shortly afterwards Child D was pronounced dead. Brother D was subsequently arrested and charged with his murder. 4. CONTRIBUTION OF CHILD D’S FAMILY AND FRIENDS As has already been noted, the entirely legitimate decision of all but one of the family and friends of Child D not to meet or contribute their experience to this Review means that our understanding of what was, or was not, happening within the household is significantly limited. 4.1. Child D’s Mother was at the beginning unwilling to contribute to this Review. However, she spoke to the author by phone on more than one occasion and also gave her permission for Brother D’s Probation Officer to talk to the author after they had spoken regarding the Review. 4.2. Before this report was completed, Child D’s Mother spoke again to the author and maintained occasional contact over a period of weeks, but ultimately decided that she did not want to meet or take an active part in the Review at that time. The Mother felt that it would be impossible to describe Child D and his 17 years of life in a way that would do him justice and that it was better to keep her memories of her son private. She did however speak to the author about her love and support for both her sons. Her grief at the loss of Child D and distress about Brother D’s actions and the consequences 14 for all concerned was very clear. Child D’s mother is fierce in her support of Brother D, but equally fully accepts the justice of his sentence. She said that mostly the two boys were good friends, despite the previous incidents, but she was also critical of some of Child D’s behaviour towards his brother. She described Child D as someone who was not at all an aggressive person, but that Brother D had a temper. She had worried that something could happen but never wanted Brother D to be prosecuted as ‘it was family and you don’t do that’. 4.3. Although the Mother did not wish to meet in person, she did share with the author her feelings about the way that agencies respond to domestic abuse when this does not involve a relationship between two adults. She did not identify any other support services that she felt would have been useful to her. Her thoughts are included in Section 5 of this report. 4.4. Prior to publication of the report contact was again made with the Mother who agreed that she would like to meet to learn about what was in the report. The author and the Board Manager therefore visited her at her home where she was joined by a friend. The report was shared with the Mother and her friend, and the author identified particular aspects of the report and the recommendations that seemed to be of most significance. The Mother was given the opportunity to read the report in full on another occasion, but decided not to take this up. 4.5. During this meeting, the Mother spoke again of her view that the Police should have responded to violence in the home in the same way that they would have done if it had been violence from one adult to another. She talked about how impossible it felt for her to make a statement against her own son and her belief that if the Police had taken more decisive action with Brother D earlier on it could have made a real difference. The Mother also agreed with the thinking behind the recommendations in the report. Other comments and views from the Mother are included within the analysis section. 4.6. Child D’s Father, who also lives in Bristol, met with the two independent reviewers and his willingness to share his thoughts about his son and what had happened is much appreciated. He explained that he did not see his son regularly, but that Child D would call in to see him and he would sometimes also go round to the family home. Child D’s Father spoke with warmth about his son, describing him as ‘a humble youth’ who made him proud ‘as he had been through a lot and was trying to put effort into his life to be a better person’. He felt that Child D had ‘get up and go’ and had hoped that he would do well in his life. Child D’s Father did not have any concerns about Child D using ‘heavy’ drugs. He was aware Child D sometimes smoked cannabis, but had no reason to be worried about anything more serious. 4.7. Child D’s Father found it very hard to understand how one brother could have killed the other and it was apparent that he felt a strong need for some answers. He described visiting the home a few months before Child D’s death when the boys had a group of friends around. Brother D had invited 15 him to stay; something that he felt was a thoughtful gesture and also seemed to suggest Brother D might see himself as the ‘man of the house’. Child D’s Father and Brother D’s Father know each other well, and this was one of the reasons that he believes Brother D accepted him in the family. He said that Brother D’s Father was also fond of Child D. Child D’s Father believed that when the boys were growing up Brother D had tended to be the more dominant character and had bullied Child D to some extent, but he had got the impression that Child D had become more assertive with his brother as he had grown older, so that this was not such a problem. Child D’s Father did not know that there had been previous incidents of violence from Brother D to Child D and would have wanted to tackle this with him had he known. He asked that why Brother D had been allowed to go back into the family home if he had previously injured Child D with a knife. 4.8. Child D’s Father met with one of the lead reviewers and the Safeguarding Board Manager to read the report and offer any contributions prior to it being finalised. He was satisfied with the report, only raising the issue of not anonymising those involved, but accepted that this would not be possible. 4.9. Brother D. Contact was made with Brother D via the Probation Service and prison staff to explain to him that the Review was taking place and to see if he would be willing to contribute. Although he did not rule out the possibility initially, he ultimately decided that he did not wish to do so. He did not wish to take up the opportunity to read the report prior to publication. 5. ANALYSIS AND APPRAISAL OF AGENCIES’ PRACTICE This analysis will be organised to identify the learning under the structure of the three overarching identified Terms of Reference specific to this report. Inevitably there will be a cross over between some of the issues within the Terms of Reference. Therefore, where an incident or issue has been analysed under one section, this will not be repeated in later sections of the analysis. 5.1. What this case tells us about the multi-agency response to domestic abuse in families in situations when this is not intimate partner abuse. 5.1.1. The Terms of Reference of this Review specifically direct us to consider the significance and potential for learning in relation to non-intimate partner abuse. Legislation, statutory guidance and definitions of domestic abuse recognise that it does not only take place in intimate partner relationships, but can also be a feature of other family relationships. Research tells us that the majority of domestic homicides do involve intimate partner relationships9, but that a smaller number include other family members. The circumstances of Child D’s death, as well as information identifying previous incidents in the home, raise the possibility of domestic abuse and as such this is one of the key features of the Terms of Reference for this review. 9 Domestic Homicide Reviews: Key Findings from Analysis of Domestic Homicide Reviews. (2016:7) 16 5.1.2. Nevertheless, despite the tragic outcome, we do not have a firm understanding as to whether domestic abuse, as it is generally recognised, was indeed a feature in Child D’s home life. There is clear evidence that violent incidents and arguments took place and Child D’s mother recognised this as presenting a future risk. The Mother talked from her own experience about the professional response to domestic abuse by a partner. She was critical that violence in the home when it was from a child was not approached as seriously. However, in the absence of a more detailed discussion it is not clear exactly how she might have defined what was happening in the home at this time. As a result, even with the advantage of hindsight it is difficult to identify a trail of events that would lead us, with confidence, to assert that domestic abuse was what was taking place within the family. This is not to suggest that there was not a potentially dangerous situation in the home or that domestic abuse was definitively not an issue. Alternatively, what was taking place in the home may have been a reflection of what is identified by Smith et al10 in their recent work on Domestic Homicide: “We want to differentiate between domestic arguing, which may or may not include violence, and domestic abuse, which is achieved through control through fear”. It is therefore important to acknowledge that whilst this violence and what lay behind it may be an indicator of domestic abuse, there is also information to suggest that it could have been of a different nature, although no less concerning. The difference between the two forms of violence is significant in the way in which support, help and risk management are best achieved. 5.1.3. Our predominant understanding of domestic abuse, as reflected in statutory guidance and much of the research, is in relation to ‘intimate partner violence’. What guidance and information there is regarding ‘non-intimate partner’ Domestic Abuse from other family members is almost entirely in relation to violence from an adolescent to a parent. There is currently no legal definition of adolescent to parent violence11 and the knowledge base is at a comparatively an early stage, although one definition has been identified as helpful in the European research12: ‘’...any harmful act by a child intended to gain power and control over a parent. The abuse can be physical, psychological or financial” An additional definition refers to such violence having the following impact on the family: “threatened, intimidated or controlled by it and if they believe that they must adjust their own behaviour to accommodate threats or anticipation of violence”13 10 Smith, Willams and Mullane (2014:3) 11 Home Office (2015:3) 12 Cottrell (2001) quoted in RCPV website. 13 Paterson (2002) quoted in RCPV website 17 Both definitions clearly reflect the expectation that coercion or control will be a part of the abuse. There is no statutory guidance, national policy or procedures and very limited information relating to domestic abuse by other family members, such as siblings. 5.1.4. Prior to the incident which led to Child D’s death the Police were called on 4 separate occasions following disturbances at the house. On two of these occasions Child D’s Mother called the Police following an argument, once between herself and Brother D, the other time between herself and the two brothers; but there was no physical violence or injury either time. On the first occasion the Mother was unwilling to take part in a DASH assessment. Why it was not completed by the Police without her involvement is not known, but this will be explored further in relation to the August 2015 incident. On both occasions the Police sent a routine domestic abuse notification to CSC in line with standard procedure whenever the Police are called to a house in relation to a domestic dispute and a child is present. Significant numbers of such domestic abuse notifications are forwarded to Children’s Social Care (CSC), with recent figures showing that these average around 500 notifications forwarded each month. In this context they do not routinely trigger action in the absence of other issues of concern. That the perpetrator was a child was noted on one occasion, but this did not lead to any direct action by CSC. 5.1.5. Also on each occasion a referral was made to the relevant victim support provider, but this was never taken up by anyone in the family. The Mother had no memory of being offered such support. On the third occasion a neighbour called the police and it appeared that 16-year-old Brother D and his older brother (Brother D2), who did not live in the house, may have been fighting. The argument between the two was recorded as Anti-social behaviour. There is also a reference by the Police in October 2013 to a fight between the brothers leading to them attending hospital but it is unclear if this was a further incident. 5.1.6. August 2015 incident: The first three incidents took place over a two year period and were of a low risk nature, with no actual injuries recorded, so in themselves would not routinely be expected to trigger particular concern. However, the incident that the Police attended in August 2015 was considerably more serious, in that Child D had been slashed on the arm with a knife, as a result of which Brother D was arrested for assaulting him. As with all the previous occasions the family did not want any action to be taken and Brother D was not ultimately charged. 5.1.7. It is expected practice that Police should actively attempt to build a case to meet the thresholds for charging14 in cases of domestic violence even if the victim is not willing to make a statement. However, the Custody Inspector concluded that there was inadequate evidence either to meet the threshold for charging Brother D or for consideration of a Domestic Violence Prevention Order. 14 CPS (2014) 18 5.1.8. Having concluded that no charge was possible, and without the benefit of a fully completed DASH form, the attending Police Officer recorded this incident as a ‘standard’ risk. The DASH Form is the tool by which professionals, including the Police, identify the level of risk to a victim, which in turn impacts on the response of agencies. The risk management framework of the DASH is based on there being three levels of risk to the victim: Standard – current evidence does not indicate likelihood of causing serious harm. Medium – There are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change of circumstances. High – There are identifiable indicators of risk of serious harm. The potential event could happen at any time and the impact would be risk of serious harm. The risk assessment is achieved by asking a series of closed questions requiring a yes or no answer, although there is also space to record the victim’s response. If the number of ‘yes’ answers reaches a total of 16 or more the case will automatically be referred to MARAC, if a total of 14 it is discussed in a pre-MARAC meeting which decides if it should be subject to a full MARAC. However, where the points threshold is not met, but a professional is sufficiently concerned about the level of risk, they can nevertheless refer this directly to the MARAC. It is a fundamental part of training for DASH assessment and is explicitly recognised in Bristol’s MARAC Operating protocol that the DASH form is a risk assessment checklist, not a full Risk Assessment Form and that professional judgement in completing it is crucial. 5.1.9. What has become clear is that the DASH form, which is designed for use with intimate partner violence, was not fit for purpose in assessing risk in relation to sibling to sibling violence, abuse or coercive control. The officer completing the DASH assessment described how difficult it was to fill in the form both because Child D was unwilling to contribute to it but also because so many of the categories did not apply in this situation. This lack of a suitable risk assessment tool clearly placed officers at a disadvantage. However, given that a weapon had been used and that the perpetrator had been ‘drug and alcohol fuelled’, professional experience and judgement might have concluded that the risk to the victim (Child D) was at least ‘medium’ rather than ‘standard’. All DASH risk assessments are reviewed by the Police Public Protection Unit but in this case there was no evident reconsideration of the risk level as a result. 5.1.10. This Review recognises that the categorisation of risk on this occasion may well not have had an impact on the outcome in this case given the apparently firm position taken by the family as to the limits of their co-operation. However, it highlights an important learning point both about the limitations of the current DASH form and the significance of professional judgement. In September 2016 a joint report by the College of Policing, 19 Cardiff University and University College London made a number of recommendations about the risk assessment process used by the Police including a review of the domestic abuse risk tool used by front line Police Officers. It is therefore the recommendation of this report that action is taken by Avon and Somerset Police in tandem with its partners to review its risk assessment processes, including as they relate to non-intimate partner violence. Recommendation 1 5.1.11. The actions and decisions taken by the Police in relation to this incident, including not to take the case to the CPS for a charging decision, also require further consideration. The attending Police Officers were at the address within 5 minutes of the Police call out; they were able to manage the immediate demands of a confusing situation calmly and effectively. A DASH form was instigated, but as noted above was of limited value and the attending officers stated they had no information before they arrived regarding any previous incidents at the address. However, the potential seriousness of what had taken place was not fully recognised. 5.1.12. Avon and Somerset Constabulary has developed a Designated Investigations Team (DIT), which undertakes many of the investigations for cases coming into the custody suite. The DIT looks at the evidence provided by the arresting officers and any other evidence that they are provided with, such as witness statements or CCTV footage. The team will speak to the victim, although in this case Child D was unwilling to make a statement. The allocated team member collates the information and sends their investigation report to the Custody Inspector who makes charging decisions. The information provided to the Review by the DIT worker in this case suggested that he had undertaken the role that was required of him comprehensively, and was also well aware of the significance of Domestic Abuse. 5.1.13. The intention of the DIT is to provide a quick response when prisoners are brought into custody, to enable the arresting officers to return to their duties in the community. DIT staff, who are civilians, are not expected to actively seek out evidence, but to work on what they are provided with by the officers bringing the individual into the custody suite. The focus is to collate the information and identify whether the evidence exists to support a charge. The quality of the investigation report is therefore fundamentally reliant on the quality of the information provided by the arresting officers and the way that those officers have understood, and therefore responded to the case at the time. The issue of whether there are vulnerabilities in relying on a team, who although they may be individually experienced in investigation, are not actually warranted police officers and have quite a boundaried role, has been of some concern to this Review. 5.1.14. This system design (i.e. ensuring quick decision making following an arrest) is arguably not fit for purpose in cases of potential domestic abuse, particularly when a case does not fit a recognisable pattern of abuse and may need a more considered investigative approach. A DASH form was attempted but the possibility that this incident might highlight serious domestic abuse from one sibling to another was not considered. One 20 contributing factor to the decision regarding charging was the stated lack of medical evidence, and yet the injury had been seen, although presumably not photographed, by the arresting officers. This was an injury which we now know led Child D to seek hospital treatment the following week. In the absence of witness statements, such evidence can and often does form the basis of charging decisions in domestic abuse cases, but this was not the case here. It is also not apparent that neighbours, who we now know had witnessed some of what happened that night, were interviewed at the time. 5.1.15. The route which determined how this case was investigated reflects some of the same issues which were raised in the HMIC report of Avon and Somerset Constabulary’s approach to Domestic Abuse in 2014.15 Overall the report concluded that the public ‘can be reasonably confident that the constabulary can identify and conduct an initial investigation into reports of domestic abuse including identifying safeguarding issues’. However, it also identified some problems with the consistency of approach, and noted the lack of a clear view as to which team should investigate individual cases. What is apparent is that a good understanding and response to the level of risk within this family was unlikely to be achieved using an approach in which the strong driver appears to have been ‘the type of crime and availability of resources’16 as it would appear was the case on this occasion. 5.1.16. Whether the charging decision was the correct one is inevitably very difficult to judge after the event. Equally, charging alone does not ensure the future security of the victim and will not always be either possible or appropriate. However, it is recognised nationally as a very significant aspect of the response to a domestic abuse incident both symbolically and practically: “Domestic Abuse crimes need to be addressed and investigated as seriously as other victim based and violent crimes”.17 It is widely recognised that many victims of domestic abuse experience a high number of incidents of abuse, before they seek help and that every opportunity should be taken to provide that help as early as possible. Recent research by Safer Lives18 identified that 85% of victims sought help five times on average from professionals in the year before they got effective help to stop the abuse. It is in this that context the approach by SafeLives of ‘getting it right first time’ has been developed. 5.1.17. It is also crucial to be aware of the extreme difficulty for a parent, in taking the step of making a statement to the Police about their own child. As already noted this family was consistent in their unwillingness to support any Police action after the initial crisis. The Mother was clear in her contribution to the Review that the family were not willing to make statements to the Police. However, she felt strongly that the Police could have taken more action even without relying on statements from the family. What this highlights is the importance in any situation of domestic abuse that the fullest 15 HMIC, 2014 16 HMIC (2014:10) 17 HMIC 2014 p98 18 http://www.safelives.org.uk/policy-evidence/getting-it-right-first-time 21 consideration is given to criminal charges in order to provide a clear message about the seriousness of these offences and the need to take every opportunity to ‘get it right’ for the family. 5.1.18. This Review has not identified evidence that Brother D was intentionally violent or abusive to his Mother or that she was routinely afraid of him or felt controlled by him. A member of staff at Brother D’s college, who was aware that some people could find him intimidating, described him “not the sort of person who disrespected his mum”. There is moreover, information that the Mother played a direct role in preventing and managing Brother D’s behaviour, including calling the Police to bring an end to incidents and removing herself and other children from the home. 5.1.19. When the Police were called to the incident in August 2015 it was difficult for them to assess exactly what had happened. However, it appeared that the Mother, who had a cut to her lip, was effectively restraining Brother D. Child D although injured by Brother D did not appear frightened of his brother and the Police Officer described the event as unusual for a ‘domestic’ call out which generally involved officers ‘managing hysterical or emotional people, but this was very different, everyone was very calm’. Child D had become involved in an argument between his Mother and Brother D to try to prevent Brother D, who had been drinking and had no driving licence, from taking their Mother’s car and he was then slashed with a knife by his brother. Child D was described as frustrated with his brother, who he felt was a risk to himself in wanting to take the car out. Whilst clearly a violent and frightening situation, the typical elements of coercion, control and intimidation did not appear to be in place. 5.1.20. Health professionals comprise one of the most significant groups in identifying domestic abuse. During the time period covered by this Review, including the years prior to 2011, the Mother did present either at the GP or A&E with a number of minor injuries. The professional opinion of the GP, both at the time and now, is that this did not constitute a pattern of injuries indicative of domestic abuse. Several of the injuries, e.g. scalds to the hands/arms, are typical of household accidents, more likely to be linked to alcohol use than domestic abuse. The injuries were of a comparatively minor nature and were not so frequent as to trigger concern. This is undoubtedly a reasonable assessment given the information available at the time. Nevertheless, had professionals linked these injuries with other information about what was happening in the home it could have led to a more inquisitive approach as to what else could be taking place, including the possibility of domestic abuse. This will be considered further subsequently. 5.1.21. The information available to the Review from the A&E departments has been quite limited, although an A&E Consultant was able to provide an overview of safeguarding practice within A&E. This included acknowledging the difficulties that staff have when someone presents at A&E in that they are unable to access GP information or information about attendance at other hospitals due to information systems not connecting. As such it would not have been possible for them to identify any pattern if, as was the case, 22 family members attended different hospitals on different occasions. In Child D’s case the hospital had properly made a referral to CSC in August 2015 as a result of him attending to have his infected wound treating and informing them that it had been caused by his brother. It was acknowledged that it was unlikely that this incident would have been understood as potential domestic abuse and hospital staff would have purely viewed this as a safeguarding issue given Child D’s age. Hospital staff contacted the police to confirm that the incident had been reported the previous week and also made a referral to CSC. 5.1.22. The limitations of information available to the Review means that it has been difficult to gain an adequate insight into the dynamics of the relationship between Child D and his brother, and from that, to better understand what resources might have helped this family. In particular identifying the line between difficult or problematic behaviour - ‘normal’ conflict between siblings, and abusive behaviour would require proactive and focussed engagement with the family over time, something which did not take place in this case. Ideally the Review would have been able to better explore and understand the dynamic between the brothers, particularly as they were growing into young men. Child D’s mother described the boys as usually being very good friends, but said that Brother D could have a temper. Other than this perspective and a glimpse from Child D’s father that Child D was starting to assert himself more with Brother D as he grew older, it has not really been possible to understand in any depth the brothers’ relationship or how they interacted on a day to day basis. 5.1.23. There is specific information that there were physical conflicts between the brothers, when it appears that Brother D was the aggressor. Child D also presented at different times with injuries, some of which were caused by his brother, but others of which happened outside the home. The professionals who seem to have the best relationship with and understanding of the boys (YOT workers and college staff) did not appear to have any concerns about Child D being controlled by or frightened of Brother D. Child D’s father referred to some bullying from Brother D to Child D as they grew up, but he had not detected anything more worrying. The references to bullying and the content of some of the arguments which appear to suggest that Brother D did not like to be challenged, and possibly saw himself as the senior male figure in the home, could be evidence that there was some level of control taking place. However, without more information from the family, this remains impossible to assess. 5.1.24. There is credible information that Brother D has accepted responsibility for the death of Child D from very early on and that he continues to be highly remorseful, even traumatised as a result of what he did. Brother D presented himself to the Police the day after Child D died, he pleaded guilty to murder and there has been nothing to suggest to this Review that he has blamed Child D. There was evidently a pattern of violence outside the home in relation to Brother D, which based on the information available does not appear to differ significantly from his behaviour at home. This combination of factors suggests that Brother D’s behaviour may have been primarily part of a wider pattern of risky behaviour, including both impetuous 23 and instrumental use of violence when challenged, combined with disinhibition due to alcohol or drug use. The implications for services for the risks presented by Brother D will be considered in the following section. 5.1.25. Irrespective of the underlying reasons for the violence, there was information that would be expected to lead agencies to consider the possibility of Domestic Abuse in this family at the time. None of the agencies who were involved and aware of the behaviour appeared to recognise the possibility of non-intimate partner abuse. It was noted by both the Police and CSC that a child was the ‘perpetrator’, but this did not lead to a fundamental examination of whether there was a continuing problem, what this might mean for the child who was the victim and whether there was a need for a more active approach or escalation of concerns. Although referrals were made to victim support services on at least two occasions, these appear to have been largely routine and it does not appear that determined attempts were made to proactively engage with this family when they did not take up the offers. 5.1.26. At the time of the incident in August 2015 Brother D was 19-years-old but Child D at 17-years-old was still a child, as a result of which a referral to Children’s Services was made by the Police in line with required practice. As such the appropriate links were in place between the two services. Enquiries were made by CSC, including phone contact with Younger Sister’s nursery, a telephone conversation with Child D’s mother and reference back to an Initial Assessment undertaken in 2013. The enquiries stated that “Brother D is an adult about whom there are significant past concerns in relation to a past history of GBH”. Brother D had at this point received an Adult Caution for assault 3 months previously, he had 3 convictions for offences involving violence, been charged then acquitted of a serious offence of wounding and come to the police’s attention on 4 occasions for disturbances in the home. This history if it was known, should have triggered a greater level of concern about the potential risk he posed both outside and inside the home. It is perhaps also significant that the records refer to the incident as a fight between the two brothers, suggesting an equality between them and as such it is clear that domestic abuse was not adequately taken into account. 5.1.27. No further action was considered necessary on the understanding that Younger Sister was not in the house at the time and that Brother D was no longer welcome at home. It would appear that the Mother’s assurances about this were accepted on face value and had a significant impact in the overall decision making by CSC. One important factor that should have been considered when assessing the Mother’s perspective on her son’s behaviour is how difficult it can be for parents to openly recognise that their child might be violent in the home.19 There was an opportunity at this point to take a more active approach towards gaining a better understanding of the family dynamics and history. It is also evident that there was a lack of adequate recognition of the potential risk to Child D. This reflects consistent research20 which has identified that adolescents, in this case a male of dual 19 Home Office (2015:5) 20 Khan, L (2017:4) 24 black/white heritage, are often not viewed as children who might be in need of protection. 5.1.28. There has been a shared recognition amongst the Review team and the practitioners who have contributed to the Review that there is a limited awareness of domestic abuse within services, beyond the more familiar intimate relationship abuse. Nationally there is a lack of focus on this issue, with limited opportunities for professional development or guidance as to good practice in these situations. This picture is also reflected locally. In 2016 the Bristol Safeguarding Children Board offered two training courses in relation to Parent Abuse, but there was limited take up and this is not something that is currently available locally. It is also the case that there are currently no services with specialist skills or experience of working with older children who may be experiencing domestic abuse or who might be abusing family members. Recommendations 2 & 3 5.2. What does this case tell us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria? 5.2.1. This section of the analysis will be structured by identifying what needs and risks appeared to be present. It will then consider key opportunities to assess these needs as a whole and as such consider the needs of all the family members and whether the cumulative effect of concerns might impact on threshold decisions. 5.2.2. Although it would not have been apparent from the outset, there were a number of indicators to suggest that Child D and his family might have needs, or be experiencing difficulties, meaning that various services could, or should have been offered to them. It is important to recognise that these needs individually would not generally be expected to result in a formal requirement for further action and would also be unlikely to meet thresholds for any statutory involvement. As a result, whilst different services were involved at different times it did not appear that any one service gained an understanding of the family’s situation as a whole and therefore what might be most helpful to them both collectively and individually. Whilst obtaining a full picture would not have been achievable or within the legitimate remit of many services individually, options such as triggering a CAF21 in order to provide early help with the family’s agreement, could have led to a more holistic understanding of what support and help was needed. 5.2.3. Substance Misuse: One of the aspects of this family that was often identified, but its significance never entirely understood, was that of illegal drug use. A mixed picture has emerged of the degree of drug use by family members and what was known about this. Both the Mother and the two brothers were known at the time to use cannabis. Mother had told her GP that it helped her to sleep and to manage her low mood. In retrospect the GP has identified that the Mother’s use of prescribed painkillers should 21 The CAF is a shared assessment and planning framework instigated with parental agreement when it is felt that children have additional needs which would benefit from a co-ordinated approach. The CAF was replaced by SAF in Bristol in April 2014. 25 ideally have triggered a conversation about substance misuse. Similarly there was limited exploration of the Mother’s cannabis use when assessments were made in relation to parenting. There was some police intelligence prior to Child D’s death to suggest that there may have been involvement in drug dealing, although neither the housing provider, nor the local beat Police Officer, both of whom would often be aware of community information about drug dealing, had any particular concerns about this family at the time. There were occasional parties and loud noise from the household, but on the limited occasions when Police were called, the Mother was co-operative and the noise controlled. 5.2.4. Cannabis is the most commonly used drug amongst young adults, with one in 5 self-disclosing drug use in the last 12 months.22 As a result the use of cannabis in itself is unlikely to trigger significant concern about an individual or family. Nevertheless, there was also information known to the Police that the brothers were both using other drugs including ‘Bubble’ (mephedrone) and other stimulants. There is nothing to suggest that any of the family members considered themselves as problem drug users or sought help for drug use. With the exception of the Police, professionals did not view the family as having significant drug problems. However, during some of the incidents of violence, substance abuse was a feature, including the night of Child D’s death when both the brothers had been drinking and using drugs, including cocaine. Alcohol had also been a factor in Brother D’s previous violent offending. 5.2.5. Had either of the brothers wanted to seek support or advice about drug or alcohol use, it is reasonable to question how and where they would have sought help. One issue of concern is that Black and Minority Ethnic communities access drug services less than white communities. A report undertaken by Safer Bristol in 201223 identified a number of barriers to members of BME communities in accessing drug services in the city, including: Lack of information about advice and treatment services Lack of trust in the cultural competence of drug services Fear about the consequences of disclosure 5.2.6. Bristol Drugs Project whilst wanting to engage with a wide range of drug users recognises that it is primarily seen as a service for heroin users. Bristol has a particularly high instance of opiate and crack users24 and the recent Bristol City Council Commissioning Strategy for drug misuse focuses its priorities on treatment and rehabilitation to a greater extent than outreach work, in line with the National Drug Strategy. There are some limited specialist outreach services for young people on the edge of harmful drug use but no specialist BME services. 22 HSCIC (2016:18) 23 Safer Bristol: June 2012 24 BCC : June 2017 26 5.2.7. Health: The Mother was described as having a good level of engagement with the GP practice and she spoke in positive terms of trusting her GP and being willing to seek her help and advice. She is described as having a complex medical history including historic experience of domestic abuse from a partner and at that time she accessed health services. Mother had a history of low mood, she was treated for depression following a reported family death in 2014 and this continued throughout the period under review. The GP practice has recognised that despite the evidence of some degree of drug use combined with depression; this did not lead to a discussion with Mother about any potential impact on parenting or consideration of whether to refer on to other services. This has been an identified learning point for the practice. 5.2.8. It is also the case that both Child D and Brother D were seen by health services for a range of medical problems, many of them routine and unremarkable, but some of more significance and several involving injuries. In the years prior to the main time period for this Review there were at least three occasions when there were more worrying presentations to the GP in relation to Child D including one quite serious injury. On each of these occasions, one of which resulted in an Initial Assessment but no further action by CSC, current practice standards would have suggested a more robust response from professionals and more active offers of support to the mother and child. 5.2.9. These incidents will not be analysed in detail here as they are unlikely to contribute anything to our understanding of any history of domestic abuse nor, given the time since these events, would it be likely to impact on learning in relation to current child safeguarding practice. What is the case however is that these incidents could have provided important context when assessments were undertaken at a later stage. 5.2.10. There is absolutely no suggestion that Child D was subject to abuse at home, however they raise questions about levels of supervision as does the pattern of missed appointments with health professionals in relation to all three children. 5.2.11. Offending: Both Child D and Brother D had some contact with the criminal justice system. Child D had one period of supervision by the Youth Offending Team in 2011/12 following an offence of affray. Child D was not assessed as posing a significant risk of harm, had no previous history of violence and did not present worrying or aggressive behaviour or attitudes. The YOT worker was aware of some cannabis use but did not identify this as a major concern. He described Child D as bright and capable and appeared to have a positive and constructive relationship with him. It was a concern that Child D’s school attendance was erratic but the school were keen to support him and maintain him in education. Child D mostly co-operated with the YOT, he was ‘a gentle lad, polite and respectful’ and his Mother also presented as supportive. The YOT assessment was that Child D was not at high risk of re-offending, unless in the company of others in his peer group and based on the information available, this appears to be a reasonable assessment. 27 5.2.12. Brother D’s offending profile was of greater concern than Child D’s particularly because it involved a pattern of violence including the use of weapons. Brother D was subject to three Youth Offending orders between 2011 and 2013 and his engagement was not as positive as Child D’s. Brother D was less co-operative and breached two of the orders, but was also personally much more challenging to work with. The worker who assessed Brother D in early 2013 identified concerns linked to impulsivity and disinhibition due to alcohol use and as a result concluded that Brother D had the capacity to cause serious harm. At the same time, it was also recognised that Brother D had the ability to manage his own anger and was able to regulate his own emotions as was demonstrated in his calm response to being arrested following the incident in October 2015. The risk assessment identified violence as a response to perceived provocation but not that there was a heightened risk to particular groups of victims, and noted that there were no concerns expressed by either his mother or his school. 5.2.13. The significance of non-resident fathers: This Review has been asked to consider the significance of non-resident fathers in the lives of young people. The information about Brother D and Child D’s fathers (including direct information from Child D’s father) suggests that they played a very limited role in the boys’ lives. Some of the professionals raised the question of whether the lack of contact with their birth fathers had an impact, particularly in how Brother D viewed his role in the family and to what degree this might have been effected by his experience as young man of dual heritage. We have little information that would help us understand the quality of those relationships or to understand the impact or otherwise of the boys’ fathers not being a resident part of the family. 5.2.14. We can say however that in relation to the role of fathers generally, research identifies good evidence that “responsible and involved fathering ….has positive effects on the wellbeing of children well into adulthood”25. The key to the significance of a father, is not in itself his being resident in the family, but being actively engaged with his children. Khan identifies a range of research regarding the role of ‘ongoing engaged fathering’ including links with ‘lower levels of impulsivity and inhibitory control” and better interpersonal relationships. However great care needs to be taken in attempting to second guess what their relationship with their fathers meant to Child D and Brother D from a theoretical perspective. 5.2.15. What is very apparent is that the role of the boys’ fathers played little if any part in professionals’ understanding of the family. There is minimal evidence of any questions being asked about their fathers or any consideration as to whether they were a significant part of their lives. The exception was one of the YOT workers who himself knew Brother D’s father and identified as being part of the same community. For this worker, who was persistent in his attempts to engage with Brother D, it was in part the fact that he knew Brother D’s father that improved his relationship with him, suggesting that this was significant to Brother D in some way. 25 Khan, L (2017) 28 5.2.16. The conclusion of this report in relation to the fathers therefore, is less about what can be learned generally with regard to the impact of non-resident fathers on children, and more about understanding the significance for those children of the relationship with their fathers. The absence of fathers in professionals’ minds, which is a regularly repeated lesson from Serious Case Reviews and wider research, is therefore the learning that should be highlighted here. As services in Bristol already clearly recognise this as an ongoing area for development, it is not considered proportionate or helpful to produce a further recommendation in this Review. 5.2.17. Risks associated with carrying or using knives. Public perceptions of young people who carry or use knives is strongly linked to involvement with gangs. No information has been provided to this Review that links either Child D or Brother D with gang involvement and specifically there is no intelligence from the Police to this effect. The only information in relation to the use of a knife as a weapon is in regard to Brother D, and there is no information available to us that evidences that he routinely carried a knife or, if he did, what his motivation for doing so was. We can look to research to help us understand what motivates young people to carry knives, and what there is suggests that: ‘fear of crime, experience – direct or otherwise – of victimisation and the desire for status in an unequal society are the chief motivations for carrying a knife.’ 26 What we do know is that Brother D was willing at times to use weapons against people both outside the family and within the family. 5.2.18. In the absence of any further information it would be unwise to reach conclusions about the wider significance of knife crime for young people and agencies within Bristol. What is however very clear was that there was a lack of recognition of the increased risk from Brother D as a result of his willingness to use weapons, irrespective of his intention or otherwise to cause harm. The concern that the Mother the mother raised in relation to use of knives was young people’s apparent lack of awareness of how even an apparently small cut could be fatal. 5.2.19. The family’s perspective: What was little understood was how the family themselves viewed their situation and whether they would have identified any needs or risks. It is evident that this is a family with considerable strengths and strong emotional bonds. Mother was evidently willing and able to access services, for example calling the police to deal with arguments or violence in the home and engaging with the GP practice. Mother was also equally able to make it clear when she did not want involvement from services and was effective in reassuring agencies that she would manage any problems herself. The Mother in her contributions to the Review acknowledged that she was not generally someone who would want to engage with services other than when she identified them herself. She impressed many of the professionals as sensible and concerned, there was no hostility and an apparent willingness to respond to any concerns that 26 CCJS (2007:21) 29 were raised. What is apparent with hindsight is that this effectively kept agencies at a distance, whether or not this was recognised at the time. 5.2.20. Both Child D and Brother D were viewed as articulate young people with potential to develop their lives. Professionals evidently found Child D more open and responsive than his brother, who although not aggressive to professionals was much more guarded in his response to them. We do not have a clear view as to the degree to which the brothers’ race impacted on their experience or their confidence in services. Child D’s YOT worker told the Review that he had never got the impression that there were any problems for Child D in the community relating to race. On the other hand, Brother D’s YOT worker, himself a black man, was of the view that Brother D would have been even more guarded with a white worker, or with someone from a very different background to himself. What we cannot know is to what degree their lived experience as young black men, and what has been described as the ‘wear and tear’ of everyday racism and discrimination27 may well have played a part in how far they, and particularly Brother D, were prepared to engage with professionals. 5.2.21. The opportunities to assess the family’s needs: There are two particular episodes of contact when referrals to CSC led to further enquiries taking place and therefore providing an opportunity to better understand the family and consider how best to offer support or challenge. In particular this could have allowed for a more holistic response to the family, drawing together all the relevant information from across the agencies and identifying the separate and shared needs of the children of the family, and of the Mother. 5.2.22. May 2013: The referral from the Police to Children’s Social Care in May 2013 related specifically to Younger Sister. The immediate concern was that 2 year old Younger Sister had been left in the care of a 15 year old boy who was drunk. What is clear from the records is that Mother’s explanation for what happened was accepted with little or no question. That the Mother stated that it had been a mistake and it was not something she would normally do, was the key factor in the recommendation that no further action be taken. There is no reference to previous family history which would have identified that there had been previous incidences of young children being left unsupervised. These records predated the computer system being put in place and to have identified the detail would have required the old paper files to be accessed, a time-consuming process that realistically would only be done when there was a much more serious concern, or the need for a full Core Assessment. Nevertheless, it would have been possible to see from the computer system that there was some history with this family. Neither is there any reference to the domestic abuse referral from the police one month earlier in which Younger Sister’s sibling was identified as the ‘perpetrator’. A primary reason for not taking any further action on that occasion had also been because the Mother was assessed as having acted appropriately. 5.2.23. Whilst a decision not to take further action on the basis of this one event, might well have been a defensible one, what is of concern is that there is no 27 https://www.centreformentalhealth.org.uk/against-the-odds 30 evidence from the records that this decision was made on the basis of anything other than self-reporting by the Mother, with no obvious questioning or reflection on the credibility of the explanation given and no basis for knowing if the mother’s reassurances would or could be followed in practice. There is no evident reflection on what family life might be like for Younger Sister or her siblings and no consideration as to whether there were other adults involved in their care. Given the passage of time since this event, we are not in a position to understand the full context for decision making. Proportionate decisions do need to be made about prioritising the time to deal with individual situations where the risk is not of the highest. However, the record of the social work involvement in this case is almost entirely descriptive and in itself does not demonstrate a clear analytical approach that is aware of its limitations as an assessment. Without analysis of the full information that is available, assessments will always be limited in their value. 5.2.24. Initial Assessment Oct 2013: When CSC undertook an Initial Assessment at the end of 2013, it was in effect in relation to three separate referrals: a Police referral regarding drug misuse, a further occasion when Younger Sister was not properly supervised, and Brother D being charged with a serious offence of violence and then remanded in custody. The decision by the First Response team manager to refer this to the duty team included clear recognition that there were risks to both brothers in the family and was an appropriate one. 5.2.25. However, what is noticeable about the ultimate assessment is that the predominant focus has become that of identifying any risk to Younger Sister rather than being equally on considering her older brothers’ needs or what risks they might be exposed to. The rationale for undertaking the Initial Assessment on receipt of the first referral states: ‘due to the age of child in the home and allegation that Bubble and Cannabis are being used, possibly in her proximity.’ Child D and Brother D are at this point aged 15 and 17 respectively and are therefore also children and whilst they are identified on the records as children themselves, there is little to suggest that their needs have been given equal priority. As before, it is noted that the Mother is very remorseful about Younger Sister being found on her own in the street and that a stair gate is going to be put up at the backdoor so this would not happen again. Child D was seen on his own in school, but there is minimal information about Brother D who was not seen alone as an intended appointment was overtaken by his remand into custody. 5.2.26. An Initial Assessment by its nature, cannot be a comprehensive assessment of all a family’s needs. It is effectively a step in a process to decide whether fuller information is needed and justified. The team manager described the need to process referrals quickly, with the work being fast paced and the volume high, with a “constant stream of new cases coming through the door”. Nevertheless, there was room for improvement here particularly in the need for a more analytical and questioning approach to the information that the family provided and to the concerns being raised by the Health Visitor. The assessment is heavily reliant on the mother’s description of 31 events, her assurance that she does not smoke cannabis near Younger Sister and that there will be no further problems in relation to supervising her. There is what can only be described as a level of naivety regarding what was originally described by the Police as ‘significant drug use’. The assessment states that the Mother is ‘honest about her drug use’ although there is no explanation as to how this has been evidenced or if it is possible to do so. It similarly lacks analysis as to the boys’ drug use relying on Child D’s assurance that he used to smoke cannabis but doesn’t any longer. 5.2.27. The capacity to manage the pressures of those teams in Children’s Social Care which act as the ‘front door’ for referrals and the first layer of assessment, is a significant challenge both locally and nationally, demanding a high level of practitioner skill and organisational support, which in practice can at times be difficult to achieve. Bristol Children’s Social Care has identified a number of developments that they consider have helped to improve the service provided at these key early points. This includes the First Response team taking on the role of information gathering and identifying any historical information before the request for assessment is passed to an allocated social worker. This is in recognition that initial information should be what directs the Social Worker as to where to ‘dig deeper’ and helps to identify patterns within individual and family behaviour. It has also since been recognised, and been identified in a previous SCR, that where ‘Working (Partnership) Agreements’ are put in place these need to be much more clearly linked to achievable goals that are understood and taken seriously by all concerned, including the implications if not adhered to. The Authority has also adapted Signs of Safety, a model for both assessment and intervention which the Review has been assured is beginning to evidence more critical thinking in assessment. It is in this context that the decision has been made that this Review will not offer a further recommendation regarding early assessment processes. 5.2.28. What has also been highlighted are some specific difficulties for Children’s Services in the assessment of risk. It is stated in the Initial Assessment that both Child D and Brother D need to refrain from violent behaviour and that they should work with services to achieve this, demonstrating a limited understanding of behaviour change and management of aggression. The assessment identifies that Brother D could be a risk to Younger Sister given the severity of the offence he has been charged with. However, there is no specific assessment of Brother D’s patterns of violence or his relationships within the home. In fact the only member of the family known to have been physically injured by Brother D was Child D. The risk that is felt to be posed by Brother D is managed by putting in place a Partnership Agreement that he will not have sole care of Younger Sister, something that will not in any event be monitored. 5.2.29. This episode identifies some important questions about the degree of experience within Children’s Social Care required to undertake risk assessment and risk management of this nature. This Assessment was signed off by a manager and as such was considered to have reached expected standards, although with hindsight the manager recognises that 32 the situation was more complex than had been understood at the time. Assessing the risk of future serious harm is a difficult task even when practitioners have specialist training and have access to good risk assessment tools. What has been highlighted is that there is a danger inherent for Child Protection Social Workers in undertaking risk assessments regarding the risk of future violence by an individual, unless it is clear they have the specific knowledge and tools to do so. The unintended consequence can be to provide reassurance that risk is understood and being managed, when that is not in fact the case. 5.2.30. There was evidence of good practice in liaison between the YOT and Children’s Services prior to the period covered by this Initial Assessment. However, what has been highlighted here, and recognised by the two services concerned, is that there was a gap in their joint working at the point when Brother D was remanded in custody and the Initial Assessment was taking place. Brother D was previously known to the YOT team and had been subject to formal risk assessments, which clearly identified that he posed some degree of risk. There was therefore a valuable opportunity here for CSC to benefit from the more specialist risk assessment skills of the YOT, but this opportunity was not recognised as such. 5.2.31. There also appeared to be some misconception by CSC that the YOT worker, who provided the initial information about Brother D being remanded in custody, had an ongoing role with Brother D, when in fact there was no actual role for the YOT at this time. When Brother D was released from custody after a few days, and therefore no longer defined as a Looked After Child, there was no further communication between YOT and CSC about him and as such no consideration as to which service, if either, might have a continuing role. It should be acknowledged that the statutory requirement to define and respond to a child as ‘Looked After’ whilst on remand, was a comparatively recent change to legislation and was not part of well-established practice. Given the brief period that Brother D was in custody, his status as a Looked After Child appeared to have been viewed as purely a formality, with the responsibility towards him coming to an end on his release. Whilst this was strictly true, what was missed here was a chance to consider his wider needs as a child, as well as the risks he presented following his release. 5.2.32. Whilst there are evidently established pathways for communication between Children’s Services and the YOT, the experience in this case highlights that there is nevertheless room for further strengthening of the working relationship. Whilst the statutory roles of each organisation are different, many young people will be known to both services. The advantages of further improving professional understanding of their different roles as well as potential for increased sharing of skills and knowledge has been recognised arising out of this Review and is subject to a recommendation. Recommendation 4. 5.2.33. Engagement: It is self-evident that when agencies identify that young people and their families may be in need of support and help they must 33 seek the involvement of those family members in order to meet these needs: ‘We define engagement here as the process by which a practitioner and a young person and/or their family connect in an authentic relationship, committed to achieving certain goals together. Such relationships can be considered the bedrock to effective practice, but they often appear to be missing when we review how young people have been supported.28 Despite the generally positive view of the Mother in this family, it is now evident that there often existed a disconnect between how services hoped the family would work with them, and to what degree the family were in reality prepared to engage with those services. Services too often were not set up to proactively seek engagement in that support would be offered, but without either a clear system or the capacity to work creatively to engage the family’s trust or interest in responding. The YOT was the one service which could to some degree require the co-operation of the family but, certainly in relation to Brother D, putting this into practice was more difficult to achieve. Comprehensive assessments were made by the YOT in relation to risk and plans outlined for what was needed to manage that risk. However, for the YOT worker whose role it was to put this into practice, the focus was in reality on achieving attendance and a basic level of engagement. 5.2.34 We have not been able to gain a really clear view of what, if anything, would have made a difference to the different family members’ willingness to engage with professionals. The Mother’s description of herself was of someone who could be quite hard to engage, and yet she also spoke very positively about the support she had gained over the years from some professionals. From listening to the Mother talking about those positive relationships there were some key qualities that made a difference: a straightforward, down to earth approach, professionals doing what they said they were going to do and having a realistic understanding of her life and experience. This Review considers that irrespective of what could or could not have been achieved in this case what it nevertheless highlights is the crucial importance of relationship building when working with families where there are both needs and challenges. 5.3. What does this case tell us about the effectiveness of safeguarding in relation to older children? 5.3.1. What is noticeable is that at times there was too little sense of Child D and his brother of being understood as children who might need a safeguarding or other protective response, in contrast for example to the clear view of their much younger sister who was always considered in terms of protection and vulnerability. The ‘perpetrator’ of violence was easily recognised as such, but there is less evidence that these two teenage boys were routinely recognised or responded to as having support needs or vulnerabilities. This lack of recognition of the dual aspect of the brothers’ needs and presenting risks would at times appear to have been as a result of individual professional’s judgements or assumptions. But more importantly it was reflected in the lack 28 Research in Practice (2014:26) 34 of accessible resources for adolescent boys, resources such as dedicated domestic abuse provision or accessible support after distressing life events. The Mother felt strongly that there were too few services for boys and that the closure of many local services in recent years, particularly the youth service was a real loss. 5.3.2. It was not the case that the Review identified that there were negative perceptions of either of the brothers or that their wider needs were never recognised. On the contrary Child D was almost always described in positive terms. Brother D seemed largely unknown to most professionals but those who did know him better, notably the YOT workers and college staff, whilst recognising that he could be challenging, nevertheless spoke of him non-judgementally, often with respect, and attempted to offer support as well as challenge. The response to Child D by the YOT when he identified problems arising out of events that had happened when he was younger, was very positive and showed a clear understanding that this was a vulnerable young person as well as one who had committed offences. It is also apparent that the college had in place good systems for providing support to the young people and was able to offer a high level of social and personal care. 5.3.3. It has been recognised for some time that adolescents who come to the notice of statutory agencies such as the Police, criminal justice agencies and Children’s Social Care can challenge those services’ established ways of working. A very high proportion of Serious Case Reviews relate to adolescents and as such have highlighted the ‘complexity and range of the risk factors facing teenagers’29. This review particularly draws attention to the need to develop a constructive practice model both with young men or boys who may not engage with services or who present risks to others as well as those who more obviously present as vulnerable. A recommendation has been made to consider this as a thematic strategic area for the SCB. Recommendation 5. 5.4 Concluding Remarks 5.4.1. Child D and his family in many ways were not identified as presenting a particular cause for concern to agencies and were not well known to those agencies. Whilst there were known to be incidents of violence in the home, some of which were referred to by services as ‘domestic abuse’, this generally remained little more than a label without an accompanying sense of curiosity about what it might mean or whether there might be a continuing cause for concern. Nevertheless, over a long period there were indicators for a number of services that this family might have needs, individually and collectively, which would benefit from further understanding and support. There were also times when better steps could have been taken to encourage the different members of the fam to engage with services in a way which they might have found helpful and to understand the nature of the risks within the family Whether the family would have welcomed such an approach is at least questionable, and other than in relation to one or two specific occasions, they would have been entitled to refuse to engage. 29 Ofsted 2011 35 5.4.2. In relation to the incidences of violence in the home, there was a basis for taking a more active approach with the family. Whether domestic abuse was or was not a feature in their lives, the level of risk that came with Brother D’s willingness to use violence, and in particular his willingness to use weapons, required greater understanding, more consideration of what was taking place in the family and a more proactive response. 5.4.3. The very understandable question was raised by Child D’s father as to why, having previously injured Child D with a knife, Brother D was allowed to return to the home. It has been clearly recognised in this Review that a different professional approach to understanding the family pressures was needed and other steps could have been considered. Yet, in the absence of a criminal charge and without real parental commitment to exclude Brother D in the long term, there was no basis for professionals to have required his removal from home. For a parent to exclude a child from their home, other than for a short period, is a profoundly difficult decision. It is very much a solution of last resort and in any event may not in itself lead to a reduction of risk. Clearly none of those concerned, professionals or family members believed that they were at this point. 5.4.4. The risk assessment undertaken by the YOT in relation to Brother D’s violence, suggests that it was related to situations in which he was frustrated or lost his temper, rather than being related to specific individuals and as such it would have been difficult to predict how and when it would be repeated. The evidence suggests that the family, particularly the Mother, genuinely believed that they could manage any risk themselves without the involvement of professionals, other than purely to deal with immediate points of conflict. Even if there had been a significant change in how the family situation was understood by professionals, it is unrealistic to conclude that there was a clear course of action that could have prevented what ultimately happened. 5.4.5. These events have nevertheless led to valuable learning in relation to work with families in the future. The primary lesson is without doubt the need to pay significantly more attention to forms of violence within the family that do not fit into familiar categories of domestic abuse. 6. RECOMMENDATIONS The approach of this Review has been to establish the key areas of new learning leading to a focussed number of recommendations that highlight significant aspects of the way the multi-agency systems can improve work both with domestic abuse and the safeguarding of children. Where there is evidence of agencies putting in place improvements in relation to identified areas for learning, these have been identified in the body of the report, but no recommendation put in place. Given that the Review has reflected on a significant period of time, it has identified a number of historical areas where safeguarding practice was not of the standard we would consider acceptable today, or where practice and standards have since changed and are judged differently. 36 One particular issue that has been repeated in different ways relates to gaps in the way agencies recognise and respond to the needs of young males who have expressed distress or trauma as a result of life events. Although it is recognised that this is not an area for complacency there have been some significant changes in practice, so for example, early sexual activity would now be considered a cause of concern and be subject to referrals on to specialist services. The recommendations are as follows: Recommendation 1: Avon and Somerset Constabulary should work with its partners within the Community Safety Partnership and Bristol Safeguarding Children Board to review the effectiveness of its Domestic Abuse Risk Assessment model and investigative practice regarding non-intimate partner abuse. Recommendation 2: The Community Safety Partnership and the Safeguarding Children Board should work with partners, including the Bristol Safeguarding Adults Board, to develop practice, knowledge and skills across agencies relating to non-intimate partner abuse and to consider whether there is a role for specialist services. Recommendation 3: The Community Safety Partnership and the Bristol Safeguarding Children Board should recommend to the Home Office that guidance, research and strategy relating to a broader spectrum of domestic abuse other than intimate partner abuse is developed nationally. Recommendation 4: Children’s Social Care and the Youth Offending Team to draw on the learning from this Review to identify ways to further develop their approach to, and arrangements for, joint working. Recommendation 5: The Bristol Safeguarding Children Board consider identifying working with adolescent boys as a thematic priority in its strategic plan. 37 APPENDIX A: PROCESS AND METHODOLOGY FOR THE REVIEW 1 Timescale for undertaking this Review. 1.1. The decision to undertake a combined review was made in August 2016. As is required, on 19th August 2016 the Department of Education was informed that the SCR was being commissioned as part of a joint review. On 16th August 2016 the Home Office was similarly informed. 1.2. The expectation for both a DHR and SCR is that reviews will be completed within a reasonable timescale and for a DHR that wherever possible this would be 6 months of the decision to undertake it. An open competitive process was followed in order to commission the independent lead reviewers as a result of which the first meeting to plan the Review took place in October 2016. Agreement then was required from the Home Office with regard to the methodology (see below) and this was received in December 2016. It is therefore acknowledged that it has not proved possible to meet the ideal timescale of 6 months. 1.3. The Review was jointly quality assured in August 2017 and subsequently received by a Joint Meeting of the Bristol Community Safety Partnership and the Bristol Safeguarding Children Board in September 2017. 1.4 The Draft report was submitted to the Home Office and considered by the Quality Assurance Panel in March 2018. Their feedback, published at section 7 of Appendix A of this report, was received in May 2018. The Panel’s feedback was considered by the report authors and a Joint Meeting of the Bristol Community Safety Partnership and the Bristol Safeguarding Children Board in June, where minor amendments to the report were agreed prior to publication. A small number of other additions were made to the report following the meeting with the Mother prior to publication. 2 Confidentiality The content and findings of this Review were strictly confidential during the Review process. Information provided was only available to the identified participating officers and professionals and their line managers until the Overview Report was approved for publication by the Home Office Quality Assurance Group and the Bristol Safeguarding Children Board. 3 Dissemination of the Report 3.1 On final completion the report will be sent to the following bodies: Bristol Safeguarding Children Board Bristol Community Safety Partnership 3.2 The following agencies will also receive copies of this report: Avon and Somerset Constabulary Bristol City Council Children and Families Service 38 Bristol City Council Housing Bristol City Council Education and Skills Bristol City Council Targeted Services Bristol Clinical Commissioning Group 4 Purpose and Terms of Reference for the Review 4.1. The purpose of the Domestic Homicide Review is to: a) establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims; b) identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; c) apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate; d) prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity; e) contribute to a better understanding of the nature of domestic violence and abuse; and f) highlight good practice. 4.2. The purpose of the Serious Case Review is outlined in Working Together as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together 2015, p74) 4.3. The guidance further identifies that SCRs should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 39 • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 4.4. It is not the role of either a DHR or a SCR to act as an inquiry into how the victim died, or who is culpable. These are matters for the Criminal and Coroners courts. Neither is it the Review’s role to initiate disciplinary or other employment procedures, as these remain the responsibility of the employing organisation. 4.5. Terms of Reference for the Joint Review were established as follows: a) Decide whether in all the circumstances at the time, any agency or individual intervention could have potentially prevented the death of Child D. b) Review current responsibilities, policies and practices in relation to victims of domestic abuse – to build up a picture of what should have happened to support the victim and review national best practice in respect of protection of individuals from domestic abuse. c) Consider whether there are issues of race, gender, religion, disability or other individual needs that were significant in the circumstances and how services responded. d) Examine the roles of the organisations involved in this case; the extent to which the victims or perpetrators had involvement with those agencies, and the appropriateness of single agency and partnership responses to the case to draw out the strengths and weaknesses and to assess whether there are any gaps in support. e) Establish whether there are lessons to be learnt from this case about the way in which organisations and partnerships carried out their responsibilities to safeguard the wellbeing of Child D and any other relevant others, within the immediate family unit. f) Identify clearly what those lessons are. g) Identify whether, as a result, there is a need for changes in organisational and/or partnership policy, procedures or practice in order to improve practice to better safeguard victims of domestic abuse. And consider A: What does this case tell us about the multi-agency response to domestic abuse in families in situations when this is not intimate partner abuse? Are agencies equipped to recognise potential adolescent to sibling or parent abuse and is the professional response effective? 40 How well do agencies recognise whole family working and the risks and needs of different family members, where there is domestic abuse taking place? How effective is the interface between the frameworks for children’s safeguarding and domestic abuse services? B What does this case tell us about the effectiveness of safeguarding in relation to older children? For safeguarding children does the age of the child impact on the response of agencies? How do professionals balance the older child’s need for autonomy with the duty to safeguard a child? C: What does this case tell us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria? How can professionals’ best gain an accurate understanding of a family who may be demonstrating multiple risk factors, e.g. early sexual activity of a child; drug and alcohol abuse, criminal activity. What role does community intelligence properly play in gaining this understanding? How effective is the single and multi-agency early intervention for families with multiple risks? Are the risks associated with young people using or carrying knives fully understood by all agencies? How do agencies understand the significance of non-resident fathers in the lives of young people and what is the impact for young people. How can professionals work with families who do not engage? 5 Methodology 5.1. The Review was led by Deborah Jeremiah and Sian Griffiths, both of whom are Independent Social Work Consultants and between them have significant experience in undertaking Serious Case Reviews and Domestic Homicide Reviews. The lead reviewers have previously worked together using a collaborative process to undertake a SCR and DHR regarding a family working together to identify the evidence and share analysis, but providing two separate reports. The report author, Sian Griffiths, has also previously authored a joint SCR and DHR. Both independent lead reviewers have undertaken Home Office DHR training. Both the independent lead reviewers are independent of the case and of all the agencies involved. 5.2. Whilst the underlying purpose and significant aspects of the approaches taken by DHRs and SCR’s have much in common, there are some differences and these have been accommodated within this joint review. The DHR statutory guidance requires a specific methodology, including the provision of Individual 41 Management Reviews by each agency involved. Previous statutory guidance in relation to SCRs took a similar approach, however since 2013 there is no longer a requirement for SCRs to use a specific model or to commission Individual Management Reviews. Instead, the guidance requires that case reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. The SCR guidance allows the use of any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro30. 5.3. A joint commissioning and scoping meeting took place with the Independent Reviewers, the Safer Bristol Crime Reduction Manager, the Bristol Safeguarding Children Board Manager and Children’s Services Safeguarding Service Manager. This meeting concluded that a joint Review, rather than two separate reviews would be the most effective and proportionate approach to adopt. The BSCB had previous experience of undertaking SCRs using systems methodology and it was agreed that this Review lent itself to such an approach. This was subsequently agreed with the Home Office and specifically it was agreed that the joint Review would not include the commissioning of Individual Management Reviews. The approach has been mindful throughout of the Home Office Guidance and incorporated the other key expectations of that guidance, including the use of a full chronology. 5.4. Whilst the Review was not conducted as a SCIE Learning Together Review, the Independent Reviewers who are both accredited in that approach, and would wish to acknowledge the significant impact their knowledge of SCIE Learning Together had in their design of the methodology. A ‘systems approach’ to learning recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it seeks to identify which factors in the work environment support good practice, and which create unsafe conditions in which poor practice is more likely. The purpose being to move beyond the individual case to a greater understanding of safeguarding practice more widely. A significant feature of the methodology was working in such a way as to minimise hindsight. 5.5. A Review Panel consisting of the Independent Reviewers and Senior representatives or Safeguarding Leads of the following agencies was established: 30 Working Together (2013:67) 42 Agency/Organisation Name Role Deborah Jeremiah Independent Lead Reviewer Sian Griffiths Independent Lead Reviewer Bristol City Council, Children’s Services Fiona Tudge Service Manager, Safeguarding and Quality Assurance Bristol City Council, Public Health Sue Moss Public Health Principal (Mental Health and Social Inclusion) Bristol City Council, Targeted Services Justine, Leyland Youth Offending Team, Manager Bristol City Council, Education and Skills Laura Gajdus Safeguarding in Education Team Manager Avon and Somerset Constabulary/Lighthouse Chris Parr Team Manager Avon and Somerset Constabulary Tamara Duddin Detective Sergeant, Safeguarding Unit Children’s Community Health Partnership Lindsey Mackintosh Designated Doctor for Safeguarding Children 5.6. The BSCB Business Manager and Project Support Officer supported and contributed to Review Team meetings as well as to the overall process of the Review. 5.7. Consideration was given at the outset, and reconsidered during the course of the Review, to inviting others who might bring a specialist knowledge, particularly in relation to Domestic Abuse, to be members of the Review team. No Domestic Abuse services had had direct contact with the family and the local relevant services were not able to provide a member of the Review Team. However, the Review Team included two members (Sue Moss and Chris Parr) with a specific remit relating to Domestic Abuse and the support of victims. The Review was also able to access other more specialist contributions during the Review, including from the IDVA. 5.8. The Review Panel met on 7 occasions, two further meetings took place jointly with relevant practitioners also present. 5.9. The Review began by gathering the necessary evidence included production of a multi-agency chronology involving all the services and agencies who had relevant contact with Child D and his family. All relevant voluntary sector and statutory agencies were contacted at the outset to check for any involvement with Child D and his family. As a result full chronologies were provided by the following agencies: Avon and Somerset Constabulary 43 Bristol City Council, Children’s Social Care (CSC) Bristol City Council Targeted Services (Youth Offending Team) Bristol City Council Education and Skills Bristol City Council, Housing Options Bristol City Council Housing Delivery Bristol Clinical Commissioning Group (for GP Practice) North Bristol Trust Hospital South Gloucestershire and Stroud College South Western Ambulance Service NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust 5.10. There then followed structured interviews led by the Independent Reviewers with the following 12 individuals who either had direct contact with the family or who were able to provide particular insights into their organisation’s practice Avon and Somerset Police, Police Constable Avon and Somerset Police, Designated Investigation Team officer Bristol City Council, Housing Manager Bristol City Council, Youth Offending Team workers (2) Bristol City Council, Children’s Services Social Worker Bristol City Council, Children’s Services Team Managers (2) General Practitioner South Gloucestershire and Stroud College, Learning Mentor North Bristol NHS Trust, A&E Consultant Independent Domestic Violence Advisor 5.11. The Review also had access to a range of primary documentation including: Statements collated by Avon and Somerset Constabulary in relation to the criminal prosecution for murder in 2016. Post Mortem Report Children’s Social Care – various records and assessments Youth Offending Team – various records and assessments Bristol Clinical Commissioning Group Overview Report regarding GP practice Health Visitor records. 5.12. The professionals who had taken part in individual interviews were then invited to attend a practitioners’ event alongside a small number of other professionals who were believed to have additional useful information to contribute. The purpose of the event was both to check the accuracy of the information that had been collated by the lead reviewers and also to contribute to the analysis and learning. 44 6 Involvement of Child D’s Family and Friends. 6.1. As is established practice in both SCRs and DHRs, Child D’s closest family members were identified as far as this was possible at the outset. Letters were sent to them in November 2016 informing them of the decision to undertake the Joint Review and they were provided with information about the Review and leaflets regarding specialist support. It was agreed that the initial family members who would be invited to contribute, including contributing to the Terms of Reference, would be Child D’s mother and father. Both parents were subsequently contacted again in January 2017 on behalf of the Review Team, by the Police Family Liaison Officer. At this point Child D’s mother declined to be involved. 6.2. Child D’s his father agreed to meet with the lead reviewers in March 2017 and his contribution is included in the report. In line with the requirements of the DHR, arrangements were also made for Child D’s father to meet with one of the Lead Reviewers and the Safeguarding Board Business Manager to read the report before it was finalised and sent to the Home Office for Quality Assurance. 6.3. It was also agreed that the Independent Reviewers would contact Brother D to ask if he would wish to contribute and a letter was delivered to him in prison by the Probation Service in January 2017. Brother D’s Offender Manager in the community spoke to Brother D, who did not feel able to contribute at that time, but he did not exclude the possibility of doing so in the future. After a period of time the Independent Reviewers again arranged for the Brother D’s Offender manager in the prison to speak to him, but he still felt unable to contribute and did not wish to read the report in advance of publication. 6.4. The absence of the family’s voice in this Review was felt to represent a significant gap and in April 2017, Brother D’s Offender Manager was asked to speak to Mother again to see if she would now be willing to speak to one of the Independent Reviewers. Child D’s mother considered this and spoke to Sian Griffiths on the phone, but she felt that her focus was at this point on supporting Brother D and as such she still did not wish to take part in the Review. She also stated that Brother D was not at a point where he would want to contribute. The Mother agreed that the Independent Reviewer could contact her again by text later in the process. 6.5. In July 2017 the Independent Reviewer again contacted Child D’s Mother, but she still did not wish to take part. Nevertheless, she agreed that she could be contacted when the Review was in a near final draft for an opportunity to read the Review and make any contributions at that stage. The Independent Reviewer as agreed again made contact by text with the Mother at this stage and there followed a telephone conversation after which the Mother decided she would like to meet, both to contribute to the report and to read the draft. However, she later decided she did not feel able to meet, but would inform the Reviewer how she wanted her children to be referred to in the report. Whilst there continued to be contact by text and phone between the Mother and the Independent Reviewer, the Mother did not in the event identify the names she 45 would want to be used. The Lead Reviewer wrote to her at the point of sending the report to the Home Office for Quality Assurance, informing her of the process and confirming that at any point prior to publication it would be possible to meet. 6.6. Following the Home Office Quality Assurance process and prior to publication the Mother was contacted again and met with the Author and Board Manager to discuss the report. The Mother did not wish to read the report in full prior to publication. 6.7. The Review had also identified that other than the parents and Brother D, there were other close individuals who might wish to contribute. Letters were therefore sent to Child D’s older brother and sister, his girlfriend and one of his friends who had been identified by services, as well as to Brother D’s Father. Letters to Child D’s girlfriend and friend were delivered personally by the Police Family Liaison Officer who also spoke to Brother D’s father. Whilst initially both Child D’s girlfriend and Brother D’s father each considered they might be willing to take part, both subsequently declined. 6.8. Information about the publication date for the report was shared with all the identified family members. 46 7. Home Office Quality Assurance Panel Feedback. 47 48 BIBLIOGRAPHY Bristol City Council: Substance Misuse Commissioning Strategy 2017 Bristol City Council: Thresholds guidance: https://www.bristol.gov.uk/documents/20182/34452/FinalThresholdsguidanceFebruary2014.pdf/a38fc4c0-3d82-4869-9e0f-97bc33ce9e60 Centre for Crime and Justice Studies (CCJS) (2007): ‘Knife Crime’ A review of evidence and policy CPS (2014): The prosecution of domestic violence cases Health and Social Care Information Centre (HSCIC): July 2016 Statistics on drug misuse. Her Majesty’s Inspectorate of Constabulary (HMIC) 2014: Avon and Somerset Constabulary’s approach to tackling domestic abuse. HM Govt: (March 2015) : Working together to safeguard children Home Office (2015): Information guide: adolescent to parent violence and abuse (APVA) Home Office (Dec 2016) Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews. Johnson, M (2008): A Typology of Domestic Violence OFSTED (2011): Ages of Concern Research in Practice (2014:26) That Difficult Age: Developing a more effective response to risk in adolescence Safer Bristol (2012): Prevalence of drug use among black and minority Ethnic Communities in Bristol SafeLives (undated): Getting it Right First Time. http://www.safelives.org.uk/policy-evidence/getting-it-right-first-time Smith, Williams and Mullane (2014): Domestic Abuse, Homicide and Gender Stanley, N & Humphreys, C: Domestic Violence and Protecting Children, (2015) |
NC52349 | Grooming and sexual abuse of an adolescent girl over many years. The abuser was sentenced to 26 years in prison, made subject of a lifetime Sexual Harm Prevention Order and will be on the sex offenders register for life. At the time of the abuse, Kate was aged 11-16-years-old and in receipt of health and social care interventions due to concerns regarding her welfare. Learning includes: initial response from specialist services did not take into account Kate's high level of distress or work in a coordinated way with universal services to address identified risks associated with the reports of parental neglect; insufficient weight was given to the voice of the child and concerns raised by her family members; the decision to refer Kate for a Youth Intervention for wasting police time was not consistent with national guidance at the time; practitioners were aware of the potential risk indicators of sexual abuse and recognised how her mother's neglect and Kate's isolation increased this risk, their response to the identified concerns was wholly inadequate. Makes a number of recommendations in relation to policy, assurance and workforce development and awareness raising including: update multi-agency procedures to ensure greater focus on pursuing perpetrators; explicit references to statutory thresholds for investigations and legal remedies and the burden of proof or use of collaborative third-party information; undertake an audit/review of the police decision making in respect of the out of court disposal for wasting police time and consider expunging Kate's record; ensure that the Police and Youth Offender Services have reviewed records of other known victims of grooming and sexual abuse and rectified these accordingly.
| Title: Report of the serious case review regarding Child D. LSCB: Surrey Safeguarding Children Board Author: Fiona Bateman Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Surrey Safeguarding Children Board Report of the Serious Case Review regarding Child D Prepared by Fiona Bateman (Independent Reviewer) in collaboration with ‘Kate’ March 2020 2 Executive Summary Background and Incident In October 2019 the LSCP commissioned a review into the serious harm of a child [known as ‘Kate’ within this review] following the conviction of her abuser in 2018 for numerous sexual and violent offences. Whilst the abuse was uncovered and prosecuted in the North of England, the majority of offences took place when Kate was aged 11-16, living in the Home Counties and in receipt of health and social care interventions due to concerns regarding her welfare. The period under review is from June 2013, when concerns about Kate’s welfare arose, to 2017 when her abuser was arrested and prosecuted. The review was asked to consider how well agencies worked together to support Kate and her family in 2013 and respond to concerns raised regarding Kate’s emotional and physical safety, particularly in relation to grooming and sexual abuse. Terms of Reference in Brief The report seeks to respond to the following questions 1. Did agencies work well together to offer appropriate support following Kate’s bereavement? 2. Did practitioners respond appropriately (namely, in accordance with relevant statutory guidance) to concerns raised regarding Kate’s emotional and physical safety, particularly in relation to grooming and sexual abuse? 3. How robust was the Child Protection process, including whilst Kate was subject to a Child Protection Plan and Missing and Exploited Children’s Conference, in identifying and addressing the risk of emotional and physical safety and sexual exploitation? 4. What is needed to improve future practice and ensure effective inventions to protect young people at risk from people in positions of trust? Summary of Findings The initial response from specialist services did not take into account Kate’s high level of distress or work in a coordinated way with universal services to address identified risks associated with the reports of parental neglect and the impact this was having to address Kate’s needs. Too much reliance was placed on onward referrals without checking those agencies were able to support Kate and her mother, or indeed whether her mother would comply. No expectations were set by CSC for Kate’s mother to change behaviours so as to meet Kate’s basic needs. No exploration was made of the triggers for Kate’s self-harming behaviours; had this been explored in line with the principles and parameters of a good assessment, Kate confirmed during conversations with the reviewer, it is highly likely she would have disclosed CD was already sexually abusing her. The investigation in 2013 into grooming and abuse by CD was not sufficiently robust given what was known of the likely presentations at the time. Information was not shared appropriately between agencies or with Kate and her wider family, despite the significant role they were given to act in a protective capacity. Insufficient weight was given to the 3 voice of the child and concerns raised by her family members. The decision to refer Kate for a Youth Intervention for wasting police time was not consistent with national guidance in force at the time. Practitioners were aware of the potential risk indicators of sexual abuse and recognised how her mother’s neglect and Kate’s isolation increased this risk. Their response to the identified concerns was wholly inadequate. Despite a high number of professionals and all key agencies having been informed of the risk, coordination was severely lacking. Information was not gathered in a way that facilitated effective shared risk assessment or managed to reduce or prevent abuse. There were too many handovers with little or no follow up to ensure that those receiving referrals had the information or skills to support Kate. Information was not gathered in a way that facilitated effective shared risk assessment or managed to reduce or prevent abuse. There were too many handovers with little or no follow up to ensure that those receiving referrals had the information or skills to support Kate. Summary of recommendations The purpose of any serious case review is not to replicate civil or criminal processes or to apportion blame, but to learn lessons and make recommendations to improve practice, procedures and systems and ultimately to improve the safeguarding and wellbeing of children and young people in the future. Findings and recommendations from this review are not intended to dilute or deflect culpability for the harm caused to Kate from both the neglect and sexual abuse she suffered whilst a child. Policy 1. The LSCP update their multi-agency procedures to ensure greater focus on pursuing perpetrators, explicit references to statutory thresholds for investigations and legal remedies (including all civil and criminal orders) and the burden of proof or use of collaborative third-party information. 2. The LSCP may wish to include guidance to child protection practitioners on accessing advice from agencies with expertise in the management of offending behaviours on possible risk reduction measures. Assurance 3. LCSP conduct an audit/ review of the police decision making in respect of the out of court disposal for wasting police time should be undertaken and consideration given to expunging Kate’s record. 4. The LSCP should seek assurance that the Police and Youth Offender Services have reviewed records of other known victims of grooming and sexual abuse and rectified these accordingly. 5. The LSCP should seek assurances that social workers, CP conference chairs and police officers involved in child protection duties have received training and apply relevant guidance when interviewing children and young people, potential witnesses (including 4 family members) and alleged perpetrators where there is a risk of grooming and sexual abuse. 6. The LSCP seek assurance that universal services and CSC practitioners are routinely utilising the Graded Care Profile2, or similar practice tools and the CE risks assessment toolkit to measure and monitor parental/ carer capacity to recognise and respond to risk of sexual abuse, neglect and parental substance misuse. 7. The LSCP establish mechanisms to monitor tracking of cases that are stepped down from PLO pre-proceedings work and those removed from CP and CIN processes where risks include sexual abuse, substance misuse and/or neglect. 8. LSCP monitor arrangements for cross boundary information sharing and outcomes of LADO investigations, particularly where this indicates a Barring referral should have been made to the DBS service. 9. The LSCP seek assurances from health providers and commissioners that trauma informed therapeutic support is available locally to young people (including those over 18 who experienced abuse as children) and their extended family. 10. The LSCB disseminate to relevant agencies and seek assurance staff, including designated safeguarding leads in schools, school nursing service, voluntary and charity sector organisations received a briefing on this review and have identified ways to improve practice. Workforce development and awareness raising 11. LSCP should consider a multi-agency practitioners’ workshop or skills-based programme to enhance shared understanding of the legal framework available to disrupt perpetrators and protect children at risk of sexual abuse. 12. LSCP to raise awareness of the Office for Civil Society’s and NCVO’s on-line resources for organisations and charities providing services to children and adults at risk to ensure safer recruitment practices and effective safeguarding investigations. 5 Supporting victims of Grooming and Sexual Abuse by People in Positions of Trust: Report into the Serious Case Review for a Local Children Safeguarding Partnership [‘LSCP’] In October 2019 the LSCP commissioned a review1 into the serious harm of a child [known as ‘Kate’ within this review] following the conviction of her abuser2 in 2018 for numerous sexual and violent offences. Her abuser was sentenced to 26 years in prison, he was also made subject of a lifetime Sexual Harm Prevention Order and will be on the sex offenders register for life. Whilst the abuse was uncovered and prosecuted in the North of England, the majority of offences took place when Kate was aged 11-16, living in the Home Counties and in receipt of health and social care interventions due to concerns regarding her welfare. The period under review is from June 2013, when concerns about Kate’s welfare arose, to 2017 when her abuser was arrested and prosecuted. The review was asked to consider how well agencies worked together to support Kate and her family in 2013 and respond to concerns raised regarding Kate’s emotional and physical safety, particularly in relation to grooming and sexual abuse. In addition, the review will explore what the barriers were to implementing effective protection through the Child in Need, Child Protection and Missing and Exploited Children’s Conference processes, including the handover when Kate moved away from the area. The review has also explored3 what is needed to improve future practice and ensure effective interventions to protect young people at risk from people in positions of trust [‘PiPoT’]. The LSCP and reviewer are extremely grateful that Kate was willing to contribute to the review. She has shown immense courage in doing so. At her request, specific members of her extended family have also assisted. Out of respect for Kate’s wishes, Kate’s mother has not been involved in this review. The perpetrator in this case has, since his conviction, made continued attempts to contact Kate; these have mostly been intercepted but, given the apparent lack of insight into the possible impact of his behaviours, no attempts have been made to include him within this review. Those commissioning this review were keen to stress the importance of the ‘voice of the child’ in identifying and understanding the risk of sexual abuse and asked that particular focus be given to how well practitioners worked together to understand what life was like for Kate. Since 1992 the UN Convention of the Right of the Child has been in force in the UK. This convention requires state bodies protect specific rights of a child to be heard (article 12) and to ensure laws and systems are designed to ensure every child can develop to their full potential (article 4 and 6) including by living free of violence, abuse and neglect (article 19) and sexual exploitation (article 34). It is easy to see how statutory child protection duties4 are shaped by these obligations, but the status of this convention means that these responsibilities should also shape decision making by all relevant practitioners working across universal services5 and child protection agencies so that they actively protect children from harm. This is the context within which practitioners should work to secure the ‘voice of the child’; doing so enables everyone involved in promoting a child’s safe development to reflect very carefully on the underlying purpose of their relevant responsibilities and how their role fortifies statutory child protection duties. 1 In accordance with reg 11. of the Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018. The name of the child and LSCP has been redacted in line with Kate’s wishes for anonymity. 2 In order to retain Kate’s anonymity her abuser will be referred to as ‘her abuser’ or CD throughout the document. 3 With input from some of the practitioners who were directly involved in the case and senior leaders now responsible for supporting frontline practitioners. 4 Specifically the duties for the local authority to lead any investigation into concerns (s47 Children Act) and to cooperate with wider statutory partners (s11 Children Act) including the police where there is reasonable cause to suspect criminal offences may be committed. 5 The term ‘universal services’ is used to describe services available to all children, such as schools, health visiting and GPs. https://www.scie.org.uk/publications/introductionto/childrenssocialcare/furtherinformation.asp 6 1. Did agencies work well together to offer appropriate support following Kate’s bereavement? 1.1 Kate first came to the attention of the Local Authority’s Children Social Care Services [‘CSC’] in early Summer 2013 when concerns were raised by her school and GP that Kate had shown signs of physical/ psychological pain, including self-harming behaviours following the death of her father that year. She was 12. Her GP, extended family members and Kate herself raised concerns about her mother’s alcohol use and the impact this was having on her ability to provide basic care to Kate. In addition, her family members had raised concerns, including to Kate’s parents, regarding the level of unsupervised contact she was having with ‘CD’ (the man subsequently convicted of sexual abuse). Prior to making the referral, her school had invited Kate’s mother and wider family members to a meeting to agree a plan of support to protect Kate. CD attended this meeting and when challenged by Kate’s uncle, claimed to be supporting Kate’s mother. Shortly after her uncle challenged CD, Kate confirmed she was told by him to make allegations against her uncle. She reported to her teacher she did not wish to stay with her uncle, as he had followed her to the bathroom. This information was reported within the referral to CSC, but not further explored. Kate confirmed as part of this review that all the allegations she made against wider family members were done because her abuser had told her what to say and threatened to hurt her or destroy items of her father’s if she didn’t. 1.2 Initially no additional support was offered; both Child and Adolescent Mental health Services [‘CAMHS’] and CSC advised the GP and school to support Kate through bereavement counselling services. School staff and her GP persevered, referring Kate’s mother for specialist intervention from alcohol abuse support services (initially unsuccessfully due to her mother’s lack of engagement) and resubmitting further referrals in July to CSC and CAMHS reporting concerns by family members to continued incidents of significant self-harm and reports by Kate that she had suicidal thoughts. CSC, satisfied that CAMHS intended to offer an assessment but without having spoken to Kate or her mother, took no further action. At this time CD contacted CSC, explaining that he was the designated safeguarding lead for a voluntary youth organisation Kate attended and knew the family in a personal capacity. He requested information about the extent of CSC’s investigation. CSC rightly advised that he seek information directly from Kate’s mother. 1.3 At this time, Kate was also interviewed by the Police as a victim of contact sexual abuse by a Person in Position of Trust in 2007/8. Following the police investigation no action was taken. It isn’t clear whether this information was available to CSC, but would likely have been if more detailed enquiries were undertaken at the time of the initial referrals. 1.4 In August 2013 the GP wrote again to CAMHS requesting an urgent appointment as Kate had taken an overdose. An initial appointment was offered 10 days later and Kate and her mother attended. Kate disclosed she had intended to end her life, that she was bullied at school, was arguing with her mother and felt she ‘wouldn’t be missed’. An internal review of the case notes reported Kate wasn’t asked if she had experienced ‘physical, sexual or emotional abuse at any time in her life’ despite this being a key question within an initial appointment. By September 2013 CAMHS ceased their involvement (despite a failure by Kate’s mother to attend a follow up appointment) reporting back to her GP that they had made a referral for bereavement support. 1.5 By 2013 much was already known of the likely presentations and impact of child abuse, as well as barriers that prevent children reporting abuse, especially sexual abuse. Thematic reviews already published by this time identified common barriers to effective child safeguarding.6 These 6 Broadhurst et al, (2010) ‘Ten pit falls and how to avoid them: What research tells us’ NSPCC available at: https://www.nspcc.org.uk/globalassets/documents/research-reports/10-pitfalls-initial-assessments-report.pdf highlights ‘it is imperative 7 highlight the critical importance for practitioners to not focus only on the most visible or pressing problem but to also pay attention to what children say, how they look and how they behave. It also warns against placing insufficient weight on information given from family, friends and neighbours. The report identified a dilution of responsibility in the context of multi-agency working; cautioning child protection agencies not to simply signpost to other agencies with no follow up. The relevant Council’s Early Help Strategy from this time identified young carers, children experiencing parental and family issues and those living with parental substance misuse among those requiring ‘support from children and families before problems escalate and reach crisis’.7 All of these issues were pertinent to Kate and, under the Council’s ‘multi-agency levels of need document’8 would have required at least a level 3 targeted and timely intervention, namely consultation and advice from a specialist service following an early help assessment. Finding: The initial response from specialist services did not take into account Kate’s high level of distress or work in a coordinated way with universal services to address identified risks associated with the reports of parental neglect and the impact this was having to address Kate’s needs. Too much reliance was placed on onward referrals without checking those agencies were able to support Kate and her mother, or indeed whether her mother would comply. No expectations were set by CSC for Kate’s mother to change behaviours so as to meet Kate’s basic needs. No exploration was made of the triggers for Kate’s self-harming behaviours; had this been explored in line with the principles and parameters of a good assessment9, Kate confirmed during conversations with the reviewer, it is highly likely she would have disclosed CD was already sexually abusing her. 2. Did practitioners respond appropriately (namely, in accordance with relevant statutory guidance) to concerns raised regarding Kate’s emotional and physical safety, particularly in relation to grooming and sexual abuse? 2.1 In November 2013 CSC did agree to ‘open a case’ following disclosure by Kate of parental ill treatment and neglect. Shortly afterwards Kate also disclosed to school staff she had suffered multiple rapes including as a young child. She described the most recent attack having occurred a few weeks beforehand. She also disclosed to school staff that she thought she was pregnant and was experiencing pain. This prompted an immediate joint investigation between the police and CSC under s47 Children Act 1989, including a police interview in line with ‘Achieving Best Evidence’ guidance and a medical examination. The clinician carrying out the medical examination commented: ‘although no abnormalities had been found this does not rule out the possibility of sexual assault having occurred as research show us that physical examination is very often normal even though there has been very clear documented penetration of both the vagina and anus. [‘Kate’] is clearly a distressed young lady who appears quite unhappy and this may be her way of trying to tell us something of a sexual nature has occurred but she is finding it hard to tell us the exact detail.’ when making initial assessments that practitioners take time to see, speak to and observe children (Glaser, 2009) … Moreover, seeing the child in the early stages of work must equate to more than just “ticking a box” and should constitute a detailed qualitative observation (Aldgate et al, 2006). Hart and Powell (2006) stated that a case file should give “a real sense of the day-to-day experiences” of the child. The practitioner should be able to picture what life is like for particular children in their families.’ 7 Early Help Strategy 2013-17, Surrey County Council available at: https://www.surreycc.gov.uk/__data/assets/pdf_file/0011/27200/Early-help-strategy-2013-2017-FINAL-updated-template.pdf 8 Launched in Spring 2013 and available at: https://www.whatdotheyknow.com/request/212709/response/529444/attach/4/11014%20Annex%201%20Levels%20of%20Need%20Document%20v%203.0%201.pdf 9 Working Together to safeguard Children, HM Government, 2013 (accessed 29.01.20 at: https://webarchive.nationalarchives.gov.uk/20130403204422/https://www.education.gov.uk/publications/eOrderingDownload/Working%20Together%202013.pdf 8 2.2 Sommers review10 highlights that visual forensic examination following a sexual assault rarely identifies genital injury. In some studies as few as 5.2% of victims had detectable gynaecological injuries. It is therefore crucial that child protection practitioners (particularly the police and social care) understand that a lack of injury does not rule out sexual abuse or child sexual exploitation and they do not put too much reliance on forensic examinations as the sole source of evidence. Clear guidance11 is available for practitioners on the approach to take when investigating concerns regarding sexual abuse. 2.3 In conversations with the reviewer Kate expressed surprise that the examination had not found evidence of sexual activity. She confirmed that by this time CD had been sexually abusing her for some time. She spoke of the high level of intimidation she endured during this period, including direct threats by him to hurt her, the way he undermined her memory of her father and the coercion he employed to disrupt her relationships with extended family members by undermining their trust in her. She also recalled he would wait in his car and intercept her on her way to school. Kate confirmed within this review that the evening before she made the allegations, she had been raped12 by him. He had texted her later that evening and, when she had not replied, he had waited for her early the next morning at the bus stop in his car and told her what she needed to say to deflect attention from him. She explained he drove her around and only let her out of his car to go to school when she agreed to act as he’d instructed. 2.4 Kate explained that she agreed to an internal examination understanding that it would provide evidence that she was being abused. She was aware he followed her to that examination and explained during conversations with the reviewer how frightened she was of repercussions from him, but also relieved. She believed this would be a turning point, because everyone would know she was being abused and so what happened next would be out of her hands. So when nothing happened, the results of the tests were not reported back and an investigation wasn’t taken forward, she lost faith that she would be protected from his abuse. 2.5 Two days later Kate was admitted into hospital having taken an overdose and collapsing at school. During the review Kate explained she felt it was the only way to get away from the abuse. Following a request by the treating psychotherapist, CSC agreed to complete a joint assessment. The psychotherapist who supported Kate during this period did contribute to this review and spoke of a clear sense from Kate of a child in notable distress who ‘did not feel believed’. Her case notes from late 2013 describe having to reassure Kate, because her earlier experiences in summer 2013 were of services having ‘walked away’. 2.6 Early within the police investigation into the rape allegations, officers separately formally record safeguarding concerns regarding contact between Kate and CD. This was prompted when the allocated social worker shared concerns with the police that he had again contacted CSC for information in respect of the investigation on hearing that Kate had been admitted into hospital. In response the police considered whether Kate was at risk of sexual harm from him. This consisted of carrying out checks of police records in respect of CD and seizing Kate’s phone. His phone was not reviewed and nor was he interviewed. The allocated social worker did challenged CD, asking if he felt it was ‘appropriate to be texting a 12 year old girl’.13 Notification was made to the Local Authority Designated Officer [‘LADO’] to carry out enquiries, but these concerns were not escalated to senior managers, nor did the social worker request advice from legal 10 Published as ‘Trauma Violence Abuse, 2007 Jul; 8(3): 270-280 and accessed on the 03.03.20 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142744/) 11 For example, https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/child-sexual-exploitation/ 12 A person commits rape if they intentionally have penetrative sex and the other person is under 13 [s5 Sexual Offences Act 2003] 13 Taken for combined case notes submitted for the review 9 services regarding when child protection processes, including formal legal steps under the Public Law Outline, should be instigated. 2.7 Case records demonstrate that Kate’s extended family also alerted the investigating police officer of their concerns that Kate was at risk from CD and notified police that, despite the confiscation of her phone, she had remained in contact with him through social media platforms. At the same time, her paternal uncle wrote to the strategic Director of CSC confirming that ‘until very recently she was still in contact with a male third party who we strongly believe should be the subject of other police / other agency investigations. To what is extent is this contact with this person being monitored? She was recently travelling very early in the morning to an unknown destination before going onto school and this has caused us great concerns. ’14 In response they were advised that information could not be shared without consent, but that as Kate had provide consent, the allocated social worker would be in touch. There is no evidence on the case records that this was followed up directly or used by the social worker to inform any risk assessment or investigation plan. 2.8 Research published by the NSPCC during this period warned against professional bias in respect of ‘troubled children’, of the unlikelihood that a young person would disclose sexual exploitation or abuse due to fear and/or loyalty to the perpetrator, lack of understanding they were being abused and lack of trust or fear of authorities. It also reported that ‘too often, even when young people do disclose abuse, no actions are taken by agencies against perpetrators or to support young people and the abuse continues.’15 2.9 The LADO commenced an investigation, obtaining the voluntary youth organisation’s child protection policy and was advised by the allocated social worker that Kate had disclosed CD had placed a tracker on her phone so he knew where she was. A multi-agency meeting on the 20.12.13 was attended by the voluntary organisation, who agreed to consider suspending CD and his partner pending an investigation and, if this resulted in their dismissal, agreeing to make a referral to DBS in line with their legal obligations.16 2.10 Kate was discharged from hospital on 22.11.13 to her maternal aunt’s care and continued to receive support from CAMHS, including a re-referral to the bereavement service, as well as liaison between that service, her GP and school nurse.17 Kate reported feeling significant distress, she told staff supporting her that she continued to experience bullying at school, missed contact with friends from the youth group through which she had met CD and that her mother’s drinking remained problematic. She was re-admitted for one night on the 17.12.13 due to suicidal ideation and self-harming (lacerations to her arm, abdomen and upper thigh) and reported to CAMHs staff she did this as she was angry that her aunt had disclosed that CD “had forced himself on her and that police would be interviewing her on the new year”. CSC and CAMHs staff did discuss this further disclosure, but only in relation as to whether the police had been informed. Neither believed it had, yet neither considered notifying the police because ‘social services were investigating’.18 This disclosure was also not passed to the LADO undertaking the investigation. Her aunt asked directly for information about the investigation into CD, but was advised to remain vigilant and to prioritise keeping Kate safe. This was a in 14 Extract taken from letter provided by family 15 Child sexual exploitation: learning from case reviews, NSPCC, November 2013 16 The Safeguarding and Vulnerable Groups Act 2006 sets out the duty to refer (s35) and that failure to do so, without reasonable excuse, is a criminal offence (s38). 17 A referral was also made to a specialist Sexual Trauma and Recovery Service, but was unsuccessful because she was in receipt of treatment from CAMHS. 18 Taken from clinical notes 10 breach of the expected standards of enquiry and information sharing as set out in ‘Working Together’ guidance and the Council’s local child protection policies. 2.11 By 2013 much was understood of the strategies used by adult perpetrators of child sexual abuse to target, isolate, groom and abuse children. Published case reviews had already urged practitioners to take into account the contextual circumstances and impact of neglect on children and young people which can make perpetrator strategies easier to carry out and more difficult to detect. Finkelhor’s research had identified a four pre-conditions model of child sexual abuse19 namely, that once a perpetrator is motivated to abuse (step 1) s/he must overcome internal inhibitions (step 2) and external constraints (step 3) to abuse and finally overcoming the child’s own resistance to abuse (step 4). There is no evidence that practitioners working to investigate and support Kate at this time understood this model or suggested techniques to assist Kate, her wider family or the voluntary sector organisation’s leaders to put in place effective strategies to frustrate this abuse. 2.12 On the 22.12.13 Kate contacted the police to complain she didn’t feel safe with her aunt, who had confiscated a new mobile phone she had acquired. CSC and police later reported suspicions this had been provided to Kate by CD and police records report there ‘were two text messages on it which appear to be [Kate] conspiring with another to provide a false explanation to cover any positive results of the forensic examination.’ Examination of her original mobile, provided evidence of contact conducted in ‘veiled speech’ between CD and Kate, but police records record ‘nothing of an obvious grooming/sexual nature.’20 2.13 Kate’s complaint prompted the investigating police officer to visit her on the 22.12.13 during which she was notified they ‘could find no evidence to support the rape allegations’. Kate retracted the allegations of rape, but confirmed during that meeting that she and CD remained in contact as she felt she could talk to him. Case notes simply report that Kate was advised not to have any more contact with CD, but no guidance was given to her or her extended family on the legal actions they could take to prevent contact. It also doesn’t appear that Kate was told about any actions taken to investigate CD’s behaviour. 2.14 Police records report that the LADO had confirmed that CD had acted in breach of the voluntary agency’s child protection policy by allowing her to stay at his address and that he (and his partner) had been suspended pending further investigation. Police recorded continued concern that CD remained in contact with Kate via ‘covert’ phones he was suspected of providing. Kate’s family were advised by the police to write to CD to ask him to stop contacting her and it was agreed this would be served on him by an officer from the Offender management unit. This was done early in 2014, at which time officers also ‘unfriended’ and blocked Kate’s known number from CD and his wife’s phone and advised they write to Kate’s mother to request Kate did not make any contact. They were also advised to drop off any of Kate’s belongings to the police station. Kate and her mother collected these and CD’s letter to Kate later that week; they were again advised not to make contact. 2.15 On the 30.12.13 Kate and her aunt informed CAMHS staff that CD had threatened Kate that he would hurt her or destroy belongs left to her by her father, if she did not make the allegations to the police against her extended family. There is no evidence that CAMHs passed this information to police or CSC. Instead it appears it was left for Kate or her extended family to 19 As detailed in ‘Steps towards Prevention- ECSA toolkit’ published by Lucy Faithful Foundation at: https://ecsa.lucyfaithfull.org/sites/default/files/attachments/Steps%20towards%20prevention.pdf 20 Taken from police case notes 11 report to the police when Kate had clearly articulated having been in fear of him only a week beforehand. 2.16 In a home visit in early January Kate confirmed she was feeling ‘a little better’ now contact with CD had stopped and felt able to disclose CD’s intimidating behaviour to her aunt. On 08.01.14 Kate’s maternal aunt emailed the investigating officer, reporting Kate had confirmed to her that ‘[CD] supplied the text for the two unpleasant emails you have been forwarded and that she copied them out because she is afraid of him and is scared that he will hurt her.’ She reiterated her fears that Kate continued to be controlled by him. In response the officer confirmed CD had been warned not to have contact and that the investigation was concluded as there were ‘no tangible proof’ of a crime.21 It should be noted that under the Protection from Harassment Act 1997 a person commits a criminal offence if they pursue a ‘course of conduct that causes another to fear, on at least two occasions, violence will be used against them’. Whilst a report by Kate’s aunt could arguably have been considered as ‘hearsay evidence’ and may have been inadmissible within a criminal trial22 this did not prevent the officer from carrying out further enquiries in response to new information. ACPO and CPS guidance23 available to officers at the time, made clear special considerations should be given where disclosures may suggest a risk of child sexual abuse. Had this guidance been applied, this information should have triggered further investigation. Furthermore, there is no evidence within the case records that consideration was given by the police to applying or supporting Kate and her family to apply for civil orders to prevent future contact. 2.17 The criminal investigation was instead concluded as ‘no crime’ with a recommendation that Kate ‘should be referred to ACT24 for her over-sexualised thoughts’ and ‘a referral was made to the YIT for wasting police time.’ This was subsequently recorded against the allegations made of ‘rape against the football club chairman’25 It should be noted that Kate had never made an allegation of rape against the club chairman; she had only given information in respect of this when approached by the police, having been identified by another victim as someone who had also experienced a sexual contact offence in 2007/8. Subsequently the Youth Support Officer assigned the disposal raised a query as to whether Kate had been notified, as relevant paperwork hadn’t been completed fully. Kate attended all YRI sessions, but was not aware (until conversations during this review) that this out of court disposal may remain on her police records. 2.18 According to relevant guidance26 prosecution of an offence for wasting police time would need consent of the Director of Public Prosecution (usually delegated to a local Criminal Prosecution Service). In the circumstances of this case, it does not seem as if this would have been forthcoming as 'in the public interest' given Kate’s circumstances and what was known about likely presentations by those subject to child sexual abuse at that time. 2.19 By mid-January 2014, Kate’s aunts reported difficulties motivating her, maintain contact and managing behaviours because of who they suspected she was in contact with. Her mother had, 21 Extract from email exchange, dated 08.01.14. 22 It should be noted that was not a decision for the police to make, this is determined by the Courts who may have considered it in the interest of justice for it to be admissible in line with S114(1) Criminal Justice Act 2003, guidance available at: https://www.cps.gov.uk/legal-guidance/hearsay 23 https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/child-abuse/ and https://www.cps.gov.uk/legal-guidance/child-sexual-abuse-guidelines-prosecuting-cases-child-sexual-abuse 24 ACT possibly stands for ‘Assessment Consultation Therapy’. As far as Kate is aware, she never receive this support. Any input at this time was purely in relation to the ‘wasting police time’. 25 Taken from police case notes 26https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/354050/yjb-youth-cautions-police-YOTs.pdf, https://www.cps.gov.uk/legal-guidance/public-justice-offences-incorporating-charging-standard and https://www.cps.gov.uk/legal-guidance/child-sexual-abuse-guidelines-prosecuting-cases-child-sexual-abuse (see especially paragraph 57) 12 until this time, not yet engaged with services to reduce her alcohol dependency and it appears from the chronology as if very little had actually changed in Kate’s life to reduce the risks posed to her welfare. Notwithstanding, CSC concluded their s47 investigation finding ‘concerns substantiated’ in respect of CD, but apart from notifying the LADO of these concerns and recommending that Kate’s family decide whether they are ‘happy’ for her to continue to attend the youth group, no action was taken. 2.20 By Late January 2014 Kate was reported to be low in mood, withdrawn and asked her social worker if she could return to the youth organisation where she met CD. She also reported a breakdown in her relationship with her maternal aunt who, until then, had been a protective factor. The social worker’s case records do not record any steps taken to assess risk that CD may seek to resume contact with Kate, nor was contact made with Kate’s mother and wider family or the voluntary organisation to ascertain if CD was still suspended from the youth organisation. The social worker did not escalate or request legal or senior management advice on what steps could be taken and by whom to enable Kate to resume attendance safely or ensure that Kate’s mother and CD understood he was to have no contact and the steps the local authority and police would take if he were to seek to do so. Kate was not given opportunities to disclose the abuse she had suffered, nor provided with assurance of any steps taken to prevent CD from contacting her. Records indicate no steps taken to ensure Kate understood the nature of the concerns regarding the risk of sexual abuse she faced. In short, Kate’s voice was not heard and her rights under the UNCHR were not respected. 2.21 Had practitioners exercised professional curiosity and sought advice/ researched child sexual abuse they would likely have contextualise both Kate’s and CD’s behavioural patterns as indicating she continued to be at high risk of both neglect and sexual abuse. In conversations with the reviewer Kate was astonished that practitioners didn’t recognise what was happening at that time. Whilst Kate may have differed in a number of ways from what was considered the ‘normal profile’ for someone at risk of sexual abuse, because (despite ongoing ‘friendship issues’ at school and crisis at home) Kate remained a good student; her attendance and achievements were notable. She also attended appointments with CAMHS and case records state she confirmed improvements in her mood, though she continued to clearly articulate her feelings that her mother was a ‘bad parent’. Her remarkable resilience should not have been interpreted to diminish the risk of significant harm posed both by CD and her mother’s ongoing neglect. It is clear from case records, her mother continued to minimise her role in providing a protective, safe environment and also undermined attempts made by extended family members to enforce boundaries to safeguard Kate.27 Her mother attended some appointments to address her alcohol misuse, though case notes suggest very little progress was made to reduce her alcohol in-take or improve her ability to care. Case notes also evidence very little was done by practitioners involved with this family (and there were many by this time) to triangulate information as a means to assess the level of risk. 2.22 Practitioners did not seem aware of evidential standards which justify using legal powers to investigate child protection concerns. A ‘reasonable cause to suspect’ a child is at risk of significant harm justifies investigations under s.47Children Act 1989.28 For police officers to 27 Mother also objected to Kate’s paternal family being involved in a family group conference in 2014 28 In R (on application of S) v Swindon BC and Wiltshire CC [2001] the High Court confirmed a local authority does not have to be satisfied on balance of probability that a person is an abuser before intervention is justified. ‘What triggers the local authority's duty under s.47 is having reasonable cause to suspect, not reasonable cause to believe, which is the test in a number of other sections. Accordingly the threshold is quite low. This is hardly surprising as their obligation is to investigate i.e. make enquiries with a view to deciding whether to take any action to safeguard or promote the child's welfare. If the enquiries lead the local authority to the conclusion that action is necessary it is required by subsection (8) to take it.’ [pg36] In addition, the courts have repeatedly recognised that the interests of persons 13 exercise their powers of arrest they must have reasonable grounds to suspect an offence has been committed, that the arrested person has committed it and that it is necessary to arrest the person.29 Clearly, it may be possible to carry out an investigation without using powers of arrest, however, once that threshold is crossed officers can proactively searched for evidence. In this case, Kate’s risk of significant harm had been substantiate and, a forensic examination had ‘not rule out the possibility of sexual assault having occurred’,30 there were allegations he had threatened her, tracked her movements and compelled her to make false allegations against family members. All of this should have sufficed to justify interviewing him under caution (e.g. for breaches of the Protection from Harassment Act 1997). It should also have lead on to consideration of other remedies open to the police (e.g. Child Abduction Warning Notice).31 Finding: The investigation in 2013 into grooming and abuse by CD was not sufficiently robust given what was known of the likely presentations at the time. Information was not shared appropriately between agencies or with Kate and her wider family, despite the significant role they were given to act in a protective capacity. Insufficient weight was given to the voice of the child and concerns raised by her family members. Too much reliance was placed on family members to impose restrictions on Kate, whilst actions to secure collaborative evidence (e.g. by interviewing CD or even re-interviewing Kate) were not taken. The decision to refer Kate for a Youth Intervention for wasting police time was not consistent with national guidance in force at the time. 3. How robust was the Child Protection process, including whilst Kate was subject to a Child Protection Plan and Missing and Exploited Children’s Conference, in identifying and addressing the risk of emotional and physical safety and sexual exploitation? 3.1 The completion (on 13.03.14) of the s47 investigation recommended an initial child protection conference; this was held on 02.04.14 and concluded Kate was at risk of significant harm of neglect. The meeting noted the impact on Kate of her role as a carer for mother and referenced concerns regarding ‘inappropriate behaviour’ between a youth group leader and Kate and her knowledge of adult issues but didn’t specify risk of sexual harm or name the source of risk. Again, the protection plan centres on a referral for bereavement services and for her School nurse to undertake a health assessment. No actions were identified to address the risk posed by the ongoing neglect, her mother’s unwillingness to allow extended family members to support Kate or to address risk of sexual grooming. No actions were listed to monitor CD’s contact with Kate. A review of the combined case records suggests drift during this period, e.g. the referral for support as a young carer still hadn’t been actioned at 22.07.14 and, whilst Kate was still requesting permission to be allowed to return to the youth group, a decision on this was indefinitely deferred. Despite clear evidence of a lack of engagement from Kate’s mother to the plan32 and Kate reporting concerns regarding her mother’s new partner, CAMHS conclude her mental wellbeing was stable and suicidal ideation has decreased so input could become less frequent. The withdrawal of therapeutic support didn’t prompt a re-evaluation by CSC as to in a similar position to CD come second to the interests of children at risk of harm. The local authorities' assessments and actions are of a nature where a wide margin of appreciation has to be given to the interpretation of the right to privacy and family life protected under Article 8 ECHR: R v DPP ex parte Kebiline [2000] 2AC 326. It should also be borne in mind that the European Court has held that in a conflict between the rights of a child and of parents, the rights of the child should prevail. Hendricks v Netherlands (ECHR) 1983. 29 e.g. because it is necessary to protect a child or other vulnerable person from the person in question[pg2.9d] or to allow the prompt and effective investigation [pg2.9e- Code G, PACE Code of Practice for Police Officers.] 30 The forensic examination confirmed only there was no evidence of the brutal nature of the attack she had alleged, not that there was no evidence of sexual activity. Given her age at that time (12) this would have justified an investigation under s5 Sexual Offences Act 2003. 31 More detailed available at: http://library.college.police.uk/docs/appref/CAWN_Procedures_final_v1.0_240919.pdf 32 Case records indicate no sustained change in mother’s alcohol use and she also cancelled a number of key appointments over several months. 14 whether Kate might need additional input to maintain or even improve her wellbeing. Kate, during conversations with the reviewer, understood that practitioners may have to balance taking action to address concerns raised by wider family members against building a relationship of trust with a child, but felt that in her case very little was done by the allocated worker to engage with her. She feels now the worker used this as an excuse and instead should’ve acted to address the legitimate concerns raised by her wider family. She couldn’t remember her allocated worker making any attempts to speak to her about the risk of sexual abuse or any advice/ discussions regarding sexual safety. She expressed regret that she hadn’t asked for a new worker but felt she wouldn’t have known she could question decisions made about her at the time. She feels, understandably, angry that her wider family were side-lined by professionals. 3.2 In July 14 Kate was admitted to hospital with a suspected sexually transmitted disease. Hospital staff, concerned she may not be safe to go home, originally agreed to admit Kate but following confirmation from CSC they will progress safeguarding concerns (though case records did not say how), agreed to discharge. There is no record that Kate or her mother were involved in any decision making or that Kate was spoken to alone. The opportunity was not taken to enquire safely whether she was sexually active and thereby explore if she was being sexually abused. 3.3 A Child Protection Review Case Conference was held on the 4th July 2014. It does not appear that Kate was in attendance and there is no evidence she was spoken to before the conference. It was reported ‘Mother has continued to engage with support services and school reports that [Kate’s] mood has improved.’ The school nurse’s records confirmed outstanding actions from plan included ‘Children’s Services have not been able to complete “keeping safe” work and results not yet received from hospital about sexual health screen’.33 Working together guidance advised the purpose of the review was to consider whether Kate continued to suffer significant harm and to review progress against the protection plan outcomes. This required social workers and their managers to share conference material within the child and family beforehand, provide information and decide whether to initiate family court proceedings. According to the statutory guidance, discontinuing the protection plan should only occur if it is judged the child is no longer continuing or likely to suffer significant harm. Despite very little having changed for Kate, outstanding key actions within the initial plan and fresh concerns that warranted investigation into whether Kate continued to be exposed to sexual abuse, the Conference chair overruled the majority and removed Kate from Child Protection Plan. Instead a Team around the Family [‘TAF’] was to support her. The school nurse formally dissented to this decision and she was informed that the Conference Chair would take the case to the Safeguarding Board dissent group. It is understood that a report was submitted, but that this was not acted on. At the first TAF meeting (held on 22.07.14) CSC cease their involvement. The internal auditor involved in this review concluded this decision for ‘TAF’ was ‘not consistent with local step-down processes and effectively meant that Kate was closed to Children’s Services. [The Conference Chair] failed to consider lack of engagement by mother in March 2014 which stepped the matter up to Strategy Discussion and ICPC or recent and historical information in relation to mother’s use of alcohol.’34 3.4 In 2014 OFSTED reported that the Council’s ‘practice of stepping down cases to universal and targeted services has led to the authority failing to provide a range and level of services to safeguard and promote children’s and young people’s welfare. A significant number of children 33 Taken from the combined chronology completed for the review 34 Taken from the combined chronology completed for the review 15 in need are not receiving the level of support and monitoring necessary to ensure their welfare and protection.’35 3.5 The next TAF meeting (held on 12.09.14) confirmed that Kate’s mother rarely attended appointments with alcohol services and whilst she reported improvements in her alcohol use, it was noted she smelled of alcohol at the meeting. Kate’s mother was advised she would not be eligible for mental health support (to address anxiety) due to her alcohol in-take. There is no consideration as to how this could impact on her ability to provide basic care or protection to Kate and no interventions put in place to support Kate. By November 2014 Kate’s mother had not attended any appointments and admitted she was drinking daily. Kate also disclosed to the School nurse her mother was drinking more than she was telling professionals, she explained she was unhappy she couldn’t attend the youth group, and no-one has explained why and that her mother didn’t want to spend any time with her. Again, despite clear indications that Kate was an isolated child, neglected by her mother and with actions to address the risk of sexual abuse still outstanding, still nothing was done to escalate this to the level of support that would have been required in accordance with National guidance or the Local Authority’s own local child protection policies. 3.6 In December 2014 the CAMHS clinical team meeting records identified that Kate had been groomed by a youth group officer, re-iterating earlier disclosures that ‘a letter was dictated by the predator, accusing her family of abusive behaviour, he threatened to harm her if she did not write the letter’. It does not appear the practitioner was advised by senior staff of their duty to share this information with the police or CSC despite clear statutory guideline36 to do so. There is no evidence that this information was used to inform a review of the risk assessment or action plan to address the perpetrators behaviour, instead CAMHS care plan focused exclusively on improving Kate’s relationship with her mother. Given the longevity and significant nature of neglect Kate had experienced by this time, Kate confirmed to the reviewer that, even at the time the focus of this input seemed wrong. She reported she felt the professional showed little empathy and she only ever remembered being asked ‘how does that make you feel?’ Kate explained it was crucial that any learning review understood the impact that her mother’s neglect, even if not intentionally malicious, had on enabling the sexual abuse to continue. She explained her mother remained oblivious to the harm she was experiencing. She remembered her mother asking her for money to buy beer and also feeling so isolated because her mother had blocked contact with her paternal family and turned her maternal aunt against her. 3.7 By Jan 2015, during a joint meeting with CAMHS, both Kate and her mother confirm they had disengaged with Kate’s paternal family and expressed fears regarding the high risk that Kate may self-harm or be harmed by ‘others’. Who posed this risk was not explored, nor is there any consideration regarding the gap left in the initial protection plan if Kate’s wider family were no longer involved. The risks were not shared with other TAF professionals. 3.8 Later that month, Kate’s mother disclosed Kate was pregnant to her CAMHS worker. This information was shared with the school who referred this to CSC. Kate’s GP later confirmed to the TAF she was not pregnant, so no further action was taken to discuss this with Kate. Kate was only aware that practitioners were told of her pregnancy as a result of the conversation with the reviewer. She confirmed the pregnancy was a result of the sexual abuse. She explained that she suffered a miscarriage. At the time, she had gone to her abuser’s home for help and they had called ‘111’ for advice, though not disclosing her name. She remembered being asked by him to 35 Inspection of services for children in need of help and protection, children looked after and care leavers Inspection date: 21 October 2014 – 12 November 2014 Report published: 3 June 2015, Available at: https://reports.ofsted.gov.uk/provider/44/80567 36 Working Together, 2013 16 leave and, despite being in excruciating pain, had done so because he was concerned his partner would come home. She spoke of her fear and of crouching in agony behind the bins near her home whilst she lost the child. This was clearly extremely traumatic for Kate and, for her, formed a major part of the abuse. She explained that if at that time, ‘just one person I trusted had taken the time to sit with me and ask, it might have taken a while, but I would have told them’. 3.9 Efforts were made by Kate’s extended family to escalate their continued concerns and by her school to escalate this to CSC. Case records indicate that the school notified CSC that her mother cancelled the TAF meeting because Kate ‘thought she was pregnant’. CSC recorded the outcome of this referral as ‘NFA letter to be sent to mother advising her to engage with TAF’.37 A few days later CSC received notification through the NSPCC seemingly reporting Kate’s maternal family’s concerns that Kate was in a ‘secret relationship with an older man called [CD]’ The referral set out the history of the earlier investigation, and new information including that ‘in December we found out that [‘Kate’] became pregnant by her older boyfriend and we found love cards hidden in her draw signed by [CD] which said in them about being together and starting a family when she is old enough and a keyring of the pair of them cuddling together at Hyde park's winter wonderland. …[Kate’s mother] and CD have now become friends and we have been informed that CD is going to be lodging with her as she is off work with depression and needs a lodger to keep up with her mortgage payments’. 3.10 It appears from case records that a status of ‘anonymous and unconfirmed’ concerns was attributed to the information contained within the NSPCC referral, though it should have been very clear with only cursory review of CSC case records that this had come from a member of the extended family. Had CSC carried out even a very brief enquiry with professionals involved in the family, they would have been able to confirm which family member; Kate’s aunt had tried to notify professionals that week of the ongoing abuse. No enquiries were conducted, nor was the matter escalated, instead CSC requested the school nurse organise a TAF meeting and invite the social worker to this. 3.11 In conversations with the reviewer, Kate’s extended family spoke of their hopelessness at the lack of response they received from the concerns they raised. They felt there had clearly articulated the level and nature of the abuse Kate was facing from CD. They had also explained her mother’s inability to monitor CD’s contact with Kate and their fears that because of the very clear parental neglect she was experiencing, Kate was unprotected. They stressed that it was not easy for them to raise their concerns, as this meant openly criticising Kate’s mother which felt like a betrayal. They explained that, at the time, they themselves couldn’t cope with the overreliance statutory services placed on them to manage the risk that her mother’s neglect and his abuse posed. They are understandably angry that such little weight was given to the information they disclosed. They explained that child protection practitioners should take into account how hard it is for families to overcome natural familial affiliations to share concerns with professionals and take those concerns seriously. They were also exasperated that, whilst they were often used by professionals to provide protective care, they were then ignored when they raised concerns about Kate’s ongoing safety. Kate’s family felt it was too easy for different agencies to dismiss their concerns and deflect back to Kate’s mother without proper consideration of her ability to understand and act to protect Kate from the ongoing abuse. 3.12 The NSPCC also referred their concerns to the police and LADO service. The initial police officer responding recognised the need to follow the ‘CSE workflow’ referring for a strategy discussion at the Multi-Agency Safeguarding Hub [‘MASH’]. They also recorded the need to consider available remedies even if the child did not engage. However, a MASH assistant later 37 Taken from the combined chronology completed for the review 17 recorded they had ‘discussed the anonymous referral with the LADO and Children’s Services who had contradictory information as Kate and her mother had been subject to TAF for some time. The LADO stated that children’s social care had ‘called’ Kate’s mother who had told them that she was facilitating contact between CD & Kate and she is clear that there is no sexual contact. Mother did think that Kate was pregnant but this was with a boy at school – a home pregnancy test was positive but a second test was negative.’ Officers carried out a home visit, though Kate was not seen alone. Kate’s mother confirmed to the police that CD was in contact and was helping her with her mortgage. The case records state ‘officers checked flat for evidence of a male lodger, which proved negative… no suggestion Kate being sexually exploited’. Kate’s mother later the same day confirmed her sister had made the report and requested she be charged.38 Shortly afterwards the LADO contacted the youth organisation and was advised that CD had been reinstated and that Kate has returned to the group after they had received written notification from her mother that she had withdrawn the ‘no contact’ agreement. The earlier decision by CSC to have no further involvement in the case appears to have been a significant factor within the youth organisation’s assessment there was no risk regarding CD’s conduct and on-going contact with Kate. 3.13 There appears to be an assumption that, because there are a number of professionals involved within the family and the length of time concerns had been known to services, the likelihood of the abuse continuing was low. It is hard to see how professionals could have formed this view. Statutory expectations regarding investigations and information sharing had not been met and there is no evidence that professionals had approached their functions with a sufficient degree of investigative enquiry or professional curiosity. There is also a distinct lack of awareness by professionals of their legal obligations and duties under the UNCRC and Human Rights Act to protect Kate. 3.14 The LADO requested CSC undertake an assessment; specifying this was to include CSE risk assessment and regular liaison with the LADO. On 20.02.15 a social worker was allocated. However, she didn’t attend the TAF meeting on the 26.02.15 and Kate and her mother confirm they’d had no contact. Eventually the family support worker, not the allocated social worker, decided to call a strategy meeting concerned that Kate had disclosed her mother was drinking 14-15 cans a day and gambling heavily. The case records report Kate feeling ‘under pressure and unhappy’. Before the strategy discussion took place, further concerns were raised by the youth organisation regarding CD to the LADO. In early March Kate was admitted into hospital following a further overdose; the fifth requiring hospitalisation in 18 months. A request was made by the ward to CAMHS for a joint assessment so that post discharge care arrangements could be agreed, but it does not appear CSC were notified. 3.15 The strategy discussion finally took place on the 20.03.15 between CSC, police, LADO and ‘paediatric liaison’. Despite her central role as lead professional until this point, it does not appear the school nurse was invited. Kate expressed incredulity when discussing this with the reviewer and highlighted that, by this time, the only person she had any real contact with was the school nurse. Again, the central focus of this meeting seems to be how difficult it may be to prove there is an ongoing ‘inappropriate relationship’. It was decided to start a further investigation under s47 Children Act 1989. There was no consideration to whether the police or local authority should seek legal advice to ascertain legal options to keep Kate safe. Given the serious longevity of the neglect, the numerous indications providing reasonable cause to suspect sexual abuse and Kate’s mother’s apparent collusion with the perpetrator (even if this was a result of grooming on her), this seems remarkable. A representative from the Council’s legal 38 Taken from the combined chronology completed for the review 18 services did confirm that, had a request been made at the time for a Legal Planning Meeting, it would have likely resulted in formal legal processes under the Public Law Outline.39 Kate commented to the reviewer that, throughout this time she was telling her abuser that CSC were investigating the abuse, but he would reply ‘no-one has spoken to me’ and it was clear to her at the time this gave him confidence that he was safe to continue the abuse. 3.16 The LADO also subsequently met with the leaders of the youth organisation, the case records available suggest both appear unsure of their legal grounds for progressing a fresh enquiry; they agreed to seek more information from the police regarding the earlier police investigation in 2013 and review at the next strategy discussion. Notes from that meeting contain factual inaccuracies (e.g. Kate had not ‘self-harmed since 2013’). Discussions identified issues that remained live concerns and note that extended family members’ fears and their alienation ‘could make Kate and her mother more isolated and potentially more reliant on CD’, but again without reference to legal advice, professionals decide no further action can be taken as concerns were ‘more allegations and suspicions than facts’.40 The LADO is tasked with ‘undertaking some safeguarding work’ with the youth organisation. 3.17 A few days later a further assessment was arranged between CAMHS and ward staff after Kate attended having taken a further overdose triggered by bullying at school (she had received sexual images on her phone). Kate told staff she ‘wants help, scared about school the next day… Felt ignored by mum when she went home, that she was invisible and no one cared’ She disclosed again the extent of her mother’s drinking, her fear that she might fall and hurt herself and she would lose her too, that she had to clean as mum can’t, mum has mood swings, shouts at her for no reason.’ Nursing staff note mother’s speech is slurred, they recognised ‘risk to self at time of assessment is low, potential for further DSH high.’41 They also record continued concern raised by Kate’s aunt regarding contact with CD but discharge Kate to her mother’s care with no clear follow up plan and no contact with CSC. 3.18 By May 2015 Kate’s mother had notified alcohol support services she wouldn’t attend further appointments (claiming anxiety at travelling) and that IAPT sessions and the TAF had stopped. Kate’s school attendance was of significant concern (77%) to justify referring to an Education Welfare Officer. If this was passed to CSC it did not factor into the decision making that her case did not meet the criteria for child protection despite ongoing ‘professional concerns and suspicion that CD has been inappropriate with Kate whilst in a position of trust … There continues to be concerns around Kate’s mother’s parenting capacity in light of long-standing alcohol misuse and mental health. If there are clear concerns, then we need to consider the appropriateness of YSS (Youth Support Service) to undertake some direct work with Kate and complete a CSE risk assessment if appropriate.’ Kate’s case was instead referred to the Missing and Exploited Children’s Conference [‘MAECC’]. This was set up to monitor medium and high-risk cases of child sexual exploitation. 3.19 CD had tendered his resignation from the youth organisation on 19.April 2015 but was suspended on the 13.05.15. Shortly afterwards (18.05.15) the building where the group met was burnt down. The fire was set deliberately and started where the organisation stored belongings. The organisation’s leader confirmed to the police CD had recently carried out a fire pre-inspection and commented if there was a fire, they would lose everything. This is potentially relevant as an indication of how confident he had become that he could act with impunity. 39https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/306282/Statutory_guidance_on_court_orders_and_pre-proceedings.pdf 40 Taken from the combined chronology completed for the review 41 Taken from the combined chronology completed for the review, DSH assumed to mean ‘deliberate self-harm’. 19 Despite having been suspended, he was not referred to the DBS services as the organisation had ‘difficulty contacting CD following his suspension and had not been able to contact Kate to further their investigation.’ They were initially challenged by the LADO to confirm whether they would have dismissed him on the information they had if he hadn’t tendered his resignation. They confirmed in October 2015 they would normally allow past volunteers to return to activities. The organisation was only subsequently contacted again by the LADO in February 2016 for confirmation as to the decision to report to the DBS. There is some evidence that the LADO was aware of her own duties (to report CD) might be triggered by the level of concerns, but when the organisation did not respond this was not pursued or escalated. The trustees/ leaders of the organisation were not offered guidance on their legal duties to complete this action or face criminal sanction. Police records indicate their enquiries into the fire had shown that, prior to and after the fire, CD had been in phone contact with Kate ‘contrary to the written agreements served on CD & Kate’ but again no further action was taken by the police to investigate this further. In fact, it was widely understood that he was by this time living with Kate and her mother. 3.20 At the first MEACC meeting in June the police were tasked with finding out more information on previous investigations, suggesting that very little of the history and nature of concerns were included within the referral. It does not appear they were aware of the ongoing investigation into the fire. There was no police representative at the following meeting in late June, so this was not progressed and by the third meeting (July 2015) it was noted Kate and her mother were re-locating to the North of England; it was believed this was to ‘lose professionals’. An instruction was given that CSC will share information ‘in regard to the risk of grooming in this case’.42 No deadline was given or named person allocated to undertake this action. By the subsequent meeting in August 2015 this remained outstanding. Police records report an email was sent to the relevant constabulary in the North of England from the MASH ‘detailing the CSE risk to Kate from CD having relocated to the North of England.’ So, presumably, it was understood by senior staff within the MAECC he had moved and was living with Kate. A review by the SAB in the North of England explored what information was shared by professionals and noted a failure by CSC to provide a copy of the most recent assessment or child in need plan. It also noted the school records did not include their safeguarding file. In addition, whilst only partial records were received by the school nursing service, sufficient information was received regarding her mother’s inability to protect, her father’s death, a previous overdose, the alleged rapes and concerns regarding grooming that warranted further enquiries which were not undertaken. 3.21 Practitioners involved in this review acknowledged the response to recognised risks in this case was wholly inadequate. This accords with OFSTED’s evaluation of the service in October 2014,43 which rated the service as inadequate. A key part of the inadequate rating was in respect of children at risk of sexual exploitation and abuse. Inspectors identified ‘in 13 of the 17 cases seen which related to risk associated with child sexual exploitation, children did not benefit from a co-ordinated response, and alerts to risk factors were not being fully identified or responded to effectively. Of the 45 team around the family (TAF) cases sampled on this inspection, 17 were found to have been inappropriately stepped down to TAF arrangements. Cases where there is potential risk to children living in neglectful households, or where there is ongoing domestic abuse, parental mental ill-health or substance misuse, are not being effectively managed and these children are not receiving the right level of support. The early help model of intervention does not provide a framework for systematically tracking and monitoring cases stepped down to 42 Taken from the MEACC minutes supplied to the review. 43 OFSTED report, inspection date 21.10.14-12.11.14, published 03.06.15 available on: https://files.ofsted.gov.uk/v1/file/50004296 20 TAF, and the outcome of interventions for these children is not known.’44 Whilst the OFSTED report wasn’t published until June 2015 those involved with the MAECC would likely have been made aware of key concerns beforehand, including that OFSTED had been highly critical that high risk cases (such that they required MAECC risk assessment) were often inappropriately managed, in that any protection plan was expected to be implemented by universal and youth services, finding that this meant ‘children were therefore not benefiting from statutory intervention and suitable social work support.’45 3.22 In the report of the Inspection of services for children in need of help and protection, children looked after and care leavers in 2014, published in June 2015, OFSTED recommended: • a review of all cases where children have been identified as at risk of child sexual exploitation and ensure services are in place to minimise risk and provide effective support. [REC 3] • Ensure that professionals, including partners, who work with children who may be at risk of child sexual exploitation have the necessary skills to recognise risk factors and to act effectively on alerts to risk [REC 12] • Improve the arrangements for joint working in the identification, collation and analysis of performance information relating to children missing from care and home and at risk of child sexual exploitation, so that the local authority can effectively use information across the partnership to drive improvement. [REC 23] By August 2015 a follow up OFSTED inspection report46 identified continuing issues with local guidance on thresholds for accessing statutory social work services, as well as leadership and scrutiny of practice for protecting those at risk of sexual exploitation. Senior representatives reported to the reviewer that in 2015 the MAECC processes were underdeveloped. Despite OFSTED’s recommendations, there is no evidence that action was taken to review Kate’s case records and ensure the receiving local authority had all the appropriate information to evaluate the risk posed to Kate by both her mother’s neglect and by continued unsupervised contact with her abuser. 3.22 During conversations with the reviewer Kate confirmed that both before and after the move to the North of England CD effectively controlled her every moment. He had cut her off from friends and family, including stopping access to the internet. She spoke about increasing levels of violence he used and of him forcing her to do all domestic tasks (cleaning, ironing, cooking and walking the dog). Kate explained that, at the time she felt powerless; it seemed to her so easy for him to do whatever he wanted as he was always one-step ahead of the authorities. Shortly after the move, her mother moved out of the home leaving her completely unprotected. Kate confirmed that the abuse continued until, in response to an emergency call in June 2017, a police officer seemingly recognising the signs of abuse told her ‘we know what this is’. She said she had been trying to tell people for so long, that this was all she needed. Finding: Practitioners were aware of the potential risk indicators of sexual abuse and recognised how her mother’s neglect and Kate’s isolation increased this risk. Their response to the identified concerns was wholly inadequate. Despite a high number of professionals and all key agencies having been informed of the risk, coordination was severely lacking. Information was not gathered in a way that facilitated effective shared risk assessment or managed to reduce or prevent abuse. There were too many handovers with little or no follow up to ensure that those receiving referrals had the information or skills to support Kate. As reported by OFSTED, child protection services did not meet 44 OFSTED 2014 Inspection of services for children in need of help and protection, children looked after and care leavers report, p. 48 45 OFSTED 2014 Inspection of services for children in need of help and protection, children looked after and care leavers report, p. 57 46 Available at: https://files.ofsted.gov.uk/v1/file/50004302 21 expected standards within national statutory guidance. As a consequence, no consideration was given to securing legal advice and instigating child protection proceedings despite long-standing, significant risk of harm having been substantiated by the s47 investigations. The LADO and voluntary sector organisation did not fulfil their legal obligation by thoroughly investigating the allegations against CD, nor did they report concerns to the DBS. 4. What is needed to improve future practice and ensure effective inventions to protect young people at risk from people in positions of trust? 4.1 In his 2003 report into the death of Victoria Climbié, Lord Laming47 stated: “I recognise that those who take on the work of protecting children at risk of deliberate harm face a tough and challenging task...Adults who deliberately exploit the vulnerability of children can behave in devious and menacing ways. They will often go to great lengths to hide their activities from those concerned for the well-being of a child.” 4.2 Alnock48 highlights many of the strategies used by adult perpetrators of child sexual abuse to target, isolate, groom and abuse children coupled with the contextual circumstances and impact of neglect on young people can make perpetrator strategies more difficult to detect. 4.3 Kate and her family spoke of the powerlessness they felt in the face of CD’s ability to manipulate professionals and deflect attention from the abuse he was inflicting. Throughout Kate’s case records, practitioners used terminology which at best deflected attention, at worst could be seen as ‘victim blaming’. Kate’s distress and self-harming was referred to as ‘attention seeking’49, reports that she had been raped, was pregnant or had contracted an sexually transmitted disease were not investigated. Throughout the case records there are numerous examples where Kate’s or her family’s disclosures are given little weight because they are reported by a third party (NSPCC or usually a trusted family member) or are simply not passed to CSC, LADO or the police. This suggests practitioners were unaware of their role in providing corrobative evidence. Kate’s experience supports research findings which identified that even if there is evidence that a child is being abused, some practitioners, or the institutions within which they work, will remain ‘wilfully ignorant’ and turn a blind eye to the abuse.50 4.4 It is also important to acknowledged that practitioners from different disciplines and agencies have their own specific, separate focus and that this can sometimes mean that there isn’t a common language or shared understanding of risk, which in turn can be exploited by perpetrators of abuse. Multi-agency protocols and services should seek to establish systems which actively impede sexual abuse, taking into account Finkelhor’s four pre-conditions model of child sexual abuse. This requires a whole systems approach with careful use of language and clarity on agencies responsibilities and legal powers to ensure partners work in a coordinated way. Existing legal and policy frameworks if properly understood could enable parents, wider family members and practitioners put in place effective strategies to secure early identification of abuse and a focused multi-agency response to disrupt and prosecute adult perpetrators. Policies and risk management processes must also highlight the importance of ensuring the voice of the child is central to 47 Victoria Climbié Inquiry, the Lord Laming Report, 2003:3 48 ‘Exploring relationship between neglect and adult-perpetrated intra-familial child sexual abuse’, Debra Allnock, available at: https://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-intrafamilial-child-sexual-abuse-evidence-scope-2.pdf 49 E.g. within referrals for CAMHS support [15.07.13] 50 University of Bedfordshire (2015) Child sexual exploitation: a social model of consent. Available at: http://youtu.be/1oyE-qE4340 (Accessed 05.02.20). 22 every decision, including a decision not to act and that practitioners explain within the multi-agency context, their rationale for decisions so that wherever necessary this encourages accountability and critical challenge. 4.5 The role of LSCP and strategic leadership within child protection agencies: OFSTED continued to express concerns in September 2018 that ‘cyclical ‘start again’ social work is compounded by a complex service structure, requiring numerous handover points and changes of social worker as children travel through the statutory social work system… Many social workers, frontline managers, child protection conference chairs and partner agencies have insufficient knowledge and understanding of the impact of cumulative neglect, exposure to domestic abuse and other adult difficulties on children….[such that use of the PLO pre-proceedings work] on the accumulative evidence of continuing harm and neglect to children is the exception rather than established practice.’ This accords with Kate’s experience and her comment that it was hard to establish relationships of trust when there was so many changes to personnel involved in her case. The complexity of the social work system made it difficult (even for the reviewer) to clearly establish which practitioner or agency was expected to lead on collating information on risk. 4.6 In September 2018, following a monitoring visit, OFSTED commented that not enough effort is made to engage men51, particularly those who have not been convicted, in perpetrator programmes or to consider their offending histories with the police and probation services, in order to inform risk assessments of their potential to further harm children. Senior representatives supporting this review recognised how practitioners investigating this case did very little to challenge her abuser’s behaviours, despite clear instructions that he had acted in breach of the youth organisation’s safeguarding policy and had breach the no-contact agreement. Details of possible legal orders are set out within the LSCP’s multi-agency policy.52 Whilst in prison and despite restrictive orders, CD has made attempts to intimidate Kate. The likely continued risk he poses on his release from prison was understood at the time of his conviction (necessitating further orders and conditions). Consideration will be needed before his release to what support she will need to stay safe and, if she chooses, to have input into the parole process. The LSCP may also wish to explore whether child protection practitioners can access advice from agencies with expertise in the management of offending behaviours on possible risk reduction measures they can lawfully employ as part of a plan and when failure to comply with any protective measures would indicate reasonable grounds to believe a child may be experiencing significant harm. 4.7 In January 2019 OFSTED noted ‘Senior managers’ attempts to escalate police responses encountered resistance. While it is essential that risks of adult exploitation and other dangers encountered by children who go missing are regularly reviewed by senior managers from partnership agencies, it is also vital that all available civil and legal avenues are used to protect children and help them to escape exploitative adults and networks. Efforts to disrupt, pursue and prosecute alleged perpetrators are not always assertive enough.’53 Again, Kate’s case demonstrated how a lack of knowledge between professionals of the possible legal orders and processes available to safeguard her, meant even when there was clear dissent from practitioners (e.g. the decision to remove Kate from child protection plan) it proved impossible for practitioners to provide effective challenge. 51 Monitoring visit of Surrey local authority children’s services, published October 2018, p. 3 52 https://surreyscb.procedures.org.uk/hkpol/procedures-for-specific-circumstances/working-with-sexually-active-young-people 53 Monitoring visit of Surrey local authority children’s services, letter dated 25th January 2019, p. 3 https://files.ofsted.gov.uk/v1/file/50056033 23 4.8 Within the multi-agency procedures (dated 2017) there is advice on how practitioners should respond to risks of sexual abuse and information on the legal framework applicable to children who are sexually active. Consideration could be given to reviewing these sections to ensure an explicit reference to the underlying purpose and legal duty to consider the voice of the child and the responsibilities for parents/carers to keep a child safe. Language used must avoid victim blaming, minimising risk or deflecting attention from perpetrators. It should also incorporate the new risk guidance and toolkit. All guidance should make clearer the link between identifying a risk of significant harm and the legislative thresholds that trigger professional duties to investigate where there is a reasonable cause to suspect criminal behaviours, or a child might be at risk of significant harm, or a person in position of trust might pose a risk. Guidance should also include the role of Legal Services and clarify when and how child protection concerns should be escalated, in line with the Public Law Outline and s31 Children Act 1989. The LSCP should consider offering guidance that where there is reasonable cause to suspect a child is at risk of sexual abuse or exploitation, this is recorded as the principle category of risk on child protection plans and other types of abuse are carefully considered against Finkelhor’s four pre-conditions model so that CP plans and contingency plans adequately reduce the risk through early detection or disruption. 4.9 It is noted that in the letter following the monitoring visit of 31st October 2019 to 1st November 2019 (published in December 2019) OFSTED recognised ‘a more committed, strategic response to child sexual exploitation has led to additional strategic partnership posts, increased awareness raising and a new risk management process to replace an earlier model that was not wholly effective in assessing and reviewing risk. Older children who are at risk of or who are experiencing child exploitation are quickly assessed and engaged by social workers, family support and targeted youth support workers. Useful information provided by children in return home conversations is immediately passed to specialist police officers, who use it to undertake intelligence mapping, disruption and dispersal activity. Senior managers recognise that assertive, persistent outreach work with children who are at acute risk needs to evolve and improve further, and they have realistic plans to build on the current constructive direct work carried out.’54 But warned ‘regular multi-agency risk management meetings review and oversee risk reduction work with those children who are at the greatest risk, but the information and intelligence from these meetings is not always easily discernible in social work case records and intervention plans… There is limited evidence, however, of reflective, curious questioning evaluating how the cumulative impact of busy multi-agency interventions are improving children’s lives, and scant evidence that managers are advising social workers about how they should approach their direct work.’55 4.10 Currently, the LSCP offers a training programme for partner agencies to support the early identification of sexual abuse and exploitation. It receives assurance through a data dashboard to enable oversight of case management of child exploitation work. There is also a multi-agency service response proposal56 detailing the expectations for support and disruption and local service guide.57 In September 2019 a new toolkit and guidance was introduced for partners. This advises of the importance of promoting positive relationships with family, friends and carers, communities and of gathering corroborative evidence to prevent overreliance on the child to report abuse. It requires a referral to CSC if there is a vulnerable child at significant risk or experiencing sexual exploitation. The risk assessment 54 Monitoring visit of Surrey children’s services, published December 2019, https://files.ofsted.gov.uk/v1/file/50134643 55 Re-inspection of services for children in need of help and protection, children looked after and care leavers, paragraph 98, published 16th May 2018 56 https://www.surreyscp.org.uk/wp-content/uploads/2017/07/CSE-MA-Response-diagram.pdf 57 https://www.surreyscp.org.uk/wp-content/uploads/2019/06/Child-Exploitation-Prevent-Prepare-Protect-Pursue-service-guide.pdf 24 tool does not, however, identify what action should be taken by those completing the tool (e.g. practitioners in universal services) if they have identified an emerging risk (i.e. a vulnerable child with one or two indicators of sexual abuse/ exploitation present). Again, partners may wish to revise this to ensure staff working in universal services understand emerging risks may trigger duties to investigate and ensure there is an established pathway so that the child, their parent/ carer and potential perpetrators can access existing preventative or early intervention support. 4.11 Child protection practitioners: Since 2017 CSC staff training has been prioritised around child sexual exploitation, ‘Total Respect’ and the implementation of a recognised strength-based model of social work practice.58 A service re-design with CSC has also reduced caseloads, but there remains continued concern the ‘views of children are captured, but, frequently, are not used to produce a clear picture of their lives at home, and the degree of continuing risk they may be exposed to. The practice of documenting risks, strengths and worries in columns, and the prevalent use of scaling exercises, can sometimes overcrowd and obscure, rather than illuminate, children’s core risks and needs. Conference chairs do not always document their analysis and evaluation of risk crisply and clearly, and this indicates a lack of rigour in their expert decision-making responsibilities. Plans often feature numerous actions that are not prioritised to help parents and professionals work on the most important elements in a sequential way… Some plans are too lengthy and are saturated with dense professional language’59 4.12 In Kate’s case, practitioners from across specialist child protection teams didn’t consider relevant statutory guidance within their decisions. This was most stark in 2013 when police officers ignored advice from the medical practitioner involved in the investigation, and contrary to statutory guidance referred her to youth services for wasting police time and again in 2014 when she was removed from the child protection plan. Child Protection Conference Chairs, social workers and police officers working within specialist child protection teams are obliged to have regard to relevant statutory guidance within their decision making. They must understand and employ key multi-agency policies to ensure information is collated and analysed appropriately. For example, a basic understanding of partner agencies’ core duties and awareness of the inter-agency escalation policy and procedure will help when leading a multi-agency protection plan effectively to ensure effective professional challenge. In addition, the crucial role of record keeping and the way in which different Courts may admit and weigh up information would enable lead practitioners to provide practical guidance to other individuals or agencies involved with the child about what information should be reported in order to provide corrobative evidence for civil or criminal proceedings. Lead practitioners should know to chase missing information (e.g. updates from services supporting Kate’s mother) and actively look for gaps in order to demonstrate decision making is robust. 4.13 Finally, staff undertaking specialist assessments must also be supported to give parity within strategy discussions to staff from universal services who have developed trusted relationships with the child. In Kate’s case, she reported finding it difficult to open up to her social worker, but trusted the school nurse. Excluding the school nurse from the strategy meeting in March 2015 meant that an opportunity to reengage with Kate and hear her voice was lost. Those leading child protection investigations must be able to explain risk management plans so these are fully understood by the child and all those involved in the child’s life. Plans should clearly set out the responsibilities of parents/ carers to engage fully 58 Monitoring visit, published 16.05.18 [pg110] 59 OFSTED monitoring visit, Dec. 2019 25 with protection plans to detect and disrupt activity. This is particularly important in circumstances such as Kate’s case where her mother was sceptical of the risk. It should be made clear to parents that any failing to adhere to the protection plan will almost always require escalation into child protection proceedings. 4.14 LADO: The reviewer had hoped to explore some of the practical difficulties experienced by those undertaking the LADO process. Unfortunately, the relevant professional involved in this case no longer works for the Local Authority and chose not to contribute. Instead the review has considered the multi-agency procedures. This sets out roles and responsibilities for all organisations which include a requirement to have safeguarding polices and a designated senior officer to manage allegations against people that work or volunteer with children.60 The procedure sets out timescales and provides guidance on actions required by the organisation, LADO and (if required) police. There is an expectation that most investigations will be completed within one month with ‘all but the most exceptional cases completed within 12 months.’ The LADO is required to track progress of all investigations and report this to the LSCP and Department for Education as required. Guidance on how information regarding the allegations should be recorded on CSC case files for children involved in the investigation are also detailed, including requiring the LADO case reference, but is explicit that information should not enable the alleged perpetrator to be identified. The investigation into CD’s behaviour was not fully concluded, although in subsequent correspondence between police staff and the LADO both express concern over the nature of allegations and lack of clarity as to whether it would be lawful to disclose the allegations if future DBS or reference requests were made. The LSCP may wish to give further guidance on standards of proof required to substantiate allegations, in line with Lady Hale guidance on this issue, namely that it is only when the nature of civil proceedings are to punish or deter criminal activity they must produce evidence to meet the criminal standard of proof (beyond reasonable doubt). In all other civil proceedings, it is the civil standard of ‘balance of probabilities’ that applies. She advised “neither the seriousness of the allegation nor the seriousness of the consequences should make any difference to the standard of proof to be applied in determining the facts.”61 4.15 In addition, in January 2020 the Office for Civil Society published an online toolkit62 to support organisations report safeguarding allegations against a person working within their organisation. Funding has also been made available to develop factsheets, tools and model policies and, depending on the location and nature of the organisation, provide face to face training. The LSCP may wish to consider supporting organisations in their area access this training and should ensure all are aware of the new resources. Organisations may also benefit from free practical guidance and risk assessment frameworks available online.63 4.16 Input from universal services, therapeutic or specialist care providers: Kate and her mother were involved with professionals working across education, social care, health and specialist alcohol services. Often those practitioners appeared unaware of the requirement and importance of disclosing information to CSC and/or the police or became frustrated that their concerns seemed to be dismissed. Although part of the ‘Team around the Family’ decisions appeared to be made by practitioners in isolation and without a shared understanding of the purpose of each intervention. For example, CAMHS a withdrawal of 60 https://surreyscb.procedures.org.uk/qkpph/safer-workforce-and-managing-allegations-against-staff-carers-and-volunteers/managing-allegations-against-people-that-work-or-volunteer-with-children#s1087 61 In Re B [2008] UKHL 35, pg.70 62 https://safeguarding.culture.gov.uk 63 For example, https://knowhow.ncvo.org.uk/safeguarding or https://safeguardingchildren.acu.edu.au/__data/assets/pdf_file/0004/1388443/Situational_Crime_Prevention_for_CSA.pdf 26 therapeutic support didn’t prompt a re-evaluation by CSC as to whether Kate might need additional input to maintain wellbeing or even improve this. OFSTED’s most recent appraisal confirms work remains to address this. 4.17 Role of Parents, Carers, Family members and friends: Kate’s aunt spoke of the pride she and the family have for Kate and how well she has rebuilt her life. Whilst she understood the need to review this case and for practitioners to consider the role of the family in recognising and reporting grooming behaviours and suspected sexual abuse, she also wanted to stress how frightening the period was for her and the whole family. She explained how devious CD was and how, even when they knew he was abusing Kate, they couldn’t get ‘evidence’ as he had coached Kate so she knew what she had to say to every question they posed. She spoke about the level of aggression the family faced from CD, how she still finds it hard to imagine how Kate coped alone with that and the pressure of making sure she maintained the deceit. Throughout the case records and from correspondence made available to the reviewer it is clear that family members persistently requested investigations into his conduct, including by approaching the youth organisation, police and CAMHS directly. She spoke of being made to feel like she was the enemy or an inconvenience for repeatedly raising her concerns with practitioners. She wished they’d been given one central point to raise concerns and report new information and was frustrated that there appeared to be little coordination between hospital discharge and the child protection processes. She admitted she was angry that Kate’s cries for help were ignored. Above all she wants to ensure, going forward, that practitioners understand children abused and coerced as Kate was may well be withdrawn. She suggested practitioners should plan for resistance, whilst at the same time enabling family members to maintain a trusting relationship with the child. She wished that Kate’s family had been better supported to prevent contact between Kate and her abuser. She confirmed she and others had reported when he breach the ‘no-contact agreement’ but were not informed what, if any action, was taken as a result. 27 Summary of recommendations The purpose of any serious case review is not to replicate civil or criminal processes or to apportion blame, but to learn lessons and make recommendations to improve practice, procedures and systems and ultimately to improve the safeguarding and wellbeing of children and young people in the future. Findings and recommendations from this review are not intended to dilute or deflect culpability for the harm caused to Kate from both the neglect and sexual abuse she suffered whilst a child. Policy 1. The LSCP update their multi-agency procedures to ensure greater focus on pursuing perpetrators, explicit references to statutory thresholds for investigations and legal remedies (including all civil and criminal orders) and the burden of proof or use of collaborative third party information. The sexual exploitation risk guidance and toolkit should be amended to provide guidance for those working in universal services on what could trigger an investigation and detail pathways for preventative, early intervention work and their role in providing collaborative information to enable child protection agencies secure legal remedies. Language in all policy documents and practice tools used must avoid victim blaming, minimising risk or deflecting attention from perpetrators. 2. The LSCP may wish to include guidance to child protection practitioners on accessing advice from agencies with expertise in the management of offending behaviours on possible risk reduction measures they can lawfully employ as part of a plan and when failure to comply with any protective measures would indicate reasonable grounds to believe a child may be experiencing significant harm. This should extend to what support should be made available to victims of abuse when perpetrators are due for release from prison. Assurance 3. LCSP conduct an audit/ review of the police decision making in respect of the out of court disposal for wasting police time should be undertaken and consideration given to expunging Kate’s record. If this is not the outcome, the LSCP (with the Police and Crime Commissioner) should write to the Home Secretary to request she explore what steps can be taken, including under prerogative powers, to ensure victims of child sexual abuse who were subject to out of court disposals or convictions linked to ‘survival crime’ or intimidation have their police records rectified. Kate should receive written confirmation that her records has been expunged within 3 months of completion of this report. 4. The LSCP should seek assurance that the Police and Youth Offender Services have reviewed records of other known victims of grooming and sexual abuse and rectified these accordingly. 5. The LSCP should seek assurances that social workers, CP conference chairs and police officers involved in child protection duties have received training and apply relevant guidance when interviewing children and young people, potential witnesses (including family members) and alleged perpetrators where there is a risk of grooming and sexual abuse. LSCP could investigate whether police and CPS locally can report on the use of special measures/reasonable adjustments made to enable vulnerable victims and witnesses provide evidence. 6. The LSCP seek assurance that universal services and CSC practitioners are routinely utilising the Graded Care Profile2, or similar practice tools and the CE risks assessment toolkit to measure and monitor parental/ carer capacity to recognise and respond to risk of sexual abuse, neglect 28 and parental substance misuse. The LSCP should conduct an audit to ensure protection plans articulate the purpose and urgency of each interventions, setting out contingency or escalation if not actioned. 7. The LSCP establish mechanisms to monitor tracking of cases that are stepped down from PLO pre-proceedings work and those removed from CP and CIN processes where risks include sexual abuse, substance misuse and/or neglect. 8. LSCP monitor arrangements for cross boundary information sharing and outcomes of LADO investigations, particularly where this indicates a Barring referral should have been made to the DBS service. 9. The LSCP seek assurances from health providers and commissioners that trauma informed therapeutic support is available locally to young people (including those over 18 who experienced abuse as children) and their extended family. 10. The LSCB disseminate to relevant agencies and seek assurance staff, including designated safeguarding leads in schools, school nursing service, voluntary and charity sector organisations received a briefing on this review and have identified ways to improve practice. Workforce development and awareness raising 11. LSCP should consider a multi-agency practitioners’ workshop or skills based programme to enhance shared understanding of the legal framework available to disrupt perpetrators and protect children at risk of sexual abuse, providing clarity on: • the role of parents and carers in protecting children at risk of grooming and sexual abuse; • legal powers and expectations (as enshrined in the UNCRC) when collating and sharing information so as to assist lead agencies (local authority, the police and CPS) progress matters into Court in a timely manner. This requires treating the child, their family support network and universal services working with the child as partners in any protection plan, giving proper consideration to disclosures or indicative behaviours from the child and wider family/ support network; • the evidential burden required to arrest for offences, including complicity offences, so that a child is supported through specialist interview techniques and any criminal investigation can commence at the earliest opportunity; • legal powers that can be employed when supporting families to ensure that perpetrators find fewer opportunities to target and abuse children. The LSCP may consider devising advice for families and young people based on Finkelhor’s four pre-conditions model [see pg2.11 and section 4 of the report]. 12. LSCP to raise awareness of the Office for Civil Society’s and NCVO’s on-line resources for organisations and charities providing services to children and adults at risk to ensure safer recruitment practices and effective safeguarding investigations. Consideration may also be given to providing a skills-based course for VCFS organisations on ‘conducting an investigation following an allegation against staff and volunteer’ to address common evidential and HR issues. Kate and Fiona wish to thank the NSPCC’s for providing freely available on-line research and training resources (available at: https://learning.nspcc.org.uk) so that everyone involved in promoting a child’s safe development can better understand how to recognise and respond effectively when a child or young person is at risk of grooming and sexual abuse. |
NC043776 | Death of a 5-week-old baby girl in February 2011, from a non-accidental head injury. Child L and her family were only known to universal services. Father was arrested and charged with murder and Section 18 Wounding Offences Against the Person Act 1861 in connection with fractured ribs, which occurred 7-10 days prior to Child L's death. Mother was charged with attempting to pervert the course of justice. Review concludes that Child L's death could not have been prevented however it recognises a failure of professionals to take a full history from father or to record whether or not he was present at appointments. Makes various interagency and single agency recommendations covering Barnsley Safeguarding Children Board, midwifery and other health services.
| Title: Serious case review: concerning Child L: overview report. LSCB: Barnsley Safeguarding Children Board Author: Peter Ward Date of publication: [2013] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Barnsley Safeguarding Children Board Serious Case Review Concerning Child L Overview Report Author of Overview Report – Peter Ward, Independent Social Work Consultant 3rd February 2012 Page 2 of 46 Table of Contents Page 1 Introduction 3 1.1 Purpose of the Review 3 1.2 Circumstances leading to decision to carry out a Serious Case Review 3 1.3 Delay in the Decision to Carry Out this Review 4 1.4 Terms of Reference of the Review 5 1.5 Contributors to the Review and Methodology 6 2 Details of Family 8 2.1 Family Composition 8 2.2 Relevant Family Information 8 2.3 Information provided for this Serious Case Review by Mother & Father 9 2.4 Action Taken as a result of the information provided by Mother and Father 11 3 Summary of Agencies Involvement 13 3.1 Description of Agencies Providing IMRs and Reports 13 3.2 Chronological summary of agency involvement 14 4 Analysis 17 4.1 Introduction 17 4.2 Chronological Analysis 18 4.3 Analysis by Terms of Reference 21 4.4 Consideration of Significant Adults 32 4.5 Analysis of IMRs 33 5 Conclusions 35 6 Recommendations 38 Appendix 1 Genogram 40 Appendix 2 Integrated Action Plan 41 Appendix 3 Abbreviations 45 Appendix 4 References 46 Page 3 of 46 1. Introduction 1.1 Purpose of the Review 1.1.1 This Serious Case Review (SCR) was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards Regulations 2006 which came into effect on 1 April 2006. In accordance with the guidance issued in Chapter 8 of ‘Working Together to Safeguard Children’ (HM Government 2010), this Overview Report has been undertaken by an Independent Author and completed in accordance with the terms of reference set out in section 1.4 of this report. 1.1.2 Working Together to Safeguard Children 2010 states that an SCR should be undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death. The purpose of this Review is to: � establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; � identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and � improve intra- and inter-agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children 2010, 8.5) 1.1.3 Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, the above three points. 1.2 Circumstances leading to decision to carry out a Serious Case Review 1.2.1 Child L was born in January 2011 and lived with both her parents. She died in Hospital in February 2011 aged five weeks. 1.2.2 On an evening in February 2011 Child L was reported to have been found “floppy” and not breathing by her parents. An ambulance was called and basic life support was commenced by Child L’s father.. This was continued by the paramedics who transferred Child L to the Emergency department at Barnsley District General Hospital (BDGH). Full cardio pulmonary resuscitation was provided in the Emergency Department and Child L regained a regular heart rhythm. Child L was ventilated and stabilised whilst in the department and specialist transfer was arranged to Sheffield Children’s Hospital (SCH). 1.2.3 There was no evidence of external injuries to Child L and an ophthalmology examination was normal. However, a Computerised Tomography (CT) scan, carried out at SCH showed that Child L had suffered bleeding into the skull which had compressed the brain. Following a Magnetic Resonance Imaging (MRI) scan it was determined that Child L had suffered irrecoverable brain injury. Consequently paediatric intensive care was withdrawn and Child L passed away during the evening. 1.2.4 The initial post mortem indicated that non accidental injury (NAI) was a likely cause of death and the full post mortem results, which were received some months later after forensic examination, confirmed this. As a result of the full post mortem Page 4 of 46 results, a meeting of the Serious Case Review Sub Group of the Barnsley Safeguarding Children Board was held on 29 July 2011, and a decision was made to recommend that a Serious Case Review be undertaken in accordance with Chapter 8 of Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children (DCSF 2010). The Chair of the Barnsley Safeguarding Children Board accepted this recommendation on 22 August 2011. 1.3 Delay in the Decision to Carry Out this Review 1.3.1 Child L died in February 2011 and the decision to carry out an SCR was taken six months later in August 2011. On the face of it this is a significant delay and therefore the Independent Overview Report Author (IORA) has sought information as to the reason for it. It is stated within the IMR from SCH that whilst Child L was at BDGH and SCH, professionals were alert to the possibility of an NAI but there were no clear pointers to this and other diagnoses were also considered. The Police and Social Care were made aware of Child L’s condition shortly after she arrived at BDGH and again when she arrived at SCH. Professionals from both services spoke to Father and Mother whilst Child L was at SCH. Staff from SCH informed the Police of Child L’s death immediately and contacted Social Care at the start of daytime working hours on the morning after Child L’s death. 1.3.2 Because there was uncertainty about the cause of Child L’s death, additional pathological investigations were undertaken. On 31 May 2011 the Police received a report which stated that there was evidence of Child L having suffered fractured ribs seven to ten days prior to her death. This report was forwarded to the Neuro Pathologist for expert opinion as to whether these injuries were likely to have been caused by an NAI. The Neuro Pathologist concluded his report on 25 June 2011 and this report demonstrated the rib fractures and head injury to be non accidental. Subsequently, in July 2011 Mother and Father were arrested on suspicion of murder. The SCR panel met on 29 July 2011 to consider whether the case met the criteria for an SCR and the Chair of the LSCB decided, on 22 August 2011, that a SCR should be undertaken. 1.3.3 There appears to have been a gap of approximately 5½ weeks between it being brought to the attention of the Local Safeguarding Children Board (LSCB) that neglect and/or abuse had probably been a factor in Child L’s death and the decision being taken to carry out an SCR. This is one week longer than the timescale in paragraph 8.22 of Working Together to Safeguard Children 2010 which was due to the limited availability of Panel members as it was the middle of summer and several key people, including the Chair of the Board, had annual leave during this period. 1.3.4 Although it was uncertain, for several months, whether Child L’s death had been caused by an NAI, Social Care took immediate action in respect of Father’s three older children. Arrangements were put in place for contact between Father and Mother and the children to be supervised and Social Care undertook an assessment of the family. An Initial Assessment was started the day after Child L died, and was completed two weeks later. A Core Assessment was then started and was completed in May 2011. Social Care considered the assessment to be very positive with all family members being very cooperative and helpful although it was also very distressing for everyone. The closing comment in the assessment Page 5 of 46 was that the family should be allowed to get back to normal family life and there was no further role for social care. The matter was discussed with the Safeguarding Unit and it was felt at that meeting that nothing could be found to say the death was suspicious, therefore the assessments were concluded. Once the Core Assessment was completed Social Care involvement ceased and there was a period of unsupervised contact. The decision to re-implement supervised contact was made in July 2011 following information from the Police that Child L’s death was believed to have been caused by an NAI and a home visit was made to sign a written agreement. 1.4 Terms of Reference of the Review 1.4.1 The period of the Review was determined by the SCR Panel to cover the period from the notification of Mother’s pregnancy in June 2010 to the date of Child L’s death in February 2011. In addition education, police, health and social care agencies reviewed their records, for Child L, her parents and her half-siblings, for a five year period to ascertain whether there had been any previous concerns which might justify expanding the review to take in a longer time period and/or Child L’s half siblings. All agencies reported that they had not been aware of any concerns in relation to any of the family during that five year period. No issues emerged in respect of domestic violence, mental ill health or child protection and the Police and Social Care had no contact with the family at all during the period in question. 1.4.2 The following Terms of Reference were agreed at the beginning of the review: 1. Construct a comprehensive chronology of involvement by the organisation and/or professionals in contact with Child L and her family. 2. Summarise the decisions reached, the services offered and/or provided to Child L and her family and any other actions taken. 3. Consider if practitioners were aware of and sensitive to the needs of Child L in their work, had the relevant knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare. 4. Did the organisation have in place Policies and Procedures for Safeguarding and promoting the welfare of children and were able to act on concerns relating to a child’s welfare. 5. What were the key relevant points/opportunities for assessment and decision making in this case in relation to Child L and her family? Do assessments and decisions appear to have been reached in an informed and professional way? 6. Were appropriate services offered/provided or relevant enquiries made in light of any assessments? 7. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child L and her family and were they explored and recorded? 8. Were Senior Managers or other organisations and professionals involved at points in the case where they should have been? Page 6 of 46 9. Was the work consistent with each organisation’s and Barnsley Safeguarding Children Board Policy and Procedures for Safeguarding and promoting the welfare of children and with wider Safeguarding standards? 10. Were there organisational difficulties being experienced within or between agencies? 11. Did any resourcing issues have an impact on the case? 12. Consider the decision making process around the request for a scan for Child L and the impact of this process. 13. Establish if the recommendation for Child X SCR for Health Visitors to document all other persons present at a visit has been enforced and embedded. 1.4.3 At a subsequent SCR Panel Meeting held on 13 October 2011 it was decided that number 13 of the above Terms of Reference was too narrow and it was replaced with the following: 13. Establish whether there are any overlapping issues between this review and the Child X Serious Case Review and, if so, what has been done to address the issues. 1.5 Contributors to the Review and Methodology 1.5.1 Peter Ward, the IORA, has a background in social care and has worked in management and front line social work. He is qualified to degree level in social work and has a post-graduate diploma in management studies. He is now the Director of Arrow Social Care Consultancy Limited and, as such, undertakes investigations and other consultancy work on an independent basis. Since 2005 he has been involved in several Serious Case Reviews as an Overview Report Author, Individual Management Review Author or Panel Chair. His appointment is in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The overview report should be commissioned from a person who is independent of all the local agencies and professionals involved and of the LSCB(s). The overview report author should not be the chair of the LSCB, the SCR sub-committee or the SCR Panel.” 1.5.2 The chair of the Barnsley Safeguarding Children Board (BSCB) is Simon Hart. The independent chair of the SCR Panel for this SCR is Diane Hampshire who is employed by NHS Leeds as Head of Safeguarding Children and Adults and is the Designated Nurse for Safeguarding in NHS Leeds. As such Ms Hampshire has considerable experience of Safeguarding Children and of the SCR process but is independent of all the local agencies and professionals involved and of BSCB. Her appointment is in accordance with the guidance at 8.16 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The Chair of the SCR sub-committee should be an experienced person and could be the independent Chair of the LSCB, or a member of the LSCB. The Chair of any SCR Panel should not be a member of the LSCB(s) involved in the Page 7 of 46 SCR, an employee of any of the agencies involved in the SCR or the overview report author. The SCR Panel Chair can be the independent LSCB Chair, someone from another LSCB which is not involved in the SCR or from an agency which is not involved in the case.” 1.5.3 In addition to the chair the following people were members of the SCR Panel: � Assistant Executive Director, Safeguarding Health and Social Care, Barnsley Children Young People & Families (CYP&F) � Head of Children’s Social Care, Barnsley CYP&F � Head of Safeguarding and Welfare, Barnsley CYP&F � Assistant Director, NHS Barnsley � Designated Nurse Safeguarding Children, NHS Barnsley � Medical Director and GP Representative, NHS Barnsley � Designated Doctor Safeguarding Children, Barnsley Hospital NHS Foundation Trust (BHNFT) � Public Protection Unit Manager, South Yorkshire Police � Solicitor, BMBC Legal � Area Manager, Education Welfare, Barnsley CYP&F 1.5.4 The SCR Panel met on 13 October 2011, 16 November 2011, 22 December 2011 and 1 February 2012 in connection with this SCR. The IORA was not a member of the SCR Panel but attended the Panel meetings in connection with writing the Overview Report. 1.5.5 The SCR Panel received and considered Individual Management Reviews (IMRs) the following agencies: � BHNFT � Primary Care, NHS Barnsley � Sheffield Children’s NHS Foundation Trust (SCNFT) � South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � NHS Barnsley (the Health Overview report) 1.5.6 The Serious Case Review Panel received and considered reports from the following agencies: � Yorkshire Ambulance Service (YAS) 1.5.7 The authors of the IMRs are all independent in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children, 2010’ which states that: “Those conducting management reviews of individual services should not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.” 1.5.8 A comprehensive integrated chronology of agency involvement and significant events for the period covered by the review has been compiled from the chronologies provided within the IMRs. This has been analysed by the SCR Panel. 1.5.9 The IORA undertook this review by making reference to the terms of reference, IMRs and other reports listed above and through discussions at SCR panel meetings and face to face, telephone and email communication with IMR authors and SCR Panel members. Page 8 of 46 1.5.10 In addition the SCR Panel considered which family members should be involved in the review and how and when to involve them. The Panel decided that Child L’s Mother and Father should both be invited to contribute to the review and this was done by way of a face to face meeting with the IORA and the Independent Chair of the SCR Panel (hereafter referred to as the Panel Chair). This meeting took place in December 2011, whilst Mother and Father were both subject to Police bail but before they had been charged with any offences. Prior to the meeting, the IORA consulted with the SCR Panel representative and the Senior Investigating Officer from South Yorkshire Police to ensure that the meeting would not impact upon possible criminal proceedings. 1.5.11 In writing this Overview Report, the IORA has been mindful of the revised approach to the evaluation of SCRs described by the National Director, Development and Strategy for Ofsted in a letter dated 14 December 2011 to Directors of Children’s Services and LSCBs. 2. Details of Family 2.1 Family Composition 2.1.1 Child L Born January 2011, Died February 2011 Relationship to Child L Referred to as Ethnic Origin Mother Mother White British Father Father White British Half sibling L2 White British Half sibling L3 White British Half sibling L4 White British Mother of L2 Adult 1 White British Mother of L3 & L4 Adult 2 White British 2.1.2 A genogram of the above family is included as Appendix 1 of this Overview Report. 2.2 Relevant Family Information 2.2.1 Child L lived with her mother and father throughout her short life. She was the first child of Mother but Father already had three children from two previous relationships. All three children lived with their mothers throughout the time that Child L was alive. 2.2.2 The SCR Panel considered which members of the family should be part of the review. Agencies identified all contacts they had had with the three siblings over the period covered by the review and found these contacts to be few in number and not to have had any Safeguarding dimension. Because of this, the SCR consider that any possible benefit of including the siblings in the review was outweighed by the possible negative impact on their privacy. 2.2.3 Father and Mother informed the IORA and Panel Chair that prior to the death of Child L, L3 and L4 had visited the family home on a daily basis and stayed overnight at weekends. Therefore during Child L’s lifetime L3 and L4 had seen her on a regular and frequent basis. Father and Mother had also maintained frequent contact with L2 although this had been less regular than with the younger children. Page 9 of 46 Following the death of Child L, Social Care requested that all contact between Mother and Father and the children should be supervised. In the case of L2 supervision is provided by Father’s parents and in the case of L3 and L4 by their mother or Mother’s parents. When the IORA and Panel Chair met Father and Mother they expressed their unhappiness with the need for contact to be supervised because it made it much more difficult to arrange. 2.2.4 It appears that Mother and Father have supportive families with whom they have frequent contact. In addition to the support being given with regard to supervision of contact Mother’s mother was present at Child L’s birth and when she died whilst Mother’s father and maternal aunt and uncle were also present when Child L died. 2.2.5 The family are white, British with English as their first language, which is typical of the area in which they live. Little information is recorded about the family’s religion although there is a record of Mother stating that she was not religious. There are no records to indicate that either parent had a disability and Child L had not been diagnosed as having any form of disability at the time of her death. 2.2.6 The family lived in an area of deprivation which was hit very hard by the loss of the mining industry in the latter part of the 20th century. Despite continued regeneration projects unemployment and child poverty remain, with approximately one third of the working age population claiming benefits from the Department of Work and Pensions and nearly 12% being in receipt of Disability Living Allowance. However both Mother and Father were in employment and none of the agencies involved had documented concerns regarding the home environment or the family’s financial situation. 2.2.7 Father has been charged with the murder of Child L and also with Section 18 Wounding Offences Against the Person Act 1861 in connection with her fractured ribs. Mother has been charged with attempting to pervert the course of justice. Neither parent has yet stood trial in connection with these charges. 2.3 Information provided for this Serious Case Review by Mother and Father 2.3.1 In their meeting with the IORA and the Panel Chair, Father and Mother were largely positive about the services they received during Mother’s pregnancy and in the weeks following the birth of Child L. Mother had received care from Barnsley midwives but attended ante natal clinics and gave birth in a neighbouring hospital. She felt that this had worked well and she described the midwife who delivered Child L as “brilliant, very supportive and professional”. 2.3.2 Mother acknowledged feeling a little upset at times, including her first meeting with the health visitor but she said that she had not been depressed and she made this clear to the health visitor. Mother’s only slightly negative comment about the care she received was that she felt that the health visitor and midwife gave slightly different advice about feeding. However this was not a significant problem and she felt reassured by the comments the health visitor made about feeding. 2.3.3 Both Mother and Father said that Father had been present during some of the appointments with health staff but had not been present for them all due to his work. Father felt that he had been included and said he felt able to ask questions when necessary. For example he said that he asked about jaundice. Mother said Page 10 of 46 that both Father and her mother had been present at Child L’s birth and she felt that she could not have done it without Father there. 2.3.4 Mother and Father were complimentary about the way they had been treated at BDGH following Child L’s collapse in February 2011. They found it particularly helpful that a nurse stayed with them most of the time and kept them informed of what was going on. Similarly they found it helpful that Embrace staff explained what was happening, made them aware that Child L would be going for a scan when they arrived at SCH and came to wish the family good luck once their role had finished. Mother and Father also commented that the police officers present at the hospital introduced themselves and Mother and Father were told that it is usual for the police to be present in such circumstances. At SCH Mother and Father again appreciated being given information; they commented that they were able to stay at their daughter’s bedside and the nurses explained what tests were being done and the machines that were being used. 2.3.5 Mother and Father are, however, unhappy with one aspect of how they were treated during the morning when they were in SCH with their daughter. A doctor came to see them and Mother and Father took an instant dislike to him because of the way he spoke to them. Social Care and the police were at the hospital and Mother and Father felt as though people were ‘pointing the finger at them’ as being responsible for Child L’s condition. The police said that they wanted to go to the house and asked for the keys which they were given; Social Care said that they could not see Father’s other children without supervision and the doctor discussed ‘shaken baby syndrome’. Mother and Father had no problem with letting the police have their house keys but feel that it was wrong for people to talk to them in the way they did at that time, whilst their daughter was dying. Father feels that Social Care have ‘cocked up’ in the past, by not protecting children, so were reacting in this way with them. It appeared that he was referring to Social Care generally rather than making a comment specifically about Barnsley Social Care. Mother and Father understand that children get injured and agencies have a job to do but strongly feel that this was not the time to be talking to them in that way. 2.3.6 Mother and Father also expressed a number of concerns regarding the services they have received since their daughter died. They remain on police bail and because of this Mother has been suspended from her job which has resulted in a reduction in their income. They are also unhappy that all contact with Father’s children has to be supervised as it is difficult to arrange this, particularly with L2. Mother and Father were due to answer bail three days after their meeting with the IORA and Panel Chair and were hopeful that they would be told that criminal proceedings were not going to be pursued and that they would be able to get their lives back in order. 2.3.7 Mother and Father were unclear what Social Care’s involvement was at the time of the meeting because, although contact had to be supervised, they said they had not seen a social worker since July or August 2011 and they had had a letter from Social Care saying that everything was back to normal and a card saying sorry and wishing them luck for the future. They were upset about this card as they felt they had been badly treated by Social Care and they ripped it up. Mother and Father also made the point that, although they were abiding by the requirement for contact to be supervised, no-one was monitoring this. Page 11 of 46 2.3.8 In terms of support, Mother said that the midwife visited and offered to refer her for bereavement counselling. A letter was sent with an appointment but Mother misread this and thought the appointment was on a Thursday when it was in fact two days earlier on the Tuesday. Consequently she missed the appointment. Mother intends to phone up to rearrange this. Shortly after the death of Child L the health visitor offered to refer the family to the bereavement health visitor but nothing has come of this. In addition, Mother’s GP offered her medication to cope with the bereavement; but she did not want this. 2.3.9 Father said that work have been very supportive of him; they have given him time off if necessary and have offered him counselling. He has a different GP to Mother and the GP did not know that Child L had died. He has not been offered counselling by the GP. 2.3.10 Father’s other children have not been offered any external support but have been supported by the family. 2.3.11 Mother and Father feel that they should have been given information about what support is available to them. However they consider themselves lucky in the sense that they have very supportive families, including both Mother and Father’s parents and the mothers of Father’s older children. Therefore they have managed without bereavement counselling. 2.3.12 Mother told the IORA and Panel Chair that she is pregnant again and is due to give birth in 2012; she has mixed emotions about the pregnancy. She is under the care of the same hospital as before and feels that they are being very supportive and are offering whatever tests she wants to have. She is also having additional midwifery appointments and expects to see the social worker for a pre-birth assessment. 2.4 Action Taken as a result of the information provided by Mother and Father 2.4.1 It is notable that Father and Mother did not make any significant criticisms about the services provided to them prior to their arrival at SCH after Child L had sustained the injuries that led to her death. Therefore the comments they made that might require attention from agencies related almost exclusively to issues outside the timescale and scope of this SCR. Nevertheless it was important that the SCR Panel took their comments seriously and considered what action to take in respect of their comments. Consequently at the Panel Meeting on 22 December 2011 the SCR Panel discussed the issues raised by Mother and Father and the following actions were then taken: 2.4.2 The Designated Nurse confirmed that there is in fact no bereavement health visitor, only a bereavement midwife. However, the Designated Nurse has contacted the health visitor involved with the family and asked her to extend support to them as they had not picked up on the support offered by the bereavement midwife. The Designated Nurse explained to the Panel that in Barnsley, a pack is given to bereaved parents by the hospital with lots of helpful contacts for agencies in Barnsley and SCH does this for bereaved families in Sheffield. 2.4.3 The SCR Panel were disappointed to learn that Mother and Father had been upset by the timing of police and Social Care involvement whilst they were at SCH and Page 12 of 46 Child L was dying. However Panel Members acknowledged that the agencies involved have important roles in respect of protecting children and investigating potentially suspicious events. Talking to parents in such circumstances is never likely to be easy and there is no good time to do it, however it does have to be done. All the professionals who were involved with Father and Mother whilst they were at SCH, carry out jobs where they will frequently be dealing with people in difficult emotional circumstances and it is important that they have appropriately training and skills. Nevertheless Panel Members felt that some people’s ‘soft skills’ are inherently better than others. 2.4.4 The Panel noted that Mother and Father said they had taken a dislike to the doctor who spoke with them on the morning that Child L died and felt that this was an understandable response as the doctor would have been viewed as the person who was effectively “pointing the finger” and suggesting that Child L’s injuries may have been non-accidental. Nevertheless it was agreed that the Mother and Father’s perceptions would be fed back to the doctor in order that he can learn from this. 2.4.5 The Head of Children’s Social Care within Barnsley CYP&F has checked the social care records and spoken to the social worker involved with Mother and Father and has provided the IORA with the following information: � The social worker clearly remembers sending a condolence card to Mother and Father after Child L’s death. She describes this as saying something like “sorry for your loss” It was most emphatically not an apology but a register of empathy at a time when the prevailing view was that Child L had died a natural death. She thinks it was sent around the end of April or beginning of May 2011, after the initial assessment was complete. � There is no record of a letter, and the social worker cannot recall sending one. It seems likely that what Mother and Father refer to as a letter, was in fact the initial assessment which does say in the last paragraph of the recommendations section: “My recommendation is that the family should be allowed to get back to normal family life. It is also important that a safeguarding meeting is held to discuss Mother’s work and make decisions about any possible return to work. Again this needs to happen as a matter of urgency as the current uncertainty is extremely stressful for Mother, Father and the extended family.” � Although Mother and Father’s recollection was that they had not had a visit from a social worker since July or August 2011 records show that a visit was made in October 2011 to explain the pre-birth assessment process. At that time the view was taken that contact arrangements were secure and it was not intended that any further action would be taken until the pre birth assessment, unless there were significant changes in the available information. The pre birth assessment commenced in January 2012 and the social worker will have more frequent contact with Mother and Father as this progresses. 2.4.6 It is notable that Mother and Father drew attention to a number of occasions when professionals explained things to them and kept them informed as to what was happening. They clearly found this to be helpful, even during the last few hours of Child L’s life. By contrast they have felt unclear about Social Care’s role in recent months and what to expect from the social worker. This is a useful reminder for all Page 13 of 46 agencies of the importance of communicating with their service users and providing clear and unambiguous explanations. 3. Summary of Agencies Involvement 3.1 Description of Agencies Providing IMRs and Reports 3.1.1 BHNFT provides a range of in patient and out patient health services within Barnsley and the surrounding area. The services which had contact with Child L and her family during the period covered by the review were maternity services (antenatal clinic and community midwifery services) in connection with Mother’s pregnancy and the birth of Child L and the emergency department at BDGH in connection with the incident that led to Child L’s death. 3.1.2 Mother chose to give birth and have scans and blood tests in connection with her pregnancy at a neighbouring hospital. The involvement of this hospital is addressed within the IMR from BHNFT. 3.1.3 The Primary Care IMR considers the family’s contact with General Practice during the period covered by the SCR. Child L and her mother were registered with one practice and Father with another. Mother visited the GP in June 2010 when her pregnancy was confirmed. She had no further contact with the GP, regarding herself, throughout the remainder of the period covered by the review. Child L was taken to see the GP on one occasion whilst Father had no contact with the GP at all during the period covered by the review. 3.1.4 SCNFT is a dedicated paediatric Trust which provides paediatric medicine and surgery, radiology, transport services and paediatric intensive care on a regional basis. The only contact that Child L and her family had with this Trust during the period covered by the review occurred after the incident which led to Child L’s death. She was transferred from BDGH to SCH, the Trust’s hospital, by Embrace, the Trust’s specialist transport service. Once at SCH she was cared for in the Paediatric Intensive Care Unit (PICU) until her death that evening. Whilst Child L was at SCH she underwent CT and MRI scans and an ophthalmology investigation. 3.1.5 SWYPFT provided health visiting services to the family, with a health visitor visiting the family home twice and Mother and Child L visiting a Children Centre baby clinic once. SWYPFT had no other contact with the family during the period covered by this SCR. 3.1.6 YAS had only one contact with the family during the period covered by the SCR. This commenced with a 999 call from Mother during the evening when Child L had stopped breathing. As a result of this call, a paramedic and an ambulance were dispatched to the family home and Child L was conveyed to BDGH. Prior to the arrival of the paramedic, staff from the Emergency Operations Centre provided instruction to the parents’ by phone. 3.2 Chronological summary of agency involvement Antenatal Period; June 2010 to January 2011 Page 14 of 46 3.2.1 Mother’s pregnancy with Child L was confirmed in June 2010 and 11 days later a community midwife carried out an antenatal booking contact. At this initial contact, screening and dietary advice was discussed and a routine mental health assessment was undertaken which did not indicate any mental health concerns. No previous obstetric history was reported and no social concerns were documented. Mother was asked about domestic abuse during the antenatal booking contact and it was recorded that she did not disclose any abuse. 3.2.2 Mother elected to have scans and blood tests and to give birth at a hospital in a neighbouring area. This decision reflects patient choice and is not an unusual decision for people living in the particular part of Barnsley in which this family lived. 3.2.3 During her pregnancy Mother had six contacts with maternity services in Barnsley and attended the ante natal clinic at the neighbouring hospital on three occasions. She attended for all appointments and no complications or concerns were noted. She was given routine health promotion advice about achieving a healthy pregnancy. This covered issues such as diet, smoking and alcohol. 3.2.4 The community midwife in Barnsley recorded a partial history for Father but he was not asked about drugs and alcohol use or mental health issues. There is no record of when the midwife saw Father although she told the author of the BHNFT IMR that she remembers him being present at some of the antenatal contacts. Birth of Child L; January 2011 3.2.5 Mother was admitted to hospital in advanced labour and Child L was born that day at 36 weeks gestation. No concerns were noted. A paediatric check and hearing screening were conducted the following day and nothing abnormal was detected. Child L was bottle feeding well on demand. Postnatal Period; January – February 2011 3.2.6 Mother and Child L were discharged home from hospital the day after Child L was born. Community midwives from BHNFT then visited them at home on the 3rd, 4th, 6th, 8th and 14th day of Child L’s life. In total three different midwives visited with the last three visits all being undertaken by community midwife 1, who had also had the majority of antenatal contact with Mother. A student midwife was also present at the final visit. Records state that Child L and Mother were both seen at all of these visits but there is no record of whether Father or anyone else was present. However community midwife 1 told the author of the BHNFT IMR that she remembered Father being present at some of the visits and she took a partial history from him. 3.2.7 During the five postnatal midwifery visits, Mother was given routine health promotion advice about safe sleeping and reducing the risk of cot death, general care and feeding. Leaflets were provided in support of these topics. No information was given about ‘Shaken Baby’ syndrome. The only concern recorded about Child L was slight facial jaundice on the first and second visit. The only concern recorded about Mother was at the final visit when she reported herself to have been feeling emotional over the last few days. Support was offered to Mother in respect of this. Page 15 of 46 3.2.8 Following the final visit from the community midwife Mother and Child L were discharged to the care of the GP and health visitor. There was no written handover from the midwife to the health visitor but both professionals report that information was passed on verbally, this included information about Mother feeling low emotionally. Neither professional made a written record of their discussion. 3.2.9 The first visit from the health visitor to Child L was made the day before the last visit from the midwife. The health visitor carried out a Guthrie screening test1 on Child L and also undertook a routine head to toe examination which gave no cause for concern. The health visitor recorded that an elderly male had been present with a small child but did not record who these people were. When the IMR author interviewed the health visitor the health visitor stated that she had not asked the identity of these people but had assumed that the adult was one of Child L’s grandfathers. The health visitor also informed the IMR author that Father had been present during the visit and had handled Child L appropriately. The health visitor had been able to discuss the family history and had been told that Father had three older children from previous relationships and also that he was supportive in the home. None of this information was included in the health visitor’s written record of the visit. The health visitor did record that Mother reported being low in mood and feeling tearful and the health visitor discussed ‘baby blues’ with Mother and arranged a follow up visit the following week to provide support. 3.2.10 The follow up visit from the health visitor was carried out one week later, as had been agreed, and the health visitor recorded that Mother’s mood was improved and she was in much better spirits. Nevertheless the health visitor discussed postnatal depression and its potential side effects. At this visit the health visitor assessed Child L’s feeding pattern and found that she had made an acceptable weight gain to 3.08 kg and was reportedly taking four ounces of milk every four hours. The health visitor told the author of the SCNFT IMR that Father was not present at this visit and she took this opportunity to ask questions in relation domestic abuse and substance misuse. Mother did not make disclosures in relation to these questions although the IMR author has written that in cases where disclosures are made this often happens at a later date when the mother’s relationship with the health visitor has developed. The health visitor also made enquiries of Mother about Father’s other children and was told that they lived with their mothers. There is no record of how much contact the children had with Father. The health visitor felt that Mother lacked confidence and the health visitor offered ongoing support for Mother at the six-week visit. In the event, the six week visit did not take place as Child L died before reaching six weeks of age. 3.2.11 The next contact with the family took place six days later when Mother took Child L to see the GP due to concerns because Child L cried when trying to open her bowels. This was the only contact that Child L ever had with the GP. The author of the Primary Care IMR describes the examination that was carried out by the GP and explains that this is a very common presentation in new babies and that a GP would not be expected to focus on anything other than the presenting problem in such a situation. Records show that the GP examined Child L’s abdomen and provided reassurance to Mother. The GP reported having no recollection of this consultation when interviewed by the author of the Primary Care IMR and there was no reference in the records to Mother’s mood at the consultation. 1 A screening test that is offered to all infants in the first few days of life to test for a number of possible health disorders Page 16 of 46 3.2.12 Eight days after the GP consultation, Mother took Child L to the Children’s Centre baby clinic where Child L was measured and weighed by a nursery nurse and the health visitor saw Mother who reported that Child L was unsettled on feeds of three ounces every three hours. The health visitor recommended that Mother revert to giving Child L four ounces of milk at each feed as she had done previously. The author of the SWYPFT IMR explains that the clinic provides an opportunity for staff to observe interactions between parent and child and that babies are weighed naked for the purpose of accuracy and the observation of the child for any medical conditions including possible injury. No concerns relating to Child L are recorded in the record of this visit. Admission of Child L to hospital and her subsequent death; February 2011 3.2.13 The day after the clinic visit, Child L was admitted to the Emergency Department at BDGH at 21:17 hours after her parents had called for an ambulance. Child L’s parents reported that she had appeared well that day and had gone to bed at about 19:00 hours after a feed. She had woken at approximately 20:30 hours and was crying; she was picked up by Mother and was then reported to have gone “floppy” and stopped breathing. Father reportedly commenced cardio pulmonary resuscitation (CPR) whilst Mother dialled 999 and requested an ambulance. YAS received the 999 call at 20:37 hours and dispatched a paramedic and a Double Manned Ambulance to the address. YAS staff in the Emergency Operations Centre remained on the phone to Mother whilst the paramedic and ambulance were en route to Child L’s home and provided advice to Mother in respect of the CPR. The paramedic arrived at 20:45 hours, eight minutes after the service received the 999 call and the ambulance arrived three minutes later. 3.2.14 Child L was transferred to the ambulance where resuscitation attempts continued and at 21:01 hours the ambulance left the scene in order to convey Child L to hospital. A pre-alert call was made to the hospital warning of an impending cardiac arrest. 3.2.15 At 20:50 hours, whilst resuscitation attempts were being made, the Police were informed of the 999 call and at 21:05 hours the police called YAS for an update. 3.2.14 On arrival at BDGH there was possibly an occasional heartbeat which was written up at around 30 per minute by the Paediatric Registrar. Full CPR was carried out and by the time the Paediatric Consultant arrived around 21:35 hours Child L had a regular heartbeat around 130 per minute and had been intubated by an Anaesthetist. She had no rash present and on examination by the Paediatric Consultant there were no signs of bruise or injury, she had normal heart sounds, no heart murmur, no signs of heart failure, her fontanel was normal tension, and pupils were 3 mm in size, non-reactive and equal. Child L was ventilated and stabilised at BDGH and the Transfer Team from Embrace were called to transfer her to the PICU at SCH. The Consultant from Embrace requested that a CT scan of the head should be undertaken prior to transfer. Because these events were taking place after 20:00 hours, no consultant radiologist was available on site at BDGH and arrangements for a CT scan had to be made in accordance with the Department of Medical Imaging Policy for Out of Hours Radiology. Under this policy, BHNFT have a contract with an external Teleradiology service. If a clinician requires a CT scan a request is made to the Teleradiology Consultant who is Page 17 of 46 responsible for authorising a radiographer to carry out the scan. Images from the scan are then transferred to the Teleradiology service which is responsible for providing an electronic written report to the clinician who requested the scan. In the case of Child L, the Teleradiology Consultant refused the request for a CT scan stating that there was nothing to indicate that it was required, it would not fit National Institute of Clinical Excellence (NICE) guidelines and she could not interpret a CT scan on a baby of this age. As a result of this response a decision was taken to progress with the transfer of Child L to SCH and to carry out the scan on arrival there. 3.2.15 Child L arrived at SCH at 02:25 hours after an uneventful transfer. A CT scan was undertaken and she was transferred to the PICU. During the course of the day various investigations and examinations took place, including an MRI scan and an eye examination and numerous phone calls and assessments were made. Child L’s parents, maternal grandparents and maternal aunt and uncle were present throughout the time Child L spent at SCH and discussions were held with them. At 19:55 hours treatment was withdrawn after discussion with Mother and Father and at 20:15 hours Child L died. 3.2.16 Prior to Child L’s transfer from BDGH to SCH, Social Care was contacted to undertake a safeguarding list check and no concerns were reported. A note in the departure list stated that safeguarding “will need to be sorted out.” The police and Social Care attended SCH and spoke with Child L’s parents. 4. Analysis 4.1 Introduction 4.1.1 The following analysis commences with a ‘freeform’ analysis of agency involvement in a chronological order. This is used to identify key issues of practice. After the ‘freeform’ analysis the IORA provides further analysis with direct reference to each of the 13 Terms of Reference identified by the SCR Panel. A repeating issue from this review concerns how agencies should work with fathers and other significant adults. Section 4.4 of this report specifically considers that issue. Finally there is analysis of each of the IMRs and the Health Overview Report. 4.2 Chronological Analysis Antenatal Period; June 2010 to January 2011 4.2.1 Through the antenatal period Mother received appropriate services in view of the information that she disclosed to health professionals. She exercised her right to choose where she gave birth and it appears that the interface between the hospital and midwives in Barnsley was managed appropriately. No information came to light to cause any concern for any of the staff who came into contact with Mother. 4.2.2 With hindsight, one apparent shortfall in the practice of staff during this period was the failure to take a full history in relation to Father or even to record whether or not he was present during the various contacts that the midwifery service had with Mother. However, this needs to be viewed in the context of the policies and procedures in place at the time of Mother’s pregnancy with Child L. The maternity Page 18 of 46 paperwork in use in Barnsley during the period covered by this review, which is national paperwork, does not have prompt fields for questions to be asked of fathers, or other significant adults in the home, relating to issues such as alcohol or drug misuse and mental health. On a local level, at the time of Mother’s pregnancy with Child L there was no expectation on midwives to take full social histories of fathers or even to document if or when the father was seen by the midwife. This is an important issue that will be considered in more detail later in the analysis. 4.2.3 The authors of the BHNFT IMR have identified that whilst Mother was provided with a range of health promotion advice both antenatally and postnatally no information was given, either verbally or in writing concerning ‘shaken baby’ syndrome. The review found that a leaflet used to be given routinely but was discontinued when the information from the leaflet was incorporated into the Personal Child Health Record (Red book). Furthermore it appears that the practise of discussing this issue has also ceased to be a common occurrence. The authors of the BHNFT IMR point out that there is no clear evidence that Child L’s injuries were the result of being shaken, but nevertheless, it is good practice for issues around managing crying episodes and the frustration this can lead to to be discussed with both parents during the antenatal period or very soon after the child is born. The authors of the Health Overview Report consider how information about the risk of shaking a baby is provided to parents in America and support the view of the authors of the BHNFT IMR that action needs to be taken as a result of this review to ensure that suitable arrangements are put in place in Barnsley. Birth of Child L; January 2011 4.2.4 The review has not identified any significant issues during the time that ML was in hospital for the birth of Child L. Postnatal Period; January – February 2011 4.2.5 There were five midwifery visits to Mother and Child L in the fortnight following Child L’s birth which appears to have been an adequate number. These were appropriately used to assess the physical health and wellbeing of Child L and Mother and the emotional health of Mother. These assessments did not identify any significant issues of concern although at the final visit Mother reported feeling a little tearful. This was addressed appropriately by the midwife at the time but information was not passed on to the health visitor in writing as it should have been. 4.2.6 The handover from the midwife to the health visitor did not include a written handover although this is required by procedure. The author of the BHNFT IMR explains that the reason for this omission was that Mother had given birth outside Barnsley and consequently the established discharge form was not included with the documentation provided by the hospital as it would have been if the child had been born in Barnsley. Given that the author of the BHNFT IMR also states that it is not unusual for pregnant women, living in this particular area of Barnsley, to give birth at the hospital in question, the IORA considers it unacceptable that there is no system in place to ensure that a discharge form is available. The IORA notes that BHNFT have made a recommendation to address this shortfall. Page 19 of 46 4.2.7 Although a discharge form was not completed, both the midwife and the health visitor maintain that there was a verbal handover between them. However there is no written record of this from either of them, which is another shortfall in practice. Irrespective of whether a handover took place, the health visitor’s first visit to Mother was actually the day before the final visit from the midwife and therefore Mother informed the health visitor that she had been feeling tearful before she informed the midwife. It is evident from the information provided by the health visitor when she was interviewed in connection with this SCR that her record of her first visit to the family was incomplete. 4.2.8 The authors of the BHNFT and SWYPFT IMRs describe Mother’s feelings of tearfulness as ‘baby blues’. The authors of the Health Overview Report explain that, according to the Royal College of Psychiatrists in 2011, ‘baby blues’ is experienced by an average of eight out of ten women three or four days after birth and that the feelings tend to disappear within a few days (ten days) after birth. The authors of the Health Overview Report compare ‘baby blues’ with postnatal depression which, they explain, is an illness which occurs between four and six weeks after birth and initially resembles the symptoms of ‘baby blues’ but is more intense and longer lasting. The authors of the Health Overview Report point out that when Mother reported feeling tearful to the midwife this was the 13th day after birth. Given that this is outside the three to ten day period identified by the Royal College of Psychiatrists the authors query whether Mother was simply experiencing ‘baby blues’ but they do not reach any conclusion. 4.2.9 Whilst it may not be possible to categorically diagnose Mother’s feelings of tearfulness as ‘baby blues’ it is the view of the IORA that the most important aspect of this is how professionals responded to Mother. The health visitor’s response at the first visit was to arrange a further visit one week later. When Mother reported, at this second visit, that she no longer felt tearful, the health visitor offered ‘listening visits’ if they were required. The authors of the Health Overview Report explain that listening visits “are an intervention designed to help women who are having mild adjustment problems in the postpartum period, and were developed in the United Kingdom. In addition to checking on the health of the mother and baby, health visitors also assess the mother’s emotional well being. If a woman is found to not to be coping emotionally, and she is not severely disturbed, the health visitor offers to provide listening visits.” The authors quote Serge L, (2007) in stating that “listening visits have been shown to be effective in the U.K.” It is the view of the IORA that the response from the health visitor was appropriate. The IORA also points out that when he met with Mother she reinforced that although she had felt a little upset at the times she had not felt depressed and had made that clear to the health visitor. 4.2.10 The absence of any record from the midwife or health visitor about whether or not Father was present at their visits is a further reflection that these services paid insufficient attention to his role in the family and the care of the child. Such failure to adequately consider the father or other male care giver in a family has been recognised and well documented over a number of years. For example in pages 51 – 54 of “Understanding Serious Case Reviews and their Impact, A Biennial Analysis of Serious Case Reviews 2005 – 07” Brandon et al (2009) identify a frequent failure by agencies to adequately engage with men in families. This includes a failure to gather information about their history or to include them in assessments. Page 20 of 46 4.2.11 Notwithstanding the above comments it should be emphasised that, in this case, Father had no known history that should have caused concern to agencies and therefore, even if he had been assessed and enquiries made, no matters of concern would have come to light. Cavanagh et al (2007) found, in their study of fathers who fatally abuse their child, that the men are “under-educated, under-employed, with significant criminal histories” there is a strong correlation to violence to women, with 75% being violent towards the child’s mother. Less than 13% were married to the mother of the child. There is nothing to indicate that any of these factors identified applied to Father or that there were any other indicators that should have given agencies cause for concern. Furthermore, although Father has now been charged with his daughter’s murder he has not yet stood trial. 4.2.12 With regard to Child L’s visit to the GP 10 days before her death, the author of the Primary Care IMR helpfully explains the accepted pattern by which a GP should conduct a consultation using the Royal College of General Practitioners (RCGP) protocol for a standard medical record. It is important to understand that such a consultation is reactive to the problems that are being presented. In this case Child L was presented with a reported history of crying when trying to open her bowel and the author of the Primary Care IMR explains that this is a common presentation in new babies and is not an event that would cause a GP to focus on anything other than the initial problem. 4.2.13 Following Child L’s death it was found that she had suffered fractured ribs around the time of the GP consultation. In the case of some previous child deaths, including that of baby Peter in Haringey, there has been concern that medical practitioners have failed to identify injuries that it was later found had been present during consultations. Because of this, IMR authors, the authors of the Health Overview Report, the IORA and the SCR Panel have all given careful consideration to whether the GP should have identified that Child L had fractured ribs at the consultation. It is the opinion of the medical experts, backed up by research, which is highlighted within the Health Overview Report, that even if Child L had sustained these injuries before the GP consultation there would have been no outward signs to enable the GP to identify them. Therefore it is the view of the IORA that the GP should not be criticised for failing to identify any injuries to Child L. 4.2.14 Similarly, consideration has been given to whether the nursery nurse and/or health visitor should have identified that Child L had these historic injuries when she was examined at the baby clinic the day before her admission to hospital. Again the IORA accepts, based on evidence within the Health Overview Report, that it would not be reasonable to expect them to have done so. Admission of Child L to hospital and her subsequent death; February 2011 4.2.15 In analysing the response from YAS the author of the Health Overview Report concludes that there is nothing to suggest that the care provided to Child L and her family was not of a good standard. The author explains that the national target response time for immediately life threatening emergencies is within eight minutes and this target was just met as the paramedic arrived exactly eight minutes after the call was received by YAS. Page 21 of 46 4.2.16 This SCR has not identified any concerns with the medical care that Child L received at either BDGH or SCH with the exception of the refusal to undertake a CT scan whilst Child L was at BDGH. Furthermore, given this refusal, the decision to transfer her to SCH without further delay is considered appropriate. Term of reference 12 specifically concerns the issue of the CT scan and therefore it will not be considered in any further detail at this point in the report. 4.2.17 In addition to providing emergency treatment to Child L, hospital staff were responsible for dealing with Child L’s parents, maternal grandparents and maternal aunt and uncle who were present. It was also necessary for hospital staff to consider possible causes of Child L’s collapse and to liaise with other agencies as appropriate. 4.2.18 Comments made by Mother and Father in their meeting with the IORA and Panel Chair suggest that both hospitals were largely successful in managing the family members in a supportive and sensitive way. Records make it clear that both hospitals appropriately considered the possibility of NAI and liaised with Social Care and the police as required. Although Father and Mother felt that there timing of the intervention from Social Care and the police was insensitive, the SCR Panel are of the view that this was probably unavoidable and it is unlikely that it would have been any easier for the family if these organisations had waited until immediately after Child L’s death. 4.3 Analysis by Terms of Reference 1. Construct a comprehensive chronology of involvement by the organisation and/or professionals in contact with Child L and her family. 4.3.1 All agencies who were asked to provide an IMR for this review constructed a comprehensive chronology on a template provided by the Safeguarding Children Unit. These individual chronologies were integrated into one chronology which the IORA has used to assist in understanding this case. 2. Summarise the decisions reached, the services offered and/or provided to Child L and her family and any other actions taken. 4.3.2 The decisions reached, the services offered and/or provided to Child L and her family and any other actions taken are summarised in section 3 of this Overview Report. 3. Consider if practitioners were aware of and sensitive to the needs of Child L in their work, had the relevant knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare. 4.3.3 Evidence suggests that, prior to Child L’s collapse in February 2011, there were no indicators of abuse or neglect and therefore it is difficult to demonstrate, with certainty that staff would have acted appropriately if such signs had been present. Nevertheless, the authors of all of the IMRs demonstrate that the staff who had contact with Child L and her family had appropriate, up to date training with regard to Safeguarding Children and knew where to seek support and information if and when they required it. Information is provided in the Primary Care IMR about appraisal and revalidation processes being undertaken by the PCT to ensure that Page 22 of 46 GP’s are able to practise safely. Safeguarding training forms a mandatory part of both these processes. 4.3.4 From the interviews they carried out in undertaking the IMR, the authors of the BHNFT IMR found that the midwife who was mainly involved with the family, and paediatric consultant who dealt with Child L after her collapse, were up-to-date with the required safeguarding training, and showed a good understanding and working knowledge of potential concerns and the appropriate procedures and guidance to be followed should concerns arise. 4.3.5 Similarly the author of the SWYPFT IMR found that the health visitor’s safeguarding training was current and that she knew who to contact regarding safeguarding issues. The IMR author explained that the health visitor demonstrated her sensitivity by offering ongoing support to Mother due to her low mood and also by not assuming that Mother would be confident with her baby simply because she worked as a child care professional. 4.3.6 Following Child L’s collapse on 16 February 2011 medical and nursing staff at both BDGH and SCH demonstrated that they had knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare. Staff in the Emergency Department at BDGH took the appropriate action of contacting the Emergency Duty Social Care team to inform them of Child L’s attendance and complete a background check. The BHNFT IMR makes it clear that practitioners considered NAI as a possible cause but there was no clear evidence at that point and there existed a number of possible differentials that could have led to the collapse. As it was unclear at this point that practitioners were looking at an NAI a direct referral was not made. 4.3.7 Similarly the IMR from SCNFT explains that NAI was considered and staff considered whether there were siblings who may have been at risk. Although the diagnosis of NAI was not clear cut, staff from SCNFT appropriately involved the Police and Social Care. 4. Did the organisation have in place Policies and Procedures for Safeguarding and promoting the welfare of children and were able to act on concerns relating to a child’s welfare. 4.3.8 All of the organisations which have provided IMRs for this SCR report that they have in place Policies and Procedures for Safeguarding and promoting the welfare of children. Furthermore IMR authors found that key professionals involved in working with Child L and her family had ready access to these policies and procedures. The author of the Primary Care IMR states that in accordance with Barnsley Safeguarding Policies, GP1 has the Barnsley Safeguarding Policies and Procedures available on his desktop, requiring just one click of the mouse to access them. The authors of the BHNFT IMR state that practitioners interviewed as part of the review knew how to access policies, procedures and guidance. The author of the SWYPFT IMR wrote that policies relating to safeguarding children are stored electronically on the Trust intranet and the LSCB’s website and that all health visitor bases have access to the internet and intranet. Finally, the author of the SCNFT IMR wrote that the Trust Policies and Procedures relating to Safeguarding Children are available on the hospital intranet, in the medical Page 23 of 46 handbook and within Embrace and PICU. In addition the author stated that the key consultants involved with Child L were aware of these procedures. 4.3.9 No concerns for Child L’s welfare were evident until Mother made the 999 call on the evening of 16 February 2011 and therefore no staff had instigated safeguarding procedures prior to this. However following the 999 call organisations appear to have acted appropriately. YAS, BHNFT and SCNFT staff all alerted the police to Child L’s injuries whilst the latter two organisations also involved Social Care. SCNFT also informed the police and Social Care of Child L’s death. It is clear that medical staff at both hospitals were alert to the possibility of the injuries being the result of an NAI. 4.3.10 The authors of the BHNFT IMR suggest that the current policy relating to providing information about the dangers of shaking a baby is insufficiently robust. They make a recommendation to address this. The IORA is in agreement with the need to strengthen this policy but is not confident that the recommendation and action plan from BHNFT is itself sufficiently robust. Therefore the IORA makes an additional recommendation about this to the chair of the BSCB. 5. What were the key relevant points/opportunities for assessment and decision making in this case in relation to Child L and her family? Do assessments and decisions appear to have been reached in an informed and professional way? 4.3.11 Each of the contacts between professionals and family members provided an opportunity for assessment and decision making in this case. These were: � the initial GP consultation when it was established that Mother was pregnant, � Mother’s attendances at the antenatal clinic, � Mother’s antenatal appointments with the community midwife, � Child L’s birth, � postnatal visits from the midwife, � postnatal visits from the health visitor , � Child L’s visit to the GP with Mother � Child L’s visit to baby clinic with Mother � attendance of YAS staff at the family home after Child L collapsed � the entirety of Child L’s attendance at BDGH and SCH following her collapse. 4.3.12 These occasions have been considered in the chronological analysis in section 4.2 of this report. Decisions were largely reached in an informed and professional way based on the assessments that were undertaken but there was insufficient consideration of Father. This could potentially have affected the decisions that were made although, in reality, based on the information that is available about him, it seems unlikely that greater consideration of Father would have led to any significant changes in the decisions made. 4.3.13 The decision taken by the Teleradiology Consultant not to authorise a CT scan of Child L was an incorrect decision based on the assessment of the child’s condition. This situation is addressed on more detail in the analysis of term of reference 12. 6. Were appropriate services offered/provided or relevant enquiries made in light of any assessments? Page 24 of 46 4.3.14 During Mother’s pregnancy and delivery and the period that Child L lived at home with her parents, routine health services were provided. This was relevant in the light of the assessment of the family. Following the injury to Child L YAS correctly transferred Child L to BDGH and she was appropriately treated there prior to transfer to SCH. Following transfer, treatment was also appropriate. 4.3.15 Again, the occasion when an appropriate service was not offered was when the Teleradiology Consultant refused to authorise the CT scan whilst Child L was at BDGH. 7. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child L and her family and were they explored and recorded? 4.3.16 Child L’s parents are white, British with English as their first language; Child L herself was white, British and was pre-verbal at the time of her death. Child L’s grandparents and two of her half-siblings also lived in the neighbourhood. The vast majority of people in the neighbourhood are white, British, English speakers and many families have lived in the area for generations. Although the area is one of economic deprivation with high levels of unemployment and invalidity, Mother and Father were both in paid employment and did not have any disabilities or significant ill health. 4.3.17 The agencies involved in this SCR all had information recorded about the family’s ethnic origin. The authors of the BHNFT IMR comment that Mother reported herself not to have any religious beliefs and that information related to ethnicity and diversity needs were all recorded, as per local practice, as part of the antenatal booking record. The author of the SWYPFT IMR, however, states that the religious conviction of the family was not recorded and ought to have been as this is basic information. 4.3.18 It was the view of all agencies that the family did not have any specific needs as a result of their racial, cultural, linguistic or religious identity or any issues of disability. When families are white, British with English as a first language it is very easy to assume that they will not have any special needs relating to these issues. Care needs to be taken in making such assumptions as even white, British, English speakers can sometimes find themselves living in an area where they feel culturally isolated. For example, this may occur if they have specific religious beliefs, come from a very different socio-economic background to those of their neighbours or live in an area where the majority of people are not white, British English speakers. However, in this instance, the IORA believes it is reasonable to assume that the family did not have any specific racial or linguistic needs that might have caused them difficulties in their local neighbourhood. 8. Were Senior Managers or other organisations and professionals involved at points in the case where they should have been? 4.3.19 Prior to the incident that led to Child L’s death, organisations and professionals did not have any particular concerns about this family. Therefore there were no occasions when one would have expected professional staff to seek child protection supervision or specific management guidance. Even now, no Page 25 of 46 information has come to light to suggest that agencies should or could have had safeguarding concerns. 4.3.20 It was appropriate for Child L to be examined by a nursery nurse when she attended the baby clinic in February 2011. The author of the SWYPFT IMR explains that nursery nurses are fully trained in child development up to eight years of age and they receive training in safeguarding. It is common practice for nursery nurses to be used at baby clinics and they are directly accountable to the health visitors in the team. 4.3.21 Following Child L’s collapse and admission to hospital, senior medical staff were involved in providing her care and treatment. During this period there was appropriate liaison between BDGH and SCH and with the police and Social Care. This is described in the analysis to term of reference 4. 9. Was the work consistent with each organisation’s and Barnsley Safeguarding Children Board Policy and Procedures for Safeguarding and promoting the welfare of children and with wider Safeguarding standards? 4.3.22 It is evident from the analysis concerning Terms of Reference 3 and 4 that work in this case was consistent with the Policies and Procedures for Safeguarding and promoting the welfare of children within each organisation and BSCB and with wider Safeguarding standards. 10. Were there organisational difficulties being experienced within or between agencies? 4.3.23 No organisational difficulties are identified in any of the IMRs with regard to services provided to Child L and her family during the period covered by this review. However the author of the SWYPFT IMR has identified some difficulties with the organisation’s change over from paper to electronic records that may impact on the management of cases. A number of recommendations have been made in the SWYPFT IMR regarding SystmOne, the electronic record. 4.3.24 The absence of a written handover from the midwife to the health visitor was an organisational difficulty because it resulted from the documentation pack not including a discharge form because Child L was not born in Sheffield. There is a recommendation within the BHNFT IMR to minimise the likelihood of this situation arising again. 4.3.25 The IORA does not regard the refusal by the Teleradiology Consultant to carry out a CT scan on Child L as an organisational difficulty. Instead it appears to have been a potentially serious error of judgement from the individual consultant. The BHNFT IMR describes action taken by the Trust in respect of this incident. This is addressed in the response to term of reference 12. 11. Did any resourcing issues have an impact on the case? 4.3.26 This review has not identified that any resource issues impacted on this case; routine appointments took place at appropriate times and there was adequate continuity of staff. The response to the emergency on 16 February 2011 was also adequate with YAS arriving at the property eight minutes after receiving the Page 26 of 46 emergency call and a responsive service from BDGH and SCH. The shortfalls in service delivery that have been identified did not result from resource issues. 12. Consider the decision making process around the request for a scan for Child L and the impact of this process. 4.3.27 It is evident that the Embrace and PICU Consultants from SCNFT wanted Child L to have a CT scan before leaving BDGH in order to assist them in making decisions about her care. However the scan was not undertaken and the aforementioned consultants from SCNFT decided to transfer Child L to SCH without further delay and undertake the scan when she arrived. 4.3.28 In undertaking this SCR it is important to identify why a scan was not undertaken at BDGH, whether a scan should have been undertaken at BDGH, what the impact was of no scan being undertaken at BDGH and, if necessary, how to minimise the risk of a similar situation occurring in the future. 4.3.29 The author of the BHNFT IMR provides a detailed explanation of the process by which scans are managed out of normal hours and explains that the Trust contract with an external provider to provide a Teleradiology service which authorises and interprets such scans. The author explains that, according to notes made by the Paediatric Consultant, the reason the scan was not undertaken was that the Teleradiology Consultant on duty that evening refused to authorise a scan on the grounds that the case did not meet NICE criteria and that, in any case, she would not be able to interpret the results on a baby of Child L’s age. The contact between BHNFT and the external provider does not allow local clinicians from other departments to contact the local Consultant Radiologist and therefore, once the Teleradiology Consultant had made her decision, the Consultants from SCNFT were powerless to arrange for the CT scan to be performed at BDGH. 4.3.30 In considering the Teleradiology Consultant’s reasons for refusing to undertake the scan the author of the BHNFT IMR explains that the out of hours Teleradiology protocol lists indications for CT scan to be undertaken and that this includes a Glasgow Coma Scale (GCS) of 13 or below, of unknown cause. This is a category into which Child L fell. The author adds that this is consistent with the NICE guidelines (NICE clinical guideline 56 – Head Injury 2007 page 9) and concludes that the Teleradiology Consultant did not follow these guidelines. On reading the BHNFT Department of Medical Imaging Policy for Out of Hours Radiology Requests at BDGH, it was clear to the IORA that where a patient meets the standard imaging criteria for a CT scan, the consultant clinician can request the scan directly from the radiographer without needing to talk to the Teleradiology Consultant. Consequently, in the case of Child L, the protocol would have allowed for the scan to have been undertaken without reference to the Teleradiology Consultant. 4.3.31 The IORA raised this matter with one of the authors of the BHNFT IMR who amended the IMR and explained that it has become accepted custom and practice for Paediatric Consultants to request scans from the Teleradiology Consultant. Furthermore, the author stated that, even if the Paediatric Consultant contacted the Radiographer directly the Radiographer would, in most cases involving a child, refer the case onto the Radiologist due to concerns about exposing young children and babies to radiation. The IORA accepts this explanation from the author of the Page 27 of 46 BHNFT IMR but considers it important that accepted practice should match written procedure. Therefore the IORA welcomes the statement in the BHNFT IMR that the protocol is being rewritten and will state that all referrals will go straight through to the Teleradiology Consultant. 4.3.32 The author of the SCNFT IMR explains that the CT scan did not need to be interpreted by the Teleradiology Consultant, as it could have been sent to SCNFT via the PAX system, and interpreted by a SCH paediatric radiologist. The author adds that this was communicated by the Embrace consultant 1 to the Teleradiology Consultant. Therefore the author of the SCNFT IMR considers that this was not an acceptable reason for the Teleradiology Consultant to refuse the request. The Teleradiology Consultant was not interviewed for the IMR and therefore it is not possible for the IORA to know whether she was aware that the scan could have been interpreted by the paediatric radiologist at SCH. The author of the SCNFT IMR has suggested that, as a specialist paediatric service, SCNFT might be able to formalise arrangements to assist radiologists serving BDGH with interpreting scans in young children. This SCR includes a recommendation that that proposal should be explored further. 4.3.33 Both the BHNFT and SCNFT IMRs consider the potential impact of the scan not being performed at BDGH and the actual impact in this case. The author of the SCNFT IMR explains that, if Child L had been found on CT scan to have required urgent neurosurgery, then she would have needed to be transferred to neurosurgical care immediately. Therefore lack of early scanning could have resulted in a delayed operation, and could have affected the outcome. Alternatively a local scan could have resulted in a decision not to transfer Child L, as a decision might have been made to withdraw care on the basis of dire scan results. 4.3.34 However the authors of both IMRs agree that, in the case of Child L, it is highly unlikely that the absence of a CT scan prior to transfer had any impact on the eventual outcome for Child L. This was because when the scan was done surgery was not indicated and, Child L’s condition was such that she was highly unlikely to survive. 4.3.35 Although the refusal of the consultant to carry out a CT scan is unlikely to have had an impact on Child L it is important that action is taken to minimise the risk of a similar situation occurring in the future. It should be noted that this incident was already being addressed by BHNFT prior to the decision being taken to carry out an SCR and the authors of the BHNFT IMR explain that since this incident the out of hours Teleradiology contract has been awarded to a different provider. The authors describe some of the safeguards that have been put in place to ensure that the contract is more robust than was previously the case. This includes new monitoring arrangements, random sampling of reports and a two way process of feedback. In addition the service is now being provided by consultants based in Australia with the result that the service will be delivered during their day time hours. This will mean that the organisation will have more staff around to offer peer review of requests and image interpretation. 4.3.36 By awarding the contract for out of hours radiology services to a new provider BHNFT have sought to ensure that the inappropriate refusal to carry out a CT scan is not repeated within their trust. However, an issue remains about how the matter Page 28 of 46 should be addressed with the organisation that was providing the service at the time of Child L’s admission and the individual Teleradiology Consultant who refused the request. This Serious Case Review has not directly involved the Teleradiology service or the Teleradiology Consultant. Therefore it is not possible to know whether any action has been taken to minimise the risk of that service or the individual making a similar decision in the future. The authors of the BHNFT IMR explain that the police have become involved in pursuing a statement from the Teleradiology Consultant and it is understood that this matter will be addressed by the coroner who will decide whether the consultant’s professional body should be notified. 13. Establish whether there are any overlapping issues between this review and the Child X Serious Case Review and, if so, what has been done to address the issues. 4.3.37 Child X died in September 2010 at just seven weeks of age and was the subject of a Serious Case Review commissioned by Barnsley Safeguarding Children Board which was completed in June 2011, approximately four months after the death of Child L. 4.3.38 There are the several similarities between the circumstances of Child X and Child L and these include the following: � Neither child was known to Social Care prior to sustaining the injuries that led to their death. � Both children died as a result of severe traumatic brain injury believed to be the result of an NAI. � In the case of Child X the father has been convicted of murder and in the case of Child L the father has been charged with murder but has not yet stood trial. � Both children had been seen by health professionals less than 36 hours before being admitted to hospital with the injuries that led to their deaths. � Post mortem medical investigations have shown that both children had old rib fractures. � Both families were white, British and were not felt to have any particular needs relating to their religion, race, language or ethnicity. There were no issues of disability. 4.3.39 The IORA for Child X listed a number of factors that are typically found in Serious Case Reviews as follows: � Insufficient focus upon the child and a greater and/or disproportionate focus upon the adults. � Failure by agencies to identify and/or report signs of abuse. � Poor recording by agencies. � Poor interagency communication. � Poor communication with children. � Poor professional knowledge. � Poor application of procedures. � Poor risk and analytic assessments. � Multiple assessments not taking account of the relevance of past history. � The rule of optimism – accepting standards of care which would not be acceptable with other families. � Not recognising the indicators of risk: chronic neglect, older children, domestic violence, mental ill health and substance misuse. Page 29 of 46 � Lack of management oversight of cases with poorly trained, inexperienced practitioners and managers and insufficient or inadequate supervision. 4.3.40 She commented that these had not applied in the case of Child X and similarly these typical features were not prominent in the case of Child L. It is therefore reasonable to say that this was not a case where a serious incident could typically be predicted. The logical extension of this is that there was no reason for organisations or individuals working with this family to have particular concerns for the safety of Child L. 4.3.41 A key difference between the cases was that there had been some earlier concerns in relation to the care of an older child of the mother of Child X and it was also known that the mother of Child X had been the victim of domestic abuse from previous partners. However in the case of Child L there had been no previous concerns. 4.3.42 With regard to the actions of organisations and professionals, the following issues applied to both cases: � There were no organisational failures or missed opportunities to safeguard either child. � Midwifery and health visiting services did not record the presence of the father at appointments and home visits. � Health professionals who saw the children shortly before they were admitted to hospital could not reasonably have been expected to have identified the existence of rib fractures. 4.3.43 The IORA has examined the Action Plan from the Child X Serious Case Review and found the following three recommendations which are of relevance to Child L’s case. Information contained within the Child L IMRs and Child X action plan indicates what action has been taken with regard to each of these recommendations. 4.3.44 Recommendation 1 (to BHNFT) - The organisation should reassure itself that the midwifery service routinely ask all women about domestic abuse. 4.3.45 Action was taken in December 2010 to reinforce the need for the midwifery service to ask this question and practice and paperwork has been amended to facilitate this. An audit was completed in September 2011, in which 100% of records sampled included a record that questions regarding domestic abuse had been asked. Furthermore, in the case of Child L, records show that Mother was asked about domestic abuse during the antenatal booking contact. 4.3.46 Recommendation 2 (to BHNFT) - A full family history (including social history) should be obtained relating to mother, partner and any members of the household. This should include previous and present alcohol misuse, substance misuse, mental illness and learning disabilities / difficulties, previous child protection concerns. 4.3.47 The author of the BHNFT IMR has explained that local paperwork has been amended to include the need for a full history to be extended to all significant adults. This change was made in December 2010, six months after Mother’s booking information was taken and a matter of weeks before Child L was born. At Page 30 of 46 the booking appointment a partial history of Father was taken, which at that time was regarded as adequate, although it does not meet the standard now expected. 4.3.48 An additional complication, for the midwifery service, with regard to recording a full history relating to all significant adults is that the national paperwork does not include provision for this. Midwifery services in Barnsley use the national paperwork because it is evidence based, regularly reviewed and perceived to be ‘gold standard’. However as a result of the Child X SCR, the BHNFT representative on the national Perinatal Institute made a suggestion to the institute in December 2010 that when the antenatal records were next updated they should be modified to include the need to take a full social history of all members of the household. This suggestion was well received and the author of the BHNFT IMR has informed the IORA that the paperwork was reissued in December 2011 having been revised in line with the suggestions made by the Barnsley representative. It now contains a specific field to ask about the father’s mental health and the boxes for information about issues such as alcohol and smoking now refer to anyone in the home. The IORA considers this to be a good example of when the findings of an SCR are used, not just to improve practice locally, but to improve things nationally. 4.3.49 Recommendation 3 (to SWYPFT) The caring experiences and responsibilities of all known responsible adults must be clearly recorded by the health visitor. 4.3.50 The action plan from the Child X Serious Case Review shows that March 2011 was the timescale for implementation of this recommendation. This was after the death of Child L and therefore health visitors were not required to record this information at the time they were working with Child L and her family. The action plan also shows that an audit of compliance will be undertaken in March 2012. The author of the SWYPFT IMR states that this recommendation has not been embedded in practice. 4.3.51 In response to term of reference 13 the author of the SWYPFT IMR has written that: “(The) recommendation of identification of people present in the household in the SCR of child X was outside the remit of this case as the timescales would not have been enacted until after the death of child L.” 4.3.52 The author of the IMR has not explained the current position but following a request from the IORA the assistant director of nursing within SWYPFT has provided information that SystmOne now includes a mandatory field on which health visitors must record who is present at a contact. Previously it was possible to move to the next screen on the records without completing the box which asks who was present but the system has been amended to prevent this. There is also a text box for health visitors to record details of the contact and this can be used to include information about the caring experiences and responsibilities of known adults. 4.3.53 Whilst this action is welcome, it does not represent implementation of the original recommendation which required health visitors to record “the caring experiences and responsibilities of all known responsible adults”, not just who is present at a contact. The issue concerning gathering information about adults will be explored in greater detail further into this section of the analysis. Page 31 of 46 4.3.54 As well as looking at the Child X Action Plan the IORA has also looked at the recommendations contained within the Overview Report and Executive Summary for Child X and has found that there are four recommendations, two each to SWYPFT and BHNFT, that are in the Overview Report and Executive Summary but not in the Action Plan. These are as follows: 4.3.55 For SWYPFT 1. Clear lines of accountability for Nursery Nurses and Health Visitors need to be established and communicated. 2. Deviations from the timings of child health assessments that are communicated from Nursery Nurses to Health Visitors need to be countersigned by the Health Visitor. 4.3.56 For BHNFT 1. The Midwifery Service should consider the feasibility and appropriateness of recording if someone else is present at a professional contact. 2. The guidance relating to post natal depression should be revisited to ensure it addresses the need to follow up appropriately concerns relating to maternal health. 4.3.57 Issues relating to nursery nurses were not particularly evident in the work with Child L as the only nursery nurse involvement was at the baby clinic when a health visitor was also in attendance. Nevertheless, the Designated Nurse, Safeguarding Children has informed the IORA that action has been taken with regard to lines of accountability and health visitors and now required to sign off nursery nurses’ work. There are some difficulties with achieving this on SystmOne but these are being addressed. 4.3.58 Although BHNFT have undertaken important work regarding taking a history of significant adults it appears that the recommendation that the midwifery service consider the feasibility and appropriateness of recording if someone else is present at a professional contact has been overlooked. It has, however, been included as a recommendation in the BHNFT IMR for Child L. 4.3.59 It is unclear whether action has been taken in relation to the recommendation that guidance relating to post natal depression should be revisited to ensure it addresses the need to follow up appropriately, concerns relating to maternal health. However in the case of L it appears that the appropriate mental health pathway was followed by the midwife. 4.4 Consideration of significant adults 4.4.1 In both this Serious Case Review and the one relating to Child X it was found that professionals had paid insufficient attention to significant adults other than the child’s mother. As has already been stated, this omission has been found in other SCRs and is discussed at length by Brandon et al 2009. 4.4.2 Recommendations relating to this issue were made in the Child X Serious Case Review and further recommendations have been made in this review. Whilst these recommendations are welcome, it is the view of the IORA that greater clarity is required as to what the problems are and what changes need to be made. Page 32 of 46 4.4.3 Across the two reviews the following recommendations have been made which relate to significant adults: 1. A full family history (including social history) should be obtained relating to mother, partner and any members of the household. This should include previous and present alcohol misuse, substance misuse, mental illness and learning disabilities / difficulties, previous child protection concerns. Child X aimed at BHNFT 2. The Midwifery Service should consider the feasibility and appropriateness of recording if someone else is present at a professional contact. Child X aimed at BHNFT 3. The Midwifery service at BHNFT should ensure that it becomes routine practice for midwives to routinely document who is present at a contact. Child L aimed at BHNFT 4. The caring responsibilities of all known adults within a family to be clearly recorded by the Health Visitor. Child X aimed at SWYPFT 5. The Business Manager to expand SystmOne (electronic records system) to include “others in the household” at home visits and also “others attending with the child” at clinic attendances. This should be a prerequisite before being able to fill in the context and content of each home visit or baby clinic attendance. This should be an addendum to Child X Recommendation as identified in Term of Reference 13. Child L aimed at SWYPFT 4.4.4 Recording who is present during visits and appointments will help agencies to build up a picture of who is significant in the family’s life whilst recording the caring responsibilities of known adults will further extend this picture. Recording histories for people who are significant in the child’s life will maximise the chance of establishing whether information is known about an individual that would suggest that they may pose a threat to the child. It is the view of the IORA that both SWYPFT and BHNFT need to be developing their staff so that midwifes and health visitors routinely undertake these tasks. 4.4.5 The action detailed above, that has been taken since the Child X SCR is to be welcomed but, the IORA believes that it needs to go further to ensure that midwives and health visitors act upon the information they gather. This will involve a degree of assessment of the information they gather and, where there are concerns, will also involve communication with other professionals, such as GP’s, Social Care and the Police, who may have information about individuals. 4.4.6 It is also important to stress that these recommendations should not be directed solely at fathers or even at men. Families are structured in many different ways and practitioners need to know how to respond in different situations. Addressing this complicated area requires a change of mindset within organisations so that professionals understand that a key part of their role is to safeguard children and, in order to do so, they need to take a pro-active role in gathering information about the individuals involved in a child’s life and to take action if they have any concerns about the way any of those people are caring for the child. Page 33 of 46 4.4.7 Finally it should be stressed that this is not solely an issue for midwives and health visitors but applies to all services who have contact with families. The emphasis in this review is on midwives and health visitors as they were the professionals who had the most involvement with the family. 4.5 Analysis of IMRs 4.5.1 All the IMRs produced for this review follow a set format specified by the Barnsley Safeguarding Children Board. As a result they are all well structured with a shared introduction explaining the background to the review and the reason it is being undertaken. They also contain a clear statement as to the time period for the review and the key issues to be addressed as set out in Terms of Reference produced by the Serious Case Review Panel. The IMRs include brief family details, a genogram and consideration of any ethnic, cultural, linguistic and religious issues relating to the family. They also include sections to summarise the agency’s involvement with the family and to analyse that involvement. Individual chronologies were written on a standard template to enable continuity and to facilitate the compilation of the integrated chronology. The IMRs have all been signed off at an appropriate level within the organisations. 4.5.2 The Serious Case Review panel and IORA provided substantial challenge to the performance and practice of agencies throughout the Serious Case Review with the result that IMRs were revised on a number of occasions. This challenge was provided in Serious Case Review Panel meetings and in individual discussions that the IORA had with IMR authors. 4.5.3 The IMR from BHNFT addresses the maternity services provided to the family from the point at which Mother had her booking in appointment until the final postnatal midwifery visit. It also considers the actions of BDGH staff from the time of Child L’s arrival in the Emergency Department following the incident that led to her death until she was transferred to the care of Embrace for the journey to SCH. 4.5.4 The IMR addresses all the terms of reference in detail and identifies the key learning points. It demonstrates that action had already been undertaken to address the issue relating to there not having been a CT scan of Child L whilst she was at BDGH and the issues relating to midwives taking a family history of all members of the household. Four SMART recommendations are made that address the other learning points from the IMR and an action plan is included that shows that implementation has taken place with regard to these actions and there are plans to audit compliance in the months ahead. 4.5.5 Whilst the IORA considers the BHNFT IMR to be of a high standard he has some concerns regarding the robustness of recommendation 3. This requires Midwifery leads to meet with Health Visiting leads to discuss the optimum time to discuss ‘Shaken Baby’ syndrome with parents and who should do this. However, whilst the action plan provides a date of December 2011 for the meeting request to be made there is no target date for when practice will have been changed to ensure that relevant information about ‘Shaken Baby’ syndrome is being routinely provided to all parents of new born babies. Given that resolution of this issue involves the co-operation and agreement of two health providers the IORA has made a recommendation to the chair of BSCB to ensure that this issue to seen through to a conclusion. Page 34 of 46 4.5.6 There was only one significant GP contact for the Barnsley Primary Care IMR to consider and consequently it is a fairly brief report. Nevertheless the IMR author has addressed all the terms of reference and has appropriately given detailed consideration to whether the GP could have identified fractured ribs at the consultation with Child L. Although it was not particularly pertinent to Child L the IMR author has identified a potential shortfall in the information contained in medical records and has made a recommendation to address this. 4.5.7 The IMR from SCNFT provides a detailed consideration of the services provided by the trust to Child L. All terms of reference are addressed and the IMR author concludes that, even with hindsight, it is difficult to see anything that could or should have been done differently. The IORA concurs with this conclusion. The issue of greatest concern for SCNFT concerned the refusal of the radiologist to carry out a CT scan of Child L whilst she was at BDGH and whilst the SCNFT IMR author does not believe the Trust could have done anything differently at the time, she does make one SMART recommendation which has the potential to lead to improvements for the future. 4.5.8 The IMR from SWYPFT addresses the involvement of the Health Visiting Service with the family following the birth of Child L. This amounted to two home visits from a health visitor and one clinic attendance when Child L was seen by a nursery nurse and a health visitor. The IMR provides a good summary of these contacts and addresses all the terms of reference. The section headed “what do we learn from this case” is incomplete; for example it does not make reference to the failure to record who was present at visits even though this is identified in the analysis and carried through to a recommendation. Four SMART recommendations are made and an action plan is included which identifies how and when these recommendations will be implemented. Three of the recommendations are focused on developing the electronic records system. The IORA believes that there is also a need for the service to develop the awareness and skills of front line staff and managers in respect of safeguarding children. It is much harder to write SMART recommendations to address these issues but it is only by raising awareness and skill that safeguarding practice will become routinely embedded in the work practitioners. 4.5.9 The Health Overview Report highlights the key issues that have been identified within the IMRs and looks at the links between the various health organisations involved with Child L and her family during the period covered by the review. The authors of the Health Overview Report have included significant amounts of research and a number of references in order to support their findings. The authors of the Health Overview Report state their support for the recommendations within the individual IMRs and add one further recommendation which relates to the implementation of the recommendations made within the IMRs. 5. Conclusions 5.1 The death of Child L at only five weeks of age was a tragic event and it was appropriate for Barnsley Safeguarding Children Board to commission a Serious Case Review. Child L’s death occurred as the direct result of a serious injury which is believed to have been sustained as a non-accidental injury and her father has been charged with her murder. However, this review has found that there was Page 35 of 46 no information available to any practitioners that could or should have led them to have concerns that Child L was at risk of non-accidental injury or even that she was a child in need. There is no suggestion that Child in Need or Child Protection procedures should have been instigated at any stage in agencies’ work with the family or even that a Common Assessment Framework (CAF)2 was indicated. Consequently it is view of the IORA and the Serious Case Review Panel that Child L’s death could not have been predicted or prevented. 5.2 The review has been conducted with a view to identifying any specific factors that impacted on the injury to Child L and also on learning broader lessons. Whilst it has found that the injury to Child L could not have been predicted or prevented it has identified a number of issues where agencies could improve their practice in order to better safeguard children. 5.3 The review has identified failings in the record keeping by both the midwife and the health visitor. There was no written record of a conversation they both state they had when the midwife handed over care of Child L to the health visitor. This problem was exacerbated because the documentation from the hospital did not include a discharge form as would have been the case if Child L had been born in Barnsley. However, given that it is not uncommon for women living in Barnsley to give birth in other areas this problem should not have arisen. In addition the health visitor’s record of her first visit to the family was incomplete. 5.4 The absence of a written handover means that there is no record of the midwife making the health visitor aware that Mother had been tearful at the midwives final visit. Apart from the absence of a written record of Mother being tearful, it does appear that sufficient consideration was given to Mother’s mental health in accordance with both the antenatal and postnatal mental health pathways. 5.5 Neither the health visitor nor the midwife documented who was present at appointments and visits, although it should be noted that this was not a requirement at that time. There is, however, a need for professionals to pay greater consideration to the wider community around a child; not just the child and his or her mother. This needs to involve being aware of who is present at appointments and making a record of this, identifying who is significant in the life of the family and gathering information about their history. BHNFT were right to identify, in the SCR for Child X, that this is a national issue that requires a national response and the IORA fully supports the action taken and welcomes the fact the suggested changes have now been made. 5.6 The review has found out that no-one discussed the dangers of shaking a baby with either Mother or Father and it appears that, whilst at one stage this was done routinely, that is no longer the case. A recommendation has been made that midwifery and health visiting leads discuss who will take responsibility for this task. The IORA stresses the need for this action to be completed as a matter of priority. 5.7 Detailed post mortem examinations revealed that Child L had suffered rib fractures seven to ten days prior to her death and therefore may have had fractured ribs when she was taken to the GP and certainly had them prior to attendance at the 2 a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children's additional needs and promote co-ordinated service provision to meet them. (Children’s Workforce Development Council website, 2011) Page 36 of 46 baby clinic. The Serious Case Review Panel and IORA have carefully considered whether the GP, health visitor and/or nursery nurse should have identified this injury during their contact with Child L. The Panel and IORA are satisfied that it would be unreasonable to expect them to have done so. 5.8 Following the 999 call in February 2011, emergency care for Child L appears to have been carried out professionally and appropriately by staff from YAS, BHNFT and SCNFT. The exception to this was the refusal by the Teleradiology Consultant to undertake a CT scan whilst Child L was at BHGH. This appears to have been a potentially serious error of judgement but one that, in this instance, made no difference to the outcome for the child. BHNFT took decisive action to investigate the incident and have now changed the provider of out of hours radiology and added additional safeguards. Whilst this is of benefit to BHNFT it will not necessarily improve the service provided by the previous provider or the individual consultant. Whilst it is understood that this issue will be addressed by the coroner this Overview Report includes a recommendation which will ensure that the Radiology Provider and the consultant are made aware of the pertinent findings of this review. 5.9 The IORA acknowledges that Mother and Father feel that a doctor at SCH spoke to them inappropriately and also that the timing of the Police and Social Care, in talking to them whilst their daughter was dying, was also inappropriate. It is understandable that Mother and Father feel this way but, having considered the matter the Serious Case Review Panel and IORA believe that the Police and Social Care acted correctly. The doctor was faced with the difficult task of effectively raising suspicions against Father and/or Mother in connection with their daughter’s injuries and in such circumstances it is not surprising to the IORA that Father and Mother took a dislike to the him. Nevertheless this information will be fed back to the doctor so it can be reflected upon and used as a learning opportunity. 5.10 Issues raised by Father and Mother about services they have received since Child L died are outside the scope of this review but have been addressed by the SCR Panel as described in the body of the report. 5.11 It is a matter of concern to the IORA that four recommendations from the Child X review are not included in the action plan although there is no evidence that the omission of these from the action plan had a detrimental impact on the work undertaken with Child L and her family. It is important that the LSCB check whether these recommendations have been fully implemented and, if they have not, they should be added to the Child X or Child L action plan to ensure that work is undertaken to implement them. 5.12 In response to an issue raised by Father and Mother about bereavement support the Designated Nurse explained to the SCR Panel that, if a child dies in BDGH, a pack is given to bereaved parents with lots of helpful contacts for agencies in Barnsley. Similarly SCH does this for bereaved families in Sheffield. Given that it is not uncommon for seriously ill children from Barnsley to be transferred to SCH the IORA believes that it should be in a position to provide a pack of appropriate contacts to families from Barnsley. Page 37 of 46 5.13 As well as identifying areas for improvement, this SCR has also identified a number of examples of good practice. The midwifery and health visiting services had an appropriate level of contact with Mother and there was good continuity with the one midwife carrying out the majority of visits and one health visitor carrying out both visits. All professionals largely complied with required policies and procedures. 5.14 Of particular note were the comments of Mother and Father who commented on how helpful they found it when professionals explained things to them and kept them informed as to what was happening. They were even able to appreciate that this had been useful during the last few hours of Child L’s life. By contrast they have felt unclear about Social Care’s role in recent months and what to expect from the social worker. This is a useful reminder for all agencies of the importance of communicating with their service users and providing clear and unambiguous explanations. 6. Recommendations 6.1 Eleven recommendations are made within the Individual Management Reviews and the Health Overview Report and these have all been accepted and signed off by the individual agencies. The Panel and author are in agreement with all the recommendations, which are listed below. An action plan has been written for the implementation of each of these recommendations and these action plans will be monitored by the Barnsley Safeguarding Children Board Quality Assurance Sub-Group to ensure that they are fully implemented. It is evident from the action plans that many of the individual agency recommendations have already been fully or partially implemented. Recommendations in the Health Overview Report 1. The Executive Director for Safeguarding Children will ensure that all recommendations identified within the health IMRs are completed within the timescales identified. Recommendations in the BHNFT IMR 2. The midwifery service at BHNFT should ensure itself that midwives have readily available to them and use all the required paperwork needed to be completed antenatally and postnatally to meet local record keeping standards. 3. The Midwifery service at BHNFT should ensure that it becomes routine practice for midwives to routinely document who is present at a contact. 4. Midwifery leads should meet with Health Visiting leads to discuss the optimum time to provide / discuss ‘Shaken Baby Syndrome’ and who should do this. 5. The Named Doctor should amend the current child death checklist to ensure it contains a prompt for the consultant leading the rapid response, to assure themselves that hospital notes folder has been created and contains all relevant information and is available for inclusion of any subsequent relevant clinical information. Recommendations in the Barnsley Primary Care IMR Page 38 of 46 6. As part of an educational programme – review record keeping with Primary Care in Barnsley Recommendations in the SWYPFT IMR 7. The Business Manager to expand SystmOne (electronic records system) to include “others in the household” at home visits and also “others attending with the child” at clinic attendances. This should be a prerequisite before being able to fill in the context and content of each home visit or baby clinic attendance. This should be an addendum to Child X Recommendation as identified in Terms of Reference 13. 8. The Business Manager to ensure completion of all data area/text boxes within SystmOne e.g. Marital Status, Religion and Ethnicity to improve diversity recording and maintaining accuracy of the status of the family unit. 9. The Business Manager should undertake an audit to ensure the recording of all conversations related to clients are recorded within records and dated and timed so they form part of the chronology of the work with the child and family. 10. The Lead Health Visitor to ensure that Health Visitors receive a discharge letter from Midwives at the end of their care, and if not received the identified Health Visitor should actively seek a written discharge letter to complete records. Recommendations in the SCNFT IMR 11. Sheffield Children’s Hospital and Barnsley District General Hospital to discuss feasibility of setting up a radiology advisory service for complex cases. 6.2 In addition to the recommendations made in the IMRs the IORA and Serious Case Review Panel make the following recommendations: Recommendations to Barnsley Safeguarding Children Board 12. The Independent Chair of BSCB, on behalf of the board, should ensure that the Chief Executive of BHNFT draws to the attention of previous Radiology Provider the findings of this SCR in respect of the CT scan and requests that they provide evidence that this issue has been considered by the organisation and that the individual consultant involved has been made aware of this. 13. The Independent chair of BSCB, on behalf of the board, should ensure that BHNFT and SWYPFT agree and implement a procedure that requires appropriate staff to discuss ‘Shaken Baby’ syndrome with the parents of all new babies either shortly before the baby is due or within days of birth taking place. 14. The Independent chair of BSCB, on behalf of the board, should arrange to be provided with information as to whether the recommendations that were made in the Child X Overview Report, but not included in the Action Plan, have been implemented. If they have not, they should be added to the Child X or Child L action plan to ensure that work is undertaken to implement them. 15. The Independent Chair of BSCB, on behalf of the board, should ensure that child safeguarding training for all staff emphasises the need to be mindful of all adults who are significant in a child’s life so that staff understand the need to routinely gather information about these adults. Page 39 of 46 Recommendation to all agencies 16. When providing feedback to staff about this SCR, all agencies should use Mother and Father’s comments to remind staff of the value communicating clearly with service users and providing clear and unambiguous explanations so that they know what is happening and what they can expect from services. Recommendation to BHNFT 17. The Named Nurse for Safeguarding Children at BHNFT should ensure that staff at the mortuary at Sheffield Children’s Hospital are provided with bereavement support information which will be of relevance to families living in Barnsley. Page 40 of 46 Appendix 1 – Genogram Genogram of Child L Father Child L2 Child L3 Child L4 Child L dob12.01.11 dod17.02.11 Mother Adult 2 Adult 1 Page 41 of 46 Appendix 2 – Integrated Action Plan No RECOMMENDATION ACTION TIMESCALE STATUS RAG rated RESPONSIBLE AGENCY & PERSON(S) PERSON RESPONSIBLE FOR MONITORING MEASUREMENT(S) OF SUCCESS 1 On behalf of BSCB the Independent Chair will ensure that the Chief Executive of BHNFT draws to the attention of the previous Radiology provider the findings of the SCR in respect of the CT Scan. Independent Chair to provide Chief Executive of BHNFT with copy of SCR findings. Report back to BSCB in March 2012. March 2012 Independent Chair, BSCB Head of Safeguarding and Welfare The Chief Executive of BHNFT provides written report to the Chair of the BSCB confirming that the issue has been considered and the individual consultant has been made aware of the issue Page 42 of 46 2 On behalf of BSCB, the Independent Chair will ensure that BHNFT and SWYPFT agree and implement a procedure that requires appropriate staff to discuss 'Shaken baby Syndrome' with the parents of all new babies shortly before the baby is due or within days of the child's birth. Independent Chair to write to the relevant managers requesting that the procedure is written and disseminated. April 2012 Independent Chair, BSCB Service Development Sub Group Through the Service Development Sub Group the procedure is agreed. Page 43 of 46 3 On behalf of BSCB the Independent Chair will ensure that all the actions identified in the Child L overview report have been implemented. If they have not been implemented they should be added to Child L and implemented. Designated Nurse to confirm the position re implementation and add to the action plan if required. To confirm this with the Chair of BSCB. March 2012 Designated Nurse, NHS Barnsley Designated Nurse, NHS Barnsley Confirmation that actions have been completed or added to the Child L Action Plan. Page 44 of 46 4 On behalf of the BSCB the Independent Chair will ensure that Safeguarding training for all the staff emphasises the need to be mindful of all adults who are significant in a child's life. Staff need to understand the need to routinely gather information about these adults. All training courses to be reviewed to take account of this requirement. Joint Training Work Group to review amended courses. March 2012 Head of Safeguarding and Welfare The Joint Training Work Group Joint Training Work Group completes review of revised courses. Page 45 of 46 Appendix 3 – abbreviations BDGH – Barnsley District General Hospital BHNFT - Barnsley Hospitals NHS Foundation Trust BSCB – Barnsley Safeguarding Children Board CAF – Common Assessment Framework CPR - Cardio Pulmonary Resuscitation CT scan – Computerised Tomography scan CYP&F – Children Young People & Families DRI – Doncaster Royal Infirmary IMR – Individual Management Review IORA – Independent Overview Report Author LADO – Local Authority Designated Officer LSCB – Local Safeguarding Children Board MRI scan – Magnetic Resonance Imaging scan NAI – Non accidental injury NHS – National Health Service NICE – National Institute of Clinical Excellence PCT – Primary Care Trust PICU – Paediatric Intensive Care Unit RCGP - Royal College of General Practitioners SCNFT - Sheffield Children’s NHS Foundation Trust SCH – Sheffield Children’s Hospital SCR – Serious Case Review SWYPFT - South West Yorkshire Partnership NHS Foundation Trust YAS – Yorkshire Ambulance Service Page 46 of 46 Appendix 4 - References Barnsley Hospital NHS Foundation Trust, Department of Medical Imaging (2011): Departmental Policy for Out of Hours Radiology Requests at BHNFT Barnsley Safeguarding Children Board (2011): Serious Case Review: Child L. Barnsley Safeguarding Children Board Brandon, M et al (2009): Understanding Serious Case Reviews and Their Impact. A Biennial Analysis of Serious Case Reviews 2005-07. Department for Children, Schools and Families Cavanagh K, Dobash RE and Dobash RP (2007): The Murder of Children by Fathers in the Context of Child Abuse. In Child Abuse and Neglect 31 (7) July 2007 p 731-746 Children’s Workforce Development Council (2011): Common Assessment Framework (CAF). Available from www.cwdcouncil.org.uk/caf Department of Children, Schools and Families (DCSF); Working Together to Safeguard Children (2010). HMSO, London Haringey Local Safeguarding Children Board (2009): Serious Case Review: Baby Peter. London: Haringey Local safeguarding Children Board. Available from: www.haringeylscb.org Segre L (2007): Listening Visits, Supportive Listening/Problem Solving Intervention, Iowa Clinical Research Centre, University of Iowa. |
NC52707 | Two siblings, aged 15 and 6-years-old, removed from their mother's care in May 2020. There was an investigation concerning sexual offences against the children involving an unrelated male who had been sent images of Child B by his father. The father was at the time a convicted sexual offender having been found guilty of downloading indecent images of children in 2014. Learning themes include: the child protection plan; the team around the family plan; effectiveness of universal health services; the voices of the children and their lived experience; disguised compliance; assessment and management of the father's risks to the children; and elective home education (EHE). Recommendations include: GP practices should be fully compliant with all relevant safeguarding procedures, including information sharing, knowledge of a child's safeguarding status and when to refer to children's social care; the EHE service should provide guidance, including an integrated decision and action pathway, that enables professionals to assess that children are receiving a suitable education, that also meets any safeguarding needs and which is subject to the prevailing statutory provisions; the Department for Education should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including a decision-making flowchart; National Probation Services and the local constabulary should take steps to ensure that offender manager practice of sex offenders is informed by a more holistic approach to assessment and risk management planning; and the College of Policing should review the active risk management system tool and consider including wider family dynamics and additional corroborative evidence beyond offender self-reporting.
| Title: Child safeguarding practice review: overview report: Child AB. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership Author: Paul Sharkey Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Overview Report: Child AB Author: Paul Sharkey MPA Date: August 2022 Publication Date: August 2022 Page 2 of 47 Contents 1. Introduction ......................................................................................................... 3 2. Terms of Reference and Key Lines of Enquiry ........................................... 3 3. Methodology, CSPR Process and Scope ..................................................... 4 4. Background and Significant Events .............................................................. 4 5. Analysis of Practice Against the Key Lines of Enquiry (KLOE) ............... 6 6. Key Findings and Learning ............................................................................ 32 7. Recommendations ........................................................................................... 36 8. Glossary of Terms ............................................................................................. 37 9. References .......................................................................................................... 38 10. Appendix 1: Aims, Terms of Reference and Key Lines of Enquiry ...... 39 11. Appendix 2: Review Methodology and Process ..................................... 40 12. Appendix 3: Elective Home Education: Current National Policy and Legalities ....................................................................................................................... 41 13. Appendix 4: Family (MAB’s) Views .............................................................. 44 14. Appendix 5: Improvements in GP Practice and actions taken by East Lancashire CCG .......................................................................................................... 46 Page 3 of 47 1. Introduction 1.1 The siblings A and B, aged fifteen and six (as of May 2020) respectively, are the subjects of this child safeguarding practice review (CSPR-henceforth known as The Review). They are from East Lancashire and are of White British heritage with unspecified religion. Child A is the elder sister to her brother, Child B. Their parents are MAB (mother) and FAB (father). 1.2 In May 2020 they were removed from their mother’s care by Lancashire Constabulary and placed in the care of the local authority. This followed information received by the Constabulary from another police force relating to an investigation concerning sexual offences against children involving an unrelated male who had been sent images of Child B by his father. FAB was at the time a convicted sexual offender having been found guilty of downloading indecent images of children in 2014. He was subject to a Sexual Harm Prevention Order (SHPO) and was being monitored by Lancashire Constabulary’s Management of Sexual and Violent Offenders’ team (henceforth referred as the MOSOVO). He was also subject to a three year community order consisting of a three year supervision requirement to the National Probation Service (NPS) with inclusion on an internet sex offenders treatment programme (ISOTP). NPS oversight was from 25.08.15 to11.10.18 and assessed him as being a medium risk. 1.3 FAB was supposed to be living apart from his family with contact to the children supervised outside of the home by MAB. Lancashire Constabulary attended the family home in May 2020 and saw the children as part of their investigation into the indecent images of Child B. In addition to sexual abuse matters, the Police were also concerned about the very poor state of the house which, according to photographic evidence, was uninhabitable. Both adults were arrested and charged with, in the case of FAB, sexual offences against children and breach of his SHPO; and child neglect by MAB. Criminal proceedings have since been concluded with guilty outcomes for both adults. MAB received two community orders with a rehabilitation requirement. FAB was sentenced to a custodial order in the summer of 2021. 1.4 Following their removal the children were made the subjects of interim care orders in mid May 2020 and placed in foster care where they remain following the conclusion of care proceedings in 2021. 1.5 Consequent to a rapid review in June 2020 by the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (henceforth referred to as the CSAP), a decision was made on the 26.06.20 to proceed to a child safeguarding practice review. An independent reviewer and chair were appointed in late 2020 ( the delay was due to the restrictions resulting from the covid19 pandemic) and the first panel meeting took place on the 20.01.21. 2. Terms of Reference and Key Lines of Enquiry 2.1 See Appendix 1 Page 4 of 47 3. Methodology, CSPR Process and Scope 3.1 See Appendix 2 4. Background and Significant Events 4.1 The children were made the subjects of Child in Need (CIN) plans between October 2014 and March 2015 due to concerns of sexual abuse arising from their father’s downloading of indecent images of children and subsequent conviction in August 2015. For this, he was placed on the sexual offender’s register, subject to a Sexual Harm Prevention Order and allocated a MOSOVO officer, in addition to probation intervention. An initial child protection conference (ICPC) was not thought necessary on the basis that the parents had separated and that the mother was considered capable of safeguarding the children. A CIN plan was deemed appropriate with contact between the children and their father supervised by the maternal grandmother. 4.2 Child A, on her mother’s initiative became electively home educated (EHE) between January to July 2016. Her previous (primary) school voiced concerns in January to the Lancashire elective home education team that she had been withdrawn to care for Child B, then a baby. Home visits were done by EHE staff in April and June. Child B had his two year developmental assessment completed by the health visiting service (community nursery nurse) in May 2016. Concerns were noted regarding poor home conditions, lack of family support, the quality of education afforded to Child A and the children having contact with their father who was supporting the mother with their care. There were no records to indicate that these concerns had been passed on to the named health visitor as intended. 4.3 An initial child protection conference (ICPC) was held on the 18.07.16 following the Police discovery that MAB was sending images of her breastfeeding Child B to FAB, in addition to poor home conditions and the mother supervising contact between the children and their father. The children were made the subjects of child protection plans under the categories of sexual abuse and neglect. Child A, as part of the plan, began attending a local secondary school (X) in September and was closed to the EHE team. 4.4 The children’s child protection plans finished on the 06.04.17, following a review child protection conference (RCPC) which decided to ‘ step down’ to a level 2 Team around the Family (TAF) plan. A local children’s centre was designated as the lead agency for the TAF, the main objective being the monitoring of home conditions for a short period. MAB was assessed as being able to protect the children from the risk of sexual abuse from their father. Agreement was reached for her to supervise contact between the children and their father , albeit in the community and not at home. On the 27.04.17, the TAF plan was finished (formally closed on the 10.05.17) , it being deemed that all of the actions were met. Lancashire Children’s Social Care (CSC) closed the case on the 31.05.17. Following this date there was no statutory agency involvement with the children until the 12.05.20 ( some three years) when the Lancashire constabulary intervened in respect of FAB’s possession of indecent images of his son. 4.5 The closures of the child protection and TAF plans in April/May 2017 were followed in September by Child A not returning to school for the new academic year. Her mother had decided to opt once again for elective home education, thus triggering EHE team involvement again. Both children had intermittent involvement with GP and hospital services in the three years up to May 2020. Child B for speech and language issues, frequent stool passage and Child Page 5 of 47 A for several matters, including viral infection, headaches, knee pain, squint, asthma and anxiety/panic attacks. Both parents also had involvement with their respective GP practices. Child A was referred by her GP to the Children’s Psychological Service on the 24.09.19 for anxiety and panic attacks. She received three sessions of brief self help intervention (known as ‘123 relax’) between November 2019 to January 2020. 4.6 The health visiting service had intermittent involvement with Child B and his mother during the three years; mainly regarding the child’s speech and language, a hospital admission follow up in October 2017, reported aspects of his behaviour and night terrors. A letter from the school nursing service was sent to Child A in August 2017 but face to face contact did not take place. 4.7 The EHE service visited the family twice in November 2017 regarding Child A’s home education following her mother’s request in early September. There are no records of any further visits after this time. 4.8 FAB received regular monitoring visits from his offender manager (MOSOVO-Lancashire Constabulary) as part of the conditions of his SHPO between June 2017 to May 2020. FAB had telephone contact on the 13.12.19 , via his GP practice, with a mental health practitioner from the speialist triage assessment, referral and treatment team (START). This was for reported symptoms of depression, anxiety and suicidal thoughts, including strong urges of accessing child pornography on the internet. He had not been taking his medication for the previous eighteen months. The Police MOSOVO reported having had contact with the START practitioner on the 13.12.19, regarding the concerns about FAB’s welfare. His phone was examined but no evidence was found of any attempts to access indecent images of children. There was no evidence of either the GP/mental health practitioner or the MOSOVO contacting children’s services regarding any consideration of their safety and wellbeing. 4.9 FAB was also subject to a three year community order consisting of a three year supervision requirement to the National Probation Service (NPS) with inclusion on an internet sex offenders treatment programme (ISOTP). NPS oversight was from 12.10. 15 to11.10.18 who assessed him as being a medium risk. 4.10 FAB was telephoned assessed on the 14.04.20 by a START practitioner some four months after his crisis assessment in December 2019. He did not think that any further intervention was needed as he reported an improvement in his emotional state since December having resumed his medication and having had a review by his GP. There was no further involvement from the START. 4.11 The Police investigation of the 12.05.20 (see above) triggered the series of events which resulted in the children becoming looked after by the local authority and care proceedings starting on the 15.05.20. The parents were charged with several criminal offences and subsequently convicted in December 2020 and 2021 respectively. Page 6 of 47 5. Analysis of Practice Against the Key Lines of Enquiry (KLOE) 5.1 The Child Protection Plan 5.1.1 The children were the subjects of child protection plans from July 2016 to April 2017 under the categories of sexual abuse (primary) and neglect (secondary) respectively. The main concerns were in respect of the risks presented to them from their father’s conviction in 2015 for downloading indecent images of children, his self confessed sexual predilection for pre-pubescent children, their mother sending him inappropriate photos of her breast feeding child B, serious questions about her ability to protect them and concerns around not meeting the children’s basic educational, social and developmental needs. Neither parent agreed with the concerns and had little insight or understanding of the identified risks to their children. They disagreed with the children being on child protection plans. 5.1.2 A core group was appointed at the initial child protection conference (ICPC) consisting of the social worker, health visitor, school nurse, home education support worker and the parents. The Police and probation service would liaise with the core group through the social worker and provide timely review reports on FAB’s progress and risk. Arguably, both of these agencies should have been included in the core group, given that FAB’s risk and its management were key issues in the case. Subsequent core groups included a family support worker from a children’s centre. Whilst not present at the ICPC due to Child A being home educated and therefore not on the school roll, school X became part of the core group and was included in the two RCPCs, following Child A’s start there in September 2016. 5.1.3 Regarding the overall effectiveness of implementation of the child protection plans the evidence suggests that this was mixed. Timely statutory social work visits were undertaken, core groups met frequently and review child protection conferences were held on time. The children were benefiting from attendance at a local secondary school (child A) and a creche (child B) respectively. FAB had complied with his probation supervision requirement and completed the internet sex offenders’ treatment programme (i-SOTP). There was no evidence that the children had suffered sexual harm or significant neglect during the period of the child protection plan. Their health and development were noted by professionals to be positive. MAB’s emotional and mental health state had improved, as had her general care of the children. 5.1.4 However, there were few unannounced visits as per the plan, partly because of obstruction by MAB and child A was rarely seen on her own to ascertain her views. There was a lack of consistent attendance by core group members which undermined the effectiveness of the child protection plan.1 Moreover, of some concern, there were no reports from the GP practice which was not aware that the 1 There was no attendance by the health visitor and school nurse at three core groups between December 2016 and February 2017, a crucial time in the child protection plans. It was possible that there was a change of staff and staff sickness. Page 7 of 47 children were on child protection plans. The police and probation service should have been included in the core group and present at the final RCPC in April 2017 (albeit they provided reports) to participate in the discussion around risk assessment and management of FAB after the ending of the child protection plans. 5.1.5 In relation to reviewing the plans, core groups and RCPCs were held within prescribed timescales. However, as mentioned above, the inconsistent and intermittent attendance of core group professionals and changes in group membership arguably diluted the group’s collective knowledge of the case and appreciation of the risks to the children. The change of IRO would have compounded this process with the statutory reviews. IRO1 who chaired the ICPC and first RCPC in October 2016 reportedly completed one, ‘mid point’, check, but their notes did not include an oversight analysis of progress with the plans. 5.1.6 The practitioners’ learning event was informed by the CSC representative that current practice would now include the IRO having a greater oversight of the child protection plan, including documenting on the, ‘ IRO monitoring between reviews’ case notes.2 5.1.7 The final RCPC at which the decision was made to end the child protection plans was chaired by a different IRO ( IRO2). It was attended by the social worker ( SW2), the allocated school nurse and health visitor and a children’s centre worker, identified as a Sure Start representative in the meeting attendee’s record. The probation representative gave apologies for absence but had provided a report. There was also a school nurse report. There were no representatives from the Police, child A’s school or anyone from the elective home education service ( possibly because child A was attending school), or either GP practice. The parents also attended. 5.1.8 The RCPC considered evidence from the reports of the social worker, school nurse and FAB’s probation officer. IRO2’s summary cited that FAB had engaged well with his community order and had completed his sex offenders’ programme with the probation service. However he had admitted to having a sexual predilection for pre-pubescent females ( 6-10 years) and was assessed as being a medium risk to children. SW2’s children and family assessment was generally positive about the progress made by the children and their mother. Work with child A around ‘ keeping safe’ and wishes and feelings had gone well and she was wanting more contact with her father. Child B had attended a creche which had been beneficial to his development. 2 The IRO service in April 2016 was significantly understaffed and operated on 51% of agency workers with an average caseload of 92 per IRO, a figure in excess of recommended caseloads at the time (see IRO handbook). 2017 saw an increase in IRO recruitment to the service (local authority) with a decrease to 75 cases per IRO by March 2017, allowing for greater case oversight as per the IRO handbook. Moreover, there were significant increases in both children looked after (7.9%) and those on child protection plans (936 in March 2015 to 1460 in March 2016, a 60% in-crease) in 2016 which added to the demands on CSC social workers and IROs. The increased pressures on both social workers and IROs led to low staff morale and high turnover of personnel. In January 2021 the IRO service had no posts covered by agency workers and had an average caseload of 62.6. IROs now have a reduced caseload compared to 2016, thus allowing for completion of the, ’Monitoring between reviews’, case notes. This contains a more detail analysis of the child protection plan. Page 8 of 47 5.1.9 9 Moreover, on the understanding that FAB was permanently living away from the family it was deemed appropriate for MAB to supervise contact between the children and their father in the community, away from the family home. This was to be underpinned by a contact agreement and a team around the family ( TAF) plan led by the children’s centre to monitor remaining concerns about home conditions. In the event that the parents resumed their relationship or FAB started another one, CSC should be alerted and consideration would be given to any potential safeguarding concerns. 5.1.10 It would seem then, that the rationale for the ending of the child protection plans and the decision to allow contact to be supervised by MAB in the community was based upon the positive reports from the agencies. However, as was identified by the CSC agency report for this review and the practitioners’ event, the assessment of MAB’s ability to safely supervise the contact in the long term would have benefited from a more specialised risk assessment from an external agency. Unfortunately, this was not available to CSC at the time, albeit is now. 5.1.11 Arguably, the CSC assessment of MAB could have been enhanced by discussion with the probation service and the MOSOVO team regarding its up to date assessments of any risks presented by FAB to his children. The OAsys3 probation assessment completed on the 28.10.15 concluded that FAB was a ‘ medium risk’4 to children. A more integrated risk assessment informed by CSC, probation and MOSOVO would, in all probability have resulted in the same risk category, namely medium risk. However, it could have provided some relevant and robust multi-agency risk management strategies in regard to the post child protection plan period, particularly in relation to the issue of MAB’s supervision of contact between her children and their father. 5.1.12 Thus, for example, there could have been a coordinated risk management approach to the children’s wellbeing and safety involving child A’s school, the family GP, the police and probation services. In the event of any significant change in the children’s circumstances, for example, the parents resuming their relationship and FAB having unsupervised contact or contact at home, or FAB entering into another relationship, this could have triggered an alert to CSC who could have considered whether to initiate any appropriate safeguarding action. 5.1.13 On balance, the decision to end the child protection plans was probably appropriate in all of the then known circumstances, given the information and knowledge of the family available to the RCPC at the time. The children could not have remained on their child protections plans indefinitely and there were insufficient grounds for local authority intervention via care proceedings. This gave the local authority a dilemma. On the one hand the child protection plans had provided the children with some protection and safeguarding. Conversely, the end of the plans handed the management of risk to MAB which was based upon 3 Offender Assessment system. 4 Defined as, ‘identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse’. (National Offender Management Service, Public Protection Manual, 2016, page 2) Page 9 of 47 the agencies having confidence and trust in her willingness and ability in the long term, to protect her children and sustain the provision of good enough parenting and care. 5.1.14 In conclusion, this turned out not to be the case. The assessment of MAB’s capacity to protect her children underestimated the risk from their father, in addition to considerations of future neglect. As acknowledged by CSC, the use of a more specialised risk assessment service looking in more depth at FAB’s risk could have perhaps led to a more structured risk management arrangement involving the police, probation and school X. Arguably, they could have remained on plans for a further six months to embed, test out and monitor improvements and facilitate the continuation of child A’s schooling. Alternatively, the child protection plan could have been, ‘ stepped down’, to a child in need (CIN) plan to achieve the above. In the event, a recommendation was made at the RCPC to place the children on a level 2 short term Team around the Family plan. 5.2 The TAF plan 5.2.1 It was not recorded in the RCPC minutes, nor the final core group or CSC child and family assessment, what the rationale was for a TAF plan, or indeed, why there was no consideration for a child in need plan. The lead agency was the children and family wellbeing service ( CFW) using a children’s centre family support worker. The CSC agency report for this review noted that the rationale for a step down to a CIN or TAF plan, following the ending of a child protection plan, should have been set out in the CSC child and family assessment and RCPC minutes. That said, the RCPC minutes noted that work had been completed with MAB concerning her understanding of abuse and the risk presented to her children by FAB. The expectation was that she was being trusted to manage these over the long run and that further testing out of her ability to do this was not part of the TAF plan. 5.2.2 In any event, it would seem that the only objectives of the TAF plan were for the children’s centre worker to monitor home cleanliness and for MAB to complete a maths and English course. There were no explicit safeguarding considerations. Unfortunately neither the children’s centre manager or the family support worker are currently employed by the CFW so it was not possible to tease out and understand fully the reasons and rationale for the three week TAF plan. The family support worker made one home visit and reported to the TAF review meeting held in late April 2017 that home conditions were adequate. Moreover, MAB had apparently completed her maths and English courses. Those attending the TAF review ( family support worker, social worker and health visitor) deemed that the family’s needs and TAF objectives had been met thus justifying case closure. It was deemed that any future needs could be met at a universal level; presumably through primary health and child A’s school. 5.2.3 This review would question the efficacy of the TAF’s short term focus on home conditions and the completion of MAB’s educational goals. Employing a cleaner would not seem to be reasonable test of MAB’s ability to sustain acceptable conditions over the longer term for her children, notwithstanding any safeguarding considerations. This review would argue that any step down plan ( CIN or a TAF) should have supported MAB and the children in embedding the Page 10 of 47 positive changes; including encouraging attendance at nursery and school for the children, over a longer time horizon, say six months. In short, three weeks for the TAF would seem not to have been long enough to test out the sustainability of change made by the family during the child protection plan. There was no evidence of any CSC or CFW management oversight or approval regarding case closure. The involvement of child A’s school in the TAF would have been beneficial. Current_Practice 5.2.4 TAFs are now reviewed online by a senior family support worker and cases cannot be ended without management oversight and a documented rationale for closure. CFW is now part of the Children’s Services, ‘ Liquid Logic’, case management system that includes access to CSC historical information on children and families, as well as child protection and CIN plan records. CFW state that it now has robust step down procedures that involve a social worker handover ( there was not one in children A and B’s case) to the family support worker in complex cases. Step down from CSC are now managed by a family intensive support team. There are escalation processes to provide for challenging whether cases meet the threshold for support or when there is a need to step up to CSC child protection statutory intervention. 5.2.5 Moreover, CSC and Early Help ( as CFW is now called) now have a service manager to ensure that transactions across the two services are consistent; that common thresholds are applied and services are aligned to ensure that children and families are effectively supported across the services. The service manager implements a robust, ‘step down’, procedure to ensure that when children and families step down from child protection the new plan addresses all areas of remaining risk and need. In addition, training around threshold guidance and transforming children’s services has also been developed for internal professionals and external partners to ensure a smooth transition between CSC, Early Help support and Universal services. 5.3 Effectiveness of Universal Health Services 5.3.1 Universal health services involved with the children and their parents included health visiting, school nursing, and the separate GP practices of mother and children and the father. The first two services were provided by Trust 1 up until April 2019 when they were transferred to Trust 2. 5.3.2 Health Visiting and School Nursing: There had been several previous health visiting episodes with the family following child A’s birth in 2005 ( Universal core programme until 2009), child B’s birth in 2014 ( initially Universal and from October 2014, targeted health visiting and school nurse intervention during the CIN plan) prior to the child protection plans of 2016/17. As mentioned above the 2016/17 period involved targeted support from the two services. 5.3.3 For some unknown reason ( not evident in the records) there was a change of health visitor for child B in July 2016 ( the start of the child protection plan) from HV1 to HV2 and then back to HV1 in September of the same year. Involvement of Page 11 of 47 the two services in the child protection plans has previously been examined above, albeit it is of some significance that there was no involvement by either of these two services between December 2016 to February 2017 when three core groups were missed ( see note 1 above). 5.3.4 Post the child protection and TAF plans in April 2017 the health visiting service provided some support and advice ( telephone and post) to MAB regarding child B’s drooling, behaviour and sleep management ( October 2017)5. There was no recorded follow up by the school nursing service regarding an outstanding action from the final RCPC to see child A in school about her mother’s concerns that she had no one to talk to in school. However, it would appear that because the contact had lapsed with the school nurse a letter was sent in August 2017 to child A offering her support if she needed it, along with information on the CHAT ( an 11-18 years safe chat service with the school nurse service) health service. Child A was weighted to universal services by the school nursing service, despite having been no follow up with Child A in compliance with the final RCPC. This appears to have been a missed opportunity for child A to have voiced her wishes and feelings about school and any other issues. 5.3.5 In October 2017, MAB was admitted to a local hospital for five days. The health visitor became aware that child B had been brought to hospital with vomiting and a high temperature by his father during that time. Child B had been discharged home to his father by the hospital staff which raised concerns about the latter’s contact with his children. Subsequently, MAB told the health visitor that her mother ( maternal grandmother) had taken child B to the hospital , along with FAB. There was no evidence that the health visitor liaised with the hospital to establish the facts or challenged the parents on whether FAB had sole care of the children or if arrangements had been made for the maternal grandmother to do this. 5.3.6 During the above episode, MAB had asked for health visiting support with child B’s behaviour and sleeping management. It was agreed that a home visit would be made a few weeks later once MAB had recovered from her illness. In mid November 2017 a planned visit was cancelled by MAB who was reportedly unwell. Information was posted to MAB and a new visit was arranged for the end of November. Rather than visit, the health visitor spoke with MAB by phone who reported that child B’s behaviour had improved slightly but he was having, ‘ night terrors’. MAB had requested her GP to refer child B to a paediatrician but was apparently told that he was too young. The health visitor gave advice over the phone, posted more literature and suggested MAB get a second GP opinion and agreed to follow up in a week’s time. 5.3.7 A follow up by phone took place in early December 2017. MAB reported that child B was continuing to have nightmares and put this down to him being insecure since her recent hospitalisation. She was offered further support but declined and weighted to universal services. A home visit in this instance to assess child B’s behaviour and night terrors would have been expected practice, given his 5 MAB cancelled a home visit by the health visitor in October 2017 due to ill health, resulting in tele-phone and postal follow up. Page 12 of 47 safeguarding history and context of only recently having been subject to a child protection plan and the concerns about his father. This episode seemed to lack sufficient child focus and was more concerned with responding to MAB. 5.3.8 Thereafter, there was no active involvement with the family from December 2017 to May 2020. The children’s health needs were assessed as requiring a Universal core programme following the ending of the child protection plans in April 2017. There were no further requests from other agencies or the family for school nurse intervention, which was not surprising given that neither child was in school or on the roll. 5.3.9 In December 2018 child B was a ‘ rising five’ and eligible to start school. The school nursing service recognised that they had no information about his school attendance and sent a letter to his mother asking her to complete and return a form indicating which school he would be starting. There was no record of MAB providing the information nor any follow up by the service. In the light of prior multi-agency involvement good practice should have involved follow up action, including a visit to see child B, to ascertain his school attendance. In the event, he was never on a school roll whilst in his mother’s care. 5.3.10 Finally, there was no recorded evidence that any of the health practitioners received supervision despite the children being subject to child protection plans.6 5.3.11 In conclusion the episodes cited above suggest that health visiting and school nursing services ( whilst part of Trust 1) fell short of expected safeguarding practice regarding a lack of child focus, professional curiosity and failure to follow up on the needs of the children. There were several missed opportunities to have seen the children, assessed their needs, safety, wishes and feelings. On this basis it can be concluded that intervention by the two services was suboptimal in safeguarding and promoting the children’s welfare and wellbeing. 5.3.12 The review was unable to view Trust 1’s records; the agency report was provided by Trust 2.7 Thus it was not possible to understand Trust 1’s organisational context and operating environment within which the suboptimal practice, actions and decisions were made by health visiting and school nurse practitioners. There may have been several barriers to expected practice such as understaffing, poor management oversight and organisational change accounting for the deficits cited above. Trust 2 has identified the relevant learning and required improvements from this practice review and implemented an action plan to ensure that current health visiting and school nurse provision is consistent with expected safeguarding policy and practice. GP Practices 6 It should be noted that prior to September 2016 staff supervision involved a reflective look at one or two child protection cases every 4-6 weeks. The focus was on practitioner reflection/ development rather than on an individual child or case. Hence, not all cases were discussed which would account for the absence of any recorded discussion regarding the children A and B. Since 2017 there has been a change in supervision policy towards a recorded consideration within six months of every child on a child protection or child in need plan. 7 Trust 2 provided all of the information regarding health visiting and school nursing contacts with the family, from Trust 1 and Trust 2. All records and staff transferred from Trust 1 to Trust 2 in April 2019. Page 13 of 47 5.3.13 The GP practices ( GP1 for the children and MAB; GP2 for FAB): The evidence examined by this review indicates that the two GP practices fell very short of contributing to the effective safeguarding and promoting the children’s welfare. There were several instances of this as set out below. 5.3.14 Firstly, for reasons unknown GP1 was unaware that the children had been subject to child protection and TAF plans in 2016/17. There were no GP records of the children’s plans, nor minutes of meetings, despite the child protection outcome plan having been sent within 24 hours to GP1’s practice. Moreover, although having been sent an invitation to attend the ICPC or at least provide a report, none was forthcoming. 5.3.15 Secondly, child A had been seen by GP1 in June 2016 ( aged eleven) for low mood and thoughts of self-harm. Her school performance had deteriorated and she was being home educated. There was no recording of any discussion with her of the reasons for her low mood and self harming thoughts, albeit a referral was made to child psychology at ELCAS ( East Lancashire Child and Adolescent Service). This episode was not mentioned at the ICPC because it had not received a GP report. In the event, the school nurse picked it up in the course of completing an individual health assessment (IHA) on child A as part of the child protection plan. Unfortunately, MAB did not make an appointment with the service and child A’s low mood and thoughts of self harm were not assessed and addressed, this being at a time when she was on a child protection plan. Neither the school nurse nor the GP followed up child A’s ‘ no show’ with ELCAS. 5.3.16 Thirdly, on the 13.12.19 FAB attended GP2 and reported symptoms of depression, anxiety and suicidal thoughts, including strong urges of accessing child pornography on the internet. He had not been taking his medication for the previous eighteen months. He informed GP2 that he had supervised contact with his children due to accessing child pornography five years previously. GP2 made a referral to the mental health team but did not think to inform Children’s Social Care or the Police given the obvious safeguarding implications of FAB’s consultation. 5.3.17 In the event, FAB was phoned triaged at the GP surgery the same day by a START8 mental health practitioner who did inform the police MOSOVO team of his urges to access indecent images of children. However, an assumption was made that the Police would share the information with CSC which did not actually happen; resulting in no safeguarding referral from START to CSC as per procedures. There was a four month delay before FAB was telephone assessed in April 2020 by the START team. He felt well and it was agreed that no further mental health input was needed. There was no record of any discussion around accessing indecent images of children or contact with his own children. ( See later section re MOSOVO/ Probation and START). 5.3.18 The above episodes ( of 2016/17 for GP1 and 2019 for GP2) are concerning and suggest a lack of safeguarding awareness, effective information sharing/recording systems and professional curiosity, tantamount to a significant 8 Specialist Triage Assessment and Referral Team (START) Page 14 of 47 disconnect/systemic failure between the two GP practices and the local multi-agency safeguarding network. 5.3.19 This review was informed by the panel CCG representative that the two GP practices in question have a generic e-mail which should be used to send information. When there is a request regarding an ICPC the CSC sends it to the CCG safeguarding team who check that the practice details are correct and then forward the request to the practice’s generic e mail and also the practice safeguarding lead. 5.3.20 The review learnt from the practitioners’ event that currently, all GP practices in Lancashire now have a designated doctor whose responsibilities include offering guidance and supervision regarding safeguarding issues. Moreover, the review was informed that all GP practices should have their own safeguarding policies and access to and should be following pan lancs procedures: https://panlancashirescb.proceduresonline.com/. 5.3.21 This review welcomes the above apparent system improvements. 9 However, notwithstanding this, the review would submit that GP practice shortcomings ( albeit several years ago) were such that the local CCG needs to reassure the Safeguarding Assurance Partnership that significant improvements in safeguarding practice ( including not only information sharing but also safeguarding awareness and professional curiosity ) have been made with the two GP practices and if needs be the wider local GP network, such that they are now operating safely and in the interests of local children and young people. 5.4 Children’s Psychological Services 5.4.1 A first referral regarding child A’s anxiety symptoms and panic attacks was made in late March 2019 by GP1 practice to the East Lancashire Child and Adolescent Service/ELCAS. There was no record of any response. GP1 made another referral six months later in late September 2019 when it was agreed that the child psychology service (CPS) was best placed to respond to child A. An appointment letter for an initial assessment scheduled for the 27.11.19 was sent out on the 09.10.19. 5.4.2 Child A’s initial assessment fell short of expected practice in that it omitted to consider safeguarding issues. MAB had mentioned the previous involvement of children’s social care (CSC) and that the children’s father had supervised contact with them because of his criminal record of sexual offences. Despite this knowledge no questions were asked about who was supervising the contact, nor was any contact made with CSC to establish the veracity of MAB’s account. 5.4.3 Child A subsequently attended for three sessions of 123 relax (brief self help intervention) with a family support worker between December 2019 and January 2020. Part of the intervention involved the support worker and Child A completing a work book that sought to capture her lived experience. 9 NB. See appendix 5 setting out the East Lancashire CCG GP safeguarding improvements and actions taken Page 15 of 47 5.4.4 Reason’s given for not triangulating with CSC were that the information from MAB was, ‘ historical’, and liaison therefore not needed. This review was informed that 95% of the children seen by the CPS have had historical or current involvement with CSC which begs the question of how often did CPS contact CSC regarding safeguarding issues during this time? This review was informed that contemporaneous safeguarding procedures were in place. However, consequent to this CSPR the LSCFT has produced a ( enhanced) procedure ( SG001) to ensure triangulation with CSC in the event of both current and ,’ historical’, involvement with the latter agency, where physical/sexual abuse and sexual offending are mentioned in the course of an initial assessment by the CPS. 5.4.5 During the course of the therapy the family support worker involved with child A contacted the CSC to enquire about support for the children during their mother’s upcoming admission to hospital for an operation. Despite being told that a response would be made within 24 hours this was not forthcoming. It is not known why there was no CSC response nor why the family support worker did not follow up the request. 5.5 Hospital Safeguarding 5.5.1 The key practice episode here concerns the time that MAB was in hospital ( H1) in October 2017. This coincided with child B’s presentation at H1’s emergency department (ED) along with his father, following a referral by GP1 practice for a high temperature and vomiting. 5.5.2 H1’s General Admission Document (GAD) had noted that MAB was living with her children. There was no documentation regarding who was caring for them, albeit H1 does point out that it is the parent’s responsibility to ensure that adequate childcare is sought for any children. The GAD has subsequently been updated to include a section on caring responsibilities encompassing children and vulnerable adults. The GAD now asks who the patient lives with and if there is/has been any social care involvement. 5.5.3 ED staff checked with the Child Protection Information System (CP-IS) and ascertained that child B had been subject to child protection plan that had finished in April 2017 and was no longer active. There was therefore no reason to interrogate the CP-IS given that the child protection plan had ended. ED completed a child risk assessment tool (CRAT) which did not identify any safeguarding concerns with child B’s presentation, thus negating any justification to contact CSC. A paediatric liaison form was sent to the health visitor regarding the attendance in line with expected practice. 5.5.4 In March 2017, child B, whilst still on a child protection plan attended H1’s ED for an arm injury ( soft tissue injury; said to have fallen over some shoes). Information was shared with paediatric liaison as per policy. In the event, the health visitor was notified of Child B’s hospital attendance which was passed onto the social worker and followed up by the health visitor. 5.5.5 In conclusion, the actions taken by ED staff at hospital H1 regarding the above episodes was compliant with expected agency safeguarding policy and practice of the time. Page 16 of 47 5.6 Elective Home Education (EHE) 5.6.1 Context: Current national policy and legalities - see appendix 3 Lancashire EHE Team Intervention 5.6.2 MAB’s decision to withdraw child A from school X in September, some five months after the ending of the child protection triggered the involvement of the EHE team. This followed School X’s notification to EHE on the 06.09.17 as per procedure. The notification stated that it was, ‘ unsure’ , if there were any safeguarding concerns or whether child A had a statement of SEN ( special educational needs). 5.6.3 There was no evidence that the EHE worker ( the same one who had dealt with the family in 2016, who knew child A’s history and the fact of a child protection plan) had contacted the school to clarify the situation around safeguarding, nor whether the school had contacted CSC to inform them, in the light of previous safeguarding concerns around sexual abuse and neglect, of child A’s removal. There was no evidence that any action ( under S.436 A of the Education Act 1996) was taken to ascertain the suitability of child A’s education and whether, in compliance with section 175 of the Education Act 2002, there were any safeguarding issues.10 5.6.4 Assuming approval from MAB, a home visit should have been undertaken. In the event that her permission was not forthcoming consideration could have been given to pursuing a school attendance order or considering child A to have been a ‘ child missing from education’. Alternatively, it would have been reasonable, in all of the circumstances, for the EHE team to have made a referral to CSC for it to consider making enquiries under the Children Act 1989 regarding child A’s ( and B’s) safety and wellbeing, given the recent ending of the child protection plans. 5.6.5 In the opinion of the lead reviewer, this omission amounted to a missed opportunity to have taken action to safeguard the children and promote their welfare. 5.6.6 Annual review letters were sent to the family in the years 17/18, 18/19 and 19/20 requesting updated details from MAB. No response was forthcoming yet despite this, there was no follow up action from the EHE team. CSC’s electronic recording system ( 'Liquid Logic’) was accessed by the EHE team annually to see if the children were on an open case but as it was closed, no further action was taken. 5.6.7 This Review would question why no follow up actions were taken as set out above, in compliance with DfE guidance. 5.6.8 Concerning Child B, his mother was under no legal obligation to notify the local authority that he was being home schooled. Because of this his name was never on a school roll and he was thus not known to the local authority EHE team or indeed any primary school. In short, he was not on the local authority, ‘radar’, from 10 In addition, the local authority general duty under sections 10 and 11 of the Children Act 2004 to safeguard and promote the welfare of children in their area, including those in home education. Page 17 of 47 a schooling/education perspective. This was detrimental to him on both educational and safeguarding grounds as later events were to show. 5.6.9 Arguably, the legal loophole not requiring parents to notify the local authority of their rising five child’s home education presents a significant gap in ensuring that the child is receiving an’, efficient and suitable’, 11 education and that any safeguarding needs12 are being met. This review would respectfully suggest that the DfE needs to address this issue in a timely manner such that local authorities are aware of the education status of all rising five children. 5.6.10 Regarding Child A, there would seem to have been a degree of ‘ silo working’ and a lack of professional curiosity shown by the EHE team, notwithstanding any possible organisational barriers within the operating environment impacting on practitioners, including a lack of suitable national and local guidance on safeguarding considerations in respect of home schooling. Moreover, as acknowledged at the practitioners’ learning event, there was an absence of considerations and actions regarding the children’s safeguarding and wellbeing. The EHE team should have challenged the suitability of home education ostensibly being offered to child A, which may also have resulted in any safeguarding concerns being referred to CSC. That said, it is acknowledged that the EHE team was operating without clear national and local guidance at the time. 5.6.11 In sum, the evidence suggests that the EHE team’s practice was ineffective in both ensuring the suitability of child A’s education and promoting their safety and wellbeing. National Developments 5.6.12 The DfE is consulting on possible changes to the current non-statutory ( 2019) EHE guidance regarding local authority registration, greater monitoring and oversight and family support of children being home educated. The Children’s Commissioner (February 2019) has called for, • A mandatory home education register requiring parents to register their children with the local authority. This would include the child’s name, date of birth and address at which they are being educated. • A requirement for parents to inform the local authority if they move away from the area and re-register the child with the new local authority. Councils should develop information sharing agreements to further ensure that children do not disappear ‘ off-grid’ after moving. • Council education officers should visit each child being home educated at least once per term to assess the suitability of their education and welfare. This will require additional funding for local authorities. Where there are concerns regarding a child’s welfare they should be spoken to without parents present. 11 As per section 7 of the Education Act 1996, see appendix 3 below. 12 As per the Children Act 1989 and other safeguarding legislation/guidance Page 18 of 47 • Advice and support: The local authority should visit the child and family within three days of a decision taken for the child’s removal from school to be home educated. Advice and support should be provided by the local authority on alternative options, including other schools the child could attend. Information should be provided to parents so that they are aware of what they are taking on, including their responsibility to meet exam costs, and offer help negotiating entry to another school if desired. 5.6.13 The National Society for the Prevention of Cruelty to Children (NSPCC) is advocating for a register of all home educated children which would, ‘ help local authorities discharge their responsibilities assessing first and foremost the safety of the child, as well as the suitability of the education provided’.13 5.6.14 A recent report published by the House of Commons Education Committee has called for a national register of home educated children in England. Its chair ( Robert Halfon, MP) stated that local authorities must,” keep a much closer eye”, on how home educated children were progressing. 14 However, greater local authority oversight of EHE was opposed by some parents’ groups such as , ’ Education Otherwise’, arguing that there was no basis, or benefit to registration of home educated children. Such a move would tend to increase EHE families’ lack of trust in public bodies even further. 5.6.15 There is no mention of EHE and safeguarding in the current ( 2018) version of ‘ Working Together’ which is a major omission. Local authorities and their safeguarding partnerships should be provided with clear and robust guidance regarding the interface between EHE and safeguarding.15 A flow chart integrating the charts at pages 41-43 in the current DfE ‘ Elective home eduction’ ( April 2019) guidance and safeguarding should be undertaken at the earliest opportunity. Guidance should include addressing the legal loophole regarding the need for parents to notify the local authority that a, ‘rising five’, child is being home educated. 5.6.16 The evidence from this review and the above national authorities ( including the House of Commons Education Committee) provide ( in the opinion of this review), compelling reasons for the adoption of mandatory local authority registration of all home schooled children. The lead reviewer would respectfully argue for the adoption by the DfE of all of the measures called for by the Children’s Commissioner as set out in paragraph 5.6.12 above. 5.6.17 Lancashire Elective Home Education: Current Developments in italics. Set against the Children’s Commissioner’s recommendations at paragraph 5.6.12 above 13 Written reply to the lead reviewer, March 2021. 14 See the recent Government announcement, ’How we plan to support families who choose home education through registers children not in school’ (3 February 2022). The intention is to set up a system of local authority administered registers for children not in school to enable local authorities to make sure they know where every child is being educated, that it is of the right quality, and that support is offered to home education families. 15 Albeit there is a brief section on EHE and safeguarding in the current edition of Keeping Children Safe in Education (September 2021, page 42) and a section in EHE guidance (April 2019), ‘Safeguarding: the interface with home education’ at page 22. Page 19 of 47 5.6.18 A mandatory home education register requiring parents to register their children with the local authority. This would include the child’s name, date of birth and address at which they are being educated. 5.6.19 Lancashire County Council (LCC) has a register of all children and young people removed from a school roll for the purpose of home education. 5.6.20 A requirement for parents to inform the local authority if they move away from the area and re-register the child with the new local authority. Councils should develop information sharing agreements to further ensure that children do not disappear ‘ off-grid’ after moving. 5.6.21 All children and young people who move out of the Local Authority (LA) are tracked out through Children Missing From Education (CME) processes. The expectation is that any child coming into the LA is thus notified by the home LA that they have arrived in LCC. 5.6.22 Council education officers should visit each child being home educated at least once per term to assess the suitability of their education and welfare. This will require additional funding for local authorities. Where there are concerns regarding a child’s welfare they should be spoken to without parents present. 5.6.23 Legislation does not allow LA's to intervene unless there are concerns that a suitable education is not being provided.16 To be able to speak to a child without a parent present would require a s.47 enquiry to be initiated. 5.6.24 Advice and support: The local authority should visit the child and family within three days of a decision taken for the child’s removal from school to be home educated. Advice and support should be provided by the local authority on alternative options, including other schools the child could attend. Information should be provided to parents so that they are aware of what they are taking on, including their responsibility to meet exam costs, and offer help negotiating entry to another school if desired. 5.6.25 The EHE support workers make telephone calls to all new parents when in receipt of EHE notifications. If there are concerns around the decision making of parent to EHE a Children's Champion is alerted and will pick up the case for the family. 5.6.26 Additionally, the council consulted (January 2021-May 2021) with partners and the EHE community and LCC guidance has now been updated and brought in line with 2019 DfE guidance. The government’s revised, strengthened 2019 EHE guidance to LAs explains how a LA’s safeguarding duties can be engaged in these circumstances, and what steps they can take. It sets out in clear terms the steps that the LA can take where it is not satisfied that the education provided by parents is suitable, including the point at which the LA’s safeguarding powers become engaged. 5.6.27 LCC’s existing powers, as set out in the government’s guidance, are enough for LCC to determine whether provision is suitable. DfE’s guidance for LAs does detail eight components (see paragraph 9.4) that LAs should consider when determining 16 Or there are safeguarding concerns under the Children Act 1989 and ‘Working Together’ 2018 guidance. Page 20 of 47 whether a child is receiving a suitable education. This includes: isolation from a child’s peers indicating possible unsuitability; enabling the child to participate fully in life in the UK; and, education not conflicting with Fundamental British Values, to name but a few. Unsuitable education would require necessary action. The guidance is available at: tinyurl.com/P4nfkxud. 5.6.28 In April 2019, the Government launched a consultation on proposals for a LA register of children not attending mainstream or registered independent schools, and support for home-educating families (should they want it). This closed on 24 June 2019. LCC awaits responses to a commitment for a mandatory system for children not in school. The system will help LAs undertake their existing duties, as well as help safeguard all children who are in scope. LCC currently operates a database of all Lancashire children and young people who are removed from roll for the purpose of EHE. An annual contact is made, and request to provide examples of suitable education are made. This is not a mandatory request. 5.6.29 Actions from LCC: • Consultation on LCC EHE guidance and appropriate updates to documents and public information (website, leaflets, letters to parents/carers) • Children's Champion posts established to work with families where the decision to EHE has not been in the best interests of the child/young person (off rolling by a school). • Peer supervision regarding cases where a concern is raised. • EHE support workers have improved learning opportunities – attending Children missing from education and missing from home panels. • New processes in place for working with SEND/Inclusion teams regarding EHCP/EHE pupils. TASS locality groups – key line of enquiry (key CYP plan priority) = numbers of EHE pupils across the partnerships, hot spots of EHE data which may highlight school practice or pocket of cultural responses to LA based educational provision. 5.7 Assessment and Management of FAB’s Risk To The Children. The National Probation Service involvement with FAB 5.7.1 Following his conviction in August 2015 for possession of indecent images of children, FAB was sentenced to a three year community order that included a requirement to complete an internet offender treatment programme(i-SOTP). The order and programme were overseen by the National Probation Service (NPS). Additionally, FAB was also made the subject of an indefinite. Sexual Harm Prevention Order/SHPO (conditions related to the use of devices that can browse the internet) and required to sign the sex offenders’ register for five years. This was overseen by the MOSOVO (Management of Sexual Offenders and Violent Offenders) team of the Lancashire Constabulary. Subsequently, in August 2018 this team took on the role of lead agency, following the ending of the i-STOP Page 21 of 47 programme in October 2016 and the three year community order to the NPS in August 2018. 5.7.2 The NPS completed an OAsys (offender assessment system) assessment post FAB’s conviction, designating him as a Medium Risk of serious harm to children.17 18 The resulting risk management plan ( RMP) of the 28.10.15 stipulated ( amongst other things) that , there would be regular contact with the dangerous and sexual offenders’ unit (the DASOU, later known as the MOSOVO), regular review of the RMP, discussion of the case in regular supervision/risk meetings and contact with CSC in the event of any child protection issues, such as FAB moving back into the family home or unsupervised contact with the children. Home visits, both announced and unannounced were to be completed as and when considered appropriate. 5.7.3 The evidence suggests that the 2015 RMP was poorly executed in so far as there was no documented liaison with the MOSOVO in 2015-2016, no annual reviews until the 12.06.18- therefore none done during the period of the child protection plans of July 2016-April 2017- and no record of any home visits in 2016-2018. Given the reason for the ICPC in July, namely the MOSOVO’s concern that FAB had downloaded pictures of child B on his phone and his unhealthy sexual interest in pre-pubescent children; this review questioned why this episode did not result in an updated OAsys ( dynamic) risk assessment and review of the RMP in the latter half of 2016? Indeed, why was not FAB dealt with as in serious breach of his community order and other ongoing sanctions?19 5.7.4 Arguably, the episode should have resulted in a raised risk profile for FAB, closer working with the MOSOVO and the CSC, unannounced home visits and triangulation visits to speak to MAB and the children. A more professionally curious and investigative approach through the visits could have provided more insight into the nature of the relationship between the parents and a better understanding of FAB’s contact with his children. Moreover, the episode and its raised risk implications for the children appeared not to have been reflected in the probation reports for the ICPC and the two RCPCs, the second of which resulted in the children being de-planned. 5.7.5 In any event, FAB completed the i-SOTP in October 2016 with a positive programme report. A post programme review (but not constituting an annual OAsys case review) was held on the 01.11.16. evidencing his improved self-management and problem solving, together with his improved strategies to manage his sexual fantasies. There was a NPS post programme (i-STOP) handover meeting on the 01.11.16 when a new offender manager (OM2) was assigned to FAB 17 See note 4 above for the definition of medium risk. 18 All registered sex offenders fall within MAPPA (multi-agency public protection arrangements). However, because FAB was assessed as being at medium risk of harm he was designated at level 1 which is local case management as opposed to multi-agency meetings at levels 2 and 3. His medium risk status would not have resulted in a higher level and hence no multi-agency oversight. 19 The episode also raises the question of why the Lancashire Constabulary appeared not to have considered whether to prosecute FAB for a possible sexual crime regarding child B, especially given he was already a registered sex offender and subject to a community order? Page 22 of 47 to see out his three year community order. This coincided with the period of the children’s child protection plans when the NPS had been part of the core group and had attended the ICPC and the first RCPC. The last recorded home visit ( presumably by OM2) to FAB was made on the 13.12.16, thereafter, it seems that all direct contact was office based. This was despite the risk management plan as mentioned above. 5.7.6 In line with national standards, FAB was seen monthly throughout 2017 by OM2 except for February when he failed to attend. This was re-arranged to early March resulting in two contacts during that month. 5.7.7 Between January to the middle of June 2017, FAB was seen at OM2’s office. OM2 did not attend the second RCPC in early April 201720 but provided a generally positive report on FAB’s progress and assigned medium risk status which contributed to the decision to de-plan the children. The report’s positivity seemed mainly to be based upon FAB’s compliance with and completion of the i-SOTP programme which was entirely based on self-reporting. Following the ending of the child protection plans in April, liaison and communication between OM2 and the children’s social worker deteriorated. FAB told OM2 at an office visit on the 25.04.17 that CSC had agreed to him having contact with his children, albeit supervised by their mother, ‘ outside of the house’. FAB visited OM2 on the 13.06.17 to say that he was seeing his children twice a week outside of the house. OM2 said that he was trying to contact CSC to clarify the contact issue. 5.7.8 OM2 tried contacting the social worker on several occasions to clarify the children’s contact arrangements with FAB and how these would be monitored given that CSC had finished its involvement with the family, but, for reasons unknown did not receive a timely response. OM2 did not receive the minutes of the RCPC and thus had no written rationale for the ending of the child protection plans or clarity around the contact issue. Again, the reason for this is not known. 5.7.9 OM2 escalated the request (in writing to CSC) for clarification of contact in June - August 2017 and received a written response from CSC in September 2017 confirming that MAB was able to supervise FAB’s contact with his children, ‘ in the community rather than in the home’. It was noted that the CSC assessment was predicated on the assumption that the parents were not in a relationship with each other nor either with someone else. In the event of a relationship resumption or a new relationship with an other, the risk to the children would need to be reassessed. OM2 showed good practice in escalating the request for further information from CSC. 5.7.10 This information should have resulted in an annual review of the OAsys risk assessment and management plan given the change in circumstances. This was relevant in regard to the unanswered question of how the contact was to be monitored in the absence of any CSC involvement. There was no indication that any thought had been given to this at the final RCPC. Greater liaison with the MOSOVO and triangulation visits, as mentioned above, to the family could have 20 The RCPC had originally been set for March 2017 but was postponed to April 2017. Page 23 of 47 provided a better understanding of how contact was progressing and whether it was being supervised safely by MAB. 5.7.11 FAB was recorded as having been seen by his OM on the 16.01.18. He told OM2 that he had been visited by a MOSOVO officer on the 07.01.18 and was also now seeing his children at their maternal grandmother’s home. OM2 was also aware from FAB that child A was being home schooled.21 These volunteered pieces of significant information should have raised concerns and questions from the NPS about the safety of the children and contact with CSC (such as a safeguarding referral), the Police (MOSOVO team) and school X. The removal by MAB of child A from school X in September 2017 took away a significant source of support for her, in addition to the withdrawal of a key line of safeguarding defence, namely the monitoring of her safety and wellbeing. 5.7.12 The OM’s omission to inform the CSC regarding child A’s home schooling marked a missed opportunity to have safeguarded the children and promoted their wellbeing. 5.7.13 On the 01.05.18 FAB told OM2 via telephone that he was seeing the children a lot of the time at the maternal grandmother’s home or, on occasions, at MAB’s cousin’s house nearby. A second, overdue OAsys risk review and accompanying RMP was done on the 12.06.18, the last one having been completed on the 29.10.15 and clearly not compliant with NPS national standards. 5.7.14 The risk of harm to the children remained unchanged at, ‘ Medium’. There were no enquiries concerning the arrangements for contact with the children, no visits to the homes of FAB and the children; and no recorded triangulation with the MOSOVO team, CSC or school X to corroborate what FAB was telling OM2. Given FAB’s self reported real world sexual interest in children; risk assessment and accompanying RMPs should have addressed his desires beyond the internet, upon which there was, arguably, an over focus. With high levels of arousal, exploring potential outlets to this was an essential element of his risk management.22 It seemed that there was a lack of an investigative approach, insufficient professional curiosity and inattention to the children’s safeguarding needs. OM2 was taking at face value what FAB choose to tell them. 5.7.15 FAB visited the NPS office on the 26.08.18, having last been seen on the 16.01.18. The existing RMP had stipulated FAB be seen monthly. He told OM2 that he was applying for the indefinite SHPO to be ended and said that the Police had indicated that they would not, ‘ fight against it’. This review was told by the panel police representative that the agency had no record of this statement. If granted, FAB would approach the CSC to see if he could have unsupervised contact with the children. 21 According to the NPS agency report at page 5, ‘The children’s voices and lived experience’ section. 22 Taken from the NPS agency report for this review, page 5. Page 24 of 47 5.7.16 He told OM2 that he was no longer seeing the children at MAB’s sister’s home.23 This was because the CSC were (apparently) involved with the sister’s family and he did not want to get involved with CSC again, given his intentions of negotiating with them to see the children unsupervised. Questions should have been asked of FAB as to why he was seeing the children in MAB’s sister’s home, given that the original arrangement with CSC was that the mother was to supervise contact ‘ in the community’. He was expecting a MOSOVO visit soon and had not been seen by them since early January 2018.24 5.7.17 Consequent to the ending of his three year community order and earlier completion of the i-SOTP, FAB’s RMP/OAsys was terminated by the NPS and the case closed on the 11.10.18. The final risk assessment remained at ‘, Medium’. There was little evidence of management scrutiny or case overview. In any event, the NPS ceased being the lead agency for overseeing FAB with sole responsibility being transferred to the Lancashire Constabulary MOSOVO team by virtue of his continuing SHPO and sex offender registration. The team would take on the tasks of risk assessment and the overseeing of a risk management plan for the duration of the five year SHPO, due to end in August 2020. 5.7.18 In conclusion, the evidence above indicates that the risk assessment and management of FAB by the NPS fell short of accepted national standards and was ineffective in safeguarding and promoting the wellbeing of child A and B. The risk management plan was deficient because; • There were Insufficient home and office visits. FAB was only seen once at his home on the 13.12.16. He was seen in the NPS office on only four occasions in 2017 and 2018. There should have been regular and unplanned home visits to test out what FAB was telling OM2. • There was too much reliance placed upon FAB’s ‘positive’ progress whilst on the i-SOTP programme. This was based upon his self-reporting which was taken at face value and no third party corroborative evidence from other sources. • FAB’s sexual interest in children beyond the internet should have been addressed in risk assessment and management. • FAB appeared to control the information flows enabling him to play off the agencies (NPS, MOSOVO and CSC) against each other and construct misleading narratives that led agencies to assume that other agencies were approving of developments.(e.g that CSC knew about the changing contact arrangements and were content with them, which was not the case.) 23 NB This was a new development. The children had reportedly been seen by FAB at the maternal grandmother’s, cousins, and now maternal aunt’s, none of which were compliant with the original condition of contact in the community. 24 According to Police records he had already been seen by his MOSOVO officer on the 18.08.18, thus raising some potential inconsistencies in his account to OM2. Page 25 of 47 • There was minimal triangulation and liaison with other agencies such as the Police (MOSOVO team),25 CSC and School X regarding several changes in location of supervision (maternal grandmother and aunt and cousin) and knowledge of child A’s home schooling. Minimal corroboration of what he was telling NPS. • Insufficient professional curiosity and the lack of a more investigative approach to the risk management of FAB. • Only two OAsys assessments during the course of the three year community order when this should have been done annually. • Lack of a,’ Think Family’, approach to include a more holistic, dynamic risk assessment involving seeing the children to ascertain their views and situation, and assessing MAB’s ability to protect. This could have been done on a multi-agency basis with the MOSOVO and CSC. • Lack of management scrutiny and oversight of OM2’s risk assessment and management of FAB. 5.7.19 The review was unable to delve into the contemporaneous agency operating environment to see if there were any systemic barriers to excepted practice. It was however, told that the OM could offer no explanation as to why practice fell short of national standards, save that case loads were high at the time. FAB was perceived as a low priority because of his medium risk assignment and his apparent compliance with the i-SOTP and other conditions. Such were the increased demands from other more high risk cases that corners seemed to be cut in regard to the supervision of FAB by the NPS. This raises the key learning point of agency senior management being aware of when front line practitioners and their line managers are struggling to meet demands and the need, when possible, to ensure that demand matches staff capacity. In short, to ensure that individual practitioners’ caseloads are manageable. The MOSOVO team’s Involvement with FAB 5.7.20 MOSOVO involvement with FAB spanned a period of nearly five years from the start of his SHPO26 in August 2015 up to his arrest in May 2020. He was classified as a category 1 offender and as such, was subject to at minimum, an annual home visit by the MOSOVO team. In the event, there were nine completed27 home visits (out of a total of seventeen) done by several officers during this time. 5.7.21 As previously mentioned, the NPS was the lead agency who, in October 2015, had assessed FAB as medium risk. FAB was first visited by two MOSOVO officers on the 23.11.15 and were told by him that he had no contact with children, including 25 New (2020) guidance has provided for joint working between the NPS and the Police, including information sharing, joint visits, and joint risk assessments and RMPs, see note 33 below. 26 It was a five-year SHPO. 27 i.e. FAB actually seen by the officer. Page 26 of 47 his own, given the involvement of CSC at the time. There was no relevant safeguarding information recorded and he was assessed as Medium risk. 5.7.22 FAB was next seen on the 28.06.16. He disclosed to the MOSOVO officers that he had an inappropriate sexual interest in pre-pubescent girls. His mobile phone was examined and found to contain several pictures of MAB naked whilst breast feeding child B. He told the officers that she thrived off shock type photographs and apparently posted them onto Facebook. She was well aware of his sexual interest in children. The officers noted that MAB was supposed to be supervis-ing FAB’s contact with his children yet was sending inappropriate pictures on line. Moreover, child A was being home schooled. There were also concerns about the physical state of the house suggestive of the children living in neglectful conditions. 5.7.23 The officers correctly assessed that FAB’s offending behaviour, his unhealthy sexual interest in young girls, MAB’s inappropriate behaviour and concerns about her ability to protect her children, in addition to child A being home schooled and,’ off the radar’, of children’s services agencies, constituted a high risk to the children. One this basis, a Protecting Vulnerable People (child protection) PVP referral was sent to CSC/ MASH (multi-agency safeguarding hub). This action led to the convening of the ICPC in July 2016 and the subsequent child protection plans for the children. The officers showed very good practice during this episode. 5.7.24 FAB was seen at the end of December 2016 for the third time when nothing untoward was noted. There was no evidence of information sharing with the core group or liaison with the NPS offender manager. 5.7.25 There were a further six home visits made by the MOSOVO team to FAB between December June 2017 and May 2020 when the parents were arrested for possession of indecent images of children and child neglect. This episode repeated the two previous offences in 2016 and 2014. 5.7.26 The MOSOVO completed three further visits between 201728 and the 11.10.18 when NPS closed FAB’s case and the Police became the single agency responsible for his risk assessment and management. FAB’s mobile phone was checked on each occasion with (perhaps not surprisingly) nothing untoward found and he remained at medium risk. Of some significance, he volunteered the information on the three visits in 2017/2018 that he was having contact with his children. Indeed, on the visit of the 18.08.18 he disclosed to the officers that contact was taking place at his mother-in-law’s and that child A was being home schooled. 5.7.27 The relevance of this intelligence regarding potential risk to the children seemed not to be recognised by the MOSOVO team. They would have had full knowledge of the case including intelligence from MAPPA (Multi-agency public protection arrangements) and child protection sources. There should have been a dynamic risk assessment undertaken to reflect the new information. In the event, there was no liaison with CSC, NPS or school X to clarify the nature of contact with the 28 July 2017, January, and August 2018 Page 27 of 47 children and whether there were any restrictions and conditions. Nor were there any recorded visits to the children to ascertain their situation. 5.7.28 It is not known why, apart from the visit in June 2016, the MOSOVO did not recognise, record, risk assess and liaise with the other agencies. Lancashire constabulary were unable to offer an explanation as to why this was the case. The agency has acknowledged that there is learning to be identified from the episode which will be captured in its action plan for this review. 5.7.29 Following the ending of the NPS involvement on the 11.10.18, FAB was seen by the MO-SOVO team in March and December 2019 and finally in February 2020. Two ARMS (Active Risk Management System) 29 assessments were undertaken 30 resulting in the ensuing Risk Management Plans (RMP). The first ARMS in March 2019, noted that, ‘ supervised contact with his children has been approved by social services and he sees them almost every weekend. His ex-wife has been deemed incapable to supervise the contact; therefore MAB’s mother has to be present at all times when children are visiting FAB’. 5.7.30 FAB’s self reporting was taken at face value as ‘fact’, with no attempt to corroborate what he was telling the MOSOVO officers. The RMP contained only one action, namely to check internet capable devices during home compliance visits. There was no action to triangulate with CSC regarding the contact issue, especially in light of FAB’s report that he was seeing the children at home on weekends, reportedly supervised by their maternal grandmother. 5.7.31 The second ARMS of February 2020, completed by two different officers from ARMS1, relied once again on self reporting from FAB who, arguably, would have had a vested interest in minimising the significance of the information given at the visit31, given he wanted to come off the sex offender’s register and be able to see his children unsupervised. He was rated as ‘low’ in all eleven categories32 with no corroborative evidence to challenge his self-reporting. The significance of FAB’s mental health deterioration 33 (depression, anxiety and suicidal thoughts) in December 2019 and his urges of wanting to access indecent images of children, seemed not to have been appropriately considered and factored into the risk assessment. 5.7.32 Rather, FAB’s explanation to the officers that the mental health workers, ‘over reacted’, as at no point did he state that he had strong urgent look at IIOC’, was 29 ARMS provides a national standard for the risk assessment and management planning of sexual offenders. It is a structured assessment process to assess dynamic risk factors known to be associated with sexual re-offending and protective factors known to be associated with reduced offending. 30 Using intelligence from ViSOR (violent offender and sex offender register), the PNC (police national computer) and Sleuth (A crime recording system used by Lancashire Constabulary). 31 E.G Stating to the officers that the majority of the indecent images were Anime cartoons and not actual girls; this is classic minimisation and part of the offender’s denial mechanism. 32 There are six risk factors (opportunity, sexual preoccupation, offence related sexual interests, emotional congruence with children, hostile orientation, poor self-management) and five protective factors (social influences, commitment to desist, intimate relationships, employment or positive routine, social investment-giving something back). Each factor is rated, low, medium or high and aggregated to provide an overall risk level. 33 See paragraphs 5.3.17/18 above. Page 28 of 47 accepted and not challenged or corroborated with the GP or the mental health services to assess its risk significance. Moreover, there were several references in the ARMS report to FAB’s children coming to his home at weekends34 for contact but not staying overnight. Indeed, it was noted that the family was going rock climbing that weekend to celebrate child B’s birthday. Again, there was no liaison with CSC to ascertain contact issues. 5.7.33 The ARMS concluded that FAB, ‘ now presents as a reformed person who puts his children and family first’. Arguably, this was an overoptimistic assessment that was overly focused on FAB’s internet activity; that did not take into account the key issues around his recent mental health episode in December 2019 and the contact arrangements with his children. As identified at the practitioners’ learning event, there appeared to be too much reliance on FAB’s self-reporting and minimal third party corroboration with CSC, the GP and the mental health services. 5.7.34 In sum, there was an over narrow focus on internet related issues (e.g checking the mobile phone for IIOC35) and a failure to think more widely (Think Family) about risk to the children who were not seen as part of the assessment. Overall, there was a lack of professional curiosity, little evidence of an investigative mindset and minimal line management oversight and scrutiny. FAB’s situation should have been seen within a wider dynamic risk framework involving, not just risk around IIOC and the internet, but risk to his children, given what he was saying and all of the then known factors. 5.7.35 This review notes the guidance from the College of Policing (Managing sexual offenders and violent offenders; authorised professional practice) which states,’ An investigative approach, underpinned by respectful scepticism, is central to every stage of managing MOSOVO offenders and PDPs (potentially dangerous offenders)…….each case should be assessed on individual circumstances and informed by static and dynamic risk models’. (page 3) 5.7.36 In the lead reviewer’s opinion, the current ARMS assessment tool is overly focussed on the offender and their offending behaviour and does not not sufficiently address wider dynamic issues around the offender’s family, including children and venerable adults. It is suggested that the College of Policing review the ARMS tool and consider amending it to include wider family dynamics. 5.7.37 In conclusion, the above evidence suggests that the Lancashire Constabulary MOSOVO team risk assessment and management of FAB did not effectively safeguard the children and promote their wellbeing. There may have been organisational barriers to safe practice inherent within the operating environment of the MOSOVO practitioners which need to be identified and addressed (e.g workload and sufficient time to undertake ARMS assessments and follow up work). 5.7.38 Current Developments As a result of this review the Lancashire Constabulary has developed an action plan that seeks to address the above deficits. Current (2020) ARMS assessment 34 This was assessed as corroborating the ‘fact that he is not overly sexually preoccupied’ 35 As previously noted FAB Page 29 of 47 guidance and processes now provide for a much greater degree of joint work, liaison and information sharing between the Police and Probation services, including the making of joint visits too offenders. 36 ‘Joint working, through positive working relationships and ongoing information sharing, remains key to the effective joint management of registered sex offenders (RSOs). It is therefore important to ensure that relevant information gained from single agency visits and interviews is shared promptly’. (Joint Risk Assessment Flowchart and Guidance, June 2020). 5.8 The School X 5.8.1 Child A attended secondary school X from September 2016 until July 2017 and for most of this time (September 2016 to April 2017) was subject to a child protection plan. The school, whilst not present at the ICPC in July 2016, was a core group member through teacher C. Teacher C attended core groups, produced written and verbal reports and liaised with the social worker via telephone and e-mail. In addition to addressing the relevant safeguarding issues for Child A, efforts were made to increase her attendance via a phased return to school education, having previously been home educated by her mother. She was also supported pastorally by staff during this time. Whilst at school X she was observed to have grown in confidence, making friends and engaging well with her lessons. She made excellent progress with her education and was working above age related expectations in many subjects. She returned to home education in September 2017 at her mother’s request where she remained until May 2020. 5.8.2 Teacher C attended the planned final RCPC in March 2017 which was postponed until early April because the CSC reports had not been uploaded onto the system. Teacher C did not attend the rescheduled RCPC due to it being held in the Easter school holiday. A report was provided but the teacher could not recall agreeing to ending the child protection plan. That said, it was the case that Child A’s school engagement was improving and there was nothing known at the time to raise any new safeguarding concerns. 5.8.3 Teacher C stated that they did not receive notification of a step down to a TAF plan and consequently did not attend any further meetings in this regard. An e-mail was sent to the social worker on the 21.04.17 stating that, ‘ I’m aware that the CP Plan has ceased as of the 6th April but is there any further provision e.g CIN, TAF etc’ ? No reply was received and Child A continued to be supported through the school’s pastoral structure until the end of the summer term in July 2017. 5.8.4 Regarding Child A’s voice and lived experience, school X reported that she was able to speak to staff about her welfare and knew that she could confide in them if needed. The phased return to school , which included the provision of two ‘ peer buddies’, was made in response to Child A’s (and her mother’s) wishes. She attained full attendance in December 2016 and made very good progress, educationally and socially (making new friends), was communicating well with her teachers and appeared increasingly happy and settled in school. It was noted by 36 See,’ Joint Risk Assessment Flowchart and Guidance’, and ‘Arms Assessment: Police Process’. Page 30 of 47 the school that she never presented with any behavioural issues and said she was happy in her form group and school. 5.8.5 Overall, the evidence provided for this review would indicate that Child A’s re-integration and time at school X were very beneficial for her in all respects, was well handled and child focused. In this respect, it would have been in her interests if the school, along with the Police and probation services, had linked up to monitor her situation via a continued CIN/TAF plan (or arguably, a six months continuation of the child protection plan) to at least see her school attendance through to September 2017. Any safeguarding or welfare concerns, including reversion to home schooling, could have been reported to CSC and appropriate enquiries made. 5.9 The Voice of the Children and their lived experience. 5.9.1 At their express wish, both children declined to meet with the independent reviewer. There is thus, no record of their views about the services received by them. 5.9.2 In the main, there was a poor response by agencies to the extent to which they listened to the voices of the children and understood their lived experience. CSC stated that Child A’s views were recorded on statutory child protection visits. She was also involved in direct work around keeping safe. However, because there was no updated child and family assessment during the course of the child protection plan there was little or no evidence of the children’s lived experience. Self evidently, expected practice should have resulted in child and family updates, including observations on the children’s lived experience. 5.9.3 There was no evidence of Child A’s involvement in the ICPC, core groups or RCPCs. Child B was not old enough to have meaningly participated in any meetings. 5.9.4 The Children and Family Wellbeing Service was unable to comment on issues around the children’s voices and their lived experience. This would suggest that there were no recordings on this issue which, if correct, needs to be addressed by the agency. 5.9.5 Health visiting records noted on numerous occasions the unsatisfactory home conditions experienced by the children. Interaction with their mother was noted as being appropriate although recordings were limited and not consistent. There was no evidence of their views being directly recorded. Child A was seen by a school nurse for the individual health assessment (IHA) provided for the ICPC but this was in front of her mother. She therefore had no opportunity to speak to the school nurse independently about her wishes and feelings. 5.9.6 As previously mentioned the family’s GP service (GP1) had no record of the child protection plans. There was no evidence of any recorded observations during the time in question of the children’s wishes and feelings or lived experience. There was a lack of professional curiosity in the primary care mental health consultation with Child A and no exploration of family and home circumstances and parenting capacity. The CCG action plan for this review has provided for inclusion of family and home circumstances in mental health consultations. However, as in the case Page 31 of 47 of most of the agencies who had contact with the family, there needs to be a greater emphasis on seeking out children and young people’s wishes and feelings as per expected practice. 5.9.7 Similarly, there was no evidence of Child A’s voice in her involvement with the hospital trust during the two admissions of March and October 2017. 5.9.8 There were no visits undertaken by the EHE service in the relevant time frame and hence no instances of the voices of the children being noted or any observations of their lived experiences. 5.9.9 The only exception to the generally poor practice by agencies regarding ascertaining the children’s voices and seeking an understanding of their lived experience was demonstrated by school X as set out in paragraph 5.8.3 above. 5.9.10 Regarding Police and Probation practice this was entirely adult focussed on FAB, lacked professional curiosity and did not consider the children’s safeguarding and welfare needs. In this sense there was no child focus shown by these agencies. 5.9.11 In conclusion, the evidence indicates that, with the exception of school X, agencies’ practice was insufficiently child focused, did not allow for the children’s voice to be heard and fell short of reaching an acceptable level of understanding of their lived experience. 5.10 Disguised Compliance 5.10.1 The parents disagreed with the child protection plans being made following the ICPC in July 2016. However, there was negligible evidence of disguised compliance37 by them following the first RCPC in October 2016 and up to the ending of the plans in April 2017. CSC state that there should have been more professional curiosity shown by way of unannounced social work visits to the family home to establish that FAB was not there. This review would agree with the suggestion. 5.10.2 Following the ending of the child protection plans in April 2017, there was evidence known to agencies- but not acted upon that MAB was not keeping to the agreed arrangements regarding FAB’s contact with the children, namely that he was not seeing them, ‘ in the community’, and supervised by MAB. Her decision to revert back to home education for the children in September 2017, deprived them of a reasonable standard of education and isolated Child A from the protective and beneficial environment of school X. The action also resulted in Child B missing out on the key stages of early years and primary education. 5.10.3 In conclusion, there was little direct evidence of parental disguised compliance, albeit a more professionally curious approach might have detected this. The parents’ decision to breach the child contact agreement and MAB’s reversion to home education were examples of overt non-compliance and were not congruent with their children’s safety and wellbeing. 5.11 Good Practice 37 Defined as, ‘involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement’. (NSPCC; Disguised compliance, learning from case reviews) Page 32 of 47 5.11.1 This was evidenced by (1) OM2 escalating the request for further information from CSC and (2) The excellent risk assessment done by the MOSOVO officer following the home visit to FAB in June 2016 leading to the ICPC of July 2016 and the resulting child protection plans. 5.12 Family Views (see appendix 4) 5.12.1 The lead reviewer met with MAB, along with her health worker, in October 2021. At the time of writing (05.01.22) arrangements are in train to see FAB in prison. 5.12.2 Key learning issues that emerged from MAB’s perspective included, • An unrealistic and over-optimistic professional perception of MAB’s ability to safely supervise her children’s contact with their father. • A greater understanding of her mental health issues and the implications for the risk assessment. • The need to provide MAB with full details of FAB’s offending behaviour in helping her understand the risks he presented to the children. • The need for an independent and more specialised professional to help her and the children better understand FAB’s risks. • The need for professionals to consider the possibility of domestic abuse and coercive control in the parental relationship. • The need to ensure that parents fully understand the rationale and purpose of child protection and team around the family plans and their role in implementing them. • For schools to address bullying. • For EHE services to follow up letters with contact and help when requested. 6. Key Findings and Learning 6.1.1 The implementation of the child protection plans was mixed. On the one hand they did keep the two children safe from sexual abuse and neglect; their health and development were positive and Child A benefited from being at school. 6.1.2 However, the lack of unannounced visits as per the plans, inconsistency of attendance by core group members, little evidence of eliciting the children’s wishes and feelings and changes mid way with the IRO, were flaws in the plans’ implementation. 6.1.3 Lesson 1: If part of the child protection plan, unannounced visits should take place. There should be consistency with core group membership, IRO oversight and challenge. 6.1.4 The rationale for the ending of the plans in April 2017 was based upon the positive reports from core group agencies, the police and probation. A key factor was the assessment of MAB’s ability to protect her children and safely supervise contact in the community with their father. Arguably, the assessment underestimated the risk and would have benefited from a specialised assessment from an external agency (which is currently the case), in Page 33 of 47 addition to a more integrated approach capturing the risk assessments from the police (MOSOVO) and probation services. 6.1.5 An integrated approach between CSC, the Police (MOSOVO) and the probation service,38 (also including the school X and the family GP) could have led to a robust risk management arrangement -possibly within a step down CIN plan-regarding MAB’s supervision of the children’s contact with their father, following the end of the formal child protection plans. Any significant con-cerns or changes (e.g Child A being taken out of school X for home schooling) could have triggered an alert to CSC who could have made appropriate enquiries into the children’s safety and welfare 6.1.6 Lesson 2: Where there are uncertainties about risk management following the ending of child protection plans, consideration, where appropriate, should be given to promoting a multi-agency approach, via a CIN/TAF plan. 6.2.1 There was no clear rationale for the TAF plan recorded in either the CSC child and family assessment or the final RCPC minutes. School X was not included in the plan. In the event, the three weeks TAF served no useful purpose in regard to promoting the safety and wellbeing of the children. 6.2.2 Lesson 3: The rationale for all step down plans should be (I) recorded in CSC child and family assessment plans and RCPC minutes, (ii) subject to management oversight, agreement and rec-orded reasons regarding closure. 6.3.1 The school nursing and health visiting services (when part of Trust 1) fell short of expected safeguarding practice in respect of, a lack of child focus, professional curiosity and a failure to fol-low up on the needs of the children. There were several missed opportunities to have seen the chil-dren, assessed their needs, safety and wishes and feelings in the period after the end of the child protection plans. The underlying systemic reasons for these safeguarding deficiencies was not available from the previous Trust 1. 6.3.2 Trust 2 has since identified the relevant learning and practice improvements from this review and has implemented an action plan aimed at securing the safety and well-being of children in its remit. 6.4.1 The two GP practices fell short of providing an acceptable level of safeguarding intervention to the children. It was concerning that GP1 had no record of the children’s child protection plans nor did it provide any information to the ICPC or core group. GP2’s omission in contacting CSC in De-cember 2019 regarding FAB’s admission, amongst other things, of having strong urges of access-ing illegal images of children on the internet, also marked significant shortcoming in safeguarding practice. 6.4.2 These episodes suggested (2016/17 for GP1 and 2019 for GP2) a lack of safeguarding awareness, effective information sharing/recording systems and professional curiosity tantamount to significant disconnect between the two practices and the local multi-agency safeguarding system.39 6.4.3 Lesson 4: The two GP practices need to ensure the local CCG and the Lancashire safe-guarding partnership that they are now fully compliant with all relevant safeguarding proce- 38 Under the auspices of the Sexual Harm Prevention and three year supervision orders. 39 But see appendix 5 for actions taken by the CCG and recent improvements made. Page 34 of 47 dures.These would include, information sharing, knowledge of a child’s safeguarding status, safe-guarding awareness, professional curiosity and when to refer to CSC regarding a child being poten-tially at risk of significant harm. 6.5.1 The Child Psychological Service: Safeguarding practice was sub-standard as evidenced by the service not including safeguarding considerations in the psychological assessment of Child A in November 2017 and not contacting CSC. This was despite being told by MAB of the recent child protection plans and FAB’s sexual crimes background. This review has had sight of the health trust’s key learning and action plan and is satisfied that all relevant lessons have been identified and have or are in the process of being implemented. 6.6.1 Regarding hospital H1, the actions taken by ED staff regarding the two contacts with the child B in 2017 were compliant with expected agency safeguarding policy and practice. 6.7.1 The EHE team’s practice-notwithstanding any possible organisational barriers within the oper-ating environment of the practitioners-was ineffective in both ensuring the suitability of child A’s ed-ucation and promoting their safety and wellbeing. There was an overall lack of awareness regarding the children’s safeguarding and wellbeing. 6.7.2 Practice was marked by an element of, ‘silo working’, and lack of professional curiosity, The EHE team should have challenged the suitability of home education ostensibly being offered to child A. This could have resulted in any safeguarding concerns being referred to CSC. 6.7.3 The EHE service lacked a protocol setting out clearly a pathway ensuring that children being home educated received a suitable and efficient education, consistent with their safeguarding needs. 6.7.4 Lesson 5: The LCC EHE service should provide guidance, including an integrated decision and action pathway, that enables professionals to assess that EHE children are receiving a suita-ble and efficient education, that also meets any safeguarding needs.40 6.7.5 Lesson 6: The EHE service needs to ensure the Safeguarding Assurance Partnership that, in respect of home educated children and young people, current policy and practice is compliant with national and local safeguarding policies and procedures. 6.7.6 Lesson 7: The DfE should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including an integrated decision making flowchart. The guidance should be included in the next editions of ‘ Working Together to Safeguard Children’ , ‘ Keeping children safe in education’ and ‘Elective home education’. 6.7.7 Lesson 8. There are compelling reasons for the adoption of mandatory local authority registra-tion of all home schooled children. The lead reviewer would respectfully argue for the adoption by the DfE of all of the measures called for by the Children’s Commissioner as set out in paragraph 5.6.12 above. 6.8.1 Regarding the NPS, the risk assessment and management of FAB fell short of national standards and was ineffective in safeguarding and promoting the wellbeing of the children. There was a lack of an investigative approach, insufficient professional curiosity, too much reliance on FAB’s self reporting, an over focus on his internet activity, a lack of a more holistic and dynamic approach to risk, no unannounced home visits, a lack of liaison with the Police 40 See for example the summary of Manchester City Council Elective Home Education Process, November 2019, see also, Manchester City Council Directorate of Children and Families: Elective Home Education Policy and Practice. Page 35 of 47 MOSOVO, CSC and school X, no triangulation with family visits and inattention to the children’s safeguarding needs. 6.8.2 The practice deficiencies arose, partly as a result of the OM having to cut corners due to a reportedly high case load which led to FAB’s supervision being deemed as low priority. 6.8.3 Lesson 8: NPS supervision of offenders should be adequately resourced. Practice should be informed by a more holistic approach to assessment and risk management planning that is dynam-ic, includes a focus on children (and when relevant, vulnerable adults), liaison with other agencies, effective line management oversight and professional curiosity beyond the index offence. 6.9.1 The Lancashire Constabulary MOSOVO team’s practice in regard to risk assessment and management of FAB did not effectively safeguard the children and promote their wellbeing. There was an overly narrow focus on internet related issues (e.g checking the mobile phone for IIOC) and a failure to think more widely (Think Family) about risk to the children who were not seen as part of the assessment. 6.9.2 FAB’s situation should have been seen within a wider dynamic risk framework involving, not just risk around IIOC and the internet, but risk to his children, given what he was saying and all of the then known factors. Consideration could have been given to seeing the children and eliciting their views after the ending of the child protection plans. 6.9.3 There was a lack of professional curiosity, little evidence of an investigative mindset, minimal liaison with other agencies (NPS, CSC, school X) and apparent shortcomings with line manage-ment oversight and scrutiny. 6.9.4 The current ARMS assessment tool is overly focussed on the offender and their offending behaviour and does not not sufficiently address wider dynamic issues around the offender’s family, including children and venerable adults. It is suggested that the College of Policing review the ARMS tool and consider amending it to include wider family dynamics and additional corroborative evidence beyond offender self reporting. 6.9.5 Current (2020) guidance on OAsys/ARMs assessment and risk management plans provides for joint working and information sharing between the MOSOVO and NPS offender managers. 6.9.6 Lesson 9: Lancashire Constabulary MOSOVO should inform its practice by a more holistic approach to assessment and risk management planning that is dynamic, includes a focus on chil-dren (and when relevant, vulnerable adults), liaison with other agencies, effective line management oversight and professional curiosity beyond the index offence. 6.9.7 Lesson 10: The College of Policing should review the ARMS tool and consider amending it to include wider family dynamics and additional corroborative evidence beyond offender self reporting. 6.10.1 Child A’s re-integration and time at school X were very beneficial for her in all respects, was well handled and child focused. In this respect, it would have been in her interests if the school, along with the Police and probation services, had linked up to monitor her situation via a continued CIN/TAF plan (or arguably, a six months continuation of the child protection plan) to at least see her school attendance through to September 2017. Any safeguarding or welfare concerns, includ-ing reversion to home schooling, could have been reported to CSC and appropriate enquiries made. Page 36 of 47 6.11.1 Excepting school X, agencies’ practice was insufficiently child focused, did not allow for the children’s voice to be heard and fell short of reaching an acceptable level of understanding of their lived experience. 6.12.1 There was little direct evidence of parental disguised compliance, albeit a more professional-ly curious approach might have detected this. The parents’ decision to breach the child contact agreement and MAB’s reversion to home education for child A were examples of overt non-compliance and were not congruent with their children’s safety and wellbeing. A more pro-active and investigative approach by agencies (principally, NPS and the MOSOVO) could have mitigated the parents’ non-compliance. 6.13.1 Good practice was evidenced by, OM2 escalating the request for further information from CSC; and the excellent risk assessment done by the MOSOVO officer, following the home visit to FAB in June 2016, leading to the ICPC of July 2016 and the resulting child protection plans. 6.14.1 Lessons from MAB; see paragraph 5.12.2 7. Recommendations 7.1 Children’s Social Care/ Children and Family Wellbeing Service: lessons 1-3 have been addressed by the agencies’ action plans 7.2 East Lancashire CCG: Within six months of the acceptance of this review, the two GP practices mentioned in this review should ensure the CCG and the Safeguarding Assurance Partnership that they are now fully compliant with all relevant safeguarding procedures.These would include, information sharing, providing reports when requested, knowledge of a child’s safeguarding status including being subject to child protection plans/ child in need plans , safeguarding awareness, professional curiosity and when to refer to CSC regarding a child being potentially at risk of significant harm. 7.3 Lancashire Elective Home Education Service: Within six months of the acceptance of this review; the Director of Children’s Services should require, • the EHE service to provide guidance, including an integrated decision and action pathway, that enables professionals to assess that EHE children are receiving a suitable and efficient education, that also meets any safeguarding needs and which is subject to the prevailing legalities and statutory provisions. • assures the Safeguarding Assurance Partnership that, in respect of home educated children and young people, current policy and practice is compliant with national and local safeguarding policies and procedures. 7.4 National Probation Service; North West Division: Within six months of the acceptance of this review, the Chief Officer of the NPS North West Service, should take all necessary steps to assure the Safeguarding Assurance Partnership that offender manager practice of sex offenders be informed by a more holistic approach to assessment and risk management planning, that is dynamic, includes a focus on children (and when relevant, vulnerable adults), liaison with other agencies, effective line management oversight and professional curiosity beyond the index offence. Page 37 of 47 7.5 Lancashire Constabulary: Within six months of the acceptance of this review, the Chief Constable should assure the Safeguarding Assurance Partnership that the MOSOVO inform its practice by a more holistic approach to assessment and risk management planning that is dynamic, includes a focus on children (and when relevant, vulnerable adults), liaison with other agencies, effective line management oversight and professional curiosity beyond the index offence. National Recommendations 7.6 It is suggested that the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership request that through the good offices of the Child Safeguarding Practice Review Panel, the following recommendations are presented to the Department for Education and The College of Policing. Moreover, that within six months of the request, the Child Safeguarding Assurance Partnership receives a response from the two organisations setting out their respective actions (if any) to the recommendations. 7.7 The Department for Education: The DfE should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including an integrated decision making flowchart. The guidance should be included in the next editions of ‘ Working Together to Safeguard Children’ , ‘ Keeping children safe in education’ and ‘Elective home education’. 7.8 The Department for Education: The Department should adopt all of the measures called for by the previous Children’s Commissioner as set out in paragraph 5.6.12 above. 7.9 The College of Policing: Within six months of the acceptance of this review, the college should review the ARMS tool and consider amending it to include wider family dynamics and additional corroborative evidence beyond offender self reporting. 8. Glossary of Terms Family Child A Child B MAB: Mother of the children FAB: Father of the children ARMS: Active risk management system CCG: Clinical Commissioning Group CFW: Child and family welfare CIN: Child in Need CRAT: Child risk assessment tool CSAP: Child safeguarding assurance partnership CP-IS Child protection information system CSC: Children’s social care CSPR: Children’s safeguarding practice review DASOU: Dangerous offender and sex offender unit EHE: Elective home education Page 38 of 47 ELCAS: East Lancashire child and adolescence service ELHT: East Lancashire hospital trust HV: Health visitor GAD: General admission document GP: General practitioner ICPC: Initial child protection conference IHA: Individual health assessment IRO: Independent reviewing officer IILC: Indecent images of children I-SOTP: Internet sex offender treatment programme LCC: Lancashire County Council MAPPA: Multi-agency public protection arrangements MASH: Multi-agency safeguarding hub MOSOVO: Management of sexual offenders and sexual offenders team NPS: National probation service OAsys: Offender assessment system OM: Offender manager PVP: Protection of Vulnerable People PNC: Police national computer RCPC: Review child protection conference RMP: Risk management plan SEN: Special educational needs SHPO: Sexual harm prevention order START: Specialist triage, referral and treatment team SW: Social worker TAF: Team around the family ViSOR: Violent and sexual offender register 9. References • Children’s Commissioner (February 2019): Skipping School: Invisible Children • College of Policing; Managing sexual offenders and violent offenders, authorised professional practice • Department of Education: Elective Home Education guidance (April 2019) • Department of Education: Working Together (2018) • Department of Education: Keeping Children Safe in Education (September 2021) • Manchester City Council: Elective home education policy • National Offender Management Service: Public Protection Manual (2016) • NSPCC: Disguised compliance, lessons from reviews CSPR Overview Report – Child A and B – May 2022 Page 39 of 47 10. Appendix 1: Aims, Terms of Reference and Key Lines of Enquiry 10.1 The overall aims and objectives are ; 1. To identify learning and improvements to safeguard and promote the welfare of children; and consolidate good practice by understanding why agencies involved with the children A and B were unable to safeguard them from sexual abuse and neglect when these came to light in May 2020. 2. To determine whether decisions and actions in the case complied with the policy and practice of named services and the CSAP. 3. To examine the effectiveness of information sharing, case handovers, transfers and working relationships between and within agencies. 4. To identify how practice can be improved through systemic changes within the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership, to prevent/minimise the reoccurence of what happened to the children. 5. For the CSAP and partner agencies to translate the findings of the Review into a programme of action that lead to sustainable improvements and the prevention of serious injury and harm to children. 10.2 Key Lines of Enquiry (KLOE) 1. The Child Protection Plan: How well was it implemented and reviewed by the core group and IRO service? What was the rationale for ending it in April 2017? What was the basis for assessing that the mother could safely supervise (in the community) father’s contact with the children; how realistic was it given all of the known risk factors at the the time? (CSC, core group agencies and IRO service) 2. The Team around the Family (TAF) Plan: What was the rationale for stepping down from the CP Plan to a TAF plan; was a Child in Need plan considered and what was the rationale for ending the TAF after only three weeks? What changes have been made to the stepping down process since April 2017 and how effective are current arrangements in ensuring the safety and wellbeing of children? (CSC, CFW service) 3. Effectiveness of Universal Services (LSCFT: Health visiting and School Nurse services): How effective, or otherwise, were the health visiting and school nurse services in safeguarding and promoting the welfare of the children? What were the reasons why they seemingly, fell short of acceptable and safe practice? 4. The Voices of the Children and their Lived Experience: How well did the agencies listen to the voices of the children and understand their lived experience whilst in the care of their mother? (All agencies.) 5. Disguised compliance: To what extent, if at all, was disguised compliance by the mother a feature in this case? If so, was it recognised by the agencies and if not, why not? (All agencies involved with the CP and TAF plans) 6. Assessment and management of FAB’s risks to the children: How effectively was FAB’s risk jointly and singly assessed and managed by the Lancashire Constabulary MOSOVO and Page 40 of 47 the NPS in regard to the children? What was the rationale for grading FAB as a low risk? How effective was information sharing by the MOSOVO with child protection and mental health services regarding potential risk to the children from FAB? What role did the probation service play in managing FAB’s risks to the children? (Lancashire Constabulary and National Probation Service) 7. School: How effective was Child A’s school in liaising with other agencies and contributing to the multi-agency effort at safeguarding and promoting Child A’s education and wellbeing? Why did Child B not get onto the school roll and start primary school in 2018? (School, Education service) 8. Elective Home Education: What was the rationale of the EHE service in not challenging the mother’s wish to educate Child A at home in September 2017, given (i) the recent concerns about sexual abuse, neglect and poor school attendance,(ii) evidence that Child A’s attendance was improving when she was on roll at the school and that she was performing well educationally? How effectively did the EHE service intervene to safeguard Child A and ensure she was being adequately educated? (EHE service) 9. GPs: How well did the two GP practices (mother’s/children and father’s) contribute to the safeguarding and promotion of the children’s welfare, including (i) any information sharing issues and (ii) bearing in mind that neither child’s child protection plans were on their patient records? If well, why; if not well, why? (GPs/CCG) 10. Children’s Psychological Services (LSCFT): How well was the initial assessment on Child A undertaken in relation to any potential issues? If well, why; if not well, why? Why was there no triangulation with CSC to verify the mothers’ account of supervised weekend contact with the father? 11. Hospital Safeguarding: How well did the ELHT safeguard and promote the children’s welfare during their mother’s four day hospital admission in October 2017 when Child B attended the ED with his father? Were there any concerns raised at Child B’s examination on the 17.10.19 regarding the appropriateness of him being breast fed by his mother at the age of 5years and 8 months? If not, why not? Why did the CPIS not identify that Child B had been a child subject to a CP Plan earlier that year (2017)? 12. Good Practice: Please give examples of any good practice (not expected practice) and say why they were good. 11. Appendix 2: Review Methodology and Process 11.1 The review is informed by elements of the, ‘Welsh model’ (Protecting Children in Wales, 2012) and the ‘Pathways to harm, pathways to protection’ framework; (Brandon et al, March 2020, pp 23- 24, NB See ‘Serious Case Reviews: Research into Practice, by Peter Sidebotham: seriouscase reviews.rip.org.uk, for an excellent video presentation of systems methodology and the pathways to harm model. 11.2 The systems approach seeks to move beyond a focus on the level of the individual practitioner towards a wider and more holistic understanding of the contemporaneous operational ( inter and intra agency context) environment in which individual practitioners took actions and made decisions. The approach seeks to provide a critical analysis, at both an inter and intra agency Page 41 of 47 levels; and looks at the organisational barriers and enablers (layers of defence) that either hinder or empower practitioners to make safe decisions and take actions that lead to optimum or adverse safeguarding and welfare outcomes for children. 11.3 However, by way of a caveat, many of the key events in this case (e.g the child protection plans of July 2016/April 2017) occurred several years ago. Because of the passage of time and the fact that some key professionals are no longer around, it has been problematic to obtain an accurate and first hand account of practitioners’ operating environment. This has made for difficulties in providing a systemic analysis to the extent originally envisaged. 11.4 The CSPR was independently chaired and led by Mr. Paul Sharkey who had no previous direct connections with any of the Lancashire agencies involved with the family. He is an experienced reviewer from a social care/safeguarding/public protection background in both the statutory and third sector. He worked with a panel made up of senior managers from the involved agencies and met three times between January and October 2021. 11.5 The review was informed by: • Individual agency reports • Relevant documentation such as ICPC/RCPC minutes and Police risk assessments • An online practitioners’ learning event in June 2021 • A real world meeting with MAB • Critical feedback on several report drafts by the panel 12. Appendix 3: Elective Home Education: Current National Policy and Legalities41 12.1 The Association of Directors of Children’s Services (ADCS) 2019 EHE survey stated that across 132 local authorities there was a total of 47,464 children and young people known to be home educated as of 3 October 2019.42 Across the 152 local authorities (the total number of local authorities in England) the estimated numbers amounted to 54,656 children and young people. There was a 20% annual increase in children and young people being home educated in the five years up to October 2019.43 These figures are likely to be an underestimate given that parents are not currently legally required to register with local authorities that their children are being home educated. 12.2 The survey analysis indicated that an average of 13% of the home educated cohort was known to Children’s Social Care (either historically and/or currently) with an average of 18% known to wider Children’s Services. Thus, nearly a third of the known cohort had some contact with 41 See,’ Home education in England’ (10.01.2022-House of Commons Library) for an excellent and up to date review of home education. 42 Since updated to around 81,200 registered children in England as of October 2021 (Home education in England (January 2022)). The estimate is very likely to be an underestimate because registration is voluntary. 43 The 2020 EHE census (taken on the 1 October 2020) gave an estimated figure of 75,668 children and young people being home educated across the 152 local authorities. This marked an estimated increase of 38% from the October 2019 census. The main reason given by parents for home educating their children was due to health reasons directly related to covid 19. Page 42 of 47 Children’s Services. Children at key stages 3 and 4 (secondary schooling) are the two largest cohorts. A majority of local authorities (103 out of 116) stated that the size of their EHE cohort relative to the wider school population was between less than 0.5% up to 1.0%.44 In the North West region of England there was estimated to be an average of 370 known EHE children per local authority.45 12.3 Parent’s Rights to Educate Parents have a right to educate their children at home as set out by section 7 of the Education Act 1996 requiring: "The parent of every child of compulsory school age shall cause him to receive efficient full-time education suitable (a) to his age, ability and aptitude, and (b) to any special educational needs he may have, either by regular attendance at school or otherwise." 12.4 Parents thus have a duty to ensure their children are educated. If they do educate children at home, section 7 means that the child should be getting an efficient, suitable fulltime education. However, the legislation does not differentiate between school attendance or education ‘otherwise’ (i.e without school). In short, education is compulsory for children between 5 and 16 but going to school is not. Moreover, the terms “efficient” and “suitable” education are not defined in law, de-spite the detailed prescription of expectations in schools. Case law46 has broadly described an “efficient” education as one that “achieves that which it sets out to achieve”. A “suitable” education is one that, ”primarily equips a child for life within the community of which he is a member, rather than the way of life in the country as a whole, as long as it does not foreclose the child’s options in later years to adopt some other form of life if he wishes to do so”. 12.5 In England, if a parent wants to home educate their child (by removing them from school) they are not required to notify the local authority, they need merely to write a letter to the school informing them of the fact (as with child A). The school must then notify the local authority. Children who have never been to school/been on a school roll (as with child B ) or who move area, may not be known to the local authority. Thus, children educated at home may never 44 See paragraph 2.8, page 6 of the ADCS’s 2019 survey 45 According to the ADCS EHE survey report, November 2020, Appendix 1, page 10, EHE cohort summary per region, North West, based on 18 out of 23 responding local authorities. 46 Mr Justice Woolf in the case of R v Secretary of State for Education and Science, ex-parte Talmud Torah Machzikei Hadass School Trust (12.4.85) Page 43 of 47 have attended school and could be invisible to education and health professionals and never come under the local authority’s,‘ radar’.47 12.6 Local Authority Obligations and Duties Local authorities under section 436A of the Education Act 1996 must make arrangements to find out so far as possible whether home educated children are receiving suitable fulltime education. (DfE; EHE Guidance: April 2019; non statutory). Thus, whilst having an obligation to identify children who are not receiving a suitable education, they have no legal duty to monitor home-educators or any powers to insist on visiting the home to carry out checks on the quality of the education, unless under safeguarding laws there are welfare concerns. This poses a problem for local authorities charged with a statutory duty under section 437(1) Education Act 1996 in that they are required to intervene: “ If it appears to a local education authority that a child of compulsory school age in their area is not receiving suitable education, either by regular attendance at school or otherwise, they shall serve a notice in writing on the parent requiring him to satisfy them within the period specified in the notice that the child is receiving such education”.48 12.7 Additionally, duties49 require local authorities to: “Make arrangements to enable them to establish (so far as it is possible to do so) the identities of children in their area who are of compulsory school age but— (a) are not registered pupils at a school, and (b) are not receiving suitable education otherwise than at a school.” 12.8 Within current guidance local authorities are “encouraged to address the situation informally” Such an approach may or may not be sufficient. The Badman report (2009) questioned how were local authorities to know what they don’t know when they had no means of determining the number of children who were being electively home educated in their area, or the quality of what was provided, without rights of access to the child? For many, perhaps the majority of home educating families, this approach may be sufficient. Badman did not believe that such arrangements were sufficiently robust to protect the rights of all children. 12.9 Local authorities can request information from parents as to the suitability of the education provided to their child but parents are not obliged to respond. In this event, a local authority 47 Lack of oversight can be disastrous; there have been six children who have died in the last decade where home education was identified as significant (Children’s Commissioner: 2019) 48 Under s.437(1) of the Education Act 1996, local authorities must act if it appears that parents are not providing a suitable education. This section states that: 49 Section 436A Education Act 1996 inserted by section 4(1) Education and Inspections Act 2006. Page 44 of 47 can pursue its attendance procedures, including invoking children missing from home procedures and issuing a school attendance order (SAO) , prosecution (or an Education Supervision Order) and or/fines. However, the process can take months and arguably, the SAO’s are too weak (Children’s Commissioner:2019) 12.10 “There are no detailed legal requirements as to how such a system of oversight should work, and it is for each local authority to decide what it sees as necessary and proportionate to assure itself that every child is receiving a suitable education, or action is being taken to secure that outcome” 12.11 In any event, the DfE recommends that each local authority: • should provide parents with a named contact who is familiar with home education policy and practice and has an understanding of a range of educational philosophies; • ordinarily makes contact with home educated parents on at least an annual basis so the authority may reasonably inform itself of the current suitability of the education provided. In cases where there were no previous concerns about the education provided and no reason to think that has changed because the parents are continuing to do a good job, such contact would often be very brief; • has a named senior officer with responsibility for elective home education policy and procedures, and the interaction with other work on issues such as children missing education, unregistered settings, vulnerable children, and welfare; • organises training on the law and the diversity of home education methods for all officers who have contact with home-educating families, possibly in conjunction with other authorities; • ensures that those LA staff who may be the first point of contact for a potential home-educating parent understand the right of the parent to choose home education. It is very important that parents are provided with accurate information from the outset to establish a positive foundation for the relationship. However, parents are under no obligation to accept support or advice from a local authority, and refusal to do so is not in itself evidence that the education provided is unsuitable; • works cooperatively with other relevant agencies such as health services to identify and support children who are being home educated, within the boundaries established by data protection and other legislation. 13. Appendix 4: Family (MAB’s) Views Child Safeguarding Practice Review; Child AB Meeting with MAB in her home held on 20.10.21 Present MAB: mother to Children A and B Professional A: Mother’s Health Worker Independent Lead Reviewer: ILR Page 45 of 47 13.1 ILR introduced himself and explained the purpose of the meeting which was to hear MAB’s views on the services offered to her and the children from the start of the child protection plans in July 2016 to their removal from her care in May 2020, following the police intervention. It was not to go over the trial. ILR explained his role in the review which was to provide an independent view and analysis of the agencies’ involvement with the children and her in respect of safeguarding. ILR would provide a written draft report with findings and lessons learnt for the agencies to improve their practice and minimise future risk to children involved in similar situations to A and B. MAB would have an opportunity to see and comment on the report before it was to be published by the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership on its website. All names would be anonymised to protect confidentiality. MAB said she understood all of the above and was happy to proceed with the discussion. 13.2 ILR started off asking about MAB’s views of the child protection plan (cp plan) of July 2016 to April 2017. MAB said that she understood that the child protection plan was because she had sent pictures of her breastfeeding child B to their father (FAB) who had previously been convicted of downloading indecent images of children. She said that she had not originally understood what could be shared on line with FAB. 13.3 She said that most of the agencies involved in the cp plan had been, ‘ alright’. However, the social worker was, ‘ against her’, and wanted to keep the cp plan going. The social worker said that MAB needed to come off anti-depressant medication before ending the cp plan. She said that she wasn’t ready to stop taking them and thought she had discussed ending her medication with her GP. However, children’s social care were , ‘outvoted’ at the meeting in April 2017 which decided to end the plan. The health visitor was helpful with advice about looking after child B. 13.4 ILR asked about the decision for her to supervise contact between the children and their father in the community. MAB said that now, looking back, she wished that she had not had to do it. She should not have been left to supervise it. Looking back, she had had mental health problems and did not fully understand the risks to her children from their father. She said that she was only told about FAB’s conviction in outline and would have found more detail helpful in understanding his risk. 13.5 She said that data protection considerations had limited her knowledge of FAB’s sexual offences which had not enabled her to fully understand how best to supervise contact with their father and protect her children. She didn’t think that Child B was at risk from FAB. She had thought about getting legal advice but said that she had been told by children’s social care that the children would be removed if she did so. 13.6 ILR asked what MAB would have liked the professionals to have done differently. She said that there was an assumption by the social worker that she had fully understood things but this was not the case. She said that it would have been helpful if someone, perhaps an independent advocate, had explained clearly the situation to her and the children so that she would have had a good understanding of what was happening, especially the risk from FAB, who she said was a controlling person. 13.7 ILR asked if there had been any domestic abuse or physical violence from FAB? MAB said that there had been, both mental and physical. PS asked if she had told anyone about this? No she had not because she was wanting to, ‘ paint a picture of a perfect family’. Page 46 of 47 13.8 MAB had no clear recollection of what the Team around the Family plan was about. 13.9 ILR moved the conversation onto the children being home educated. MAB said that Child A was getting bullied at her primary school by the teacher; that she was coming home from school crying. This was the reason why home schooling was started in 2016. Child A was and is a clever child and has recently passed several GCSEs. Later on during 2016/17 Child A was subject again to some bullying; being followed home from school, and became unhappy. MAB found her upstairs with a razor blade and was concerned and told the social worker. Child A was asking to be home educated and did not want to continue at the secondary school. MAB decided to once again home educate Child A because of the distress caused by the bullying. She received a letter from the local authority Elective Home Education team but no further contact was made by them. She got support from a local EHE group. 13.10 ILR asked about why child B had not been on a school roll. MAB said that apparently Child B was hyperactive when young and she didn’t want him labelled as such, if he had started at a primary school. So she decided to home school him also. PS clarified with her that Child B had had no formal diagnosis of hyperactivity which was the case. Child B is good with numbers but not so good with his reading. 13.11 ILR asked MAB what she thought the lessons were in her dealings with the child protection agencies? She thought the use of an advocate would be helpful and for professionals not to assume that parents were fully understanding of agency concerns about children and whether they ( parents) were able to really manage the risk where, for example, they were being asked to supervise contact with offenders, as in this case. 13.12 ILR thanked MAB for her views and said that he would write up the discussion in draft and let her see a copy, via Professional A and have an opportunity to amend it if she wished. Once this had been done to her satisfaction, ILR would include her views and suggested lessons in the final report . MAB said that she felt the meeting had given her a voice. 14. Appendix 5: Improvements in GP Practice and actions taken by East Lancashire CCG 14.1 Current practice in relation to children on child protection plans is outlined in the Royal College of General Practitioner’s toolkit. Once informed a child is on a child protection plan – there is a code entered on the EMIS system that puts an alert on the child’s records. When a child protection plan is discontinued this alert is removed but the information remains as a historical event on the records. There is a separate alert box on the records that is completed if the child is classed as CIN, has a CAF or TAF plan or any other relevant information. 14.2 The GP records were searched as part of the IMR/Chronology /timeline request and there was no evidence of receipt of the children’s child protection plans or ICPC/RCPC minutes. Current day practice would be once received, these are added onto the child’s records. 14.3 In terms of ICPC requests to attend /submit information although an invite was not sourced as part of the original records search, current processes are robust around this. The CCG receives the initial request and coordinates attendance/report submission for all ICPC’s. This is subject to ongoing audit and scrutiny, and any learning cascaded for all the Safeguarding ‘champions’/’leads to disseminate into their practices. Page 47 of 47 14.4 Each GP practice across East Lancashire has a nominated ‘Champion’ who attends regular training/update sessions on key safeguarding issues and has responsibility to share with /embed into their practice. 14.5 Safeguarding practice in Primary Care has moved on significantly since the time of these incidents and lessons learnt have been embedded into practice. We have specific Safeguarding Practitioners and Named GP’s within the CCG’s who work with Primary Care colleagues in developing Safeguarding awareness and offer support around this. We have in East Lancashire as part of the Primary Care contract an identified safeguarding Champion within each practice who is mandated to attend GP Champions training on a quarterly basis (and more frequently if required). 14.6 They also take responsibility for updating policies and processes around Safeguarding in their practice. There is a Sample GP safeguarding policy that CCG’s have disseminated into Primary Care, and robust processes for flagging concerns, raising alerts, seeking support, and appropriate referral mechanisms in place. Every GP Practice has to submit an annual SAF (Safeguarding compliance self-assessment tool) to CCG’s for oversight and scrutiny. CCG works with any (all) practices who require additional support in key areas or more bespoke training. 14.7 There is an action plan for the two GP practices highlighted in this review that we are working with them with directly, and will offer assurance to CSAP on completion. |
NC52683 | Deaths of Child D aged 24-days-old and Child C aged 21-months-old seven months apart in 2013 following breathing difficulties at home. Several years later Child E was admitted to hospital with breathing difficulties. In 2018 Child C and Ds father was arrested and found guilty of murder and attempted murder. Learning themes include: perplexing presentations (PP)/fabricated or induced illness (FII) and physical abuse in children; medically unexplained deaths in children including sudden unexpected death of children (SUDC) arrangements, child death overview panel (CDOP) arrangements and criminal investigation; and coercive control and domestic abuse. Recommendations for the childrens safeguarding assurance partnership include: review the implementation plan developed in support of the new local arrangements for perplexing presentations or fabricated or induced illness in children and consider the inclusion of the proposals for learning identified in this review; request paediatricians consider a review of using an assessment tool such as the Brief Resolved Unexplained Event (BRUE) model to support their clinical practice and to improve the risk assessment of children attending with brief resolved unexplained events; conduct a partnership wide audit with their acute hospital trusts to review the effectiveness of the arrangements for facilitating strategy discussions/meetings in the hospital setting; request that the integrated care systems across the partnership review their child death arrangements and provide assurance that the proposals for learning have been addressed; consider how the local in-school programme on coercive control and healthy relationships can be expanded and delivered to young people not in education.
| Title: Child safeguarding practice review: overview report: Child C, D and E. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Kathy Webster Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Overview Report: Child C, D and E Author: Kathy Webster Date: November 2022 Publication Date: November 2022 2 Contents Acknowledgement ........................................................................................................ 3 1. Introduction and Background .......................................................................... 4 2. Overview of the family and context ............................................................... 6 3. Key Learning Themes .......................................................................................... 9 4. Perplexing Presentations (PP), Fabricated or Induced Illness (FII) and Physical Abuse in Children ........................................................................................ 10 5. Medically unexplained deaths in children The Sudden Unexpected Death of Children arrangements, Child Death Overview Panel arrangements and Criminal Investigation ........................................................... 18 6. Coercive Control and Domestic Abuse ...................................................... 24 7. Impact statement at the trial ......................................................................... 25 8. Good Practice ..................................................................................................... 26 9. Conclusion ........................................................................................................... 26 10. Recommendations ............................................................................................ 26 11. References ........................................................................................................... 28 12. Statement of Reviewer Independence ....................................................... 29 13. Appendix 1: Terms of Reference Child Safeguarding Practice Review............................................................................................................................. 30 3 Acknowledgement With grateful thanks to Dr Nicola Bamford – Designated Doctor in Safeguarding - for providing paediatric expertise and for her editing and support during the production of this review. 4 1. Introduction and Background 1.1. The background of the Child Safeguarding Practice Review (CSPR) This CSPR was commissioned by Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership (CSAP). The subject children of this review will be known as Child C, Child D and Child E throughout the report. The catalyst for this CSPR was that in 2013, there were two separate child deaths from the same family within 7 months of each other. Both children died following breathing difficulties at home which had resulted in emergency medical responses prior to their deaths. The first child who died (Child D) was only 24 days old at the time of death, followed by Child C at the age of 21 months. In the absence of any definitive medical cause for the children’s deaths a level of medical uncertainty existed but did not progress until a number of years later when another child (Child E) started to experience breathing difficulties at home resulting in admission to hospital. The pattern of hospital admissions relating to Child E followed breathing difficulties at home and this, in conjunction with the history of Child C and Child D and the adult male involved was recognised by paediatricians who initiated a short child protection investigation for Child E who was removed to a place of safety. These actions averted the probable eventual death of Child E. A finding of fact hearing on behalf of Child E took place in the Family Court which found that the family context at the time of each serious incident corresponded with the breaking down of the adults relationship and that the same male had been in sole care of the children just prior to, or at the time of the respiratory collapse of each child. The finding of the court was that Child E had no medical condition or illness to explain the onset of a sudden respiratory arrest and that the male involved had probably been responsible for deliberately causing this. This court hearing triggered a highly complex criminal investigation of the male involved who was arrested for the children’s murder/ attempted murder in 2018 by which time there was a further murder charge relating to the death of his most recent partner. This woman was not connected to the children in this review and died at home as a result of deliberate drug poisoning. A ten-week criminal trial completed in the latter part of 2021 found that the male involved was guilty of the murder of Child C and Child D and his then partner. He was also found guilty of the attempted murder of Child E. The identity of Child E has been protected throughout this report for legal reasons. During sentencing, the judge described the convicted male as being an, “exceptionally controlling, selfish and cruel man.” He was sentenced for a minimum jail term of 40 years and following a review of the sentence was sentenced to a further 8 years. During the trial it was accepted that no one else with any caring responsibility for any of the children had been aware or suspected the involved male of any untoward actions at the time the incidents occured. Child Safeguarding Practice Review - (previously known as a Serious Case Review (SCR)) is undertaken when a child dies or the child has been seriously harmed and there is cause for concern as to the way organisations worked together Child Safeguarding Assurance Partnership (CSAP) – The safeguarding partners work together to agree on ways that they will co-ordinate their safeguarding services, act as a strategic leadership group in supporting and engaging others, and implement local and national learning. 5 1.2. Delay in carrying out this CSPR On the commencement of the Police investigation it was decided that in view of this case highlighting probable child murder and attempted murder, that a Child Safeguarding Practice Review (CSPR) should be commissioned in line with the national statutory regulated practice guidance and the national child safeguarding practice review panel. The review did not commence until after the criminal trial of the male involved had been concluded to ensure that the highly complex detail of the medical and pathological police evidence was fully protected. The purpose of this review has been to recognise both historical and more recent child safeguarding practice arrangements and to highlight good practice and any progress or gaps in local safeguarding systems and practice. A number of recommendations have been produced which are based on the lessons learned from this review in order to improve safeguarding arrangements for children in the future. 1.3. Methodology The review has been conducted in line with Working Together (2018) statutory guidance and the National Child Safeguarding Practice Review Panel: practice guidance 2019. An Independent Reviewer with relevant expertise and experience was commissioned to conduct the review with terms of reference which sets out the scope and key lines of enquiry for the review (Appendix 1). A Panel of managers and safeguarding leads from the agencies/organisations involved in the review have been actively involved throughout the process. The Independent Reviewer virtually attended the summing up and sentencing of the male involved's criminal trial and has since met with the mother of Child C and Child D to hear her testimony and her feedback on services provided to her children and family which has been greatly appreciated. Extracts from the comments made by the mother of Child C and Child D have been transcribed within the report and written in blue to promote her voice on behalf of herself and the children. Working Together 2018 is interagency statutory guidance produced by the government which outlines how practitioners working with children and families should work together to safeguard and promote the welfare of children. National Child Safeguarding Practice Review Panel - are an independent panel commissioning reviews of serious child safeguarding cases. 6 2. Overview of the family and context The children who are the subjects of this CSPR were all white British and living in the north of England. The children had lived within an urban community and within easy reach of the adults' friends and family. The male involved (MI) was fully employed in a well remunerated construction job throughout the review period and the father of Child C and Child D. 2.1 Parental background Historically, the Mother of Child C and Child D (MCD) was known to have experienced a troubled childhood and following the death of her own mother had been predominantly looked after by her older sister. The household MCD was brought up in had been chaotic and her school attendance was extremely poor. MCD entered into a platonic relationship with MI when she was 10 years old and became reliant on him and his family. MI, also had a troubled childhood; he had experienced behavioural issues and was a victim of domestic abuse. He too had an extremely poor school attendance record. As a youth he was known to the Police for anti-social behaviour and he experimented with alcohol and drugs. MCD became pregnant by MI at the age of 19 years. One month prior to the first pregnancy being confirmed there was a brief history of deliberate self-harm by MCD involving an overdose of prescribed medication. MCD was supported by mental health services at the time and remained under the care of her own GP for management of her mental health. Professionals working with the family at the time were not aware of MI’s drug dealing and gambling which resulted in him having debts amounting to thousands of pounds which impacted on the couple’s relationship. It was only after the couple finally split up that MCD became aware that she had been manipulated and controlled by MI throughout their relationship, the scale of which was only fully realised by MCD at the end of the criminal trial in 2021. 2.2 What happened – Child C and Child D MCD’s first midwifery assessment was at 8 weeks of pregnancy. The midwife appropriately took into account her psychosocial circumstances which resulted in MCD’s maternity care being referred to a Caseload Midwife who is a midwife with a limited caseload to provide additional support and to promote continuity of care. A Common Assessment Framework (CAF) was completed resulting in the family receiving the Early Start Programme which provided intensive parenting support during MCD’s pregnancy and throughout Child C’s first year. The Routine Enquiry questions on domestic abuse were asked on a number of occasions throughout the antenatal period with no concern being flagged. Common Assessment Framework (CAF) – is a process used to identify children and family unmet needs and support them. Early Start Programme – is a local authority programme offered to support vulnerable families during pregnancy and infancy. Routine Enquiry - involves asking women direct questions in relation to domestic abuse during pregnancy and child’s early infancy. 7 Child C made good developmental progress and was appropriately taken to hospital on three occasions. Child C was 11 months old when professionals became aware that mother was pregnant with Child D. There were no significant issues identified by the Caseload Midwife during this pregnancy and additional support from Early Start Programme was not required. MCD was encouraged to access local services at the children's centre. Child D was born healthy and with no new family issues being identified. The child attended hospital on 2 occasions (age 7 days and 17 days) after having reported breathing difficulties at home. On both occasions the child quickly recovered and following a period of observation was discharged home. The day following the second discharge from hospital, Child D was found to be not breathing at home by MI. A 999 call was made and MI commenced resuscitation as instructed. The child was taken to hospital but did not recover and died. The Paediatrician was shocked by the child’s death given that the child had been well on the ward just a few hours earlier. The cause of death reported by the Coroner was Bronchopneumonia. Child C was 17 months old when Child D died. The child was reviewed and found to be developing normally with no safeguarding concerns. When the child was 20 months old, they had a sudden respiratory arrest at home requiring a short admission to hospital for observation. Twenty days later Child C was found unresponsive in a pushchair at home and was taken to hospital where the child was later pronounced dead. Paediatricians were surprised by the child’s death and harboured some concern that something untoward had occurred to the child because there did not appear to be any medical explanation for the child’s death. The cause of death reported by the Coroner was unascertained and an open verdict was concluded at the Coroner Inquest. There were no other children involved at this point. Bronchopneumonia - inflammation of the lungs, arising in the bronchi or bronchioles Coroner Inquest – are legal inquiries into the cause and circumstances of a death, and are limited, fact-finding inquiries 8 2.3 What happened – Child E Two years following the death of Child C the mother of Child E (ME) attended midwifery services and following assessment was referred to a Caseload Midwife and the mental health assessment team, but ME did not engage with the mental health service. The pregnancy and early neonatal period was appropriately managed by health teams as there were significant health risks established to be present for the baby and ME largely complied with these measures. In the event Child E was born healthy and there were no development concerns and the child was thriving. When the child was 5 months old there was an alleged high-risk domestic abuse incident which was reported to the Police by MI. This was followed by a second incident reported to the Police the following day involving an altercation between ME and another adult who had been caring for Child E. There was an appropriate referral to the Multiagency Safeguarding Hub (MASH) by the Police with a same day contact by Children's Social Care and the commencement of a child and family assessment. One-week later Child E was admitted to hospital following a respiratory arrest. The child quickly recovered. ME informed the allocated Social Worker of the child’s admission. The Social Worker contacted the Paediatrician who shared information about concern surrounding the deaths of Child C and Child D and MI’s involvement with all three children and of an emerging pattern of possible Fabricated or Induced Illness (FII). A discharge meeting involving the Health Visitor, Social Worker and Paediatrician was arranged for the following day which concluded that Child E was fit for discharge home with a plan arranged by Children's Social Care for ME, and child to stay with an aunt for support and supervision. Three days following discharge, Child E was found to have a further episode of sudden respiratory difficulty requiring hospital admission. At the time of the episode Child E was in the care of MI. A Strategy Meeting was held two days later where it was agreed that the threshold to undertake a section 47 investigation (child protection) had been met with a plan to secure the safety of Child E. Child E was monitored in hospital until Children's Social Care obtained an Interim Care Order through Local Authority (LA) care proceedings. These ongoing family court proceedings led to a criminal investigation of MI resulting in his eventual conviction and incarceration. Multiagency Safeguarding Hub (MASH) – brings together professionals from a range of agencies into an integrated multi-agency team and provides triage and multi-agency assessment of safeguarding concerns in respect of vulnerable children. Fabricated or Induced Illness (FII) – is a rare form of child abuse and happens when a parent or carer, exaggerates or deliberately causes symptoms of illness in the child Strategy Meeting – should take place where there are concerns about the safety and/wellbeing of a child or children. This is a statutory process as part of national safeguarding arrangements for children Interim Care Order – a temporary order made by the Court at the beginning of Care Proceedings and places a child in the care of the Local Authority and gives them shared parental responsibility with the parent. 9 3. Key Learning Themes Firstly, it must be stressed that this is a rare and highly complex review involving child murder by MI. It is recognised that much of the learning is based on historical information and the knowledge of hindsight from evidence produced firstly in the family courts and then by the Police which has been disclosed in the criminal court setting. The review highlights a number of positive changes to safeguarding practice and systems which have already been made locally. Secondly, it is recognised that professionals working with children and their parents do so based on the principle that parents want what is best for their children and want to keep them safe. In this case, the good work of all the agencies involved with the children and family resulted in recognising and responding to concerns at a dangerous point in the life of Child E which ultimately saved the child’s life. 3.1 Key Learning Themes identified: • Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) and Physical Abuse in children. • Medically Unexplained Deaths in Children – including Sudden Unexpected Death of Children (SUDC) arrangements, Child Death Overview Panel (CDOP) arrangements and Criminal Investigation. • Coercive Control and Domestic Abuse Sudden Unexpected Death of Children (SUDC) arrangements – involves a rapid multiagency response by a trained team of local professionals who will support the parents and investigate the circumstances of the death and report back to CDOP and the Coroner. Child Death Overview Panel (CDOP) – is a statutory requirement of Working Together 2010. The purpose of the CDOP is to ensure that when a child under the age of 18 dies there is a comprehensive and independent review of the circumstances. Coercive Control – this is described as controlling behaviour designed to make a person dependent by isolating them from support, exploiting them, depriving them of independence and regulating their everyday behaviour. Domestic Abuse - is violence or other abuse that occurs in a domestic setting, such as in a marriage or cohabitation. 10 4. Perplexing Presentations (PP), Fabricated or Induced Illness (FII) and Physical Abuse in Children 4.1 Introduction Guidance on FII has been available from the Royal College of Paediatrics and Child Health (RCPCH) since 2009. Since then there has been significant developments in this area of medicine. The term Perplexing Presentations was suggested in 2013 with development around recognising, risk assessment and how to manage these types of presentations to improve safeguarding and child outcome. A perplexing presentation is the essence of alerting signs is the presence of discrepancies between reports, presentations of the child and independent observations of the child, implausible discrepancies and unexplained findings or parental behaviours (RCPCH 2021). The guidance suggests that there had been uncertainty around the criteria for PP/FII and the threshold at which safeguarding procedures should be involved. There has been a helpful shift towards early recognition and intervention without the need for proof of deliberate deception by a care giver. The challenge remains that paediatricians are faced with medical emergency /presentations which rely on accurate and truthful reporting from parents and care givers. Parents and carers who harm their children will fabricate stories to cover up their actions leaving the paediatrician with complex and emotionally stressful dilemmas. 4.2 Narrative following a review of the children’s presentations to hospital in chronological order. All three children attended the same hospital children’s department and were treated by the same paediatricians which was a positive feature given that this alerted the paediatricians to the pattern of medical presentations and raised their concern for the safety of Child E which ultimately saved the child’s life. 4.3 Child C – featured four admissions to hospital prior to the birth of Child D. Child C’s first hospital attendance (age 7 months) was for a Viral Upper Respiratory Tract Infection which was appropriately treated prior to being discharged home. There was a return visit the following day with concerns of a wheezy chest (possible asthma) and this was treated accordingly. The third hospital attendance (age 9 months) came following a 999-emergency call by MI for medical assistance. The story from MI was that he had left the child playing unattended and, on his return, had found the child asleep and unresponsive on the floor with paracetamol next to the child. MI said that the child was “drowsy” when they came around. However, there appeared to be a flaw in this story because Paracetamol does not cause drowsiness even in large doses until a few days after administration and this should have alerted staff to inconsistencies in MI's account. The child’s observations and behaviour were normal on admission to hospital and a blood test for toxicology was negative for Paracetamol. The medical conclusion at the time was that the child had not taken any Paracetamol therefore no medical treatment was necessary and no checks about the child’s home situation were made as part of the overall clinical assessment. The reflection on learning here may provide an opportunity for paediatricians to consider the use of new assessment guidance for the evaluation, risk stratification, investigation and management 11 of children presenting to hospital with a Brief Resolved Unexplained Event (BRUE). The guidance / pathway is intended to replace the previous guidance on Apparent Life-Threatening Events (ALTE). (NHS Greater Glasgow and Clyde, 2018). The guidance has been shown to be effective in recognising infants who are at risk of repeated BRUE episode or identifying an underlying disorder. Whilst the guidance helps the practitioner explore medical findings it also considers the wider socio-environmental factors which promotes more effective risk assessment and safeguarding. Proposal following Learning 1 The CSAP via the Integrated Care Board and Acute Hospital Trusts should request that local paediatricians consider using a consistent assessment tool such as the BRUE model across the partnership to support their clinical practice and to improve the risk assessment of children admitted with brief resolved unexplained events. Possible ingestion of substances is not an uncommon event for children. Parents are encouraged to err on the side of caution particularly with paracetamol because of its level of toxicity. However, the collapse history seems to have been lost/forgotten with the finding of normal blood tests. It is important to consider the presentation of the child and see whether the results explain that. Even if there had been paracetamol in this child’s system it would not have explained an unresponsive child. There were a number of features around this event which did not appear to be plausible and were not explored at the time. How could a 9-month-old child who was not yet walking manage to stand and get the Paracetamol packet off the mantle piece? Did the child have the manual dexterity to remove the tablets from the blister pack – even if using their teeth as was suggested? Why would anyone caring for a 9-month-old child leave them on their own without supervision for 20 minutes? Why was there a history of unresponsiveness and drowsiness when the child had been reported as ingesting paracetamol? Why would a child who had been collapsed, requiring resuscitation at home, be well on admission to the ward? During discussion at the learning event, the paediatricians felt that it was common to see children admitted with drug/substance ingestions and at the time nothing raised any alarm that something sinister had happened. Whilst paediatricians are not expected to be criminal forensic investigators there should be an expectation for them to be professionally curious when parental histories potentially do not match clinical findings with a view to promoting safeguarding. Best practice would have been for the hospital staff to have made safeguarding checks with MASH and the Health Visitor to better understand the situation at home. A CAF was already in place for the child and this event should have been worthy of a multiagency “team around the child” meeting to consider how the family were functioning and to identify any future risks for the child. A request for the Health Visitor to visit the home for health and safety checks was appropriately completed by the Children's Department Paediatric Liaison Nurse. The Health Visitor visited the child two weeks later for a pre-arranged appointment. 12 This visit was taken up by MCD being distressed because she had split up from MI recently and his family had made threats to take the child from her which indicted that there was increased tension within the family that had been worthy of further consideration. Whilst the Health Visitor recognised the need for support around domestic arguments and advised MCD to attend women’s domestic abuse and refuge services it did not lead to any additional assessment of family functioning as it should have done. MCD told the Independent Reviewer that over this period of time she had been trying to get away from MI because she thought he was gambling again, “but he would not let me go”. She had no money of her own and she was not happy in the relationship. MCD recalled to the Independent Reviewer that on the day of the paracetamol incident she had told MI that she was going shopping and when she returned, he would have to leave. She had just reached the door of the supermarket when MI rang her to say that Child C had taken paracetamol and had collapsed and he was on his way to the hospital. MCD went straight to the hospital to meet with MI and Child C. MCD reflected with the Independent Reviewer that when children (such as Child C) are admitted to hospital with a history which does not appear to match up “there should be checks about what is happening at home”. Hospital staff had not fully considered the situation at home or the state of the parent’s relationship which prevented them from seeing the bigger picture. NSPCC learning from case reviews (2017) suggest that where there are vulnerable families with increasing stress and rising tension that children are at greater risk of abuse. There is therefore, validity in mother’s proposal for checks at home for children where there are perplexing presentations even if concerns are only low level. Professionals should be particularly alert to these types of presentations because they may be a precursor to something more serious happening in the future, as occurred in this case. At MI’s murder trial there was a suspicion in court that he may have fabricated the story about paracetamol and he himself caused the collapse of the child to deflect the situation of the couple breaking up. Whilst the learning is both historical and heavily based on hindsight there is a lesson here about professional curiosity and information gathering/sharing and how hospital and community children services work together to assess risk to safeguard children when the child’s presentation is perplexing or where elements of a given situation are inconclusive or doubtful. Proposal following Learning 2 The new safeguarding policy for Perplexing Presentations / Fabricated or Induced Illness in Children which is in line with the RCPCH guidance (2021), should act to raise awareness of how to manage children where there are elements of uncertainty in the history of a child’s medical presentation and establish pathways for gathering information about a child and family home and environmental factors as part of the clinical assessment. Child C (11 months) had a further appropriate hospital admission for a minor urinary problem which was resolved with antibiotics. This presentation was unremarkable and appropriate. 13 4.4 Child D – featured 2 hospital admissions prior to the child’s death Child D (age 7 days) attended hospital with oral thrush and medication was appropriately given. The Health Visitor was notified and visited 3 days later with no concern identified. Ten days later, Child D (age 17 days) required a 999-emergency response due to breathing difficulties at home and quickly recovered when the paramedic arrived. The child was admitted to hospital for 2 days with signs of an upper respiratory tract infection. Medical tests and observations were all normal prior to discharge and the child appeared well. Following discharge home, the child had a cardio-respiratory arrest and died just a few hours later. The paediatricians had not found any perplexing features in any of Child D’s hospital admissions. It was the suddenness of the child’s death following discharge which the paediatricians found perplexing. 4.5 Child C – (continued) features 1 further hospital admission prior to the child’s death. When Child C was 18 months old (6 months after the death of Child D), MI made a 999-emergency call because the child was said to be having difficulty breathing. Full screening tests took place at the hospital which were all normal. The child remained well whilst in hospital. MI requested to take the child home on “home leave” with an arrangement to return the following day to be seen again by the paediatrician. The child was not returned to the ward as arranged and the parents were not contacted by the hospital to check the reason for this. The discharge summary to the Health Visitor did not reflect that the child had not been returned for review as planned. There is an issue here around “was not brought” (formally known as did not attend) procedures. Best practice would have been to alert the Health Visitor in the community that the child had not attended the hospital as planned. Paediatricians at the learning event did not feel that this was an issue because MI had not taken the child home against medical advice. Professional curiosity around why the child had not been returned as planned should have been expected with a call to the parents to check on the circumstances to ensure a safe discharge from hospital. Progress New local arrangements are now in place within the hospital's Children's Department where the hospital children's nurses are available to contact parents/carers direct to chase up any issues and to share information with other services and agencies. Three weeks following this hospital admission, Child C was brought into hospital and found to be dead. The nature of this death was perplexing in that this was a sudden and unexpected death of a child who had been otherwise healthy and developing well. 4.6 Child E – features 3 hospital admissions prior to the child being safeguarded. By the time Child E attended hospital at the age of 9 weeks the child had already undergone extensive screening to exclude any cardiac, metabolic or genetic conditions all of which were normal. 14 Child E’s first hospital attendance occurred at the age of 9 weeks because the child was sleepy and unsettled when awake following vaccinations and a low threshold to admit the child had been identified. The child was found to be well and was discharged. The second admission occurred when Child E was 4 ½ months old. At this point at least two serious domestic abuse incidents had been reported to the Police by MI about ME’s (mother of Child E) alleged violent behaviour and mental health issues (both of which ME denied) resulting in ME’s arrest and a referral to MASH (Multi-agency Safeguarding Hub). A child and family assessment had been appropriately commenced with a focus on ME as a potiential perpetrator of domestic abuse. Child E’s third admission to hospital came via another 999-emergency response call with a history that MI had found the child with breathing difficulties. On arrival at hospital the child was alert, smiling, interacting and observations were all normal. ME sent a text to the Social Worker involved with Child E to inform them that the child had been admitted to hospital which resulted in a professional’s discussion between the Social Worker, Health Visitor and Paediatrician. During the discussion, the Paediatrician reported that the child was well enough for discharge. There were no concerns at the hospital about the care of Child E provided by the child’s mother (ME). The Paediatrician shared medical concerns about the circumstances of the deaths of Child C and Child D and MI’s involvement with children including the possible features of FII. The circumstances highlighted by the Paediatrician were serious enough to trigger a formal strategy discussion/meeting to include the Police prior to the child’s discharge to ensure effective decision making to safeguard Child E but this did not occur. The Social Worker raised a concern that Children's Social Care had limited information about Child C and Child D deaths and that careful decision making was needed around Child E’s discharge home. This lack of available information will be discussed later in the report. The safeguarding team at the hospital had not been informed of the child’s admission or concerns raised by professionals on the ward at this point. Their assistance and expertise were not utilised to assist in the safeguarding process in line with the hospital’s safeguarding arrangements. This lack of communication fell short of best practice expectation within the hospital safeguarding arrangements. Progress The hospital safeguarding team now have a safeguarding practitioner who is based on the ward during office hours. They complete safeguarding walk rounds on the ward and are available for advice and support. This safeguarding function is proactive in supporting clinical staff to safeguard children The hospital safeguarding team were later informed of Child E’s admission by the Children's Social Care team manager who asked for further information about Child C and Child D’s deaths and shared concerns about the family history and current admission. Information was ascertained from the ward that following the meeting between the Social Worker and the Peadiatrician the plan was for Child E to be discharged home with ME with supervision 15 from an aunt. Children's Social Care reported that they planned to speak with the police about previous deaths to ascertain information from the post-mortems following the deaths of Child C and Child D. This contact did not trigger any further risk assessment into the safety of the proposed plan for the child to be discharged prior to all reasonable checks being made and for the opportunity for a strategy meeting to be considered. The following day, a different Paediatrician was covering the ward and was keen to discharge Child E to prevent exposure to infection. The initial Paediatrician had now remembered the deaths of Child C and Child D and felt there were concerns about Child E going home because there was a pattern of possible FII emerging which needed further exploration. Again, this should have triggered a multi-agency safeguarding strategy meeting prior to the child’s discharge. The appearance of a level of urgency by the Paediatrician to discharge Child E from hospital once the child was found to be medically well is a common feature of hospital-based practitioners. The perspective within hospital settings is often that a hospital children’s ward bed is not a “place of safety” for children for Children's Social Care to use as an easy option placement. However, had Children's Social Care insisted on a strategy meeting prior to the child’s discharge, this may have resulted in the child remaining on the ward for longer to allow for relevant multiagency checks to be made. This being the case, it may have enabled professionals to meet the threshold to investigate under section 47 (child protection) resulting in more effective risk assessment and planning at this earlier stage. In the absence of a strategy meeting and the uncertainity around the allegation of domestic abuse against ME, Children's Social Care concluded that Child E could go and stay with ME at another family member's (an aunt) home who could provide support and supervise the child’s care. The word 'supervise' may have provided a false sense of security that the child was to be protected by the collective family. With the benefit of hindsight, the safeguarding risk assessment and planning was inadequate to protect Child E given that there were immediate concerns of FII taking into consideration the deaths of Child C and Child D and the involvement by MI. At some point prior to the child’s discharge, MI admitted to the Social Worker that he had lied about the risk ME may pose to Child E and agreed that the child should be returned to ME’s care. MI admitting that he had lied to agencies over something so serious should have alerted the Social Worker to the increased level of risk. ME told the Independent Reviewer that the Social Worker had a discussion with her and aunt prior to discharge. The arrangement was to have the aunt around in case ME needed any support with Child E at home. There was no actual supervision arrangement in place and ME said that “no one told us there was any safeguarding concerns”. It is the case that raising concern with parents/carers around FII can make the situation more dangerous because the parents/carer may do something untoward to the child to prove agencies wrong in their quest to provide evidence that there is some form of medical condition affecting the child. Concerns of the emerging patterns of hospital presentations and FII by the Paediatrician were further discussed and the Social Worker requested chronologies of all three children. The Paediatrician declined to do this due to workload pressures and advised that Children's Social Care 16 should formally request the information from the hospital. However, following the hospital safeguarding team's involvement they began to collate the chronologies the next day. They emailed the Peadiatrician for information about the death’s of Child C and Child D and asked for a copy of the internal mortality investigation to assist in the compiling of the chronologies in support of the case. It is acknowledged that paediatricians are the lead agent in FII cases and this is a very time-consuming role. The work needed to make a diagnosis of FII would require a temporary work plan change to allow time for this work to be done if appropriate. It is important that paediatricians understand their role and responsibilities when managing concerns of FII and that there are clear procedures in place to support the Paediatrician in carrying out this important safeguarding function. Progress and Proposal following Learning 3 The new Multi-agency Perplexing Presentations and Fabricated Induced Illness Guidance will require effective implementation and training. To ensure that all those working in this area understand their own roles and responsibilities as well as the nature, language and context of the guidance. There will also need to be a robust undertaking by hospital trusts to support their paediatricians in this work both practically and emotionally. The day after discharge, the Social Worker visited Child E and ME and a Family Support Worker (FSW) was allocated. Two days following discharge, MI made a 111 call to report that Child E had a worsening cough. Other adults caring for Child E were not told about this call. The next day, Child E was allegedly found by MI to have stopped breathing resulting in a 999 call for emergency assistance. On attendance by the ambulance crew the child had rapid breathing but the child quickly recovered and was transported to hospital where all observations appeared to be within normal limits. Another adult contacted the Emergency Duty Team (out of hours social services) at ME’s request to inform them that Child E was being taken to hospital again. The Social Worker was informed the following day and contacted the hospital for further information. A strategy meeting was agreed in response to the identification of the high level of risk to the child and this was arranged to take place in two days’ time. A same day urgent strategy meeting would be expected practice in line with safeguarding procedures. A further review strategy meeting could have been convened two days later to discuss information gathered. Delay of the strategy meeting was put down to medical tests needing to be completed to enable the Paediatrician to provide or exclude a medical diagnosis. In acknowledgement of the greater level of concern for the child there was a move to nurse them on the main ward (instead of a side ward) for supervision. This was good practice to enable hospital ward staff to supervise the situation more closely. The Hospital Named Doctor was informed of the serious case and the Named Nurse once alerted was able to be present at the Strategy Meeting to support hospital professionals. There would have 17 been merit in the Named or Designated Professionals being brought into the situation sooner to provide safeguarding guidance and expertise. The strategy meeting was well attended by all the agencies. It was recognised that MI’s story had some inconsistencies and that he had had time alone with Child C and Child D prior to their deaths. The outcome was a unanimous decision for a section 47 (child protection) investigation with a rationale that FII was an evident concern in the absence of any medical condition to cause to the child’s sudden respiratory difficulties. Proposal following Learning 4 The CSAP should conduct an audit in partnership with the Acute Hospital Trust around the effectiveness of safeguarding arrangements for facilitating strategy discussions/meetings in the hospital setting. The audit should include timescales, identify the attendance of the statutory agencies and consider the effectiveness of decision making. There were some challenges for the paediatricians that came to light at the Strategy Meeting with a discussion about the risk of them being seen as being overzealous but with their overriding concern being around the potential dangers to the child. This provided an insight into the plight of medical professionals who often have to address dilemmas whilst protecting professional reputations. Further medical specialist advice was taken by the Paediatrician about Child E’s presentations to hospital, which was good practice and produced a working hypothesis that whilst a genetic condition could not be ruled out a deliberate induced event needed to be considered as a significant possibility. Paediatricians are trained to diagnose and treat ill health in children and to work in partnership with parents on the basis of trust. The learning event raised an important issue around the negative emotional impact of paediatricians and other professionals being party to the removal of a child from their parents in care proceedings. This highlights the importance of debriefing and supervision following distressing incidents and reinforces the importance of utilising the skills and knowledge of the Named and Designated Professional's expertise within the hospital setting. Child E remained in hospital until the Local Authority was granted an Interim Care Order with a care plan to keep Child E safe. Named Professionals – have a key role in promoting good professional safegurding practice within health trusts and provide advice and expertise to fellow professionals. Designated Professionals – denotes dedicated professionals with specific roles and responsibilities for safeguarding children, including the provision of strategic advice and guidance to organisational boards across healthcare services and to local multi-agency safeguarding organisation. 18 5. Medically unexplained deaths in children The Sudden Unexpected Death of Children arrangements, Child Death Overview Panel arrangements and Criminal Investigation 5.1 Introduction NSPCC Child deaths due to abuse or neglect statistics briefing (2021). This briefing looked at what data and statistics were available about child deaths due to abuse or neglect. It suggested that official measures are likely to be underestimations of the number of children who die due to a number of reasons, including: • the legal complexity of proof of homicide • misdiagnosed cause of death • abuse not being the immediate cause of death, but being a contributing factor • cause of death remaining unknown or unexplained. However, based on the number of child homicides recorded by the police each year, there is on average, at least one child killed a week in the UK. It is recognised that the incidence of two children experiencing sudden unexpected deaths from the same household is extremely uncommon and should be viewed as a high alert to guide further investigation into the possibility of deliberate harm to a child. 5.2 Narrative following review of SUDC and CDOP arrangements Both Child C and Child D had died in the same year just 7 months apart and were siblings from the same household. Child D was only 24 days old when the child died and Child C was 21 months old. Both had historical hospital admissions which had been viewed as being unremarkable at the time. Both had been healthy before they suddenly and unexpectedly died in similar circumstances. It has only been with the benefit of hindsight following a criminal trial that we have been able to consider the learning around deliberate harm to the children. 5.3 Circumstances around the death of Child D Child D had a respiratory arrest within 8 hours of returning home from hospital (age 24 days) whilst in the care of MI. The account provided closely resembled those often given in cases of sudden unexpected death in infancy. The Rapid Response and Sudden Unexpected Deaths in Children (SUDC) processes at the time were well provided and the parents were supported throughout. The SUDC nurse was not available to support the process until the following day because their hours of working at the time was 9-5, Monday till Friday with no Bank Holidays and the child died on a Bank Holiday. 19 Progress Following a review of the SUDC service in 2018, additional funding was made available to expand the SUDC nursing service which is now a 7-day service including bank holidays with working hours of 9-5. Outside of these hours the Consultant Paediatrician on duty carries out the tasks required at the hospital following the child death with the Police. Communication and information sharing was good, although there was a delay with sharing the hospital medical records because the child died within 48 hours of hospital discharge resulting in the need for a Root Cause Analysis Review of the circumstances which concluded that all care had been appropriate and that the child had been well on discharge from hospital. The initial findings from the post-mortem examination were recorded as unascertained. The final verdict of the Coroner inquest was that the death had been by natural causes with a final post mortem report recording acute bronchopneumonia. The CDOP meeting closed the case within seven months and received relevant information that medical practice at the hospital had been reviewed and found to be appropriate at the time and that both parents had smoked which was an increased risk factor for SUDC. No further action was recommended by CDOP. The paediatricians reflected at the learning event that they remembered that they had found the Coroner’s verdict surprising given that Child D had been so well prior to leaving hospital. They recalled a discussion at the hospital mortality meeting (this meeting would have been separate to the CDOP process) that they raised low-level concerns about the child’s death being attributed to bronchopneumonia and the paediatric view being that the death was unascertained. This difference of opinion was not recorded or shared within the CDOP process which left a loose end of information which was lost other than to the memory of the doctors concerned at the time. The views raised by the paediatricians had been valid pathological/medical information and would have been useful information had it been shared within the CDOP or other Child Death processes. Progress Since 2018, there has been a new statutory requirement for multiagency attendance at a Child Death Review Meeting (takes place prior to CDOP) where all relevant information about the child and family is shared. These meetings are expected to be effectively recorded with appropriate information sharing via the “draft analysis form” to CDOP. It is the case that had Child Death Review Meetings been in place at the time there would possibly have been a better opportunity for the concerns of the paediatricians to be shared, recorded and addressed. Root Cause Analysis Review - is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. Bronchopneumonia – inflammation of the lungs usually caused by a bacterial infection or virus. 20 Proposal following Learning 5 The CSAP should be assured that the local arrangements for Child Death Review Meetings are well established and consistently applied across all areas of the partnership in line with Working Together 2018. Any concern which has a bearing on the death of a child should be recorded as an opinion in the Child Death Review Meeting minutes even if this is not a unanimous view. Relevant information should be placed on the individual agency child’s record for future information scrutiny. Individual agencies should take responsibility for the effectiveness of record keeping following Child Death Review Meetings and other associated meetings. Whilst Child Death Review Meetings were not available at the time the fact that Children's Social Care had very little information about Child C and Child D's deaths on their record management system when safeguarding concerns arose bears testament to a potential shortfall in effective record keeping. Proposal following Learning 6 The CSAP should ensure that agencies attending Child Death Review Meeting’s have effective processes for the transfer of important information being recorded on their agency’s child and family record systems. There were no feedback mechanisms at the time to share the differences of opinion raised by the paediatricians to the Coroner or CDOP. The benefit of having such feedback arrangements locally is that it provides a forum for further discussion and learning. Proposal following Learning 7 The CSAP should consider with the Coroner their relationship and potential for feedback between the Child Death Overview Panel and Coroner when managing difference of opinion. 5.4 Circumstances around the death of Child C Child C (21 months) had been found by MCD to be unresponsive at home in a pushchair having been out for most of the day with MI. A 999-emergency call was made and the child was found to be in cardiac arrest and despite appropriate resuscitation by paramedic’s and other health professionals the child was found to be dead shortly after arriving at the hospital. Following the death of the child, a Rapid Response Meeting was requested by the Police Senior Investigating Officer with Children's Social Care and Consultant Paediatrician at the hospital. It was recognised that this was the second child death from the same family which led to the Police taking a greater level of forensic attention of the home to identify any evidence of abuse of which none was found. 21 The medical history for Child C was provided and the parents were interviewed by the Police. Whilst the routine investigation which takes place within the SUDC process were robust, it did not extend to requesting a medical review of the two children’s medical records together which would have been best practice. In hindsight, this may have drawn attention to a number of medical concerns which were surfacing of possible FII following the deaths of the two children. Proposal following learning 8 The CSAP should ensure that where there have been two or more children dying suddenly and unexpectedly from the same family that these are viewed as indicative that the cause of death for the children is likely to be the same and further assessment of the children’s cases together may provide either a diagnosis or an explanation. As such, all medical records should be reviewed by an experienced senior Paediatrician who should report on the child’s medical history and present any findings to the Joint Agency Response Team and CDRM/CDOP. On medical examination there were a number of small marks and bruises on Child C’s face, back of neck, and legs and a small upper torn frenulum in the mouth. These were put down to accidental toddler injuries and the trauma of the resuscitation process which was a reasonable hypothesis. However, with the benefit of hindsight following the criminal trial these marks may have been pointing to something more sinister. Keeping an open-minded approach during the SUDC process is essential in order to ensure that professionals are not ruling out areas of uncertainty too soon. The initial post mortem results for Child C was recorded to be unascertained and samples were sent for toxicology testing and formal police statements were taken from the parents. The final post-mortem was undertaken by a Home Office Pathologist whose report confirmed that the child’s cause of death was unascertained. The Coroner’s final verdict was that the child’s cause of death was unascertained and therefore an open verdict was recorded. The CDOP review was closed after 14 months which was 6 months after the Coroner’s final verdict. The reason for the delay is not known other than the workings of CDOP at the time. The meeting recognised that the child had previous hospital admissions with breathing difficulties possibly related to asthma. It was noted that the child’s sibling had died earlier in the year and that both children had been in the care of their father prior to their death. The concerns around the circumstances of the deaths of the two children were discussed at CDOP which was recalled at the learning event. Given the odd circumstances and absence of any clear medical cause for the children’s deaths there were concerns about possible deliberate harm to the children but these concerns were not regarded to be supported by sufficient evidence to provoke a criminal investigation. Concerns and suspicion were not recorded in the CDOP minutes as it should have been for future information and scrutiny. Both parents were still young and were now childless making it highly likely that there would be future pregnancies for them either together as a couple or individually as part of another couple. Frenulum – is situated inside the mouth. It is a thin tissue connecting the upper lip to the upper gums just above the front teeth. 22 Issues around MCD’s mental health, parental smoking, sleeping arrangements and parental supervision were all well recorded and good practice around bereavement support was acknowledged. There were no recommended actions for the safeguarding of any future children born to the parents as would have been expected. Best practice would have been for the Joint Area Response Team to recommend a multi-agency Pre-Birth Assessment for any future pregnancies to provide a vehicle for sharing information, risk assessment and to safeguard any future children born to the couple. Proposal following learning 9 The CSAP should ensure that where there are suspicious circumstances surrounding a child death, a recommendation should follow from the Joint Area Review strategy meeting, Child Death Review Meeting or Child Death Overview Panel for future pregnancies to ensure effective multi-agency Pre-birth Assessment. This should take place for the couple if they remain together or individually as part of other couples. A lack of feedback from the Child Death processes back to individual organisations record created a gap in information connectivity. However, Child Death Review processes changed in 2018 and Child Death Review Meetings have supplemented other meeting structures such as hospital mortality meetings. They should have multi-agency representation to ensure safeguarding issues are appropriately managed and recorded within individual agencies with action plans being shared with Child Death Overview Panel. Proposal following learning 10 The CSAP should review the effectiveness and consistency of the child death review arrangements across the area of the partnership to promote information sharing and risk management. Whilst the Child Death Overview Panel is expected to maintain anonymity, this can be broken where a safeguarding or medical risk to a living or potential future child or family member is uncovered during the process and action taken to reduce that risk. In conclusion to the SUDC and CDOP arrangements at the time, whilst they were found to be good and continue to be improved, it was not the engagement of these two processes which protected Child E. It was the good fortune that the child attended the same hospital and was seen by the same Paediatricians who remembered the deaths of Child C and Child D, including MI’s involvement with them and the concerns they had at the time. From this, the pattern of FII more clearly emerged and Child E was safeguarded. Children should not need to rely on good fortune in order to be protected. Children need their child death processes to be robustly applied to leave a record trail of relevant information to aid any future risk assessment to protect children. 23 Proposal following learning 11 The CSAP should be assured that those attending CDRMs and CDOP understand their roles and responsibilities and there are quality assurance arrangements in place to monitor effectiveness. 5.5 Criminal Investigation There was no role for a criminal investigation beyond the child death processes (as previously described) identified by the Police until Child E’s second admission to hospital when they were invited to a strategy meeting. Police were fully involved in the child protection investigation and were aware that Children's Social Care were developing a case for the Family Court for a Finding of Fact hearing. There was relevant information sharing by email between Children's Social Care and Police about Child E’s Care Proceedings and the expert reports being prepared for the Finding of Fact court hearing which contained serious concern that MI may have caused harm to all three children. At the conclusion of the Care Proceedings best practice would have been for Children's Social Care to contact the Police directly to discuss the outcome of the court proceedings. The lack of effective communication at the time resulted in the delay of the Police being notified that the Judge had found that MI was culpable of the deliberate harm of the three children and that no-one else was involved in the incidents. The court requested the Police to initiate a criminal investigation which commenced a short time later. At the time the Police were based at a different site to Children's Social Care and communication was less fluid than it is now. Progress The establishment of the new Multi-agency Safeguarding Hub (MASH) arrangements has developed lines of communication between the agencies to ensure effective information sharing. The Police were provided with all the reports obtained within the family proceedings. The Police criminal investigation involved extensive gathering of medical information which included at least 12 medical and pathology expert reports which is to be commended. The magnitude of this investigation cannot be overestimated and much of the information gathering took place during the national COVID lockdown period making access to people and physical evidence more challenging. The final Police file which was presented to the criminal trial had more than 800 pages of medical evidence which had to be fully referenced and crossed referenced. This along with the evidence given by expert witnessess in the court eventually delivered a verdict of murder and attempted murder by the male involved and brought justice to the deceased children and late partner. Another positive aspect to this case was that evidence gathering was enhanced by the level of continuity of police work. The Independent Reviewer is aware that the Senior Police Officer for the case retired during the time but agreed to return to Police service to continue with the case and take it to it's eventual successful end. 24 Proposal following learning 12 The partnership should consider writing to the Police Chief Constable in recognition of the excellent work and outcome outlined in this review. 6. Coercive Control and Domestic Abuse 6.1 Introduction Domestic violence and abuse can be defined as: “Any incident or pattern of incidents of controlling coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members, regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse: psychological, physical, sexual, financial and emotional”. (Gov 2021). NSPCC briefing on learning from serious case reviews (2017) identified issues raised in this review including adults who are in an abusive relationship may not realise they are being abused. As a result, they may underestimate the effects on themselves and their baby, which can have an impact on their ability to keep their child safe. Domestic abuse poses a significant risk to a baby’s wellbeing. Professionals do not always understand the dynamics of domestic abuse and how it affects very young children. There was a deeply toxic undercurrent within the relationships that MI created which was unknown to professionals and MCD at the time. Since, their relationship ended and with counselling undertaken with domestic abuse services, MCD has been able to recognise that she was a victim of coercive control and domestic abuse. It is recognised in the review timeline that professionals appropriately covered Routine Enquiry questions with MCD about her relationship to detect and issues of domestic abuse. On all occasions MCD gave a positive report about the state of her relationship which is what she believed at the time. 6.2 There were two main incidents in the timeline which indicted domestic abuse as follows: The first incident was when Child E was around 5 months old. MI contacted Police to report an alleged serious incident. MI said ME was missing and he was concerned about the state of her mental health. ME was found safe at another address and she denied the allegations made by MI. The incident was recorded as high-risk domestic abuse and referred to the Multi-agency Safeguarding Hub for risk assessment. In view of the uncertainty, an agreement was made for Child E to remain with MI at the home of another adult until Children's Social Care had completed their assessment. The following day ME and another adult attended where MI was staying and was begging to see her baby. A brief altercation took place between ME and another adult at the property and the Police were called to have ME removed from the house. ME was arrested for Assault. One week later Child E was admitted to hospital (as previously discussed) during which time it was ME that the Social Worker viewed as a perpetrator of domestic abuse and not MI who had raised 25 the original concern. It was only just prior to the child’s discharge that MI admitted that he had been lying about his concerns around ME's mental health. The enormity of this deception did not result in a change of plan for the child’s discharge and the new information appeared to be accepted without further risk assessment. This demonstrated the level of manipulation of professionals by MI who was intent on hurting ME by preventing her from caring for her baby when in fact she had done nothing wrong. Professionals should be aware that controlling the actions of those who have a role to support and safeguard through manipulation is a common trait in coercive controlling behaviour. Practitioners assessing and intervening in these circumstances need to have appropriate levels of professional curiosity to explore the full range of explanations and hypotheses regarding the presenting behaviours of both adults concerned. 6.3 MCD’s engagement with domestic abuse services Following the final split of the parents of Child C and Child D, MCD effectively engaged with domestic abuse service practitioners, who were able to help her realise the abusive nature of the relationship and negative impact this had on her self-esteem and confidence. MCD shared with the Independent Reviewer that most of the arguments the couple had were about money and MI’s gambling which was putting the family in debt. It was at these points that MCD would give MI the ultimatum to leave but something always happened to prevent him needing to leave. MCD told the Independent Reviewer at their meeting that when she was with MI, she thought he was “perfect”. “It was only later that I found out he was the perfect guy in disguise”. MCD said that they had a lot of history together and he knew how to support her and calm her down. MCD reflected that she had been young and naive about how relationships should be at the time and following counselling she feels much wiser and would be able to spot the signs of controlling behaviour in any new relationship in the future. The Independent Reviewer asked if MCD had one lesson to share with other women living in a controlling relationship and she said “before he did what he did he was brilliant. When in that relationship it is so hard to see anything wrong with it”. It therefore needs the attention of family, friends and professionals to help women to see what is happening in their relationship and to seek the right advice and support. Proposal following Learning 12 The partnership should consider how the local in-school programme on coercive control and healthy relationships can be expanded and delivered to young people in other educational settings and for those not in education. 7. Impact statement at the trial MCD said that all she ever wanted was to be a mum and to “give my children the opportunities I never had growing up”. 26 She said that “when the children were born, they consumed my world” “I loved them every day I had them”. “He was their daddy; he was one of the two people who was meant to love and protect them the most in the whole world”. “Instead he did the opposite.” 8. Good Practice A number of areas of good practice were recognised during the reviewing process: • There had been good early assessment and good family support services being provided to support Child C. • There was good bereavement support following the deaths of the Child C and Child D. • The actions of the paediatricians who raised concern about FII and concerns for Child E. • The actions of social workers following confirmation of possible FII. • The Police investigation which was extremely challenging had a positive result. 9. Conclusion This case has been called “the complex case of all complex cases” and whilst this case is historical and much of the learning is based on the benefit of hindsight there is learning here for professionals about the nature of and the unthinkable consequences of extreme coercive control in adult relationships and the devastating impact this can have on children. 10. Recommendations 1) The CSAP should review the implementation plan developed in support of the new local arrangements for Perplexing Presentations / Fabricated or Induced Illness in Children and consider the inclusion of the “proposals for learning” identified in this review. 2) The CSAP should request that local paediatricians consider a review of using an assessment tool such as the BRUE model to support their clinical practice and to improve the risk assessment of children attending with brief resolved unexplained events. 3) The CSAP should conduct a partnership wide audit with their Acute Hospital Trusts to review the effectiveness of the arrangements for facilitating strategy discussions/meetings in the hospital setting. The audit should include timescales, attendance by statutory partners and quality of decision making. 4) The CSAP should request the Integrated Care Systems across the partnership to review their Child Death arrangements and provide assurance that the “proposals for learning” identified in this review have been addressed. 5) The CSAP should consider writing to the Police Chief Constable to express recognition of the magnitude of the police investigation outlined in this review. The evidence gathered was enhanced by the level of continuity of police work, particularly by the Senior Police Officer who agreed to return from retirement to continue with the case. 27 6) The CSAP should consider how the local in- school programme on coercive control and healthy relationships can be expanded and delivered to young people in other educational settings and for those not in education. Clinical commissioning groups (CCGs) were created following the Health and Social Care Act in 2012 and replaced primary care trusts on 1 April 2013. They were clinically led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. As of 1 April 2021, following a series of mergers, there were 106 CCGs in England. However, they were dissolved in July 2022 and their duties taken on by the new integrated care systems (ICSs). 28 11. References Sudden unexpected death in infancy and childhood Multi-agency guidelines for care and investigation. The report of a working group convened by The Royal College of Pathologists and endorsed by The Royal College of Paediatrics and Child Health Chair: The Baroness Helena Kennedy QC (2016) https://www.rcpath.org/uploads/assets/874ae50e-c754-4933-995a804e0ef728a4/Sudden-unexpected-death-in-infancy-and-childhood-2e.pdf Child Death Review Statutory and Operational Guidance (England) (2018) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859302/child-death-review-statutory-and-operational-guidance Infants: learning from case reviews: Summary of risk factors and learning for improved practice around working with children aged two and under. (November 2017 https://learning.nspcc.org.uk/media/1343/learning-from-case-reviews_infants.pdf Fabricated or induced illness by carers (FII): a practical guide for paediatricians, Royal College of Paediatrics and Child Health (RCPCH) (Oct 2009). https://www.rcpch.ac.uk/system/files/protected/page/Fabricated%20or%20Induced%20Illn ess%20by%20Carers%20A%20Practical%20Guide%20for%20Paediatricians%202009.pdf Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children – guidance RCPCH (March 2021) https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/?msclkid=b7c58368cee911eca008919853d08857 Brief Resolved Unexplained Event or BRUE (ALTE guideline update) December 2018 – NHS Greater Glasgow and Clyde https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/emergency-Working Together to Safeguard Children (HM Government 2015 & updated 2018) https://www.bing.com/search?q=working+together+to+safeguard+children+2015&qs=HS&pq=working+together+to+safeguard+children+201&sk=HS1&sc=8-42&cvid=FDF5E39011164A21B6DB63BFA7915B25&FORM=QBRE&sp=2 Protecting Children in Wales – Guidance for Arrangements for Multiagency Child Practice Reviews (Welsh Government 2012) https://gweddill.gov.wales/docs/dhss/publications/121221guidanceen.pdf New Learning from serious case reviews: a two-year report for 2009 – 2011. London. DfE. Brandon. M. et. Al. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf The Little Book of Adverse Childhood Experiences. Lancashire University (2018) Siobhan Collingwood, Andy Know, Health Fowler, Sam Harding, Sue Irwin and Sandra Quinney. Editor: Dr Claire Coulton. 29 medicine/brief-resolved-unexplained-event-or-brue-alte-guideline-update/?msclkid=2409d776ceec11eca7962b39acd08380 American Academy of Paediatrics; Brief resolved unexplained events (formerly Apparent life-threatening events) and evaluation of lower risk infants. Paediatrics 2016, 137(5) Infants: learning from case reviews: Summary of risk factors and learning for improved practice around working with children aged two and under (November 2017) https://learning.nspcc.org.uk/media/1343/learning-from-case-reviews_infants.pdf 12. Statement of Reviewer Independence The reviewer, Kathy Webster, is independent of the case and of Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership. Prior to my involvement with this Local Child Safeguarding Practice Review: • I have not been directly concerned with the child or any of the family members or professionals involved with the child, or have I given any professionals advice on this case at any time. • I have no immediate line management of the practitioners involved. • I have appropriate recognised qualifications, knowledge and experience and training to undertake this review. • The review has been conducted appropriately and with rigorous analysis and evaluation of the issues as set out in the Terms of Reference. This report has been produced in good faith and is based on the information provided. Signature: Name: Kathy Webster – Independent Reviewer Date: November 2022 30 13. Appendix 1: Terms of Reference Child Safeguarding Practice Review Introduction This Child Safeguarding Practice Review (CSPR) was commissioned by Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership (CSAP) in accordance with “Improving Child Protection and Safeguarding Practice” Chapter 4 of Working Together to Safeguard Children guidance HM Government 2018. The CSPR will be conducted using a research evidence-based systems approach methodology. A multi-agency Panel established by the local CSAP will conduct the review and report progress to the Board. Membership will include an Independent Lead Reviewer and senior / safeguarding representatives from key agencies who had been involved with the child and family. The tasks specific to the review panel: 1. To set the time frame for the review. 2. Agencies involved with the child and family will provide information of their involvement for the preparation of a composite timeline which will be used to form hypotheses of themes. 3. A case summary should be included to provide any relevant additional background information from significant events outside the timeframe for the review. Information about action already undertaken or recommendations for future improvements in systems or practice may be included if appropriate. 4. The Panel, through the support of CSAP and Independent Reviewer will consider contributions to the review from appropriate family members and provide feedback at the conclusion of the review process. 5. The Panel will take account of any criminal investigations or proceedings related to the case. 6. The Panel with the Lead Reviewer will plan a learning event for practitioners; Identifying attendees, preparing and supporting them prior to the learning event and feedback following the event. 7. The learning event will explore hypotheses, draw out themes, good practice and key learning from the case including any recommendations for the development or improvement to systems or practice. 8. The Panel will receive and consider the draft report/presentation prepared by the Independent Reviewer, to ensure that the terms of reference for the review have been met, initial hypotheses addressed and any additional learning is identified and included in the final report/presentation. 9. The Panel will agree conclusions from the review and an outline action plan and make arrangements with the Independent Reviewer for presentation to the CSAP for consideration and agreement. 31 10. The Panel will plan arrangements for reporting to CSAP and feedback to the family and the practitioners at the learning event. The contents of the final report/presentation will be shared for wider learning. 11. The Chair of the CSAP will be responsible for making all public comments and responses to media interest concerning the review. It is anticipated that there will be no public disclosure of information other than the CSPR report/presentation for publication. The key lines of enquiry for the review: • Examine the effectiveness of the local safeguarding children arrangements for teenage pregnancy including use of CAF/Early Help processes. • Establish the effectiveness of the use “Routine Enquiry” in establishing possible domestic abuse and coercive control. • Examine the effectiveness of information sharing and working relationships between agencies and within agencies. • Establish any learning from the case about the way in which local services and professionals work together to safeguard children across the hospital and community divide. • Explore the way that concerns around Fabricated and Induced Incidence (FII) were addressed and utilised. • Explore the multi-agency response to the death of each child and the support provided to the family at the time. • Explore the effectiveness of the Care of Next Infant (CONI) arrangements in this case. • Explore how follow-on information about the deaths were utilised to manage any risks to future children. • Explore the roles of SUDC processes and CDOP at the time and consider how any learning from the children’s deaths were utilised locally to improve welfare outcomes for future children in the family and other local children. |
NC050346 | Inflicted abdominal trauma to a 6-year-old child, in June 2014 while in the care of mother's partner. Child G lived with their mother, her partner and younger half-sibling, while two maternal half-siblings lived with a family member following a series of safeguarding concerns prior to the birth of Child G. In 2012, mother of Child G allocated a home in Oldham, to assist in moving from an abusive relationship. Over the following ten months, Child G's school made referrals to children's social care, resulting in an initial assessment. In June 2014, Child G presented unwell at school and was taken home. After a serious episode of vomiting, Child G was taken to the GP and then to the regional children's hospital by ambulance. Doctors concluded Child G had been subject to inflicted abdominal trauma, and referred the findings to children's social care. Child G and their half-sibling were placed in foster care. Child G later disclosed that their mother's partner had caused the abdominal injuries in June 2014. Mother's partner charged with assault of Child G and faces criminal trial. Findings include: professionals engaged in multi-agency working must be attuned to non-verbal methods of communication and advocate for a child that is not being heard. Recommendations include: LCSBs must ensure GPs are part of multi-agency safeguarding arrangements; and working directly with men in families must be embedded in professional thinking. Please note that this report was written in July 2016 but was published in February 2018.
| Title: Serious case review report: Child G. LSCB: Oldham Local Safeguarding Children Board Author: Oldham Local Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Report Child G July 2016 This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has: used initials to represent people made no reference to the gender of children avoided where possible the use of exact dates not used any details about local services which could lead to recognition of the children and family 1. Introduction 1.1 This Serious Case Review (SCR) concerns Child G who was 6 years old when a serious physical non-accidental injury was discovered. Child G is the third of four children born child to the mother MG, all of the children have different paternity. Child G has two maternal half siblings who are several years older and live with a close family member following a series of safeguarding concerns prior to the birth of Child G. 1.2 Child G lived with MG and a half sibling S1 who is 13 months younger in age. All four children were born whilst MG lived in a neighbouring Local Authority. None of the children’s fathers had any substantial involvement in the children’s care, but following the birth of the Child G and S1, MG had a partner MP1 who lived with the family for a period of time. The relationship between MG and MP1 was characterised by domestic abuse, and in order to assist MG moved away from an unhealthy relationship, MG was allocated a home in Oldham in 2012. Around this time, MG also met a new partner MP2, and for several months the family moved between his home and their property in Oldham. MG, MP2 and the two children permanently settled in Oldham in January 2013. Child G transferred to an Oldham School aged 4 years and 8 months. 1.3 When MG and MP2 first met, MP2 was full time employed whilst MG was a full time carer to the children. After moving to Oldham, MG began working between the hours of 8am - 2pm and MP2 ceased working and became the primary carer for the children. 1.4 Over the following ten months, the School made a total of three referrals to Children’s Social Care, the third of which resulted in an Initial Assessment and a Parenting Worker allocated for a period of three months. 1.5 Six months later in the summer term of 2014, Child G presented as unwell in School and was taken home by MP2. Concerned by a serious episode of vomiting, Child G was taken to the GP by MG. Child G was then taken directly to the regional children’s hospital by ambulance. The symptoms mimicked appendicitis and Child G was treated with an appendectomy, however, once completed the symptoms did not diminish. A further scan was suggestive of a condition called malrotation and further surgery took place. During the surgery, it was discovered that malrotation was not present but that Child G had severe bruising to the duodenum which was the cause of the vomiting and abdominal pain. Paediatric opinion concluded that the most likely explanation for the medical findings was that Child G has been subject to an inflicted abdominal trauma which on balance of probability, and in the absence of any other explanation, was best explained as an inflicted injury. 1.6 The regional Children’s Hospital referred their findings to Children’s Social Care, but were concerned that the response was not as they expected nor in keeping with Section 47 of the Children Act 1989 and associated multi-agency child protection procedures. 1.7 Once the facts were properly established, as a consequence of the injury to Child G, Child G and S1 were placed in foster care. Child G was six years old and the foster carers reported a number of issues of concern for Child G, this included low weight, speech which was unitary words rather than sentences, a constant need for reassurance and physical affection and a severe lack of confidence which affected the child emotionally and practically. In contrast, it was deduced that S1 was a much favoured child and that as a consequence of different parenting approaches, their sibling relationship was problematic. 1.8 Once in foster care, Child G’s developmental progress improved considerably, the child gained weight, was managing increased self-care tasks and reaching increased educational attainment. The sibling relationship improved with both children having a more equal status. As Child G grew in confidence, the child disclosed that MP2 had caused the abdominal injuries in June 2014. 1.9 MP2 was charged with Assault of Child G under Section 20 Offences against the Person Act 1861. 2. Decision to Hold Serious Case Review 2.1 The Serious Case Review sub group considered the issues relevant to the case and a recommendation was made to initiate a Serious Case Review. The Sub Group was influenced by the following issues: That Child G was a 6 year old child who was diagnosed as in receipt of a serious and potentially life threatening non-accidental injury; That concern existed about how agencies had worked together when the serious incident occurred; That although Child G was not known to Oldham Children’s Services at the time of the incident, previous referrals had been made which indicated prior concerns about physical abuse; MG had extensive contacts with the police, frequently related to incidents of domestic violence involving a series of partners. 2.2 The Chair endorsed this recommendation and a notification was made to the National Panel about the intention to hold a Serious Case Review. 3. Methodology 3.1 Oldham Local Safeguarding Children Board appointed an Independent Reviewer to facilitate the Review and provide an Overview Report. This Review was overseen by a Panel of senior officers from participating agencies which included: Greater Manchester Police Oldham Council Children’s Social Care Pennine Care Foundation Trust Central Manchester Trust Oldham Education Safeguarding Advisor for Schools The OLSCB Business Manager CCG Designated Doctor 3.2 Working Together 2013 requires SCRs to be conducted in a way that: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; This SCR was undertaken in line with statutory guidance. The review focussed on what happened to Child G, but also set out to understand some of the factors that influenced professionals to act as they did or why they may not have acted at all. 3.3 The Review Panel did not set detailed Terms of Reference as they did not want to pre-determine the most significant areas of practice, preferring the key issues to unfold from the analysis of emerging information. The Panel was however keen to explore the following key areas: To what extent were indicators of risk present and adequately responded to by agencies working with Child G; Were multi-agency processes utilised to support agencies to work together to meet Child G’s needs; Did multi-agency services work together to respond to the critical incident in relation to Child G. 3.4 The Review focussed on the multi-agency activity over a period of eighteen months between January 2013 and June 2014. The Review Panel made a considered decision to begin the time period at the point Child G moved to Oldham as it was believed that this would generate the best local learning and provide the opportunity to focus on local multi-agency working. 3.5 At the start of the Review, each agency submitted a timeline of interventions alongside a short report which contained a reflective narrative of the single agency responses to the needs of Child G. The individual agency timelines were combined to illustrate the multi-agency activity, who knew what and when. 3.6 Practitioners were invited to contribute their views directly to the review process by meeting with the Independent Reviewer and a panel member. The following practitioners undertook such a conversation: Children’s Social Care Manager - MASH Team Manager, Social Work Assessment Team Manager, Social Worker 2, Senior Practitioner; Pennine Care Foundation Trust – School Health Advisor, Health Visitor, Safeguarding Advisor; Primary School - Acting Head Teacher, Assistant Head Teacher (designated safeguarding lead); Greater Manchester Police - Detective Sergeant, Public Protection; Central Manchester Trust – Paediatrician. 4. Engagement of Family Members 4.1 The Independent Author was keen to involve both MG and MP2 in the Review. Early into the Review the Panel was advised that MP2 had been charged and was pleading not guilty to a charge of assault of Child G, and that MG would be a key witness at the trial. As such a request was made not to discuss the case in detail with either party until the criminal trial was concluded. 4. 2 A court date is in July 2016 when a date for the trail will be set, this could be in 2017. 5. Parallel Processes 5.1 Child G and S1 have been the subject of public law proceedings. During the proceedings neither MG nor MP2 have accepted responsibility for causing or having knowledge of the injuries to Child G. 5.2 MG and MP2 have been subject to an ongoing police investigation and MP2 now faces a criminal trial. 6. Overview of what was known to Agencies 6.1 MG, MP2, Child G and S1 moved to Oldham on a permanent basis in January 2013. Between 2004 and 2008, MG and her two older children had intermittent involvement with Children’s Social Care in a neighbouring Local Authority and on one occasion, when her second born child was left with an unsuitable babysitter for a lengthy period, Police Powers of Protection were exercised. Ultimately the two older children were made subject of a Residence Order to a family member. Two years before the birth of Child G, records describe MG as having sporadic contact with her two older children because of a chaotic lifestyle. 6.2 Prior to moving to Oldham, there are numerous records of Police being called to instances of domestic abuse between MG, various members of her family and several different partners including the fathers of her children. GMP identified eleven incidents of domestic abuse following the birth of Child G and S1 and found that the children were recorded as being present at three incidents. One incident described that MG was strangled in public in front of Child G at the age of four years. No referrals were made by the Police to other agencies on the three occasions the children were known to be present. There are also a number of occasions when MG reported harassment but did not attend follow up appointments; similarly, referrals in respect of these incidents were not made to Children’s Social Care. MG was subject to ongoing harassment by MP1 after the relationship ended. 6.3 Prior to Child G’s birth in a neighbouring Local Authority a referral was made by health services to Children’s Social Care which expressed concern that MG was drinking throughout the pregnancy. An Initial Assessment was undertaken in the knowledge that MG had two children living away from her care and a decision was made for No Further Action. Child G was born with no additional involvement from specialist safeguarding agencies other than what would be usual for universal services. S1 was born very premature just thirteen months after Child G. 6.4 The first contact with Child G in Oldham was a movement-in visit by the Health Visitor who ascertained that the family had moved to the area because of fleeing domestic abuse and that that MG had formed a new relationship. Child G was 4 years and 7 months and was referred for speech and language therapy, audiology and the children’s outreach team because of concerns about the child’s development. Child G commenced School at around the same time. 6.5 In the following two months, the Health Visitor experienced four no access visits to pre-arranged home visits and the nursery placement that she had organised for S1 was not taken up. The School Nurse followed up on Child G’s health history and found that Child G has been previously referred for speech and language therapy but that MG had not engaged with Child G’s previous school. The school’s Special Educational Needs Co-ordinator (SENCO) expressed concern about Child G’s presentation in school. This included appearance, punctuality and behaviour which included a tendency to bark like a dog. 6.6 Child G had a health assessment completed by the School Nurse in school. MG returned a health questionnaire which had been sent to her by the School Nurse which stated that Child G was naughty at home. The School Nurse noted that Child G was lively and chatty, but that speech and language was poor. A further referral was made for an orthoptist and audiology appointment as well as for a Special Educational Needs Medical Assessment. After some failed attempts to speak with MG by telephone, the School Nurse sent a text requesting a conversation with MG which was responded to. The School Nurse advised of the appointments and urged MG to make an appointment with the School to discuss any worries she may have about Child G’s behaviour. 6.7 The following month (April 2013), Child G attended a Paediatric Audiology Clinic for a hearing assessment, the results were satisfactory and no follow up was needed. 6.8 In May of 2013, the MG’s previous partner MP1 was given a suspended prison sentence and a five year Restraining Order in respect of offences towards MG. 6.9 Six months after moving to Oldham, Child G was registered with a GP. GP records note that the School Nurse was following up concerns about learning difficulties and speech and was aware that MG had no red child health book and therefore the child may need vaccinations. 6.10 In June, an anonymous call was made to the police reporting that MG had slapped [Child G] so hard it made the child spin round and fall down three concrete steps. The police spoke with MG and Child G and believed this to be a malicious call which related to MP1. MG stated she had also been receiving unwanted pizza and taxis to her address. 6.11 During the School summer holiday, Child G was seen with MG by the Community Paediatrician and a variety of tests were undertaken. A request was made for the SENCO to refer to an Educational Psychologist to begin the process of Education Statementing. Child G was assessed as needing Speech and Language therapy and placed on a waiting list for the service. 6.12 One month into the School term, Child G was noted to have a black eye, an older bruise to the side of the face and a mark under the chin. Child G said to a Teaching Assistant that [Child G] ‘felt angry when my Dad hits me’ and that this had happened the previous night. This information was referred to Children’s Social Care. MG stated that the bruising had been caused by S1 hitting Child G. Children’s Social Care advised the School to commence a CAF assessment with a view to identifying possible parenting issues. 6.13 Eight days later, a second referral was made by the School to Children’s Social Care when Child G was noted to have two faded marks to the neck which it was thought resembled grab marks. At the same time, S1 was observed to have a plaster of paris to the leg. Child G had stated that the marks were from having fallen down a staircase the previous day. The School also reported that the Child G was showing some odd behaviour such as hiding under tables. An Initial Assessment was undertaken by Children’s Social Care, and both Child G and S1 were spoken to, Child G indicated that the marks had been caused by a child in School and the social worker considered that the marks did not appear to have suspicious causation. The Initial Assessment noted that Child G had speech, language and cognitive developmental delay which results in frustration and lashing out and that MG requested support with parenting skills. The assessment concluded that sufficient explanation had been given to account for the bruising and that observations of interaction between MG and the children was positive. A plan was formulated to allocate a Family Support Worker for a short term piece of work. The Family Worker made four visits to the home to discuss routines and behaviour management before closing the case to Children’s Social Care. The work of the Family Support Worker occurred without the case management of a Social Worker and without using a multi-agency Child In Need approach. The School subsequently sought support from the CAF team but was advised that due to the volume of Family CAF Assessments being undertaken that they are unable to support the process. 6.14 Two weeks prior to Christmas 2013, Child G was taken by MG to accident and emergency at the local hospital because the child was vomiting with streaks of blood. Child G was discharged for GP follow up and the letter from Accident and Emergency to the GP stated that Child G was generally unwell and contained the following comment – ‘GP please do some routine bloods on this patient as presents with multiple bruises’. Following this there are no records of bloods having been taken; the request was considered to be unusual as bloods are not taken from children under 8 years in the GP surgery. One week later, after getting no response to phone calls, a letter was sent to MG requesting that she contact surgery for follow up regarding Child G’s recent attendance at A&E. There is no indication that MG’s failure to respond was further followed up, that Child G was referred for blood tests, or that that any clarification was sought about the presence of bruising. 6.15 In the first month of the New Year, S1 was taken to Accident and Emergency with a cut to the face which was said to have happened by falling on the radiator, and Child G was taken to an emergency GP appointment because of a further episode of vomiting and abdominal pain. The GP diagnosed viral gastroenteritis and MG was advised to return if the symptoms did not resolve within two days. 6.16 In February the Police were contacted by a neighbour of the family who reported hearing shouting and children crying inside the address, with a male shouting ‘get off them and get out of my face.’ When the police attended MG refused to give her name or that of the children, and stated that the neighbour was causing her problems. The incident was closed, deemed to be malicious and recorded as a verbal augment, with no further actions. This information was not shared outside of the Police. 6.17 In March, Child G was again taken to Accident and Emergency with a temperature and sickness and was discharged with minor medications. Child G was seen for a second time by the Community Paediatrician for medical follow-up and review associated with the education statementing processes. 6.18 In May, there was evidence that MP1 had breached a Restraining Order by contacting MG over a social networking site. That same month, it was noted that MG arrived at School with a black eye. 6.19 A CAF meeting took place in School with the School Nurse, MG attended. MG stated that she was struggling with Child G’s behaviour and wanted support. MG agreed that a referral should be made to a Consultant Paediatrician with an accompanying report from the School. The School Nurse followed up the speech and language appointments and it was confirmed that Child G was due to be seen in 6-8 weeks. 6.20 In the month leading up to the serious incident, Child G was noted to have a bruise to the cheek on two separate occasions, and that the School had put in place that a Parent Support Worker who would visit the family home to meet with MG. 6.21 On the day that the serious injury came to light, Child G and S1 were brought to School by MP2 approximately one hour late. Child G began to complain of stomach ache and appeared in discomfort before vomiting. School staff noted the vomit to be a particularly concerning colour. The School contacted MG and MP2 collected Child G from school. It was later that afternoon when MG took Child G to the GP surgery from where the child was transferred and admitted to the Regional Children’s Hospital. 6.22 Four days after Child G’s admittance to hospital and after a second episode of surgery whereby the internal bruising was unexpectedly discovered, the Consultant Paediatrician requested that the ward staff make a referral to Children’s Social Care. The referral explained that Child G had been admitted to hospital and had to have bowel surgery as a response to acute abdominal pain and that a Strategy Meeting was required. The hospital was concerned by the response from Children’s Social Care who determined that a Strategy Meeting was not necessary. The Consultant Paediatrician enlisted the support of the Designated Nurse for Safeguarding within the Hospital Trust who in turn contacted the Named Nurse in Oldham. The Paediatrician sent a second more detailed referral outlining the nature and potential causes of such injuries. The Named Nurse in Oldham escalated the concern about the response to Children’s Social Care, and a telephone conversation took place between the Social Worker in the MASH team and the Consultant Paediatrician. The Consultant was told that Children’s Social Care did not consider a Strategy meeting was necessary at this stage because no disclosure had been made by Child G and therefore other explanations, such as the first surgery could be viable. 6.23 It is specifically recorded in Children’s Social Care records that the manager of the MASH Team made a decision that a Strategy meeting would not be convened but that a Social Worker and Police Officer would attend the hospital to ‘gather more information’. In the event three officers attended the Hospital, a Police Sergeant, a Social Worker and the Family Support Worker that had been previously known to the family. 6.24 The Paediatrician recalled that a discussion took place in a corridor seating area about her findings and that she impressed upon the officers the need for a Strategy Meeting. Although a decision was made not to convene a Strategy Meeting, the discussion was recorded by Children’s Social Care on a proforma recording template used for the recording of Strategy Meetings which the Paediatrician indicated she was not aware of and had never received a copy. The Detective Sergeant’s view was that a discussion took place but not a Strategy Meeting. This document recorded the seriousness of the injury, the fact that there was no explanation and therefore it was most likely non-accidental and that further investigation and Strategy Meeting was required. 6.25 Whist in attendance at the hospital, the Detective Sergeant consulted with a Detective Inspector and Police Powers of Protection were invoked for both children. Child G remained in hospital whilst S1 was placed in foster care. Three days later both children were made subject of an Interim Care Order and on this date restrictions to parental unsupervised contact were applied. 6.26 A Strategy Meeting took place four days after the Police and Social Worker had attended at the hospital, the record of this meeting states that it was a second Strategy Meeting. The meeting was attended by the Social Worker, two Police Officers, the School, the School Health Advisor and Paediatrician. During this meeting, the Consultant Paediatrician raised concerns that child protection procedures were not adhered to following the referral to the MASH and that restrictions to parental contact should have been applied at an earlier point. 7. Analysis The examination of multi-agency working in respect of Child G has identified several inter-agency issues that need to be addressed alongside significant reflections about how judgements were applied at key points of interventions. The analysis is structured around the particular questions set by the Review Panel and incorporates the key issues that have come to light throughout the Review. The analysis is drawn from the agency’s written contributions to the Review, the reflections of practitioners, the discussion that occurred within the Review Panel as well as the Reviewers own contributions. 7.1 To what extent were indicators of risk present and adequately responded to by agencies working with Child G 7.1.1 Child G was the subject of a number of referrals to Children’s Social Care which commenced before birth, both prior to and when living in Oldham. In the eighteen month period that Child G was permanently resident in Oldham, three referrals are made to Children’s Social Care, two by School and one by a Paediatrician all of which followed observation of physical injuries. In addition, two referrals were made to the Police by members of the public, neither of which was shared across agencies beyond the Police Force. When Child G commenced School, teaching staff quickly identified concerns about the impact of a speech and language delay, impairment of cognitive functioning and some unusual behaviour such as hiding under tables and barking like a dog. Child G was a child high on the radar of the School and they were concerned about Child G long before they considered they had evidential reason to make a referral to Children’s Social Care. 7.1.2 There was good liaison between community health professionals, the Health Visitor had been alerted that the family had moved into the area by their previous Health Visitor and ensured an early contact was made to assist the family to access relevant health and support services. The Health Visitor alerted the School Nurse of Child G’s family history and heath needs and the School Nurse followed up on the health issues as soon as Child G began School in Oldham. The School Nurse enlisted additional support by referring Child G for speech and language therapy and by commencing the process of paediatric assessment for a Statement of Special Educational Needs. Aware that MG had not previously attended Speech and Language therapy with Child G, the School Nurse worked hard to engage MG to access appointments, which was generally a positive strategy. 7.1.3 The Health Visitor and School Nurse were aware that MG had moved to the area because of fleeing domestic abuse in the previous locality, and although diligently following up health issues for Child G, a wider safeguarding perspective would have provided a greater focus on MG’s judgement and vulnerability in terms of relationships and the impact this could have on the safety of herself and her children. MG had a well-documented history in successive relationships of being both a victim and perpetrator of domestic abuse, and her ability to make safe choices was undoubtedly compromised by her life experiences and the impact many years of abuse had on her expectations of a relationship. The relationship with MP2 quickly became a co-habiting relationship, and shortly after MP2 took over care of the children and the home whilst MG became employed. The agency records do not signify that professionals at that time were attuned to the risk of recurrent domestic abuse and possibly they were overly re-assured by the presence of a new partner when risk was perceived to be from the previous partner. 7.1.4 Child G did not come to the attention of any other safeguarding agencies until the summer of 2013 when an anonymous call was made to the Police which stated that that MG had slapped Child G and thrown the child into a taxi. Police Officers spoke with MG and saw Child G and accepted MG’s testimony that the call was likely to be malicious and probably related to her reported ongoing harassment by MP1. Clearly this was a judgement applied by the Police Officers responding at the time, however, the information gave quite a precise description of how and when this incident took place, and no further enquiries took place either with other safeguarding agencies or by way of investigation such as the local taxi firms. No referral was made to other agencies and this limited the potential for professionals around Child G to, at a minimum, be additionally alert to signs of physical or emotional distress. In essence, the Police relied solely on the self-reported information of MG which determined whether information sharing was appropriate. This episode was dealt with by a non-specialist officer and no coding was applied for the matter to reviewed by the Police Vulnerable Persons Unit. 7.1.5 At this time, and particularly following the summer holidays, both Child G and S1 remained high on the radar of concern by the School who were becoming increasingly concerned that Child G was frequently presenting at School with bruises and injuries that had a ‘plausible’ explanation by MG. When Child G presented at School with a black eye and an old bruise to the side of the face, and stated to a Teaching Assistant that [Child G] “felt angry when my dad hits me”, and that this had happened the previous night, a referral was made to Children’s Social Care. 7.1.6 Without a doubt this referral should have resulted in a Section 47 investigation and a Strategy Meeting should have been convened. The fact that the child had an injury and had made a direct allegation about being hit by a parental figure should also have also alerted professionals to the need for a medical consultation. Child G could have had injuries not visible when clothed or noticeable to an untrained eye. At the time of this referral a newly formed Multi-Agency Safeguarding Hub (MASH) had just become operational, with representatives of Police and Children’s Social Care co-located in a first response service. There is no information to suggest that this referral was discussed with the police, but this may well have occurred without being formally recorded. The failure to invoke safeguarding procedures is a flawed judgement and although feeling powerless but to accept the advice, it was clear that the School did not agree with the response when asked by Children’s Social Care to explore the information further with the child. This advice compromised safeguarding procedures in a number of ways. The lack of a Strategy Meeting meant that information known to different agencies was not shared effectively, no joint police investigation occurred and had the child made further disclosures this could have been declared criminally inadmissible without an interview conducted under achieving best evidence conditions. The response to this referral was misguided by Children’s Social Care, and, although dis-satisfied by the response no effective challenge was pursued by the School. 7.1.6 The School did make a second referral eight days later when Child G presented with another old bruise and marks to the face which they considered had the appearance of grab marks. Child G told a teacher that the marks had been caused by a child in the classroom. This referral also referenced the School’s concerns about Child G’s behaviour, and stated that the child was acting strangely in school, refusing to follow normal class routines, hiding under a table, not wanting to talk to familiar adults and refusing to go for dinner. This referral presented an opportunity to review the response one week earlier and address the flawed response. For the second time, Children’s Social Care did not initiate a Section 47 investigation but did commence a single agency Initial Assessment. The Initial Assessment focussed almost exclusively on MG’s response that she was struggling to manage behavioural challenges by Child G, and disregarded completely the testimony of Child G that the child was hit by Dad. MP2 was not spoken to as part of the Initial Assessment and this was a significant error given what had been said by Child G and the fact that MP2 provided much of the children’s day to day care. The Initial Assessment permitted MG to direct the course of action when her testimony that Child G was frustrated and lashed out because of speech difficulties was accepted without really considering this information against what was observed by the school. The observations by the School suggested a distressed and troubled child. 7.1.7 The tendency to overlook the role that men play in families is well documented in many multi agency reviews, and has been previously identified in an Oldham Serious Case Review Child A. The NSPCC’s analysis of Serious Case Reviews around thematic issues from analysis of Serious Case Reviews found that two categories of hidden men emerged, men who posed a risk to a child which resulted in significant harm and men who were capable of protecting and nurturing the child but were overlooked by professionals. In this instance, it may be that because MG had sole parental responsibility for Child G MP2 was not considered as significant and this became a reason not to involve him, it could equally be however that MG was guarded and deliberately misleading in her response to the issues of concern in an attempt to deter professionals from examining deeper the questions raised by Child G’s statement about MP2. Whatever the reason for this, the social work intervention should have been sufficiently alert to the dangers of not involving males in assessments, in particular the risks from men involved with children’s mother who don’t have paternity and the impact this can have on understanding or misunderstanding the family dynamics, and ultimately the ability to achieve safety for the child. Men in families need to be seen as critical to assessments whether or not they have parental responsibility and this needs to become institutionalised in services. It is hard to appreciate at this distance from practice why Child G’s statement about MP2 did not alert professionals to the significance of his presence in the child’s life. This concurs with the Ofsted report, The Voice of the Child: Learning the Lessons from Serious Case Reviews (2011) which concludes that there have been many cases where professionals have evidence from the child’s perspective, but do not listen to what the child has told or interpret the evidence in a way that safeguards the child. Practitioners are starkly reminded in this report to ensure actions take account of children’s views and to recognise behaviour as a means of communication. This was a significant omission, as it took a very serious injury and several months in a safe and secure foster placement before Child G found a voice to talk about MP2’s behaviour towards the child. 7.1.8 Given that the Initial Assessment concluded that further work was necessary by the Family Support Team from Children’s Social Care, this would suggest that the conclusion should have resulted in a further period of assessment which would include a Core Assessment and an analysis of the extent to which the Family Support work was considered to address the needs of Child G and the family. The decision to arrange four sessions of family support work was a plan with no value, without any case management review of its effectiveness or indeed any deeper analysis of the family functioning or parental need for change, the impact and outcome of this work was meaningless. A robust Core Assessment at this time which effectively consulted with partner agencies would have exposed a number of significant risk factors: MG’s history of domestic abuse and ability to make safe relationships with limited recognition of the impact upon her children; That MG had been unable to protect her older children from significant harm; That MP2 had joined the family in a cohabiting relationship with MG whilst she was highly vulnerable; That MG had a history of poor engagement with child led services; That Child G exhibited behaviours at School suggestive of distressed child and was articulating fear of MP2. The absence of a Lead Professional and the precipitous closure by Children’s Social Care meant that there was no mechanism in place whereby information was shared on a continuing basis. This was particularly significant two months later when Child G presented at A & E with gastric pain, and once again safeguarding procedures were not invoked despite medical concern that Child G had unexplained bruising. 7.1.9 Child G’s presentation at the local hospital in December 2013 was precipitated by symptoms similar to those presented when the internal bruising was discovered in 2014. The absence of any specific explanation or diagnosed condition, along with the hospital identifying that Child G had ‘multiple bruises’ begs the question as to whether undetected injuries could have been present at this time. Hospital records offer no other information about the ‘multiple bruises’ and no explanation as to why this finding was not further investigated or referred through child protection procedures by the hospital. The hospital made no welfare checks or referrals to any other agencies, and had this occurred then the information known to Children’s Social Care two months earlier could have been factored into further analysis and judgement, this should have added weight to the need for a Strategy Meeting which in turn would have revealed the anonymous allegation to the Police. Between October and November 2013 there were three points of lost opportunity to bring together information known across three core safeguarding agencies which, if carefully analysed, would have raised greater questions about Child G and the child’s experience of family life. The common denominator across all agencies was a lower level response than was indicated, and this raises concerns about the application of thresholds across the multi-agency partnership. When the School attempted to initiate a CAF with the support of the CAF team they were unable to achieve this but continued to pursue this process but with a sense of frustration that they were not achieving any true engagement from MG. 7.1.10 The first referral to Children’s Social Care by the Paediatrician when Child G was substantially injured outlined that Child G was in the regional specialist hospital under the care of an experienced Paediatrician. The referral to Children’s Social Care was made by Child G’s ward staff on 23.6.2014 at 10.30am and the response was escalated to the Paediatrician later that afternoon. The Paediatrician spoke with a Duty Social Worker in the MASH Team who she recalled was being advised by the manager whilst on the telephone. The Paediatrician asked for a Strategy Meeting to take place to commence a joint investigation under Section 47 Children Act 1989. Records from the hospital and within Children’s Social Care both indicate that the decision by Children’s Social Care was to refuse a Strategy Meeting because Child G had not made an allegation. Frustrated and somewhat alarmed by this response, the Paediatrician reflected on why Children’s Social Care would make such a decision and decided to send a second referral written on a multi-agency referral form to ensure clarity; this was sent by e-mail to Oldham Children’s Social Care at 9am on 24.6.2014. The referral stated that Child G had severe unexplained bruising of the bowel that required bypass surgery, and that with no history of trauma and no medical explanation, and given that such an injury is typically caused by blunt force trauma, there is a concern that a history of inflicted injury is being withheld. The referral went on to state that no disclosure had been made by Child G who had speech difficulties and was very distressed. The Paediatrician had enlisted the support of the Named Nurse in Oldham who had established through the School Nurse that there was no history of trauma whilst at school. The multi-agency response to this critical incident is considered in 6.3. 6.2 Were multi-agency processes utilised by agencies to work together to meet Child G’s needs 6.2.1 The LSCB in Oldham has in place comprehensive policies and procedures to support multi-agency working through a continuum of response to need; this includes the Common Assessment Framework (CAF), Child in Need and Child Protection procedures. Implemented effectively, they support and guide strong multi-agency partnerships around the child. Multi-agency working relies on sharing of key information across agencies, robust assessment and analysis of risk with targeted planning and review of progress towards the objectives set out in a child’s plan. 6.2.2 There is evidence of good information sharing between health professionals and between health and education, particularly in relation to pursuing a Statement of Special Educational Needs. There were however three points of missed opportunity to share information that could have benefitted Child G, namely the two referrals to the Police and the concern expressed by the Hospital that Child G had bruising that required further exploration. This request to the GP to follow up with blood testing also became lost to follow up when MG failed to respond to contacts. 6.2.3 The opportunity for agencies to work more effectively together was primarily lost through some key decisions taken in Children’s Social Care, these being the failure to identify the referrals from the School as Section 47 investigations and the closure of the case despite identifying further work with the family was necessary. A further significant lost opportunity was the approach taken by the Hospital following the presentation at the Accident and Emergency Department when concerns and questions about bruising were only further raised with the GP. The concerns of the School did not diminish, but they were frustrated in their subsequent efforts to achieve an effective multi-agency approach through CAF because of the lack of parental commitment to the process. Establishments such as schools can feel more isolated in pursuing concerns about a child once a determination is made there is no role for increased intervention or conversely can be falsely re-assured that their concerns are unfounded. In this case the School did continue to try to achieve a meaningful multi-agency plan but could not access the support of the CAF team to achieve this. This case reminds professionals around children not to accept a position of hopelessness, if a CAF is necessary and parental engagement cannot be achieved then this an indicator that heightens the need for a statutory intervention rather than diminish the likelihood of achieving what is needed for the child. In such circumstances, professionals close to the child must advocate for that child and use challenge and escalation procedures to a point of resolution. 6.2.4 From November on 2013, the MASH received all referrals for Social Care Services for children, this replaced a previous system whereby referrals were addressed as part of a duty social work arrangement. The purpose of setting up the MASH was to streamline the routes of referrals and notifications of concern to the council, and to create an environment within which safeguarding partners could share information in a dynamic way to support efficient identification of risk, quick decision making and, timely and proportionate interventions. Establishing the service brought together a range of agencies that had safeguarding responsibilities to support children and families through the whole continuum of need. 6.2.5 Examining the response to the three referrals made to Children’s Social Care suggests either a lack of defined thresholds to support decision making or an error of judgement in applying the criteria. Oldham has, and did have at that time, clear definitions of thresholds and each of the referrals met the threshold for invoking Section 47 investigations. This does therefore raise questions about the judgement in applying thresholds and it is of particular concern that this case shows a pattern over a nine month period. 6.2.6 The Department for Education commissioned a research project which reported in 2014, Clinical Judgement and Decision-Making on Children’s Social Work: An analysis of the Front Door System. The specific question that was set for the project team was ‘what behavioural factors affect social workers decisions and the front door and how can we improve the front door process to help social workers make better decisions’. The analysis concluded that there are four key behavioural factors that complicate or reduce the efficiency of social workers ability to make complex and analytical decisions. These being: time and work load pressures increasing reliance on intuition to make decisions, a range of behavioural biases that compromise objective judgements, including inaccurate probability judgements, confirmation bias and a tendency to judge cases on their relative rather than objective merits, that many sequential decisions have to be made in the course of a day which engenders ‘decision fatigue’, that information supplied to social workers is often low quality meaning that significant energy is expended piecing together a full picture leaving less time for analysis. 6.2.7 It is vital that multi-agency professionals, particularly those with the responsibility of making constant judgements are aware of the common pitfalls that affect the quality of decision making, and that safety mechanisms around professionals, such as supervision, inter-agency challenge and feedback offer opportunities for learning and continued development of safer practice. 6.2.8 In this case multi-agency processes were not used to best effect, the precipitous closure by Children’s Social Care without any other multi-agency plan in place limited the initiation of systems around a child that facilitate and promote information sharing across agencies. For example, although speculative, potentially, had Child G’s voice been heard in a Section 47 investigation, the child may have been subject to a Plan known to the GP which would have highlighted a third significant concern about bruising to Child G in a three month period. 6.3 Did multi-agency services work together to respond to the critical incident in relation to Child G 6.3.1 The repose to the critical injury to Child G is the precipitating reason for this review and it clearly raises a number of concerns about the implementation of Section 47 procedures, the confidence and trust between professionals of different disciplines, and the effectiveness of challenge within the safeguarding arrangements. 6.3.2 Child G was admitted to a regional children’s hospital as a medical emergency in acute pain. Initially the symptoms were believed to have a medical causation but through a process of elimination and exploratory surgery a very serious injury was detected that had no reasonable explanation. The seriousness of the injury was likened to the impact of a car crash and one that could only have been caused by a blunt impact trauma. The Hospital is a regional children’s hospital, the Paediatrician is therefore highly specialist and experienced in matters of child protection. The Paediatrician and ward staff identified the need to make a referral to Children’s Social Care and fully expected that standard processes to commence a Section 47 investigation would be initiated. 6.3.3 The Paediatrician advised that she tried to speak directly with the MASH manager and/or Police Officer but her telephone calls were not returned. Concerned by the response, the Paediatrician tried to understand why a Section 47 investigation had not been initiated and decided to make a second referral with additional detail in case this had not been made clear enough. Upon receiving the second referral which clearly outlined the severity of the injury, the absence of reasonable explanation and Child G’s distress, the MASH Team Manager, advised that she did not accept that the threshold was met for Section 47 investigation, but did agree to arrange for a social worker from the CAT Team and a police officer from PPIU to attend the Hospital to gather further information. The MASH Team Manager did not contact the Paediatrician to seek any further clarification prior to reaching this judgement. The attending Police Officer recalled that upon arriving at the hospital it was clear that the Paediatrician was unhappy that a Strategy Meeting had not been convened, the Police Officer and the Social Worker advised that they had not been well briefed prior to attending the hospital and had not been aware of the position of the Paediatrician until they spoke with her. The Paediatrician recalled that the attending officers seemed uninformed and somewhat flustered by her position, however, once she had given them the same information that she had already referred to Children’s Social Care, she was assured that they did appreciate the seriousness of the issues and endeavoured to invoke procedures to protect each child. The attending officers agreed that both Child G and S1 were at risk of significant harm given the extent of the injury, and the strong likelihood that it was non-accidental, and agreed that S1 needed the protection of being removed from parental care at least until additional facts could be established as to how the injury was caused to Child G. Both the Police Officer and Social Worker consulted with and advised their respective senior officers of what was needed, and it was agreed that the police would exercise Police Powers of Protection for both Child G and S1. With the same information that had been available the previous day, the Police Officer and Social Worker both identified a very serious risk and a need to invoke a multi-agency strategy meeting when the MASH Social Worker and Manager had not. 6.3.4 The MASH Team Manager told the Lead Reviewer that there were two reasons why she did not agree that a Section 47 threshold was met and a Strategy Meeting was not convened to manage the process. The first reason was that it had not been ruled out that the injury could have been caused by the recent surgery, and the second reason was that Child G had made no disclosure and therefore no direct allegation had been made. These reasons disregard several very important factors, firstly, that the Paediatrician making the referral had expert medical knowledge and was satisfied that this was not an injury caused by surgery, and secondly, that Child G was a child who was in great distress, had speech and language difficulties and in common with many children in such circumstances was too fearful or traumatised to talk about what had occurred. A disclosure from a child is not a qualifying determination for a Section 47 investigation and this expectation demonstrated a very poor understanding of the child’s world at that time. Through discussion with senior officers from Children’s Social Care, the agency has accepted that this was a flawed decision with a poorly analysed rationale. No other explanation as to why Children’s Social Care took such a rigid position on the matter of convening a Section 47 investigation has been offered which leaves a significant concern about the applications of thresholds, the recognition of risk and the avoidance of a multi-agency approach to planning in critical circumstances. 6.3.5 Despite clear recording and recall that a Strategy Meeting would not be convened, there is a record completed by Children’s Social Care of the discussion that took place at the hospital with the Police Officer and Paediatrician on a recording format for a Strategy Meeting. Furthermore, when the first Strategy Meeting did take place six days later, it was recorded as a second Strategy Meeting. Both the Police Officer and Paediatrician indicated that they had not been aware that their discussion had been recorded as a Strategy Meeting and that they had received no copy of this recording. The Social Worker advised that this was completed in this way to reflect that it was a multi-agency discussion, this was however a misleading record which at worst could be seen as an attempt to backtrack on the earlier decision not to hold a Strategy Meeting and misrepresent the decision making process. 6.3.6 A further consequence of the instinctive rather than planned response through a multi-agency Strategy Meeting with clearer focus on risk is that for three days after Police Powers of Protection were exercised, Child G remained on the hospital ward with unsupervised parental visits. The Social Worker allocated to the case advised that this was occurred because the Department had no legal basis on which to put controls into contact arrangements. This response rests on the belief that the Local Authority needed to acquire Parental Responsibility through and an Interim Care Order to be able to protect a child. If it is believed that a child needs protection, then it must follow that the Local Authority must use the range of powers and applications under the Children Act to achieve this, in these circumstances, an application for an Emergency Protection Order could have been considered. That said, the exercising of Police Powers of Protection under Section 46 Children Act 1989 does allow the ‘designated officer’ to do what is ‘reasonable in all the circumstances of the case for the purpose of safeguarding or promoting the child’s welfare’. In addition Section 46(10) states the designated officer shall allow the child’s parent or anyone living with the child but does not have parental responsibility ‘to have such contact (if any) with the child as, in the opinion of the designated officer, is both reasonable and in the child’s best interests’. It is simply incongruous to believe powers of protection do not allow for the child to be protected. An alternative explanation is that there was an assumption that the hospital and ward staff would take sole responsibility for managing contact between Child G and MG and MP2. 6.3.7 In the three days of unsupervised contact, MG and MP2 could have said anything to Child G designed to maintain the child’s silence or fear or indeed coached the child to adopt an untrue explanation. Child G was described as highly traumatised and extremely poorly, the absence of considering his needs for protection beyond simply being in a hospital ward were overlooked and the placed the child in further danger and emotional distress. Only many months later, through feeling safe in foster care was Child G able to talk about what had happened. 6.3.8 At this distance from the incident, and without an understandable explanation from relevant practitioners, it is difficult to appreciate why the clear application of threshold to initiate a Section 47 investigation was not only not applied, but refused in the face of a clear medical opinion about the likelihood that a non-accidental physical injury was the only remaining explanation for the injuries to Child G. Whilst trying to elicit an understandable reason would be purely speculative, there was undoubtedly a lack of trust and respect for the medical expertise and this represents a petulant position by Children’s Social Care. The Paediatrician commented that she wished she had mounted a greater challenge, particularly in relation to parental contact, but on reflection may have been so relieved that the issues were being responded to that her guard on the wider safeguarding needs was dropped. 7. Learning Outcomes Whilst endeavouring to maintain a multi-agency focus to the review, given the identified limitations in practice, inevitably much of the learning focuses on Children’s Social Care and the implementation of threshold criteria. It is important to be aware however, that multi-agency working is about enhancing safety though greater collaboration and challenge and with this in mind, the limitations exposed in one agency impact of the whole potential for successful outcomes. 7.1 Professionals engaged in multi-agency working must remain highly attuned to the voice of the child, be attuned to non-verbal methods of communication and advocate on behalf of a child that is not being heard. This Review has revealed that Child G was unheard as a child in need of protection. This is particularly evident by the poor response to Child G indicating, ‘I don’t like it when Dad hits me’ and by an insufficiently questioning approach to the reasons for aspects of the child’s behaviour perceived to be ‘odd’. Ensuring the presence and prominence of the Voice of the Child is integral to the work of Local Safeguarding Children Boards, yet there are clear patterns across multi-agency reviews nationally this is an issue on which multi-agency work and partners fall short. The Safeguarding Board does need to be satisfied that professionals invest time getting to know children with whom they are working and have the skills and confidence to work with children to develop their plans for safety. Recommendation 1 That the Board undertake a thematic audit which involved practitioners directly in addressing the Voice of the Child to establish how well this is embedded in multi-agency working, share examples of good practice and address the barriers to achieving this. 7.2 There is a need to be satisfied that Children’s Social Care have, and are, consistently and appropriately implementing threshold criteria in relation to their Section 47 duty to investigate. This Review raises serious questions about the application of thresholds in relation to Section 47. In relation to Child G, this was twice misjudged by Children’s Social Care over a ten month period. Arguably, had a robust investigation been undertaken when the School first referred bruising and an allegation to Children’s Social Care, this could have changed the critical pathway of events for Child G who went on to experience at least one, and possibly more episodes of significant harm. The high threshold of Section 47 initiation could suggest that one of the unintended consequences of the MASH arrangements were that Children’s Social Care took on a police culture, working to the criminal threshold of beyond reasonable doubt as opposed to the more relevant questions of likelihood and probability. The findings of this Review in this respect concur with a number of case reviews which suggests that this is a wider issue of practice. The Independent Reviewer has discussed this matter and carefully considered the evidence with the Director of Children’s Services. In accepting the findings of this report, and concerned about the need to establish whether the findings are indicative of systemic or individual influences, the Director of Children’s Services has committed to a review the application of the threshold by the MASH Team during a relevant period to be agreed by audit and sampling, as well as to review the understanding and application of the thresholds by key staff. Recommendation 2 The Board should be provided with the evidence by Children’s Social Care of the appropriateness of recent application of threshold criteria in relation to Section 47, that any barriers to compliance are addressed and an assurance that current application is sound. 7.3 Children who are at risk of harm need the structure of a multi-agency plan, shared with the Child’s General Practitioner, to promote information sharing and collaborative assessment methods that use past family history, findings from research and current assessment to support analysis of risk. Although Child G was not subject to a multi-agency plan when the hospital shared with the GP that blood tests were necessary because of the presence of bruising, arguably the child should have been and may well have been if the Section 47 threshold had been applied robustly and the child’s voice had been heard. This review demonstrates how if information held by each agency was put together, along with a comprehensive assessment that reviewed MG’s earlier parenting, this history of relationships and domestic abuse, this would have suggested the presence of some risk. The outcome of the first assessment paved the way to many difficulties, as already stated, the child’s voice became lost, MA’s parenting history was insufficiently explored, MP2 was not involved and the decision to close the case to a social worker but agree a programme of family support without review meant that MG’s tendency to see Child G as the problem became an accepted definition of where problems lay between MG and Children’s Social Care. Child G was registered with a GP but the GP had no knowledge of any of the interventions or concerns, if the GP had been notified of this then the information about bruising from the hospital may have created a greater alert and need to share information across the multi-agency partnership. Both the A&E Hospital Trust and the Clinical Commissioning Group need to share the overall effect of not sharing information in the way through safeguarding training using this case as a local case scenario. Recommendation 3 The Board need to be satisfied that GPs are connected into multi-agency safeguarding arrangements across the spectrum of need to ensure the most diligent approach to information sharing about children and their carers. Recommendation 4 The Named Doctor for Safeguarding Children at Pennine Acute Hospital Trust to present and discuss the case at Peer Review and invite Designated Professionals from the Clinical Commissioning Group to reflect with relevant medical staff the need to share information appropriately, follow up on safeguarding concerns to a point of satisfaction and take definitive action to refer safeguarding concerns which remain unresolved. 7.4 The need to work directly with men in families must be robustly embedded in professional thinking, case planning and single and multi-agency practice. A great deal of work had been done in Oldham to achieve this aim since the Initial Assessment was completed in respect of Child G. Nevertheless, it is disappointing to see this issue as a feature of a further review, and this should be used to reinforce the messages given to practitioners about just how significant an issue this is, and how a failure to do this can so easily result in unassessed and growing risk for children. Recommendation 5 That this case is used as an instructive local case scenarios in multi-agency training to re-inforce the need for safeguarding practitioners to work with men in families and avoid the often easier route of working through women, and the consequences of failing to do so. 7.5 Although Children’s Social Care act as Lead Professionals in multi-agency planning where they have an agency presence, it is evident that partner agencies find it difficult to offer any meaningful challenge when dis-satisfied by outcomes or decisions. The Paediatrician at the regional children’s hospital pursued the referral until she received a satisfactory outcome, this took a great deal of time and energy. The Paediatrician found this a frustrating experience but thankfully had the confidence, knowledge and position to enable her to do this. This is not always the case for other multi-agency professionals who see Children’s Social Care as the ‘experts’ on risk and although they may know the child well, as with the School for Child G, find it much harder to construct the basis for challenge. This case truly demonstrates the need for challenge and in any system model, challenge is an essential part of getting things right and learning for the future. To this end, it would be prudent to work more pro-actively to create a culture of challenge across agencies and for the Board to be satisfied that the barriers to challenge are understood and mitigated against. Recommendation 6 The Board to facilitate a series of multi-agency practitioner seminars for the purpose of developing the culture of challenge, promoting the value of challenge in safeguarding terms, modelling techniques to achieve intended responses and sharing the positive and less positive examples of where challenge, or absence of challenge has impacted on outcomes for a child. |
NC50687 | Accidental death of a 7-year-old boy in July 2015. Child R was found deceased in a pipe on a building site following a police search. He had been at a friend's house in the afternoon and had not returned home. He became subject to a child protection plan in March 2015 under the category of neglect. During Child R's early life there were instances of domestic abuse and substance misuse which impacted his mother's parenting capacity. In June 2015, Child R's behaviour was becoming more challenging; he was reported missing on several occasions from home; and care proceedings were being considered if required changes as set out in the child protection plan were not achieved. Ethnicity or nationality of Child R is not stated. Findings: unrealistic expectation by agencies for mother to address her substance misuse in a self-motivated manner; Child R not referred for specialist assessment or counselling as a result of the domestic abuse situation between his mother and father; at age six and a half, Child R was found to have considerable attachment and emotional issues but appears not to have benefited from psychological assessment or professional therapy. Recommendations: to review, with South Yorkshire Police, the current design of the child protection incident form to ensure it captures essential data to discharge appropriate safeguarding responsibilities to a child; to ensure that children's social care explores the need for specialist input into child protection conference proceedings, where the specialist is not currently engaged with the family and, therefore, not automatically invited.
| Title: Child R: serious case review – summary report. LSCB: Barnsley Safeguarding Children Board Author: Barnsley Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child R Serious case review – Summary report February 2018 2 Contents Contents .................................................................................................................... 2 1 Introduction ....................................................................................................... 3 2 Terms of reference ............................................................................................ 4 3 An overview of the life of Child R .................................................................... 5 4 Constructive analysis of efforts made by agencies to safeguard Child R . 11 5 Summary of key learning points arising from this review ........................... 13 6 What improvement actions have agencies already taken? ......................... 14 6.1 Parental capacity and capability (Children’s Social Care) ......................................... 14 6.2 NHS Barnsley Clinical Commissioning Group ........................................................... 14 6.3 Public Protection Unit ............................................................................................... 15 6.4 Bank End Primary School ......................................................................................... 15 6.5 Barnsley Children’s Services .................................................................................... 16 6.6 Phoenix Futures ....................................................................................................... 17 7 Conclusions..................................................................................................... 18 8 Learning and improvement opportunities .................................................... 20 8.1 Learning and improvement opportunity 1 .................................................................. 20 8.2 The incident of 9 March 2015 – learning and improvement opportunity 2 ................. 20 8.3 Substance misuse – learning opportunity 3 .............................................................. 21 8.4 Substance misuse – learning opportunity 4 .............................................................. 21 8.5 Raising professional concerns – learning and improvement opportunity 5 ................ 22 8.6 Response to domestic abuse incidents rated medium to high – learning and improvement opportunity 6 ............................................................................................. 22 9 Appendix 1 ....................................................................................................... 24 9.1 The process of the serious case review .................................................................... 24 9.2 First Panel meeting ................................................................................................... 24 9.3 Second panel meeting .............................................................................................. 24 9.4 Third panel meeting .................................................................................................. 25 9.5 The frontline professionals’ day ................................................................................ 25 3 1 Introduction On the evening of 26 July 2015, a seven-year-old boy – Child R – was reported as missing to South Yorkshire Police by his mother, when he had not returned home, after the agreed time. It appears that, on this day, Child R had been to play at a friend’s house on the estate in which he lived. Both boys, it is believed, had returned to Child R’s home at some point in the afternoon to collect his Xbox. Child R left his friend later that afternoon and did not return home. On 27 July 2015, following a police search, Child R was found deceased in a pipe, on a building site he is known to have frequented. It is not known how he came to be in the pipe; he may have fallen into it, or he may have hidden in it when people were looking for him. After the death of Child R, a parental support adviser was visiting Child R’s friend and his mother, and reported that Child R’s friend stated that Child R would have hidden if he had been aware that the police were looking for him. The friend felt that Child R would not have wanted the police to find him because he did not like them. The precise sequencing of events during the night of 26 July, through to the time Child R was discovered on 27 July, is unknown. However, the circumstances of Child R’s death were tragic, and it is important that the antecedent period to it is understood as far as it is possible to achieve. At the time this occurred, Child R was the subject of a child protection plan. Consequently, there was a requirement to look at the antecedent chronology leading up to his death, to determine whether the case management around the safety concerns for Child R was reasonable, and whether there was reasonable scope, at the time, for involved agencies to have acted to have prevented the accident that happened. It was decided by the Independent Chair of the Barnsley Safeguarding Children Board, with unanimous agreement from the members of the Serious Case Review Panel meeting, that the case met the criteria for a Serious Case Review. The independent author of this report was commissioned to conduct that review. This report sets out the considerations of the serious case review panel, and the independent author, in respect of the above. 4 2 Terms of reference The initial brief for the serious case review was to answer the following questions. • Were the agencies involved with the child and family fully meeting the needs of the family? • Were policies, procedures, and practice expectations of the agencies followed? • Were appropriate plans in place to safeguard the child, and were opportunities to safeguard the child missed? • How can services develop to ensure that similar incidents do not occur in the future? However, following a detailed review of Child R’s entire chronology in relation to all involved agencies, except his initial primary school, it became clear that, although there were practice issues emerging from Child R’s pre-birth chronology and the chronology between his birth and 9 March 2015, practice across a number of the involved agencies has already changed significantly between 2008 and 2016; therefore, a detailed review of the historical contact with Child R, and his family, was unlikely to deliver new learning and improvement opportunities for the agencies involved. The most significant period of Child R’s life, and the period when there may have been the opportunity for a different outcome for Child R, was between 2014 and 2015; the critical period being March 2015 to July 2015. As a consequence, the independent author proposed focusing attention on the last 12 months of Child R’s life, in particular, on the period in March 2015 when Child R’s case became the subject of a child protection conference. The intent was to examine whether the agencies acted in the best interests of Child R, and made reasonable decisions to monitor and protect his safety. This proposal was accepted by the chair of the serious case review panel and all panel members, as it delivered reasonable proportionality, and focused the review on maximising the learning and improvement benefit that could be achieved. The methodology for conducting the Serious Case Review is attached at Appendix 1 5 3 An overview of the life of Child R This section of the report sets out a concise overview of Child R’s life, from the time of his birth, to his death in 2015, insofar as the panel and independent author have been able to compile it from a review of involved agency records. During mum’s pregnancy and Child R’s early life, there were instances of domestic violence and substance misuse, which impacted at various times, and in varying degrees, with mum’s capacity to parent Child R. 2012 – 2015 Child R started school in 2012 and, during the next twelve to eighteen months, there are indications that there was an escalation in the number of domestic violence incidents (resulting in a letter from Children’s Social Care in November 2012 explaining the negative impact on children who witness domestic abuse) between Child R’s mother and father, which, whilst not recorded as having caused any resulting physical harm to Child R, must have impacted on Child R’s mother’s parenting capacity. In 2014, it became clear that, whilst Child R presented as having a good attachment with his mum when they were both met by Children’s Social Care in February, generally, this period marked a significant deterioration in Child R’s behaviour, in his school attendance, and an escalation in concerns for his emotional, physical, and psychological safety. During the spring of 2014, Child R’s second primary school was sufficiently concerned with his behaviour that they decided to conduct a Boxall Profile assessment, which seeks to identify likely causes for challenging behaviour. The results of the Boxall Profile assessment led the primary school to seek support from Education Psychology; in hindsight Child R’s psychological needs might have been more complex than could be resolved simply by Education Psychology interventions. Through the summer of 2014, Child R’s behaviour continued to present as extremely challenging, with his mother finding it more difficult to manage, culminating, on one occasion, with his maternal grandmother presenting with Child R at the local police station, asking for help, insinuating that nobody else was doing anything. 2015 – Child R seven years old Although 2014 may have provided a small number of opportunities for a more robust, proactive response to signs that Child R was displaying ‘unmanageable’ behaviour at home and at school, 2015 represented the critical antecedent period leading to his tragic death; it is the year in which Child R became the subject of a child protection conference and a child protection plan. His case was one where professionals were on the cusp of needing to make the decision to remove him from his mother; he was termed as ‘on the edge of care’. 5 February 2015 Child R’s school highlighted a range of concerns relating to: • Child R’s attendance • financial issues 6 • suspected misuse of cannabis • Child R’s mother not engaging with them • Child R being fed by a family friend. A child protection assessment was commenced the same day. Between 5 February and 9 March 2015 Concerns about Child R’s mother continued, with the school experiencing her attending to collect her son under the influence of alcohol. On one occasion, this resulted in Child R making his own way home from school, contrary to the agreement the school had in place with Child R’s mother, which required her to collect her son. The school alerted children’s social care to the situation, and two social workers attended at Child R’s home to assess the situation; neither mother, nor son, were at home. They then contacted the local police force to request a same-day safe-and-well check. When this occurred, Child R was at home alone. His mother was unable to care for him that evening, owing to alcohol intoxication, so his grandmother cared for him. Child R was fit and well at this time. 10 March 2015 A strategy discussion and Section 47 investigation was progressed. Consequently, it was determined that the situation for Child R had moved beyond that which could be managed within the common assessment framework, and a decision was made to progress to case conference. Between this decision being made and the case conference, Child R returned to live with his mother, in line with a written agreement involving children’s social care; he had also expressed a wish to go home. This agreement included a range of commitments to behavioural changes in Child R’s mother; the purpose of this agreement was to emphasise, to Child R’s mother, the actions she needed to take to improve her parenting behaviours. However, the agreement had no enforceable status, and no consequence ensued, if it was not adhered to; compliance with the agreement would be assessed in subsequent case conference and core group meetings. 26 March 2015 In line with the procedures and timescales in place at the time, the child protection conference was convened, and Child R was made the subject of a child protection plan under the category of neglect. Present at the conference were Child R’s mother, his maternal grandmother, the education welfare service, his school, and a social worker. 27 March 2015 Child R’s case was transferred to Safeguarding Families West; this is the team that worked with the child protection plan, and thus Child R and his mother, until the time of Child R’s death. Note: between this time, and the time of the tragic accident involving Child R, the social worker and advanced practitioner involved have reported undertaking a “balancing act”; bearing, in their minds, the potential impact of taking the decision to place Child R in care, versus working with Child R and his mother in line with the child protection plan that remained in place at the time of his death (and had been signed up to by all involved agencies). 7 It is important that all readers of this report remember that any decision to take a child away from its family requires careful consideration, and an exhaustion of all reasonable effort to have achieved successful maintenance of the family unit. The many considerations, checks, and balances required of agencies involved in such a decision-making process cannot be underestimated. Professionals do not tend to make the decision to leave a child with its family where they can see, and have acknowledged, that the safety threshold has been passed. Therefore, if it is perceived that the threshold for removal had been met prior to Child R’s death, it is possible that this perspective was reached with the benefit of hindsight; hindsight provides clarity of perspective that is rarely available to professionals managing complex situations ‘on the ground’, as they are progressing. April to 13 July 2015 There was a combination of nine announced, and unannounced, visits to the home of Child R and his mother over this period; in seven of these visits Child R was seen, and direct work was undertaken with him and/or his mother. 16 April 2015 The social worker records reported that Child R’s mother, and his grandmother, attended at the social work team office, and told the allocated social worker that neither of them could cope. The team reaffirmed their commitment to work with the family to achieve some change. The social worker involved reported that her rationale for persisting with the supportive work she was engaged with Child R’s mother in, and for not placing Child R in alternative care was: “Child R had only recently gone onto a child protection plan and the focus was on supporting him to be safe in the care of his mum and wider family. A key focus of the plan was addressing the negative portrayal of grandma in this meeting that Child R was the ‘problem’, rather than helping mum to access support to address her own needs while recognising the impact her behaviour and that of her estranged partner would have on a child. Child R loved his mum and she loved him. Even a short period of accommodation risked damaging further their attachment to each other. Children often have poor outcomes from untimely or poorly planned separations from their caregivers. Hence, we continue to support and work with children in the community to promote family life. It was at a later stage of our involvement that the PLO process was appropriately considered.” 19 June 2015 The second child protection conference was held; Child R remained the subject of his child protection plan. There were small incremental improvements noted in his situation, although concern remained. Therefore, a decision was made to continue with the plan. 24 June 2015 The social worker allocated to Child R recalls that, following the child protection review case conference (where the level of concern had abated slightly), the level of concern for Child R then escalated. She is noted to have reported that she understood that Child R’s mother was known to be associating with two individuals who were known to social workers in relation to child care issues. The social worker also noted in her record, that Child R’s behaviour seemed to be more worrying at this 8 time, than previously. Reports about Child R, and the social worker’s own observations, began to indicate a level of aggressive, and confrontational, behaviour that the social worker had not observed before. Notwithstanding this, there were continued attempts to work with, and support, Child R’s mother. However, even though children’s social care continued to work with Child R’s mother, they also considered that they might be entering a situation where further consideration of Child R’s needs and best interests would be required. A key determinant would be evidence of ongoing deterioration in the engagement of Child R’s mother, and of no progress being made. 20 July 2015 A Gen 117 safeguarding concern was raised by the local police force. Child R had been reported missing on several occasions from his home, or when out with relatives; he would simply “run off”. The social worker involved with Child R was asked about her knowledge of Child R’s missing episodes, and recalled that the behaviour was occurring on a weekly to fortnightly basis during the time she was the allocated social worker (March 2015). 21 July 2015 Child R’s social worker referred him to the local children’s centre, to try to achieve intensive parenting and support, three times per week, throughout the school holidays. The children’s centre already knew the family and were considered to be the most appropriate source of regular support and advice during the school holiday period. The children’s centre agreed to give this support. 22 July 2015 A home visit was conducted at Child R’s home; it is not known if this was a planned or an unplanned visit. As with a previous visit, the general environment within the home raised no concern in the visiting professionals; Child R was well presented and there was no concern regarding his physical health. However, as on recent occasions, Child R was observed to be aggressive in his tone with his mother and constantly pushed the boundaries she put in place. Child R was also noted to be rude in his mannerisms and used bad language. His mother was observed to attempt to apply boundaries to his behaviour. At this home visit, the professionals noted that Child R was using an age-inappropriate digital game; the possible negative impact of these for Child R was discussed with his mother, who then placed the games on top of the kitchen cupboards. Child R became aggressive when she did this, and started smashing up objects in the family home. The professionals present supported Child R’s mother in managing this situation, and in determining appropriate boundaries. Child R’s mother was advised that the social care team would increase their visits to weekly, so that enhanced support could be provided. Child R’s mother, and the professionals, talked about how to keep Child R safe, especially around his ‘going missing’ episodes. The records indicate that Child R’s mother recounted some of the strategies she had used to prevent her son from slipping out unnoticed by her, one of which included locking the windows, although she had found her son unlocking them with a pair of scissors. 9 A plan for both Child R’s mother, and his maternal grandmother, to attend a parent course, so that they could achieve consistency in their strategies with Child R, was also discussed. The records show that one of the children’s social care professionals had a discussion with Child R about house rules. This was noted to have progressed well when talking about rules and his maternal grandmother, but not his mother. When the conversation turned to home house rules, Child R was noted to have disengaged. The overall impression formed by professionals, at the end of this home visit, was that Child R’s behaviour continued to escalate, and that the relationship between him and his mother continued to deteriorate. Also reported, was that Child R’s mother engaged well in the session, and was happy for an increased level of support. Finally, there was a one-to-one conversation with Child R about the dangers in the community and the risk he was putting himself in. Child R was noted to respond that he was ok, could look after himself, and he didn’t care; they could put him in care. The professionals noted that they advised him that they wanted to keep him safe in the home. Child R referred to himself as a “dickhead” at this meeting, and the professionals considered his self-esteem presented as low. This reflected the findings of the earlier Boxall assessment in 2014. 24 July 2015 The social worker for Child R was concerned that his behaviour was escalating, however, the experienced supervising manager considered the threshold for intervention would not be met if the local authority sought an emergency protection order. Police officers who had previous, and current, contact with Child R had not sought to exercise police powers during this period, despite being faced with the same risks to manage. The consideration of the children’s social care professionals was the agreed plan of support and development of positive parenting package in place for the summer holiday (which mum was committed to); this would undermine an abridged or emergency application. They, therefore, elected to seek approval to progress to PLO (Legal Gateway Meeting), and give notice to Child R’s mother that the local authority was considering care proceedings, should the required changes as set out in the child protection plan not show evidence of being achieved. 26 July 2015 Child R was reported to the police as missing from his home by his mother. He had been expected home by 8pm. On this day, Child R was known to have been playing at a friend’s house. An individual providing parental support to Child R’s mother, and other women in the locality, reported to the independent author that Child R and his friend went to Child R’s home to collect a computer game that afternoon, and then returned to the friend’s house. Child R left his friend’s home later that afternoon. This did not cause undue concern at the time, as he was within his local neighbourhood and everyone knew him. It was only later, when he did not return home, that a concern materialised. 10 27 July 2015 Following a police search Child R was found stuck in a pipe on a building site. He had passed away before he could be located. 11 4 Constructive analysis of efforts made by agencies to safeguard Child R Traditionally, there is a detailed commentary about a child’s management from birth to the date of death, where a child has been known to safeguarding children’s services at the time of death. This has led to reports that are rich in narrative storytelling, but have, historically, been less robust in terms of analytical content. In this analysis section, a decision was made to focus on aspects of the chronology in the last years of Child R’s life, which provide optimal opportunity for reflection, learning, and improvement in, and across, the agencies involved. This, after all, is the purpose of the serious case review process; to learn and to improve. Part of ‘improving’ is to recognise aspects of single and multi-agency actions and interventions that went well; these are set out immediately below. What went well for Child R? Although the behaviour of Child R’s mother, and the efforts made to support her, dominate all agency timelines, there are a number of points that represent activities that seem to have been specifically beneficial for Child R, or placed him as the focal point of attention. These were: • his first primary school provided him with regular and consistent support to help him engage in school and to try to support his behavioural issues; between September 2012 and 23 January 2014 there were 13 interventions or meetings for, or about Child R – these must have been reasonably successful, as, during the same period, the behaviour log identified no more than four incidents involving Child R • in February 2015, nurture provision was set up in Child R’s second primary school, and Child R was given the highest level of access to this throughout the school week; this was a provision that Child R was invited to access and was found to be positive towards • the Boxall profile was completed to ensure his individual needs were targeted and met through the nurture sessions; this gave a very clear picture of possible issues for him • in January 2014, Child R’s mother was referred to Parent Partnership, so that she could be supported with her son’s special needs assessment, as she did not understand the process • also in January 2014, there is evidence that shows that Child R’s learning mentor had engaged with him, and that Child R was coming up with excellent ideas for the agreement, including in relation to the statement ‘When we are together we …’. Child R was able to identify things he did well, and those issues he got into trouble for, such as running in school • Child R was referred to the behavioural support service by his school; this referral initiated the involvement of educational psychologist support for Child R • in March 2014, Child R’s first primary school completed a common assessment framework (CAF) for him; it was at this time that Child R was exhibiting bullying behaviour towards girls, and had had a recent ‘fixed-term 12 exclusion’ from school; the commencement of the CAF placed Child R’s school at the forefront of ‘working together’ to keep Child R safe • the interventions of the education welfare service were effective; the attendance of Child R at school increased from 76% to 81.2% in three months, and by 24 June 2014, it was at 92.65%, which was considered to be a good improvement – Child R’s case was closed by the education welfare service on 8 May 2014 • in May 2014, following a Team Around the Child meeting at Child R’s school, further efforts were made to try to secure a parenting course for Child R’s mother • the involvement of the educational psychologist for Child R; it was agreed that the aim of educational psychology involvement was to explore social and emotional needs, as well as self-regulation skills, and calming techniques • personal behaviour plans were utilised for Child R after he became subject to a child protection plan; these divided Child R’s day into small, manageable parts so that there was ample opportunity for praise and positive reinforcement for him, including rewards • in October 2014, Child R’s family was referred to the Troubled Families programme, and in November 2014 Child R’s family was escalated to a family intervention service key worker for more intensive support, the service was available seven days a week and provided both dispersed (support in alternative accommodation) and outreach (support within clients’ own homes) family support – the specialist housing provider delivered this service alongside its usual property management services. The types of interventions provided were: • individual support • parenting skills and support • anger management • communication skills • dealing with difficult situations • workshops to build motivation and self-esteem • social skills and life skills • budgeting and benefit advice • tenancy workshops • making sure people use their leisure time in a beneficial way. All of the above were of the utmost relevance to the situation of Child R and his mother. • In the summer of 2015, the social worker and the local children’s centre brokered a package of support for Child R to sustain him through the summer holiday period; this was to provide him with support, three days a week, and also to provide enhanced support for his mother. At this time, the children’s centre was under no obligation to agree to provide any support, as Child R was over the age of five, the upper limit for service provision. The brokerage of this package, therefore, represents excellence in partnership working between teams, and in the determination of the professionals to achieve a workable and robust support package for the family.13 5 Summary of key learning points arising from this review Whenever a retrospective review takes place, there is always the opportunity for learning and improvement; the case of Child R is no different. There are seven key learning and reflection points arising from this review, these are as follows. 1. Child R’s mother had substance misuse issues that neither she, nor her mother, could accept were unmanageable. Agency response to this was to require Child R’s mother to address her substance misuse issues in a ‘self-motivated’ manner, which was an unrealistic expectation. 2. It was recognised that Child R had been affected by the domestic abuse situation between his mother and father, however, he was not referred for specialist assessment or counselling as a consequence of this. It was documented that his mother had agreed to do this for him, but there is no evidence that this was followed up, on Child R’s behalf, by any agency. 3. There were approximately 21 domestic abuse related incidents towards Child R’s mother between 2009 and 2014, of which 10 appear to have met the threshold for a medium risk categorisation. Apart from writing to Child R’s mother advising her to contact domestic abuse support services, there does not appear to have been a proactive outreach approach to try to secure her engagement in a suitable recovery programme that would have benefitted her, and her son. There was, and is, a free, 10-week Freedom programme that she could have been encouraged to attend. Pathways Family Support Centre also offer a home visiting service, as well as a town centre drop-in service. More positive support should have been provided to her. 4. The Pathways Family Support Centre has an informative website that is not the easiest to navigate or read. This may act as a barrier to engagement with some individuals experiencing abuse. 5. The ranking system utilised in the child protection conferences, in March and June 2015, highlighted stark differences in the professional and family perceptions of risk for Child R; these appear not to have been considered as robustly as they might at the time of Child R’s case conference. Furthermore, professionals currently expressing concern did not utilise the escalation of concern avenues open to them, to express professional concern at the time. 6. Child R’s Boxall assessment, conducted in January 2014, highlighted that Child R had considerable attachment and emotional issues at the age of six and a half, however, structured interventions for him only materialised within the education system; he appears not to have benefitted from a psychological assessment from anyone experienced in childhood trauma, or from any professional therapy, at an early enough stage to assist him in exploring and addressing these issues in an age-appropriate way. 7. Although well managed by Child R’s social worker, and the children’s centre, in the summer of 2015, this case has highlighted the dearth of provision of structured summer activities for children such as Child R, who are over the age of five and whose parents cannot afford to enrol them in summer clubs and camps. 14 6 What improvement actions have agencies already taken? 6.1 Parental capacity and capability (Children’s Social Care) The models now utilised in Barnsley include Signs of Safety, supported by Harnett’s procedure for assessing capacity to change (placing greater emphasis on measuring what change has actually occurred rather than what the parent’s stated intent is). The DiClemente (1991) model of change (the change cycle) forms the basis of the understanding of motivation to change, and is the model cited within the current Barnsley Assessment Framework. Since July 2015, there has been a comprehensive audit of all children subject to child protection plans within Barnsley; the action plan that has derived from that is focused on ensuring that high-quality SMAART (specific, measurable, agreed, achievable, relevant, and timely) plans are produced, that support the assessment of parental capacity for change. Development of the procedures for child protection conferences now result in consideration being given to the capacity to change within conferences, and a new conference reporting template asks all professionals to consider what harm and safety look like, and what both the strengths and the complicating factors are. This is being supported with training, the promotion of web-based resources (for example https://www.rip.org.uk/events-and-online-learning/change-projects/change-projects-resources/smg-change-project/) and regular auditing against these defined criteria; allowing the measurement of organisational change. 6.2 NHS Barnsley Clinical Commissioning Group The workforce management and development subgroup of Barnsley Safeguarding Children Board plans to focus on the toxic trio of mental health disorder (and/or depression), drug and alcohol abuse, and domestic abuse at its October 2016 conference, in order to enhance awareness and understanding among safeguarding professionals of the complexity of these issues, and their impact on the wellbeing of a child. The chief nurse for the clinical commissioning group is leading a work stream entitled ‘Future in Mind’ in Barnsley. This work aims to promote, protect, and improve the mental health and wellbeing of children and young people. One impact of this project has been to reduce the waiting times experienced by young people referred to, and accepted for, a child and adolescent mental health team assessment to five weeks. The child and adolescent mental health service has a new service manager, and she has made alterations to the existing referral service, so that education professionals can now refer a child directly to the child and adolescent service, rather than being required to progress this via a general practitioner (GP). The child and adolescent service has initiated training for GPs, so that they know what information to include in a referral letter for a child or young person. The information provided directly contributes to any decision by the child and adolescent 15 service to accept a referral or not; it is therefore important that the content of any referral letter is as good as it can be. In 2015, the clinical commissioning group implemented a practice delivery agreement to encourage GPs to send reports to child protection conferences. This means that there are financial penalties for GP practices that do not send child protection conference reports. The clinical commissioning group is monitoring the impact of this incentive. 6.3 Public Protection Unit There are a number of changes already enacted, as follows. • The multi-agency risk assessment conference (MARAC) confidentiality statement has been amended. • The MARAC meetings are now fully recorded, and the recordings are kept, and can be accessed if required. • There has recently been a further campaign on the South Yorkshire Police intranet, enforcing the fact that the children involved in any domestic abuse incidents are spoken to, and checked upon, by the officers attending, and the forms are submitted to social care. Posters have been printed and distributed in prominent positions around the buildings for officer information. • The College of Policing have run, a trial of a reduced frontline DASH form. After a second-level review it will be evaluated, and depending on the result, may be rolled out nationally. • Missing-from-home procedures now include guidelines, which state that three missing-from-home incidents within a 28-day period require the escalation of the concerns. Actions are then taken to identify the reasons for the child being away from home, and an action plan is implemented to minimise the risk of any further occurrences. Furthermore, a strategy meeting should be convened when a child or young person has been missing for a period of 72 hours, or when a child or young person has gone missing three times in any 28-day period, where it has been deemed that the child is at risk of significant harm, following a risk assessment. 6.4 Bank End Primary School The school told the independent author: “As a school we are always concerned at the start of a long holiday that we will not be in touch with our children and families for a significant time. We know that Bank End Primary School is at the heart of the community in which we are and every day we are providing support not just for our children whilst they are in school but support for families at home too. Since summer 2015, as a Senior Leadership Team we have discussed ways to provide some form of activity during the longer holidays that will provide two things. • Purposeful and safe activities for our children • An opportunity for our staff in school who know our families well to be in more regular contact with the community during the holidays. As a staff team we have been able to generate a team of Middle and Senior Leaders, including our Parent Support Advisor, who are willing to work and be 16 available in school during some weeks of the holidays. We initially trailed [sic] this during March 2016 during the Easter Holidays. This initiative was self-funded by the school. From this initiative the school saw positive engagement from families and found a manageable system for staff to cover. (Note the staff volunteer to make themselves available during the holiday period). For the summer of 2016 the school has a clear plan in place for this provision to continue, providing holiday clubs and sports camps during four separate weeks. These are at a significantly discounted rate and are run by staff in the school. The school already has uptake from families who have signed up for these clubs. Another development for the primary school is how they escalate their concerns about children of concern. For example, if a concern is raised to social care and the school considers further action is needed, their concerns are now escalated via the appropriate pathway with that service. In order to ensure this consistently happens we have adapted the cause for concern system used in the school. The school has added an additional section to the reporting system for follow up. Weekly the Safeguarding Team meet to review Cause for Concerns received that week and chase up any that we have not had feedback from a service from or feel have not been addressed in the way we would like or expect. With regards to domestic abuse the school has developed links with the Pathways Service and now have a ‘Helping Hands’ therapy session running constantly in school. This is a course of 4 weeks therapy, for groups of up to 6 children at a time, delivered by a trained Pathways worker alongside our Nurture Staff in school. This programme helps children develop self-esteem, manage their own feelings and recognise and value their own safety. The programme has been positive and valuable for a number of children and as a consequence the school will continue to run it for as long as Pathways as a service are able to provide it. The three themes reinforced for children throughout the course are: • We all have the right to feel safe all the time • Others have the right to feel safe with us • There is nothing so small or so awful we can’t talk about it with someone.” 6.5 Barnsley Children’s Services Children’s services in Barnsley have been improving since their Ofsted inspection in 2012. That inspection identified sub-optimal practice in relation to core child protection practices, and judged Barnsley’s children’s services overall to be inadequate. The Department for Education issued an improvement notice, setting out the improvements Barnsley was expected to make, and specifying that Barnsley should establish an improvement board with an independent chairperson. After being inspected again under the single inspection framework two years later, in June 2014, the inspection again noted improvements required in Barnsley’s children’s services. “The Department for Education lifted the Improvement Notice in November 2014 following a further Ofsted inspection under the single inspection framework in June 2014. The outcome of this inspection was more positive and consequently 17 there was an overriding message that Barnsley Children’s Services were improving and continuing to build on their achievements. The service has been able to maintain the momentum for improvement. As Barnsley Children’s Service continue to be judged as requiring improvement, the governance for service improvement was transferred from the Improvement Board to Barnsley Safeguarding Children Board and Children and Young People’s Trust Board.” A continuous service improvement framework remains in place, that is shared right across the partnership, to collectively deliver services that are judged to be ‘good’ or better, so that the best possible outcomes for children and young people in Barnsley are achieved. The framework is designed to secure continuous improvement for Barnsley children and young people’s services, and is supported by Barnsley’s continuous service improvement plan; this provides the means by which progress and impact on services and outcomes for children and young people will be measured. The plan is mapped against the Ofsted requirements (following the child’s journey) and enables both Barnsley Safeguarding Children Board, (BSCB) and the Children and Young People’s Trust, to determine whether sufficient progress is being made, in the right direction, and at the right pace. A strong performance management culture is now firmly embedded in children’s social care, to ensure that the service is delivering improved outcomes for vulnerable children. The improvement plan has progressed beyond the actions and requirements arising from the 2014 Ofsted inspection, all of which have been met. Key activities that enable the continuing momentum for improvement include learning from a programme of case file audits, serious case reviews, frontline visits, and observations of practice; these activities all shape and drive further improvements in getting it right for children. 6.6 Phoenix Futures Since August 2015 Phoenix Futures has recruited and trained peer mentors, specifically because of the experiences they can bring and share with people, such as Child R’s mother, who may be ambivalent about change in relation to their behaviours or addictions. Peer mentors are people who have lived through the experience of substance misuse and treatment services, and want to support others in some way. The aim is to engage individuals in the early stages of their recovery journey. The peer mentor can share their personal experiences of treatment and recovery, while encouraging individuals to embrace a variety of treatment options. 18 7 Conclusions This is a tragic case of the sudden death of a young boy aged seven. By all accounts, although there were serious concerns about Child R’s mother’s ability to parent him to a satisfactory level, and about his behaviours of pushing and not respecting boundaries, wandering off, and being aggressive towards other children, the incident leading to Child R’s death was an accident. A key question for the serious case review was the predictability of a tragic accident for Child R. Although it is clearly recorded that there was concern that Child R might have an accident and that his behaviours presented a clear risk of this (hanging out of bedroom windows, climbing onto flat roofs, not returning home at the agreed scheduled time, wandering off in the dark), there was nothing in his behaviours that would have reasonably prompted his family, or professionals, to consider him at risk of a life-threatening event; it was more likely that Child R would fall and suffer a broken bone, or have a fight with local boys. There was scope for Child R to be involved in a road traffic accident, but this was less likely. The second key question is the potential of avoiding Child R’s death; this is a much more challenging question and requires an objective, non-emotional consideration of his life course and the interactions he, and his mother, had with the range of agencies involved. These mainly constituted: • the police • Children’s Social Care • education services (school, and education welfare) • Family Intervention Services (housing provider). These agencies were aware of the challenges facing Child R and his mother, and a range of interventions and strategies were employed to support and improve the parenting of Child R. There were also interventions that were aimed at supporting Child R to moderate his behaviours, especially in school. Having read all the information provided, the independent author considers that the only way the death of Child R could have been avoided was if he had: • stayed at his friends, rather than deciding to leave • not been able to access the building site he was found on; this issue is outside of the authority of the serious case review process • already been removed from his mother into care. This report has already made clear that removing Child R from his mother, prior to his death, was not something that was reasonably achievable in the situation pre-dating it. The decision to try and achieve this via a non-emergency route was a reasonable one; there was nothing that required an immediate and urgent removal of Child R from his mother, and this was not a child who had dropped off the radar of agencies – far from it. ‘When is the right time’ to remove a child from their home? The answer is not easily arrived at, and is a decision that cannot be seen in black-and-white terms. It also cannot be considered with the benefit of hindsight, when information is available that was not available to the agencies when they were managing the complex situation. 19 The independent author has not seen, or heard, any information that robustly shows the decision to continue to work with Child R’s mother to achieve a satisfactory outcome, was wrong. However, had any of the following been true, it may have provided a different chronology for Child R and his mother, with regards to the case conference and case conference outcomes; had: • there been a structured approach to assessing parental capability and the capacity of Child R’s mother to change at strategic points between 2008 and 2015 • Child R’s mother been proactively referred to substance misuse and domestic abuse services as part of the child protection plan, if not before • Child R received trauma counselling and interventional therapy as part of the child protection plan, if not before. One cannot say how it would have impacted on the tragedy that occurred 20 8 Learning and improvement opportunities The agencies in this case have demonstrated a proactive commitment to improving aspects of their services where their own internal management reviews demonstrated that this was required. Many of those actions are listed above. The issues set out below, have been identified by the independent author of this review, to represent the additional actions or considerations that are required within and across agencies, in the borough of Barnsley. 8.1 Learning and improvement opportunity 1 It is recognised that the multi-agency risk assessment conference (MARAC) coordinator has already acted on aspects of the process highlighted during this serious case review process as requiring attention. However, because, on 23 February 2016, some agencies reported that they were not empowered to share important information emerging at MARAC with relevant frontline professionals, and the quality of notes captured during the 2014 MARAC minutes did not demonstrate delivery of the MARAC aims, or relevant consideration of child safety issues, the Safeguarding Children Board, alongside its adult equivalent, must satisfy itself that: • due consideration of child safety issues (physical and psychological) is consistently taking place at MARAC meetings • an appropriate assessment of risk is conducted and documented • frontline case workers, care coordinators, the education welfare service, head of school, etc, are properly debriefed about the key issues and plans emerging from a MARAC meeting • MARAC representatives from all agencies are surveyed to determine how many of them are consistently taking information from the MARAC meeting and sharing this with the frontline case workers • frontline staff from all agencies are surveyed to obtain their perspective on the reliability with which information from a MARAC meeting is communicated with them, so that they can case-manage effectively; a series of straightforward audits could achieve this, a one-off audit would not be sufficient. Furthermore, the Safeguarding Children Board needs to be assured that, where a child becomes subject to child protection conference proceedings, the process of preparing for the meeting includes a standardised enquiry to the MARAC coordinator about any MARAC meetings held, that relate to the child’s family, and the key risk factors associated. It is essential that a child protection conference chair is as situationally aware as possible, so that informed decisions, in the best interests of the child, can be made. 8.2 The incident of 9 March 2015 – learning and improvement opportunity 2 One of the difficulties in maintaining a grounded perspective in the assessment of this incident was the lack of attention to detail in the information recorded by frontline professionals. 21 The design of the child protection incident report, utilised within the local constabulary at the time, did not require a police constable to set out: • his or her assessment of safety for the child • how decisions were made regarding the safe placement of the child, if removal from the family home was required • to whom in children’s social care the case had been communicated • what the position statement was, 72 hours after the child had been placed with ‘another’ person, other than his/her parents. The form design did not place a police officer in a position of being able to demonstrate retrospectively that the responsibilities conveyed by the Children Act 1989 were known, understood, and delivered. Furthermore, although, objectively in this case, the threshold for a supervision order appears not to have been reached, there was nothing to prompt any record of why the case was not considered to meet the threshold for a care or supervision order. Given the scrutiny that agencies receive following unexpected child deaths, it seems sensible that documentation tools are designed to support professionals in recording core data, that retrospectively helps them demonstrate that they did their jobs well, and that the best interests of the child were preserved. The Safeguarding Children Board is recommended to review, with South Yorkshire Police, the current design of the child protection incident form, to ensure that it captures the essential data set necessary to demonstrate legislative compliance and appropriate discharge of safeguarding responsibilities to a child. 8.3 Substance misuse – learning opportunity 3 The child protection conference plan, in relation to achieving a change in behaviour around the substance misuse by Child R’s mother, was insufficiently robust. Substance misuse services were not invited to be active participants in the child protection conference process, and there was, therefore, no expert input to the child protection plan in respect of the substance misuse concern. The service director for children’s social care and safeguarding is recommended to ensure that the service explores how it can enable its conference chairs to recognise the need for ‘specialist’ input into the child protection conference proceedings, where the specialist is not currently engaged with the family, and, therefore, not automatically invited. 8.4 Substance misuse – learning opportunity 4 Throughout the engagement of services with Child R’s mother, there were missed opportunities for professionals to optimise the opportunities for her to recognise the destructive nature of her alcohol and cannabis use. All agencies are asked to consider the extent to which frontline professionals are encouraged, or required, as part of their professional development, to attend ‘open’ addiction recovery meetings; those hosted by statutory, non-statutory, and self-help groups in the area of Barnsley, including groups focusing on the support of families living with people with addictions. The issue of substance misuse is such a dominant 22 feature in domestic abuse and child neglect, that attendance at such meetings could be considered essential, as well as an effective way to enhance professionals’ insight into these complex issues. 8.5 Raising professional concerns – learning and improvement opportunity 5 8.5.1 Part A Although the flow chart set out in Barnsley Metropolitan Borough Council’s ‘Protocol for Resolving Professional Disagreements When Safeguarding Children and Young People’ (June 2011) is straightforward, it would benefit from the inclusion of relevant contact email addresses and telephone numbers for ease of use and reference. Consideration could also be given to moving the placement of this flow diagram to the beginning of the protocol document, with a cross-reference to additional guidance notes contained within the document; it may make the protocol document easier for partner agencies to use. Furthermore, all agencies working within the borough council need to have easy and immediate access to this, and any, updated version of this protocol. Therefore, consideration could be given to including a link to it on the safeguarding page of the borough’s safeguarding children and safeguarding adult’s website. 8.5.2 Part B: With regard to disagreements arising directly from a case conference, in particular where professionals are not in agreement with the overall risk score arrived at for the child, the protocol is insufficiently directive. Currently the policy says: “3.10. In cases where professionals dissent from the decision made at a Child Protection Conference they may formalise their reasons for dissent in writing to the Chair of the Policy, Procedures and Practice Developments Sub-Committee who will arrange for the disagreement to be considered by an independent Panel.” The protocol does not set out clear timescales for the receipt of concerns raised, or the response to the concerns raised. It needs to set these out. The protocol also needs to address the steps required, in advance of writing to the chair of the Policy, Procedures and Practice Developments Sub-Committee. The nature of a child protection conference (an open meeting at which the family are present) can present an obstacle to one or more agencies voicing dissent at the time of the meeting. It makes logical sense for there to be a defined process whereby any individual/agency present can raise issues directly with the chair of the conference in the 24–48 hours immediately after the case conference. The safeguarding board manager is asked to ensure that this learning opportunity is presented to the person tasked with the responsibility of updating the 2011 protocol. 8.6 Response to domestic abuse incidents rated medium to high – learning and improvement opportunity 6 23 The domestic abuse steering committee is recommended to initiate a partnership piece of work to determine how responses to domestic abuse incidents rated medium to high can be more proactively managed. In this case the standard response to the domestic abuse incidents experienced by Child R’s mother was to send her a letter advising her of the local support networks available. This was not proactive and the domestic abuse steering committee needs to consider a wider range of options for more successfully engaging those experiencing domestic abuse. 24 9 Appendix 1 9.1 The process of the serious case review The process for this serious case review followed a blend of the traditional ‘panel’ model and the principles of the Learning Together model; once the panel itself had achieved clarity that the level of understanding necessary to form fair and reasonable judgements about the decisions made regarding ‘safeguarding Child R’ could not be made without involving frontline practitioners as active participants in the case review process. 9.2 First Panel meeting There were four panel meetings and one frontline professionals meeting (attended by staff engaged with Child R or his family and their managers). The first panel meeting was an opportunity for all agencies to be introduced, and for the initial chronology across the agencies to be presented. The format of this was challenging to work with, and a variety of coded references were used to depict Child R and his parents. It was agreed by all present that the document in its then format was not useable for the review. Furthermore, the chronology, as compiled, gave no indication as to each agency’s consideration of: • the case management • where internal standards had been met, or exceeded • where standards had not been met, and the seriousness of any such instance. The independent author asked the agencies if, instead of producing a traditional IMR (Initial Management Review report), they would be willing to work with an alternative model of chronological timeline that required commentary throughout, about where standards were met and not met, and the magnitude of any lapse. The independent author agreed that she and her team would import all the data already supplied by agencies into this alternative template, and separate the data into individual chronologies for Child R, his mother, and his father. The agencies present agreed to work in this way. Each agency was subsequently presented with the alternative timeline format, which included a number of questions the independent author wished to pose to the agency about its involvement with Child R or his parents. These questions emerged from the independent author’s reading of all of the initial data submitted by the agencies to Barnsley Metropolitan Borough Council. 9.3 Second panel meeting This meeting enabled agencies to provide feedback on how they had found using the alternative chronology model, compared to the more familiar IMR report they would have written. 25 The feedback was mixed: • most agencies reported finding it helpful to be able to see the entire chronology for Child R, his father, and his mother, as this was not something they usually had access to at such an early juncture in the process • a number of agencies reported that it was helpful to have questions posed by the independent author at this early stage, as it supported a constructive and reflective process • some agencies considered that the process reflected the approach they took in their IMRs, but in a different format • a high percentage of agencies reported a lack of the necessary IT knowledge to work with the Excel-based tool as easily as they would have liked • some agencies had such a volume of data that it could not be contained in the maximum number of characters a single Excel cell could accommodate; this resulted in their truncating of the information provided. 9.4 Third panel meeting The focus of this meeting was to agree the key areas requiring exploration and commentary in the serious case review report. The challenge for all present was to achieve, and maintain, a focus on the most important issues; to not get distracted by historical information and/or gaps in historical information that were not going to be filled owing to either changes in staff or memory loss over time. This meeting was pivotal for the serious case review process, as all agencies present recognised and agreed that to achieve a grounded understanding of how decisions were made about the case management of Child R, frontline professionals who remained in the employ of an agency, and who also had care contact/case management contact with Child R, his mother, or father, needed to be invited to a frontline professionals day so that they could contribute their ‘first-hand’ experience of working with Child R and his parents. 9.5 The frontline professionals’ day In preparation for this event, the independent author produced three separate chronologies • Child R’s pre-birth chronology • Child R’s chronology from birth to 9 March 2015 (i.e. just before he was made subject to child protection proceedings via case conference) • Child R’s chronology from 10 March to 26 July 2015. Attendees at the meeting were asked to focus their attention on the last five to six months of Child R’s life, to ensure that the optimal opportunity for meaningful learning and safety improvement was achieved. As previously stated in this report, the dominant reason for this was the criticality of the last five months of Child R’s life. It is indisputable that there are reflective learning opportunities for several agencies in the time period predating March 2015. However, the purpose of a serious case review is to establish what lessons can be learnt to improve child safety for the future. 26 In this case, the possible opportunity for lessons learnt predating March 2015 will, for much of Child R’s chronology, have been superseded by contemporary developments in practice within single agencies, and across agencies. Furthermore, the most important questions about the reasonableness of Child R’s management, in terms of his safety, arise in the five to six months preceding his death. At the start of the day, because a significant number of panel members attended the frontline professionals meeting, each work group was facilitated in working privately, utilising the private post box method; this is where post boxes are provided to each working group so that they can contribute experiences and observations without having to articulate these in a large group, which can be daunting. Professionals present were also asked to reflect on, and respond to, a series of 18 core questions, of relevance to the last five months of Child R’s life. This was well received by the professionals most closely involved with Child R and his mother, in the last five months of his life. |
NC52400 | Murder of an 11-years-old girl by her stepfather in May 2018. Ella's mother was also murdered. Learning includes: the important role of family and friends as source of support; the need to consider the voice of the child; consider the impact of a new step-parent and their background on a child's life; health professionals need to know and document who has parental responsibility for a child as well as the other adults in a child's life; the need for all services to ensure they have adequate policy, training and record-keeping procedures to address domestic abuse, and for services to benchmark themselves against best practice or national guidance; all front line professionals need to confidently speak to survivors of domestic abuse about their situation despite any denial or minimisation, to understand where barriers come from, and to address domestic abuse beyond basic inquiry; the need for strategic boards for domestic abuse, safeguarding and health and wellbeing to work together to adequately resource and support multi-agency and best practice in relation to domestic abuse. Recommendations include: all agencies should provide domestic abuse training, including economic abuse and the homicide timeline; local safety partnership agencies to ensure stronger links with the domestic abuse board; local safety and children's safeguarding partnerships to ensure that national mapping data on domestic abuse, child fatalities and child safeguarding is applied countywide.
| Title: Overview report into the death of Laura and Ella. LSCB: Gloucester City Community Safety Partnership, Safer Gloucestershire and Gloucestershire Safeguarding Children Board Author: Gemma Snowball Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 122 Copyright © 2020 Standing Together. All rights reserved. GLOUCESTER CITY COMMUNITY SAFETY PARTNERSHIP SAFER GLOUCESTERSHIRE AND GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD JOINT DOMESTIC HOMICIDE REVIEW AND SERIOUS CASE REVIEW Overview Report into the death of Laura and Ella May 2018 Independent Chair: Nicole Jacobs Report Author: Gemma Snowball Date of Final Version 14: January 2021 Page 2 of 122 Copyright © 2020 Standing Together. All rights reserved. “Laura was an extremely loving and caring mother, daughter, sister, granddaughter, aunty, niece and cousin. She lived life to the full and full of fun, with a great sense of humour. Laura was friendly to everyone and a happy person who loved to make others happy. She was adored by all of her family and by her many friends- by so many people. Laura was always the one who would be getting us together and organising family parties and meals out. She arranged a wonderful formal 90th birthday party for my mother, what such a lovely, thoughtful tribute to her grandmother. Laura cared about others. Several times she organised fund raising events for local charities. Laura, with her kind and giving nature, was always willing to go out of her way to help anyone. Laura was a really hard worker. She had done brilliantly well in setting up her own wedding planning business. She was expanding it all the time and had won several awards. In 2017, she won the South West Region, ‘Guide for Brides Customer Service Award’ and the ‘Three Counties Wedding Award’. She always went the extra mile to help her couples and they had nothing but praise for her. This is a typical review: “Simply amazing- couldn’t have asked for a better service- fab lady and fab company.” She was held in such high regard in the wedding industry that they have created a special award in her memory… Most importantly, Laura was a wonderful, devoted mother, who absolutely adored her three children and showered them with love and affections. She loved having fun with them…Laura had so much to live for and so much promise.” – Mother of Laura “Ella was my adored first grandchild and we were extremely close. She was such a beautiful, loving, happy girl. She was also very talented at ballroom dancing… She loved to dance and was a natural performer, so good that she achieved 93% marks on her dance exam- the highest in the dance school… She adored her mother and they were also great friends, who loved shopping together and doing girlie things like pamper days. She adored her father and his family and loved spending time with them also. She adored her siblings and was like a little mother to them, always looking out for them. She adored her cousins and was very close to them. She had many friends and had just made many more at her new school.” – Ella’s maternal grandmother “Ella was our only grandchild and she brought great joy and love to our lives. She was a lovely girl and was adored by everyone. Ella was a very talented dancer, she had studied Ballroom and Latin American dancing since the age of five years old. Her great-grandmothers and her other grandmother and I would accompany her to dance competitions in the Southwest and Page 3 of 122 Copyright © 2020 Standing Together. All rights reserved. Midlands. We all loved to watch her dance, she won many awards and we were all so very proud of her. It made a lovely family day out for Ella and all of her grandmothers. I cherished that time with Ella and I’m deeply saddened that I will never see her dance again.” – Ella’s paternal grandmother “Ella would usually spend every weekend with us, she would also come for tea midweek or I would take her out for a treat. We were so close, she was real Daddy’s girl. I loved her with all of my heart and was so very proud of her. She was my world and I cannot see my future without her”. Her uncle recalls, “I would try to give Ella guitar lessons on her pink (her favourite colour) guitar that I bought her for her eighth birthday. We would make singing and dancing videos and write stories and scripts together. Ella loved to play her keyboard and enjoyed anything that was creative. We all enjoyed some lovely holidays together and I miss her terribly. She was a gorgeous child.” – Tributes from Ella’s father and uncle Page 4 of 122 Copyright © 2020 Standing Together. All rights reserved. 1. Preface ........................................................................................................................................... 5 1.1 Introduction ................................................................................................................................ 5 1.2 Timescales ................................................................................................................................. 7 1.3 Confidentiality ............................................................................................................................ 7 1.4 Equality and Diversity ................................................................................................................. 8 1.5 Terms of Reference .................................................................................................................. 10 1.6 Methodology ............................................................................................................................. 11 1.7 Contributors to the review ........................................................................................................ 12 1.8 The Review Panel Members .................................................................................................... 13 1.9 Involvement of Family, Friends, Work Colleagues, Neighbours and Wider Community ............ 15 1.10 Involvement of Perpetrator and/or his Family: .......................................................................... 16 1.11 Parallel Reviews ...................................................................................................................... 16 1.12 Chair of the Review and Author of Overview Report ................................................................. 17 1.13 Dissemination .......................................................................................................................... 18 2. Background Information (The Facts) .................................................................................... 19 2.1 The Homicide ........................................................................................................................... 19 2.2 Background Information about Laura and Ella .......................................................................... 21 2.3 Background Information about the perpetrator ......................................................................... 21 3. Chronology ............................................................................................................................. 23 3.1 Summary of key events and information by year from 2007 onwards ....................................... 23 4. Overview ................................................................................................................................. 47 4.1 Summary of Information from Family, Friends and Other Informal Networks: ........................... 47 4.2 Summary of Information from Perpetrator: ............................................................................... 47 4.3 Summary of Information known to the Agencies and Professionals Involved ........................... 49 5. Analysis .................................................................................................................................. 59 5.1 Domestic Abuse/Violence ......................................................................................................... 59 5.2 Analysis of Agency Involvement: .............................................................................................. 64 5.3 Equality and Diversity: .............................................................................................................. 92 6. Conclusions and Lessons to be Learnt ................................................................................ 94 7. Recommendations ................................................................................................................. 95 7.1 Overview Report Recommendations: ....................................................................................... 95 7.2 Progress on Overview Recommendations at the point of conclusion of the DHR ..................... 95 7.3 Individual Management Review Recommendations: ................................................................ 97 Appendix 1: Domestic Homicide Review Terms of Reference ................................................... 100 Appendix 2: Action Plan ............................................................................................................... 103 Page 5 of 122 Copyright © 2020 Standing Together. All rights reserved. 1. Preface 1.1 Introduction 1.1.1 Domestic Homicide Reviews (DHRs) were established under Section 9(3), Domestic Violence, Crime and Victims Act 2004. This review is also a Serious Case Review (SCR) which is overseen by the Gloucestershire Safeguarding Children’s Board (GSCB). 1.1.2 This report of a Domestic Homicide Review examines agency responses and support given to Laura and Ella, a mother and daughter who were residents of Gloucester prior to the point of their murders at their home in May 2018. 1.1.3 The following is from the sentencing remarks by Hon. Mrs. Justice May DBE: In retrospect there were danger signs: in 2010 you have been convicted of assaulting your then partner when she told you that the relationship was over. There was an episode on Boxing Day when Laura ran to neighbours, telling them you had assaulted her. When one of Laura’s friends reported to her that they had seen you out, you called her telling her that she and her family should “watch their backs”. The same friend saw you punch a hole through a wall in temper. By all accounts you were never kind to Ella, often referring to your 11-year-old stepdaughter as a “cunt”. Around the start of the year Laura discovered that you were having an affair. That was effectively the end of the marriage although due to convenience and financial necessity, you both remained living at the same address, with all three children. Ten days before the murder, one of Laura’s friends got a text from Laura saying that she had had to leave the house. Laura said that you had gone for her; she said she wanted a divorce, after which you had punched a hole in a wall telling her, “that was meant for your face”. Your hand was in a plaster cast from that incident when you murdered Laura and Ella 10 days later. On the evening of the murder, Laura went out to the pub with friends. She was in good spirits. She told her friends that she had asked to you to leave the house within 2 weeks and that you were not happy about it. She got home around 1 in the morning and went to bed from where she had a FaceTime call with her aunt. Page 6 of 122 Copyright © 2020 Standing Together. All rights reserved. You have not given the Police a complete account of what happened next that night…Perhaps the most coherent account is the separately sad one given by your 6-year-old child when they were interviewed by the Police 2 weeks later. 1.1.4 The sentencing remarks go on to describe how the children heard shouting and banging downstairs and the smallest children went to the top of the staircase where they were comforted by Ella and put back to bed. They heard screaming and something breaking. The perpetrator appeared with blood on his hands and carrying a knife. Child A reported that the perpetrator said he had killed their Mummy and sister and to wait in bed until their Nan arrived. He put on a DVD for them, changed his shoes and left the house. 1.1.5 The perpetrator pleaded guilty to murdering Laura and Ella and in November 2018 received a life sentence with a minimum term of 29 years. 1.1.6 The review considered agencies contact/involvement with Laura, Ella and the perpetrator from the birth of Ella in 2006 until the date of Laura and Ella’s murders in May 2018. This was later reviewed following a further meeting with Laura and Ella’s family and it was agreed that all involvement prior to the relationship between Laura and the perpetrator commencing in 2010 would be summarised and the review would only consider key events prior to 2010. 1.1.7 In addition to agency involvement, the review also examined the past to identify any relevant background or trail of abuse before the homicide, whether support was accessed within the community and whether there were any barriers to accessing support. By taking a holistic approach the review seeks to identify appropriate solutions to make the future safer. 1.1.8 The key purpose for undertaking a DHR is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence and abuse. In order for these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future. SCRs are also conducted in order to identify not just what happened but what can be learned from the case following the death of a child. 1.1.9 This review process does not take the place of the criminal or coroner’s courts nor does it take the form of a disciplinary process. Page 7 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.1.10 The Review Panel and Chair wish to acknowledge that reviews benefit enormously from the input of family members but that it takes courage to become actively involved in the review process. The panel and chair thank the family and the family’s advocate and support, AAFDA for their active involvement in this review from the start to the end. The panel and chair express its sympathy to the family, and friends of Laura and Ella for their loss and thanks them for their contributions and support for this process. 1.2 Timescales 1.2.1 The Gloucester City Community Safety Partnership in conjunction with Safer Gloucestershire and in accordance with the December 2016 Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews commissioned this Domestic Homicide Review (hereafter ‘review’). The Home Office was notified of the decision in writing on 12/06/2018. The GSCB decided after the first-panel meeting that it would be appropriate to establish this as a joint DHR/SCR, appropriate notification was made under Working Together (2015). 1.2.2 Standing Together Against Domestic Abuse (Standing Together) was commissioned to provide an independent chair for this DHR/SCR on 17/07/2018. The completed report was handed to the Gloucester City Community Safety Partnership, Safer Gloucestershire, and the GSCB on 12/01/2021, and submitted to the Home Office for Quaility Assurance 24th February 2021 1.2.3 Home Office guidance for DHRs states that the review should be completed within six months of the initial decision to establish one. Working Together (2015) similarly states that SCRs should be completed within 6 months. Delays occurred due to the need to pause the review process during the criminal trial and then to ensure that there was adequate time between meetings to meet with family members, and to arrange and undertake a meeting with the perpetrator. Additional time was given in order to allow the family opportunities to provide their feedback on multiple versions of the draft report. There were also separate meetings arranged throughout this process for the family to meet with particular panel members and with agencies in order to answer questions the family had, the latter of these being held virtually due to the COVID-19 pandemic. The report was then virtually circulated to the panel and approved November 2020. 1.3 Confidentiality Page 8 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.3.1 The findings of this report are confidential until the Overview Report has been approved for publication by the Home Office Quality Assurance Panel for DHRs. Information is publicly available only to participating officers/professionals and their line managers. 1.3.2 This review has been suitably anonymised in accordance with the 2016 guidance. The specific date of death and the gender of Laura’s other children have been removed and only the independent chair and Review Panel members are named. 1.3.3 The review author discussed the use of pseudonym names with the victim’s family in order to protect the identity of the victim, the perpetrator and family members, however, the family requested permission from the Home Office to use the real names as the case is widely known in the local area so the use of pseudonym names would not successfully protect the identities of the two victims. The names of the two younger children have been anonymised in order to maintain their anonymity. The victim’s family did not wish for the perpetrator to be given a pseudonym and therefore he will be referred to as the perpetrator throughout the report. The following terms have been used throughout this review: 1.3.4 The adult victim: Laura – real name 1.3.5 The child victim: Ella – real name 1.3.6 The perpetrator 1.3.7 Older child of Laura and the perpetrator: Child A 1.3.8 Younger child of Laura and the perpetrator: Child B 1.4 Equality and Diversity 1.4.1 The Chair of the Review and the Review Panel considered all the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation during the review process. 1.4.2 Laura was a 31-year-old heterosexual white British female. Laura was not registered as being a person living with a disability. Laura and the perpetrator had been married for 4-5 years and had two children together. The protected characteristics of gender reassignment, religion/belief and sexual orientation do not pertain to this case in that neither party was at any stage of transitioning from one gender to the other. They did not Page 9 of 122 Copyright © 2020 Standing Together. All rights reserved. hold particular religious or other beliefs as far as we can tell from the records and Laura was not pregnant. 1.4.3 Ella was Laura’s daughter from a previous relationship and was aged 11 at the time of her death. The panel considered the biological factors relevant to this case given that the perpetrator was the biological father to two of Laura’s children but not the biological father of Ella. This is analysed in more detail throughout the report. 1.4.4 The perpetrator is a white British male who was aged 28 and had been in a heterosexual relationship with Laura but was estranged at the time of Laura and Ella’s murder. Whilst the perpetrator was not registered as having a disability throughout the scope of the review the panel considered the perpetrator’s epilepsy diagnosis in relation to the Disability Discrimination Act (DDA). The perpetrator’s inconsistent compliance with treatment made it challenging for the panel to fully understand his condition and to determine the impact it may have had on his situation and the violence that he perpetrated. It is noted that his epilepsy assessment was based on description, rather than medical professionals witnessing a fit. Whilst only a disability tribunal could say for certain whether the perpetrator’s epilepsy could have been classed as disabled under the Disability Discrimination Act1, the Act specifies that people are likely to be classed as disabled if someone has: • epilepsy that has a substantial effect on the persons day-to-day activities; or; • epilepsy that would have a substantial effect if someone were not taking their epilepsy medicine. A substantial effect might include being able to get around, hear, see, remember and concentrate; or; • a type of epilepsy that is not currently causing any problems or needs epilepsy medicine, but could come back; or; • epilepsy that has lasted, or is expected to last, for at least 12 months The perpetrator’s epilepsy and lack of engagement with services was identified throughout the chronologies and IMR’s and will be reviewed at the relevant sections later in the report. 1 https://www.epilepsy.org.uk/info/equality/disability-discrimination-act Page 10 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.4.5 Sex: Sex should always require special consideration. Analysis of domestic homicide reviews reveals gendered victimisation across both intimate partner and familial homicides with females representing the majority of victims and males representing the majority of perpetrators.2 This characteristic is therefore relevant for this case, the victim of the homicide was female and perpetrator of the homicide was male. 1.4.6 The Review Panel provided special consideration to sex and disability throughout this review to determine if responses of agencies were motivated or aggravated by these characteristics. 1.5 Terms of Reference 1.5.1 The full Terms of Reference for this DHR/SCR are included at Appendix 1. This review aims to identify the learning from Laura’s, Ella’s and the perpetrator’s case, and for action to be taken in response to that learning: with a view to preventing homicide and ensuring that individuals and families are better supported. 1.5.2 The Review Panel was comprised of agencies from Gloucestershire, as the victim and perpetrator were living in that area at the time of the homicide. Agencies were contacted as soon as possible after the review was established to inform them of the review, their participation and the need to secure their records. 1.5.3 At the first meeting, the Review Panel shared brief information about agency contact with the individuals involved, and as a result, established that the time period to be reviewed would be from July 2006 to the date of the homicide. Due to this report being a joint DHR and SCR, the panel felt that it would be of benefit to review agency involvement for the duration of Ella’s lifespan. Agencies were asked to summarise any relevant contact they had had with Laura or the perpetrator outside of these dates. 1.5.4 Key Lines of Inquiry: The Review Panel considered both the ‘generic issues’ as set out in the 2016 statutory guidance and identified and considered equality and diversity as described in 1.4 above, as well as the following case specific issues: 2 “In 2014/15 there were 50 male and 107 female domestic homicide victims (which includes intimate partner homicides and familial homicides) aged 16 and over”. Home Office, “Key Findings From Analysis of Domestic Homicide Reviews” (December 2016), p.3. “Analysis of the whole Standing Together DHR sample (n=32) reveals gendered victimisation across both types of homicide with women representing 85 per cent (n=27) of victims and men ninety-seven per cent of perpetrators (n=31)”. Sharp-Jeffs, N and Kelly, L. “Domestic Homicide Review (DHR) Case Analysis Report for Standing Together “ (June 2016), p.69. Page 11 of 122 Copyright © 2020 Standing Together. All rights reserved. o The communication, procedures and discussions, which took place within and between agencies o The co-operation between different agencies involved with Laura, Ella, the perpetrator and the wider family, specifically Child A and Child B o The opportunity for agencies to identify and assess domestic abuse risk, including during any contact with Laura, Ella, the perpetrator and / or Child A and Child B in relation directly to domestic abuse and / or other needs and issues o Agency responses to any identification of domestic abuse issues. o Organisations’ access to specialist domestic abuse agencies. o The policies, procedures and training available to the agencies involved on domestic abuse issues. 1.5.5 While the Review Panel included agencies that could bring expertise in relation to these additional issues, due to this report being a joint DHR/SCR there was also representation on the panel from the GSCB Business Unit Manager in order to satisfy that all aspects of child protection and child death were included within the scope of the DHR review. 1.6 Methodology 1.6.1 Throughout the report the term ‘domestic abuse’ is used interchangeably with ‘domestic violence’, and the report uses the cross government definition of domestic violence and abuse as issued in March 2013 and included here to assist the reader, to understand that domestic violence is not only physical violence but a wide range of abusive and controlling behaviours. The new definition states that domestic violence and abuse is: 1.6.2 “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; and emotional. 1.6.3 Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. 1.6.4 Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.” Page 12 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.6.5 This definition, which is not a legal definition, includes so-called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnic group. 1.6.6 This review has followed the 2016 statutory guidance for Domestic Homicide Reviews issued following the implementation of Section 9 of the Domestic Violence Crime and Victims Act 2004. On notification of the homicides, agencies were asked to check for their involvement with any of the parties concerned and secure their records. The approach adopted was to seek Individual Management Reviews (IMRs) for all organisations and agencies that had contact with Laura, Ella, the perpetrator, Child A and Child B. A total of seventeen agencies were contacted to check for involvement with the parties concerned with this review. Six agencies returned a nil -contact, and after Panel consideration, six agencies submitted IMRs and chronologies. The chronologies were combined and a narrative chronology written by the Overview Report Writer. 1.6.7 Independence and Quality of IMRs: The IMRs were written by authors independent of case management or delivery of the service concerned. All IMRs received were comprehensive and enabled the panel to analyse the contact with Laura, Ella and/or the perpetrator, and to produce the learning for this review. Where necessary further questions were sent to agencies and responses were received. Six IMRs made recommendations of their own, and evidenced that action had already been taken on these. The IMRs have informed the recommendations in this report. The IMRs have helpfully identified changes in practice and policies over time, and highlighted areas for improvement not necessarily linked to the terms of reference for this review. 1.6.8 Documents Reviewed: In addition to the six IMRs, documents reviewed during the review process have included previous DHR and SCR reports in the area, Victim Impact Statements of the family for the criminal trial, and DHR Case Analysis from the Home Office. 1.6.9 Interviews Undertaken: The chair of the review has undertaken four interviews in the course of this review attended by two or three family members together. This has included three face to face interviews, one telephone interview, and one zoom meeting. The chair is very grateful for the time and assistance given by the family and friends who have contributed to this review and to their expert advocate at AAFDA for her support to ensure that the views of the family are integral to this review. 1.7 Contributors to the review Page 13 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.7.1 The following agencies were contacted, but recorded no involvement with the victim or perpetrator: o Gloucestershire County Council Adult Social Care Services o Gloucester City Council Local Authority Housing services o Gloucester City Homes o Gloucestershire Domestic Abuse Support Service (GDASS/ Greensquare) o Change, Grow, Live (CGL) (commissioned substance misuse service) o Working Links Probation Community Rehabilitation Company (CRC) 1.7.2 The following agencies and their contributions to this review are: Agency Contribution Clinical Commissioning Group (CCG) (GP’s for Laura, Ella, the perpetrator, Child A and Child B) IMR and Chronology Gloucestershire Care Services NHS Trust Community Health Services (e.g. health visiting, school nursing and community physiotherapy) IMR and Chronology Gloucestershire Hospitals NHS Foundation Trust IMR and Chronology Gloucestershire Council Children’s Services IMR and Chronology Gloucestershire Constabulary (Police) IMR and Chronology Safeguarding in Education Traded Services Team (Education) IMR and Chronology 1.8 The Review Panel Members 1.8.1 The Review Panel members were: Page 14 of 122 Copyright © 2020 Standing Together. All rights reserved. Name & Job Role Agency Annette Blackstock, Designated Nurse Safeguarding Children Clinical Commissioning Group (CCG) Rebecca Williams, Associate Named Nurse for Safeguarding Children Gloucestershire Care Services NHS Trust Clare Hicks, Specialist Nurse Safeguarding Adults Gloucestershire Care Services NHS Trust Jon Burford, Divisional Chief Nurse Division of diagnostics & specialties Gloucestershire Hospitals NHS Foundation Trust Andy Dempsey, Director for Partnerships Gloucestershire County Council Children’s Services Kanchan Jadeja, Quality Assurance and Improvement Consultant Gloucestershire County Council Children’s Services Anne Brinkhoff, Corporate Director Gloucester City Council Georgina Summers, Safeguarding Children Manager (education) Safeguarding in Education Traded Services Team Dave Jones, GSCB Business Unit Manager Gloucestershire Safeguarding Children Board Business Unit Alison Feher, Safeguarding lead 2gether NHS foundation trust Heather Downer, Deputy Manager Gloucestershire Domestic Abuse Support Service (GDASS) DCI Richard Ocone, DCI for CID and Police DA lead Gloucestershire Constabulary Sophie Jarrett, County DASV Strategic Coordinator Seconded to role of Outcome Manager for violence prevention during review but remained on DHR panel. Gloucestershire Constabulary Helen Pritchard, County DASV Strategic Coordinator Seconded into role during the review and joined panel. Gloucestershire Constabulary 1.8.2 Independence and expertise: Review Panel members were of the appropriate level of expertise and were independent, having no direct line management of anyone involved in the case. 1.8.3 The Review Panel met a total of 4 times, with the first meeting of the Review Panel on the 23/10/2018. There were subsequent meetings on 31/01/2019, 11/07/2019 and 13/12/2019. 1.8.4 The last full panel meeting was attended by family members and the Chair would like to thank AADFA for their support in this important meeting, the family for their candour and bravery and the panel for their willingness to engage so openly in the discussion. This Page 15 of 122 Copyright © 2020 Standing Together. All rights reserved. mutual understanding is a key aim of the DHR process which is emotional and difficult at times but it is both critical and beneficial to the process. 1.8.5 The Chair wishes to thank everyone who contributed their time, patience and cooperation to this review. 1.9 Involvement of Family, Friends, Work Colleagues, Neighbours and Wider Community 1.9.1 The Gloucester City CSP, in conjunction with Safer Gloucestershire, notified the family of Laura and Ella in writing of their decision to undertake a review via the Gloucestershire Constabulary Family Liaison Officer (FLO) in August 2018. The Chair of the Review and the Review Panel acknowledged the important role Laura’s, Ella’s and the perpetrator’s family could play in the review. From the outset, the Review Panel decided that it was important to take steps to involve the family, friends, work colleagues, neighbours and the wider community. 1.9.2 Consideration was initially given to approach Laura’s family and Ella’s biological father. 1.9.3 A letter was sent from the chair via the FLO, describing the DHR and SCR process, that participation in the review was voluntary, and that the family could contribute in a number of different ways. The letter was accompanied by the Home Office leaflet for families, as well as a leaflet describing the support available from Advocacy After Fatal Domestic Abuse (AAFDA). This letter was sent to the FLO in September 2018. 1.9.4 The family were supported throughout the duration of the review process by a specialist and expert advocate from AAFDA. The AAFDA advocate established contact with the Chair of the Review in December 2018. 1.9.5 The chair initially had email and telephone contact with Ella’s paternal grandmother prior to the first-panel meeting. 1.9.6 The terms of reference were shared with the family of Laura and Ella to assist with the scope of the review. 1.9.7 The family were updated regularly and reviewed the draft report in private with agreed adequate time which was aided and negotiated via the AAFDA advocate. The family were given the opportunity to comment and make amendments to the report as required and their feedback was incorporated into the report. 1.9.8 The family met the Review Panel on the 13/12/2019. Page 16 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.10 Involvement of Perpetrator and/or his Family: 1.10.1 In March 2019 the perpetrator was sent a letter from the chair via both the prison governor and his probation officer with a Home Office leaflet explaining DHRs and an interview consent form to sign and send back. He sent back the signed consent form and the chair met him in prison for an interview on 30/04/2019. 1.11 Parallel Reviews 1.11.1 Criminal trial: The perpetrator initially pleaded not guilty to two murder charges in a hearing at Bristol Crown Court on July 2018. The perpetrator accepted he was responsible but indicated he would cite diminished responsibility due to loss of control and abnormality of mind. A medical report on September 2018 found there were no grounds for the perpetrator to argue there was a diminished responsibility. He pleaded guilty to the murders in November 2018 at Bristol Crown Court. The criminal trial concluded on 5th November 2018 and was sentenced to life imprisonment with a minimum term of 29 years. 1.11.2 The Gloucestershire Constabulary Senior Investigating Officer (SIO) was invited to the first meeting of the Review Panel. It was agreed approaches would not be made to witnesses until after the criminal trial had been concluded, with the exception of an introductory letter to Laura and Ella’s family as described above. However, as the trial was concluded shortly after this first meeting, this had a relatively limited impact on the timeframe of the review. 1.11.3 No parallel reviews: An Inquest was opened and suspended in June 2018 at Gloucester Coroners Court. Following the perpetrator’s conviction, Her Majesty’s Coroner decided no investigation was required and therefore closed the matter. Consequently, following the completion of the criminal investigation and trial, there were no parallel reviews that impacted upon this review. 1.11.4 Combined SCR/DHR: Prior to the DHR starting, consideration was given to whether a separate SCR should be carried out following the death of Ella. A SCR is a locally conducted multi-agency review into the circumstances where a child has been abused or neglected, resulting in serious harm or death and there is cause for concern as to the way in which the relevant authority or persons have worked together to safeguard the child. The GSCB felt that the circumstances around Ella’s death and subsequent learning would be best placed to be combined with the DHR in order to combine the learning. In order to ensure that the DHR considered all of the relevant learning points from a SCR the Terms Page 17 of 122 Copyright © 2020 Standing Together. All rights reserved. of Reference were reviewed at the first-panel meeting to ensure that this was in line with the SCR requirements. The panel also had representation from the GSCB Business Unit Manager in order to ensure that all SCR considerations were considered and explored throughout the duration of the review. 1.12 Chair of the Review and Author of Overview Report 1.12.1 The Chair of the Review is Nicole Jacobs, who during the course of the review was CEO of Standing Together. Nicole has received training from her predecessor at Standing Together, Anthony Wills and attended the Home Office training on DHRs in 2013 and she attended an initial Home Office training on DHRs. She has over 20 years of experience working in the domestic violence and abuse sector and has chaired five DHR reviews and has led in the work related to dissemination of findings of all the Standing Together chaired DHRs with the Child and Women Abuse Studies Unit at London Metropolitan University, published in 2016. In late September 2019, Nicole was appointed to the role of Designate Domestic Abuse Commissioner. Nicole negotiated finishing this DHR with the Home Office and has not charged the CSP for any further work on this DHR since her appointment. 1.12.2 The Author of the review is Gemma Snowball, during the course of the review she was Domestic Homicide Review and team development manager at Standing Together. Gemma has completed the Home Office Domestic Homicide Review Chair’s training delivered by AAFDA. Gemma has previous managerial experience in the domestic violence and abuse sector including management of Multi-Agency Risk Assessment Conferences (MARACs) and Independent Domestic Violence Advisor (IDVA) service provision within London. Gemma left Standing Together prior to the report being finalised so the final stages of the report were completed by Nicole Jacobs and the Standing Together DHR Team. The chair wishes to apologise to the family for any disruption or unnecessary stress caused by these changes at the final stage of the DHR Process. 1.12.3 Standing Together is a UK charity bringing communities together to end domestic abuse. We aim to see every area in the UK to adopt the Coordinated Community Response (CCR). The CCR is based on the principle that no single agency or professional has a complete picture of the life of a domestic abuse survivor, but many will have insights that are crucial to their safety. It is paramount that agencies work together effectively and systematically to increase survivors’ safety, hold perpetrators to account and ultimately prevent domestic homicides. Page 18 of 122 Copyright © 2020 Standing Together. All rights reserved. 1.12.4 Standing Together has been involved in the Domestic Homicide Review process from its inception, chairing over 70 reviews. 1.12.5 Independence: Both Nicole Jacobs or Gemma Snowball have no connection with Gloucester City Community Safety Partnership (CSP), Safer Gloucestershire, or any of the agencies involved in this case. 1.13 Dissemination 1.13.1 The following recipients have received/will receive copies of this report: o Panel members listed below o Family members o Standing Together DHR Team o Gloucestershire Safeguarding Children Executive and Delivery Board o Safer Gloucestershire o Police and Crime Commissioner Page 19 of 122 Copyright © 2020 Standing Together. All rights reserved. 2. Background Information (The Facts) The Principle People Referred to in this report Referred to in report as Relationship to V Age at time of V death Ethnic Origin Faith Immigration Status Disability Y/N Laura Adult victim and mother of Ella 31 White British No religious affiliation British Citizen N Ella Child victim and daughter of Laura 11 White British No religious affiliation British Citizen N The perpetrator Husband (pending divorce) of Laura and step-father of Ella 28 White British No religious affiliation British Citizen Epilepsy Child A Child of Laura and the perpetrator Redacted White British No religious affiliation British Citizen N Child B Child of Laura and the perpetrator Redacted White British No religious affiliation British Citizen N 2.1 The Homicide 2.1.1 Homicide: Laura and Ella were murdered by Laura’s husband, whom she was in the process of separating from, and Ella’s step-father. Laura had been out for a meal with a friend and took a taxi and arrived home at 1:10 am. Laura was on Facetime with her Aunt at 01:18 am. In between then and 4:30 am the perpetrator killed Laura and Ella at their home. Both Laura and Ella were attacked in the kitchen, it is believed that Ella came Page 20 of 122 Copyright © 2020 Standing Together. All rights reserved. downstairs to intervene and had also been killed. Both Laura and Ella had received multiple stab wounds consistent with defence wounds to their faces, necks, hands, and body. After both were attacked, the perpetrator went into the bedroom of Child A and Child B who were awake. The perpetrator is reported to have gone upstairs after the murder, put a DVD on, and then left the children in the property to leave and call his mother. As retold to family member later the children recalled that when doing so, the perpetrator was covered in blood and carrying the murder weapon in his hand. 2.1.2 Laura and the perpetrator had been married 4 years and lived together in their Gloucester home with their two children Child A and Child B and Ella, Laura’s child from a previous relationship. Laura had become aware that the perpetrator had had an affair earlier in 2018, Laura asked him to leave and informed him she wished to end the relationship and would be seeking a divorce. 2.1.3 The Police and ambulance were called at 4:50 am by the perpetrator’s mother’s partner. In between this time and the time of the perpetrator’s arrest the Police officer exchanged multiple phone calls with the perpetrator to encourage him to turn himself in. When the perpetrator was subsequently arrested he had one of his hands in a cast which is believed to have been sustained by punching a wall during a previous incident that was not reported to Police. 2.1.4 Post Mortem: The Coroner conducted a Post Mortem examination of Laura and Ella at Gloucester Mortuary the day after their deaths. The cause of death in both cases was given as multiple stab wounds. Laura was stabbed 18 times and Ella stabbed 24 times. 2.1.5 The family commented that the attack on both Laura and Ella was so ferocious to both including injuries to the face that meant that the family were unable to fully say their goodbyes and mourn the loss of both Ella and Laura due to the severity of the injuries sustained. 2.1.6 Criminal trial outcome: The criminal trial concluded in November 2018, with the perpetrator pleading guilty to both Laura and Ella’s murders. In November 2018 the perpetrator was sentenced to life imprisonment with a minimum term of 29 years. 2.1.7 The perpetrator initially claimed diminished responsibility due to loss of control and abnormality of mind. The perpetrator’s solicitor had argued that he had a history of depression and epilepsy. These were some of the reasons they gave as to why they were considering the ‘loss of control’ as a defence. Following a medical report completed in Page 21 of 122 Copyright © 2020 Standing Together. All rights reserved. September 2018, it was determined that the perpetrator had no grounds for claiming diminished responsibility. 2.1.8 Judge’s sentencing summary: On sentencing the perpetrator in November 2018, the judge described the murders as “unspeakable savagery” and paid tribute to “brave” Ella for going to her mother’s aid. “She would have witnessed some part of your murderous attack on her mother and tried to stop you before you turned on her”. “What a brave girl. She and her mother were found lying together, side by side.” 2.2 Background Information about Laura and Ella 2.2.1 Laura was a much-loved mother, daughter, sister, cousin and friend. She was a loving mother who raised her children among a close-knit community of family and friends. She was hard-working and entrepreneurial and put the needs of her family and friends first. At the time of her death, Laura was 31 years old. She was White British and had no known disability or religious affiliation. Laura was a successful businesswoman who started her work life at age 14 when she started working part-time in a local hairdresser. At the time of her murder, she ran a business offering bespoke bridal gowns and wedding planning services. 2.2.2 Ella was a talented and energetic daughter, sister, granddaughter, niece, cousin and friend. She was loved and adored by her father, siblings, grandparents, aunts, uncles, cousins and friends. She attended her grandmother’s nursery and every nuance of her spirited personality was known to her family. Much like her mother, she was close and open with her friends and family and was able to share her hopes, thoughts, feeling and concerns. Although her parents had separated, both sides of her family always got along well and shared in their commitment to her care and wellbeing. She had a passion for dance and had competed and won awards for her dancing skills. At the time of her murder, Ella was in secondary school. 2.2.3 Laura had three children. The perpetrator was the biological father of the youngest two children (Child A and Child B). The birth father of Ella was contacted as part of the review. His participation in the review was done via his mother, Ella’s grandmother, due to the severe mental trauma and anguish he has experienced since the death of his daughter. 2.3 Background Information about the perpetrator 2.3.1 The perpetrator was aged 28 when he murdered Laura and Ella. He is White British and has no religious affiliation. The perpetrator does not have a diagnosed disability but does Page 22 of 122 Copyright © 2020 Standing Together. All rights reserved. have a diagnosis of epilepsy. This was later used by the perpetrator to claim diminished responsibility due to loss of control and abnormality of mind which was not upheld by a medical report completed in September 2018 which concluded that the perpetrator had no grounds for claiming diminished responsibility. Page 23 of 122 Copyright © 2020 Standing Together. All rights reserved. 3. Chronology 3.1 Summary of key events and information by year from 2007 onwards 3.1.1 Although the panel reviewed all agency involvement from the date of Ella’s birth in 2006 through to the beginning of the relationship between Laura and the perpetrator in 2010 only key agency involvement has been included in the overview report. From 2007 to 2010, Laura and Ella were seen by medical services for routine appointments and minor health issues. The following are details that relate to the perpetrator’s interaction with services from 2007-2010 prior to him forming a relationship with Laura in 2010. 2007 3.1.2 In mid-March, the perpetrator attended hospital with injuries to his left hand but did not wait to be seen. He would not have known Laura at this time. 3.1.3 In late summer, the perpetrator attended the emergency department for an injury to his left ankle and was treated and discharged. 2008 3.1.4 In late March the perpetrator attended the emergency department with an injury to his right index finger. The perpetrator was treated and discharged. 3.1.5 In early July the perpetrator attended the emergency department following a road traffic collision. The perpetrator was diagnosed with bruising and discharged. 2009 3.1.6 In mid-March, the perpetrator attended the Emergency Department after his first epileptic fit. The seizure was witnessed by the perpetrator’s partner at the time who described the seizure to the ambulance staff and the Emergency Department. The perpetrator reported that he had been working 24 hours on a factory site and an aluminium ladder fell onto his forearm and head. He later had a seizure at home. The perpetrator’s presentation at the hospital was consistent with someone experiencing their first epileptic fit and therefore there were no grounds for questioning this diagnosis following the referral to neurology outpatients. The epilepsy nurse made contact however the perpetrator did not get back to her to make an appointment. The perpetrator was advised not to drive and to inform the Page 24 of 122 Copyright © 2020 Standing Together. All rights reserved. Driver and Vehicle Licensing Agency (DVLA) of the fit. DVLA guidance3 states that someone must notify the DVLA if they have had any epileptic attacks, seizures, fits or blackouts and must stop driving straight away and should remain fit free for a period of 12 months before permitted to drive again. Attempts to contact the DVLA to confirm that the perpetrator had notified them of this seizure were unsuccessful as to date the DVLA has not responded to requests for information. Should someone not notify the DVLA about a medical condition that affects their driving they can be fined up to £1,000 for failure to notify and may be prosecuted if they are involved in an accident as a result. The Neurologist noted that the perpetrator had a car accident in 2008 when he rolled his car and there were no other vehicles involved. 3.1.7 In late June the perpetrator attended the Emergency Department with a cut to his right wrist. He was treated and discharged. A few days later the perpetrator was seen at the GP surgery for dressing of cuts, having broken three knuckles after punching a mirror in anger. The perpetrator was advised to see the doctor for anger management in relation to a “stress reaction” relating to issues regarding recent job loss, relationship & finances. The perpetrator was referred to a mental health worker appointment the same day and was started on Propranolol to lower anxiety. There is no record of him keeping this appointment. A few days later he was started on an antidepressant, Citalopram. 2010 3.1.8 In early April, Gloucestershire Constabulary responded to a domestic assault where the perpetrator was recorded as the perpetrator and the victims were the perpetrator’s partner at the time (not Laura) and her mother, the attack took place in front of the partner’s two young children. The perpetrator had pushed her into a set of shelves, then kicked and punched her repeatedly. There was also damage to three doors and her mobile phone. The perpetrator was arrested and charged with two counts of Assault and Criminal Damage. The perpetrator later pleaded guilty and was sentenced to a suspended imprisonment for Actual Bodily Harm (ABH), battery and Criminal Damage and was assessed as a high-risk perpetrator of domestic abuse. 3.1.9 Three days later, the perpetrator was seen by his GP presenting with memory loss symptoms. The perpetrator reported drinking “mildly” and was still taking Citalopram. The 3 https://www.gov.uk/epilepsy-and-driving Page 25 of 122 Copyright © 2020 Standing Together. All rights reserved. perpetrator reported his violent behaviour towards his partner and her mother but said he had, “no recollection”. The GP was concerned about seizure activity so referred the perpetrator back to neurology and this was expedited after a further seizure in late April. The perpetrator was started on medication (Epilim) in July and followed up by neurology until the perpetrator defaulted appointments and was discharged in October 2011. 3.1.10 On two occasions in April, the neurology service received a letter from the perpetrator’s GP requesting an appointment. The GP had concerns that the epilepsy nurse had not made contact with the perpetrator and flagged the perpetrator reporting of multiple episodes of memory loss. 3.1.11 In mid-May, the perpetrator attended a neurology outpatient appointment. The perpetrator’s epilepsy dosage was increased, alongside a conversation around driving issues and lifestyle related to epilepsy and a detailed letter was sent to the perpetrator’s GP. This appointment was requested by the GP following the seizure in 2009. The consultation recorded the perpetrator’s trouble with the Police 4-5 months previous and states that the perpetrator had been arrested when trying to visit his partner in hospital. The partner is not named in the records. 3.1.12 In mid-June, a letter was sent to the perpetrator from the neurologist who informed the perpetrator that the recent MRI results came back normal. 3.1.13 In later June, the perpetrator failed to attend an appointment with the Epilepsy Specialist Nurse. A letter was sent to the perpetrator’s GP. 3.1.14 In late July the perpetrator attended his appointment with the Epilepsy Specialist Nurse. The perpetrator disclosed that he had run out of his medication and had not been taking it for a few weeks. Medication was prescribed. A letter was sent to the perpetrator’s GP confirming the diagnosis of epilepsy which had been confirmed with the consultant neurologist and a record of their discussion and advice given. 3.1.15 The perpetrator attended the clinic without an appointment to see the Epilepsy Specialist Nurse as he was concerned that his rising stress levels were going to cause seizures. The perpetrator’s medication was adjusted and a summary letter sent to the perpetrator’s GP. The letter detailed that the perpetrator had focal epilepsy with complex partial seizures Page 26 of 122 Copyright © 2020 Standing Together. All rights reserved. and tonic/clonic4 seizures. The letter states that the Neurologist was trying to stabilise the perpetrator’s medication and the stress of an upcoming court case was causing difficulties in stabilising the perpetrator’s epilepsy. 3.1.16 In early December, the perpetrator attended his scheduled appointment with the Epilepsy Specialist Nurse who recorded the perpetrator’s compliance with medication had improved. A letter was sent to the perpetrator’s GP. 3.1.17 Late in this year, Laura and the perpetrator began a relationship. The perpetrator remembered that they connected through Facebook. The family have clarified that the perpetrator pursued Laura and approached her for friendship on Facebook. They had not ever met until mid-December. Laura’s family report that he came to the door during a family gathering at Christmas which was the first time they were alerted to this new relationship. 2011 3.1.18 The perpetrator moved in with Laura and Ella at the start of this year, just weeks after meeting and starting to date. This was a sudden decision from the perspective of Laura and Ella’s family and one they were unsure about. They had heard information about the perpetrator from neighbours and previous girlfriends which caused them to be concerned about his previous treatment of women but none of it was easy to substantiate. 3.1.19 At the start of February, Laura brought Ella to the GP due to concerns over hyperactive behaviour. It was recorded that Ella was experiencing problems with sleep as well as hitting and biting other children. Laura’s family, who spent time with Ella regularly, were not aware of this behaviour and question its validity. Advice was provided at the first GP consultation. Health Visitor and School support were advised to keep a symptom diary. A further consultation occurred in June 2011 but the symptom diary was not seen. Other behaviours were described, including Laura being concerned regarding Ella’s “obsessive” behaviour. The referral to Child and Adolescent Mental Health Services (CAMHS) was declined in mid-June 2011. The records noted that Laura’s fiancé had moved in 7 months prior although no name was recorded. There are also notes that the GP discussed the case with the Youth Emotional Support team (YES team) at the Kaleidoscope Children’s 4 Tonic seizures involve sudden stiffening and contraction of the muscles. Clonic seizures involve rhythmic twitching or jerking of one or several muscles. Tonic-clonic seizures are a combination of these two types in a specific pattern and are a type of generalized seizure. Page 27 of 122 Copyright © 2020 Standing Together. All rights reserved. Centre. The notes also make reference to further follow up letters to suggest involvement with the School Nurse and a note that the YES team verbally said that they were able to accept the referral but that the referral was not accepted. Laura was also referred to a parenting course and to a parental support advisor. 3.1.20 In mid-February Ella was brought to the Walk-In centre with reports from ‘Dad’ that Ella was ‘vomiting pure blood’. The IMR author highlighted that the notes make reference to ‘Dad’ but it is unclear whether this was the perpetrator or Ella’s biological father. The family have confirmed that this was referencing the perpetrator. The report sheet stated ‘nil [concerns] of note’ and advice was given. 3.1.21 In early March the School Nurse recorded a meeting between Ella’s ‘parents’ (referring to Laura and the perpetrator) and the School Nurse. It was recorded that Ella lived with her mum (Laura) and mum's partner (the perpetrator). It was noted that they have recently moved house. Laura and the perpetrator were described as engaging with the school and it was noted that Laura was supported by the perpetrator. The records indicated that Laura tended to not be consistent with discipline, it is unclear how this conclusion was established. The perpetrator told the School Nurse that Ella responded well to him and the school acknowledged this. Ella was considered to have good attendance and presented as well cared for and was in general good health. It was reported in this meeting that Ella had a tendency to wake during the night and early hours of the morning and had been refusing to go to sleep again. Ella’s bedroom was on the second floor which was located away from Laura. It was noted that the school had identified some behavioural issues in class and discussed the need for firm boundaries. It was also noted that Ella was not mixing well with children her own age, and usually engaged better with older children. It was recorded that Ella tended to be obsessive at home e.g. lines up toys, pens, and was described as liking everything in place and liked to be in control and have a routine. This conclusion has been strongly refuted by Ella’s family who did not see any indication of this in their frequent contact with her. Ella was also described as having tantrums and screams at home until the point of nearly being sick. They recalled once having to go to A&E due to Ella coughing up blood after extensive screaming. The family believe that had this been discussed with Ella, it would be clear that these behaviours were not true or were exaggerated and the root of the issue was more to do with the negative impact on the perpetrator in the home with Ella. Page 28 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.22 It is noteworthy the perspective of Laura and Ella’s family during this time; they felt that Ella was unhappy with the recent change as the perpetrator had moved in with them. They had open discussions with Ella at the time about her unhappiness with her new living arrangements and they felt that many of the disruptions for Ella at school were due to her feeling unhappy and unsettled at home and the growing tension and emotional abuse and control of Ella by the perpetrator. 3.1.23 The action plan stemming from the meeting with the School Nurse included; parenting advice given regarding strategies and boundaries; a reward chart; the introduction of a night time routine and discussion of a second routine to settle, such as a storybook tape to comfort Ella due to her being on a different floor to Laura; encouraged play and out of school activities; and Parentline Plus information provided to Ella. Strategies were also put in place at school including monitoring and liaison, the use of home- school book for communication, and the SEAL programme (Social and Emotional Aspects of Learning for secondary schools). The School Nurse met with Laura and the perpetrator for this Health Needs Assessment as part of a routine Primary School drop-in which was normal practice at the time. 3.1.24 In early April Laura called the GP surgery complaining of waking up with right arm pain. Laura was advised on the phone and then advised to come for an appointment later that day but did not attend. 3.1.25 In early July, Laura called the GP out of hours reporting a fall onto her abdomen. Laura was reported as being 10 weeks pregnant at the time. 3.1.26 Laura’s family recalled how motivated the perpetrator was to begin a family. He had moved in with Laura within the first months of their relationship and openly spoke of wanting to start a family from their earliest interactions. 3.1.27 Throughout July to September Laura attended several ante-natal scans and blood tests. It was not recorded if the perpetrator attended with her. 3.1.28 In late August the perpetrator attended the Emergency Department with an injury to his right ankle recorded as a sports injury. The perpetrator was treated and discharged. It is noted that from Laura’s family’s understanding, he was not playing sports at this time. 3.1.29 In early September, Laura spoke to the GP complaining of low abdominal pain and was recorded as being pregnant. Laura attended the Emergency Department with possible Page 29 of 122 Copyright © 2020 Standing Together. All rights reserved. appendicitis. Laura was referred to maternity triage. The obstetrician diagnosed gastroenteritis and discharged. It was not recorded if perpetrator attended with her. 3.1.30 In early November Laura reported the first of three separate acute episodes of low back pain between November 2011 and April 2012. The cause of the back pain was not known, the family believe that this could have been as a result of abuse within the relationship, however, this is unclear. It was not recorded if the perpetrator attended with her. 3.1.31 In October the perpetrator’s GP was sent a letter from the Neurologist advising that the perpetrator had failed to attend his appointment. No subsequent appointment was provided with the proviso that the GP re-refer the perpetrator if needed. 3.1.32 Laura’s family can recall an incident in 2011 which was an example of a general pattern of the perpetrator excluding Ella from family activities which led to Ella feeling excluded from feeling part of the family. The family describe Ella being left alone in the car outside the perpetrator’s mother’s house as Ella was not allowed inside the home. A neighbour had seen Ella alone in the car so went outside to speak to Ella. There are further examples of this intentional exclusionary behaviour referenced later in the report. 2012 3.1.33 Ella received her MMR vaccine and immunisations and had some medical involvement for a minor injury to her eye when playing with a friend at school. 3.1.34 In late January the perpetrator attended the Emergency Department with swelling to his right arm four days after having a tattoo. The perpetrator was referred to his GP for a same day appointment. Laura’s family recall the perpetrator had arranged his tattoo appointment on the day he and Laura were moving house, leaving her to organise and move everything on her own whilst 8 months pregnant. 3.1.35 Child A was born in February and the perpetrator was recorded as being present throughout the labour. 3.1.36 A new birth visit was conducted in early March and Laura was seen alone. The Health Visitor recorded asking Laura about domestic abuse and recorded no reports of abuse being disclosed. Laura reported having a good support system of family and friends. 3.1.37 In late March Laura and the perpetrator were visited at home by the Health Visitor for Child A’s six-week check-up. There were no concerns raised and Laura reported she felt well and had good family support. Page 30 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.38 In early April the perpetrator attended the Emergency Department following an epileptic fit which lasted five minutes. The perpetrator sustained a cut to his upper lip and dislocated his left shoulder both of which were treated in the Emergency Department. The perpetrator attended his scheduled appointment at the fracture clinic. He was advised to rest his shoulder for another week and then return for an orthopaedic review. The perpetrator attributed these injuries to a car crash following an epileptic seizure, however, there is no Police record of a road traffic accident involving the perpetrator covering this time period and the health records document that the injuries were a reoccurring sports-related injury. Laura’s family recall damage to the sink unit and cloakroom around this time and question if these could be related. 3.1.39 GP records note further dislocation of the perpetrator's shoulder due to sports and on-going shoulder issues for months. GP records noted 18 recurrent dislocations up until April 2018 resulting in the perpetrator being signed off work and referral back to orthopaedics. 3.1.40 In April the perpetrator’s GP sent a letter to the neurology service at the hospital requesting a review following the perpetrator’s first seizure in three years. The perpetrator attended his appointment at the fracture clinic and was referred to physiotherapy with a recommendation to return for an orthopaedic review in six weeks. A physiotherapy assessment was completed during this appointment and a subsequent meeting scheduled for the start of May. The physiotherapy notes recorded that the perpetrator was working as a fabricator of metal doors and participated in rugby and cage fighting. Laura’s family were not aware of any involvement in cage fighting. 3.1.41 In May, the perpetrator attended physiotherapy where a thorough assessment was carried out and tailored exercises were prescribed. The perpetrator was advised not to go to rugby. In April he reported improvement and agreed that he was happy to self manage and he was discharged in July after being told during a neurology outpatient appointment of the importance of taking his medication as prescribed. A letter was sent to the perpetrator’s GP which highlighted that the perpetrator had run out of his medication two weeks prior to his fit in April 2012. The perpetrator continued to play rugby and was again injured later in the year. Laura’s family have highlighted they were unaware he played rugby. 3.1.42 Child A was taken by Laura to routine medical appointments throughout this year. Page 31 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.43 In May there were several behaviour issues related to Ella at her school, this behaviour may have been an indication that there was stress and difficulty at home. Laura was contacted by the Children and Families Worker (CFW) and a home visit was agreed as well as a referral to the Special Educational Needs Coordinator. Ella’s birth father was not informed. 3.1.44 The family of Ella recall that during this period, Ella was eager to help with her infant sibling but that she was often not allowed and admonished for trying to help by the perpetrator. They feel that Ella felt alienated at home and remained unhappy about the perpetrator when speaking about him to her wider family. They feel this definitely affected her behaviour in school. Ella was only allowed to help with her siblings’ care when the perpetrator was not around. 3.1.45 In November Laura attended the GP seeking cosmetic nose surgery stating that this was a cause of being bullied when at school and was affecting her self-esteem. Laura was advised that this was not funded on the NHS. Both in 2007 and 2012 when having infant babies, Laura made these approaches to GPs which may indicate low mood and anxiety. Family members of Laura recall that the perpetrator was critical of her appearance and Laura told her family that the perpetrator stated that she had a “nose like a Jew”. They did not recall Laura being bullied at school but felt it may have been emotional abuse by the perpetrator that caused this request. 3.1.46 In early December, Laura was seen alone by the GP with anxiety. It was recorded that Laura was working three jobs and had a baby and a young child and was struggling to manage a work life balance. Laura was referred for mental health support and prescribed Citalopram, which was recorded as helping. 2013 3.1.47 Throughout the year Laura took Child A to all needed routine medical appointments. 3.1.48 This year the perpetrator had continued medical appointments, physiotherapy and Accident & Emergency (A&E) visits related to the injury to his shoulder. He also had a non-attendance with the Epilepsy Specialist Nurse. 3.1.49 In late October Ella was seen by the GP after Laura and the perpetrator raised concerns regarding her behaviour. They reported apparent issues previously at Infant School and then at Junior School, as well as at home. Laura and the perpetrator were advised to seek help from the school and a referral was made to Community Paediatrics. There is no record that Ella was sent an appointment or that the appointment was “chased up” by Laura or the perpetrator. Page 32 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.50 In early November a letter was received from the paediatrician by the GP, requesting an opinion on Ella’s behaviour. The letter detailed that since the age of 4-5 years Ella’s behaviour was of concern to Laura and the perpetrator and that Ella would lash out and use bad language for up to an hour, then get upset saying ‘I don’t know what I am doing’. Laura was recorded as saying there were no problems at home. Laura’s family refute this and believe she deeply disliked the perpetrator, and his control of Laura, which affected her behaviour. 3.1.51 The family of Laura felt these appointments were initiated by the perpetrator and his feeling about Ella. Ella is described quite differently by her wider family during this time who would say that while she was known to be spirited and to speak her own mind, that she was happy and agreeable outside of the family home. 2014 3.1.52 In early January, Ella was not bought to a scheduled paediatrician appointment and was discharged. 3.1.53 Child A is reported to have medical appointments and sickness very typical of a child of this age throughout this year. 3.1.54 In early March Ella was bought to A&E with a head injury following a road traffic collision. Ella was accompanied by her birth father and paternal grandmother. Ella had been in the car with her father when another car drove into the nearside passenger door. Ella had sustained a small mark to her forehead. A safeguarding risk assessment was completed and no concerns identified. Ella was discharged with head injury advice being provided to her father. Ella’s only other medical appointment is this year was due to vomiting later in July. 3.1.55 In late April Health Visitor records recorded Child A being brought into A&E with a nose injury. Family members recall the child walking into a lamppost which was the cause of this injury although it is not noted in the medical record. 3.1.56 Days later, GP records indicate that Child A sustained a fractured nose. There are no records of a follow-up letter being provided to the GP and no clear information recorded about the injuries despite the injuries being considered unusual for a two-year-old child. There was a follow-up check and a two-year check shortly after from the Health Visitor. 3.1.57 In late June, Laura visited the GP surgery and was seen alone after collapsing and was referred to the neurologist however there are no records of Laura being seen. Family Page 33 of 122 Copyright © 2020 Standing Together. All rights reserved. recall this period of time when Laura collapsed or passed out several times, they believe this was due to stress. 3.1.58 In early August, Laura attended the GP alone, reporting of knee injury following a fall. Laura was referred to orthopaedics. The cause of ongoing pain was identified as a pre-patella bursa. 3.1.59 On Boxing Day in late December, Police were called after Laura attended a neighbour’s address with a facial injury following an assault by the perpetrator at 1 am resulting in a lump to her forehead. The perpetrator was arrested and Laura declined to support a prosecution. The perpetrator was later released without charge following a Police interview in which the perpetrator denied any wrongdoing. A Domestic Abuse, Stalking, Harassment and Honour Based Violence Police risk assessment (DASH RIC) was completed with Laura by Police which initially graded her risk of harm as “standard” but this was later changed to “medium risk.” A DASH RIC is a nationally used and recognised risk checklist that professionals use in order to assess and identify risk factors.5 This will be further addressed in the analysis section. 3.1.60 On this day, Laura was taken to A&E by ambulance with a head injury following the assault. Laura was treated for Haematoma to the forehead. Laura was reported to be unsure of what happened but remembers waking up at her neighbour’s house. Laura disclosed that the perpetrator had a history of domestic abuse towards his ex-partner. A DASH RIC was completed with Laura and assessed as medium risk. Domestic abuse support was given but Laura reported to feel not at risk. Ella and Child A were reported to be with the paternal grandparents of Child A. The perpetrator was believed to be in custody when Laura was discharged home. The Health Visitor liaison form was attached to Laura’s SystemOne record 10 days later and sent to the Health Visitor and School Nurse in relation to the whole family. Laura did not meet the clinical criteria for a CT scan. 3.1.61 The hospital’s record indicated that there had been an argument between Laura and the perpetrator late in the evening on Boxing Day over the perpetrator returning home late. Laura’s family have since clarified that this was not correct as Laura and the perpetrator were given a lift home by the family after a meal together. During the completion of the DASH RIC assessment which was assessed as medium risk Laura disclosed that the 5 http://www.safelives.org.uk/practice-support/resources-identifying-risk-victims-face Page 34 of 122 Copyright © 2020 Standing Together. All rights reserved. perpetrator had ‘lost it’ (direct quote from Laura noted on the file) and punched her in the face. No immediate loss of consciousness was recorded, but Laura left the property immediately with Ella. Whilst there is no record to indicate that an IDVA referral was discussed, this risk assessment would not have triggered a referral to an IDVA as no consent had been given and the DASH RIC was not graded as high risk. It is not known if Ella witnessed the assault. Once Laura was outside of the address she collapsed, it is not known if this was outside Laura’s address or the neighbour’s address. The neighbour called Police and an ambulance. The notes made several references to the perpetrator being sober at the time of the assault, however, the family have stated that the perpetrator had been drinking during the evening. The family provided a different account of this evening advising that the family had been together for Boxing Day and both had been drinking, Laura’s sister had then dropped both Laura and the perpetrator back to their home address at the same time. It was also noted in the hospital records that Laura was working three jobs at this point including being a private hire driver, owning her own business and working in a pub but was experiencing financial problems. Laura’s family explained that the perpetrator made Laura pay for everything and they believed that the perpetrator controlled the family finances. 3.1.62 5 days later6 the Police sent a Multi-Agency Referral Form (MARF) form to Children’s Social Care. The DASH RIC referral sent by the Police had assessed the risk to Laura as medium. However, the Social Worker later highlighted that the risk is likely to be high. 3.1.63 It is notable that the entries above describe the incident from the recorded perspective of the Police, Social Worker or medical professionals involved. Laura’s family recall this night vividly as many had seen Laura just prior to the incident and Laura’s sister arrived at the scene when the Police were still there. 3.1.64 Laura’s family have reflected that they feel this was a critical missed opportunity to reach Ella and to address her trauma in seeing her mother in distress. Laura’s family provided the following recollection of the night. Both the perpetrator’s mother and Laura’s sister arrived to help, the perpetrator’s mother arrived first and was questioning the neighbour as to why she had called the Police. Laura’s sister stood at the Police car as they drove off with Ella and Child A begging for the Police to listen to her so that Ella was not taken to 6 This is explored further within the analysis section. Page 35 of 122 Copyright © 2020 Standing Together. All rights reserved. the perpetrator’s parents’ home. She made her objections clear in particular her objections to the perpetrator’s mother’s differential treatment of Ella and her challenging the rationale for Police being called but they feel this was ignored. The Police allowed for both Ella and Child A to go home with the perpetrator’s mother and the Chair and panel acknowledge that their intention would have been for the children to be cared for in another location as quickly as possible. 3.1.65 There is no recording of decision making about the placement of the children on the night and with changes and personnel and the length of time since the incident, the full context of this decision is unclear. This level of recording is not unusual. Police make many decisions of this nature spontaneously every day and there is not an expectation that this rationale for this kind of decision making is recorded. However, Laura’s family feel strongly this was the wrong decision for a number of reasons. First, Ella was not the grandchild of the perpetrator’s mother. Her relationship with her was significantly different than her younger sibling who received gifts from her and was treated as a grandchild. They feel certain that it would have been more comfortable for Ella to have been with her mother’s family members or with her biological father during this time. They also highlighted that there were no efforts to contact Ella’s birth father. They feel the consequence of this was that Ella shut down and decided not to speak to her wider family about what had happened that night, what she saw or experienced. 2015 3.1.66 Seven days after the Boxing Day incident, Children’s Social Care Multi-agency Safeguarding Hub (MASH) received a call from a neighbour and the record of contact was recorded on the Early Help system. The neighbour had raised concerns following the domestic violence incident and concerns for Laura and the children. A plan was made for Children’s Social Care to liaise with the School Nurse Team regarding the children. A referral to the Health Visitor was completed with a request to do a follow-up visit in addition to a referral to the multi-agency support team. 3.1.67 In 2014, the Boxing Day incident was recorded by Children’s Services five days after the incident and was considered in the MASH the next day. The MASH manager reviewed this case two days later and the information about this incident was sent to partners for information sharing. The case was closed a week later. Partners, including Children’s Social Care responded with any information they held between those dates. The MASH manager finalised the case by saying, "This incident is not high in its own right however Page 36 of 122 Copyright © 2020 Standing Together. All rights reserved. the perpetrator has been previously high. Positive Police action has been taken although due to no complaint no additional action has been taken. This is also going to MASH from Social Care and I will discuss consideration of Domestic Violence Disclosure Scheme (DVDS) with them before they carry out any visit". This will be further discussed in the analysis section. 3.1.68 A standard DASH RIC was completed and recorded as medium risk. Laura did not “wish to press charges”. Police reported that the perpetrator had been recorded as a high-risk offender of domestic abuse towards a previous partner. A MASH episode was instigated under the Children Act 2004. A separate MASH record was made in relation to the perpetrator’s previous assault towards his ex-partner in April 2010. It was also noted that Laura did not wish to be referred for support from Gloucester Domestic Abuse Support Service (GDASS). An amber RAG rating was recorded and the outcome was to initiate an assessment. 3.1.69 The same day, Ella’s school record was uploaded on Children’s Social Care records. No specific concerns were recorded however attendance was identified as being low at 88.82% with 7.24% unauthorised absence. 3.1.70 The next day, Gloucestershire Care Services sent a letter to schedule a home visit appointment for 5 days later due to being unable to reach Laura over the phone. 3.1.71 Mid-January, a record was made by Children’s Social Care for Ella’s case to be stepped up to Children’s Social Care, detailing initial assessment to be completed and consent to be obtained to share information. The decision behind carrying out the initial assessment was recorded as being due to the assault on Boxing Day and the perpetrator’s previous high-risk domestic abuse history. 3.1.72 In Mid-January the Health Visiting service attended the home address for a scheduled home visit to see Child A who was under universal health visiting services however there was no answer. A new visit letter was sent with a date for the end of January. 3.1.73 At the end of January, Children’s Social Care carried out a visit to complete the Initial Assessment. Laura was spoken to alone and advised the Social Worker that there had been no violence and the perpetrator had not punched her. Laura informed the Social Worker that the perpetrator’s elbow had slipped and Laura had fallen. Laura said that she went upstairs and lost her footing and hit her nose on the bannister. Laura categorically said that the perpetrator did not hit her in the face deliberately. The Children’s Social Care Page 37 of 122 Copyright © 2020 Standing Together. All rights reserved. record indicates that Laura was ‘drunk’7 at the time of the incident. However, the Police records recorded that the perpetrator had denied the offence and stated that Laura had been drinking and the injuries she had sustained were as a result of her “drunken behaviour”. This potentially gives perpetrators of abuse the possibility of controlling the narrative and discrediting the account and potentially controlling the narrative, especially in circumstances where the victim is unable to or does not wish to make a statement. Laura’s family believe that an assumption was made that Laura was drunk due to her appearance and presentation, however, the family believe that the symptoms that were interpreted as Laura being drunk were more likely to have been that she was stunned as a result of sustaining an assault to her head and the possibility of concussion. 3.1.74 The worker spoke to Ella who said that her “father” elbowed her mother and Laura fell. The perpetrator informed the worker that Laura and he “got on well”. It is unclear if Ella described the perpetrator as her father or if this was how her comments were recorded. Laura’s family stated that Ella would not have referred to the perpetrator as “father” as she would not describe him as a step-father and would only ever refer to the perpetrator by his first name. January supervision notes are recorded by Children’s Social Care that detail the Social Worker challenging Laura’s account of the incident and questioning her version of events in relation to the domestic abuse. The notes also detail previous incidents of domestic abuse which the Social Worker was aware of. Actions for follow up were recorded as well as a record of next steps and Claire’s Law. 3.1.75 The initial assessment was completed and accompanied by assessment notes. It was noted that Ella had lower attendance at school due to a family holiday. When the Social Worker spoke to Ella about school Ella informed the worker that she liked dance and maths. Ella then went on to tell the Social Worker that the perpetrator and her mother got on well. The Social Worker noted that this had not been prompted by the Social Worker so wondered why Ella had said this. Laura’s family believe that the perpetrator would have pressured Ella to say this. Later during the conversation with the Social Worker, Ella said that the perpetrator had hit her mother at which point the Social Worker recalled that Laura looked shocked and paused talking. Laura then stated that he had hit her with his elbow. The Social Worker recorded that Laura had provided several different versions of 7 Laura’s family recall that Laura was not drunk at the time and both Laura and the perpetrator had been drinking prior to being returned home. The use of language and recording of alcohol factors is explored further within the analysis. Page 38 of 122 Copyright © 2020 Standing Together. All rights reserved. what happened, and that it was only when Ella had disclosed that the perpetrator had hit Laura that Laura then added that the perpetrator had hit her. The Social Worker also later spoke to Ella’s birth father who said that he had seen no change to Ella’s behaviour and that Ella was doing well at school. The outcome of this initial assessment was recorded as no further action. 3.1.76 The health visiting service recorded no access to the rescheduled planned home visit. This was followed up with a call to the GP to confirm contact details. 3.1.77 At the end of January, a different number was recorded on the GP records. A call was made to Laura to arrange a visit from the Health Visitor. This contact was successful and a visit was arranged for the following week. 3.1.78 In early February, the health visiting service carried out a family health needs assessment review at the family home. No concerns were raised in relation to Laura’s mental health. Laura was recorded as not having any concerns for Ella or Child A’s physical health. The Health visitor recorded seeing both Laura and Child A at the home. Domestic abuse was discussed and the incident on Boxing Day was discussed as part of this. Laura disclosed that she and the perpetrator had been drinking at her parents’ house and that she was quite drunk8. When they got home the perpetrator was at the top of the stairs with the children ready to put them to bed when he turned and caught Laura with his arm. Laura described losing her balance and fell on the stairs hitting her nose on the bannister. Ella screamed and went to the neighbours who then rang the Police. Ella was recorded as speaking to the Police and confirmed how the accident happened. Ella and Child A were recorded as staying with their paternal Grandparents whilst Laura was at hospital and the perpetrator was at the Police station, this refers to the perpetrator’s mother as opposed to Ella’s paternal grandmother. Laura’s family felt that no verification of relationship was sought and therefore did not enable the children an opportunity to disclose. The Health Visitor asked Laura if she was afraid of the perpetrator or if he had ever been physical towards her to which she answered no to both. A good reciprocal relationship was noted between Child A and Laura. No parental concerns were reported for Child A who presented as a lively happy child and was up to date with all immunisations. No further action was taken and the outcome was that Ella and Child A were put on universal health 8 Laura’s family refute this and believe Laura said this to protect the perpetrator. Page 39 of 122 Copyright © 2020 Standing Together. All rights reserved. services. The Health Visitor ensured Laura could contact her anytime and had open access to the Health Visitor alongside ensuring that Laura had contact information about GDASS (the domestic abuse service). 3.1.79 In early February, the perpetrator attended the Emergency Department with an injury to his left shoulder after playing rugby the previous day and then falling off stairs on the day of attending. The perpetrator was treated and discharged. 3.1.80 In mid-February, Children’s Social Care supervision records note that Laura had been contacted about domestic abuse history but had not responded to the Social Worker. An action was set for the school and health to be contacted for further information for the assessment. The perpetrator had informed the Social Worker that Laura was aware of his domestic abuse history and conviction. 3.1.81 Towards the end of February, the Social Worker exchanged emails with the Local Authority Designated Officer (LADO). The LADO informed the Social Worker that Laura had minimised the impact of domestic abuse and the perpetrator’s violent behaviour history and therefore should not be working with other children. The concerns were shared that Laura was minimising the recent incident and denying domestic abuse which was raised as a concern due to Laura working as a driver for Gloucestershire County Council and therefore had contact with children. Laura’s family commented that if the Social Worker had safeguarding concerns then this should also have extended to safeguarding concerns to the two children residing in the household. 3.1.82 The same day, the Social Worker called Laura to discuss concerns around the perpetrator’s previous history of violence towards an ex-partner and her mother for which he was convicted of assault. It was recorded that Laura believed that the perpetrator had been convicted due to pleading guilty in order to “get it over with”. The Social Worker stressed that without evidence, the perpetrator would not have been convicted but recorded that this “made no difference to her”. 3.1.83 At the end of February the Social Worker called Ella’s father, who informed the Social Worker that he had seen Laura with two black eyes over Christmas and Ella had not mentioned the incident. There was a discussion about the recent incident and the Social Worker informed him that Ella had gone to the neighbour’s house with Laura when the Page 40 of 122 Copyright © 2020 Standing Together. All rights reserved. incident occurred9. This assessment was recorded in supervision notes for the Social Worker which indicates oversight of this issue. 3.1.84 In early March, Laura attended the Emergency Department with an injury to her left knee. Laura was seen in triage and advised that as it was a long wait that evening she would be safe to return in the morning. 3.1.85 In mid-March, records show that there was a discussion with the Deputy Head who reported that Ella had been in school and had some absences due to a holiday. It was determined that there was no role for the school nurse. 3.1.86 In early April, the health visiting service recorded telephone contact with Children’s Social Care as the allocated Social Worker had contacted them wanting information on Child A due to a recent referral for a domestic abuse incident. Whilst notes were not explicit, this appears to be in relation to the incident on Boxing Day (3 months earlier). It was agreed that the level of service would change to Universal Partnership Plus, with an action for the Health Visitor to await the outcome from Social Care. It was noted that Child A’s parents needed to provide a conflict-free environment so that this does not impact on Child A’s emotional health and well-being. This resulted in the case being re-opened to the Health Visiting Service on the Universal Partnership Plus (UPP). UPP is an enhanced level of service. 3.1.87 In mid-May, a case closure letter was sent from Children’s Social Care to Laura and the perpetrator, the school10 and Ella’s father. 3.1.88 In mid-July, Laura booked an appointment with the community midwife. An antenatal assessment was completed and an appointment schedule was drawn up. The midwife’s records noted the perpetrator’s diagnosis of epilepsy and recorded no social problems or concerns around mental health. 3.1.89 In late July Laura’s maternity book was completed with her during a home visit. Laura was asked about domestic abuse during this visit and advised that there was no history of domestic abuse. A lone working community midwifery risk assessment was completed 9 Laura and Ella’s Family have subsequently stated that Ella did not attend with Laura during this incident 10 It is noted there is no evidence the school received this letter. This is further discussed in the analysis section. Page 41 of 122 Copyright © 2020 Standing Together. All rights reserved. and indicated a low risk of violence or aggression in the home which is the lowest grading available. 3.1.90 In early August Laura attended A&E with a burn to her left index finger. Laura was referred to the burns clinic as the burn involved a joint. Laura was pregnant at the time and was not asked about how the burn was sustained. 3.1.91 Between August and October Laura attended routine ante-natal check-ups and scans. 3.1.92 In early December Laura was seen in the ante-natal clinic with pelvic pain and was referred to physiotherapy. 3.1.93 Just before Christmas, Laura was seen in the ante-natal clinic and a note was recorded of her plans to travel to Disney the following day. 2016 3.1.94 In mid-January, Laura had telephone contact with maternity seeking advice for pelvic pain and was referred to the GP and physiotherapist. A few days later Laura was seen in the ante-natal clinic and was using crutches for pelvic pain. This contact extended into February as the pain was ongoing. 3.1.95 Child B was born in February. The perpetrator was present with Laura throughout the duration of the labour. Laura’s family recall that the perpetrator’s mother attended the birth before Laura’s existing children had met their new sibling. They remembered that Laura had wanted her children to see Child B before other visitors attended. 3.1.96 In late February, the Health Visiting Service carried out a new birth visit which took place with both Laura and the perpetrator. A discussion was had around maternal wellbeing and the Health Visitor had no concerns over their physical health. Family health was discussed and Best Practice Benchmark was completed where no health needs were identified. Laura stated that she was well and the maternal mental health checks raised no concerns with no history of poor mental health reported. It was agreed that the level of service was Universal. No domestic abuse question was asked due to the perpetrator being present. Attempts were not made to speak to Laura alone. All checks with Child B were completed with no concerns. A follow up was scheduled for six weeks. 3.1.97 In late March, a 6-8 week post-natal check-up was completed with Child B. Discussion took place around maternal wellbeing. No enquiry around domestic abuse was asked due Page 42 of 122 Copyright © 2020 Standing Together. All rights reserved. to Ella being present. No health concerns were identified so it was agreed for the level of service to remain as Universal. 3.1.98 In late May, Child B was taken to the Health Visitor Clinic. Records indicate that the domestic abuse question was unable to be asked due to the perpetrator being present. There were no plans recorded as to how this enquiry could be achieved by seeing Laura on her own. 3.1.99 At this appointment, advice was given about weight management and a discussion about maternal wellbeing. The local Health Visitor Service and amenities were explained. A repeat development review was scheduled for three months time due to Child B not meeting all of their developmental milestones. Laura was advised to contact the Health Visiting team if she needed anything prior to the next scheduled review. Laura disclosed an episode of depression before having Child B when she was setting up her own business. Laura felt that this was due to work stress and reported feeling better after medication. There were no current mental health concerns raised at the time. Advice was given in relation to speech and language development and Laura was advised to see the GP if some raised spots on Child B’s nose did not clear in a couple of weeks. It was noted that the perpetrator was present for these visits and contact with the clinic, so no discussion was had in relation to domestic abuse. 3.1.100 Between June and November, there are various services for the three children and for the perpetrator for routine or unrelated medical concerns. 3.1.101 In early December the Junior School recorded that Ella had made comments both verbally and via text message to others in the class. It was recorded that Ella had been affected following the traumatic death of her second cousin in 2015 and had since written text messages that indicated that she was under stress. These were not admitted to by Ella but Laura was informed during a telephone call with the school. Ella had sent a message saying ‘life is rubbish and I have no friends’. Laura was encouraged to seek support for Ella via the GP or another agency. It is recorded that Ella had fallen out with her friends at school and Laura stated that Ella’s Dad had bought her a phone and Laura didn’t agree with this decision. Laura’s family recall that it was the perpetrator who was not happy with Ella having a phone and he had intentionally broken two of Ella’s phones by smashing them, including once when he smashed the phone with a hammer, however, the school was not made aware of this. Page 43 of 122 Copyright © 2020 Standing Together. All rights reserved. 2017 3.1.102 From interviews with Laura’s family, they recalled further examples of alienation of Ella. For example, the perpetrator would not allow Child A and Child B to share a room with Ella. Ella had to always sleep in a separate room away from her siblings. Ella was often told by the perpetrator that she “was not a [Perpetrators Surname]”. Child A was heard saying to Ella “my dad said you’re not [Perpetrator’s Surname] you’re a “[Ella’s biological fathers’ surname], you’re not part of this family”. 3.1.103 In late February, Laura was seen by the GP for acute low back pain. An MRI was completed and a referral made to the musculo-skeletal services. 3.1.104 In late September, the Infant School received a request for unauthorised absence for November as Laura and the perpetrator were unable to secure holiday during the summer months due to work demands. This leave of absence was refused by the school. Laura’s family recall that the family had gone on holiday at the perpetrator’s insistence. 3.1.105 In late October, the Health Visiting Service phoned Laura to check on Child B’s development. Laura reported being happy with Child B’s development and felt that their speech was progressing. Laura declined a visit from the Health Visitor at this time and was happy to see the Health Visitor at the two-year check-up. 3.1.106 In early November, Laura phoned Ella’s school to advise that Ella would be on holiday for two weeks. Laura was advised that a possible penalty notice would be issued. 3.1.107 In mid-December, a penalty notice was issued as a result of Child A’s unauthorised absence from school (for the November holiday). 3.1.108 In late December a letter was sent to Laura and the perpetrator regarding the amount of incidents that Child A had been late after the registration had closed. This was recorded as four incidents totalling 95 minutes. 2018 3.1.109 In January the teacher phoned Laura regarding an incident during class and a meeting was scheduled for the following day to discuss Ella’s school progress. Laura did not attend this meeting due to having another appointment and was happy not to rearrange the meeting. 3.1.110 In late January Ella was recorded as being upset at school. Ella disclosed that she ‘was taking on too much’ and ‘supporting mum’. When asked what she was upset about Ella Page 44 of 122 Copyright © 2020 Standing Together. All rights reserved. said she was upset over her step-dad’s affair. Ella was asked if she was “ok with [the perpetrator]” and Ella said yes. Ella was asked if she was worried about the perpetrator and she said she was not worried but that she was confused over the affair. This was followed up with a telephone call to Laura who explained that the women the perpetrator had had an affair with had called the family home over the weekend and had told her about the affair. This was why Ella was upset in school as Ella did not understand why her mum was still with the perpetrator after the affair. Laura also asked if the school could look into some issues that Ella was having with some other students. Ella was offered support from the school. 3.1.111 Laura’s family recalled an incident in March where the perpetrator had attempted to isolate Laura from her support network as he had tried to prevent Laura from seeing her mother for Mother’s Day and had threatened her stating “if you go to see your mum on Mother’s Day we’re finished”. 3.1.112 In mid-March, Laura was seen by the GP regarding weight-loss related to stress which was associated with her divorce. A review appointment was booked but not kept. 3.1.113 On two occasions in March Child B was not bought to the developmental clinic. A follow-up text was sent to Child B’s parents to rearrange. 3.1.114 In late March, a telephone call was made to Laura regarding Child B’s two-year check, Laura stated that she had no concerns and declined. This is consistent with Child A’s two-year check that was also declined. 3.1.115 Laura’s family recall that in late April the perpetrator sent flowers to multiple female family members of Laura with a note saying “my sincere apologies” which they describe as his way of apologising to the family for having an affair. 3.1.116 In early May Laura had received a steroid injection which the family explained Laura had received due to having a back injury that had been causing her pain. Laura’s family recall that at the same time Laura was bought a new car however the perpetrator would not allow Laura to drive this stating that this was due to her poor health as Laura was experiencing problems with her leg which kept giving way. They felt that these injuries could potentially have been as a result of domestic abuse as Laura had also lost a significant amount of weight and was reported as being frequently exhausted. 3.1.117 Laura’s family described how Ella’s behaviour visibly changed about two weeks prior to the homicide. Page 45 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.118 In mid-May, the perpetrator attended the Emergency Department and was diagnosed with a displaced fracture of the base of his 4th finger. This required surgery to repair so he was admitted. Temporary improvement was achieved and the perpetrator asked to go home overnight as his wife had to go to work. The surgeons agreed to an overnight leave and for the perpetrator to come back in for surgery because they were not able to take him to theatre until the following day and there was nothing clinical to be gained by him staying overnight in the hospital. The perpetrator reported falling awkwardly against a wall on an outstretched right hand. The perpetrator was at no stage asked to clarify his account despite the discrepancies between the injuries and the reason given. The panel was advised that the injuries sustained to his hand would only occur if his hand had been closed into a fist. Therefore, the injury could only have occurred if he were holding an object tightly in the hand as he fell or if he had punched something. The panel discussed that the injury did not fit the explanation but that medical staff would tend to accept the reason given by a patient in this circumstance and that any referral made would be done with the consent of the patient. 3.1.119 During this time Child A told the school that their Dad had broken his hand and was in hospital. Child A was asked if the perpetrator had had an accident and Child A said that he smashed the door with his hand and Child A could see the big lump. Child A was asked if they had seen it happen and Child A confirmed that they had seen it happen and it was a bit scary. It was recorded that Laura and the perpetrator had been having a row and they were shouting, the perpetrator then hit his arm on the wall. This does not appear to have resulted in any follow up with either Police or Children’s Social Care in relation to children witnessing aggression in the household. 3.1.120 Laura’s family noted that following Child A’s disclosure to the school the perpetrator started doing all of the school pickups whilst Laura would be required to remain in the car. This has not been able to be verified by school records but is Laura’s family’s recollection. Laura’s family believe this was in order to ensure that the school were unable to speak to Laura on her own regarding the disclosure. 3.1.121 A few days later the perpetrator had surgery to fix the fracture to his hand. He was discharged with a plan to review at the end of May and remove the wiring after four weeks. 3.1.122 The next week the perpetrator attended a follow-up appointment in the Fracture Clinic where checks were made and a new plaster fitted. Page 46 of 122 Copyright © 2020 Standing Together. All rights reserved. 3.1.123 Laura’s family recall Laura had ended the relationship and had been heard saying to the perpetrator “you’ve got a week to get out, it’s over”. 3.1.124 In late May the perpetrator murdered Ella and Laura at their home and was arrested after initially fleeing the scene. 3.1.125 The same day of the homicide the Police brought the perpetrator into the Emergency Department with cuts to both hands and legs. Later that day he was brought back again with Police, claiming to have taken excess medication for the last week. The perpetrator was returned to Police custody after no toxic features were found in blood tests. Page 47 of 122 Copyright © 2020 Standing Together. All rights reserved. 4. Overview 4.1 Summary of Information from Family, Friends and Other Informal Networks: 4.1.1 The chair and report author met with the family of Laura and Ella on three occasions, and the panel met with the family on one occasion. The Chair also took part in two Zoom meetings; one prior to a meeting with Children’s Services and the other with the family and Children’s Services. Throughout this report, the views of the family are embedded in both the Chronology section and the Analysis and Lessons to be Learned. The chair and panel thank them for their valuable insight and engagement throughout this process. Their contributions have greatly enhanced this review. 4.2 Summary of Information from Perpetrator: 4.2.1 The perpetrator was interviewed for this review on 30/04/2019. 4.2.2 He described his upbringing as happy. He was the only child of a couple who were married for 26 years and had separated when he was an adult. Both parents were active in his adult life. 4.2.3 He described that his seizures started at age 17 and had lasted for 5 years. He said that his last seizure was in 2012 when a seizure caused a car crash and when he broke his shoulder. Health records indicate that these dislocations were primarily as a result of the perpetrator continuing to play rugby despite repeat dislocations. 4.2.4 Laura’s family note that they believe his shoulder broke during an incident at home, rather than in a car accident. They also highlighted that the perpetrator had been told on multiple occasions not to play rugby and that he should have submitted the details of his alleged epilepsy to the DVLA. 4.2.5 He described his profession as a data engineer. He worked in Newcastle before Gloucester and worked long hours. Attempts were made to contact Network Rail as the perpetrator’s employer but these were unsuccessful so this was unable to be verified. 4.2.6 When asked about any early source of support or help, he referred to an incident many years before meeting Laura when he sustained injuries to his hand after breaking a mirror in frustration and anger shortly after a relationship breakdown. His father accompanied him to the GP and he was prescribed anti-depressants but there was no discussion of his relationship breakdown. He felt this medical intervention worked. He was able to move to Newcastle and work. Page 48 of 122 Copyright © 2020 Standing Together. All rights reserved. 4.2.7 When asked about his understanding of domestic abuse, the perpetrator clearly understood that the range of abusive behaviours included coercion and control. However, he denied this was a dynamic of his relationship with Laura. When asked about the known Police incidents of domestic abuse with his previous partner and with Laura, he described them as isolated incidents and was unable to connect these behaviours with any other wider controlling behaviours. 4.2.8 The perpetrator noted that he had accumulated £30,000 of debt and had an Individual Voluntary Arrangement (IVA) by the time of the murders. He noted that despite financial worries, their decision to take costly holidays was due to the pressures on the family and so they needed to get a break. 4.2.9 Laura’s family have stated that the perpetrator had told Ella that she was not allowed on the holidays that were booked which the family described as the perpetrator’s further attempts to isolate Ella. They also recalled how £28,000 of this debt was the perpetrator’s and £2,000 was Laura’s prior to this debt being linked. They explained that Laura was not aware of the extent of the perpetrator’s debts until after her bank card was stopped and she had gone into the bank to enquire why her card had been blocked. Further examples of economic abuse were also present as Laura’s family recalled that all of Laura’s money was always directly transferred into the perpetrator’s bank account. Every month when Laura received her wages they were automatically transferred into the perpetrator’s account. 4.2.10 The perpetrator said that over a period of two years while working, he often felt suicidal and remembers considering jumping in front of trains. This was due to his financial issues and the pending divorce of his parents. The perpetrator felt he would have sought help from his employer but knew that they had strict policies which would mean that he would not be able to work if he disclosed his suicidal thoughts. He knew that any medication he would be prescribed would be disclosed to the on-call chemist at his work which could have meant that he would have been unable to work. 4.2.11 The perpetrator was active in rugby and had a network of friends through this sport, but he did not feel able to speak to teammates about his feelings or problems. 4.2.12 The perpetrator disputes that he and Laura were separating at the time of the murder. He states they had a planned trip to Mexico. 4.2.13 It is noted that it is now known that he had been asked to move out by this time. Page 49 of 122 Copyright © 2020 Standing Together. All rights reserved. 4.3 Summary of Information known to the Agencies and Professionals Involved 4.3.1 Primary Care and health information regarding Laura 4.3.2 Laura sought health services when she had sustained injuries which may or may not have been related to domestic abuse. In the period from July 2011 to April 2012 Laura reports one fall onto her abdomen and further episodes of low abdominal pain to the GP surgery. Through this time period, Laura is pregnant (with Child A). 4.3.3 In November 2012, Laura self-reported low self-esteem. One month later (December 2012) she was seen for anxiety, and seemingly a discussion about stressful home circumstances and work/life balance. Anti-depressants were prescribed alongside a mental health referral. 4.3.4 In June 2014, Laura is referred to neurology following a collapse but there is no evidence that she was seen there. In August 2014, Laura reports falling and injuring her knee. 4.3.5 In January 2015, Laura is noted as being assaulted, she initially disclosed to Police she was punched in the face, but later says she hit her nose on the bannister on Boxing Day 2014. 4.3.6 In February 2017, Laura is seen for low back pain, initially started as an acute episode but prolonged and then referred for specific support. Although not disclosed or recorded by agencies, Laura’s family believe her back pain was due to the perpetrator’s abuse. 4.3.7 In March 2018, Laura presented with stress issues and weight loss, expressing that she has stress related to her divorce. 4.3.8 Gloucestershire Care Services NHS Trust information regarding Laura 4.3.9 Laura was supported by health visiting staff throughout the early lives of all of her children. Records indicate proactive follow up for routine visits and care for all three children. Routine questions regarding domestic abuse were asked when Laura was alone. 4.3.10 After the Boxing Day incident in 2014, Laura was seen in A&E with a head injury following an alleged domestic assault by the perpetrator. From the Paediatric Liaison Health Visitor (PLHV) record, Laura reported to hospital staff that she was unsure how this injury had happened and had woken up at a neighbour’s house. A DASH RIC was undertaken and noted as medium risk. The score was not recorded within GCS records. The perpetrator was taken into custody. The children were noted by Police to be with their paternal grandparents and Laura was discharged home (although it is important to note that while Page 50 of 122 Copyright © 2020 Standing Together. All rights reserved. Ella was with her siblings, she was noted to be in the care of her paternal grandparents, the perpetrator’s parents). The GCS recorded planned liaison with School Nurse and a referral to the Health Visitor was made. 4.3.11 Heath Visitors were made aware of the Boxing Day incident in 2014 and were proactive in following up with Laura and her family. After three no access visits, the Health Visitor was able to visit the family in early February 2015. The visit took place at home and a family health needs assessment was undertaken and Laura was asked about the recent alleged domestic abuse incident. It is recorded that Laura stated she and the perpetrator had been drinking at her parents’ house and she was quite drunk11. When they got home the perpetrator was at the top of the stairs with the children ready to put them to bed, when he turned and caught Laura with his arm, Laura lost her balance, fell down the stairs and hit her nose on the bannister. Ella was spoken to by the Police, and she confirmed this was how the accident happened. The Health Visitor asked Laura if she was afraid of the perpetrator or if he had ever been physical towards her and she said no to both enquiries. 4.3.12 Primary Care and health information regarding Ella 4.3.13 All the records regarding Ella from her infant/early years reflect the range of appointment and health services that one would expect during infancy and early childhood. The panel found that as notes are not always clear, it is not fully understood when the perpetrator was present or not which poses a challenge for understanding the context of the appointments. 4.3.14 In February 2011, there were a series of GP consultations from Laura’s concerns about Ella’s behaviour being hyperactive, with sleep problems and some challenging issues from Ella (biting and hitting other children). This would be the same period of time when the perpetrator moved in with Laura and Ella (two months into the relationship between Laura/the perpetrator). A referral to a CAMHS support team appears to be declined but with a signposting to parental support and a parenting programme. 4.3.15 A letter from Ella’s GP to the Community Paediatricians at Gloucestershire Healthcare Trust (GHT) dated early November 2011 asking them to review behaviour as parents had noticed that, Ella did not listen when they talked to her and that she would get very angry 11 Laura’s family have advised that both Laura and the perpetrator had been drinking but were not drunk. Page 51 of 122 Copyright © 2020 Standing Together. All rights reserved. if repeatedly asked to do something. The letter stated she would then lash out and use bad language for up to an hour and then get upset saying ‘I don’t know what I am doing’. This behaviour was occurring at home and at school. At this point, Child A was aged 21 months and Laura had told the GP there were no problems at home or overt sibling rivalry. An appointment was arranged, but Ella was not brought to this. Laura’s family’s reflection on this is that they saw Ella on a regular basis and did not witness any evidence that would corroborate this account of Ella’s behaviour. They felt as though this account was fabricated by the perpetrator as a means of discrediting Ella as this account did not actively reflect any of their experiences of Ella. They feel that Laura had potentially been coerced into supporting the perpetrator’s account or did not feel able to contradict this. 4.3.16 In October 2013, the perpetrator and Laura attended the GP with concerns about Ella’s behaviour. They discussed previous issues at Infant School, now at Junior School as well as problems at home. Alongside advice to seek the help of the school, the GP made a referral to Community Paediatrics, which is expected practice, but it is unclear about the status of follow up with this appointment or whether the child was taken to this. Laura’s family stated that the perpetrator always accompanied Ella to the GP so Ella would not have had the opportunity to speak to the GP alone. GPs do not regularly record if an adult accompanies a child to an appointment. GPs should consider seeing a child alone when he/she may seem reluctant in front of the parent and will have to employ professional judgement in these situations. Learning from this review should highlight the need for GPs to consider when to speak to teens alone to fully understand how they relate to parents and or step-parents, in order to understand the protective factors or potential risks to the child. 4.3.17 Gloucestershire Care Services NHS Trust information regarding Ella: 4.3.18 In February 2011, Ella attended Gloucestershire Walk-In Centre due to vomiting. Noted to be seen with ‘Dad’, but it is not clear whether this is the biological father or the perpetrator. ‘Dad’ has stated that Ella is ‘vomiting pure blood’, although hospital records from this presentation are clear this was not observed. Laura’s family have confirmed that this was not Ella’s biological father but instead refers to the perpetrator. 4.3.19 Primary Care and health information regarding the perpetrator 4.3.20 Most of the perpetrator’s contact with medical professionals stem from the treatment of epilepsy and injuries related to sport. There are indications throughout the perpetrator’s contact with medical professionals that he reported stress and disclosed he had conflict Page 52 of 122 Copyright © 2020 Standing Together. All rights reserved. with others including intimate partners. The perpetrator was regularly recorded as not attending appointments and non-compliance with his medication in relation to his epilepsy which was described by panel members with experience of responding to epilepsy as not being untypical of how many patients with a similar diagnosis behave. 4.3.21 In July 2009, the perpetrator presented to GP for dressings to hand, with knuckle injury following punching a mirror. The perpetrator has disclosed stress issues, related to losing his job, relationship and financial worries. The GP refers to mental health and treats for anxiety. There is mention of the GP surgery discussing further with the perpetrator’s father, this is noted to be supportive and caring practice. There is no reference to who the perpetrator is in a relationship with, which would not necessarily be an expected question to ask in these circumstances. 4.3.22 In December 2010, the perpetrator was subject to probation but the GP Practice did not record what this related to, so it is unclear what they knew about this and whether it may impact on any relationships or family contacts. 4.3.23 Gloucestershire Hospitals NHS Foundation Trust regarding the perpetrator 4.3.24 The perpetrator has attended GHT frequently over the period in question mainly for treatment and assessment of epilepsy and for shoulder injuries related to rugby. In 2008, he started having epileptic fits and subsequently had several appointments with neurologists and the Epilepsy Specialist Nurse. It is evident at the beginning of this period that the perpetrator has been involved in domestic abuse with a previous partner as mention is made of a pending court case. Throughout this period the staff involved endeavoured to ensure that the right medication and dosage was prescribed to keep the perpetrator fit-free. The perpetrator did not attend all his appointments, but notes show that letters sent to his GP and him after each appointment, whether or not he attended. 4.3.25 Children’s Social Care (CSC) summary of information related to all parties: 4.3.26 Children’s Services became involved following the Boxing Day incident in 2014 when Laura was injured and fled to her neighbour’s house. In the assessment by CSC there was consideration of both the incident and the perpetrator’s previous conviction for assaulting a previous partner. The Social Worker recorded that Laura minimised the risk from the attack to the perpetrator’s previous partner and her mother in front of her two young children. Laura told the Social Worker that: “she said that it was a lie and he pleaded guilty to get it over with. I stressed that without evidence, he would not have been Page 53 of 122 Copyright © 2020 Standing Together. All rights reserved. convicted but this made no difference to her. Laura stated that there are no concerns within her relationship with the perpetrator”. 4.3.27 At the end of January CSC carried out a visit to complete the Initial Assessment. Laura advised the Social Worker that there had been no violence and the perpetrator had not punched her. The Social Worker spoke to Ella and recorded Ella as saying that her father elbowed her mother and Laura fell. January supervision notes are recorded by CSC that detail the Social Worker challenging Laura’s account of the incident and questioning her version of events in relation to the domestic abuse. The notes also detail previous incidents of domestic abuse which the Social Worker was aware of. Actions for follow up were recorded as well as a record of next steps and Claire’s Law. 4.3.28 The initial assessment was completed and accompanied by assessment notes. It was noted that Ella had lower attendance at school due to a family holiday. Later during the conversation with the Social Worker Ella had said that the perpetrator had hit her mother at which point the Social Worker recalled that Laura looked shocked and paused talking. Laura interjected stating that he had hit her with his elbow. The Social Worker recorded that Laura had provided several different versions of what happened, and it was only when Ella had disclosed that the perpetrator had hit Laura that Laura then added to the version that Laura had already given to the Social Worker. The Social Worker also spoke to Ella’s birth father who said that he had seen no change to Ella’s behaviour and that Ella was doing well at school. The outcome of this initial assessment was recorded as no further action. 4.3.29 Education and school nursing summary of information related to all parties 4.3.30 The School Nurse met with both Laura and the perpetrator in school in March 2011. At this time, in 2011, the School Nursing service ran regular drop-in sessions at Primary Schools. Laura and the perpetrator reported to the School Nurse that Ella had been displaying behavioural issues in school and at home. Ella had good attendance at school and appeared well cared for. At home, Ella tended to wake in the night/early morning and refused to go back to sleep again. Ella slept on the 3rd floor away from her mother. Ella tended to be obsessive at home e.g. lining up pens and toys and liked everything in its place12. Ella was not mixing well with children her own age but preferred to engage with 12 As noted previously, Laura’s family did not recognise this behaviour. Page 54 of 122 Copyright © 2020 Standing Together. All rights reserved. older children. Ella’s general health was described as good by Laura and the perpetrator, however, she had tantrums and screamed at home until nearly sick. Laura’s family believe this was due to Ella’s dislike of the perpetrator. 4.3.31 Early in 2012 changes in Ella’s behaviour had started to become noticeable whilst on roll at her Infant School. This was 6-8 months after the perpetrator moved into the family home with Laura and Ella. Ella was taking things that didn’t belong to her, and when questioned could not remember the incidents13. The Child Family Worker arranged to go out and see the family at home and referred Ella to the school Special Educational Needs Coordinator (SENCO). Whilst there is a record of contact with Laura it is not clear from school records as to whether either the home visit or the SENCO referral happened. There are no SENCO records on file. 4.3.32 In May 2012 Laura expressed her frustration to the school about coping with Ella’s behaviour whilst at home. Records indicate that in school at this time Ella seemed unhappy, shutdown and not engaged. Laura was contacted by the Child Family Worker and a meeting arranged, but Laura cancelled due to just giving birth to Child A. It was also recorded by the school that Ella seemed very agitated by the end of May 2012 culminating in a need for increased one to one supervision and support at lunchtime from the Child Family Worker at the school. 4.3.33 There is a ‘cause of concern’ recorded in the Junior School files dated 02/12/2016. It stated that Ella had an old iPad that was linked to Laura’s shop computer. Laura saw the messages related to self-harm and distress. School staff spoke to Ella at this time, but Ella said she didn’t know who had written the messages. The school spoke to Ella’s friend, who had received some of the texts, and her mother. Laura then rang Ella’s birth father to discuss the messages found on the iPad. From the meeting with the family, Ella’s biological father was not noted as being aware of this information and was also not involved in the discussion with the school despite having parental responsibility. This would have been in line with the school’s practice since they had already spoken to Ella’s mother. 4.3.34 In September 2017, the perpetrator put in a request for an authorised absence to the Infant School for 2 weeks during November 2017 for Child A as both parents could not get 13 It is noted that Laura’s family also refute this. Page 55 of 122 Copyright © 2020 Standing Together. All rights reserved. leave in the summer months due to work demands. The request was refused by the Head teacher. There was no similar request submitted to the Secondary School attended by Ella. 4.3.35 In early November 2017, Laura phoned the Secondary School to say Ella was on holiday for two weeks in Florida. It was recorded by the school as an unauthorised absence. Whilst a penalty notice was not issued, it was indicated this was a potential course of action in a letter sent to Laura after the phone call. 4.3.36 By mid-November 2017 Child A’s attendance had dropped to 81.4%, falling further to 75% by the end of November 2017. 4.3.37 In December 2017 and again in January 2018, the Infant School wrote to parents regarding the number of incidences where Child A was arriving late to school after the register had closed. Laura’s family have noted that around this time, in January, Laura found out about the perpetrator’s affair. 4.3.38 In mid-January 2018, Ella’s behaviour was recorded by her Secondary School as being disruptive, with minimal school work completed. By the end of February 2018, the Designated Safeguarding Lead (DSL) at the Secondary School took a phone call from another school as students there had raised some concerns with regards to Ella which suggested that there were problems at home during the February half-term. It was suggested that Ella had threatened to harm herself by jumping out of a window. The Designated Safeguarding Lead (DSL) spoke with Ella who disclosed that she had self-harmed before. Although there is no record of when this might have been, it is recorded that she had not done so for a long time. Ella assured the DSL that she had no intention of doing so again. 4.3.39 Towards the end of January 2018, an incident was recorded by the Secondary School where Ella was alleged to have pushed another student over in the locker area. Laura was contacted by phone and a meeting was arranged. The record shows she did not attend due to another appointment. 4.3.40 A few days later the Secondary School recorded that Ella was upset in school as she felt that she was taking on too much with supporting her mother. When asked by staff what was troubling her, Ella disclosed that her step-father, the perpetrator, had had an affair. It is further recorded that Ella was not worried about the perpetrator, but was just confused over the affair. The school spoke to Laura, who explained that the woman with whom the Page 56 of 122 Copyright © 2020 Standing Together. All rights reserved. perpetrator had had the affair with had phoned Laura on her mobile. Ella was upset as she couldn’t understand why her mother was still with her stepdad following the affair. 4.3.41 In mid-May 2018, Child A disclosed to the Infant School that their Dad had broken his hand and he was in the hospital. This was recorded on a Cause for Concern Monitoring Record. The School asked if the perpetrator had had an accident to which Child A said no, “he smashed the door with his hand” and that they, “could see the big lump”. School asked if they had seen it happen, to which they replied, “yes it was a bit scary”. 4.3.42 The incidents recorded by the schools were by and large treated in isolation as this is how they were experienced at the time. With hindsight, there was a pattern of behaviour which could have been further explored and certainly would have been had the initial assessment and closure letter been received by the school. In the absence of the initial assessment, each incident was dealt with appropriately and seen as ‘behavioural’ rather than safeguarding. The panel felt that if the records made also included the school’s observations and concerns such as a detailed account of the changes in behaviour, there may have been sufficient concern to trigger involvement with the schools safeguarding lead and school escalation processes. 4.3.43 During interviews carried out with the school during the completion of the IMR a discussion was had with the school who had advised the IMR author that they had sought professional advice following the disclosure made by Child A. This was subsequently reviewed with the Head Teacher of the school following the panel meeting with the family where it was clarified that this was not the case and they did not obtain advice from the MASH. Further consultation was had between the Education Service and MASH to find out if the disclosure would have met the threshold and it was determined that the information available to the school at the time would not have met the MASH threshold. The school note that if the closure letter had been received the disclosure would have been considered in line with safeguarding practice. 4.3.44 Gloucestershire Constabulary summary of information related to all parties 4.3.45 There were three key domestic incidents/crimes that the IMR focused on; • A domestic crime in early April 2010 with the perpetrator recorded as the perpetrator of an assault on his previous partner (not Laura) and her mother in front of her two younger children. There is also an associated crime relating to a separate assault on his previous partner’s mother as part of the same incident. Page 57 of 122 Copyright © 2020 Standing Together. All rights reserved. • A domestic crime on Boxing Day 2014 with Laura recorded as the victim of an assault by the perpetrator at their home address in front of Ella and whilst Child A was in the house. • The murder of Ella and Laura by the perpetrator at their home address at the end of May 2018. 4.3.46 Early April 2010: At just after midday an Emergency Care Practitioner called the Police to report concerns she had for a patient (the perpetrator’s previous partner). In particular, she detailed that this patient had been ‘beaten up’ in front of her two young children by her current partner, the perpetrator. The patient’s injuries were described as possibly including a fractured jaw as well as soft tissue injuries to her head and body. She had been in a relationship with him since August 2009 but the relationship had deteriorated and she had told him she wanted to end their relationship. An argument started which ended when he attacked her by pushing her into a set of shelves, then kicking and punching her repeatedly. The perpetrator also damaged her mobile phone. The perpetrator then further assaulted his former partner’s mother when she asked him to leave following the assault on her daughter. The perpetrator was charged with offences of assault actual bodily harm (s47) and criminal damage and common assault (s39). The perpetrator pled guilty to the three charges and received a 9 and 4 month concurrent suspended sentence order for 24 months with a supervision order and unpaid work requirement, he was also required to pay compensation charges to the victims. 4.3.47 Boxing Day 2014: At 1 am Police were called by Laura’s neighbour stating that she had just been woken up by Laura knocking on her front door in a very distressed state. The neighbour stated she had been asleep in bed when she heard the noise downstairs. The neighbour stated that Laura had a visible lump on her head which she stated had been caused by the perpetrator hitting her. Laura also told her neighbour that the perpetrator was still at home. Police attended, and Laura was taken to hospital by ambulance for her head injury and the perpetrator was arrested. When Police attended, the perpetrator’s mother was on the scene after being called by her son. 4.3.48 The morning after the incident on Boxing Day, Laura was again spoken to by Police at her home address. She provided a statement in which she confirmed that she would not support any action in regard to the perpetrator. In that statement, she detailed that she had consumed too much alcohol during the evening and that her memory was less than clear. It is noted that her family, who were with her that night, are clear that they do not Page 58 of 122 Copyright © 2020 Standing Together. All rights reserved. believe she had too much to drink. Laura said she did not regard the perpetrator as a violent man and would not support any action against him. She stated that she believed the injury she sustained to her head was a non-intentional act. Laura also clarified that Ella was still awake at the time of the incident although she did not state if she witnessed the actual incident leading to the injury. Laura was offered and declined a GDASS (domestic abuse service) referral. As a result of this further interview with Laura, a supervisory officer amended the DASH RIC from standard to medium. 4.3.49 A referral was made by Police to Children’s Social Care following the incident that took place on Boxing Day, this was picked up at the MASH 5 days following this. The incident recorded that Laura had returned from a family meal at Laura’s mother’s house and the perpetrator had punched her. She went to a neighbour’s house to ask for help. 4.3.50 When Police asked Laura for a statement she informed them that she had not been punched but had hit her head on the bannister. She told them that she did not want to make a statement to the Police about the incident. A DASH RIC was completed by Police and the outcome recorded on Children’s Social Care file as ‘standard’ or medium. This indicates that “there are identifiable indicators of risk of serious harm. The offender had the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances”. The statement supervisory review signed by a supervising officer from Police indicates that, “I have reviewed this form, the risks identified and the quality of the investigation to date. I confirm that they have been completed to a satisfactory standard and all reasonable risk management actions have been taken. Parties have been separated which will remove any immediate risk.” 4.3.51 End of May 2018: At approximately 1.10 am Laura arrived home following a night out with a friend. This coincided with Laura having recently told the perpetrator to move out after the perpetrator’s recent affair and breakdown of their relationship. At some point between 1.10 am and 4.30 am the perpetrator murdered both Laura and Ella using a knife to inflict multiple stab wounds to their faces and bodies, while the other children were in the house. Later examination of the scene by an expert offered the explanation that the assaults had started in the kitchen near the dining table and that Laura had been attacked first. It would appear the perpetrator also went upstairs after the attack to speak to his younger children and tell them what he had done. The knife used in the assaults was seized from another bedroom. At 4.30 am the perpetrator called his mother to disclose that he had killed Laura and Ella. There are twenty minutes between the call from the Page 59 of 122 Copyright © 2020 Standing Together. All rights reserved. perpetrator to his mother, her attending the scene with her partner, and him calling Police. She was then allowed to leave the scene with the children. Laura’s family believe that the children should have been placed in care for the night. 5. Analysis 5.1 Domestic Abuse/Violence 5.1.1 The cross-government definition of domestic violence and abuse as issued in March 2013 and included here to assist the reader to understand that domestic violence is not only physical violence but a wide range of abusive and controlling behaviours. The definition states that domestic violence and abuse is: “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; and emotional”. 5.1.2 Domestic Abuse towards Laura: Taking into account the government definition above, information gathered by the Police as part of the murder investigation, information provided by agencies on this panel as well as information provided by family indicates that Laura had been a victim of domestic abuse from the perpetrator extending beyond the one reported physical incident. In addition, Ella was also subjected to abuse from the perpetrator including a range of coercive and controlling behaviours in addition to psychological abuse. Exposure to domestic abuse or violence in childhood is considered child abuse whether this is directly or indirectly witnessed14. 5.1.3 It is clear that the perpetrator used a range of coercively controlling tactics throughout his relationship with Laura. This ranged from physical abuse to emotional abuse, intimidation, financial abuse, and isolation. Laura’s family noted how the perpetrator tried to ensure that she had little contact with her family and they were so concerned that they made enquiries about Clare’s Law. Clare’s Law was relatively new to policing in general at the time and her family were not aware that they could make a 3rd party request for information. 14 https://learning.nspcc.org.uk/child-abuse-and-neglect/domestic-abuse/ Page 60 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.1.4 Despite the abuse, Laura maintained an active life with busy work activities and was a loving parent. She understood that her family was sceptical of the perpetrator and at times she protected him but because of the strong bond with her family, she was always able to maintain good relationships with them. They could see the toll the relationship was taking on Laura by her increased anxiety, weight loss and exhaustion towards the end of her life. After finding out about the perpetrator’s affair, Laura was in the process of ending her relationship with him. She was speaking to her friend about this on the night of her murder. 5.1.5 Laura is noted throughout this report as not wishing to engage in the help of services, denying the perpetrator’s previous conviction of domestic abuse or denying the incident of known domestic abuse against her. This does not mean that Laura accepted or condoned the perpetrator’s behaviour. She had three young children and was juggling many responsibilities and privately spoke to trusted friends and family about her situation. She did not want involvement from services or professionals and kept them at bay by her denials to them. She trusted her supportive network of friends and family and did not feel the need to involve professionals whom she may have perceived would bring more complications to her already stressful circumstances. Laura’s family described a significant extent of control within the relationship one example was that there was only one house key for the property which Laura was responsible for. This meant that Laura’s movements were controlled by the perpetrator as Laura was required to always be home before the perpetrator arrived home. A further example given was that the perpetrator bought multiple family pets as a means of further limiting her independence as she was responsible for providing care for the animals. Both of these were viewed by the family as controlling Laura’s movements and trapping Laura making it harder for her to be away from the family home for long periods. 5.1.6 There are many practical and psychological barriers that stand in the way of a woman leaving an abusive relationship, be it psychological, emotional, economic or physical threats, and women will often attempt to leave several times before making the final break. “One of the most important reasons women don’t leave is because it can be incredibly dangerous. The fear that women feel is very real – there is a huge rise in the likelihood of violence after separation. 55% of the women killed by their ex-partner or ex- Page 61 of 122 Copyright © 2020 Standing Together. All rights reserved. spouse in 2017 were killed within the first month of separation and 87% in the first year”15 16. 5.1.7 Economic abuse as an aspect of domestic abuse is notable in Laura’s experience. There were times when the perpetrator actively impeded Laura’s business activity by placing constraints that made it difficult for her to work. One incident described by a family member demonstrates this clearly. Laura had a wedding reception to set up and the perpetrator would not allow her to take her van. In a panic, she called her sister to use her car and to help her set up the reception. There were also expensive family holidays that at times Laura and Ella would tell various family members that they did not wish to go on but were instigated by the perpetrator. 5.1.8 Laura’s family are aware that at any family outing the perpetrator always had Laura’s bank card and would use it to buy food and drinks. There were also debts taken out in Laura’s name and monthly transfers of cash from Laura’s bank account to the perpetrator’s account. At one point she was shopping with her sister and found her bank card not working. They went into the bank and found that the perpetrator had made arrangements to consolidate their debt. She did not indicate that she knew about this arrangement. Her family assert that a small portion (£2k) of the £30k of debt was actually Laura’s and that most of this debt was accumulated by the perpetrator. Perpetrators of economic abuse often use debt to gain power and control over their partner. In this case, Coerced Debt was used as a means of increasing Laura’s isolation by causing increased financial instability which can increase someone’s risk due to being trapped in a relationship that they are unable to leave. Perpetrators will often use controlling behaviour in relation to debt. This may include hiding the extent of their debt or hindering payments being made on time. This can therefore be linked to credit damage which can result in long-term effects17. 5.1.9 Laura had also sustained injuries, for example, the incident on Boxing day in which she had visible injury to her head at the point in which Police had arrived to the property. The perpetrator had informed professionals that Laura’s presentation was due to the fact that she had been under the influence of alcohol. However, Laura presentation may have been 15 https://www.womensaid.org.uk/information-support/what-is-domestic-abuse/women-leave/ 16 https://www.refuge.org.uk/our-work/forms-of-violence-and-abuse/domestic-violence/barriers-to-leaving/ 17 https://survivingeconomicabuse.org/wp-content/uploads/2019/09/What-is-coerced-debt.pdf Page 62 of 122 Copyright © 2020 Standing Together. All rights reserved. due to blows to her head. During this incident, Laura’s family believe the perpetrator controlled the narrative of this incident using alcohol as a means of discrediting Laura and this resulting in the perpetrator’s account being used to form the basis or referrals and assessments with partner agencies without consideration being given for an alternative viewpoint. This may have impacted on how agencies interacted with Laura following the assault and could have reinforced the perpetrator’s control and contributed to the decision of Laura recanting her allegation. Attending officers noted there was some evidence that she had been drinking, however, they acknowledge that overall her intoxication level cannot be judged accurately. 5.1.10 Domestic Abuse and Ella: There is no doubt that Ella did not like or feel comfortable with the perpetrator. This is most vivid in speaking to Ella’s extended family who were clearly her refuge from her home environment with the perpetrator. It is evident that Ella’s school behavioural issues began just as the perpetrator came into her life and moved into her home. Laura’s family find it regrettable that the school did not investigate the reasons behind issues with Ella. 5.1.11 The female role models in her life are all strong characters and Ella is described as a strong and determined person. She did not express fear of the perpetrator but that does not mean that she was not fearful of him. She felt a strong sense that her extended family were supportive and understood her and her situation and she would have felt great comfort in that. Laura’s family recall that Ella was extremely pleased when on Mother’s Day in 2018 Laura announced she was ending her relationship with the perpetrator. 5.1.12 Ella spent a lot of time in the home of her paternal grandparents and father and the home of her aunt and maternal grandparents. Notably, just before the murders, she asked to stay at home with Laura which demonstrates that she was potentially concerned about her safety and put herself in a role of protector which is consistent with the theory that she was killed when intervening and trying to protect her mother. 5.1.13 It is unclear if Laura fully understood the alignment between Ella’s behavioural changes and the perpetrator’s involvement in her life. She met with the school and GP often with the perpetrator to discuss these concerns. She may have felt coerced to do this or it may be that she was genuinely concerned about Ella’s behaviour and wanted support. She may have been influenced by the perpetrator’s assessment of Ella’s behaviour. It is noted that Laura’s family are concerned with the amount of influence the perpetrator had with Page 63 of 122 Copyright © 2020 Standing Together. All rights reserved. the school and that they did not question his role in the family or involve or inform Ella’s birth father. 5.1.14 It is important for health professionals to know who has parental responsibility for a child as well as other adults who play a key role in that child’s life e.g. stepparents. It is good practice to always ask, clarify and document who the adult is accompanying a child to appointments or who is ringing the practice about a child. 5.1.15 There are two common issues noted in the RCGP Child Safeguarding toolkit18: 5.1.16 “'Not seeing the child' reflects the reality that the needs of the child can easily be overshadowed by those of the parents, the needs of the child should always come first. It can be helpful to consider 'what is the daily lived experience of this child?' and act accordingly. When working with adults, it is always important to consider whether there might be any children who could be at risk of abuse or neglect as a result of the adult's health, behaviour or circumstances – see the child behind the adult. It is important to remember that the children who may be at risk may not always be within the family and may not be living locally or even in the UK.” 5.1.17 And; 'Not seeing the adult' - It is important to establish who is in the child's life. Practitioners need to bear in mind that there may be new adults in the child's life such as new partners of their parents or friends/family members who may be staying within the household who may pose a risk to the child – 'see the adult behind the child'.” 5.1.18 Furthermore, the 2015 NSPCC briefing19 highlights the risk factors for hidden men in Serious Case Reviews and learning for improved practice: • Lack of information sharing between adults' and children's services • Relying too much on mothers for essential information • Not wishing to appear judgmental about parents' personal relationships • Overlooking the ability of estranged fathers to provide safe care for their children. 5.1.19 There were missed opportunities to accurately record and capture the voice of Ella and her siblings. It was noted through various agency IMRs that the records relating to disclosures made by Ella had been written in the professionals interpreted language as 18 https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/child-safeguarding-toolkit/types-of-abuse-and-indicators.aspx 19 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf Page 64 of 122 Copyright © 2020 Standing Together. All rights reserved. opposed to accurately recording Ella’s individual account. This, therefore, resulted in inconsistency of record-keeping as it was not always clear who the records were referring to and what the exact disclosure had been. Many of the records refer to Ella’s disclosures about the perpetrator however the family were clear that this is not the language that Ella would have used when referring to the perpetrator as she would have referred to him only using his first name. However, when this information has been recorded these disclosures have been adapted, losing the voice of the child. There were also occasions whereby Ella was spoken to, however, this was not done in a safe way to enable disclosure due to either the perpetrator or Laura being present which may have hindered Ella’s disclosures. 5.2 Analysis of Agency Involvement: 5.2.1 Evidence of good practice of primary care 5.2.2 Consistent support, advice and treatment was offered to Laura as she attended for help with a variety of concerns. There was continuous support and GP treatment for her low mood, anxiety and depression. There is some recognition that her home and relationship situation is acknowledged, in regard to her stating a relationship break up (August 2009). However, there is no clear indication of routine domestic abuse enquiry from any of the contacts that Laura has with the GP surgeries. 5.2.3 GPs appear to have supported and referred Ella in a timely and effective manner when Laura raised concerns about Ella’s development as a baby. Where the family did not attend the Community Paediatrics, Public Health Nurses followed up and communicated to Primary Care. 5.2.4 In regard to Ella’s early school years and Laura and the perpetrator’s concerns about her challenging behaviour, GPs monitoring of her symptoms was followed by referral for specific behavioural support. Although CAMHS service was deemed not appropriate, there was signposting to parenting support and a parenting programme. It is unclear from GP records whether this was taken up by the family, but it is referred to in a later GP consultation in 2013. 5.2.5 As a young man (19 years) the perpetrator had disclosed stress issues, related to losing his job, relationship and financial worries. The GP referred him to mental health and treated him for anxiety as well as discussing family support with his father which is supportive and caring practice. 5.2.6 Wider context of primary care current good practice Page 65 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.7 It is not clear whether the circumstance of this family raised sufficient concern for the Practice to discuss their circumstances at their planned Liaison/Safeguarding meetings. From a recent Gloucester Clinical Commissioning Group (GCCG) audit (July – Oct 2018) the medical practice highlighted a clear protocol set out to enable sharing information amongst all clinicians. The medical practice also reported holding regular Practice Liaison meetings to discuss both adult and child safeguarding concerns and domestic abuse notifications. 5.2.8 Both surgeries involved with this case have confirmed that both clinical and administrative staff undertook the domestic abuse training offered by GDASS, and continue to engage with training offered. This was rolled out to all GP Practices over 2017/18. The Safeguarding Lead GP (Adult and Child) attended training on October 2017 & February 2018, and advocated the value of this training in illuminating how people can access help, advice and support. The GP Practice displays GDASS posters and information in waiting areas and toilets. 5.2.9 With regard to GP Practices engagement and links with the Multi Agency Risk Assessment Conference (MARAC) process, the process for GPs to provide research evidence to contribute to MARAC is currently reliant on a contact from the MARAC coordinator, dependent on whether the GP is named and identified within the domestic abuse referral. 5.2.10 GCCG and GCS (Gloucestershire Care Services – the NHS Community Health Trust) are working together to improve the research administration process to enable all GPs to routinely be contacted by the MARAC administrator. That stated, the Domestic Abuse Lead Nurse (a GCS Specialist role) is a link professional making contact with GPs by telephone contact direct to the surgeries. 5.2.11 Further analysis of the CCG and primary care: 5.2.12 Very little is known, or it is not clear, what the GP Practice knew about Laura’s relationships or the father of all 3 children. GPs will not routinely know the status or connection of family relationships, and may not ask when attendance is for a physical problem. In the case of Laura, she was attending for emotional support whilst Ella was quite young, and Laura shared some information about relationship difficulties in relation to stress. The question of relationships is again raised in 2009 when Laura attends. When being seen for mental health concern, there is, of course, a potential to ask about important others she can speak to, and family support. Page 66 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.13 In May 2014 Child A is noted to have a fractured nose. The diagnosis was made by the Emergency Department and follow-up was apparently arranged with an Ear Nose Throat (ENT) specialist for a week later. A nose fracture would be very unusual in a child of this age, but there is further uncertainty about the clinical accuracy of this as a diagnosis. An X-Ray was not taken as this would cause an unacceptability high dose of radiation to the child’s developing eyes and brain, therefore diagnoses are always made clinically based on the visual appearance of the nose. It would be expected that this event on a 2-year-old child would have created a Health Visitor Liaison follow-up by the allocated Health Visiting Team. 5.2.14 Laura’s family have confirmed they were told that this injury was sustained by an accident. 5.2.15 There is no clear note about the assault incident on Boxing Day 2014, informing about who may be the perpetrator of the assault and what information was shared and thoughts about referrals made that consider the needs of all three children. It is most likely that a multi-agency referral form (MARF) would be submitted to Children Social Care (via the MASH) if this information was alerted now. 5.2.16 The assault that Laura experienced on Boxing Day 2014 was an opportunity to further support Laura and the Health Visitor followed this up and communicated with the GP. There is significance in this injury, occurring over a holiday period with a possible delay in supportive follow-up. Laura’s family have reflected that because it is generally known that domestic abuse incidents increase at Christmas and escalate in terms of severity – this should be reflected in staffing rotas. 5.2.17 It is unclear from the GP records whether Laura had made a disclosure about domestic abuse to any health professional (pertaining to the assault in December 2014). Currently, Gloucestershire uses a Mid-Wife / Health Visitor/ GP liaison form that captures information on the vulnerability of women whilst pregnant, sharing this across these 3 key services for information. These forms are in routine use now, but may not have been formulated at that time (2014/15). 5.2.18 Further, it is unclear from the GP records whether this assault was disclosed to professionals, through routine enquiry, or whether an assumption was made. 5.2.19 There is an Early Intervention and Health Pilot delivered by GDASS which is noted above which has been well received and accepted as improving the health response to domestic abuse. This pilot was based on evidence from IRIS (Identification and Referral to Improve Page 67 of 122 Copyright © 2020 Standing Together. All rights reserved. Safety). IRIS is a general-practice based domestic violence and abuse training, support and referral programme for primary care staff. The funding for this was due to expire in March 2020 but has since been agreed for additional funding to continue. 5.2.20 It is not clear from the GP records if Laura had been accompanied to all of her appointments or if she was given an opportunity to meet with the GP alone. This could potentially have acted as a barrier to disclosure due to the perpetrator being present at appointments. 5.2.21 Evidence of good practice of the Gloucestershire Hospitals NHS Foundation Trust 5.2.22 The care offered matched the need presented and was routine. Laura and the perpetrator presented as engaged and caring parents, interacting well together and with their children. The one known incident of domestic abuse was thoroughly assessed and actions followed guidelines and policies to the letter. Laura was offered a referral to GDASS (domestic abuse support) and was given an information leaflet in case she later changed her mind. The children were referred for follow-up by their Health Visitor, who visited the family. 5.2.23 Maternity care was routine. Laura attended all her appointments and the perpetrator was present at the birth of both of his children. Communication between Midwives, Health Visitors and GP was routine and unremarkable. 5.2.24 Further analysis of Gloucestershire Hospitals NHS Foundation Trust 5.2.25 Of most particular note is the domestic assault on Laura by the perpetrator on Boxing Day 2014, witnessed by Ella. This was recognised as domestic abuse on presentation to hospital and a DASH RIC form was completed. This was assessed as medium risk at the time. The DASH was re-assessed by a Safeguarding Nurse the following day and categorised as ‘Medium – no consent to share’ and therefore they would require consent from Laura to share information with other agencies. 5.2.26 The clinical assessment on Boxing Day 2014 was extremely thorough and the history was carefully documented. The children were referred for Health Visitor follow-up as a result. 5.2.27 Laura’s family feel that the disclosure made to hospital staff in relation to the injuries being sustained as a result of a punch should have triggered information sharing and an onward referral. However, as noted in 5.2.25 this would have required Laura’s consent. 5.2.28 This Trust should maintain and strengthen its links with GDASS and consider the emerging tools from DOHSC funded Pathfinder sites as the interim and final evaluation of Pathfinder sites culminates in 2020. Page 68 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.29 Laura’s family commented that it would also have been beneficial for national services to have been provided as an alternative avenue to accessing support in addition to the local GDASS provision. Laura was known amongst the community and her family felt that it may have potentially been a barrier for Laura to access a local service for a variety of reasons such as knowing people accessing support from or working for GDASS, therefore, her anonymity may not have been completely achievable. 5.2.30 Evidence of Good Practice with Gloucestershire Care Services 5.2.31 Laura and her children were open to Universal health services (GP, Health Visitor, and School Nurse). Laura’s attendance at appointments or being at home for planned visits were inconsistent. For working, busy parents some non-attendance is to be expected and would not normally raise concerns unless there were known safeguarding issues. 5.2.32 There were occasions when Laura was asked about domestic abuse when the perpetrator or Ella was not present, which is clearly good practice as per GCS practice benchmark (2017). 5.2.33 The School Nurse made a detailed action plan for Laura and the perpetrator, giving advice on strategies and boundaries. Ella’s birth father however was not invited to these meetings as they did not have his information on record. The School Nurse planned to monitor through school if there were further concerns. There were no further concerns raised by school to the School Nurse. Contact with the School Nurse was another opportunity for Laura to disclose, however, none was made. Laura’s family note that the perpetrator did not allow Laura to be alone at school, impeding her ability to safely disclose. 5.2.34 After the Boxing Day incident, the Health Visitor discussed with her team whether the domestic abuse incident required a home visit follow up. The outcome of this was that the Health Visitor assessed that a home visit was required due to the nature of the incident. To speak with the mother on her own at home was considered best practice and would have allowed Laura to understand that she could contact Health Visiting in the future if she wished, or seek specialist domestic abuse services as appropriate. The Health Visitor could have considered rescheduling the meeting to a time when the perpetrator was not present. 5.2.35 There was good practice identified in terms of asking the domestic abuse question when possible, and recording when and why this was not possible. The follow-up visit by the Page 69 of 122 Copyright © 2020 Standing Together. All rights reserved. Health Visitor to Laura at home following the domestic abuse incident on Boxing Day 2014, was also good practice. This allowed the Health Visitor to ensure Laura had the relevant information on how to get specialist domestic abuse support from GDASS. 5.2.36 In 2011, the GCS School Nurse Service provided drop-in sessions for parents at Primary Schools countywide. This was a good opportunity in this case for the School Nurse to meet Ella’s mother and birth-father and provide parenting advice and support. It also provided effective communication between school staff and health where there were concerns about a child’s emotional wellbeing. This was normal practice at that time and followed The Healthy Child Programme (2009) guidance. 5.2.37 There is a rolling programme of GCS domestic abuse training available to all staff, delivered by the Specialist Nurse for Domestic Abuse. 5.2.38 Where there is known domestic abuse following a high-risk DASH, a red flag is added to child’s/children’s record. Previously the flag would be removed after one year, however, the flag is now maintained to denote historic or current domestic abuse within the household. 5.2.39 The Gloucestershire Hospitals NHS Foundation Trust and Gloucestershire Care Services have a joined-up service by way of a Paediatric Liaison Health Visitor. This post was likely to have been in place at the time of Child A’s nose injury. Currently, this service has undergone development to deliver more effective communication and liaison service between Emergency Departments, Walk-in-Centres and the Public Health Nursing service. 5.2.40 Wider context of the Gloucestershire Community Services NHS Trust good practice 5.2.41 Domestic Abuse Policy (2017), is designed to ensure a consistent and systematic response to clients/patients and colleagues who are, or have been affected by domestic abuse and may require information and assistance. 5.2.42 GCS is committed to training all staff in the use of the DASH RIC screening tool, and raising staff confidence in supporting victims of domestic abuse. 5.2.43 A previous Gloucestershire DHR ‘Rosie’ (2015) highlighted the need for organisations to have a single point of contact for domestic abuse. GCS employ a full time Specialist Nurse for Domestic Abuse within the Safeguarding Children Team, who is involved in both delivering of single and multi-agency domestic abuse training and supervision. Page 70 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.44 Responding to domestic abuse: a resource for health professionals (2017) highlights it is often health services that are the first point of contact for victims of domestic abuse. We know that those suffering from abuse find it very difficult to speak out. However, many drop hints or display behaviours which may indicate an issue. It is essential staff are trained adequately and feel confident to pick up these indicators and to enquire in a safe manner in order to elicit information and provide appropriate assessment and referral, as they are in a key position to recognise indicators of abuse and to offer support and referral for protection. 5.2.45 Gloucestershire Domestic Abuse and Sexual Violence Guidance for Professionals on Identifying and Responding to Domestic Abuse (2018) provides countrywide best practice, including procedures for identifying domestic abuse by both routine and selective enquiry, and guidance on how to respond in the most appropriate manner, by way of risk assessment and signposting. 5.2.46 Training: public health nursing staff in GCS are offered both single and multi-agency training, which is deemed ‘Essential to Role’. This is set out within by National Institute of Health and Care Excellence (NICE). Domestic violence and abuse: multi-agency working NICE Public Health Guidance 50 (2014). The training aims to provide a universal response to give staff the basic understanding of the dynamics of domestic abuse and the legal framework which it relates to, underpinned by an awareness of diversity and equality issues. It provides staff with the skills and knowledge to undertake routine enquiry of domestic abuse and what they need to do next if a disclosure is made. NICE guidance (p.20) sets this out as: ‘Level 2: Staff should be trained to ask about domestic violence and abuse in a way that makes it easier for people to disclose it. This involves an understanding of the epidemiology of domestic violence and abuse, how it affects people’s lives and the role of professionals in intervening safely. Staff should be able to respond with empathy and understanding, assess someone’s immediate safety and other referral to specialist services.’ 5.2.47 Routine enquiry asking clients about domestic abuse is part of GCS public health nurses benchmarks for all core contacts with families following the birth of babies to explore any past or present experiences of domestic abuse (GCS Best Practice Benchmarks, 2017). All GCS staff have access to this. 5.2.48 Further analysis of the Gloucestershire Care Services: Page 71 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.49 Although the follow-up home visit by the Health Visitor to Laura following the domestic abuse incident on Boxing Day 2014 was good practice, there seemed to be a delay between the time of the assault and the contact from the Health Visitor (9 days). Also, it is not fully clear whether this was raised to Children Social Care or shared with the Police. Laura suffered a significant physical injury to her face, hitting it on the bannister. This event must have been significant for Laura and the children and it is unclear what follow up ensued. 5.2.50 While much of the progress at GCS is commended, there still remains an element of professional curiosity that is lacking in some instances. Domestic abuse questions were asked and recorded when Laura was alone but there is less evidence that staff feel supported and confident to address domestic abuse if the victim/survivor denies or minimises the abuse. Often this is done for logical reasons and an enhanced level of skill is needed to continue with the conversation about potential abuse if cut short by the victim/survivor. 5.2.51 The GCS domestic abuse policy requires a review, to ensure it includes advice on what to do if a practitioner cannot ask the domestic abuse question, and if indicators are present but the victim is denying/minimising the risks to themselves and/or their children. And for the policy and training to approach denial and minimisation in a non-blaming way. 5.2.52 GCS should assess the indicators which would measure adherence to their domestic abuse policy to ensure there is adequate oversight throughout the services provided. 5.2.53 Children’s Social Care Analysis: 5.2.54 This section contains particular analysis of Children’s Social Care for two reasons. The first is the strength of feeling of Laura and Ella’s family in terms of how Children’s Social Care and the Police addressed particular situations involving Laura and Ella. Secondly, there are aspects of this case that are similar to previous SCR’s in Gloucestershire. 5.2.55 In June 2017 – An Ofsted report found Gloucestershire County Council Children’s Services to be ‘inadequate’. The report noted that areas such as “Assessments, decision making and planning for children are poor and frequently adult-focused.” “Management oversight is inadequate. It lacks rigour and direction. It continually fails to identify key weaknesses in social work practice or ongoing risks to children.” (Ofsted June 2017). 5.2.56 The above Ofsted report is likely to reflect the practice in 2015. However, the most recent Ofsted monitoring visit notes that “Increasingly, effective management oversight of Page 72 of 122 Copyright © 2020 Standing Together. All rights reserved. decision-making by Social Workers and the quality and timeliness of assessments are leading to improvements in children’s circumstances” (Ofsted Monitoring Visit Report 25th October 2018). Therefore, Ofsted has reflected the improvement in practice within the system since June 2017. 5.2.57 The Social Worker noted that Laura was not providing an accurate account of the incident that took place on Boxing Day 2014. Laura and the perpetrator were spoken to separately and this is good practice in cases of domestic violence where the victim may not feel able to disclose in front of the perpetrator. This could be evidence of coercive control within their relationship whereby Laura is minimising either on the basis of what the perpetrator has told her and she simply believed him, or minimising through fear. The analysis does not sufficiently explore the impact that domestic violence/abuse is likely to have had on Laura, Ella and Child A. The records suggest that it is likely that the Social Worker did not explore the possibilities of coercive control and the dynamics of domestic abuse relationship beyond physical abuse. The records also show that Ella was not spoken to alone which would have provided her with an opportunity to speak more openly about what had happened on Boxing Day and her home life in general. 5.2.58 The Gloucestershire Safeguarding Children’s Levels of Intervention Guidance (LOI) document would have provided the framework for making threshold decisions. The referral was responded to in the MASH Information was shared by agencies including Police about the perpetrator’s history of violence against his previous partner. These procedures were followed appropriately. Laura’s family expressed concern over the reliance on the DASH RIC which did not adequately highlight the risks to Laura or Ella, this is further discussed in 5.2.86. 5.2.59 At the point of the Police making a referral into MASH following the Boxing Day incident, there were no daily domestic abuse meetings. Current practice consists of a daily domestic abuse meeting chaired Monday to Friday in the MASH that considers all Standard and Medium VISTs. All High-risk VISTs are referred to MARAC. The 5-day delay was reviewed by the MASH manager who determined that this incident pre-dated the use of Unifi Enquiry (2017), at the time the Access database was used. There were no recorded delays or backlogs at that time. Christmas duties would create a delay in any referral process. Boxing Day 2014 was a Friday which would have meant that it was likely that with bank holidays there would have been no staff in until the 30th December. Records show that this case was recorded on the 30th December which is when any referral to Page 73 of 122 Copyright © 2020 Standing Together. All rights reserved. Children’s Services was also made. At that time domestic abuse cases were put into the MASH in cases where it was the first recorded incident between the parties, which it was for Laura and the perpetrator. This report was subsequently input into MASH on 31st December and was reviewed on 2nd January 2015. This was sent out at 08:00 am on the 2nd January to all partners and was finalised on 8th January. Partners, including Children’s Social Care responded with any information they held between those dates. Ultimately this meant that the initial delay in referring to partners was 5 days predominately caused by the staffing over the Christmas period. As previously noted, Laura’s family feel that because it is known that incidents often increase during the holiday period, staffing provisions should reflect this. 5.2.60 Staff working for Gloucestershire Children’s Social Care have access to the Gloucestershire Safeguarding Children’s Board training on domestic violence. The training provides Social Workers with detailed information about perpetrator profiles, the impact of domestic violence on the children and victims. The two-day course includes interviewing victims and others. Current statistics of attendance by Social Workers to these courses are that they are low and it is likely to have been the case in 2015 when the same courses were made available to Social Workers. There has been much discussion in previous SCRs, and in the workforce subgroup in Gloucestershire about training required to address the issues highlighted above for both front line and supervisory/management staff. A thoughtful approach to workforce development is required to fully address the need for both training and oversight tools so all Children’s Social Care and all safeguarding professionals can work in a more nuanced and trauma-informed way to address domestic abuse with adult and child victims as well as perpetrators of abuse. This should be done working closely with the newly established social work academy and workforce subgroup of the safeguarding board. While training alone will not fully achieve the workforce development needed, agreed mandatory training and refresh training for particular roles should be agreed. Multi-agency approaches that have worked in the city of Gloucester should be considered countywide. 5.2.61 Voice of the Child: The analysis section of the Initial Assessment recorded the discussion held with Ella. However, it does not highlight the voice of the children and the impact of domestic violence on Ella and Child A. This is a key feature that could have been explored further. For example, professional curiosity could have been exercised to understand what Ella and Child A’s lived experience was like and how vulnerable they were within the household. The Social Worker had highlighted that Ella had provided some conflicting Page 74 of 122 Copyright © 2020 Standing Together. All rights reserved. information; this line of enquiry should have been further explored within the Initial Assessment. In addition, Ella had presented as a child who was ‘doing well’ at school and when she was with her birth father, he had reported no concerns about her well-being. When Ella’s birth father was interviewed by the Social Worker, he informed the Social Worker that Ella had not told him about what happened on the night of Boxing Day 2014. This suggested that Ella did not share the difficult experiences of life in the family home with her birth father. However Laura’s family assert that this assumption is untrue and it was the fact that Ella was left in the care of the perpetrator’s family after the Boxing Day incident that shut down Ella’s confidence to speak about the truth of what was happening in her family home, they believe Ella’s voice was lost when she was spoken to about the Boxing Day incident. 5.2.62 A follow-up interview and a more detailed assessment could potentially have highlighted further evidence of domestic violence in the home and its impact on Ella. A Single Assessment, in line with Working Together 2013, could have provided further insight into Ella’s lived experience in a household with domestic violence and the impact of this on her. A Single Assessment would have required at least two visits to see Ella alone. It is unlikely that there was no impact on her given that she had witnessed two domestic violence incidents that were reported and as the MASH contact indicates that there are likely to have been more unreported incidents. 5.2.63 The decision was taken not to re-visit Ella or meet with her in school to discuss the incident and its impact on her as a child. There is a record of a discussion with the Child Protection and Safeguarding Lead at the school and this recorded that there were no concerns about Ella. This could have been explored further in order to build a clearer understanding of the history and potential continued risks. 5.2.64 It is not clear in any of the Children’s Social Care records if the perpetrator and Laura were separated after this event. Police records indicated that when called they had asked the perpetrator to leave the family home. The risk that the perpetrator potentially posed to Laura, Ella and Child A because he continued to live in the same household after the incident on 26th December 2014 was also not sufficiently highlighted in the Initial Assessment. 5.2.65 Children’s Social Care record of DASH RIC is followed by a statement about a previous incident when the perpetrator had attacked his ex-partner at the time and her mother. At that time, the assessment of risk was identified as medium to high. He had punched his Page 75 of 122 Copyright © 2020 Standing Together. All rights reserved. ex-partner and her mother in front of her two young children and had caused criminal damage, the record indicated that he was, therefore, a ‘high-risk perpetrator’ of domestic violence and he received a suspended sentence of imprisonment for Actual Bodily Harm, Battery and Criminal Damage. The risk posed by the perpetrator would have warranted a strategy discussion, section 47 enquires and an Initial Child Protection Conference to discuss the likelihood of significant harm to Ella. 5.2.66 The referral was progressed to an Initial Assessment. The outcome of the Initial Assessment was ‘no further action’ and the case was closed. The conclusion section of the Initial Assessment is analysed in another part of this review. 5.2.67 The referral was recorded mid-January 2015, 13 days after the incident, following the receipt of consent to share information. The decision in the MASH was appropriate, although it was delayed by MASH. Laura’s family believe this was too long a gap between the incident and the meeting. The MASH manager stated that the reason for delay should have been recorded on case records but this did not happen and this is likely to “reflect practice at the time”. She also informed that at the time, the front door had limited resources and there were only two decision making Social Workers – this has now changed and there are twelve Social Workers in the MASH. This is no longer an issue in the MASH. The recent Ofsted visit noted that progress has been made in the MASH on timeliness. 5.2.68 The management decision in MASH was to progress to an Initial Assessment “based on information held within the MASH”. This followed arrangements set out in Working Together 2010, however at the time Working Together 2013, which introduced a Single Assessment should have been applied – that is to be carried out within 45 days of the referral. 5.2.69 The improvements to the MASH in the past year are accepted by all partners. The MASH is now adequately staffed. The domestic violence agency, GDASS, is now based in the MASH, alongside Children’s Social Care and Police. All three agencies are engaged in assessing and reviewing the support needs of victims of domestic violence. Where a threshold has been met for a strategy discussion or a Section 47, this is progressed with Children’s Social Care. 5.2.70 Where there are concerns that the victim/survivor of domestic abuse is reluctant to progress with a statement or support and there are concerns identified, the outcome of the contact is progressed to single assessment in line with Working Together 2018 to assess Page 76 of 122 Copyright © 2020 Standing Together. All rights reserved. the safeguarding needs of the children. In line with Working Together and the Gloucestershire Threshold document, a single assessment may be completed even if the victim/survivor does not consent. These decisions will be made at Team Manager level in the MASH. Where it is assessed that a victim/survivor may benefit from Early Help support this is offered if the victim has given consent to access the support. 5.2.71 An Independent Domestic Violence Advisor is based in the MASH to provide support to those subject to domestic abuse. 5.2.72 Government guidance on Working Together 2013 stated that ‘All Local Authority Children’s Services were required to use the framework no later than 1st April 2013”. Ella and Child A’s Initial Assessment was completed in April 2015. It appears that Gloucestershire Children’s Social Care as a whole had not implemented Working Together 2013 two years after the required timescale. The reason for this is not known, but the liquid logic system records prompted Social Workers to complete an Initial, not a Single Assessment in 2015. 5.2.73 The referral form decision section sets out the following: “IA [Initial Assessment] needed to be allocated as a priority as mum may not be reporting DV, young baby in the home, older child (Ella) called Police, partner a perpetrator appears to have a violent history”. This decision is appropriate and relevant and set out clearly what the potential risks were and took account of the perpetrator’s history of violence. The decision also recorded that Laura “may not be reporting Domestic violence incidents to the Police”. The reason for the late completion of the Initial Assessment is recorded on the electronic file as ‘lack of worker availability’. 5.2.74 The decision recorded by the MASH manager was not appropriately and fully followed through to the Initial Assessment. The MASH manager informed that the use of Initial Assessment instead of Single Assessment was an oversight. However, the record of the ‘Initial Assessment’ notes that it was commenced on 15th January 2015 when the contact was completed and it was due on 22nd January 2015 (timescale for Initial Assessment) and yet it was completed on 28th April 2015, three months later than the due date. It is not possible to determine why the Social Worker had carried out an Initial Assessment or the team manager did not challenge this because they were not available to comment on this issue. The Initial Assessment was completed after interviewing Ella once in the family home. She was interviewed alone (in line with Working Together 2013) and she told the Social Worker that her mother was punched by her step-father. The Social Worker notes that “It also became apparent that Ella was primed on what to say and was upset when Page 77 of 122 Copyright © 2020 Standing Together. All rights reserved. she accidentally told me, through chatting away, that the perpetrator hit her mother and also stated that the perpetrator and her mother were getting on well.” The conversation was interrupted by Laura entering the room and Ella did not discuss the incident further. This is of concern and good practice would indicate that this required further discussions with Ella. 5.2.75 The Initial Assessment included the perpetrator’s account of what happened. The perpetrator told the Social Worker about how Laura sustained the injury – “they had argued at the top of the stairs as Laura wanted another glass of wine. The perpetrator said he accidentally extended his arm and his elbow caught Laura in the face and she stumbled back to the bannister causing injuries to her head. The Social Worker questioned this account in the Initial Assessment and also appropriately challenged the perpetrator about his account. She mentioned his previous conviction for attacking his ex-partner and her mother, in front of her two young children, by punching and kicking her. When asked about this, the perpetrator responded that the description was “‘far-fetched’ and told the Social Worker that “he had no reason to lie and he is honest”. It is noted this was clearly his way to distract from concerns regarding his previous conviction of violence. 5.2.76 The Social Worker reported that when the two incidents were assessed together, they caused her concerns about the perpetrator. When she raised her concerns with the perpetrator, he responded that he had a good relationship with Laura and they were fine. These concerns were not progressed further. 5.2.77 The risks to Ella are set out in the Initial Assessment and recorded as “domestic abuse and the impact of this on the child development – risks surrounding emotional harm”. The risk section noted that Laura minimised concerns as she may not be “fully protective”. The risk section does not sufficiently review the perpetrator’s previous conviction for domestic violence/abuse offences. In other parts of the Initial Assessment, the Social Worker notes that the mother was ‘protective’ of her children. 5.2.78 If coercive control and other forms of domestic violence/abuse were considered, the Social Worker could have considered the complexities of domestic violence and how these impact on victims. It is unlikely that the Social Worker would have concluded that Laura was acting protectively towards her children. The Social Worker would be expected to assess risk and vulnerability of Ella, Child A and Laura. Research into understanding victims of domestic violence suggests that there are indicators and outcomes that could Page 78 of 122 Copyright © 2020 Standing Together. All rights reserved. have led Laura to believe she was acting protectively by not raising concerns about domestic violence. She may have remained in the relationship as a means of protecting herself and her children because in her view, leaving the relationship could potentially mean that they would be at even higher risk. The information provided to Laura by the Social Worker was to give her information about GDASS - domestic violence specialist support. 5.2.79 The Initial Assessment noted that there was one interview with Ella and this was not followed up by having a discussion with her about what she saw, especially as the first interview was interrupted by Laura entering the room. Laura’s family believe that by failing to follow up on this Ella’s voice was lost. 5.2.80 Parenting Capacity and the voice of the perpetrator and Laura. The parenting capacity of Laura as a victim of domestic violence was not fully explored in the Initial Assessment. For example, the only times that she had contacted Police was when she was in immediate danger. The impact of the control that may have been exercised on Laura as a victim of domestic violence and how this would have impacted on Ella and Child A should have been further explored in the Initial Assessment. 5.2.81 The Initial Assessment recorded discussions with the perpetrator as the perpetrator of domestic violence both in the incident in 2014 and with his previous partner. He minimised the impact on both blaming his previous partner and not fully explaining why Laura would have gone without him to a neighbour if the incident was an accident. He was recorded as being articulate in presenting how the injuries occurred when discussing the incident on 26th December 2014. The Initial Assessment records that “Parents have been in a relationship for several years and there have been no other reports of concern”. “Mother acted protectively”. The Initial Assessment appropriately identified research about the risks to children living in homes where domestic violence took place but did not sufficiently follow up the risk identified in the MASH episode that mother may not be reporting other incidents. 5.2.82 The Initial Assessment decision was that there should be ‘no further action’. If underlying risks and the likelihood of risks had been further explored, then the outcome could have been to progress to an in-depth assessment or potentially an Initial Child Protection Conference. The perpetrator was living with Laura and her children and the Initial Assessment did not contain any insight into the impact of domestic violence/abuse on the children in the family and his partner. Page 79 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.83 The Initial Assessment was carried out by a qualified Social Worker in line with Working Together 2013: Page 19 which sets out the components of a good assessment. This should be child-centred and based on the safeguarding needs of the child. Section 38 notes that “Children should, wherever possible, be seen alone and local authority children’s social care has a duty to ascertain the child’s wishes and feelings regarding the provision of services to be delivered. It is important to understand the resilience of the individual child when planning appropriate services”. Whilst Ella was seen alone when she inadvertently informed the Social Worker that the perpetrator had punched her mother, this was not later followed up by the Social Worker. 5.2.84 The Social Worker’s Initial Assessment noted that Ella is ‘doing well’ at school and the school reported that she had missed days at school due to a family holiday. Ella had presented as ‘coping well’ at school and this was recorded in the Initial Assessment. Further evidence of how she presented at school and the impact of domestic violence/abuse on her in the school environment could have improved the Initial Assessment. The statement provided insufficient insight and evidence of what “coping well” meant for Ella. The Child Protection and Safeguarding Lead in the school was not asked for further information about Ella’s presentation with evidence-based questions. This was a missed opportunity because Ella may have shared information with the school or the school may have had an understanding about the impact of the home situation on her presentation and behaviour. 5.2.85 Domestic violence was reported to Police and they made a referral to Children’s Social Care which progressed to an Initial Assessment. A DASH form was completed. Children’s Social Care records indicate that based on the previous attack on his ex-partner and her mother in front of two young children, the perpetrator was assessed as of medium to high risk. The purpose of the DASH is to set out the risk as identified by the victim; however, the Social Worker could have exercised professional judgement about what happened and how this would have impacted on Ella, Child A and Laura. Front line professionals should ensure there is not an over-reliance on the DASH assessment, they should recognise that risk is fluid and keep in mind that professionals will often not know the whole situation. 5.2.86 It is noted that the GDASS DASH training specifically highlights the importance of professional judgment and that it should not be viewed as a tick box exercise. Although this training was paused at the beginning of the COVID-19 pandemic, at the point of Page 80 of 122 Copyright © 2020 Standing Together. All rights reserved. writing it is due to be continued virtually due to the ongoing pandemic. This will sit alongside guidance already produced since by the Gloucestershire Domestic Abuse and Sexual Violence (DASV) Strategic Coordinator which states the importance of recognising fluid risk and the role of professional judgement. 5.2.87 Detailed information from the school was not requested by the Social Worker and as such, the school’s information regarding how Ella presented at school was not used in the assessment. The information would have been helpful to understand her relationships at school, whether she presented with any behaviours that were challenging and whether she had discussed domestic abuse with teachers or friends or discussed her relationship with the perpetrator. Children’s Social Care records do not clarify whether education colleagues/school teachers were aware of the domestic violence incident and how this may have impacted on Ella at school. The school staff at the time have said that they were not made aware of the nature of the incidence and that there was nothing on the social care file to suggest that information regarding this was shared with them. 5.2.88 Gloucestershire Children’s Social Care closed the case on 23rd April 2015 once the Initial Assessment was completed. Laura was offered a referral to a domestic violence support service and she informed the Social Worker that she did not want to attend. Laura’s family believe that at this point, something should have been offered to Ella, however, there was no further enquiry with the school at the time of assessment. No other support was provided for and there are no records of discussions with Laura about the impact of domestic abuse on Laura and her children. 5.2.89 It is important that front line workers gain the confidence of the victim to engage with services in respect of domestic violence as well as ensuring that a referral is made to specialist services. If the victim chooses not to engage with specialist services, it is still incumbent on the front-line worker, in this case, the Social Worker, to engage with her on the impact of domestic abuse. 5.2.90 Management oversight: Supervision took place on a monthly basis during the time that Ella was allocated to a Social Worker, in the first supervision session on 28th January 2015 the team manager reports that the school and Health Visitors should be contacted for the assessment and “a reflective discussion took place which included disclosing about domestic abuse and Claire’s law”. 5.2.91 Claire’s Law, or DVDS, has two functions: ‘right to ask’ - this enables someone to ask the Police about a partner’s previous history of domestic violence or violent acts. A precedent Page 81 of 122 Copyright © 2020 Standing Together. All rights reserved. for such a scheme exists with the Child Sex Offender Disclosure Scheme; and ‘right to know’ - Police can proactively disclose information in prescribed circumstances. At the time of writing, the Domestic Abuse 2020 bill is being debated and within it, proposes to change Claire’s Law to allow concerned family and friends to access information as well. This review is supportive of this change which may have allowed Laura’s family to become away of the perpetrator’s past domestic violence. 5.2.92 Claire’s Law was discussed in supervision and information about the perpetrator was shared by the Police. That is, the perpetrator had previously attacked his ex-partner. The supervision notes refer to the discussion with Laura where she told the Social Worker that she knew about the conviction and she was not concerned about it. 5.2.93 The discussion held in supervision about Claire’s Law was not progressed or does not appear to have been discussed with Laura. Protection orders such as Non-Molestation Orders, Restraining Orders or Domestic Violence Protection Orders were not discussed or applied for. “The perpetrator contacted and outlined that mother does know about his past DA history”. The supervision session discussed Ella being seen alone and this is good practice, however, there is no discussion about Ella disclosing that the perpetrator punched her mother and then said that her mother and stepfather ‘got on well’ when her mother entered the room. 5.2.94 The following supervision session in mid-February 2015, noted that the perpetrator has a domestic violence criminal conviction and that “mother knows about his past domestic violence history”. Robust planning about what action to take as a result was not discussed in supervision. 5.2.95 The supervision session does not reflect upon the risk posed by the perpetrator given his violent behaviour towards his ex-partner and her mother in front of her two young children. The Social Worker informed her manager that she had challenged the mother about going to the neighbour’s because he had punched her and later retracting the statement when the Police asked her to make a statement. The supervision session could also have reflected upon the need to protect Ella and her siblings from domestic abuse and Ella’s disclosure that the perpetrator had punched Laura in the face. 5.2.96 The final supervision on file is in mid-March 2015 and reported the perpetrator had called his previous partner a liar and Laura had agreed with this assessment of the perpetrator’s ex-partner. Ella’s biological father informed the Social Worker that he was concerned about not knowing what happened that evening. In a previous note on file Laura’s ex- Page 82 of 122 Copyright © 2020 Standing Together. All rights reserved. partner (Ella’s birth father) had informed the Social Worker that he had seen Laura with two black eyes over the holiday period. This was referring to the visible injuries following the Boxing Day assault in 2014. This does not appear to have been followed up. 5.2.97 The Initial Assessment noted that Ella’s birth father was “a protective factor”. The Social Worker could have been encouraged to exercise greater professional curiosity about why Ella did not inform her birth father of the incident on the 26th December 2014 if he was a protective factor. 5.2.98 The reasons for outcome in the Initial Assessment is recorded “the perpetrator has a past domestic abusive conviction which raises concern and makes me question whether he did assault Laura, rather than it be an accident”. The reasons for no further action are provided as the school has no concerns, “she sees her father regularly throughout the week which is a protective factor and therefore there is no current role for social care, in future if domestic violence comes to our attention, the case may need to be escalated in order to ensure the children are not at risk of emotional or physical harm”. The fact that the children were living with the perpetrator is not identified as a risk in the assessment. The contact with Ella’s biological father is recorded as a protective factor for her. The children continued to live in a home where there has not been sufficient review of risk. 5.2.99 The Social Worker was aware that the perpetrator was considered a high-risk perpetrator to his former partner as he had a previous conviction for attacking her and her mother in front of her two young children. This should have raised her concern for the risk to Laura and the children in this family. 5.2.100 Laura was offered the domestic violence service but she did not have any one to one or bespoke support to reflect on what had happened to her and the impact of this on her and her children. It is essential that front line Social Workers assess domestic violence and its impact on victims and work with this as part of completing assessments. 5.2.101 The communication between agencies was appropriately minimal because of the journey of the child followed from referral to MASH episode completion of initial assessment and then closure. However, more work could have been carried out in engaging with the Health Visitor and the school for assessing whether there were latent domestic violence behaviours such as coercive control and indicators that may have supported the Social Worker to come to a different conclusion at the end of the initial assessment. Page 83 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.102 Ella had learnt to conceal domestic violence and to tell professionals what she was likely to have been told to say. She inadvertently tells the Social Worker that the perpetrator did in fact punch her mother and as her mother comes into the room she stops the discussion. It is essential that children’s voices are heard, they are seen alone and if they disclose an incident they are seen again to follow up on the discussion that they held with their Social Worker. This was a missed opportunity as the Social Worker may have had more access to information about what was happening in the household in respect to domestic violence. Child A’s lived experience is not sufficiently evidenced in the initial assessment. 5.2.103 The correlation between the DASH outcome and the decision made by Children’s Social Care could have been better linked. For example, the outcome of the DASH was that the risk of domestic violence even in 2015 is medium to high. This may have warranted further work rather than the case being closed and could potentially have assessed the likelihood of significant harm. Social Workers should complete their own risk assessment and safety plan when completing a Single Assessment. 5.2.104 Although there is no formal risk assessment – the single assessment identified the following two risks: (i) Domestic abuse and the impact of this on child development - risks surrounding emotional harm. (ii) Laura’s minimisation - concerns she may not feel able to be fully protective. 5.2.105 The initial assessment concluded that there was no previous involvement with Children’s Social Care, the couple had been together for several years and the risk of abuse was mitigated by Laura seeking help next door as a protective measure. Ella had contact with her birth father and this was seen as a protective factor. 5.2.106 Professional Supervision took place in line with supervision policy once a month. However, there was insufficient challenge in supervision and reflective practice. They discussed Claire’s Law, but it was not explored fully nor was a discussion held about how it connects with Laura, Ella and Child A. 5.2.107 Evidence of Good Practice with Gloucestershire Children’s Social Care: When the initial referral was made into MASH, the MASH assessor appropriately progressed the referral for an initial assessment. This was based on information that was held in the system in respect of the perpetrator and his previous domestic abuse. Page 84 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.108 The decision making in the MASH was based on an accurate assessment of the risk posed to Laura and Ella by the perpetrator’s violent behaviour. The records indicate that an assessment was required because “mum may not be reporting DV and there is a young baby in the household and the perpetrator appears to have a violent history”. 5.2.109 The assessment was progressed and the Social Worker attended the family home to interview Laura and Ella and to gather information about the incident of domestic abuse. 5.2.110 The Social Worker appropriately probed Laura about the domestic violence and challenged the perpetrator about his violent behaviour. When referring to his violent behaviour towards his ex-partner, the perpetrator informed her that his previous partner’s perspective about what happened was “farfetched and he has no reason to lie”. Children’s Social Care records indicate that the Social Worker remained concerned about the perpetrator’s violent behaviour and progressed with the assessment. 5.2.111 The Social Worker assessed that Laura had acted protectively and appropriately, that Ella’s birth father was a protective factor in supporting her, and that she had presented as a child who could talk to her birth father “if things were difficult”. 5.2.112 Supervision took place in line with supervision policy and management oversight considered different approaches to supporting Laura, including the use of Claire’s Law to gather information to protect Ella and Laura. 5.2.113 Analysis for Education: 5.2.114 Children that live with domestic abuse face increased risk for their physical safety as well as harm to their emotional well-being and all aspects of their life. The Adoption and Children Act (2004) states that witnessing the ill-treatment of another person constitutes significant harm, therefore causing enormous disruption and trauma. 5.2.115 For schools, gaining an insight into children’s home/social circumstances depends on the information they receive via disclosures from children or adults; the presentation of children in school; and the behaviour of children. It also depends on identifying patterns over a period of time which is in turn dependent on keeping good records in line with the schools safeguarding policy. Teachers, Designated Safeguarding Leads and Head Teachers also have to make the judgement about what they are seeing and whether or not it meets the threshold for intervention through either early help or statutory children’s social services. Page 85 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.116 In reviewing the actions of the three schools Ella attended it is important that events are considered as they were at the time rather than through the lens of hindsight. It is also important to see them in context; for example, all schools now record safeguarding and other behavioural incidents on CPOMs – an electronic recording system. This has greatly improved the retention and recoding of information. Recording at the time was through the filing of handwritten forms and associated notes. 5.2.117 Ella attended Infant, Junior and Secondary School. Each school operated a safeguarding policy in line with and based on the GSCB policy at the time. In the case of both the Infants and Junior School, a key element of the policy was to use a ‘case of concern form’ (CoC). The CoC would be initially filled in by a teacher who may be concerned about a pupil’s behaviour or presentation, or have received information from a child /adult /parent. The CoC would be reviewed by either the designated safeguarding lead (DSL) and/or the Head Teacher who would determine whether the matter was a ‘safeguarding’ or a ‘behavioural’ issue. Safeguarding issues led to the establishment of an individual safeguarding file and behavioural issues into a class file with a chronology of records on the cover. 5.2.118 The School nursing service operated a school ‘drop-in’ service in 2011 and in March Laura and the perpetrator attended such a session as they were concerned that Ella was displaying ‘difficult’ behaviour. A plan was agreed, and school nursing decided that they would reassess should the Infant School identify further concerns. The Infant School had no cause to raise any further concerns. This was an appropriate action within the policy and practice in place at that time. 5.2.119 There are three CoCs concerning Ella. Two concern a period in May 2012 whilst at the infants’ school, they are dated 22nd and 29th May 2012 and also refer to an incident on 28th May 2012. The issues were to do with Ella’s behaviour both at home and in school. The school responded by working with Laura via the Child and Family Worker based in the school. Some of the required action coincided with the birth of Child A and this meant that a meeting with Laura was cancelled. The Infant School acted within its policy framework and the matter was deemed ‘behavioural’ and filed appropriately. 5.2.120 The third CoC was in December 2016 whilst Ella was at the Junior school. This concerned disclosure from another pupil who knew Ella that she had sent her some ‘worrying texts’. The school acted appropriately and discussed this with Ella, Laura and the other pupil’s mother. It was established that Ella was struggling to come to terms with the death of her Page 86 of 122 Copyright © 2020 Standing Together. All rights reserved. cousin and this was impacting on her mood which was reflected in some of the texts. Laura was encouraged to seek support for Ella via her GP and that was appropriate. The CoC form was filed as a ’behavioural issue’ in line with the school’s policy. 5.2.121 In between these CoC recorded incidents phone contact was made with the Junior School by the Social Worker conducting the Initial Assessment following the events of Boxing Day 2014 detailed elsewhere in this report. Records held by Children’s Social Care do not record whether or not the Social Worker revealed to the Designated Safeguarding Lead the events that had led to the initial assessment but accurately records that the school had no safeguarding concerns. Given no safeguarding file was ever opened for Ella it must be assumed that this was the case and without the contextual knowledge the response of the school was correct. Social care records also record that a closure letter and Initial Assessment was sent to the school but there is no record of the school having received it. There is no doubt that under the school’s policy at the time information regarding this incident whether given in the phone conversation, or via the closure letter and Initial Assessment, would have resulted in a safeguarding file being created. With the benefit of this additional information the response to any future events, including the transfer of safeguarding information when Ella moved to Secondary School, would have been different. 5.2.122 Whilst at Secondary School there were again some behavioural issues as detailed elsewhere in this report. In the absence of there being any safeguarding concerns known and /or recorded, the actions of the school were in line with their policy and practice. 5.2.123 There was also a disclosure made in May 2018 by Child A to the infants’ school in relation to witnessing the perpetrator smash the door with his hand during an argument. The school recorded this on a CoC as a safeguarding disclosure and it was considered by the Designated Safeguarding Lead. The Designated Safeguarding Lead recalls following up with Child A who gave the same account, presented normally, was ‘jolly’ and ‘happy’, and said words to the effect that 'everything is okay/better now’. In the absence of any other information on this family which gave concern and no other paperwork or previous concerns from any stakeholders, a decision was made, by the Designated Safeguarding Lead and the class teacher, to ‘monitor’. This was in line with the school’s safeguarding policy where the school would make one of three decisions on disclosures: to discard; monitor; or, refer. The school decided that this incident, on its own, would not meet the threshold for a referral to the MASH. Without any other information, it is unlikely that this Page 87 of 122 Copyright © 2020 Standing Together. All rights reserved. incident, should it have been referred to the MASH, would have met the threshold for multi-agency investigation, assessment or action.20 5.2.124 Laura’s family spoke at length about the relationship between Laura and the schools. They felt that Laura may not have viewed the school as a safe space in order to make a disclosure in relation to the domestic abuse and difficulties she was experiencing at home. The felt that this was largely stemming from the dispute with the school due to a fine being issued for unauthorised absence following a family holiday. They felt that this could in turn have hindered the school’s response in relation to safeguarding concerns not being shared due to the school potentially further corroding the rapport between Laura and the schools. 5.2.125 Given that the schools were unaware of the events of Boxing day 2014, they did not consider Ella’s behaviour to be a safeguarding issue. Whilst each incident was taken seriously and appropriate action involving the parents and other services, they were spread over a period of time and in the absence of any other disclosure or information were seen as the sort of behaviours some children display whilst going through school. The critical observation is that the initial assessment in 2015, if it had been shared, would have alerted the schools to the fact that Ella’s behaviour may have its roots in what would have been deemed safeguarding issues. It is noted that Operation Encompass21 now has a helpline for teachers which can be consulted when concerns arise. 5.2.126 Whilst it is recognised that there will often be an adjustment following a new step-parent figure this should also be considered in light of the fact that there is an increased risk posed to children from non-biological parents such as step-parents22. Safeguarding training does include such information, but we must not underestimate how hard it is for schools to make the link between school behaviour and home circumstances when as in 20 The Home Office Quality Assurance panel asked for further exploration regarding this disclosure. The school provided additional commentary and the Chair was satisfied that the Panel sufficiently explored this and notes that correct procedure was followed, and in light of previous incident information not being known, this was a proportionate response. The school confirmed they have initiated a higher level of domestic abuse training which has been built into their safeguarding training. They also agree, and are committed to the need for increased information sharing and good communication between police, social services and schools. They note that the high level incidents that occurred previously should have been shared with the school to ensure we are informed and therefore empowered to be extra vigilant in monitoring the child’s wellbeing and acting in line with our duty of care. 21 Operation Encompass directly connects the police with schools to ensure support for children living with domestic abuse in their homes when there has been a police attended incident of Domestic Abuse. For more information: https://www.operationencompass.org/ 22 https://www.psychologytoday.com/gb/conditions/child-abuse Page 88 of 122 Copyright © 2020 Standing Together. All rights reserved. this case the parent/step-parent do appear to be acting in the interests of the child and engaging with the school and other services. 5.2.127 Finally, it is worth stating that in all records where Ella is asked about her experience of school she talks positively about being happy in school and how she enjoys her favourite subjects. 5.2.128 Police Analysis 5.2.129 Gloucestershire Constabulary was subject to a targeted domestic abuse HMIC Inspection in 2013 which was critical of the force's response. In June 2014 the force was re-inspected and inspectors ‘commended the force on the strong progress made to date’ in respect of 13 recommendations that had been made by the 2013 Inspection. These 13 recommendations are available via the HMIC report ‘Gloucestershire Constabulary’s approach to tackling domestic abuse’23. 5.2.130 In assessing Police involvement it is also important to place in context the age of some of these incidents which stretch back over many years. The policing response to domestic abuse and multiagency practice in Gloucestershire have changed significantly over that time, not least with the inception of the MASH in April 2014 and subsequently the instigation of the daily domestic abuse meeting in February 2016. 5.2.131 The 2010 incident between the perpetrator and his former partner and her mother: The Police response to this case was effective. The suspect was quickly arrested and later prosecuted for the offences committed against the perpetrator’s former partner and her mother. A DV1 was submitted (the appropriate paperwork for this type of incident). It is not recorded if the perpetrator’s former partner was offered specialist Domestic Violence/Abuse support services. This conviction is important as it meant the perpetrator had a relevant conviction for domestic assault held on file. 5.2.132 DVDS/Claire’s Law: DVDS is of interest to the family of Laura and Ella as they would like to have known of the perpetrator’s previous conviction themselves and also to be reassured that Laura was told. The DVDS was rolled out to Police Forces in March of 2014. Although this is referenced on the MASH enquiry it does not appear that Police completed a formal disclosure to Laura in reference to the perpetrator’s previous, relevant 23https://www.justiceinspectorates.gov.uk/hmicfrs/wp-content/uploads/gloucestershire-approach-to-tackling-domestic-abuse-revisit.pdf Page 89 of 122 Copyright © 2020 Standing Together. All rights reserved. conduct. It is likely that the force’s use of DVDS was in its infancy. Gloucestershire Constabulary now have a mature and robust system for DVDS which has recently been commented upon by the Home Office and HMICFRS as national best practice. However, as noted in this report, the previous conviction of the perpetrator was discussed with Laura by Children’s Social Care during their assessment in early 2015. Additionality, it is worth noting that in Gloucester DVDS disclosures can only be made directly to the person in the relationship. 5.2.133 The 2014 Boxing Day incident: This incident is significant in that it is the only known precursor crime committed by the perpetrator against either Laura or Ella prior to their murder in 2018. The initial Police response was effective and swift with the incident being graded as immediate response and officers arriving at the scene within minutes. This incident was however viewed as a missed opportunity to hear the voice of the child. 5.2.134 The perpetrator was quickly arrested and removed. Statements were taken from the neighbours to whom Laura had fled. Photographs were taken of Laura’s injuries and she was spoken to away from the suspect. Laura disclosed an assault but did not wish to support Police action. 5.2.135 At around midday the following day, officers from the Domestic Abuse Safeguarding Team interviewed the perpetrator. He denied the offence and stated that Laura had been ‘drunk’ and the injuries she had sustained were as a result of her ‘drunken behaviour’. There were missed opportunities at this stage to link in with other agencies involved at the time who could have provided additional information to support a victimless prosecution, for example, the information known to the hospital in relation to the disclosure of Laura being punched in the face. A Domestic Violence Protection Notice (DVPN) was considered but not deemed appropriate in the circumstances. The perpetrator was released without charge. Laura’s family felt that the use of a DVPN may have been a useful intervention at this stage. 5.2.136 Laura was offered a referral to GDASS but she stated that she did not wish to contact the service. A DASH RIC form was completed and re-graded from standard to medium risk following reconsideration by the Domestic Abuse Safeguarding Team after revisiting the victim. This would not meet the threshold for consideration by MARAC which considers only high-risk cases. 5.2.137 The initial sharing of information about the Boxing Day incident was 4 days after the incident and a formal request for information sharing was made 2-3 days later. Page 90 of 122 Copyright © 2020 Standing Together. All rights reserved. 5.2.138 Evidence led prosecution: This case was not considered for a Crown Prosecution Service (CPS) decision by Police despite a good evidential picture being available to officers. In particular, the accounts provided by witnesses, the injury photographs taken from Laura, the comments made by Ella and others at the scene, the perpetrator’s bad character and the initial account provided by Laura which confirmed the assault had occurred. This decision was made by the custody sergeant in consultation with the officers who were dealing with the case. Those officers were domestic abuse specialists. While this complied with force policy at the time and was a subjective decision, it is clear that there may have been evidence to proceed with a prosecution. Laura’s family noted that there was additional evidence that could have been gathered at this stage from other professionals in order to support a victimless prosecution using information from other agencies. 5.2.139 No attempt was made to secure evidence from Ella which may have further supported the case. Listening to the voice of any children involved is an important action. The Constabulary has invested significant training into this area since 2017 under the banner of Op Guardian. 5.2.140 Nationally and locally CPS are now more supportive of evidence led prosecutions and one of the key tools to facilitating such outcomes is body-worn video which would have significantly assisted this case. 5.2.141 Police made a decision at the scene to place Child A and Ella for the night in temporary accommodation with the perpetrator’s mother. The decision making by the Police was not recorded and the Chair and panel acknowledge that the intention of the attending officers was to ensure the children were safe and were able to go to the home of a family member as soon as possible. The fact that Child A and Ella went to the home of the perpetrator’s mother is of huge consequence to the family of Laura and Ella. The family assert that were members of Laura’s family who arrived at the scene and offered to take Ella and the other children home with them. Instead, they were placed in the care of the perpetrator’s mother. The family strongly believe this was a key reason why Ella did not speak to her father or others about this incident. They feel she was encouraged not to speak about it as Ella disclosed this to the family in 2017 when the perpetrator’s affair come out. The family was able to communicate their views on the handling of this situation directly to the review panel when they attended the panel meeting. While it is acknowledged that full understanding of family ties and context is challenging for Police in the middle of an arrest Page 91 of 122 Copyright © 2020 Standing Together. All rights reserved. of this nature, the decision of where the children should be placed temporarily should be considered in light of safeguarding policies and their ties to family members and their potential to be a witness. 5.2.142 The decision to interview a child as a witness to a criminal offence requires an exploration of a multitude of factors so cannot be restricted to a simple age threshold. Some children will naturally be more confident and capable at a younger age and much will also depend upon the circumstances of the case. There are a number of guidance documents that set out for officers what should be considered and how an interview should be planned and approached. Invariably the main issues that are considered are the competence of the witness, the severity of the offence, the nature and weight of the evidence that the witness is believed to possess, the potential impact on the child witness of firstly the interview and then secondly the court process. In this case, Child A was very young and was not believed to have witnessed the incident. Ella was not interviewed although she may have witnessed the incident, she certainly witnessed the immediate period after the assault. In 2014, evidence led prosecutions were not commonplace in Gloucestershire and once Laura declined to support a prosecution, this was not pursued. It is likely that parental consent would have been required for an interview with Ella. Given the perspective of Ella now known from her family during this review, this example should be considered by Gloucester Constabulary in how to carefully weigh up considerations related to interviewing children in relation to domestic abuse incidents. The author acknowledges that the decision to interview is subjective and dependent on the circumstances of each case. This would include if there is sufficient evidence for evidence led prosecution that would not depend on the child’s account. And sadly, we will never know for certain if Ella witnessed this particular incident. 5.2.143 The DASH was considered by the MASH and on the 2nd of January 2015, a MASH enquiry was completed that involved Children’s Social Care, Police and GDASS sharing information. The outcome of that enquiry was recorded as follows: “This incident is not high in its own right however the perpetrator has been previously high risk. Positive Police action has been taken although due to no complaint no additional action has been taken. This is also going into the MASH from Social Care and I will discuss consideration of DVDS with them before they carry out any visit.” 5.2.144 The perpetrator was a serial perpetrator and Gloucestershire Constabulary do not have an offender management process in place to specifically address serial perpetrators of Page 92 of 122 Copyright © 2020 Standing Together. All rights reserved. domestic abuse. Gloucestershire Constabulary should consider the emerging practice from MATAC (Multi-Agency Tasking And Coordination) and DRIVE and the Secondary School of Policing practice guidance on their next steps in improving practice in relation to serial perpetrators. Gloucestershire Constabulary visited Northumbria Constabulary in September 2018 to look at MATAC. This works on a Recency, Frequency, Gravity (RFG) matrix24. Gloucestershire Constabulary note that it is unlikely that the perpetrator would have scored highly enough to warrant intervention prior to 2014 and may not have done so after that date, however, this is in hindsight and cannot be confirmed. The Constabulary continues to assess the best way forward in this area for something that makes a meaningful difference and is sustainable. 5.2.145 Gloucestershire Domestic Abuse and Sexual Violence Coordinator has produced guidance documents that aim to build a coordinated approach to Domestic Abuse & Sexual Violence (DASV) across all organisations, ensuring all professionals are confident and competent in their response to DASV. The documents provide support on creating DASV policies, dealing with disclosures of DASV and understanding what DASV is and how it may present. Employers should be able to offer a proactive and supportive response which leads to improved outcomes for adults and children affected by DASV. 5.2.146 The guidance documents come with a training standards pathway that maps out the level of awareness or training of DASV we would recommend staff are accessing depending on their role in an organisation. 5.3 Equality and Diversity: 5.3.1 The Chair of the Review and the Review Panel considered all the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation during the review process. 5.3.2 Throughout discussions with the review panel and Laura’s family, Laura did not appear to have suffered any negative consequences due to her age, race, marital status, beliefs or sexual orientation. She was grounded in her home community and with family support 24 https://middlesbrough.gov.uk/sites/default/files/One-Minute-Guide-10-MATAC.pdf Page 93 of 122 Copyright © 2020 Standing Together. All rights reserved. and appears to have successfully avoided services that she did not wish them to be involved with her or her children. 5.3.3 Age is a key consideration. Ella was a child but old enough to have a clear understanding of her experiences at home, but she was overlooked by Children’s Social Care and the Police to speak to alone and to fully understand her circumstance. Likewise, the schools seemed to take on the views given to them by others, including Laura and the perpetrator, rather than considering her circumstances as a whole. The impact of the perpetrator on her life is clear in the chronology sections where her behavioural issues in school begin at the same time as he moves in with the family. 5.3.4 Ella’s status as a stepchild is overlooked as is the potential for increased harm to her as a stepchild from a convicted perpetrator of domestic abuse. Her status as the perpetrator’s stepchild is overlooked by the Police on the night of the Boxing Day incident in 2014 when she is sent home with the perpetrator’s parents instead of Laura’s family. 5.3.5 Sex should always require special consideration. Analysis of domestic homicide reviews reveals gendered victimisation across both intimate partner and familial homicides with females representing the majority of victims and males representing the majority of perpetrators.25 This characteristic is therefore relevant for this case, the victims of these homicides were female and perpetrator of the homicide was male. 5.3.6 The perpetrator’s epilepsy and engagement with services were identified throughout the report and demonstrate a proactive and supportive response to his condition. The perpetrator’s diagnosis, treatment and management in relation to his epilepsy were in line with NICE guidance26. 25 “In 2014/15 there were 50 male and 107 female domestic homicide victims (which includes intimate partner homicides and familial homicides) aged 16 and over”. Home Office, “Key Findings From Analysis of Domestic Homicide Reviews” (December 2016), p.3. “Analysis of the whole Standing Together DHR sample (n=32) reveals gendered victimisation across both types of homicide with women representing 85 per cent (n=27) of victims and men ninety-seven per cent of perpetrators (n=31)”. Sharp-Jeffs, N and Kelly, L. “Domestic Homicide Review (DHR) Case Analysis Report for Standing Together “ (June 2016), p.69. 26 https://www.nice.org.uk/guidance/cg137 Page 94 of 122 Copyright © 2020 Standing Together. All rights reserved. 6. Conclusions and Lessons to be Learnt 6.1.1 The role of the family and friends of survivors who require support to understand and safely address domestic abuse as they are often the first and sometimes only source of support for survivors of domestic abuse. 6.1.2 The consideration of the voice of the child victim requires more prominence in safeguarding analysis and decision making, specifically with officers and Social Workers seeking to understand whether the wider family would seek to suppress disclosures or influence child witnesses. It is positive to note that at the point of writing the new Domestic Abuse Bill due to be passed in 2020 will note children as victims in their own right within the statutory definition of domestic abuse. Locally, this has already become a feature of awareness and training amongst staff. 6.1.3 The importance of considering the impact of the introduction of a step-parent and his/her background into a child’s life. 6.1.4 The importance for GPs, or any health professional, to know who has parental responsibility for a child, as well as the other adults who play a key role in that child’s life e.g. step-parents. It is good practice to always ask, clarify and document who the adult is accompanying a child to appointments or who is ringing the practice about a child. 6.1.5 The need for all services to ensure they have adequate policy, training and record-keeping procedures to adequately address domestic abuse. And for these services to ensure they benchmark themselves to the best practice or national guidance in these areas. 6.1.6 The ability for all front line professionals to confidently speak to survivors of domestic abuse about their situation despite any denial or minimisation and to understand where these barriers come from and to address domestic abuse beyond basic inquiry. 6.1.7 For strategic boards for domestic abuse, safeguarding and health and wellbeing to work together to adequately resource and support multi-agency and best practice in relation to domestic abuse. Page 95 of 122 Copyright © 2020 Standing Together. All rights reserved. 7. Recommendations The recommendations below should be acted on through the development of an action plan, with progress reported on to the Area Community Safety Partnership within six months of the review being approved by the partnership. 7.1 Overview Report Recommendations: 7.1.1 Recommendation 1: All agencies to ensure Domestic Abuse training for their staff includes in depth detail about economic abuse, and District Councils to ensure DA training is available to all staff in debt advice services locally. 7.1.2 Recommendation 2: Gloucester City Community Safety Partnership and Safer Gloucestershire to ensure stronger links between the SG executive, the countywide CSP/ delivery board for domestic abuse, and the health and wellbeing board. 7.1.3 Recommendation 3: Gloucester City Community Safety Partnership and Gloucestershire Safeguarding Children’s Partnership Executive (GSCP) to ensure that the mapping identified through the National Panels countrywide data which found that domestic abuse is present in 41% of all child fatalities and 42% of all serious safeguarding incidents nationally is applied countywide for wider understanding and learning of the implications of domestic abuse in front line safeguarding services. 7.1.4 Recommendation 4: Health professionals to seek to know who has parental responsibility for a child, as well as other adults who play a key role in that child’s life e.g. stepparents. Agencies should always ask, clarify, and document who the adult is accompanying a child to appointments or who is ringing the practice about a child. Details of the child’s birth parent should be recorded and the status of the child’s relationship with that parent should also seek to be recorded. 7.1.5 Recommendation 5: For all agencies to ensure the learning from the homicide timeline work is built into all DA training, and for Safer Gloucestershire to explore the best dissemination of Jane Monckton Smith’s formal training. 7.2 Progress on Overview Recommendations at the point of conclusion of the DHR 7.2.1 Recommendation 1: Across Gloucestershire, work is already underway to improve links between the key strategic boards, Safer Gloucestershire, Health and Wellbeing Board and Children’s safeguarding executive. These boards all share DA as a strategic Page 96 of 122 Copyright © 2020 Standing Together. All rights reserved. priority and now ensure some shared key membership, regular reports across boards and also recently held a joint development session to agree approaches to shared priorities and the differing perspective and roles each board takes. This work is ongoing and development days are planned to become a regular occurrence to ensure a robust strategic response to shared priorities such as DA. 7.2.2 Recommendation 2: Recent work undertaken by the Children’s Safeguarding Executive Business Unit has highlighted that DA is present in 65% of 293 child protection cases in the county. This has now been shared across the key strategic boards (Safer Gloucestershire, Health and Wellbeing Board and Children’s safeguarding executive) and work is now underway to develop initiatives to address this. Work already in development includes, roll out of face to face training, e-learning, workshops and practitioners briefings to increase awareness of DA and how to appropriately identify and response. Much of this training is being linked across the South West. Increased resources for DA in the MASH are also being explored. 7.2.3 Recommendation 3: Recent work undertaken by the Children’s Safeguarding Partnership Business Unit has highlighted the National Panels data that DA is present in 42% of all Serious Safeguarding incidents Nationally and 41% of all child fatalities nationally. This has now been shared across the key strategic boards (Safer Gloucestershire, Health and Wellbeing Board and Children’s safeguarding Partnership) and work is now underway to develop initiatives to address this 7.2.4 Recommendation 4: The GHFNHST recording system within the Acute Trust now has embedded the process whereby the mother is consistently added as next of kin to every baby born in Gloucestershire since December 2016. When audited in November 2020, this process was shown to be effective: all the under 5s had mum on their records as next-of-kin. As a high priority, GHT are working with project leads for the Trust IT systems set up so that staff can ask and record who any patient comes to hospital with, capturing both their name and role in the patient’s life. The Gloucestershire Health and Care NHS Foundation Trust (GHC) Safeguarding Team are working with its Quality Improvement Team to develop a solution to make it easier for staff across the Trust to record who is in the childs household and family/personal network. This includes documentation of who has parental responsibility. 7.2.5 Recommendation 5: Homicide timeline included in training delivery to new police recruits and the training delivered by the Safeguarding Children’s Partnership. The new Page 97 of 122 Copyright © 2020 Standing Together. All rights reserved. DA strategy for the county prioritises training for all agencies and there will be a focus on investment in Lot 5 of the commissioning framework for fund a multi-agency DA training pathway 7.3 Individual Management Review Recommendations: Gloucester Clinical Commissioning Group 7.3.1 Recommendation 1: Primary Care should always discuss concerns about suspected or known issues of domestic abuse amongst the Multi-Disciplinary Team to ensure awareness of cases, and the opportunity to join up discussions or concerns about all children and household members, and their fathers and partners. Primary Care information will benefit from improved MARAC liaison (knowledge of domestic abuse incidents and contribution to MARAC research). All discussions should be noted within records. 7.3.2 Recommendation 2: There must be continued, consistent and strengthened links between the work of GDASS and Primary Care in order to maintain awareness of domestic abuse issues and the impact that this has on victims and children. This should include consideration of continued service provision for the GDASS pilot beyond March 2020. 7.3.3 Recommendation 3: Where there are out of hours’ attendances to unscheduled care settings (both for adults and children) GP Practices should have a clearly identified process in place that supports recognition for potential follow up to significant illness or injury. Specifically, the role of hospital paediatric liaison needs to be further clarified in relation to effectiveness and how this currently links with Primary Care. 7.3.4 Recommendation 4: Practice and learning from IRIS should be considered by the CCG as domestic abuse practice is developed for primary care settings. Gloucestershire Care Services NHS Trust 7.3.5 Recommendation 1: To review the GCS Domestic Abuse Policy as the current focus is for staff to know what to do in the event of a disclosure. More guidance is required within this policy about the indicators of potential domestic abuse to enable effective signposting to specialist services. 7.3.6 Recommendation 2: GCS domestic abuse training needs to encompass all the indicators of domestic abuse which may be evident prior to a disclosure. This training Page 98 of 122 Copyright © 2020 Standing Together. All rights reserved. model is for a continuous rolling programme available to all GCS staff, within both adult and children services. 7.3.7 Recommendation 3: Where there is a known history of domestic abuse within a relationship, GCS practitioners take every opportunity to explore this with the victim when safe to do so and demonstrate consistent professional curiosity. This should be reinforced within the domestic abuse training, group safeguarding children supervision, GCS Domestic Abuse Policy and all GCS staff forums. Gloucestershire Hospitals NHS Foundation Trust 7.3.8 Recommendation 1: Staff need to retain professional curiosity at all times and to ensure continued training is in place for Trust staff. 7.3.9 Recommendation 2: For the Trust to consider the tools and findings from DOHSC funded Pathfinder sites to ensure that they are maintaining and further developing best practice in relation to domestic abuse. Gloucester Education Services 7.3.10 Recommendation 1: All schools in Gloucestershire to reassure themselves through refreshers or by implementing mechanisms that their staff understand domestic abuse and the context of professional curiosity in the wider family context. 7.3.11 Recommendation 2: All schools to agree a system with Children’s Social Care whereby receipt of key safeguarding information is recorded so that there is no doubt on whether that information has been received and acted upon. 7.3.12 Recommendation 3: That the learning from this review be incorporated into school safeguarding training to enable the difficult issue of the threshold between ‘behavioural’ and ‘safeguarding issues’ to be constantly reviewed by schools in the light of the evidence of this and other SCRs. Gloucestershire County Council Children’s Social Care 7.3.13 Recommendation 1: All GSCB domestic abuse training should help Social Workers to develop skills to engage children who may conceal domestic violence. 7.3.14 Recommendation 2: Social Workers to have updated training on patterns of domestic violence to better understand how Laura and her children were impacted upon by the abuse and what actions they would take as a result of the training. Page 99 of 122 Copyright © 2020 Standing Together. All rights reserved. 7.3.15 Recommendation 3: To explore and challenge what has happened and why. For example, the school and Health Visitor were involved but the sharing of information about the children could have improved. A Multi Agency GSCB briefing on the outcome of this IMR to all partners and MASH. 7.3.16 Recommendation 4: The assessment of Parenting Capacity in Social Worker Single Assessments to be strengthened to include evidence based strengths, risks and vulnerabilities to children. 7.3.17 Recommendation 5: All Social workers, their managers and leaders to have workshop, team discussions (facilitated by practice learning team) on ACE’s wellbeing of parents and what resources are available for work with parents. 7.3.18 Recommendation 6: All Social Workers and their managers to attend a workshop or training on perpetrators of domestic abuse (with use of restorative practice methods) to ensure appropriate responses to perpetrators and awareness of current service provision. 7.3.19 Recommendation 7: All Social Workers and their managers to attend a workshop or training to include interviewing techniques to ensure the child’s voice is heard and identify the wide range of indicators of domestic violence and coercive control. Programme to be started immediately and outcomes reported to Gloucestershire Safeguarding Delivery Board. Gloucestershire Constabulary 7.3.20 Recommendation 1: Gloucestershire Constabulary should maximise the use of Body Worn Video in situations of suspected Domestic Abuse. 7.3.21 Recommendation 2: Gloucestershire Constabulary, in conjunction with the Crown Prosecution Service, should continue to recognise and progress evidence led prosecutions. 7.3.22 Recommendation 3: Gloucestershire Constabulary should ensure that officers at Domestic Abuse incidents recognise the evidence that can be provided by children and, where appropriate, seek to secure and preserve that evidence. Page 100 of 122 Copyright © 2020 Standing Together. All rights reserved. Appendix 1: Domestic Homicide Review Terms of Reference Domestic Homicide Review/ Serious Case Review Terms of Reference: Case of Laura and Ella This Domestic Homicide Review/ Serious Case Review is being completed to consider agency involvement with Laura, Ella and the perpetrator following the death of Laura, Ella in May 2018. The Domestic Homicide Review/ Serious Case Review is being conducted in accordance with Section 9(3) of the Domestic Violence Crime and Victims Act 2004. Purpose of DHR/ SCR 1. To review the involvement of each individual agency, statutory and non-statutory, with Laura, Ella and the perpetrator during the relevant period of time Ella’s birth in 2006 to the date of the homicide. To summarise agency involvement prior to Ella’s birth. 2. To establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims. 3. To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result. 4. To apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate. 5. To prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity. 6. To contribute to a better understanding of the nature of domestic violence and abuse. 7. To highlight good practice. Definitions: Domestic Violence and Coercive Control 8. The Overview Report will make reference to the terms domestic violence and coercive control. The Review Panel understands and agrees to the use of the cross government definition (amended March 2013) as a framework for understanding the domestic violence experienced by the victim in this DHR. The cross government definition states that domestic violence and abuse is: Page 101 of 122 Copyright © 2020 Standing Together. All rights reserved. “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; and emotional. Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.” This definition, which is not a legal definition, includes so-called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnic group.” Equality and Diversity 9. The Review Panel will consider all protected characteristics (as defined by the Equality Act 2010) of both Laura, Ella and the perpetrator (age, disability (including learning disabilities), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation) and will also identify any additional vulnerabilities to consider (e.g. armed forces, carer status and looked after child). 10. The Review Panel identified the following protected characteristics of Laura, Ella and of the perpetrator as requiring specific consideration for this case; age of Ella and the sex of Laura. 11. Consideration has been given by the Review Panel as to whether either the victim or the perpetrator was an ‘Adult at Risk’ Definition in Section 42 the Care Act 2014. 12. If Laura, Ella and the perpetrator have not come into contact with agencies that they might have been expected to do so, then consideration will be given by the Review Panel on how lessons arising from the DHR/ SCR can improve the engagement with those communities. 13. The Review Panel will not reflect on immigration status as it is not deemed an issue. 14. The Review Panel agrees it is important to have an intersectional framework to review Laura, Ella and the perpetrator life experiences. This means to think of each characteristic of an individual as inextricably linked with all of the other characteristics in order to fully understand one's journey and one’s experience with local services/agencies and within their community. Key Lines of Inquiry Page 102 of 122 Copyright © 2020 Standing Together. All rights reserved. 15. In order to critically analyse the incident and the agencies’ responses to Laura, Ella and/or the perpetrator, this review should specifically consider the following points: a) Analyse the communication, procedures and discussions, which took place within and between agencies. b) Analyse the co-operation between different agencies involved with Laura/ Ella / the perpetrator [and wider family]. c) Analyse the opportunity for agencies to identify and assess domestic abuse risk. d) Analyse agency responses to any identification of domestic abuse issues. e) Analyse organisations’ access to specialist domestic abuse agencies. f) Analyse the policies, procedures and training available to the agencies involved on domestic abuse issues. As a result of this analysis, agencies should identify good practice and lessons to be learned. The Review Panel expects that agencies will take action on any learning identified immediately following the internal quality assurance of their IMR. Development of an action plan 16. Individual agencies to take responsibility for establishing clear action plans for the implementation of any recommendations in their IMRs. The Overview Report will make clear that agencies should report to the Gloucester City Safer Partnership on their action plans within six months of the Review being completed. 17. Gloucester City Safer Partnership to establish a multi-agency action plan for the implementation of recommendations arising out of the Overview Report, for submission to the Home Office along with the Overview Report and Executive Summary. Page 103 of 122 Copyright © 2020 Standing Together. All rights reserved. Appendix 2: Action Plan DHR/SCR LAURA AND ELLA- ACTION PLAN Recommendation Scope Action to take Lead Agency Key milestones in enacting the recommendation Target Date Date of Completion and Outcome RAG Gloucestershire Multi-Agency Recommendations All agencies to ensure Domestic Abuse training for their staff includes in depth detail about economic abuse and District Councils to ensure DA training is available to all staff in debt advice services locally. Local -Review of current DA training and ensure economic abuse is covered clearly. -Training rolled out to all key staff -debt services to receive specific training Safer Gloucestershire and Gloucester City Council -Training reviewed and implemented. -plans for training roll out developed -training delivered to key staff as per training plan Item to be taken to the GSCP Districts Subgroup 2022 to review a collective response to understanding of Economic Abuse and Domestic Abuse. and evidence of cascade of Briefing supplied by DASV strategic Coordinator. April 2021 and ongoing Economic abuse has been a key feature in the county comms plan for 2020/21 as well as information circulation to professionals. Plans around training are ongoing. The new DA strategy for the county prioritises training for all agencies and there will be a focus on investment in Lot 5 of the commissioning framework for fund a multi-agency DA training pathway. Outcome: to ensure that all relevant professionals are able to effectively identify and respond to economic abuse and offer support at an early stage. Gloucester City Community Safety Partnership and Safer Gloucestershire to ensure stronger links between the SG executive, the countywide CSP/ delivery board for domestic abuse, and the health and wellbeing board. Local -Develop clear shared priority and strategic leadership. -Run development sessions between boards. -Shared board membership and reporting to ensure connections are maintained. Safer Gloucestershire -Clear processes in place for boards linking and working together. -Clear roles and responsibilities to tackling share priority outlined. Ongoing Ongoing: Across Gloucestershire, work is already underway to improve links between the key strategic boards, Safer Gloucestershire, Health and Wellbeing Board and Children’s safeguarding executive. These boards all share DA as a strategic priority and now ensure some shared key membership, regular reports across boards and also recently held a joint Page 104 of 122 Copyright © 2020 Standing Together. All rights reserved. development session to agree approaches to shared priorities and the differing perspective and roles each board takes. This work is ongoing and development days are planned to become a regular occurrence to ensure a robust strategic response to shared priorities such as DA. The new countywide DA strategy will be owned collectively by these partnership boards. Gloucester City Community Safety Partnership and Gloucestershire Safeguarding Children’s Partnership Executive (GSCP) to ensure that the mapping identified through the National Panels countrywide data which found that domestic abuse is present in 41% of all child fatalities and 42% of all serious safeguarding incidents nationally is applied countywide for wider understanding and learning of the implications of domestic abuse in front line safeguarding services. Local -Raise awareness of mapping -promote learning -include into training plans Safer Gloucestershire (alongside Gloucester City CSP) and the GSCP -Circulation of key learning -Training rolled out with key learning incorporated. April 2021 and ongoing Recent work undertaken by the Children’s Safeguarding Partnership Business Unit has highlighted the National Panels data that DA is present in 42% of all Serious Safeguarding incidents Nationally and 41% of all child fatalities nationally. This has now been shared across the key strategic boards (Safer Gloucestershire, Health and Wellbeing Board and Children’s safeguarding Partnership) and work is now underway to develop initiatives to address this. Work already in development includes, roll out of training, e-learning, workshops and practitioners briefings to increase awareness of DA and how to appropriately identify and response. Much of this training is being linked across the South West. Increased Page 105 of 122 Copyright © 2020 Standing Together. All rights reserved. resources for DA in the MASH are also being explored. Data relating to DA and the impact n the lived experience of children forms a section of the GSCP’s data reporting schedule to ensure the partnership is proactively looking at DA and the impact on children For all agencies to ensure the learning from the homicide timeline work is built into all DA training, and for Safer Gloucestershire to explore the best dissemination of Jane Monckton Smith’s formal training. Local -DASV coordinator to circulate necessary information with the request that agencies include this in their training. -Safer Gloucestershire to request updates from agencies as to their training plans and how this work is embedded. -Safer Gloucestershire to discuss options for disseminating any formal training and agree approach. Safer Gloucestershire September 2021 Information circulated by DASV strategic Coordinator. Homicide timeline included in training delivery to new police recruits and the training delivered by the Safeguarding Children’s Partnership. The new DA strategy for the county prioritises training for all agencies and there will be a focus on investment in Lot 5 of the commissioning framework for fund a multi-agency DA training pathway. Discussions ongoing in relation to the future of Safer Gloucestershire in light of its postponement during the pandemic and PCC elections. Outcome: Homicide Timeline work is included in training to support understanding of DA Individual Agency Recommendations Gloucestershire Constabulary Gloucestershire Constabulary should maximise the use of Body Worn Video in Local Since commencement of DHR BWV has been Gloucestershire Constabulary BWV has now been comprehensively rolled out by the force. April 2021 BWV has now been comprehensively rolled out by the force with full training and Page 106 of 122 Copyright © 2020 Standing Together. All rights reserved. situations of suspected Domestic Abuse. taken into standard use in force. -Ensure compliance with procedural guidance on use. -Review sufficiency of training, procedures and operational knowledge. Ensure all officers are utilising product where possible dealing with perpetrators. Ensuring use of BWV in securing DVPN/O’s and other protective orders. Use of BWV footage in training. Focus is on reviewing practice, identifying the operational reality and if necessary providing further training/instruction or guidance on best practice. guidance in place. Outcome: BWV is in consistent use. Gloucestershire Constabulary, in conjunction with the Crown Prosecution Service, should continue to recognise and progress evidence led prosecutions. Local -Procedural guidance for DA has been amended in support of this recommendation. -This is now part of standard training for new recruits. -DA Best Practice Framework offers a system for CPS and Police to monitor referrals and scrutinise on a quarterly basis. Gloucestershire Constabulary -As per column three. Data specifically for EL prosecutions is needed, there may be limitations on this due to data availability. Tracking of proportion of cases and intervention where necessary. Dip sampling to ensure compliance. April 2021 and ongoing -Procedural guidance developed alongside specific ELP guide. ELP and taking positive action a key feature in all DA training delivered to new recruits, with practicals also required as part of the training. CPS and police dip sampling ongoing to monitor cases NFA for opportunities to learn re: ELP. Outcome: Increased use of ELP Page 107 of 122 Copyright © 2020 Standing Together. All rights reserved. -CPS dip sampled DA cases in 2019 to ascertain if threshold was pitched at correct level for referrals. -Ongoing monitoring of data required. -DA refresher training. Gloucestershire Constabulary should ensure that officers at Domestic Abuse incidents recognise the evidence that can be provided by children and, where appropriate, seek to secure and preserve that evidence. Local -Since the incident that generated this recommendation the force has enacted Op Guardian. This was in response to a HMIC CP Inspection in 2017. This contained training and awareness material for officers. -To be incorporated in training for new recruits and refresher training. -To be incorporated in ABE training. -To be briefed to frontline responders and investigators. -To ensure the specialist DAST officers advocate this approach where appropriate. Gloucestershire Constabulary -Incorporation in relevant training plans. -Awareness raising via a communications plan. -Dip sampling of cases to ascertain compliance. June 2021 and ongoing Op Guardian enacted with communications across the force raising awareness of the ‘voice of the child’ and the requirements of officers, including frontline responders and investigators. Importance of ‘voice of child’ included in training to new recruits and ABE training. Outcome: 1. The constabulary needs to have a consistent programme of ABE training available for appropriate constabulary roles and consideration for appropriate Social Workers 2. The Voice of the child should be present in VIST Children’s Social Care Page 108 of 122 Copyright © 2020 Standing Together. All rights reserved. GSCP domestic violence training to be attended to include direct work, communication and engagement skills with children who may conceal domestic violence. (ED did not want to discuss domestic violence with the Social Worker and so social workers need to be equipped to address this especially when children feel pressure from parents about sharing information about domestic violence and/or abuse in relationships and the family home. Regional This element of training to be incorporated in the domestic violence training provided by safeguarding boards and executives GSCP in Gloucestershire and other safeguarding boards or executives in the South West Region Yes there has been progress made within the GSCP to enact this action in the domestic violence work carried out by the practice manager December 2021. This has now been included in the on line child protection interagency agency training by GSCP and the new virtual DA Training package will address the possibility of unrecognised and unreported DA. This virtual package will be available in 2022. In the Social Work Academy the Essentials 3.0 Critical Learning Module is aimed specifically at Social Workers and designed to be a gateway into the multi-agency training. It focuses specifically on types of Domestic Abuse, impact, likelihood and evidence based intervention with a specific focus on the child. Following content moderation the module has been shared and cross referenced with GSCP Multi Agency Training. Outcome: Social Workers feel confident and competent in dealing with Domestic Abuse as evidenced through supervision. Social Workers to have updated training on patterns of domestic Abuse to better understand how LB was impacted upon by the violence and what actions they Regional This element of training to be incorporated in the domestic violence training provided by safeguarding boards and executives. GSCP in Gloucestershire and other safeguarding boards or executives in the South West Region Yes there has been progress made within the GSCP to enact this action in the domestic violence work carried out by the GSCP Practice Development Manager December 2021. This is now included in the on line multi agency training provided by the GSCP. The pilot Child Protection Interagency course started in September 2020 with a complimentary Domestic abuse eLearning course. Attendance on Virtual and Page 109 of 122 Copyright © 2020 Standing Together. All rights reserved. would take as a result of the training eLearning has increased from 4000 enrolments to 12,000 individual enrolments across the virtual curriculum showing an increase in multi-agency training through 2020 and into 2021 Outcome: 1. Social Workers feel confident and competent in dealing with Domestic Abuse as evidenced through supervision. 2. This case is included as a case study within training. The assessment of Parenting Capacity in Social Worker Single Assessments to be strengthened to include evidence-based strengths, risks and vulnerabilities to children. Local and regional Training on Essentials in Gloucestershire to include professional curiosity in completing parenting assessments. Gloucestershire Children’s Social Work Academy To incorporate in Essentials 2.0 Programme December 2021 This has been included in Practice Standards and Essentials 2.0 Programme and is reviewed annually by the Social Work Academy as part of its annual review. Essentials 2.0 Programme modules support professional curiosity (using the Anchor Principles etc.) Following mandatory completion of these modules staff can access the Essentials 3.0 Programme including a ‘Critical Learning’ module about the ability to change. Outcome: Supervision sessions to include support and challenge on parenting capacity in single assessments. Page 110 of 122 Copyright © 2020 Standing Together. All rights reserved. All Social workers, their managers and leaders to attend workshops, facilitated discussions and team meetings (facilitated by the Academy or managers) on ACE’s perspective on the wellbeing of parents and what resources are available for work with parents. Local. Incorporate ACE’s in work of Academy and working with parents. Gloucestershire Children’s social care Yes there has been progress made within the Gloucestershire Safeguarding Children Partnership on impact of ACE’s on parenting. December 2021 Work has started on this and all GSCP safeguarding courses include understanding of ACE’s. This has now been included in the on line multi-agency Child Protection Inter agency training started October 2020 and showing a significant enrolment of practitioners across the partnership. Included the Partnership has been assessing and working on a trauma informed assessment approach and impact of ACE’s on both children and parents. The Essentials 3.0 Programme ‘Critical Learning’ modules offer specific focus on key ACEs – including Parental Mental Health, Parental Substance Misuse, Domestic Abuse and Neglect Evidence Informed Practice will also focus on a trauma informed approach when working with children and young people. Part of the Children’s social care transformation Plan includes a new Trauma Informed Model of Practice with Dr Ana Draper from the Tavistock Clinic. The TIMOC training started to be delivered in early November 2020. Outcome: ACE’s perspective on the wellbeing of parents is Page 111 of 122 Copyright © 2020 Standing Together. All rights reserved. communicated to all Social Workers to assist in informing practice, specifically single agency assessments. All Social Workers and their managers to attend a workshop or training on working with perpetrators of domestic violence. The aim of these workshops/training sessions is to improve social worker’s confidence levels in engaging with perpetrators (both male and female) of domestic violence to support them to identify patterns of abuse and its impact on victims. Local Gloucestershire Children’s Social Care Training on Essentials in Gloucestershire to include professional curiosity in completing parenting assessment Children’s Social Work Academy. To incorporate in Essentials 3.0 Programme Module to be completed by December 2020 and training to be completed by December 2021. A programme has been developed by the Social Work Academy with a focus on ‘Working with Males’. This include male perpetrators of domestic violence/abuse in the Family module) which forms part of the wider PQS curriculum and is rolled out as part of the suite of training for social workers and their managers. Training on female perpetrators of domestic violence/abuse work will be included in the domestic violence programmes led by the Social Work Academy and the GSCP. Outcome: Social workers reporting a better understanding of domestic abuse and all its aspects through supervision All Social Workers and their managers to attend a workshop or training to include practice led learning and development opportunities for practitioners to increase skills, knowledge and confidence in Local Gloucestershire Children’s Social Care and Early Help, Family Support Staff Training on essentials in Gloucestershire to include professional curiosity in completing parenting assessment Gloucestershire Children’s Social Work Academy and GSCP To incorporate in Essentials training To be completed by end of September 2021 This work has started as part of the domestic violence development programme led by the Social Work Academy and there will be further training which will be based on the learning from this DHR from now until End of September 2021. The Essentials 3.0 Programme includes a Page 112 of 122 Copyright © 2020 Standing Together. All rights reserved. identifying the wide range of indicators of domestic violence and coercive control. Programme to be started immediately and outcomes reported to Social Work Academy Board. ‘Communication in Practice’ module which incorporates courageous and difficult conversations and further supports the mandatory ’Relational Practice’ module. Outcome: Social workers reporting a better understanding of domestic abuse and all its aspects through supervision GSCP domestic violence training to be attended to include direct work, communication and engagement skills with children who may conceal domestic violence. (ED did not want to discuss domestic violence with the Social Worker and so social workers need to be equipped to address this especially when children feel pressure from parents about sharing information about domestic violence and/or abuse in relationships and the family home. Regional This element of training to be incorporated in the domestic violence training provided by safeguarding boards and executives GSCP in Gloucestershire and other safeguarding boards or executives in the South West Region Yes there has been progress made within the GSCP to enact this action in the domestic violence work carried out by the practice manager December 2021. Work has now been included in the on line multi agency Child Protection Interagency training rolled out in Gloucestershire as a new virtual platform in 2020. All training reflects the impact of DA on the lived experiences of the child. Attendance at GSP training is showing an increase through the Virtual Platform and ongoing attendance will be monitored via the Quality and Improvement in Practice Subgroup. In the Social Work Academy the Essentials 3.0 Critical Learning Module is aimed specifically at Social Workers and designed to be a gateway into the multi-agency training. It focuses specifically on types of Domestic Abuse, impact, likelihood and evidence based intervention with a specific focus on the child. Following Page 113 of 122 Copyright © 2020 Standing Together. All rights reserved. content moderation the module will be shared with the GCSE. Outcome: professionals reporting a better understanding of domestic abuse and all its aspects through supervision Gloucestershire Education Services All schools in Gloucestershire to reassure themselves through refreshers or by implementing mechanisms that their staff understand domestic abuse and the context of professional curiosity in the wider family context. Local Domestic Abuse and Intimate Partner Violence e-learning training to be launched and promoted to Educational and Early Years settings. A bespoke webinar on Domestic Abuse, that includes definition of DA, and includes coercive and controlling behaviour. Looks at impact on parenting and key tools available to be commissioned, and delivered. Operation Encompass to be rolled out to Early Years Nurseries. Gloucestershire Safeguarding Children Partnership Practice Development Manager with support from Safeguarding in Education Manager Gloucestershire Safeguarding Children Executive Practice Development Manager with support from Safeguarding in Education Manager and County Domestic Abuse and Sexual Violence (DASV) Strategic Coordinator Safeguarding in • E-Learning course to have been commissioned. • Training to be promoted to educational settings • Uptake to be monitored through completion of S175 audit • External expert to be commissioned to write webinar. • Date to launch to be agreed. • Webinar to be promoted • Webinar to be delivered. • Webinar to be recorded • Review of current Training materials to ensure they meet the requirements for Early Years. • Dates of delivery to be confirmed. • Training dates to be promoted. • Training to be delivered. • Operation Encompass to go live for Early Years settings. • Training to be reviewed and updated. June 2020 June 2020 February 2021 September 2020 September 2020 November 2020 December 2020 December 2020 November 2020 June 2020 To date 291 Education Professionals have undertaken the E-Learning module. June 2021 over 7000 education staff have attended all GSACP eLearning courses with an 88% completion rate. The DA Course forms a part of the learning suite which supports the DA course to provide context around DA in the safeguarding arena. June 2020 – an email was sent to all Designated Safeguarding Leads. Information included on the Education Bulletin Board. August 2020 – Tess Biddington a DA specialist commissioned to undertake this piece of work. A two part webinar was delivered by Tess Biddington and Clare Roche in December 2020 and January 2021. September 2020 – agreed to Page 114 of 122 Copyright © 2020 Standing Together. All rights reserved. Training to be developed promoted and delivered to both Education and Early Years settings. Review of training offered to schools to that Professional Curiosity is woven through all elements of training. (whole school training, CPIA, Safeguarding Admin course) Education Manager in partnership with GDASS, Senior Education MASH researcher and Inclusion Service Gloucestershire Safeguarding Children Executive Practice Development Manager with support from Safeguarding in Education Manager October 2020 October/November 2020 November/December 2020 December 2020 November 2020 launch as part of 16 days of action. Whole School Training has been reviewed and is currently compliant with actions from this and other reviews relating to DA. Safeguarding Admin Course was delivered in September 2020 with further courses delivered since to all school admin staff linking to their role in supporting the DSL and SLT in their safeguarding responsibilities. Child Protection Inter Agency training is rolled out and now being delivered successfully to approximately one thousand practitioners with 544 education colleagues attending during 2020/2021. Ongoing monitoring of training will be undertaken by the QiiP. November & December 2020 – Operation Encompass Training rolled out to Early Years sector. 14th December 2020 – Operation Encompass went live to the Early Years sector. Professional Curiosity brought into whole school training and the Safeguarding Administrators course. Page 115 of 122 Copyright © 2020 Standing Together. All rights reserved. Practice briefing circulated to all schools. Outcome: Schools report that staff feels confident and competent in recognising and responding to Domestic Abuse. All schools to agree a system with Children’s Social Care whereby receipt of key safeguarding information is recorded so that there is no doubt on whether that information has been received and acted upon. Local The Joint Working Protocol between Education and Children’s Social Care to be embedded into practice. Education and Early years Sub Group in collaboration with the JWP task and finish group. • The JWP to be agreed by both Education and Children’s Social Care. • The JWP becomes integral to the work between partner agencies April 2021 Ongoing work needed – delayed due to COVID-19 Outcome: Effective safeguarding record keeping is implemented across all educational settings .23 That the learning from this review be incorporated into school safeguarding training to enable the difficult issue of the threshold between ‘behavioural’ and ‘safeguarding issues’ to be constantly reviewed by schools in the light of the evidence of this and other safeguarding Reviews. Local Review of current school training and ensure that the issue of threshold between ‘behavioural’ and ‘safeguarding issues’ is covered clearly and regularly reviewed. Training to be continued to be offered for settings every 3 years. CPIA Training will include learning from this SCR and others both nationally and locally Gloucestershire Safeguarding Children Executive Practice Development Manager with support from Safeguarding in Education Manager • Training reviewed and being offered virtually in light of Covid 19. • Reminders to be sent to schools where 3 yearly training has lapsed. • Training reviewed and being offered virtually in light of Covid 19. November 2021 April 2021 Whole School Training has been reviewed and is currently being piloted. Ongoing – systems implemented to send reminder to schools regarding expiry of 3 yearly training. Scrutiny of compliance undertaken through S175 Audit arrangements Child Protection Inter Agency training is rolled out and now being delivered successfully to approximately one thousand practitioners with 544 education colleagues attending during 2020/2021. Page 116 of 122 Copyright © 2020 Standing Together. All rights reserved. Ongoing monitoring of training will be undertaken by the QiiP. Outcome: Schools report that staff feels confident and competent in recognising and responding to Domestic Abuse Gloucestershire Clinical Commissioning Group Primary Care should discuss concerns about suspected or known issues of domestic abuse amongst the Multi-Disciplinary Team to ensure awareness of cases, and the opportunity to join up discussions or concerns about all children and household members, and their fathers and partners. Primary Care information will benefit from improved MARAC liaison (knowledge of DA incidents and contribution to MARAC research). All discussions should be noted within records. Local GCCG facilitates GP Safeguarding Forums x3 per year each for adult and child GP SG Leads. a) Continue same – GPs already have regular MDT meetings for vulnerable adults – and this is frequently reminded and discussed at GP forums b) CCG are supporting GPs involvement with MARAC and sharing of MARAC information through training at GP Forums. We aim to scope the role of a health MARAC specialist nurse c) Rolling out the ‘Ardens’ SG adult template will support identification of SG incidents CCG a) Usual practice at Forums b) MARAC information sharing capacity is on the CCG risk register – an ‘all health’ scoping to be undertaken – date TBC c) Roll out training on adults SG template to ensure info recorded within patient notes a) ongoing BAU b) GPs continue to respond to MARAC as requested from direct MARAC requests for information. This is BAU. Scoping / Review of an integrated ‘all health’ MARAC research process will be progressed in Jan 2021. c)Ardens template training is 14th October Actions denoted a) is business as usual. b) Scoping / Review aimed for Jan 2021 with outcome and recs March 2021. c)completed - GP Forums 14th October (children) and 4th November (adult) Of note: CCG is progressing a project that will bring together the work of the 3 health Safeguarding Teams for each organisation (CCG/ GHC / GHT) that will include addressing combined MARAC responses and research within health. Outcome: 1. Practitioners report they are confident and competent in recognising and responding to Domestic Abuse. 2. Primary care will be always approached for information in MARAC Research including Page 117 of 122 Copyright © 2020 Standing Together. All rights reserved. information on MARAC outcome There must be continued, consistent and strengthened links between the work of GDASS and Primary Care in order to maintain awareness of domestic abuse issues and the impact that this has on victims and children. This should include consideration of continued service provision for the GDASS pilot beyond March 2020. Local CCG confirm that this service is now commissioned until end of June 2023. GP Development Workers (through GDASS) are funded to support surgeries – processes and training that increase DA awareness, improve the uptake of DA champions, and direct practice changes (safe space, management of high risk cases, as well as direct 1;1 support routes). CCG/GDASS As per column 3 – this is in place. Outcome: Consistent commissioning of domestic abuse support for primary care Where there are out of hours’ attendances to unscheduled care settings (both for adults and children) GP Practices should have a clearly identified process in place that supports recognition for potential follow up to significant illness or injury. Specifically, the role of hospital paediatric liaison needs to be further clarified in relation to effectiveness and how this currently links with Primary Care. Local Process in place is that the GP gets a written notification of the attendance from OOH, MIU of ED in the form of a discharge summary or attendance sheet. It is not the role of GPs to follow up beyond normal analysis but MDT discussion must be considered when necessary. Strengthen links between PHVL role and GPs - The role of the paediatric liaison is with GHC/GHT CCG a)in place as Business as usual b)Designated Dr is completing work with PHVL and Acute Trust. Opportunity to link / clarify GP liaison a)ongoing BAU Outcome is given and BAU / routine practice Outcome: This work is BAU within the PLHV / GHT Named Nurse / Des Dr to evidence data – shared to Strategic Health Group and onwards to QIIP. Page 118 of 122 Copyright © 2020 Standing Together. All rights reserved. Practice and learning from IRIS should be considered by the CCG as domestic abuse practice is developed for primary care settings. Local Confirmation that GDASS model covers this work as covered above as covered above as covered above as covered above Within commissioned service, but not the IRIS specific programme Outcome: Consistent commissioning of domestic abuse support for primary care that incorporates best [practice approaches in this field. Gloucestershire Health and Care NHS Foundation Trust (Formerly Gloucestershire Care Services and 2gether Trust) Health professionals to seek to know who has parental responsibility for a child, as well as other adults who play a key role in that child’s life e.g. stepparents. Agencies should always ask, clarify, and document who the adult is accompanying a child to appointments or who is ringing the practice about a child. Details of the child’s birth parent should be recorded and the status of the child’s relationship with that parent should also seek to be recorded. Gloucestershire Health and Care NHS Foundation Trust (GHC) CCG Safeguarding Team will undertake a scoping exercise across all Practices in Glos to ascertain how and when GPs request evidence of PR. -On the basis of this SCR/DHR recommendation, the CCG Safeguarding Team will request that all GPs use the ‘gold standard’ registration form forthwith. - CCG Safeguarding Team will undertake a scoping exercise across all Practices in Glos to ascertain how and when GPs request evidence of PR. - CCG Safeguarding Team will continue to encourage the use of Ardens as good practice, both the Child Template and the Safeguarding Template. Our work with GP Practices (through the GP Forums) will promote the need to ask who is Ongoing - As a high priority, GHT are working with project leads for the Trust IT systems set up so that staff can ask and record who any patient comes to hospital with, capturing both their name and role in the patient’s life. For the GHT Safeguarding Team, this helps with additional background whereby they may be able generate a genogram where needed. -The Gloucestershire Health and Care NHS Foundation Trust (GHC) Safeguarding Team are working with its Quality Improvement Team to develop a solution to make it easier for staff across the Trust to record who is in the childs household and Page 119 of 122 Copyright © 2020 Standing Together. All rights reserved. accompanying a child, their relationship with the child, and thus add this to the consultation record. family/personal network. This includes documentation of who has parental responsibility. This is part of GHC audit programme which will provide assurance for quality improvement. Outcome: All records will be contemporaneous with details of the child’s birth parent and the status of the child’s relationship with that parent. To review the GHC Domestic Abuse Policy as the current focus is for staff to know what to do in the event of a disclosure. More guidance is required within this policy about the indicators of potential domestic abuse to enable effective signposting to specialist services. Local The GHC Domestic Abuse policy to be reviewed. Review all mandatory safeguarding training packages at all levels, and group safeguarding supervision, to ensure these issues are fully explored. GHC The GHC DA Policy outlines specific guidance in relation to not only routine enquiry but also selective enquiry e.g. for example where there is a history of DA or where there are specific indicators i.e. • Inconsistent relationship with health services • Physical symptoms • Reproductive/ sexual health issues • Emotional/psychological symptoms • Intrusive ‘other person’ present These factors Alongside professional curiosity are emphasised and reinforced throughout training December 2019 Complete, with ongoing review Further review completed July 2021. Policy now includes - • A 5 minute guide on how to respond to domestic abuse • Flow chart of domestic pathway • Range of support services available • High risk indicators • Cites the new Domestic Abuse Act Outcome: Policy to include most up to date guidance in line with domestic abuse best practice Page 120 of 122 Copyright © 2020 Standing Together. All rights reserved. and GHC group supervision. Regular review by the GHC Safeguarding Sub Committee. GHC domestic abuse training needs to encompass all the indicators of domestic abuse which may be evident prior to a disclosure. This training model is for a continuous rolling programme available to all GCS staff, within both adult and children services. Local The GHC Domestic Abuse policy to be reviewed. Review all mandatory safeguarding training packages at all levels, and group safeguarding supervision, to ensure these issues are fully explored. GHC There is clear and consistent guidance in the GHC Domestic abuse policy which advises Trust staff what to do in the event of disclosure, what the indicators of DA are, and where to signpost, both in the event of an emergency or follow on support from local Support Services. Revision of the policy remains ongoing given the recent guidance outlined in the Pathfinder Assessment Tool DHSC June 2020 which provides a template for not only policy but also training, most of which our current policy and training is aligned Regular review by the GHC Safeguarding Sub Committee. December 2019 Complete, with ongoing review Level 2 mandatory safeguarding training explores domestic abuse within a family situation. GHC Domestic Abuse policy includes indicators for domestic abuse in adults and children. There will be further development of this with the Local Domestic Abuse Partnership, and workforce development is part of the Gloucestershire Domestic Abuse Strategy. Outcome: Practitioners report they are confident and competent in recognising and responding to Domestic Abuse Where there is a Local The GHC Domestic GHC As above action points. December 2019 Complete, with ongoing review Page 121 of 122 Copyright © 2020 Standing Together. All rights reserved. known history of domestic abuse within a relationship, GHC practitioners take every opportunity to explore this with the victim when safe to do so and demonstrate consistent professional curiosity. This should be reinforced within the domestic abuse training, group safeguarding children supervision, GCS Domestic Abuse Policy and all GCS staff forums. Abuse policy to be reviewed. Review all mandatory safeguarding training packages at all levels, and group safeguarding supervision, to ensure these issues are fully explored. The GHC Domestic Abuse Lead Nurse delivers bespoke training available to all staff, including at staff forums, and it is also included in mandatory Safeguarding training at all levels. GHC Mental Health staff and Public Health Nurses (PHNs) routinely ask about Domestic Abuse at assessment. PHNs further enquire at every core appointment as per Practice Benchmarks. This is underpinned within mandatory safeguarding training and supervision. The GHC Safeguarding Advice Line is available for all staff and would provide support and advice regarding domestic abuse issues, and promote and encourage professional curiosity. Outcome: Practitioners report they are confident and competent in recognising and responding to Domestic Abuse Gloucestershire Hospitals NHS Foundation Trust Staff need to retain professional curiosity at all times and to ensure continued training is in place for Trust staff. Local Weave professional curiosity into every aspect of safeguarding training GHFT - Strengthen professional curiosity in all training packages November 2020 Safeguarding training restructured as a result of COVID with greater emphasis on professional curiosity as a cross-cutting theme Outcome: Practitioners report they are confident and competent in recognising and responding to Domestic Abuse For the Trust to consider the tools and findings from DOHSC funded Pathfinder Local Compare tools from Pathfinders sites to current practice in Trust and complete GHFT compare tools currently used to tools available elsewhere establish options for gaps December 2021 Ongoing activity Outcome: Practitioners report they are confident and Page 122 of 122 Copyright © 2020 Standing Together. All rights reserved. sites to ensure that they are maintaining and further developing best practice in relation to domestic abuse. gap analysis identified competent in recognising and responding to Domestic Abuse |
NC049407 | Death of Child G in October 2016 whilst in the care of a local authority children's home. Death was later recorded as central nervous system and pulmonary depression and morphine use. Child G had a diagnosis of ADHD and dyspraxia, he struggled with alcohol and substance misuse, was anxious and depressed, went missing frequently from home and was involved with criminal behaviour. There were concerns that he was at risk of child sexual exploitation especially when he reported a sexual assault. He became the subject of a child protection plan in May 2015 following an assault he made on his mother. He received support services from an adolescent support unit, substance misuse services, Child and Adolescent Mental Health Services, Child Sexual Exploitation team and sexual health services and Youth Justice and Reparation. Child G had brief spells in foster care and two children's homes. Lessons learnt include: as Child G's behaviour became more severe, more agencies became involved without considering which interventions were being effective; a multiplicity of protective and preventative actions does not necessarily lead to improved outcomes. Uses the Significant Incident Learning Process (SILP) model. Recommendations include: the LSCB should require that partner agencies are competent working with adolescents with challenging behaviours, learning difficulties and those who may be impacted by Adverse Childhood Experiences; the LSCB should review the strategy meeting process for complex cases; the LSCB should ensure substance abuse training includes alerting workers to changes in substance use and indicators of when medical assistance is needed.
| Title: Serious case review of the circumstances concerning Child G. LSCB: Blackburn with Darwen Local Safeguarding Children Board Author: Karen Rees Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW OF THE CIRCUMSTANCES CONCERNING CHILD G Author: KAREN REES February 2018 2 Foreword by Local Safeguarding Board Chair This serious case review (SCR) was commissioned in February 2017 following information presented to me that Child G had died and had been known to a significant number of services. All SCRs identify findings that individual agencies and multi-agency systems need to learn from so that the future recurrence of similar circumstances can be reduced. This case is no different and as an LSCB, covering all services involved in this SCR, we have accepted the multi-agency recommendations made by Karen Rees. In addition to these recommendations, the agencies directly involved with Child G and his family have also identified a significant number of learning points (single-agency learning in Appendix 5) so their practitioners improve their practice and the agencies improve their safeguarding processes. All of these actions are being monitored by the LSCB – for some agencies their implementation has been completed and for others it is anticipated their actions will be fully implemented over the coming months. The schools sector in particular has embarked on awareness raising and training on children’s emotional health and wellbeing, led by two of the schools Child G attended. In addition to the recommendations from this SCR and the work the schools sector are undertaking, the LSCB has prioritised improvement actions in its 2017-18 Business Plan aimed at continuing to develop the skills and competencies of practitioners that work with our children and families so that indicators of abuse or neglect are responded to and children and families receive the services that are available locally. In January 2018, I chaired the Quality Assurance Committee of the LSCB and I was provided with an update on the work completed with implementing the recommendations from this SCR, both multi-agency and single-agency. I will continue to monitor how work is being completed and challenge agencies where progress has not been made. Our collective aim remains to maintain a local safeguarding system that helps in preventing abuse and neglect, and where abuse and neglect does take place that children are effectively safeguarded. Finally, I would like to offer my heartfelt condolences, on behalf of all the agencies involved in this SCR, to the family of Child G for their tragic loss. I would also like to thank the family members that contributed very bravely to this SCR, especially mother for her insights into how services can be improved in the future. Nancy Palmer Independent Chair, Blackburn with Darwen LSCB February 2018 3 Contents 1. Introduction 4 2. Significant Incident Learning Process and Scope of Review 4 3. Parallel Proceedings 5 4. Family Involvement 5 5. Structure of the Report 6 6. Key Episodes 7 7. Analysis by theme 14 8. Good Practice 33 9. Conclusions and Lessons Learned 34 10. Recommendations 36 Appendices Appendix 1: Terms of Reference (Redacted) 37 Appendix 2: Services involved with Child G (Anonymised) 41 Appendix 3: Pathways to Harm, Pathways to Protection 46 Appendix 4: Tables of Key Episodes: Pathways to Harm, Pathways to Protection 47 Appendix 5: Single Agency Recommendations 55 4 1. INTRODUCTION 1.1. At the time of his death, Child G had been known to numerous agencies in the locality. He had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)1 and Dyspraxia2 . He had struggled with feeling different to his peers and developed chaotic substance misuse and associated criminal incidences resulted. Child G also later developed depression and anxiety. His circumstances led to concern that he was at high risk of and possibly a victim of Child Sexual Exploitation; any disclosures he made were later retracted. His family struggled to manage him at home and as a result he became subject to S203 care in a local authority children’s home. In early October 2016, after spending the day with family, his mother drove him back to Children’s Home 1 (see appendix 2). On return it was apparent that he had been drinking but was in good spirits. He spent the evening chatting to staff, had food and drink and played on his computer. That night staff went into Child G’s room at 1am, turned his TV and light off. At 11am the following morning Child G was found deceased with a large bottle of vodka under his body. Initial cause of death was not suspicious and is recorded as central nervous system and cardio pulmonary depression and morphine use. 2. THE SIGNIFICANT INCIDENT LEARNING PROCESS (SILP) AND SCOPE OF REVIEW 2.1. This Serious Case Review (SCR) is undertaken following a notification of the childcare incident to Ofsted in October 2016 and subsequent discussions within the Blackburn with Darwen Local Safeguarding Children Board (BwD LSCB) that the criteria for a SCR was met with a notification to Ofsted & National SCR Panel of a SCR being commissioned in February 2017. 2.2. The BwD LSCB agreed to undertake this review using the Significant Incident Learning Process (SILP), a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. 2.3. The SILP model of review adheres to the principles of: Proportionality Learning from good practice The active engagement of practitioners involved at the time Engaging with families Systems methodology Avoidance of hindsight bias 1 Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. http://www.nhs.uk/conditions/Attention-deficit-hyperactivity-disorder/Pages/Introduction.aspx 2 Developmental co-ordination disorder (DCD), also known as dyspraxia, is a condition affecting physical co-ordination that causes a child to perform less well than expected in daily activities for his or her age, and appear to move clumsily. http://www.nhs.uk/Conditions/Dyspraxia-(childhood)/Pages/Introduction.aspx 3 (S20) Section 20 of the Children Act 1989 makes provision for the Local Authority’s duty to provide a child with somewhere to live because the child doesn’t currently have a home, or a safe home: 1. There isn’t anyone who has parental responsibility for him 2. The child has been lost or abandoned; 3. The person who has been caring for the child can’t provide him with a suitable home, whatever the reason for this and regardless of whether this is short term or long term problem. Parental agreement is required negating the need for the Local Authority to go to court to make a care order. The Local Authority do NOT share parental responsibility for the child. Under section 20(8) any person who has parental responsibility can remove the child from Local Authority accommodation at any time. 5 This SCR has been undertaken in a way that adheres to these principles. 2.4. The Terms of reference agreed that the period under review would be from November 2014 until Child G’s death. Further details of the methodology, process and reviewers can be found in Appendix 1. 2.5. The final report was presented to BwD LSCB on 10th October 2017. 2.6. For the purposes of this review agencies will be known by the service they offered to Child G and his family; details of these and the services that they provided are included in Appendix 2. 3. PARALLEL PROCEEDINGS 3.1. There were no suspicious circumstances related to the death of Child G therefore there were no ongoing police investigations. 3.2. There was an Inquest in June 2017. The coroner concluded that this was a drug related death. The coroner recorded that the issues related to the events on the night that Child G died had been addressed in an action plan by Children’s Home 1 and that no further action was required. 3.3. Children’s Social Care single agency report for this Serious Case Review identified the significant work and action plan for the residential care network that had already been put in place to address the issues related to the circumstances surrounding the death of Child G. The action plan is subject to monthly review. It is largely completed with outstanding actions well under way. 4. FAMILY INVOLVEMENT 4.1. For the purposes of this review the family will be known in the following way: Family member: To be called: Subject Child Child G Mother of Child G Mother Father of Child G Father Step Father of Child G Step Father Child G’s sibling Child G’s sibling or sibling 4.2. The Chair and the author met separately with Child G’s Mother and Step Father on the afternoon preceding the Learning Event. This was to ascertain their views on the services received by Child G and the family and to find out more about Child G. Due to his needs at the time, Father was not in a position to be able to be involved in the review; the reviewers 6 respected this request from the family. 4.3. The family views have been incorporated into this report at appropriate points. 4.4. Following the completion of the serious case review process, the author and BwD LSCB manager met with Mother to feedback the findings, conclusions and recommendations. Some of Mothers comments and additions have been added as a result. Mother’s comments on substance misuse training were felt to be of additional help to the review. They have been included in the report, and lead to a further recommendation. Mother indicated that she was accepting of the report’s findings and hoped that the recommendations would lead to improved experiences for children and young people like Child G. 4.5. Father and Step Father declined to receive any feedback following the completion of the serious case review process. 5. STRUCTURE OF REPORT 5.1. Working Together to Safeguard Children 20154 does not prescribe a fixed methodology for Serious Case Reviews, but states that the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined and should be conducted in a way in which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 5.2. The author has considered the issues and learning in each key episode using the model presented in the Triennial Analysis: Pathways to Harm, Pathways to Protection Model5 (Appendix 3). This is used to identify context, vulnerabilities and risks against the key areas for prevention and protection, with an analysis that identifies barriers that then lead to learning and recommendations. 5.3. The text in section six is supported by tables in Appendix 4 to represent the use of the pathways model in each of the five key episodes. Appendix 4 provides more in depth detail of referrals and work undertaken and depicts the escalation of events (showing number of incidents where significantly relevant) and actions throughout the key episodes in a graphic format. This aids understanding and supports analysis. 5.4. As the chronology of involvement is extensive, the episodes within the scoping period are summarised in order that analysis and learning can be addressed and understood. Individual 4 HM Government (2015) Working Together to Safeguard Children 5 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education https://www.gov.uk/government/publications/analysis-of-serious-case-reviews-2011-to-2014 7 agency reports analyse single agency involvement in detail and many organisations have produced action plans to address their own learning (Appendix 5). 6. KEY EPISODES A ‘key episode’ is an episode from which it is possible to gain an understanding about the way the case developed and was handled. Key Episode One: Background prior to scoping period; setting the context 6.1. The following provides a summary of information gathered from agencies that falls outside of the scoping period set in the Terms of Reference for this review (Appendix One). It sets the context with which the later scoping period begins, it identifies early risks and vulnerabilities and the early intervention by Universal Services in school and health to prevent and protect from harm (See Appendix 4). 6.2. Child G was the first born to Mother and Father. Histories taken by the Hospital Trust indicate that the parental relationship was that of an ‘on/off’ nature and would suggest that parents did not live together. Some agencies in the early stages were aware of parental histories. It is not clear if these issues impacted on Child G as Adverse Childhood Experiences6 and this will be addressed within the analysis. Child G was nine years old when it is recorded that Mother had a new partner; Child G’s sibling was born four days before his 12th Birthday. Mother told the reviewers that she was first concerned that Child G may have some difficulties when he was seven. She noticed he was struggling to concentrate and was not progressing socially as she thought he should. As early as when he was eight years old she sought help from her GP which resulted in a referral to a paediatrician. He was referred to occupational therapy, speech therapy and for a parenting course. A diagnosis of Dyspraxia was made when Child G was nine but no other diagnosis was made at this time. 6.3. Appendix 4 indicates the outcome of the assessment by the occupational therapist; a Common Assessment Framework7 or Statutory Special Educational Needs Assessment8 were not started nor is there evidence that a discussion was held with Child and Adolescent Mental Health Services regarding a possible referral at this time which was a suggested action from the outcome of the assessment. 6.4. At a home visit made by the Educational Psychologist, Mother concurred that she felt that Child G had dyspraxia tendencies, difficulty with organisation and was, at times, obsessive. It was also reported that Child G had night terrors and had a poor sleep pattern. Mother 6 Adverse childhood experiences (ACEs) are stressful or traumatic events, including abuse and neglect. They may also include parental separation, parental mental ill health, household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders. ACEs are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan, including those associated with substance misuse. 7 The Common Assessment Framework is a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children and young people's additional needs and promote coordinated service provision to meet them. 8 A Statutory Assessment of Special Educational Needs is undertaken to identify what extra help a child needs in school and leads to a statement of special educational needs that describes a child’s needs and all the extra help they should get. The system is now superseded by Assessment for an Education, Health and Care Plan. 8 disclosed that Child G had threatened her with a knife and had hit her. This disclosure did not result in any referral to other agencies at this point. 6.5. Child G’s ongoing needs were managed within school and he was subject to School Action Plus9. There was a period of improvement where strategies and input appeared to be helping. School also reported that Step Father appeared to be a male role model that had a positive impact at this time. 6.6. On leaving primary school, Child G was achieving well socially and academically and had developed strategies to cope with stress but it was felt that he would be vulnerable at transition. 6.7. Child G transferred to High School as planned and was placed on the school’s Special Educational Needs Register remaining at a level of School Action Plus. Transition to high school proved difficult for Child G and previous progress soon deteriorated. His behaviour was volatile and additional concerns were raised about Child G leading to a further referral to Educational Psychology. During the second year, the school funded anger management sessions. Child G engaged well and showed good reflection on his actions. 6.8. Lack of academic progress and increasing frustration with himself manifested in self-harm and led to further referrals as can be seen in the Key Episode table (Appendix 4). 6.9. Some positive one to one work was undertaken by the Family Support Service (following a referral from school) with Child G clearly indicating what changes he wanted to make (see the Key Episode table). When he was 13, Child G first disclosed to Family Support Service worker about his drug and alcohol use. Mother disclosed that Child G had returned home drunk on several occasions when he was just turned 14. School attendance remained good in this period. 6.10. Initial work by Family Support had a child focus but moved to an adult focus when there was a change of allocated worker i.e. there was a lot of emotional support to Mother. This is not surprising as Child G’s behaviour was escalating and his sibling was only 19 months old at the time. Mother told the reviewers that she started to be concerned about the safety of her younger child. 6.11. The Social Communication Panel concluded that Child G was not autistic when he was 14 years old. 6.12. Despite the considerable support that was offered to Child G, the number of severe behaviour incidents escalated and at the point of permanent exclusion he was referred to the Pupil Referral Unit and commenced on roll in year nine, just before his 14th Birthday. Once on roll at the Pupil Referral Unit, school attendance dropped significantly. 9 School Action Plus ("SA+") is used where SA (School Action) has not been able to help the child make adequate progress. At SA+ the school will seek external advice from the local Education Authority support services, the local Health Authority or from Social Services. For example, this may be advice from a Speech and Language Therapist (SaLT), an Occupational Therapist (OT) or Specialist Advisory Services dealing with Autism, Behavioural Needs etc. SA+ may also include one-to-one support and the involvement of an Educational Psychologist. As well as the use of external services, SA+ requires more detailed planning of interventions for children whose progress has been limited. A child's progress at SA+ stage should also be reviewed regularly (i.e. at least twice a year) and an Individual Education Plan (IEP) should also be written to assist the child. http://www.specialeducationalneeds.co.uk/school-action-and-school-action-plus.html 9 Key Episode 2: Child in Need to Child Protection, November 2014 to May 2015 6.13. The first referral to Children’s Social Care was made after Child G became intoxicated and required hospital treatment. Ambulance services attended and police assistance was requested due to aggression. Child G’s behaviour deteriorated and he was taken into police custody but later returned to Accident & Emergency following a decision by the custody nurse that his medical needs must be a priority. He was sedated in A& E and became calmer and was then admitted. 6.14. The police had risk assessed the incident using their Protecting Vulnerable People system as medium risk and submitted that on their vulnerable child referral into the Multi Agency Safeguarding Hub (MASH). This was responded to by Children’s Social Care and was categorised as Child in Need10 with high risk indicators and progressed to a Child and Family Assessment. Whether this system should have been accessed earlier will be analysed further. 6.15. The following day there was a professionals’ meeting attended by schools and the Family Support Service to review educational plans. The minutes of this were shared with Children’s Social Care. The increasing number of systems that were applied will be referred to further in the analysis. 6.16. Considerations of possible diagnoses were ongoing. A referral was made by the community paediatrician to Child and Adolescent Mental Health Services to assess for ADHD. The GP contacted Child and Adolescent Mental Health Services to expedite the referral. A diagnosis of ADHD was made at the Child and Adolescent Mental Health Services appointment in March 2015; Child G was 14. 6.17. Young People’s Substance Misuse and Recovery Services 1 began to try to engage Child G. Child G did not engage in any ongoing support work but did agree to some work regarding harm reduction but he refused any further engagement and avoided contact. Mother engaged and was involved in trying to set up suitable and appropriate appointments. It is recorded that Child G was now using drugs daily. 6.18. The Police Early Help Service (see Appendix 2) became involved with Child G and his Mother. Child G was seen in school by the allocated worker but further attempts to engage with Child G were unsuccessful. The allocated worker continued to be a point of contact and attend meetings. 6.19. As other services were becoming involved the Family Support Service agreed to close the case, making an onward referral to Troubled Families intervention services. In fact, the Family Support Worker remained involved and, following agreements by the specialist early help panel, Family Support Services continued involvement as they had positive relationships with Child G. 6.20. There had been a delay in the social worker contacting the family due to high workloads but the social worker did see Child G alone at a home visit in December 2014. The first Child in Need meeting took place in mid-January 2015 and although there was attendance from Education, Police, Social Worker and Young People’s Substance Misuse and Recovery Services 1, there was no health representation despite several health services being involved. This gap was rectified by the second meeting with invitations to health staff, although the GP was not 10 Section 17 Children Act (1989) Provision of services to children in need and their families 10 invited and no other health representation attended. Child in Need meetings continued every 6- 8 weeks in this period. 6.21. The social worker completed the assessment by early March and plans were to include involvement of the Adolescent Support Unit (See Appendix 2). 6.22. Issues for Child G began to escalate and the table in Appendix 4 summarises the ongoing and escalating concerns within this period that several agencies and processes were seeking to support and address. It is of note that the majority of the services and processes (listed in the last column in Key Episode 2 Table, Appendix 4) would have individual assessments, plans, and interventions. 6.23. At the Learning Event, it became apparent that there was significant history within the parents’ lives that were either not known, or not considered or explored further as part of assessment processes. This is discussed further in the analysis in terms of the impact it may have had on the life of Child G. 6.24. The escalation in incidents and behaviour led to a Child Protection Conference in May 2015; Child G became subject to a child protection plan. Key Episode 3: Section 20 Accommodation to Movement out of Area, June to December 2015 6.25. For the first few weeks of June 2015, there was a period of improvement and engagement from Child G. 6.26. He appeared to have responded well to the boundaries and possible consequences of not adhering to what was required of him by the Youth Justice Team. A specialist school placement was sourced and outreach was offered from the Adolescent Support Unit. Child G remained mainly drug free for a period of three weeks. 6.27. Child G’s behaviour escalation had led to him being cared for by various other family members for short periods. This realisation of the consequences of his behaviour leading to difficulties in Child G living with his Mother and sibling, may have been another contributing factor to some period of improved engagement. 6.28. This improvement was not sustained and in late June 2015 there was a serious incident during which Child G assaulted his Mother. He was arrested and remained in custody overnight and was placed at the Adolescent Support Unit and then into emergency foster care until further decisions could be made. 6.29. Child G went missing from home on several occasions and these were reported by the Foster Carer to the Police with return home interviews undertaken, carried out by the Child Sexual Exploitation Team as per protocol. 6.30. Child G remained in Foster care for a month when he moved to Children’s Home 1 as a suitable longer term foster placement could not be found. This was undertaken via a S20 agreement with parents as they were not able to care for him due to the risk he posed to Mother and younger sibling. 11 6.31. Reparation continued as per the youth caution requirements and the Youth Justice Team engaged Child G in domestic abuse perpetrator work following the assault on Mother. 6.32. Missing from Home episodes became a greater feature in this Key Episode with an associated increase in risk. Child G was not willing to state where he had been and who he had been with when he was missing. 6.33. Child G began at Special School at the beginning of Year 9, just after his 15th Birthday. Due to various events, he did not attend well at first. There were two periods in October 2015 and November 2015 that year where attendance was better and represented the most consistent attendance in some time. 6.34. In this episode, Child G disclosed that he had been subject to a sexual assault that could have been indicative of Child Sexual Exploitation. A police investigation commenced but Child G later stated this was consensual activity. The Child Sexual Exploitation Team worked to support Child G and to protect and prevent harm. Child G also disclosed a further sexual assault that had happened prior to him being accommodated. Neither investigation led to any prosecution as details of potential offenders could not be obtained. This resulted in increased activity by Police and the Child Sexual Exploitation Team. It was also at this time that Child G was informed that an out of borough placement had been authorised. It is possible that this information contributed to a period of improvement. 6.35. Child G did not want his parents to be informed about the disclosures and following legal advice, it was agreed that information could be given about physical harm but not sexual harm. There was a Section 47 enquiry that documented escalating risks and that despite the numerous agencies and systems in place to support and protect (Appendix 4), there continued to be very significant concerns. An out of area placement was sought and agreed for a period of three months to break the local links, reduce access to drugs and allow time for reflection and change. Key Episode Four: Out of Area Placement, December 2015 to March 2016 6.36. An out of area placement was found and Child G moved in December 2015. He was informed about the three-month placement by the social worker and the Child Sexual Exploitation Team worker. 6.37. The plan of care given to Children’s Home 2 was based around provision of parenting to reduce missing episodes, provide education, provide opportunities to develop social skills with peers and to engage Child G in substance misuse work (see Appendix 4). 6.38. There were almost immediate improvements in that Child G initially had no access to drugs and began to show an interest in the gym and other leisure activities. Contacts with family were largely positive. 6.39. It is of note that Child G refused to engage in education and substance misuse work. At first, he spent a lot of time in his room but began to interact more at the home as he settled. 6.40. On one occasion an empty bottle of whisky was found in his room which he stated be brought with him. On another occasion in January 2016 it was believed that he stole a bottle of whisky from a supermarket and became intoxicated, was sick and caused damage to his room. He ran away and police were called, he was later found by staff and his behaviour led to arrest with 12 Community Resolution. He had admitted to taking ketamine. Child G was remorseful for his behaviour. 6.41. Following this Child G continued to follow boundaries set, interact positively with staff, accessed the gym but still did not engage with education or substance misuse services. Child G was also stating that he no longer wanted not take anti-depressant medication and did not take his medication consistently. 6.42. At the beginning of February 2016, he warned staff at the home that he would jump on a train back home if he was not out of there within two weeks, but continued positive engagement otherwise. In February, a bong was removed from his room and he was warned about smoking cannabis in there. 6.43. Child G continued to engage positively and was looking forward to returning to home area in March 2016. 6.44. Looked After Child Reviews continued in this period. Education services were also reviewing progress and education plans in readiness for Child G’s return. 6.45. This plan was then changed as it was felt returning to the home area on a Friday would carry risks. He was informed of this by staff at the home and he stated that he was not happy but remained positive with staff. He told staff that he may be getting the train home the next day. Key Episode Five: Return to Home Area to Date of Death, March to October 2016 6.46. This episode started with Child G absconding from Children’s’ Home 2 in March 2016 after hearing of the change of plans detailed above; he was missing for six days. 6.47. He returned to Children’s Home 1 but throughout this period there were increasing concerns about his chaotic substance misuse. Missing from Home episodes increased and he refused to say where he had been because of the problems police searches caused with his friends. 6.48. There was apparent confusion about his education provision in this episode as the special school stated that they did not know of Child G’s return and the special needs team believed that the Special School had refused to accept Child G back. This led to Child G not being back in education until May 2016. 6.49. With the increasing issues for Child G, he became more aggressive at times and engaged in violence against others and self-harm. His risk of Child Sexual Exploitation was significant and he was friends with other young people who were known to the Child Sexual Exploitation Team (albeit due to criminal histories not as identified victims of Child Sexual Exploitation). 6.50. Child G refused to engage with services and his level of substance misuse and missing from home episodes was such that very little appropriate work could be undertaken by Child G and Adolescent Mental Health Services or the Child Sexual Exploitation Team. Child G often refused to get out of bed for appointments or to see visiting professionals. He also had occasions where he attended the Urgent Care Centre with overdoses of drugs, deemed to be accidental. 6.51. The continuance of S20 accommodation created tensions as some professionals challenged if parents could keep him safe and make appropriate decisions given the level of his challenging 13 behaviour. 6.52. There were also several professionals who challenged if Children’s Home 1 remained a safe and appropriate placement but these challenges did not lead to significant change in the placement at that time and is discussed within the analysis. 6.53. Following consent from Mother, Child G spent some time with a cousin. The rationale for this was that it was a little further away and he might be safer. He spent overnight stays with the cousin which raised concerns for the children’s home staff as they had a regime of observing him overnight if he was intoxicated or under the influence of drugs. The decision at this stage to continue S20 and its appropriateness is discussed in the analysis. 6.54. Child G attended Accident & Emergency in June 2016 following a further disclosure to the Child Sexual Exploitation Team worker of consensual sexual activity that he thought had caused internal damage. This added to his anxiety and troubles; Child G had ongoing concerns of physical health issues such as abdominal pain and chest pain that are evidenced in Appendix 4; no physical cause could be found for these and they were largely attributed to anxiety. 6.55. There is evidence offered in the agency reports that lead to suggestions that in fact this was a violent sexual assault and that Child G later changed the explanation to consensual activity. 6.56. It was during this phase that the long-term plan for reunification with family changed. Child G voiced that he knew he could not achieve what he wanted to and that he was further away from getting home than he had ever been. 6.57. The table in Appendix 4 for this episode is characterised by an increased number of meetings under different headings. All those meetings were trying to establish protection for Child G that eventually culminated in, after being originally refused by senior managers in Children’s Social Care, an agreement for a further out of borough placement. 6.58. Child G was then involved in a serious assault on another child leading to Magistrates requiring an out of borough placement as part of bail conditions. Finding a suitable placement proved difficult and was then deemed not to be in in Child G’s best interests; the court approved amendment to conditions to agree that Child G should remain at Children’s Home 1 under intensive bail arrangements. Following Child G’s arrest in September 2016 for this offence, he stated that he would do anything not to get a custodial sentence and this appeared to be a trigger for a period of improved engagement to comply with the requirements of the bail package that was put in place. 6.59. The Young People’s Substance Misuse and Recovery Services 2 offered a change to a male worker and this appeared to have significant positive impact with Child G’s engagement. 6.60. In early October 2016, following a significant disclosure to his Mother at the end of a day spent with family, Child G returned to the Children’s Home and had been drinking, he was in apparently good spirits. The events that unfolded are described in section 1. 14 7. ANALYSIS BY THEME 7.1. By analysing the agency reports and using the information gathered at the Learning Events it is possible to identify areas where there is learning that can lead to improvement. Understanding Child G and his voice 7.2. Child G developed complex risky behaviours leading to intense assessments and plans to try and meet his needs and improve his outcomes. In order to provide possible explanations for his presentation it is important to consider any learning related to who Child G was and what his voice may have been telling those that were involved in his life. 7.3. Child G lived at home with his Mother and then with his Step Father and new sibling. He was a child whose parents had voiced concerns about from the age of 7 and this ultimately led to a diagnosis of Dyspraxia and ADHD. These conditions have many similar features such as: Literal use of language Difficulty in organisation Poor short term memory Difficulty adapting to new situations Anxiety Sleeping difficulties Social difficulties Easily distressed Impulsivity Difficulty in attention Difficulty in staying still. 7.4. These issues meant that Child G was likely to struggle in the complex world around him and indeed from being a young child he was acutely aware of these difficulties telling his Mother that he felt different, that there was something wrong with him and that he was not normal. On feedback of findings of the review to Mother, she added that Child G would show signs of depression, anxiety and distress from an early age. 7.5. Child G was also approaching his adolescent years as these diagnoses were becoming evident. It is well researched and studied further by Romer (2010)11, that adolescent risk taking behaviour is part of normal development and is in some part explained by the maturation processes within the brain. Strategies to manage adolescent risk taking behaviour are multifaceted and depend on early childhood experiences and interventions to manage and control using campaigns to highlight risks (e.g. media and educational programmes) as well as motivation to achieve certain life goals. 7.6. It was also known that Child G was exposed to some Adverse Childhood Experiences. The impact of these was not wholly understood or assessed in the work of some agencies, although the School Action Plus intervention was to manage social, emotional and behavioural issues. 11 Romer, D. (2010). Adolescent Risk Taking, Impulsivity, and Brain Development: Implications for Prevention Dev Psychobiol 52(3): 263–276. http://onlinelibrary.wiley.com/doi/10.1002/dev.20442/epdf 15 7.7. For Child G, the diagnoses and difficulties he was facing could have meant an inability to think through the wider and long term implications of his behaviour. This required professionals to understand the difference between normal risk taking of adolescence, Child G’s behaviour related to his learning difficulty and later on his mental health issues as well as any impact of Adverse Childhood Experiences. There is some evidence in recent research that there are links with early Adverse Childhood Experiences and a later diagnosis of ADHD12&13. This needed to be considered in the work that professionals were undertaking with Child G in order that his voice could be truly understood. 7.8. Professionals then needed to apply strategies that recognised the difference at an early point. It does appear that this was the understanding of professionals in Key Episode 1 but did not appear to influence practice of all professionals in later key episodes. 7.9. The Equality Act (2010)14 places a duty on all services to make reasonable adjustments in order that a person with a Learning Difficulty is not disadvantaged when compared with a person without that characteristic. This is the basis under which services operate best practice. 7.10. In the early Key Episodes, we can see that the educational response was to manage these difficulties using the services that were available to them. It was hoped that obtaining a diagnosis which would explain the emerging behaviours and difficulties would enable an appropriate Individual Educational Plan (IEP). 7.11. This essentially worked well initially and Child G responded to the support; by the time he left primary school he was achieving well academically and socially. Primary school was a place that could manage the issues detailed above in a small contained environment that he was used to. 7.12. The transition to senior school, although it falls out of the scope of the initial review scoping period, is an important time in understanding how Child G may have seen the world and his place within it. It could be argued that the transition was not well managed given the difficulties that Child G was displaying. It is acknowledged that diagnoses of the above conditions were made later but the list of difficulties that Child G had were well known. The transition focussed on what was required to support Child G to enable academic achievement with support to manage behaviour. The transfer to a large very busy environment that was unknown to him at a time where there were other changes in his life i.e. a new sibling, required a different approach. 7.13. On feedback of the report to Mother, she expressed some concerns that she experienced in trying to support Child G at this time and felt that the school were not making appropriate allowances in managing and supporting Child G’s difficulties. 12Manuel E. Jimenez, et al (2017) Adverse Childhood Experiences and ADHD Diagnosis at Age 9 Years in a National Urban Sample. Acad Pediatr 17(4): 356–361 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5555409/pdf/nihms881325.pdf 13 Brown NM et al (2017) Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity. Acad Pediatr May - Jun;17(4):349-355 https://www.ncbi.nlm.nih.gov/pubmed/28477799 14 The Equality Act came into force on 1 October 2010 and brought together over 116 separate pieces of legislation into one single Act. Combined, the Act provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act simplifies, strengthens and harmonises legislation to provide a discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society. https://www.equalityhumanrights.com/en/equality-act-2010/what-equality-act 16 7.14. Understanding these difficulties that Child G faced, other ways to have supported him in this move may have included a phased transition that allowed for him to spend short periods of time in the new environment and carefully managed strategies to support his learning needs with all the staff clear about best ways to approach and work with Child G. 7.15. Child G remained subject to School Action Plus plans, but within the senior school these were not reviewed regularly nor did they involve parents. 7.16. An earlier instigation of a statutory assessment of educational needs may have afforded a systemic approach that would have had a multi-agency element to support the specific needs of Child G and would have involved parents. The Individual Education Plan (IEP) and the School Action Plus approach was not applied robustly but even if it was, it may not have been enough to manage and contain the needs of Child G from a long-term perspective. 7.17. As the Key Episodes progress, there are many other examples of where a helicopter view of the long-term issues required different approaches. Child G was subject to many processes and systems all that had his protection at their heart and the effectiveness of these is discussed further below. What was clear from the agency reports in response to the question about addressing and responding to Child G’s diversity issues, is that some agencies did not know about these issues, and they did not feature in all referrals that were made to services. There is little evidence that services responded to him in a way that would be meaningful and appropriate for a child with those needs e.g. Breaking tasks down into steps Setting clear boundaries Focusing on positive behaviour Giving very specific instructions Using incentive schemes Intervening early when frustration is likely Encouraging exercise Managing sleep. 7.18. As well as his Learning Difficulty diagnosis, Child G also developed anxiety and depression. These mental health conditions alongside any impact of possible Adverse Childhood Experiences would have compounded the difficulties he faced in dealing with issues that were affecting him. The mental health issues also required professionals to consider how best to adjust services to meet his needs. 7.19. That is not to say that some services did not undertake to meet his needs and some good examples were noted with practitioners adjusting appointments to see Child G at home or in an environment that suited him better; e.g. Child and Adolescent Mental Health Services offered appointments in his own environment to reduce anxiety about attending an outpatient clinic, the special school and the Pupil Referral Unit offered a personalised timetable and hours that would suit him better. 7.20. Staff at Children’s Home 1 informed Child G of his appointments and took him to many appointments. They also reminded him of when professionals were due to come and see him. 7.21. An example of where less attention was paid to Child G and his needs was identified by the Family Support Service. They initially focussed on Child G and the support he needed to manage the feelings and anxieties that were causing his behaviour. Later this focus switched 17 to family mediation and the support mother required in managing Child G. In trying to establish a reason for this it is clear that there was very little discussion or information sharing early on regarding the emerging mental health and learning needs that Child G was experiencing. This left the Family Support Service not being able to consider this within their decision making and care planning. 7.22. Agreements had been made in a multi-agency meeting that school would work with Child G on his behaviour and the Family Support Service would work on home life home life with the adults. Whilst this may well have been considered the best way forward, it could be argued, and indeed the agency report for the Family Support Service identifies, that the lack of information sharing meant that the voice of Child G became largely lost from this point in the Family Support Service recordings. 7.23. It is of interest that the times within Child G’s life when he showed compliance with what was required and an improvement in his positivity about life, were as a direct result of the strategies outlined in 7.17 being used either coincidently or deliberately. 7.24. Examples from the Key Episodes include as mentioned above in primary school but also other examples when clear boundaries and incentives had a positive impact e.g. when Child G moved to the out of area placement he was aware that good behaviour and compliance meant that he would return to the home area and he stated that he knew this. He was encouraged to take care of himself physically and he found exercise helped him. Staff in Children’s Home 2 have recognised the need for training regarding ADHD and Dyspraxia, but were not able to access this during the time that Child G was placed with them. 7.25. Child G also responded well when subject to the Intensive Supervision & Bail Support package and largely complied well with this, again there were strict boundaries and an incentive to avoid custody. 7.26. The change to a male substance misuse worker who was assertive with Child G and waited and insisted that Child G came out of his room to see him was responded to positively by Child G and a trusting relationship began to form. 7.27. None of the agencies could identify how they made reasonable adjustments to ensure that Child G could fully engage in meetings that were about him; given his age it would be expected that he was fully engaged. He did take part in his Looked After Child Reviews but there is nothing specifically recorded as to how this was managed in respect of his learning needs. 7.28. There were several reasons why some professionals did not employ strategies and reasonable adjustments when working with Child G. There were misunderstandings regarding the impact of the diagnoses and some professionals assumed health professionals would inform them of such impacts. Health professionals argued that as Learning Difficulty is wide spread, they would have expected non-health professionals to seek advice from them if this was the case. 7.29. Professionals also articulated that Child G was able to reflect on his actions and clearly understood the impact that his actions had on himself and those around him. This contrasts with what one may have expected given his Learning Difficulty. It was clear though that at times he was unable to think at the time and stop himself from undertaking harmful actions. It is acknowledged that many adolescents behave in a similar manner. 18 7.30. This then, reminds us of the research referenced in 7.5 (Romer ibid) into adolescent behaviour and the importance of considering whether it is the learning difficulty, mental health issues, normal adolescent behaviour or other influences (e.g. Adverse Childhood Experiences, substance misuse) that are underlying explanations for chaotic and risky behaviours. 7.31. It could be argued in Child G’s case it was probably a combination of all of these reasons. It can be seen, therefore, why professionals did not consider making plans that focussed on learning difficulty and mental health above other issues. 7.32. It is of note that multi-agency meetings did not generally make mention of Child G’s Learning Difficulty. This meant that the duties required of professionals under the Equality Act were not considered. 7.33. What is clear is that as more services, assessments and interventions were added in an attempt to manage and contain Child G’s escalating risky behaviours, the more he appeared to increase those behaviours. His learning and mental health needs and the responses to those may go some way to explain why that might be. Child G might well have been voicing his frustration and anxiety to the complexity that was materialising around him. Complexity in Child Protection 7.34. Child G was a child with complex needs as identified above. The services that were becoming increasingly involved to meet these needs added to the complexity of working effectively in a multi-agency environment. As well as Child G’s emerging learning and mental health needs was the addition of substance misuse. This risky adolescent behaviour added into his other issues created additional risk and complexity. 7.35. It is useful to draw on the work of Stevens and Cox (2008)15 as a theoretical framework for understanding complexity in Child Protection and why the assessments and interventions did not achieve their goals. Stevens and Cox gathered information from several sources and identified that the systems that children and families live in are complicated ‘open’ systems. They contend that families and services are complex and can be unstable systems and 15 Stevens, I. & Cox, P. (2008) Complexity Theory: Developing New Understandings of Child Protection in Field Settings and in Residential Child Care. British Journal of Social Work 38, 1320–1336 Learning Point 1: Differentiating between learning difficulty, common adolescent behaviour and understanding any impact of Adverse Childhood Experiences is vital to inform strategies for assessment, support and intervention. (Recommendation 1a) Learning Point 2: Adjustments required by the Equality Act (2010) to service provision and plans may increase engagement and reduce anxiety. (Recommendation 1b) Learning Point 3: Seek advice across the multi-agency network to understand the impact of conditions such as learning difficulty. (Para 10.1) 19 therefore are prone to the impact of abrupt changes. 7.36. They further argue that a small change in one part of the system may lead to unpredictable change or even no change at all. This is unlike a closed system where a change in one part will always create a predictable change in another part. This means that in an open system an event may well happen but when and how the event will occur is not as predictable; even when a situation is predictable there are other factors that may steer the event one way or another at a point where there are options and choices. 7.37. Stevens and Cox further found that policies and procedures do not allow for a range of predictable options. 7.38. In this case practitioners were following many processes that were linear in type and were more akin to a closed system i.e. the policies and processes are expected to create a change that is predicted and beneficial. In themselves there was nothing wrong with each individual process, they are tried and tested. However, when there are so many processes being undertaken in so many services, each with individual risk assessments and interventions a change, positive or negative, in one part of the system is likely to lead changes that are unpredictable or even have no affect at all in another part in the system. 7.39. There are many of the issues identified above and in later sections in the analysis that impacted upon single agency involvement that added to complexity (e.g. management oversight, limited supervision, recording issues, newly qualified practitioners as well as, not following guidance and procedures). If single agency involvement does not achieve the right goals using set out processes, then it will not lead to effective multi agency working, especially within a complex case such as this. 7.40. The following are examples of the processes and how they affected other parts of the system. 7.41. The processes of early individual agency assessments and focus on diagnosis possibly contributed to a failure to make early referrals into Children’s Social Care via the Multi Agency Safeguarding Hub. There was evidence of clear risk and unmet needs that were being presented to various agencies e.g. primary school, GP, Paediatrician, occupational therapy, speech and language therapy, secondary school, Pupil Referral Unit and Family Support Service. None of these services effected change in another part of the system by objectively using the system of the BwD LSCB Continuum of Need16 to identify level of response required. 7.42. Assessments across all Key Episodes did not appear to consider any impact or risk from parental history on Child G. It is not apparent within assessments that the possibility of any Adverse Childhood Experiences were considered or assessed so it is not known if there were any specific experiences that had any impact. 7.43. The Police Protecting Vulnerable People system of assessing risk and sharing that risk with social care and health is at work and evident throughout the key episodes. This is not, however, in line with the BwD LSCB Continuum of Need iibid and is based on the policing system and what is known to the police at the time of the incident. Therefore, if a medium risk 16 BwD LSCB: Children’s Continuum of Need and Response Framework http://www.lscb.org.uk/wp-content/uploads/Childrens-Continuum-of-Need-and-Response-Framework-April-2016.pdf accessed 29th May 2017 20 Protecting Vulnerable People alert is received, that does not necessarily translate automatically to a medium risk along the continuum of need but may persuade practitioners to believe that. 7.44. The decision in November 2014, on receipt of the first Protecting Vulnerable People alert into the Multi-Agency Safeguarding Hub, that the level was Child in Need and medium risk, at that point may well have been the right one. Accepting however, what is understood about complex open systems, there needed to have been a full consultation with all the agencies that were involved. 7.45. The Child in Need meeting in January 2015 did not have all the agencies together that were offering services and support to Child G and his family at that point. There were several health services that had seen and assessed Child G during Key Episode 1 and further referrals had been made but none of these were represented at the meeting. Therefore, even at this first stage in the Child in Need process, the complexity was not fully understood or addressed; decisions were made on what was known and not what was knowable had there been information from other sources. Key agencies held historic information that would have better informed the assessment at that time. There was information from the first key episode (i.e. from the Educational Psychologist) of considerable concern (see 6.4) that does not appear to have been judged as high enough risk to escalate to child protection. This therefore impacted on the quality of the assessment and the outcome of the process. 7.46. A high risk Protecting Vulnerable People alert was submitted later in January 2015 and contained some significant evidence of escalating concerns but this did not translate into a review of the level of need and it remained at Child in Need level when it should have been at Level 4 (Child Protection) according to the BwD LSCB model ibid. There was still no representation from any of the health services that were involved even though there were some meeting invitations. These issues were not escalated (see 7.79). 7.47. This therefore provides evidence that abrupt changes in the circumstances did not result in a responsive change in the system that it should have. 7.48. Other examples of this are seen throughout the Key Episodes; When Child G first became subject of youth justice services in April 2015 a lack of understanding of the history and all the information by that service led to a risk score of below that which would have resulted in a Multi-Agency Risk Management Meeting as per protocol17. At the Learning Event, professionals from that service identified that had they had all the information that was knowable at the time, the risk score would have been higher and triggered a Multi-Agency Risk Management Meeting. Again, this would have been a further opportunity to understand risk and complexity by all. 7.49. The system used by the Police to record Child Sexual Exploitation risks and actions, discussed later in the analysis, also highlights where systems and processes can add to complexity if they are not coordinated and managed appropriately. It provides a further example of where changes in the system did not have the desired impact to another part of the system. 7.50. The length of out of borough placement was not sufficient to allow time for relationships and trust to build and effect change in Child G as was initially intended and the purpose of the 17 Operational Protocol Between Children's Services (Social Care, Leaving Care) and the Youth Justice Service http://blackburndarwenchildcare.proceduresonline.com/chapters/p_operational_proto.html#marm 21 placement, therefore no change occurred. There was too much required of a short-term placement for a child with very complex needs. 7.51. Communication difficulties within education when Child G returned to the local area, resulted in Child G not being offered a place back in Education for two months following his return; communication issues within the system did not lead to the required change. 7.52. It was noted that many professionals asked Child G about his substance misuse. Throughout the timescale covered by this review, Child G disclosed many and varying drugs that he was using and that he also used alcohol which would increase risk. It became apparent during the learning events, that many professionals did not necessarily recognise the implications that this would have on the intervention and/or risk management that the substance misuse workers would employ when working with Child G; substance misuse workers were not aware that he was using opiates. 7.53. It was also noted that periods of sudden abstention from drugs was seen as a positive step, however, this would need to have been managed well due to risks of changes in tolerance levels and risks of overdose. 7.54. Again, these changes in Child G himself, were not recognised as significant and information was not shared with substance misuse workers who would have been able to try and effect change in another part of the system. This leads to learning for non-substance misuse workers about the importance of communicating types of substances involved and any change to the nature of substances. 7.55. On feedback of the report’s findings to Mother, she indicated that she felt that substance misuse training should include supporting practitioners to recognise the difference between a person who is ‘gouching’18, from someone who is merely sleepy and in those cases the importance of seeking urgent medical assistance. 7.56. At the Learning Event, various services identified the elements of their risk assessment processes which were helpful in adding to the understanding of complexity. It is clear that each service is required to risk assess independently as their services are responding to slightly different needs. 7.57. In this complex case, it could be argued that practitioners were not able to offer and think about more dynamic approaches as their focus was on their own element and largely were not able to understand the wider picture; many services were not aware of others involved. 7.58. What would have been of benefit is the summary of all those risk assessments being used in a plan that was understood by all and that was worked to by all. This would have meant that the factors in play and the abrupt changes to the open system could have been managed more dynamically. 7.59. Bringing all the assessments, plans and interventions that were being undertaken together in one place, that clearly identified the ongoing risks from each service’s perspective and included information on history and diagnoses that was known to all may have given a wider picture of the complexity and risk. That is not to say that professionals did not understand that 18 Gouching is a term sometimes used to describe a period of sedation and tranquility also known as being "on the nod” following ingestion of some substances such as opiates. 22 this was a complex case, but they did not appear to be able to identify exactly what needed to be undertaken differently and by who. A pooling of ideas and resources with a solution focus regarding the various issues of risk that were being presented may have been helpful. 7.60. There were existing multiagency assessment and planning processes that were in use during most of the scope of this review (e.g. Child in Need, Child Protection and later Looked After Child reviews) and others that should have been e.g. Common Assessment Framework). Had there been good use of these processes with good attendance and effective multi agency challenge (see from 7.68 below) this would have been the place to discuss all existing plans. Where practitioners were finding issues difficult to address, there is scope to include more senior managers for support. 7.61. Indeed, Children’s Social Care has identified, in their single agency report, that there should be a better use of their strategy meetings process. This multi-agency review supports this but would take this further with a view that all agencies should review their input into strategy meetings in complex cases to ensure that there is a sharing of single agency plans. The support and involvement of senior managers where required would enhance strategy meetings for complex cases. If robust, this should be able to provide every service with an overall plan and view of the goals and required outcomes. Again, that is not to say that each service would not have their own plan, but that each plan would have been cognisant of the other plans and interventions and assurance that there was no overlap or gap in provision. 7.62. Professionals at the learning events felt that a system that brought together senior managers from various key agencies, where cases are significantly complex would be very supportive of professionals who were feeling that their actions were not making a difference and is discussed in section 7.87 (multi agency supervision). 7.63. Multi agency contingency planning as part of a strategy meeting in complex cases would have been a useful feature to aid planning for sudden changes that was understood by all e.g. there was a ‘Missing from home’ trigger plan that was identified as a Police response to missing episodes due to the level of Child Sexual Exploitation risk and this was shared with Children’s Social Care. Others at the Learning Event accepted that this may be a Police trigger plan but, that if shared with other professionals, it may help in early location and identification of further risks e.g. a notification to health services may identify a missing person if they attend a health service whilst missing. 7.64. Some services represented at the Learning Event stated that they had no idea at the number of services that were involved but what was also apparent was that each service was absolutely trying everything that they could to make a difference to Child G and sought to find the intervention that would help him address his issues. 7.65. One of the health organisations identified that they had several nurses, all with slightly different roles who were involved with Child G. There was a nurse for children Looked After, a Child Sexual Exploitation nurse as well as a school nurse/youth nurse. Single agency learning for that organisation has identified the importance of clarifying and recording who will be the lead/key worker to avoid duplication or gaps in provision and to provide clarity of role to other professionals and the child/young person and their family. 7.66. From Child G’s perspective, the services and plans around him must have seemed overwhelming. Given the learning identified above (7.2 to 7.33), he must have struggled to understand who was doing what and how he could engage with all the services, many of 23 which were in play at the same time. It is of significant note that Child G’s comment to the Child Sexual Exploitation nurse regarding a dental appointment that he’d ‘had enough of speaking to professionals and would attend the dentist on another occasion’ gave a clear voice of how he felt about this. 7.67. It could be argued, that it would have been in Child G’s best interests to rationalise the services that were actively involved in offering direct interventions and recording the rationale for those decisions. Management oversight and scrutiny in strategy meetings in this complex case may well have been of benefit here with senior managers agreeing which services were to continue offering support and a rationale recorded within the multi-agency plan/s. The role of challenge, supervision and reflection 7.68. There are several areas evident from the agency reports and discussed at the Learning Events where there were challenges across services and several others where it was evident that challenge might have been appropriate. 7.69. It was from Child G’s Independent Reviewing Officer19 where most challenge was seen. This included challenges regarding the appropriateness to continue with S20 accommodation and whether the move back to the local area was right for Child G. These challenges where wholly appropriate and happened internally within Children’s Social Care. 7.70. The Independent Reviewing Officer raised concerns that a return to the local area may not be in Child G’s best interests unless effective work had been undertaken. Indeed, Children’s Home 2 identified that there were issues for them regarding the length of the placement. Given Child G’s learning and mental health needs, it is not surprising that he would take a while to settle and to trust the staff in Children’s Home 2. With that understood, by the time he had settled 19 Independent Reviewing Officers (IROs) are qualified social workers with at least five years’ experience, and who have ideally had some management experience. The role of the IRO is to review, monitor and scrutinise the care plan. The review checks that the care plan is the right one; and that what is in it is actually being carried out. If the IRO believes that the practice or policy of the local authority is detrimental to the child’s welfare or if the child’s human rights are at risk of being breached, they have a duty to challenge the local authority. Learning Point 4: Complex cases require dynamic approaches to child protection and support from senior managers. (Recommendation 2) Learning Point 5: Shared contingency planning in complex cases provides clarity of required response for all predictable outcomes. (Recommendation 2) Learning Point 6: It is important that professionals are aware of: the need to share information about specific substances being used with substance misuse workers in order that risk management can be substance specific. Identification of indicators drug induced symptoms that may require medical assistance. (Recommendation 4) 24 he was already planning his move back to the local area. Children’s Home 2 commented in their agency report that there was little time to undertake any meaningful work and indeed he was on the waiting list for Child and Adolescent Mental Health Services for most of his placement. Child G did not engage with drug services whilst out of area and this would have been a key component of recovery work. A longer placement may well have given practitioners a chance to build a good enough relationship for Child G to accept services. 7.71. The challenge regarding the continuance of S20 accommodation was also wholly appropriate. On return to the local area, Child G’s risky behaviour was escalating. It was known that Mother was now fearful of him and that it was difficult for her to say no to him especially when he was stating where he wanted to stay and areas he wanted to frequent. It also became evident later on that Child G had been drinking and accessing drugs when with wider family members further adding to the indication that parents may have been having difficulty exercising parental responsibility appropriately. 7.72. In May 2016, when the first challenge was made, the Children’s Social Care agency report author states that at that time this may have been the right decision and legal advice had been sought. These internal challenges followed the processes required within the single agency. 7.73. By May 2016 there was general agreement that a further out of area placement was necessary and there was consideration of secure accommodation. A challenge to this was that it was felt that Child G was in receipt of a comprehensive package of support and that a movement at that time would impinge on this. The author of the Children’s Social Care agency report and indeed the author of this review refutes this as Child G was not actively engaging at that point and there was evidence that he was safer and undertaking less risky behaviour when he was placed out of area. 7.74. Professional challenge can also come from outside of an agency where there is disagreement regarding the right way forward. The earlier reluctance to find a second out of area placement should have prompted challenge. This may have resulted in an earlier decision to move Child G away from local risks and influences. 7.75. There was good external challenge from the Special School who argued alongside the Independent Reviewing Officer and others, that Children’s Home 1 or indeed the whole locality was not a safe place for Child G. Whilst there was challenge here, it was not escalated when not heard and no action taken. Some of the reason for this was due to the issue being discussed within several meetings and different emphasis. Also, the strategy meetings where it was discussed were chaired by different managers. The lack of consistency appears to have resulted in detail of all concerns regarding the placement not being heard in one place and therefore the challenge and escalation was not robust or wholly understood in decision making. 7.76. There were other occasions that received no challenge across agencies that may have been missed opportunities: 7.77. An earlier Statutory Assessment of Educational Need would have involved and brought together a multi-agency view of Child G’s educational needs and may have resulted in an earlier referral into Children’s Social Care for assessment of risk and need. 25 7.78. The Child in Need plan should have been challenged earlier as there was evidence by the second Child in Need meeting in that Child G’s unmet needs were at Level 4 according to the BwD LSCB Continuum of Need Framework ibid. 7.79. It is also of note that, when practitioners were not involved in multi-agency meetings as they thought they should have been, this was not challenged formally nor was non-attendance at multi agency meetings following invitation. Multi agency assessment and decision making relies on the involvement of all agencies and therefore, if the system is defective in this area, then it should be challenged and escalated in order that outcomes are effective for children. 7.80. When challenge does not lead to change and practitioners remain concerned that their reasoning is not being heard, it is important that escalation policies are used to lead to appropriate resolution of professional differences of opinion. 7.81. The BwD LSCB has a Protocol ‘Resolving Inter-Agency Disagreements’20, although there is no evidence that it was used when there were concerns. It is not clear why this was but links to currently unpublished serious case reviews in the area identify that the guidance requires refreshing and leads to support for the recommendations of previous serious case reviews. 7.82. There is also an element in this case where there should have been more challenge of Child G. Many of the services identified that he appeared to choose the services he wanted to engage with and when. As identified in Section 7.2- 7.33, Child G had learning needs and other issues that would suggest that clear boundaries, targets with incentives and consequences may have worked well if they were broken down into understandable chunks. It can be seen from the Key Episode tables that those services and professionals that he engaged with the most were ones that had those set elements either as a statutory requirement (e.g. Youth Justice) or because that was the way the professionals worked (e.g. male Young People’s Substance Misuse and Recovery Services 2 worker). Had more services challenged Child G in this way, they may have engaged him more effectively. 7.83. This review does acknowledge that some of the possible reason that Child G may have chosen to engage more at times may have also been on the occasions where there were incentives towards being able to live with family. That manifest itself initially when Child G could no longer be cared for within the family and more latterly when there were possibilities for reunification with family. These occasions did see some improved periods of engagement, albeit for a limited amount of time. 7.84. Opportunities to challenge should be highlighted by the opportunity for robust reflective supervision and management oversight of practice. Some of the agency reports did not identify if supervision was taking place, of those that discussed it, all identified areas for improvement, commenting that there was little evidence of reflection and challenge within the recording of supervision. Some agencies reported significant issues with supervision not being recorded appropriately. 7.85. The role of effective and robust supervision has long been argued as an important element in safeguarding children. Learning from Serious Case Reviews nationally, as identified in the Triennial analysis of Serious Case Reviews ibid and locally21 identify effective supervision as 20 Pan Lancashire Policy and Procedures for Safeguarding Children Manual 8.1 Resolving Professional Disagreements http://panlancashirescb.proceduresonline.com/chapters/p_resolving_prof_disagree.html accessed on 26 May 2017 21 LSCB – Learning from Serious Case Reviews, BwD LSCB Briefing October 2016 (unpublished) 26 elements of learning. Bruton (2009)22, brought together a range of sources in a safeguarding briefing, identifying that not only should supervision have reflection and challenge but also identified the need for professionals to play devil’s advocate to aid their own critical thinking when situations are changing rapidly. 7.86. The Triennial Analysis identifies that in circumstances where resources are finite and services undergo restructure, and it could be argued, retendering, the role of supervision becomes even more important for frontline practitioners. 7.87. There could also have been a case for multi-agency supervision with managers and practitioners coming together to share reflections on the case progress. Sharing of thoughts and ideas for solutions and identifying what had made a difference where services had engaged with Child G successfully may have been supportive of the professionals. A finding from a recently published SCR in Hartlepool concurs that: “All practitioners need to be supported and challenged in their practice to constantly reassess their views on a case and professional supervision provides the most appropriate forum for this to take place. Where multi agency professionals can come together to be supervised jointly, this will be even more effective.”23 7.88. There is also similar learning in a, yet unpublished, SCR that has been undertaken by BwD LSCB. Learning from this and other SCRs locally and nationally was shared at a professionals’ briefing in October 2016. This case has led to further learning regarding supervision and professional challenge. 7.89. A culture of challenge (Assertive practice), Reflective supervision along with Knowledgeable practitioners (ARK) is a contemporary framework that was introduced by a national safeguarding expert at a recent BwD LSCB development day and this is currently being used as a longer-term framework to promote best practice in safeguarding. 22 Bruton, S. (2009) The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? C4EO Safeguarding Briefing 3 National Children’s Bureau. http://archive.c4eo.org.uk/themes/safeguarding/files/safeguarding_briefing_3.pdf accessed on 25th May 2017 23 Serious Case Reviews – “Olivia” and “Yasmine” Executive Summary and Board Response http://lscbhartlepool.org/ Accessed 13 July 2017. Learning Point 7: An embedded culture of internal and multi-agency professional challenge enhances safeguarding children practice. (Para 10.1) Learning Point 8: Robust reflective supervision encourages challenge and critical thinking regarding views of current practice challenges. (Para 10.1) Learning Point 9: In complex cases, multi-agency reflective supervision to identify blocks and barriers to managing risk and complexity may support dynamic approaches. (Para 10.1) 27 Identifying Child Sexual Exploitation and its Response 7.90. There has recently been much national press and interest in the progress of systems regarding recognising and responding to Child Sexual Exploitation in the wake of national inquiries into the issue. This review has given an opportunity to analyse the practice in this case against recognised current local and national best practice and guidance. 7.91. From the Key Episode tables, it can be identified that Child Sexual Exploitation was first highlighted formally as a risk for Child G in August 2015 when assessment identified a high-risk score. Child G had been known to the Multi Agency Child Sexual Exploitation Team from June 2015 as it is that team who undertake the Missing from Home Return Interviews due to the associated link between Missing from Home and Child Sexual Exploitation24. 7.92. It appears that some areas within the Pan Lancashire Child Sexual Exploitation Standard Operating Protocol25 were not followed resulting in a much later identification of Child Sexual Exploitation risk and identifying Child G as a possible victim of Child Sexual Exploitation. 7.93. It is of note that the first Child in Need meeting identified that Child G had been missing from home on several occasions but that formal return home interviews were not conducted as per the Missing from Home protocol. This was because those missing episodes had not been reported to police or any other agency by parents. The parents were encouraged to report future episodes but a retrospective return interview was not undertaken at this point contrary to advice in the Pan Lancashire Missing from Home Protocol26. 7.94. At the first Child in Need meeting in January 2015 there were many indicators of Child Sexual Exploitation risk; of the nine indicators from the SAFEGUARD acronym (included in the Pan Lancashire Procedures) to support professionals in identifying Child Sexual Exploitation risk, there was only one not to be a known feature for Child G. 7.95. National27 and Local Guidance (Pan Lancashire Protocol ibid) related to Child Sexual Exploitation also identifies the vulnerabilities sometimes referred to as ‘Push-Pull’ factors that often lead to increased risk of Child Sexual Exploitation. The Push factors for Child G factors such as family breakdown’ low self-esteem, emotional and learning difficulties. Pull factors that were possibly drawing Child G into risky situations were being offered drugs, alcohol and gifts, getting a buzz and the excitement of risk taking/forbidden behaviour and being offered somewhere to stay where there were few rules/boundaries. 7.96. The Children’s Social Care assessment at that time did not draw together all the risk indicators to identify that there was a high risk of Child Sexual Exploitation for Child G. The knowledge of these indicators should have led to a risk assessment and referral being completed, and as 24 Emilie Smeaton, E. (2013) Running from hate to what you think is love: The relationship between running away and child sexual exploitation. Ilford Barnardo’s https://www.barnardos.org.uk/15505_cse_running_from_hate_2l_web.pdf accessed 29 June 2017 25 Pan Lancashire Child Sexual Exploitation Standard Operating Protocol http://panlancashirescb.proceduresonline.com/pdfs/lancs_Child Sexual Exploitation_standard_op.pdf 26 Pan-Lancashire Joint Protocol: “Children and young people who run away or go missing from home or care” http://panlancashirescb.proceduresonline.com/pdfs/joint_proto.pdf 27 Dept. for Education (2017) Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/591903/CSE_Guidance_Core_Document_13.02.2017.pdf accessed 20 July 2017 28 already open to children’s social care, a strategy meeting involving the Child Sexual Exploitation Team should have been convened. 7.97. Neither the Missing from Home nor the Child Sexual Exploitation Protocols were followed. This was because the allocated social worker was newly qualified and had not recognised these issues as requiring a response under the protocols. 7.98. There were other practitioners involved in the Child in Need process who had responsibility to understand the requirements of protocols and processes and should have been able to advise the social worker. There were also later multi agency processes (Child Protection and Looked After Child) as well as two case decision forms signed off by Children’s Services social care heads of service and meetings that did not identify child sexual exploitation concerns and therefore did not consider a referral to the Child Sexual Exploitation Team in line with the protocol. 7.99. A newly qualified social worker, or indeed any newly qualified professional, needs mentorship and careful supervision and support in order that they can develop their skills and understand the processes that are in place to support practice. Therefore, the fact that the social worker was newly qualified should not have made a difference if the support and the multi-agency partners were working effectively. Learning from a very recent, unpublished SCR (Child R) undertaken by BwD LSCB also identified this as a learning point. 7.100. This earlier identification of indicators of concern would have alerted all professionals to the Child Sexual Exploitation risk and preventative work could have started earlier. 7.101. When the Missing from Home interviews were conducted by the Child Sexual Exploitation Team from June 2015 onwards no Child Sexual Exploitation concerns were identified and it was not until a risk assessment carried out by the Children’s Social Care Child Sexual Exploitation worker in August 2015 that the score was deemed to indicate high risk of Child Sexual Exploitation. Despite the number of missing from home episodes, this did not result in an earlier ‘Missing from Home Trigger plan’; it could be argued that this was a missed opportunity for an earlier identification of risks. 7.102. The police early help worker who had engaged with Child G in early in 2015 also had a role in prevention of Child Sexual Exploitation as part of the Police Universal offer to support early help and intervention. The Police Early Help worker had issued Section 2 notices28. Section 2 notices are issued as part of the prevention work in Child Sexual Exploitation in an attempt to stop adults providing inappropriate gathering places for children. It was identified at the Learning Event that the team that the worker worked within did not record information on the same system as the usual police teams and did not record anything until April 2015 and that there are multiple police recording systems. This meant that police information, including information about the serving of Section 2 notices, was stored in several places albeit shared verbally at multi agency meetings. For this reason, there is an impact on the police understanding of the multi-agency perspective at various points as it was this worker that was attending Child in Need, Child Protection and other professionals’ meetings to represent the 28 Section 2 Child Abduction Act 1984 – (offence) A person not connected with the child is guilty of an offence if, without lawful authority or reasonable excuse, they take or detain a child under the age of 16 so as to remove the child from the lawful control of any person having lawful control of the child. This offence applies to any child under 16. Once a potential perpetrator has been identified they can be served with notice requirements under S2 and S49 on behalf of the parent, carer or guardian of the child/young person. From the Pan Lancashire Child Sexual Exploitation Standard Operating Protocol. 29 police. Other officers in other policing teams responding to various risks and crimes were not able to see everything in one place and there is no flagging system for child sexual exploitation visible to all across the system. This has been addressed within the single agency learning by the Police and recommendations have been made to address this. 7.103. The multi-agency meetings regarding Child Sexual Exploitation that are undertaken monthly as part of the wider Child Sexual Exploitation protocol, first included mention of Child G in October 2015. It is the contention within this review that that he could have been included much earlier had the right risk assessment and known information been used and shared. The first disclosure from Child G that could have indicated that he was a victim Of Child Sexual Exploitation came within the same month. 7.104. There were also some accepted difficulties that were discussed at the Learning Event, with the recording and information sharing from these multi agency meetings that were not minuted. The record that was created was stored within police systems and not shared formally so was not incorporated into the Looked After Child review. The record identified disruption actions but did not identify the significant issues that could have been suggestive that Child G was a victim of child sexual exploitation. It was expected that attendees at the meeting would make notes and take these back to their own agency. The system therefore does not support formal information sharing from this multi-agency meeting. This adds further weight to the learning identified above regarding the issues with multiple plans not being shared in a formal process. 7.105. It is not known whether earlier identification and intervention would have had an impact given the level of Child G’s engagement, but it would have evidenced staff being knowledgeable and alert to the systems and processes that allow for early identification of risk. 7.106. Despite the above, it is of note that adults who may have been increasing or contributing to risk factors for Child Sexual Exploitation continued to be served Section 2 notices. Disruption of possible perpetrators is also an important part of managing Child Sexual Exploitation and its risks. Whilst this was good practice and part of earlier intervention, it was not part of an overall Child Sexual Exploitation action plan that was incorporated into other plans. 7.107. It is pleasing to note that the system for issue of Section 2 notices by the Police Early Help Worker has been reviewed. Authorisation by a Detective Sergeant or Inspector is now needed to ensure coordination and management oversight. 7.108. It is also of note that the agency reports do not evidence how they formulated plans to engage and hear Child G’s voice related to disclosures he made. His learning needs may well have been significant in the type of intervention at this time at the Sexual Assault Referral Centre, by the Child Sexual Exploitation team and within sexual health services. If there had been grooming and coercion of any sort, the needs of a person with Learning Difficulty may have made the ability to see any action as abusive even more difficult than for other young people; this is known to be a significant factor in the disclosure of Child Sexual Exploitation by children. 7.109. Recent work at a Sexual Assault Referral Centre within the same region has identified the issue of working with people with Learning difficulty who have been sexually abused and made a funding application to help improve the accessibility, appropriateness and effectiveness of sexual assault services for clients with learning disabilities and therefore also helpful when working with people with a learning difficulty. These resources will be a useful 30 for all practitioners working in those areas. 7.110. The disclosures that Child G did make about sexual assault could not be progressed to possible prosecution of perpetrators by Police as Child G later retracted that they were assaults and stated that the activity had been consensual. There is further learning here in the way that professionals see and understand disclosure and retraction of such in cases of possible Child Sexual Exploitation. 7.111. On one occasion related to a disclosure to the Child Sexual Exploitation team, Child G had stated that his memory was hazy as he had taken a cocktail of drugs and alcohol. This sexual activity, therefore, could not have been consensual as, at the time, he did not have the capacity to consent. There were other identified occasions where it was apparent that Child G made disclosures that indicated that he had sex when under the influence of drugs and/or alcohol. 7.112. Secondly, research29 would suggest that suspected Child Sexual Exploitation victims who have suffered the most severe abuse may be least likely to cooperate with service agencies and that imminent threats from offenders may also lead to suspected victims deceiving law enforcement during initial stages of investigations. 7.113. In light of the current research and ‘key messages’ from the Centre of Excellence for Child Sexual Abuse30, a more robust approach to dealing with possible perpetrators was required, rather than sole reliance on prosecution from disclosures. The support to build effective relationships with specifically identified professionals (see below 7.117) should also have included support to understand the possible criminal processes that may have ensued following any disclosure. 7.114. It could be argued, therefore, that if professionals are alert to the above information, then children such as Child G should be seen and treated as victims of Child Sexual Exploitation as opposed to being ‘at risk of’. Some professionals at the Learning event indicated that they were treating Child G as a victim, but others were not aware of the ‘victim’ status until they read the agency reports as part of this SCR. Child G as a victim, did not feature in plans and interventions and was not discussed overtly at meetings. 7.115. Child G’s family were not aware of the above professional viewpoint. It could be argued that they could therefore not exercise any protection using that knowledge and parental responsibility that they retained as part of the S20 status. One of the reasons for this was because Child G had requested confidentiality regarding any sexual harm, and following legal advice this had been respected. Professionals faced a dilemma and did respect Child G’s confidentiality. With hindsight, however, working with Child G towards disclosure to his Mother may have afforded more protection and open working in the context of Child Sexual Exploitation. 7.116. Seeing Child G as a victim may have led to a further view of the nature and underlying causes on all aspects of his presentation (chaotic substance misuse, depression and anxiety, constant fear of physical damage/symptoms, and increasing violence against others) or at least why he 29 Srikantiah, (2007) & Moossy, (2009) In Ahern, E. et al (2017) Wellbeing of Professionals Working with Suspected Victims of Child Sexual Exploitation. Child Abuse Review Vol. 26: 130–140. 30 A suite of publications, ‘Key Messages’ include four tailored for specific professional groups and one for the multi-agency team. Three are paired – with one for frontline practitioners and one for commissioners. https://www.csacentre.org.uk/research-publications/key-messages/ accessed 25 September 2017 31 did not feel able to address these issues. 7.117. Many of the elements of the ‘See me, hear me’ Framework identified in the Inquiry into Child Sexual Exploitation in Gangs and Groups31 is in place in the area. One of the key elements of what young people and evidence informs us works with supporting young people who are at risk of Child Sexual Exploitation, is building positive relationships and trust. This was evident in this case with several workers being allocated to Child G for a considerable length of time (e.g. Social Worker, Child Sexual Exploitation Team worker, a youth nurse). Child G did not always engage with these workers but they remained consistent in their attempts to support him and build trusting relationships with him. Early identification, however, and a review of ‘what works’ from a solutions perspective to engagement may have been helpful in understanding earlier exposure and risk and to build positive relationships much earlier. 7.118. Very recent guidance related to Child Sexual Exploitation32 supports much of the learning that this review has found including the important role that parents can play in prevention, recognition and protection from abuse. Current guidance also identifies the work of Shuker (2013)33 that there are three key elements to safety i.e. relational, physical and psychological. The movement away from the locality may have been positive in terms of physical safety but it did not recognise the importance of relational safety and the fact that new professional relationships needed to be formed in the new area. Movement out of area also disrupted the psychological support Child G required. 7.119. Practitioners in this case were not working within that framework as it is not included within the current guidance. Some of those practitioners were focussed on the presenting escalating behaviours and attempting to deal with those, rather than seeing those escalating behaviours as indicators of possible child sexual exploitation. As noted above some professionals did not understand this element of Child G’s life until they read the agency reports during the process of this review. 31 Berelowitz, S. et al (2013) If only someone had listened Inquiry into Child Sexual Exploitation in Gangs and Groups, Final Report. Office of the Children’s Commissioner, London 32 Child sexual exploitation: How public health can support prevention and intervention (2017) Public Health England. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/629315/PHE_child_exploitation_report.pdf Accessed 14 August 2017 33 Shuker, L (2013a) 'Constructs of Safety for Children in Care affected by Sexual Exploitation' in Melrose, M (Ed) Critical Perspectives on Child Sexual Exploitation and Trafficking. Palgrave Macmillan. Via CSE Research: Short films for practice Research Briefing Note #11 https://www.beds.ac.uk/__data/assets/pdf_file/0007/461437/RBF.11.Shuker-jhLS.pdf accessed 14 August 2017 32 Learning Point 10: Local and national guidance to support early identification of Child Sexual Exploitation risk, including response to Missing From home episodes is key to early intervention and possible prevention. (Recommendation 3) Learning Point 11: Guidance and support for newly qualified workers is required from managers and supervisors as well as from the multi-agency partners involved in a case. (Para 10.1) Learning Point 12: Risk of Child Sexual Exploitation and possible victim status needs to explicit in all plans and shared with all professionals. Where appropriate, family should also be aware of this to add layers of protection. (Recommendation 3) Learning Point 13: Children and young people who have specific learning needs require different and specific approaches when attending sexual health services following disclosures of sexual abuse. (Recommendation 3) Learning Point 14: Local guidance needs to reflect current research. (Recommendation 3) Learning Point 15: Professionals must consider the nature of capacity to consent in decision making. (Recommendation 3) Learning Point 16: All professionals working with a child or young person are responsible for following protocols and processes and must support/advise and challenge where this is not happening. (Recommendation 3) Learning Point 17: Where there are multiple recording systems, information must be cross referenced so that there are no gaps in information. (Recommendation 3) Learning Point 18: The recognition of early indicators of Child Sexual Exploitation risk are required in order to trigger multi agency responses to prevent and protect from harm. (Recommendation 3) Learning Point 19: Robust recording of meetings via centrally produced minutes that are distributed to all involved, ensures for accurate responses and information sharing to all partners. (Recommendation 3) Learning Point 20: Due to the nature of grooming, coercion and abuse, victims of child sexual exploitation are very likely to retract statements and disclosures. This should not preclude formal action against possible perpetrators. (Recommendation 3) 33 8. GOOD PRACTICE 8.1. This case featured a plethora of good practice from knowledgeable and dedicated practitioners who worked tirelessly to encourage Child G to engage in services that would support him to make the required changes to keep him safe. Notwithstanding the learning identified in the previous section, the following represent some examples of that good practice identified by the professionals themselves at the learning event. 8.2. The Child Sexual Exploitation Team demonstrated that they were knowledgeable about the risks and indicators of Child Sexual Exploitation once the risk was identified and worked hard to engage Child G and reduce risk. There is acknowledgment that this serious case review has identified that Child G should have been seen as a victim of Child Sexual Exploitation. 8.3. Despite the lack of involvement of all agencies in some of the meetings and processes, there was evidence of some good multi-agency working with some positive co-location of services within the Child Sexual Exploitation Team. 8.4. Several workers remained constant and this enabled establishment of relationships with professionals and with Child G e.g. the social worker and the child sexual exploitation team worker. 8.5. The Pupil Referral Unit identified that they could contact any agency and ask for help. The Youth Justice Service responded immediately when they were contacted regarding an issue. 8.6. The Missing from Home trigger plan was comprehensive albeit it was not put in place at the time that it might have been. 8.7. At the prospect of custody, Children’s Social Care, the Children’s Home and Youth Justice Service came up with a good plan which was felt to have good prospects. 8.8. The senior school saw real qualities in Child G and never gave up. Awareness that Child G was easily distracted and influenced led to giving him responsibilities and tasks such as Fire Safety Officer where Child G completed some work with the Fire Service. There was good pastoral care. 8.9. Professionals tried hard and worked closely together and there was a genuine desire to make a difference. Professionals generally kept Child G in the centre of their attention, stuck by him, did not give up and showed care and compassion. 8.10. When Child G went to the Pupil Referral Unit, the senior school completed work around this and maintained contact. 8.11. When Child G was bailed and one of the conditions was three hours’ education; the pupil referral unit persisted to ensure that Child G had a chance of education. 8.12. Child and Adolescent Mental Health Services and Children’s Home 1 worked well together. 8.13. There were good challenges from the Independent Reviewing Officer in respect of the legal status and appropriateness of the placement which created thinking and stimulated discussion. 34 8.14. There is evidence of good communication and good information sharing at daily briefings by the Child Sexual Exploitation Team. 8.15. There was good communication and commitment from Child and Adolescent Mental Health Services. 9. CONCLUSIONS AND LESSONS LEARNED 9.1. Using the Triennial Analysis Pathways to Harm and Pathways to Protection model alongside the terms of reference for the review enables a review of the conclusions and overall learning in this case. 9.2. Child G was a young man with a diagnosis of ADHD and Dyspraxia. This review has shown how this was the key vulnerability that was identified very early in his childhood by his parents. There was some family history of family breakdown, a new relationship, new sibling and new home that provided the context within which Child G lived. Professionals had mixed understanding of this in their interventions with Child G and his family and therefore did not robustly apply duties required under the Equality Act (2010). 9.3. Early preventative actions included those in health and education trying to establish a diagnosis and meet his educational needs. Despite these actions, Child G, after initially responding well, did not cope with the transition to senior school. This, along with an indication that Child G felt he was different adding to his anxiety and stress ultimately resulted in aggression and risky behaviours developing. Not all the history known to professionals in Key Episode 1 was shared and incorporated into later assessments leading to a gap in understanding Child G and his needs. 9.4. Initially there was a delay in identifying that assessments should be being undertaken from a multi-agency perspective with statutory assessment of educational need and referral to the Multi Agency Safeguarding Hub not happening as soon as they could. Once the referral to Multi Agency Safeguarding Hub was made, there was a delay in stepping up to Child Protection and identifying risk of Child Sexual Exploitation. 9.5. Child G also developed mental health issues and complex emotional needs. As Child G’s risky behaviours further developed and escalated, there was an increase in the number of protective and preventative actions by others in an attempt to prevent the pathway to harm. It could be argued that the more risky and dangerous that Child G’s behaviour became, the more complex it became to protect and prevent harm and the more services, assessments, interventions and plans were added. This made it difficult for services to understand what was working and what was not in order that plans could be reviewed for their effectiveness. 9.6. This review has attempted to understand what happens in complex child protection cases and has identified, that whilst each preventative and protective action in itself can be reasoned, that does not necessarily lead to improved outcomes for the reasons that have been identified. This therefore is a hypothesis as to why the systems were not able to protect Child G. 9.7. A more robust approach would be to use the existing available multi agency processes to share all plans and to coordinate and review interventions from a solution focus, identifying what is working and consideration of rationalising the services involved. Those services 35 prioritised for delivery, may be those that are most likely to be effective in reducing risk and preventing further harm. 9.8. Listening to the child is also important. Child G was showing increasing anger and frustration at how his life was spiralling out of control. At the same time he showed that where there were clear boundaries and consequences to his actions he did in fact respond well to these. There was evidence that he was able to develop trusting relationships with professionals and these were leading to significant disclosures. 9.9. More effective supervision and challenge alongside management oversight may have supported professionals to identify this and may have led to a change of strategy. 9.10. Risk of Child Sexual Exploitation was a key feature in this case that some of the professionals were aware of and working to reduce, however not all professionals working with Child G were aware that the view had moved to the fact that he was possibly a victim. 9.11. Professionals did not consider the number of key indicators alongside the presence of ‘push-pull’ factors early enough. These factors may have prevented engagement and Child G’s ability to address his mental health and substance misuse issues. 9.12. As far back as 2009, Eileen Munro’s work to improve child protection systems, identified that it is not possible to remove all risk and that a ‘risk sensible’ model, where the benefits of protective action must be weighed up against the cost of protective action in disruption to family life and other unintended consequences. Professionals in this case were cognisant of that and were engaged in many meetings, particularly towards the beginning and mid 2016 that were trying to discern the best approaches to keep Child G safe. 9.13. There is no one element of learning in this case that can be identified that would have changed the outcome. Indeed, there were some significant improvements in engagement by Child G that may well have been due to improved relationships that led to him having the confidence to speak to his Mother about concerns he had. 9.14. Child G was using drugs and alcohol and becoming increasingly involved in violence towards others before he died. Professionals discussed the possibility that he may die as a result of his behaviour. Indeed, Child G himself wrote letters to his family acknowledging this risk. He was also concerned about physical symptoms he was experiencing that he felt may lead to his death. It was not possible to predict with certainty that Child G would die, and even more when it would happen. In fact, it did happen at a stage that was possibly the least predicable when there was some considerable improvement in the way Child G was engaging. 36 10. RECOMMENDATIONS 10.1. This review recognises that many of the identified learning points (3, 7, 8, 9, 11) have been addressed by recommendations in recent reviews, actions against which are already underway and/or completed. Further recommendations are therefore not made within this review. 10.2. The following recommendations are made in respect of the additional learning and assurance required from this Serious Case Review: 1. BwD LSCB should require its partner agencies to provide evidence that: a. When working with children and young people, professionals are competent to manage the needs of adolescents with challenging behaviour who also have a learning difficulty and maybe impacted by Adverse Childhood Experiences. Agencies should also evidence ability to signpost professionals for further help and support in managing complex adolescents with learning difficulty, mental health issues and impacts of Adverse Childhood Experiences. (LP 1) b. Relevant staff have received training regarding duties under the Equality Act (2010) and can demonstrate, via audit if appropriate, how reasonable adjustments have been made to support adolescents with a learning difficulty to access and engage meaningfully with services. (LP2) 2. BwD LSCB be assured that Children’s Social Care along with key identified partners, review the strategy meeting process for complex cases and specifically that the review incorporates the learning from this serious case review (LPs 4 & 5). 3. BwD LSCB should undertake a further case file audit at a relevant future point related to Child Sexual Exploitation to ensure that actions taken and reviewed guidance since this and other recent learning are making a difference to the identification of Child Sexual Exploitation and its response in BwD. (LPs 10 & 12-15). 4. BwD LSCB should require commissioners of substance misuse training to ensure that course content includes the importance of ensuring changes in substance use is alerted to substance misuse workers and indicators of drug intoxication that would require medical assistance. (LP6) 5. BwD LSCB should include ALL the learning points from this review in their next practice briefing and seek assurance from agencies regarding its dissemination to all relevant staff. (Impact assessment via audit of knowledge of the learning may offer some assurance). 37 Appendix 1: Terms of Reference (Redacted) 1. Introduction: 1.1 This Serious Case Review is commissioned by Blackburn with Darwen Local Safeguarding Children Board following the death of Child G. 1.2 Child G had been in local authority care from June 2015, initially in foster care and then in two residential units. Prior to this the child had been known to a number of agencies for early help services, known to Children’s Services at Child in Need and subject to a child protection plan. The parents of Child G requested in June 2015 that he be placed in local authority care as they could not manage his behaviours. He had assaulted his mother on two occasions in 2015. 1.3 Child G was regularly reported missing from foster care and residential care and was assessed at high risk of child sexual exploitation. Due to the assessed risks, Child G was placed in an out of borough residential placement for a period of three months and then returned to the residential unit in Blackburn. In September 2016, Child G was charged with assault, affray and possessing an offensive weapon, and was subject to intensive supervision surveillance (ISS) bail conditions including to reside at a residential unit in Blackburn. Child G was found unresponsive in his bedroom at the residential unit. He died in early October 2016. 2. Legal Framework: 2.1 Serious Case Reviews and other case reviews should be conducted in a way in which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Chapter 4 para 11, Working Together, 2015) 3. Methodology: 3.1 This Case Review will be conducted using the Significant Incident Learning Process (SILP) methodology, which reflects on multi-agency work systemically and aims to answer the question why things happened. Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements. The SILP learning model engages frontline practitioners and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written Agency Reports with Learning Events. 3.2 This model is based on the expectation that Case Reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight. 3.3 The SILP model of review adheres to the principles of: Proportionality Learning from good practice Active engagement of practitioners 38 Engagement with families Systems methodology. 4. Scope of Case Review: 4.1 Subject Child G 4.2 Scoping period: from November 2014 [period when first referred to Multi Agency Safeguarding Hub for concerns about risky behaviours] to October 2016 [date of Child G’s death]. 4.3 In addition agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of Child G and his immediate family. This will include any significant events that falls outside the timeframe if agencies consider that it would add value and learning to the review. 5. Agency Reports: (NB. Please see Appendix 2 for the list of services covered within these agency reports) 5.1 Agency Reports will be requested from: Children’s Services (Social Care) Children’s Services (Education and Schools) Independent Children’s Home Police Ambulance Service Clinical Commissioning Group (CCG) for family GPs Health and Care NHS Foundation Trust NHS Hospitals Trust Family Support Services Substance misuse and recovery services 1&2 Youth Justice Service. 5.2 Agencies were requested to use the report template that was provided BwD LSCB. 6. Areas for consideration: 6.1 Critically evaluate the quality of assessments and decision making. Was the risk to Child G and his unmet needs fully understood? How were developments responded to, including changing levels of risk, eg in the case of allegations of assault? Was appropriate action taken? Also include any risk Child G posed to his mother. 6.2 How well was the history understood for the purposes of assessment? How well were relationships within the sibling group understood? If any preventative work or escalation had taken place or if there were missed opportunities in Child G’s case from 2009 to 2014 was this known or shared during the scoping period? 6.3 Analyse the approach taken to Child G’s non-engagement. How did this continued lack of engagement impact on service provision as the case progressed? How did it affect agencies’ ability to safeguard Child G? 6.4 Multi-agency meetings were taking place in Child G’s case. However, could communication and information sharing have been improved between agencies as part of this process? Were the correct agencies in attendance for meetings? 39 6.5 What role did management oversight play in enhancing the quality of practice? 6.6 Did services fully understand and meet Child G’s diversity needs, for example in relation to his learning difficulty? Please comment in the context of duties under the Equalities Act 2010. 6.7 How was Child G’s voice incorporated into assessments? 6.8 Did communication within and between services operate effectively, for instance during transitions between parts of a service or between practitioners? What role did record keeping play in this? 6.9 Identify examples of good practice, both single and multi-agency. 7. Engagement with the family 7.1 A key element of SILP is engagement with family members, in order that their views can be sought and integrated into the Review and the learning. BwD LSCB will inform the family that this Review is being undertaken. The independent lead reviewers will follow up by making contact with Child G’s parents and step-father. 7.2 Their contributions will be woven into the text of the Overview Report and they will be offered feedback at the end of the process. 8. Timetable for Case Review: Scoping Meeting February 2017 Letters to Agencies February 2017 Agency Report Authors’ Briefing February 2017 Engagement with family Begin March 2017 Agency Reports submitted to BwD LSCB April 2017 Agency Reports quality assured April 2017 Agency Reports distributed May 2017 Learning Event May 2017 First draft of Overview Report to BwD LSCB June 2017 Recall Event July 2017 Second draft of Overview Report to BwD LSCB July 2017 Presentation to BwD LSCB of Final Overview Report October 2017 9.0 The Lead Reviewers 9.1 Donna Ohdedar is a solicitor with a public law background as Head of Law for a metropolitan authority. Karen Rees is from a nursing background, having worked for 36 years in the NHS. Latterly Karen worked in safeguarding roles at a strategic level in two NHS organisations. Karen has worked with both Safeguarding Adult and Safeguarding Children Boards over a number of years and specifically on Serious Cases and Case Review sub groups. 10.0 Process 10.1 Following the decision by BwD LSCB to commission a SCR, a scoping meeting and authors’ briefing took place in February 2017 to agree the Terms of Reference with representatives for BwD LSCB and to introduce the SILP model process and expectations to authors of agency reports. 40 10.2 Agency reports identified within the Terms of Reference were completed within the timescale. A Learning Event took place in May 2017 which was well attended by authors, managers, practitioners and safeguarding leads from the organisations involved with Child G and his family. 10.3 A Recall Event took place in July 2017 prior to which the first draft of the report was circulated to attendees. The recall event tested out the learning and gave opportunity for participants to give their feedback and perspectives. 41 Appendix 2: Services Involved with Child G (Anonymised) Agency Service Provision/Service Type Remit Parameters (if Any) Family Support Services Family Support Service Third Sector/Registered Charity (commissioned through individual schools) Offering school based family support and mediation Early Help Reparation Services Third Sector /Registered Charity (commissioned service through Youth Justice Service) Support for Young people who have committed offences to pay back to local community for Young people who have committed offences Appropriate Adult Services Third Sector/Registered Charity (commissioned service through Youth Justice Service) Support for Young people in custody Support where it is not possible for family member to be Appropriate Adult Placement Services Third Sector/Registered Charity (commissioned through Children’s Services) Source suitable fostering placement Local Constabulary The Police Statutory Universal Police Early Help Additional statutory Targeted to children who display behaviours that may result in future criminal justice service involvement Early Help before Youth Justice Service involvement Children’s Services (Social Care) Multi-agency safeguarding hub Statutory multi-agency team To screen contacts for s.17 & s.47 referrals; onward referral to early help services for contacts not meeting the statutory threshold s.17 and s.47 case allocation Children’s Social Care Statutory Children’s social work Where Threshold for Children’s Social Care Intervention at Child in Need & Child Protection is met. 0-18 on referral and threshold met Child Sexual Exploitation Team Additional Statutory Multi Agency Team Risk of child sexual exploitation and missing from home services 42 Agency Service Provision/Service Type Remit Parameters (if Any) Looked After Children Team Statutory Children’s social work Looked after children and children leaving local authority care 0-18 on referral and threshold met – up to age 25 for leaving care services for children with learning difficulties Children’s Home 1 Residential Care and Support Medium to long term accommodation for Looked after children, support for young people to prepare them for independent living Ages 11 to 17 Adolescent Support Unit Day and overnight respite care for children on the cusp of care or in a range of looked after placements Short to medium term support for children to rebuild family/carer relationships Ages 11 to 17 Review & Protection Team Statutory for children on child protection plans and Children Looked After Review, monitor and scrutinise the CP/care planning. Ratify the plan and challenge the Local Authority when there is drift or delay in progressing the plan and improving outcomes Child Protection and Looked After Child. Youth Justice Service Youth Justice Service Statutory Provide all services to support a young person through out of court disposals, courts and conviction and to ensure orders/sentences are served and reoffending is minimised; services for young people displaying sexually harmful behaviours Under 18 on conviction until order ceases Independent Children’s Residential home Children’s Home 2 Private Residential Care Provide residential care commissioned by Children’s Social Care 43 Agency Service Provision/Service Type Remit Parameters (if Any) BwD Children’s Services (Education & Schools) Educational Psychology Statutory Educational Psychology On Referral application of psychological theory, research and techniques to support children, young people, their families and schools to promote the emotional and social wellbeing of young people. Social, emotional and behavioural difficulties requiring psychology services but below psychiatry thresholds Special Education Needs & Disability Statutory Universal Assess, support and monitor progress of children who may have SEND Virtual Head Statutory for children looked after and children leaving care Provide oversight and referral to additional services to support education attainment, attendance and behaviour for looked after children and leaving care children LAC & Leaving Care The Primary School Statutory Universal General Education Ages 4-11 The Senior School Statutory Universal General Education Ages 11-16 The Pupil Referral Unit Statutory Education for Excluded/High Risk Children/suspended 11-16 Age Range On Exclusion or threat of exclusion The Special School Independent School Education for children with Social Emotional Behavioural Difficulties (SEBD) SEBD Ambulance Service Paramedic and Ambulance Service Statutory Universal Responding to Emergency calls for medical emergencies Emergency Service 111 NHS Call Service Statutory Universal 24 hour signposting to local health services online and by phone GP Practice GP Statutory Universal Providing Primary Health Care To those registered with the practice 44 Agency Service Provision/Service Type Remit Parameters (if Any) The Health Care Foundation Trust School Nurse Health Visitor Statutory Universal (commissioned by LA Public Health) Public Health Service for children Ages 0-18 Child Sexual Exploitation Nurse Statutory Additional (commissioned by Clinical Commissioning Group) Work with Young People at risk of Child Sexual Exploitation On Referral LAC & Leaving Care Nurse Statutory Additional (commissioned by Clinical Commissioning Group) Provide oversight and referral to additional services to support health needs for looked after children and leaving care children LAC & Leaving Care Criminal Justice Liaison & Diversion Statutory Additional (commissioned by NHS England) General health and mental health screening in custody suites On arrest and subject to police custody Occupational Therapy Statutory Universal (commissioned by Local Authority Public Health) Enabling participation in daily activities for health and well being Those with disability, illness or family circumstance mean that they need additional support Speech and Language Therapy Statutory Universal (commissioned by Local Authority Public Health) To assess and provide therapy for a range of speech and language difficulties Genito-Urinary Medicine Statutory Universal Sexual Health Services (commissioned by LA Public Health from April 2016) Sexual Health Service Children & Young People (up to age 25) Sudden Unexpected Death in Children Nurse Statutory (commissioned by Clinical Commissioning Group) Responding to sudden and unexpected death in childhood For all children that die unexpectedly (i.e. the death was not expected the previous 24 hours) Adult Mental Health Statutory (commissioned by Clinical Commissioning Group & NHS England) Psychology, psychiatry and inpatient adult mental health services commissioned through Clinical Commissioning Group and NHS England. Child and Adolescent Mental Health Age 16 into adulthood 45 Agency Service Provision/Service Type Remit Parameters (if Any) Services for 16-17 year olds. The Hospitals NHS Trust Paediatrics Statutory Clinical medical paediatric assessment and intervention Emergency Department/ Urgent Care Centre Statutory Accident and Emergency Services Hospital inpatient assessment Unit Statutory Inpatient paediatric assessment Child & Adolescent Mental Health Services Statutory Child and Adolescent Mental Health Services Ages 5 to 16 Genito Urinary Medicine Statutory Universal Sexual Health Services (commissioned by Clinical Commissioning Group prior to April 2016) Sexual Health Service Children & Young People (up to age 25) Teaching Hospitals NHS Trust Sexual Assault Referral Centre Additional statutory (commissioned by NHS England) All age forensic police and medical assessment for victims of sexual assault All ages Substance misuse services Young People’s Substance Misuse and Recovery Services 1 Third Sector/Registered Charity (commissioned by Public Health up to March 2015) Young Peoples Substance misuse recovery services Young People’s Substance Misuse and Recovery Services 2 Third Sector/Registered Charity (commissioned by Public Health from April 2015) Young Peoples Substance misuse recovery services 46 Appendix 3: Pathways to Harm, Pathways to Protection from Triennial Analysis of Serious Case Reviews 47 Appendix 4: Key Episodes; Pathways to harm, pathways to protection Key Episode 1: Background prior to scoping period; setting the context (significant events and service provision before November 2014) Context Vulnerabilities Risks Protective/Preventative Actions and Systems Family and Parental histories Mother and Father live separately Step Father part of family New sibling Some professionals undertaking assessments become aware of parental histories. Early parental concerns Mother seeking support for diagnosis but does not accept parenting courses due to work commitments. Possible emerging Learning Difficulties Dyspraxia diagnosed 2010 Child G feels different and that something is wrong Child G’s increasing frustration With himself that he was not achieving in education Reports of self-harm Hits and bites himself and bangs head on walls Behaviour is beginning to present challenges Behaviour manifests at school and home Substance misuse Child G reports he had tried Cannabis and alcohol as a stress reliever Mother reports has come home drunk on several occasions Potential physical abuse Experienced by Child G from father observed slapping in school grounds Referrals to various health services (GP, Pediatrician, Speech and Language Therapy, Education Psychology, Occupational Therapy) to identify possible diagnoses and therefore provide protective interventions based on need. Occupational Therapy identified need for parenting/Common Assessment Framework/ Mental health assessment/ Special Educational Needs assessment School Action Plus and associated assessments Trying to address Child G’s education needs and keep him engaged and focused on positive outcomes Family Support Service Commenced work with family in April 2014 - Child G wanted a focus on anger management and improving family relationships Support from Family Family seeking help and support for Child G. 48 Key Episode 2: Child in Need to Child Protection, November 2014 to May 2015 Context Vulnerabilities Risks Protective/Preventative Actions and Systems Family Separation Mother and Step Father separating, issues lead to Child G being cared for by other family members and some time at adolescent support unit Parental histories Some assessments and services were being offered without a full understanding of the family history and any impact that may have had on the parents or Child G Multiple referrals for support Increasing number of referrals to try and support Child G and his family Multiple appointments Multiple referrals led to an increase in the number of appointments and contacts expected of Child G Family Stress Incidents with Child G impacting on parents mental health and wellbeing and relationship issues due to concern for sibling Learning Difficulties ADHD Dyspraxia Child G feels different and that something is wrong Child G telling professionals & family that there is something wrong with him and that he is not ‘normal’ like others - this increases vulnerability to isolation as he finds it difficult to engage with peers and education Possible emerging mental health issues Early signs of anxiety and stress that require further mental health assessment Fear from Mother Behaviour escalates and violence increases, Mother becomes frightened of him - Child G has always had a strong bond with his mother so his mother becoming a victim of his anger leaves him vulnerable if he loses the support of the person who is his strongest advocate Not engaging with services By not engaging with support, he is vulnerable to services not being able to improve outcomes for him Child G’s engagement with Substance misuse Substance misuse increases in this period; now daily occurrence; shows insight that it is the drugs that he needs to deal with Missing from home Initially Missing from Home episodes not understood and reported retrospectively by family. Reporting and responding to these becomes part of plans trying to gain an understanding of where he goes (becomes more of a feature in the next episode) Becomes a victim of crime whilst missing Violence to others and criminal incidents Threats and actual violence towards Mother are increasing and concerns expressed about safety of Child G’s younger sibling. Risk for Child G he can no longer live with the family that are his closest bond; this leads to periods in custody and inclusion of Youth Justice Service Violence in school leads to being educated separately Total of six incidents where Child G is perpetrator of Ambulance Service/ A&E attendances Conveyed to A & E for safety and treatment total of 11 times sometimes when under influence of drugs and alcohol; requested police support to keep Child G safe. Eight A&E attendances in this episode for a variety of reasons related to mental health and physical symptoms of substance misuse. Child in Need Plan (Jan-May 2015) Social Worker leads Multi Agency planning to ensure a robust plan of support from all the agencies involved. Three meetings take place in this period. Child and Family Assessment Social work assessment: Identification of Strengths and risk issues on which to build a Child in Need plan. Family Support Service Supporting the whole family, but needs outweighed what this service could offer so plans to transfer to Troubled Families programme. Substance misuse service support and intervention First engagement by services to directly address substance misuse. School Action Plus and associated assessments -Commencement of Special Educational Needs Statutory Assessment Identification of needs requires specialist intervention. Assessment identifies needs and the resources required to meet them. Three reviews take place in this episode. Police Early Help Officer Support to engage and discuss risks and issues. Attempting to build a trusting relationship. Also, searching properties Child G attends Child and Adolescent Mental Health Services Assessment Attempts to identify any underlying metal health illness and to support with ADHD issues. Commenced treatment but stopped after overdose on medication. Substance misuse prevents accurate diagnosis as causing 49 Context Vulnerabilities Risks Protective/Preventative Actions and Systems services became more difficult Physical symptoms of stress and substance misuse Child G having increasing physical pain symptoms thought to be anxiety related - strengthens his belief that there may be physical health needs adding to anxiety. Has ongoing physical symptoms such as palpitations and chest pains etc. Missing Education As education find it increasingly difficult to manage him and he disengages with education he is more on his own and left to his own devices and begins to go missing Placement moves (within Family) Following increasing issues, Child G goes to live with Father for a period, then returns home, then to Grandparents after assault on Mother Returns home after accommodation not sanctioned from Children’s Social Care crime Victim of crime On two occasions Child G is identified as a victim of Crime Self-harm Frustration, anxiety and anger result in some episodes of self-harm e.g. punching walls and punching and hitting himself Risk of Child Sexual Exploitation The risk of Child Sexual Exploitation begins to emerge as Child G’s behaviour escalates Paediatric assessment Possible neurological or medical causes for Child G’s agitation that could not be contributed to his ADHD diagnosis was lost due to multiple appointments (one for LAC medical assessment, one for the agitation and one for overall case management from the GP’s referral back in 2014 – all three paediatricians were in separate teams) leading to father cancelling appointments associated symptoms. Child Protection Plan (May 2015) Follows escalating concerns and assault on mother and damage to property. Produced multi agency plan with social worker as Key Worker to support Child G back to School and address substance misuse. Accommodation split around family. One Initial Child Protection conference and one core group meeting take place. Adolescent Support Unit Offering interventions and strategies to help address his issues and prevent him becoming Looked After. Overnight accommodation when not able to be at home. Support from Family Family remained committed to Child G. This was important to Child G and he identified this as a focus of any work he engaged with. Youth Justice and Reparation To work to prevent further reoffending and therefore keep Child G safe. To complete sentence requirements of Youth Caution. 50 Key Episode 3: Section 20 Accommodation to Movement out of Area, June to December 2015 Context Vulnerabilities Risks Protective/Preventative Actions and Systems Family Separation S20 accommodated Multiple referrals for support More services become involved Multiple appointments Continue Multiple assessments Continue Family Stress Adults continue to be impacted with the circumstances affecting mental health wellbeing Learning Difficulties ADHD Dyspraxia Child G feels different and that something is wrong Mental health issues S20 accommodated Now living away from family and contact with younger sibling denied by Step Father due to risk Not engaging with services Chooses which services to engage with – (often those with specific boundaries and consequences) Physical symptoms of stress and substance misuse Continues to be troubled by physical health symptoms that cause increased anxiety Missing Education Continues to miss education but new placement for specialist education found Placement moves Foster Care, brief period in Substance misuse Substance misuse slightly reduced in this period but continues alcohol use Missing from home Missing from Home episodes (27 in this Key Episode) start to become a real concern The Child Sexual Exploitation team now involved with return home interviews Refuses to say where he is when he is missing Violence to others Assault on Mother results in a second youth caution Victim of crime On one occasion Child G is identified as a victim of Crime Self-harm Continues self-harming behaviour Risk of Child Sexual Exploitation The risk of Child Sexual Exploitation begins to escalate as Child G’s missing episodes increase Adolescent support unit Continues to offer support via outreach during the day. Substance misuse service support and intervention Contract moved to new provider, remained involved but little engagement from Child G; ended in October 2015. Youth Justice and Reparation Continued until November 2015. Support in custody Appropriate Adult Services34 were provided to support Child G in custody. Looked After Child Review (x2) & Strategy Meetings (x6) Social work involvement continued following S20 accommodation - became subject to Looked After Child Reviews in order that multi-agency planning continues to identify Child G’s needs to support and keep him safe. Challenges to partners by IRO. Police Actions: PVP reports Information sharing of Incidents: Risks identified to Children’s Social Care and Health Managing criminal behaviour Community resolution used for offence at local supermarket. Integrated Proactivity Partnership (Two Meetings) Proactively manage Child Sexual Exploitation risk - disruption of known adult associates. Allocating professionals, tagging systems, information sharing. Missing from Home Trigger plan. MARAC35 Issues discussed to ensure Mother and Child G are safeguarded and getting support (NB MARAC is Victim focused but due to issues, plan includes support for Perpetrator - Child G) 34 Appropriate Adult Services provide independent support for any vulnerable adult who comes into contact with the Criminal Justice System, whether as an alleged offender, victim or witness of a crime. The Appropriate Adult role was created by the Police and Criminal Evidence Act (PACE) 1984 with the intention of safeguarding the rights and welfare of vulnerable young people and adults in police custody. 35 A Multi Agency Risk Assessment Conference (MARAC) is a victim focused information sharing and risk management meeting attended by all key agencies, where high risk cases are discussed. The role of the MARAC is to facilitate, monitor and evaluate effective information sharing to enable appropriate actions to be taken to increase public safety. 51 Context Vulnerabilities Risks Protective/Preventative Actions and Systems Adolescent Support Unit then Residential Care Special Educational Needs Assessment Specialist provision sourced to try and provide appropriate education. Child G. Commenced Special School in September. Attendance initially more consistent than previous episode. Child and Adolescent Mental Health Services CAMHS were continuing with assessments in this period that conclude that Child G does not suffer from psychosis but is depressed; has medication for depression and sleep issues prescribed and is offered individual therapy, family therapy, anxiety therapy and counselling. Ambulance Service/A&E Continued as per Episode 2. Two A&E attendances in this episode. Child Sexual Exploitation Team Provide support and protection following missing episodes to try and prevent further episodes and to ascertain activity and whereabouts whilst missing. Missing from Home Plan This was added now that the Missing from Home episodes were significant (27 recorded by police in this period with 92 in total in Key Episodes 2 to 5). Sexual Health Services Nurse offered sexual health advice (part of Child Sexual Exploitation Team) and healthy lifestyles support and arranged for screening. Child G attended for sexual health assessment on one occasion and was seen at the local Sexual Assault Referral Centre for medical. Support from Family Remained the same support albeit that they could no longer provide safe accommodation. Family Support This service continued even though in September 2015 there was a referral to the Troubled Families Programme. 52 Key Episode 4: Out of Area Placement, December 2015 to March 2016 Context Vulnerabilities Risks Protective/Preventative Actions and Systems Family Separation S20 accommodated; Out of Area Placement Sporadic engagement Periods of improved engagement but not sustained Learning Difficulties ADHD Dyspraxia S20 Accommodated Now living away from family and all contacts at the out of area placement/locality Not engaging with services Continues to have sporadic engagement despite less services being involved Missing Education Failed to attend Residential Care Company’s school and agreed to be taught at the children’s home - did not engage and received no education whilst out of area Placement moves Moves to out of area placement Child and Adolescent Mental Health Services Discharged from service on leaving home area. Out of area Child and Adolescent Mental Health Services had waiting list of three months Medication not available Anti-depressant and sleep medication running low in first few days. Delays in obtaining medication. Refuses on occasion to take the medication Substance misuse (mainly alcohol at this time) Criminality whilst intoxicated Risk of being victim whilst intoxicated Admitted to taking ketamine and alcohol Missing from Home One occasion in this period 3 Month placement plan Appeared to have positive impact as knew placement could be extended if did not comply with boundaries. Children’s Home 2 Environment Encourage healthy lifestyles; access to gym and leisure activities Children’s Home 2 staff encourage access to these activities and Child G engaged with these. Looked After Child Review LAC Review continues and two meetings held. Plan for transition back to home area and still for reunification to family. Education Plan Review To review SEN Plan & plan move back to locality. Support from Family Regular phone contact and some visits, with outings and staying at a local hotel with Mother and sibling. Contact over Christmas period an issue; Child G low in mood on Christmas day. Substance misuse service support and intervention Child G refused to engage. GP Accesses GP for medical concerns when necessary but sometimes refused to go for appointment. Issues related to physical symptoms possible from substance misuse and other concerns. Sexual Health Services Child G requests appointment but refuses to attend. Police & Youth Justice Action Community Resolution for offence under public order act and being intoxicated. IPP meetings Child G continued to be discussed within IPP meetings during this period (two were held) 53 Key Episode 5: Return to Home Area to Date of Death, March to October 2016 Context Vulnerabilities Risks Protective/Preventative Actions and Systems Family Separation Remains S20 accommodated Returns to Children’s Home 1 Learning Difficulties ADHD Dyspraxia Child G feels different and that something is wrong Depression and Anxiety Refusing prescribed medication Delay in Child and Adolescent Mental Health Services referral when back in area S20 Accommodated Living back at Children’s home 1 Spending time from May 2016 at mother’s and cousins with the consent of mother Not engaging with services Begins to show some engagement Physical symptoms of stress and substance misuse and sexual assault Continues to be troubled by physical health symptoms that cause increased anxiety Missing Education Continues to miss education although it becomes part of the Bail plan later Change of workers Transferred to Looked After Child social worker as no Substance misuse Drug use now out of control and impacts on ability to undertake any focused work on Child Sexual Exploitation, substance misuse & mental health Missing from home Absconds from out of area placement and remains missing for six days Missing episodes escalate (41 in this period) Violence to others and Criminal incidents Violence against others escalates and Child G is arrested for assault in March 2016, bailed and charged Assaulted staff member at Children’s Home 1 Total of six incidents of Child G being a perpetrator of crime Arrested for assault in September 2016, bailed and charged Victim of crime On at least four occasions Self-harm Begins to talk about dying due to knowledge of risks of lifestyle Risk of Child Sexual Exploitation Scored very high on new Child Sexual Exploitation assessment Education Further review of SEND plan. Child Sexual Exploitation Team Provide support and protection following missing episodes as before. Child G refuses to say where he has been because it had caused problems in the past with his friendships. Also, undertook new Child Sexual Exploitation assessment. Strategy meetings for Missing From Home Considers another out of borough placement but concerns that may hinder access to current level of support. A total of nine strategy meetings take place. Sexual Health Services Receives assessment on two occasions and self-reported risks identified. GP Number of missed appointments for complaints of physical symptoms, but attends an appointment in August where a disclosure of sexual abuse is made leading to a referral to Paediatrics. Looked After Child Review (x2) & Risk Management Strategy Meetings (x9) Considers significant escalating risk and seeks legal advice. Challenges if S20 still appropriate. Consideration of further out of area placement. 6thLooked After Child Review August, little progress or change noted. Child and Adolescent Mental Health Services Seen again in this period, but for periodic review as refused specific therapy. Substance misuse service support and intervention Some sporadic engagement but most importantly a change to a male worker in September who manages to increase engagement. Ambulance Service & A&E Attendances Continued to convey as per previous episodes. Attended A&E on 11 occasions in this episode for varying reasons: anxiety and 54 Context Vulnerabilities Risks Protective/Preventative Actions and Systems plans for Child G to go home Change of Child Sexual Exploitation worker that causes Child G anxiety Plans start for transition In both Child and Adolescent Mental Health Services and Children’s Social Care who are now involving relevant professionals e.g. School nurse for care leavers Unwell on return from a missing episode, had money from an unknown source, sold belongings and is shoplifting depression, drug related physical symptoms, injuries from violence and self-harm/ overdoses. Support from Family Remained supportive but they were unable to keep Child G safe. Youth Justice and Reparation Recommenced reparation in June for offence in March. Two professionals meetings to consider safeguarding risk management Subject intensive supervision following offence in September. Support in custody Criminal Justice liaison service visited Child G in custody on two occasions. On the second occasion, denied substance use for over a year and stated drank socially. Intensive Supervision & Bail Support package Following Youth Referral Order for assault in September 2016. Largely conformed with the requirements of this package. Police Actions: PVP reports Information sharing of Incidents: Risks identified to Children’s Social Care and Health. Managing criminal behaviour Further arrest September 2016. Multi Agency Child Sexual Exploitation Meetings (replaced IPP) Created further plans on return as Key Episode3; met six times in this episode under IPP arrangements and twice under MACSE arrangements. 55 Appendix 5: Single agency recommendations (redacted for publication) Children’s Services - Children’s Social Care Recommendation Detailed actions In complex cases, agencies should collaborate at a strategic level to determine which agency takes the lead in overall risk management. Senior Management to meet and agree: Key risks and which agency will take overall lead on risk management Agree to jointly fund specialist resources where appropriate, including placements Prioritise and sequence risks and services in one overarching multi-agency plan addressing the holistic needs and risks. This may mean making decisions that some services will not be involved until a later stage. All Children’s Social Care case records should be on one system – Protocol. Residential Unit records should be written on Protocol. They should retain the written record for the young person, but also keep case records on Protocol under case notes. Adolescent Support Unit should record their involvement on Protocol under case records. CSE Team and IRO already record involvement on Protocol, but this should be consistent and include all interventions. Children’s Social Care needs to fund technology in Children’s Home 1 and Adolescent Support Unit to ensure that they have good access to Protocol. Children’s Social Care need to update Liquid Logic to be able to include residential and support services. Events from Residential Units, Adolescent Support Unit, CSE Team and IRO should be part of the chronology. All staff in Residential Units, CSE Team and Adolescent Support Unit will receive training in use of Protocol and in writing case records and chronologies. Risk Assessments should be updated every three months and a new Risk Assessment completed and signed by management. Risk Assessments will be reviewed every three months. Notes of the review will be made and the Risk Assessment updated, dated and signed off by the manager. Compliance with Risk Assessments will be the responsibility of the manager and should be reflected, where appropriate, in supervision 56 Recommendation Detailed actions notes. Put Risk Assessments in Forms on Protocol. Case Decision Forms should be used consistently across the service. Head of Service (Assessment Teams) will provide brief guidance for all staff when Case Decision Forms should be used. It will be made clear to staff that a Case Decision Forms will need to be completed when a decision has not been actioned. Consistent use of Strategy Meetings. Ensure staff understand the mandate for meetings, particularly when to use formal Strategy Meetings. Strategy Meetings must be recorded on the template and put in forms in Protocol. There should be enough Business Support staff to support this process. Children’s Services – Education and Schools Recommendation Detailed actions Early identification, intervention and prevention. Agree a profile for vulnerability in terms of emotional health and well-being. Provide related continuous professional development for school staff and local authority officers. Audit offer of targeted support for Social Emotional & Mental Health (SEMH). Improve signposting to support for SEMH. Improved continuity in case recording, management and escalation in Education Psychology. Audit current processes and systems. Review case management and escalation strategy. Implement new ways of working. Improved support on transition between schools in relation to children who have been identified as vulnerable. Develop School Transition Policy to improve information sharing between education providers at points of transition. Identify effective strategies and resource to support vulnerable children on transition. Develop better communication pathways between Inclusion Services, Education Psychology, Virtual School and Children’s Social Care. Audit current communication pathways and decision-making processes. Jointly develop new ways of working e.g. greater schools & education involvement in MASH. 57 Independent Children’s Home Recommendation Detailed actions Develop more efficient process in terms of handover of young persons from one CAMHS to another. Review of process of referral and handover from local to current CAHMS service. That team training in the area of Dyspraxia and other learning difficulties is identified as a need in the Impact Assessment process. A service is identified for carrying out such training to teams once needs are identified via Impact Assessment. That the placing authority are efficient in processing the referral for an updated CSE assessment based on new placement and location where CSE has been previously identified as a risk for a young person. Process reviewed in respect of CSE referrals and the allocation of young person to CSE worker. This to be supported by CSE Manager in the Group’s Management Team. Local Constabulary Recommendation Detailed actions To ensure a joined up approach with information sharing within the organisation between specialist teams, from those that identify early signs of CSE to those dedicated to work with CSE. To ensure the new CONNECT computer system that is being implemented force wide as a full IT infrastructure will adhere to this required outcome by linking information recorded by both Early Action and CSE Teams. This has been raised with the CONNET implementation team and has been added to their work plan. This will further allow sharing of information through all departments as it will be an organisational data capture site incorporating MASH, through the investigation recording of incidents. To address the retention of information regards vulnerability and how this recorded and actioned with a corporate footprint. Ensuring that multi-agency activity is recorded on corporate systems allowing all staff to identify who is responsible and the current position when working with children. To ensure the new CONNECT computer systems that is being implemented force wide as a full IT infrastructure will adhere to this required outcome by linking information through the organisation and MASH allowing for a corporate footprint. This has been raised with the CONNET implementation team and has been added to their work plan. The recording of investigations through the data retention arm of CONNECT will allow that multi agency activity can be recorded specific to each child or person with connection to the constabulary and will be retained digitally on the system. Furthermore the recording and retaining of actions for specific children will be recorded on the child’s 58 Recommendation Detailed actions investigation plan and as such will be shared with the allocated action owner in line with regional policies. To ensure any vulnerability training includes mental health and is inclusive of the Equality Act to ensure learning difficulties and other conditions are considered. To ensure vulnerability training which includes all aspects of mental health, learning difficulties is delivered across the constabulary to all employees and support staff. To ensure the continued use of the Mental Health Triage Team and refresher awareness of its capability to be shared with all employees and support staff. To contact the College of Policing to gain direction with regards national training available in regard to ‘less obvious’ hidden conditions (Learning difficulties etc.) Ambulance Service Recommendation Detailed actions Promote awareness of the safeguarding policy and procedures for all staff groups across the trust. Communications plan & safeguarding awareness week bulletin to promote updated policy and procedures. Learning review with staff involved with Child G. Hold a learning event including all relevant staff to highlight missed opportunities to refer. Share the learning across the trust via the learning lessons forums, bulletin and clear vision articles. Promote awareness of the vulnerabilities of all young people displaying risk taking behaviours and the impact of the abuse of alcohol and substances in teenagers. Include children in care and alcohol and substance misuse in the next wave of mandatory and level 3 training. Discuss with the Frequent Caller Team the thresholds for children. To discuss if thresholds for child frequent callers are adequate and if there was anything that may have changed our practice with regards to Child G. To monitor and audit repeat safeguarding concerns submitted by Ambulance Service. To review on a monthly basis the repeat safeguarding concerns submitted on the ambulance service database and work alongside outside agencies. 59 Clinical Commissioning Group (CCG) for GPs Recommendation Detailed actions All practitioners within the practice to have an awareness of and the ability to act in identifying and protecting children who are at risk or experiencing abuse including sexual, physical, and emotional. Bespoke training in respect of sexual abuse and CSE to be accessed, by the practice. Review Sample GP policy for safeguarding children to strengthen and include links to LSCB safeguarding procedures and safeguarding advice and support structures that are available for them to access. The safeguarding responsibilities expected from GP’s to be outlined within the policy. Strengthen the role of the safeguarding lead within the practice: CCG setting up GP safeguarding lead/ champion meetings on a quarterly basis, to ensure leads feel supported within their leadership role Practice meetings to include a specific section for practitioners to discuss any safeguarding concerns Safeguarding lead role outlined in the GP safeguarding policy. All practitioners within the practice to feel confident and competent to recognise and respond to disclosures of domestic abuse when the child is identified as the perpetrator. GP sample domestic abuse policy to be reviewed and refreshed and be inclusive of the management of domestic abuse when the child is the perpetrator. All clinical staff within the practice should be trained to the appropriate level as per NICE Guideline 50. https://www.nice.org.uk/guidance/ph50/chapter/7-Glossary#disclosure Learning review feedback to take place with the practice. Hold a learning event with the GP practice to highlight the key lessons learned from the review. Health and Care NHS Foundation Trust Recommendation Detailed actions In the new Trust Supervision Policy launched December 2016, a new process to be embedded in practice – where all CIN/Children on CP Plans/LAC will be brought to supervision on at least a 6 monthly basis. New Supervision process is currently being piloted within the Children & Family Health Service. The new supervision process ensures all targeted cases are discussed in a timely manner. Guidance to be written by the Safeguarding Team advising practitioners to bring appropriate cases to supervision where there are concerns with non-engagement. 60 Recommendation Detailed actions Complex Case Supervision Processes Complex cases to be discussed at group supervision sessions. Each month supervision session between CSE Nurses/line manager to discuss a number of complex cases; this should be recorded within the ECR record of the child. Clinical supervision To be undertaken with line manager on a monthly basis. Individual cases to be discussed. Cases should also be documented within health records when discussed in supervision. Adherence to the Individual Health Assessment (IHA) Strategic Operating Protocol (SOP). For the IHA SOP to be re-launched. Supervisors/Team Leaders to challenge School Nurses when IHA’s are not completed in timely manner. Review and re-launch Safeguarding Meetings booklet with Children & Family Health Service. Re-launch Safeguarding Template with Children & Family Health Service. Booklet to include prioritisation of attendance at Safeguarding meetings by CHFS and ensure the use of Safeguarding Template. CIN/Core Group Minutes/CP Plans/Care Plans to be saved within child’s record and discussed at supervision sessions. Identification of lead Trust health professional. Upon notification of child/young person becoming known to the CSE service, there should be discussion re: who will be the most appropriate lead health professional. This discussion should include any Trust professionals involved with the case, and should be clearly documented within the health records. The co-ordination of care will then be the responsibility of the identified practitioner. Clear documentation using case record tab ‘Other professionals’ involved. Use of the ‘additional information’ box on case records clearly stating who the lead health professional is for the Trust. The Trust’s Safeguarding Team Vulnerable Young People’s Portfolio Group & High Risk Cases. To attend interagency forum to discuss high risk cases and prevent duplication amongst health professionals. Information sharing – improve the lack of interagency liaison. To ensure that there is liaison between inter agency professionals and multi-agency professionals, to ensure that relevant information is shared within a timely manner. Attendance at meetings to be by the most appropriate health professional and actively chasing minutes from meetings if not received within a timely manner. 61 Recommendation Detailed actions CSE Nurse has access to Children’s Social Care Protocol database and the Trust’s ECR recording system to ensure information sharing. In the absence of any electronic system, verbal communication will be undertaken. CSE Nurse record of meetings/minutes. In involvement with child/young person, CSE Nurse to contact social worker informing of involvement and that they should be invited to meetings. If minutes not received, CSE Nurse/admin support to actively chase up with Children’s Social Care, to record within the ECR record of the child that this has been actioned. Received minutes to be saved in health records. Adequate record keeping on child’s records -health systems and Protocol (Children’s Social Care). For the Specialist Nurse Care Leavers (SNCL) to record on both the Trust’s ECR recording system and CSC’s Protocol recording system. Formalise Young People’s Information Sharing Agreements. Agree and Formalise Information Sharing Agreement with Youth Justice Services. Establish clear links and referral pathways for Young People in custody. Ratification and Implementation of Strategic Operating Procedures (SOP) for the Criminal Justice Liaison & Diversion (CJL&D) Services. To have the current draft SOP ratified and available to support and guide all CJL&D service staff. For individual reflection and team learning - to ensure CJL&D practitioners to take all possible measures to accurately identify those individuals referred by seeking collaborative information. Facilitate individual reflective learning. Establish collaborative confirmation and checks as routine practice through team meetings and management and clinical supervision. Consideration of child’s wishes and feelings/child’s voice. To ensure that all information is recorded on the relevant recording system and that it is clearly documented that the child has been consulted with and their views considered. Specialist Nurse for Care Leavers (SNCL) remit is to be clarified as 18 – 25 year old care leavers. All members of staff are made aware of SNCL remit - Children 0-19 remain the responsibility of the child family health service. Transition for care leavers approaching 18 to be undertaken in a multi -agency forum. SNCL to liaise with relevant health professionals to complete handover to ensure smooth transition of health care needs. 62 NHS Hospitals Trust Recommendation Detailed actions To ensure Child Adolescent Mental Health Services (CAMHS) are informed of all children under their care who attend the Emergency Department (ED), Urgent Care Centres (UCC) or Minor Injury Unit (MIU). Confirm that the method of flagging patients who are under the care of CAMHS is in place. Reinforce flagging method across ED, UCC and MIU and CAMHS. Hospital Trust Safeguarding Team share information with key clinicians involved with individual children. Hospital Trust to review current information sharing systems and processes to ensure all information is shared appropriately. All allegations of rape/sexual assault must be reported to the police. Responsibility lies with the practitioner and /or manager to whom the abuse is disclosed. Raise Staff awareness of this requirement via: - safeguarding children training - safeguarding children policy - safeguarding intranet page - Trust forums, including the Internal Safeguarding Board. To review current referral pathways for children with alcohol or drug misuse, and to include criteria for CAMHS referral within those pathways. Review current Standard Operating Procedure (SOP) Include criteria for CAMHS referral. Raise Staff awareness of this requirement via: - safeguarding children training - safeguarding children policy - safeguarding intranet page - Trust forums, including the Internal Safeguarding Board. To ensure information-sharing processes are in place for children at risk of CSE. Review and strengthen existing processes for flagging children on the special register for CSE. Review information-sharing pathways to ensure information is shared appropriately both within the Hospital Trust and external agencies, such as the CSE Team. Family Support Service Recommendation Detailed actions Revised management arrangements for family support service. Clear management structure Clarity of roles and responsibilities/reporting arrangements Clarify of decision making responsibilities Ongoing management training Management oversight Clear organisational expectations Processes in place to evident oversight Staff clear about safeguarding processes Decision making and escalation Escalation policy to be implemented Staff to be made aware of this Case closure/change of interventions To be discussed with manager To be clearly evidenced in case record 63 Recommendation Detailed actions Wishes and feelings of young people All staff to be aware of importance of young people’s views Documentation amended to evidence views Participation promoted Substance Misuse Recovery Service 1 Recommendation Detailed actions Consider management sign off for complex / non-engagers receiving non-structured interventions. Inform staff within training sessions. Ensure induction for new practitioners incorporates learning from SCR. Substance Misuse Recovery Service 2 Recommendation Detailed actions Implement a young person’s missed appointment checklist. The service to review how centrally designed tools, such as the Missed Appointments Checklist are used within the service, and are young person specific. Develop a plan for implementing their use with all staff. Implement a local engagement and transfer process and pathway. Local guidance to be developed to support the effective and timely handover of service users from one worker to another to limit impact and ensure continuity of care. The service to review how it works with young people when they are moved into a secure placement and/or in to, or out of area. Risk Pack to be available and to be used within service. The service to schedule time to run a workshop with staff utilising the ‘Risk Pack’ resources to improve risk management techniques and encourage professional curiosity. Staff to be re-trained on “safeguarding for young people”. All young people staff to arrange, and time to be protected, to attend the organisation’s specific Safeguarding Young People training. Improved record keeping and competence of staff. Improve competence of record keeping via a workshop, for staff - including referencing defensible decision making in relation to actions taken. Guidance to be developed for staff to refer to. Management plan in place for all service users that have a family member, carer or significant other employed within the service. For there to be management plans produced for service users, where family members are employed within service - to ensure boundaries, safe and appropriate information sharing - with the service 64 Recommendation Detailed actions user at the heart of what we do to understand the possible impact/barriers this might produce in a person engaging with services. To ensure that alternatives are considered. Increase resources available to complete thorough safeguarding reviews. Additional Designated safeguarding lead (DSL) to be identified, specific for young people’s service within BwD - to oversee reviews and supervision. Template to be developed for use within safeguarding supervision by DSL. Youth Justice Service Recommendation Detailed actions Review of the Multi-Agency Risk Management Meetings (MARMM) Process and Intensive Support Service (ISS) Provision. Determine what triggers a MARMM and what the YJS ISS offer is. Briefings to other teams on YJS services. Team briefings on developments and responsibilities of the YJS. The development of an integrated adolescent strategy for vulnerable adolescents. Leads from the service to develop a more coordinated response based on innovative ideas and best practice. Better understanding of Learning Difficulties e.g. Dyspraxia. Need for both training and understanding the BwD offer and referral route. |
NC52295 | Malnutrition of a 3-year-old girl in 2020. Child C was admitted to hospital due to breathing difficulties requiring cardiopulmonary resuscitation, where it was discovered that she had severe anaemia and was malnourished. Learning includes: health visitors must ensure that the correct level of need is recorded on case management systems; work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice; there is a need to remind GP staff to contact health visitors directly regarding children that raise concerns; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referral; professionals need to be reminded of the need to effectively coordinate and manage case transfers; hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies; processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point; professionals have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn't attend. Makes no recommendations but the serious incident report and root cause analysis completed as part of this review identify actions to address concerns.
| Title: Child safeguarding practice review: a learning report concerning Child C. LSCB: Ealing Safeguarding Children Partnership Author: Ealing Safeguarding Children Partnership Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Ealing Safeguarding Children Partnership Child Safeguarding Practice Review A learning report concerning Child C. This report is strictly confidential and must not be disclosed without discussion and agreement with the ESCP prior to publication The disclosure of information beyond that which is agreed, will be considered as a breach of the subjects’ confidentiality and a breach of the confidentiality of the agencies involved 2 Contents 1. Context. 2. Introduction to the case and summary of learning. 3. Process. 4. Family structure. 5. Background prior to the incident. 6. Analysis of key practice episodes and the identification of learning. 7. Conclusion and next steps. 3 1.Context 1.1 The history and timeframe of this case relate to the period immediately before an incident that occurred on the 10/01/20 when the above child was transferred to West Middlesex Paediatrics requiring CPR. 1.2 This report focuses on the learning for the wider children’s system as a result of the individual agencies contributing to a serious incident and management information request. 2. Introduction to the case and summary of learning 2.1 This review is in respect of a female 3-year-old child, known as Child C. Child C came to the attention of the Ealing Safeguarding Children Partnership, initially as an item of any other business and without any clear details; this was chased by the partnership but delayed because of other pressures in the health system at the time. The child had attended a routine mental health appointment with her mother on the 10th January 2020. This appointment had been with a counsellor at a GP practice venue. Whilst there, Child C had become distressed and developed breathing difficulties; she required cardiopulmonary resuscitation and was successfully resuscitated by the GP and surgery staff. Both she and her mother were taken by ambulance to West Middlesex Hospital. 2.2 At the point of admission the child had severe anaemia and was reported to be malnourished due to her poor diet. She received a blood transfusion and was started on oral iron. She was discharged on 13th January 2020. 2.3 The learning identified from this Review is in relation to the following, these have been identified from single agency reports and discussion. They include: • The importance of health visiting staff correctly recording the levels of support to families based on levels of identified need and risk, in line with the London Continuum of Need threshold • The importance of all professionals understanding the impact on children that familial mobility, particularly in the early years, has on access to services. GPs, ED & hospital staff and community paediatricians should liaise with the child’s local health visiting team so that further support and assessment in the community may be implemented • All staff must be aware of the continuum of need and use it appropriately. • Health staff must contribute to meetings, particularly important with children in the early years. • The importance of all involved agencies being proactive in liaising with appropriate partners following incidents of concern. The importance of effective multi-agency assessment in informing planning. • The importance of effective discharge planning following a stay in hospital where the presenting incident has caused concern. • The importance of understanding the impact of adverse experiences for adults and the effect this may have on successful parenting. • The importance of effective and timely information exchange. 4 3. Process 3.1 The process of reviewing this case has not been easy given the number of organisations involved pan London; this, together with the mobility of the family, has created some challenge in coordinating and exchanging information. Given that the family have moved away from Ealing and into another London Borough, we are assured that information has been shared appropriately and we will share this learning report relating to the specific incident. The review has been conducted locally and is a proportionate response to identify learning at a multi-agency level. It seeks to build on individual agency reports and to consolidate the learning for dissemination across the whole system. 3.2 Any review, must be based on a premise of not seeking to attach blame to any individual professional or agency. On the contrary, this case review has been actioned to understand the rationale, impact and context of the agencies’ response to the family, particularly following the incident in January 2020. 3.3 The LSCP has approached this in a proportionate way, pulling together individual agency reports, including learning identified, into a consolidated review for the purposes of system learning. This has been produced under the requirements set out in Working Together 2018 and is a Child Safeguarding Practice Review. 3.4 The case presents significant challenges with two clear positions relating to this child and her dietary condition at the point of hospital admission. These are: • That the child was reported to be a ‘picky’ eater and that the family sought to provide her with food that she would eat namely bread and milk without understanding the impact this might have on her health. It is not clear who first identified this, whether a GP or hospital, however, this was not actioned by an earlier referral to the HV Team. The child had suffered severe reflux for a long period of time, treated by hospitals. The consequence was that mother was reluctant to try new foods for fear of making her child vomit. • That the family took insufficient action to support her improving her diet and to get her physical development back on track. However it is known that her mother sought help from her GP and the ED approximately fifteen times over 2.5 years, mostly for gastric related issues and one febrile convulsion: mother was seeking help, but the services she chose to access did not resolve her concerns by referring to the health visiting services to support mother with feeding. This review considers both of those perspectives but recognises the significant concern regarding C’s health at the point of admission and the serious risk to her life. 3.5 In scoping this work it has been important to consider the following objectives: • To gain an understanding of the multi-agency response to the family of this child; to extract any learning from this specific case; and to strengthen safeguarding in Ealing. • To ascertain whether this case can highlight any wider learning given the number of agencies outside Ealing involved. 3.6 This report is intended to reflect on the circumstances of Child C leading up to her admission to hospital, however, given her age, there is very little by way of historical context that involves her specifically. The main focus therefore relates to the handling of her case then, immediately prior to admission and post discharge. 5 3.7 The history of her mother and the circumstances of her arrival into the UK are considered in this case, in so far as the impact those factors may have had in relation to C and her care. 4. Family Structure 4.1 The relevant family considered as members in this review are: Subject: C – Aged 2 years, 6 months at time of key incident Mother: CM – Aged 22 years Putative Father: CF – Aged 29 years At the time of the incident it is believed that CF was residing with another female partner. It is also unclear if he is the father of the subject child in this case. In part, the difficulties in ascertaining clearly who is the father relates to the difficult past of CM, however it is clear that this is being addressed in further work. 4.2 The ethnic origin of mother and father is reported to be Albanian; the child was born in the UK. The understanding and details relating to the circumstances by which the family came to be living here are highlighted in the section below. 4.3 There are no other family members known to be residing in the UK, although at varying points mother has highlighted members of the community who have provided support to her and her child. 5. Background prior to the Incident 5.1 This family had lived in Ealing for only a few weeks prior to this incident occurring. It is clear from piecing together the history that they had been resident in the Greater London area for some time, the mobility of the family being a challenge to professionals in gaining a clear understanding of life for them. 5.2 In July 2017, Barnet Multi Agency Safeguarding Hub received a referral from a midwife who reported that she had become aware of a young woman living in the area who was pregnant and about whom she was concerned. The referral highlighted a number of issues pertinent to this review. At the time of the referral CM was living with an Albanian family in the area but it was reported that she knew little about this family, having arrived with them in very difficult circumstances. It was also reported that the living arrangement was extremely unstable and that it had the potential to break down quickly. 5.3 The referring midwife had been able to ascertain that CM had arrived in the country illegally suspecting that she had arrived on a lorry with a group of other migrants. The circumstances of her leaving Albania were understood to relate to honour-based threats of violence from her family should she refuse to go ahead with a marriage to a much older man. Hence, she had taken the opportunity to escape and to make the journey to the UK. It is understood that this journey was via the near continent where she reported that she was forced to work as a prostitute for two weeks. However, she escaped, seeking an opportunity to travel to the UK, where she took refuge with the family who took her in. As a consequence of the route of her arrival in the UK, CM had no recourse to public funds and no status and at the time of the situation being picked up by the midwife was heavily pregnant. 5.5 Gathering exact details of the history was reported as challenging as CM spoke little English and much of the translation was provided via the family. 6 5.6 It is understood that C was born by emergency caesarean section as she was a breach presentation at 38 weeks’ gestation. The health visiting service in Barnet were alerted to the birth when C was six days old and attempted a new birth visit five days later, on 7th August 2017. They were unable to gain access at this point and tried repeatedly to contact mother via a mobile number that had been supplied to the midwife. Contact was eventually established, and a new birth visit conducted on 19th August 2017. The child was nineteen days old at this point and had already had one attendance at A &E with digestion issues. 5.7 Details from records at this time suggest that mother used her friend as a translator, declining the use of Language Line. CM explained that she was moving to a new house and that she was between properties. There were no concerns noted regarding the baby or mother although the full history as above is known to have been shared. A plan was agreed that included: • Attendance at baby clinic • The offer of a level 4 service due to the maternal and social history • To use the GP service for routine health appointments • To continue to liaise with social services 5.8 There was a further attempt to contact mother on 22nd August 2017 using the mobile number, this was unsuccessful. 5.9 The health records indicate that C was seen on three occasions at A&E • 11th August: referred by a midwife as C’s stomach was distended – no treatment is recorded • 6th September: again, with concerns re digestion – CM on this occasion was described as worried, but it was recorded that the child was well • 11th October: with reflux for which Infacol was prescribed. 5.10 On 7th September, alerted by the visit to A&E, the health visiting service was tasked to visit at home. No visit is recorded as having taken place. In May 2018 the Central London Community Healthcare Trust identified that C was living in Dagenham with her mother and the health visiting service in Dagenham were notified; this was done by both email and by sending a ‘task’ on SystmOne. However, during the course of the record gathering for this review it would appear that Dagenham were unaware that the family were living in this area. It wasn’t until 23rd December 2019 that the GP records suggest that a routine notification was sent to the Ealing health visiting service that C and her mother had moved into the area, although records suggest she was seen twelve and fourteen days earlier by a GP who could have flagged the transfer sooner to the health visiting service. There is no record of this notification on the health visiting records. Subsequent enquiries suggest that the family had moved from Barnet to Dagenham, to Newham and then onto Ealing. 5.11 The family were living in Ealing when the incident of concern described at 2.1 occurred. On 13th January 2020 a request for an urgent visit by the health visiting service in Ealing was received from the Named Nurse for Safeguarding Children at West Middlesex University Hospital. The request related to an urgent request for a health visitor to conduct an assessment to consider child neglect: Child C had been discharged from hospital on the preceding day without a discharge meeting taking place. 5.12 Social workers and a CLCH health visitor saw mother and child on the same day – 13th January. A strategy meeting was convened on the same day; the health visitor was unable to participate but requested an update from the hospital named nurse. A number of issues were discussed, including the fact that mother indicated she had been concerned regarding C’s eating prior to her admission; she confirmed that visits to the GP on 9th and 11th December were to discuss those concerns. 7 On the social work visit, mother was living in a house of multiple occupancy in her own room. It was clean and tidy, with separate sleeping for C. The fridge was full and included fruit and vegetables. The social worker reported helping mum to cook a meal and witnessed attempts to feed C. At a further visit on 14th January 2020, CM indicated that she welcomed support and that C was gradually eating more. Health support was coordinated through CLCH with a dietician’s advice and the further support of a nursery nurse. Access was made for CM to a local food bank. 5.13 Alongside this, a package of support was coordinated for CM to support her mental health needs and to help her with her adverse experiences. 5.14 Some time in early March 2020, SC moved again to Newham, re-establishing her relationship with CF. The case was formally transferred. 6. Analysis by Key episode and identification of learning 6.1 Key episodes are periods of intervention that are judged to be significant to understanding the work undertaken with C and her family. The episodes are key from a practice perspective rather than to the history of the child, so they do not form a complete history, but will summarise the significant professional involvements that informed the review. The identification of such episodes has drawn heavily on the serious incident and root cause analysis reports of health agencies. 6.2 This report has been produced in a proportionate way appropriate to the learning and with cognisance of the impact on capacity of the Covid pandemic. It has not been possible to engage mother or other family members: in early July the family were given permission to travel to Albania and international travel restrictions have delayed their return. It is understood they do intend to travel back once restrictions are eased and there has been some planning between Ealing and Newham as part of the transfer of case responsibility. 6.3 The following key practice episodes have been identified Practice Episode Ensuring the correct health visiting pathway is identified and recorded for families The processing and recording of information are critical Robust plans must be in place when a child is discharged following an incident of concern Understanding social factors and the contribution to risk planning Ensuring the correct health visiting pathway is identified and recorded for families 6.4 In gathering the information for this review and in seeing the Root Cause Analysis completed by CLCH a number of issues have emerged regarding the health visiting response and the service to this family. A new birth visit which took place on 14th August 2017, after some delay in being able to contact the family, documented that the family, as a result of the social history, should be at level 4, or Universal Partnership Plus Offer. 6.5 This offer sets out an expectation of work being undertaken with agencies and with the parents in the provision of multi-agency intensive and targeted packages of support. The aim being to support families where there are complex health or safeguarding needs. Clearly this approach recognised the complexities of CM’s experience in being trafficked to the UK, the perilous nature of her housing and the added difficulties of stable support for her in caring for C. 6.6 However, from the RCA report completed it is clear the while the health visitor identified the correct pathway in Level 4 care, this was not logged correctly on the health visiting system. The family were 8 placed on a universal caseload following the new birth visit. The difference in service level as a consequence of this human error is that the LCN Level 1 offer – universal - is primarily focused on delivery of the Healthy Child programme from ante natal care to school entry by working in partnership with parents. 6.7 A number of other issues emerged in the RCA exercise including the quality of recording relating to risk. When identifying a Level 4 service was the most appropriate way to address concerns, it was important to document the identified risk factors and the mitigation actions that are required to reduce that risk. If this had been done effectively, health visitors subsequently picking up the case notes may have spotted the error. Learning: 1. Health visitors must ensure that the correct level of need is recorded on case management systems 2. Work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice The processing and recording of information are critical 6.9 The analysis of this case has highlighted a number of issues relating to the recording and the processing of information. One of those issues is referred to above at 6.7. There were, though, other issues that emerged in the course of this review. 6.10 In May 2018 the Central London Community Healthcare Trust identified that C was living in Dagenham. Documentation suggests that this was relayed to Dagenham Health Visiting service in an email and by tasking sent on the case management system. It would appear that they were unaware of her arrival and so no service was offered. 6.11. The family made other moves, from Barnet to Dagenham and Newham before arriving in Ealing, registering with a GP on each occasion, but their arrival was not shared with health visiting services, resulting in coordinated services not being made available to C and her family. 6.12 On 23rd December 2020, the GP records suggest that C had moved into Ealing and that a routine notification was sent to the Ealing Health Visiting service. Receipt of this notification is not recorded. If this referral had been documented in the community record this would have identified the family for a moving into area visit, although not immediately requiring a enhanced service. Such a visit would have identified the circumstances that mother and C were living in and would have enabled some discussion regarding C’s health needs and development. From events post the incident of concern mother has disclosed her ongoing concern regarding C’s diet and eating pattern, which may have been picked up earlier if the information and exchange of data had been clearer, although this isn’t recorded on any GP visits or ED attendances which were also chances for health services to pick this up and signpost to support. 6.13 In reality, this family did not receive the identified level of service at Universal Plus and missed health input at critical points. Learning: 3. There is a need to remind Central London Community Healthcare Trust administration team of the vital role they play in safeguarding children and why it is imperative that administration protocols are followed in a timely way. 9 4. There is a need to remind GP staff to contact HVs directly regarding concerning children; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referrals. 5. All professionals need to be reminded of the need to effectively coordinate and manage case transfers. Robust plans must be in place when a child is discharged from hospital following an incident of concern 6.14 The serious incident report completed by Chelsea and Westminster Hospital highlights the concerns relating to the discharge from hospital of C. The circumstances of her admission are set out earlier in the report, the medical assessment of her condition on admission was serious. The factors of collapse, anaemia, failure to thrive coupled with her age and the range of social issues made this the case. 6.15 Following transfusion and the treatment with oral iron she was, however, discharged later that weekend, with poor onward planning, no strategy discussion and no referral to social care. The referral to social care only occurred following the involvement of the Safeguarding Children nurse on the day after discharge, with a strategy discussion arranged for 15th January 2020. 6.16 The report highlights a lack of communication regarding the severity of the safeguarding and nutritional aspects of the child’s presentation. The senior medical and nursing team did not work together to consider the risk factors and to engage social care in any discussion about next steps prior to discharge. Indeed, there was no development of a multidisciplinary plan for C to manage the longer-term health issues. Instead the case was passed between staff and shifts without effective communication. 6.17 The lack of professional curiosity regarding the lived experience of C and the unknown aspects of her medical and social situation at the point of discharge had the potential to put her and her mother at greater risk. Learning 6. Hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies 7. The processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point. 8. Procedures for escalation of issues by nursing staff who are concerned regarding safe decision making must be clear and disseminated Understanding social factors and the contribution to risk planning 6.18 The challenges of family mobility in this case meant that while the concerns relating to CM’s history and her arrival in the UK were known they were not consolidated into a clear appraisal of risk because information sharing was weak. When a strategy discussion was held following C’s admission to hospital and subsequent discharge, key professionals did not attend. 6.19 The health visitor was invited to the strategy discussion, but was unable join the discussion, arranging instead to contact the hospital named nurse to request an update post-meeting. Much of the health visiting history wasn’t therefore fully available to the meeting. The health visitor also took no 10 action to discuss the specific concerns or to liaise with the social worker. This in effect meant that not all the information was available, and professionals were not collaborating in partnership. 6.20 The Root Cause Analysis from Central London Community Healthcare Trust highlights the passivity of the health visitor after the strategy discussion, assuming no responsibility for contacting partners in order to discharge the health visiting role in the protection plan. There were in fact 19 days between the incident taking place and the health visitor and social worker communicating with each other. Learning 9. Staff in all organisations to be reminded of their responsibility for playing an active part in safeguarding planning 10. All professionals to be reminded that they have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn’t attend. Including the specific role they are expected to play in delivering outcomes 7. Conclusion and next steps 7.1 Child C had a history of gastric issues and potential seizures and she was seen by GPs, EDs and paediatricians before she suffered a serious and potentially life-threatening collapse, as a result of malnourishment and poor diet. Later medical investigations show increased faecal calprotectin level which could indicate underlying difficulties such as inflammatory disorders The medical background, coupled with a social history and significant mobility, meant that she was at risk. 7.2 The information exchange in this case was poor from a number of organisations, resulting in no consistent health visiting service being offered to the family. The number of moves was undoubtedly a factor in this, however, the systems within health organisations are designed to mitigate against children going under the radar. The incorrect use of these systems, poor recording practice and failure to follow up meant that for large periods of C’s life, her mother was not provided with the expert advice, support and interventions to support her development. 7.3 The Serious Incident report and Root Cause Analysis completed as part of this review identify actions to address the concerns. Lessons have been identified about how agencies worked together and they have been recognised in agency reports as well as this overview report. Ealing Safeguarding Children Partnership will continue to work with agencies to embed this learning and to ensure that practitioners have the skills and awareness to drive forward practice. |
NC50710 | Serious injuries to a 6-year-old boy following a road traffic collision in April 2017. Police had recorded incidents of Billy and other children playing unsupervised on a busy dual carriageway in 2015 and referrals were made to Children's Social Care. At the time of the accident, Billy and three siblings were subjects of Child Protection Plans due to neglect, including lack of adequate care and supervision of the children and mother's substance misuse. Mother, father and mother's partner have historic incidents of domestic abuse; mother had mental health problems. Family is White British. Findings: all children within a family need to be considered in assessments and plans; professionals need to identify when parental cooperation with a plan is superficial; the need to be curious about information held by other agencies and be proactive in sharing information that may improve the understanding of the child's lived experience; consider the daily life of all the family through the child's eyes when working with parents who misuse substances; view with respectful caution a parent's self-report of their drug taking; good quality plans and reflective supervision is key to effectively recognising and challenging neglect. Uses the Significant Incident Learning Process (SILP) methodology. Recommendations: to consistently capture the voice of the child and lived experience with meaningful analysis; to request assurance from partner agencies providing early help about arrangements for reflective supervision for their practitioners; and how can the LSCB ensure that the impact on children of parental substance misuse is appropriately considered in multi-agency assessments and plans.
| Title: Serious case review: SCR Billy: review report. LSCB: Middlesbrough Safeguarding Children Board Author: Jane Appleby Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 1 Serious Case Review SCR Billy REVIEW REPORT Lead Reviewer: Jane Appleby Agreed by MSCB: 20.6.18 This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with Middlesbrough Safeguarding Children Board prior to publication. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 2 CONTENTS Page Number 1. Summary of the learning 2 2. Process for conducting the review 3 3. Family Structure 4 4. Background prior to the scoped period 5 5. Key episodes 6 6.1 Thematic Analysis 9 Each child’s lived experiences Planning and review Parental Drug Misuse Neglect 7. Conclusions and Recommendations 20 1. Summary of the learning from this review 1.1. Billy1 was six years old when admitted to hospital with serious injuries having been involved in a road traffic collision on a dual carriageway, which is a busy major route through the town. 1.2. Billy lived with his mother, her partner and three siblings. He had contact with his father. 1.3 At the time of Billy’s accident the children were subjects of Child Protection Plans due to neglect. The issues included the lack of adequate care and supervision of the children, and the impact of Mother’s misuse of amphetamines. 1.4 This Serious Case Review (SCR) has closely examined the involvement of a number of agencies who came into contact with Billy and his family. Learning has been identified for individual agencies and for the Middlesbrough Safeguarding Children’s Board (MSCB). The most significant learning is: Professionals should be aware of the details within the ‘plan’ for the case. It provides the basis for work with the family and should be used to monitor and evaluate progress Plans and multi-agency meetings need to consider and analyse any contact and direct work with children, and should capture the voice of the child and their lived experience Successful interventions to support families affected by parental substance misuse must depend on holistic approaches and for all professionals to understand the situation from the child’s perspective When working with cases of neglect it is a risk that professionals will become reactive to each individual incident. It is important to take a step back and consider each child’s lived experience over time and the impact on them of cumulative neglect 1 It is important to try and protect the identity of the child and his family, so the name Billy has been chosen for the SCR and is not the child’s name. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 3 There are benefits in providing preventive work and early access to help and support for children and their families The effective use of information, rather than just the recording of information, is critical to effective safeguarding arrangements 2. Process for conducting the review 2.1 MSCB agreed that the SCR would be undertaken using the Significant Incident Learning Process (SILP) methodology, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time. 2.2 Agency reports were completed where agencies had the opportunity to consider and analyse their practice and any systemic issues. These reports provided details of the learning from the case within the agency and allowed agencies the opportunity to reflect on actions and make recommendations for improving their own practice. Following these reports being submitted, practitioners, managers and agency safeguarding leads came together for a learning event. All agency reports were shared in advance and the perspectives and opinions of all those involved at the time were discussed at the event. The same group then met again to examine and debate the first draft of the SCR report. Later drafts were also commented on by all of those involved and they made an invaluable contribution to the learning and conclusions of the review. 2.3 It is stated in Working Together 20152 that SCR’s should be conducted in a way that: recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. 2.4 It was agreed that the scope of the review would begin from December 2015 when a Common Assessment Framework (CAF)3 was undertaken to the date that an Interim Care Order4 was made in April 2017, following Billy’s road traffic collision. Relevant information prior to these dates was also considered as required, particularly any significant and relevant agency involvement with family members. 2.5 Family engagement is required as part of the SILP model of review. MSCB notified both Mother and Father were contacted and invited to contribute. Mother did not respond to a number of attempts to engage her. Father agreed to discuss his experience with the Lead Reviewer but then did not respond to numerous attempts to speak to him. They will be notified of the conclusions of the review prior to publication. 2 Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015 3 Common Assessment Framework (CAF) is an early help inter-agency assessment. It offers a basis for early intervention of children’s additional needs, sharing of inter-agency information and coordination of service provision. 4 Interim Care order- An order that can be made by the court before a final hearing in order to collect evidence to make a final decision about a child’s future STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 4 3. Family Structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child Billy Mother to Billy Mother Father to Billy and Sibling 2 Father Siblings Sibling 1 Sibling 2 Sibling 3 Father to Sibling 3 Mother’s Partner 3.2 There was no evidence in any of the reports submitted by agencies involved with the family that any issues of race, religion, language or culture affected events in this case. The family’s ethnicity was White British. 4. The background prior to the scoped period 4.1 Prior to the dates of the key episodes considered below, a number of incidents were recorded in Children’s Social Care (CSC) records. There was a S47 investigation5 regarding concerns about the care of Sibling 2 while in Father’s care during contact in 2011. The assessment concluded that Mother was a protective factor. A Working Agreement with Father was implemented to restrict Father’s overnight contact with Billy and the siblings. 4.2 A second S47 investigation was undertaken in 2014 when Father did not seek medical attention for Sibling 2. A further Working Agreement was implemented with Father to restrict contact until the issues were addressed. 4.3 Mother, Father and Mother’s Partner have historic incidences of domestic abuse recorded in some agency records. 4.4 The Police recorded incidents in August 2015 and again in September 2015 when Billy and other children were found on the busy dual carriageway unsupervised. Police returned the children home and gave Billy’s Mother words of advice around safety and supervision. A referral was made to Children’s Social Care on both occasions. 4.5 Mother approached school in September 2015 as she was concerned about Billy’s behaviour at home. She reported him not listening to her, playing out away from the house, and getting into fights. School offered to support Mother and made an appointment for her to discuss her concerns with a Parent Support Advisor (PSA).6 It is standard practice in schools to intervene early when any problems emerge. The PSA showed a clear awareness of Billy’s vulnerability and chose to give Mother practical advice on good parenting, for example how to set clear boundaries for behaviour. In addition, the PSA provided Mother with a ‘golden book’ so she could record positive comments about Billy, to help reinforce good behaviour and encourage adherence to the newly established boundaries. This was not completed. Initially school had 5 S47 Investigation places a statutory duty under the Children Act 1989 on Children’s Social Care when they have reasonable cause to suspect that a child is suffering, or likely to suffer significant harm. 6 Parent Support Advisors work with Schools, pupils and families to offer practical help and emotional support to families such as poor attendance, overcome barriers to learning and help parents to support their children’s learning STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 5 no concerns in regard to Billy’s behaviour, however unacceptable behaviour began to emerge and escalate in school, which was monitored. 4.6 Following the referral from the Police and the concerns expressed by School, CSC reviewed what information they held on the family, a Family Practitioner7 from the Stronger Families Team (Early Help) was allocated to initiate an early help assessment (CAF)8, which was undertaken in October 2015. This assessment focussed on Billy’s behaviour, concerns for the safety of the children, parenting capability, and the family’s finances. 5. Key Episodes 5.1 The time-frame under review has been divided into three key episodes, which are periods of intervention that are judged to be significant to understanding the work undertaken with the children and family. They are key from a practice perspective rather than the history of the child. They do not form a complete history of the case but summarise relevant activities that occurred, and include the information that is thought to be most helpful in informing the learning from the review. 5.2 The evidence has been extrapolated from the agency reports, the joint agency chronology and the Practitioners Learning Event. 5.3 The key episodes identified in this review are: Key Episodes 1 Common Assessment framework (CAF) and Team Around the Family (TAF) 2 Child Protection Planning 3 Response to Road Traffic Collision Key Episode 1: Common Assessment Framework and Team Around the Family (December 2015 – September 2016) 5.4 Following the early help assessment undertaken in October 2015 a Team Around the Family (TAF)9 meeting was held in December 2015, which the school and stronger families professionals attended. It was established that Mother was a single parent, not sleeping, feeling anxious, and that she was concerned about Billy. Neither the GP nor School Health Nurse were invited to attend the meeting. School agreed to monitor, support and nurture Billy, and help him cope with any difficulties outside of school. Mother agreed to attend a 10 week nurturing group at the Children’s Centre. (She did not attend, stating she no longer required support.) The case was closed as Early Help felt that Mother was able to meet all of her children’s basic needs and because Mother withdrew her consent for ongoing support. At the time in Middlesbrough when a person withdrew from Early Help there was an expectation 7 Family Practitioner is assigned to a family to help families beat some of the long standing, emerging and difficult challenges that may be facing them in everyday life. 8 Common Assessment Framework (CAF) is an early help inter-agency assessment. It offers a basis for early intervention of children’s additional needs, sharing of inter-agency information and coordination of service provision. 9 Team Around The Family (TAF) is a meeting between the family and professionals to find support and help for a family where the social worker is not at this stage, considering “Children In Need” status or “Child protection” Status. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 6 that consideration be given to step up to Tier 410 to have discussions on whether there were any outstanding issues. It was decided at that time if there was a further incident that consideration would be given to progressing the referral to children’s social care, on this occasion the case was passed back to Early Help to action. 5.5 During the early help assessment in October 2015 Mother revealed to professionals within the Early Help team that she attended the GP Practice for stress and anxiety and was prescribed Amitriptyline (for sleep and depression) and that the GP was monitoring her monthly. 5.6 When around 10 weeks pregnant with Sibling 3, in March 2016, Mother booked with the Community Midwife for antenatal care, and attended for a dating scan. She attended all follow up community midwifery appointments. The Father of Sibling 3 was a new partner of Mother and new into the family. 5.7 In May 2016 the Family Practitioner from the Stronger Families Team found Billy with two younger children ‘wandering’ unsupervised. At this point the family were not open to Stronger Families due to Mother withdrawing consent. Billy was returned home and the worker spoke with Mother and advised her that she would make a referral to Children’s Social Care, which she did the same day. The SAFER referral did not meet the threshold for a Level 4 Children’s Social Care assessment and so was passed to a member of the Early Help HUB who supported school to organise a Road Safety Officer11 to work with Billy either on a 1:1 basis or in a group at school. It was also suggested that School forge links between Police, Road Safety, School and Mother. In September 2016, an incident was reported to a Teacher at school that Billy had been involved in attempting to remove ‘Dusters (hubs)’ from a car. The owner was angry and threatened to report the incident to the Police. The Teacher spoke to Billy about the incident and about ‘playing nicely and not damaging other people’s property’ and no further action was thought to be necessary at this time. Key Episode 2: October 2016 – Child Protection Planning 5.8 When Sibling 3 was born in October 2016 they were admitted to the neonatal unit following respiratory distress and neonatal seizures, requiring intubation. The Midwife had raised concerns with the hospital safeguarding team regarding Mother falling asleep during labour, not waking to check the baby, and needing ‘quite a lot of prompting’ whilst dressing and caring for Sibling 3. Mother was asked on four occasions if she had taken any non-prescription drugs during pregnancy but she consistently denied this. The Neonatologist and Neonatal Unit staff had significant concerns for Sibling 3 and a urine toxicology test was ordered. The results were positive for amphetamines12, Gabapentin13 and Benzodiazepines (Benzos)14 so a referral was made to Children’s Social Care. A Strategy meeting15 was held on the neonatal unit and Children’s Social Care stated that Sibling 3 was only to have supervised contact with parents. The Hospital safeguarding children’s team challenged the Children’s Social Care Team Manager with regards to the children at home remaining in parents care if supervised contact 10 Tier 4 threshold for child protection in Middlesbrough is when a child has complex or significant needs that require specialist or statutory intervention. 11 Road Safety Officers are responsible for the operation of road safety education, training and publicity and promotion the local area Road Safety Plan. 12 Amphetamines are a Stimulant- Class B Speed, known to keep people awake, energetic and alert. 13 Gabapentine- When misused it produces euphoria, improved sociability and relaxation (similar to marijuana) 14 Benzos (Benzodiazeine) are usually prescribed for a variety of medical and mental health concerns as minor tranquilizers, often misused to counter effect of ‘uppers’ like cocaine, speed and E and ‘downers’ such as heroin and alcohol 15 A Strategy Meeting is held when there are concerns that a child has suffered or is likely to suffer significant harm STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 7 was required for sibling 3. The Local Authority legal representative to the meeting gave the view that there were different thresholds for Sibling 3 and the other siblings. 5.9 Prior to Sibling 3’s discharge from hospital, S47 enquiries were made after a hair strand test from Mother showed long term amphetamine use. This was followed by an Initial Child Protection Conference (ICPC)16 and the children being made subject to Child Protection Plans under the category of neglect. Children’s Social Care were willing to discharge Sibling 3 to home if Sibling 3’s father moved into the family home to act as a protective factor. Prior to this Mother did not consider him to be her partner and informed the Health Visitor, when she made contact at an antenatal contact, that she was not in a relationship with him. This plan had been made following the discharge planning meeting, where the Health Visitor challenged the fact that Mother was still denying the level of substance misuse, despite the hair strand test results, and that there was no substance misuse services involved to support Mother. 5.10 Core groups were held to develop a child protection plan, and work was undertaken with Mother and her partner, Sibling 3’s Father. Mother was invited to attend 1:1 parenting sessions, however due to poor attendance professionals felt the sessions were ineffective. At a RCPC in March 2016 the Independent Reviewing Officer (IRO)17 stated that “presenting concerns have not been addressed and there is a clear lack of evidence to highlight a reduction in risk, although there are many positives; on that basis further work is to be undertaken to reduce the level of potential risk to the children”. However, as Mother had clearly disengaged this was not achievable. 5.11 Following her hair strand test, Mother admitted to the social worker misuse of amphetamines 2-3 times per week, but claimed that her partner was not aware. The social worker negotiated Mother’s consent for the drug misuse to be disclosed to him. He admitted using “skunk”18 himself in the past but denied any current use. There is no evidence to suggest that he presented under the influence during visits or appointments. A referral was made to Middlesbrough Recovering Together Services (Substance Use and Alcohol Services) but Mother did not engage. 5.12 Sibling 3 was not developing as expected and continued to have complex medical needs requiring high level health input from the Neonatal Community Sister and other professionals (Speech and Language Therapist, Physiotherapist and Dietician). Sibling 3 was taken to all assessment and follow up appointments. 5.13 Mother restated to the social worker that she had issues with her mental health, partly due to a close family member dying, and that she used Amphetamines for motivation. Mother had also spoken to the Health Visitor but never provided an explanation as to why she used drugs despite many discussions around this and never made any reference to her mental health or bereavement being a trigger or that either of these issues were impacting on her functioning. 5.14 Billy’s behaviour both at home and school continued to deteriorate. He had poor focus in class and started to arrive at school tired and with dark circles under his eyes. It was reported that he was staying at Father’s house more frequently and staying up late, and was involved in friendships with much older boys. It was reported at school by another parent that Billy’s 16 Initial Child protection Conference (ICPC) must be convened when concerns of significant harm are substantiated and the child id judged to be suffering, or likely to suffer significant harm. 17 The IRO is an independent social work manager who chairs child protection conferences. 18 Strong cannabis resin. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 8 Father and a friend smelt of alcohol outside the school gate and that Billy was caught throwing stones at a house. An investigation was undertaken by police and CSC, and Billy’s behaviour was said to improve following the suspension of unsupervised contact with Father. Key Episode 3: April 2017 – Response to Road Traffic Collision 5.15 On 22nd April 2017 Billy was involved in the road traffic collision that led to the decision to undertake this review. He was unsupervised on a major dual carriageway. Prior to the accident Billy was in the company of 3 older boys. Police and Ambulance Emergency Services attended the incident. Billy had reduced consciousness levels and significant haematomas to both sides of his head and required intubation and ventilation at the scene of the accident. He sustained a closed fracture to his left tibia and fibula (lower leg bones). Billy was transferred to the Paediatric Intensive Care Unit. He required major surgery to his leg. He had other wounds to his ear, elbow, shoulder and arm, which required treatment. 5.16 Following admission to Hospital both the Police and Ambulance Services made a referral to Children’s Social Care. An urgent Strategy Meeting was held at the hospital attended by a range of agencies who all expressed concerns regarding the family. 5.17 Children’s Social Care sought and received appropriate legal orders on the children. 6. Thematic Analysis 6.1 Thematic analysis is described as ‘a method of identifying, analysing and reporting patterns’ (Brown and Clarke 2006). It is helpful when there is important information, when there are large amounts of text (agency reports), and where the views and experiences of people are gained in focus groups (Practitioners Learning Event). From the information extrapolated, a number of key themes (issues) have emerged where relevant findings relating to the terms of reference considered at the outset of this review being commissioned have been incorporated. The following themes are judged to be most significant and enable us to identify learning for the MSCB and its partner agencies: Each child’s lived experience Planning and review Parental drug misuse Neglect 6.2 Each child’s lived experience 6.2.1 The need to listen to children and to make sure their views are taken into account in child protection cases was highlighted in an report analysing the findings from 67 SCRs (Ofsted 2010; The Voice of the Child: Learning Lessons from Serious Case Reviews). The SCRs had highlighted the importance of seeing, observing and hearing the child. In some of the reviews they found that the child was not seen by the professionals involved or was not seen frequently enough, and that professionals focused too much on the needs of the parents and overlooked the implications for the child. In other cases, even where the child was seen, they were not asked their views or about their feelings. 6.2.2 The United Nations Convention on the Rights of the Child (UNCRC, 1989) enshrines the rights of children to be involved in all decisions that affect their lives. Working Together 201519 19 Working Together to Safeguard Children – HM Government 2015 STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 9 states that each child who has been referred into CSC should have an individual assessment to respond to their needs and to understand the impact of any parental behaviour on them as an individual. Every assessment must be informed by the views of the child as well as the family. Every assessment should reflect the unique characteristics of the child within their family and community context. It is essential to ensure that engaging with children takes the child’s age into consideration (with observations of younger pre-verbal children essential) and that any tools used are age and ability appropriate. It then important to ensure that what we have learned from engaging with children has an impact on the plan for the child. 6.2.3 There were four children in the family, and agencies needed to ensure they focused on each child in all assessments, and that each child’s individual needs were considered, recorded and addressed at each stage of the case. This didn’t happen consistently, partly due to the complexity of the family with three different fathers and sets of paternal grandparents. The only consistent adult within the family was Mother. There were also specific concerns for a child that led to assessments. The initial focus of the case was on Billy following concerns expressed by Mother in regard to his behaviour, and the reports that he was playing out unsupervised and in dangerous places with older boys. While the focus was on Billy, Sibling 1 appears to have rarely been seen by professionals despite moving to live with their paternal grandparents stating it was due to the conflict caused by different males in the household. There is no evidence that this was explored fully with Sibling 1 at the time. Sibling 2 had reportedly stopped going to Father’s for contact due to his drinking. Again, this was not pursued with the child. The children lived in a household which was not consistent and agencies were not always able to track where the children were or to see them either together or individually. The children all attended the same school however, and this would have provided an opportunity for professionals to see the children in their school setting and gain an understanding of what life was like for them and to explore their feelings and any anxieties they may have had. It is important that engaging with children on a plan is not a one-off event, but is done regularly to build a relationship and to consider the child’s voice over time. 6.2.4 Good practice was identified when the Police and School, at an early stage of concerns being reported, attempted to support Billy and Mother through setting positive behaviour mentoring, road safety and assigning a PSA to assist. However, Mother disengaged early from this support. It would have been helpful to include other professionals such as the School Nurse who could have worked with Mother regarding her disengagement, discussed any health issues relating to Mother with the GP and undertaken a health assessment of Billy. Billy was given an opportunity to meet with the PSA and some good work was undertaken, but this did not continue due to Mother’s withdrawal of consent. 6.2.5 It was reported by School that Billy told a worker that he had taken on some ‘Child Care’ responsibilities and on at least one occasion was left to look after Sibling 3. Consideration should have been given to the risks associated with such a young child caring for a baby with complex medical needs. There was also the potential that Billy was at risk of becoming a Young Carer. Mother was spoken to, and it was made clear to her by the social worker that this was unacceptable. She denied Billy’s claim, and it was not pursued further with him or the other children. 6.2.6 There was insufficient consideration of the older children’s relationship with their Father and the risk that he might pose to them. It was known that he had long term issues with alcohol and that he had neglected the children’s needs in the past. It was only following police and STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 10 CSC involvement in key episode 2, when the children were on a child protection plan, that contact was again stopped. There had been ineffective use of written agreements on three occasions, with the plan of ensuring the children did not spend time with Father. These agreements were not enforceable and relied on Mother to make them work. There was also insufficient consideration of Mother’s Partner’s role in the family. He moved in after the birth of Sibling 3 and there was no meaningful consideration of domestic abuse in his past and his reported historic use of skunk. There were reports of poor relationships between him and the older siblings but these were not explored other than superficially, and little was known about the impact of Mother’s Partner living in the home on the children. He was rarely present during statutory visits and he did not fully engage in any work, including the parenting programme he agreed to attend in key episode 2. 6.2.7 In larger families there is always the risk that professional’s time and efforts are spent on the child most in need or those with problematic behaviour. Following Sibling 3’s birth, the professional focus shifted to this child. This was due to Sibling 3 having complex medical needs, plus the realisation that Mother had been misusing drugs through her pregnancy. There was a significant increase in the number of health workers providing care and as the health experts their work very much focussed on a care plan to meet Sibling 3’s medical needs, rather than the broader social issues that may impact on the siblings. However the challenge by health staff that if Sibling 3’s contact was supervised, there needed to be an assessment of the impact of Mother’s drug use on the other children living at home was a good one. An ICPC was held and it was acknowledged that all of the children were at risk of significant harm due to Mother’s drug misuse and the associated neglect. 6.2.8 There were a number of examples where direct work was undertaken with the children. Earlier in the case the early help worker completed a small piece of work with all the children together using the ‘bear cards’ regarding how they felt. However, there did not appear to be any analysis of these feelings or consideration given to sharing findings with Mother or the school to understand how feelings linked to behaviours or to gain a full understanding of what was happening in family life. It has been reported that early help staff lacked knowledge and skill in engaging the children at the time. Since this review there has been a change in structure, increased support for frontline practitioners and a range of tools are now available to support professionals. 6.2.9 The school provided detailed descriptions of the older three children to core groups and conferences, and gave an insight into their emotional well-being. However the area where the children’s views is recorded in the conference reports was not completed and no instruction was given to seek and provide their voices. A change of IRO while the children were on a CP plan had an impact on the oversight of the case. 6.2.10 The School Nurse undertook a health assessment on Billy and Siblings 1 and 2 which included their views. The social worker completed direct work with Billy and Sibling 2 when undertaking the assessment, using a range of tools such as ‘three houses’ and booklets and talked to them alone. There were fortnightly statutory visits due to the child protection plans, some of which involved the social worker seeing the children alone, however no direct work was undertaken to elicit their views. The social worker recognised that she did not see the children as frequently as she would have desired due to workload, and that she did not prioritise any direct work. Had all those involved at various times with the children discussed their findings and experience of the children with each other it may have helped professionals across agencies to draw together a wider picture of the impact on the children of their lived STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 11 experiences, particularly the emotional and practical impact of the seemingly inconsistent parenting they were receiving. The child’s voice would then be available to inform assessments, planning and decision making. 6.2.11 Mother was said to be able to meet the children’s basic care needs. She made all of Sibling 3’s many health appointments and the children were described as well presented. This was a superficial assessment however. Mother seemed unable to consistently prioritise the needs of her children and concerns were evident at the time about her long term commitment and her ongoing attachment to the children. There was a concern that she was less interested in them when they were older and became more challenging. The emotional bond that forms between an infant and caregiver begins with the infant getting their primary care needs met and then becomes the engine of subsequent social, emotional and cognitive development (attachment theory in psychology originates from John Bowlby 1958). Had professionals fully explored and analysed the emerging issues there would have been a greater understanding of the ‘meaning of the child’ to Mother and to Mother’s Partner, and an understanding of what life was like for the children living within their family. Learning: All children within a family need to be considered in assessments and plans. The impact of a significant event for one child should also be considered from the point of view of siblings. Each individual child should be considered in all meetings. There should be a multi-agency consideration of the child’s experiences which analyses and describes the impact on the children of their experiences since the last meeting. This should be included on the agenda for core groups and other multi-agency meetings. 6.3 Planning and Review 6.3.1 Two distinct phases of planning and review happened; early help (Tier 3) and child protection (Tier 4). Working Together to Safeguard Children (HM Government 2015) describes Early Help as ‘a means of providing support as soon as a problem emerges, at any point in a child’s life’ and that ‘Early Help can prevent further problems arising.’ Effective early help relies upon local agencies working together to: identify children and families who would benefit from early help undertake an assessment of the need for early help, and provide targeted early help services to address the assessed needs of a child and family which focusses on activity to significantly improve outcomes, for the child. Early Help is a key part of delivering frontline services that are integrated and focussed around the needs of children, starting with the completion of an early help assessment. The system in Middlesbrough at the time was that Stronger Families and Early Help Teams were locality based and would co-work with schools providing services to children and their families who required more than the universal provision of services, but who didn’t meet the criteria for services from CSC. 6.3.2 One-to-one support was put in place for Billy in regards to safety without considering whether a 5 year old was able to fully understand how to manage safely and protect himself from harmful and risky situations. Young children rely on adult supervision and guidance, and it was critical that this work was completed jointly with Mother. Although it was good practice STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 12 that the school allocated a PSA to work with Billy, and this work was helpful, they did not pursue with Mother and/ or Billy why the ‘golden book’ was not completed and if there was anything additional that could be done to support them both. Due to Mother’s patchy engagement and limited insight into her role in Billy’s behaviour, it was challenging for professionals to work in partnership with her. 6.3.3 Mother had engaged well with the initial early help assessment and appeared keen to engage with support around managing Billy’s behaviour and her emotional health. However Mother started to disengage and did not participate in the support offered and was more focused on Billy being the problem rather than wanting to consider her parenting of Billy and her other children. Professionals didn’t challenge this. Mother had disclosed during the assessment that she had emerging mental health issues, however there was no evidence of professionals either exploring or analysing Mother’s mental health. She reported that she was not sleeping and was struggling with stress, which she put down to Billy’s behaviour. Considering the impact of her mood and stress would have led to an understanding of why Mother lacked motivation and her capacity to engage with change. There was no evidence that the GP was contacted in regard to Mother’s mental health or medication and whether this would have an impact on her capacity, capability or emotional availability to care for her children, and to engage in the early help work. The lack of consideration of her mental health (prior to professional awareness of her drug misuse) acted as a barrier to gaining a deeper understanding of Mother’s mental health, parenting challenges and the impact on the children. 6.3.4 Following the birth of Sibling 3, Mothers misuse of substances were recognised as an issue and SAFER Referrals20 from a number of agencies resulted in a child protection response with an ICPC and a child protection plan being put in place. In some ways the child protection planning replicated the early help planning however, with the focus being on the child with most needs, limited consideration of the children’s lived experience, and insufficient challenge of the parents. The focus was on the feeding of Sibling 3, including whether Mother could safely tube-feed the baby when she had been using amphetamines. There were no specific tasks in the child protection plan regarding Siblings 1 and 2 although they were named subjects of the plan. 6.3.5 A referral was made to the Middlesbrough Change, Grow, Live (CGL)21 drug and alcohol services (previously Middlesbrough Recovering Together Services)22 regarding Mother’s amphetamine use. The aim was to provide an assessment of Mother’s substance misuse, including triggers, to identify and respond to any health and social care needs such as physical and mental health issues in relation to her drug use, and to consider the impact on the children living within the household. A comprehensive assessment was not fully completed however, and no family risk management plan put in place. This was due to Mother’s lack of engagement. 6.3.6 From the start of involvement with the family the focus of agency assessments and professional concerns tended to be reactive, depending on what was of most concern at the time. A more holistic view of the family and the children’s experience of being parented 20 SAFER Referrals- Situation, Assessment, Family, Expected Response, Recording – Middlesbrough multi agency tool 21 A change of commissioning of the drug and alcohol services in Middlesbrough in 2016 22 ‘Middlesbrough Recovering Together (MRT)’ is the umbrella term that encompasses 3 different organisations within it, namely- 1. Foundations (prescribing), 2. CGL (psychological / wrap-around support) and 3. Recovery Connections (long-term recovery, employment / societal reintegration STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 13 by Mother, Father and Mother’s Partner was largely missing. Examples of this were when the focus was on Billy’s behaviour or Sibling 3’s complex health needs. This resulted in the other children, Sibling 1 and 2, being largely invisible. Additionally there was little evidence to suggest that the children’s fathers were fully included in assessments and plans, although the child protection plan following Sibling 3’s birth did include a limited assessment of Mother’s Partner. He had said he was not aware of Mother’s drug misuse prior to Sibling 3’s birth and he refuted that it had a negative impact on her parenting, despite Sibling 3’s health needs. As a household member and father of one of the children he should have been an equal part of any plan, and an understanding of his role as a increased risk or a protective factor in the family was essential. This was not undertaken until after Billy’s accident and as part of the care proceedings that followed. 6.3.7 In order to fully understand a family and a child’s lived experience there also needs to be consideration of the role of wider extended family, and whether they are potentially a protective factor. Involving grandparents (as would have been relevant in this case) in assessments and plans can be extremely beneficial. Little was known about the wider family, partly because Mother was not keen to provide information, but also because it was not adequately pursued by professionals. Equally there was no exploration of Mother’s, Father’s, or Sibling 3’s Fathers own life experiences and history. Understanding parental history is vital in informing assessments of vulnerability and risk and to inform plans. 6.3.8 Engagement by Mother in the plans made for her children was partial and appeared to give the appearance of engagement rather than the reality of her limited cooperation. The Victoria Climbié enquiry23 highlighted that professionals must maintain a ‘healthy scepticism’ and ‘respectful uncertainty’ in order to see beyond what is often being presented by parents. It requires skill and experience to keep a healthy scepticism regarding parents while still building and maintaining a trusting relationship. Mother was very plausible and showed a degree of disguised compliance. Disguised compliance involves parents giving the appearance of co-operating with child welfare agencies, without meaningfully working in partnership in the best interests of the children. Partial compliance, as in this case, can result in professionals feeling optimistic, and a belief that the parent is engaged in the plan and was able to care for the children. The optimism felt at various stages of the plans needed to be balanced against the evidence and on-going risks. Disguised compliance has featured in a number of SCRs and the NSPCC published helpful guidance in 2014: ‘Disguised Compliance: Learning from Serious Case Reviews - summary of risks and learning for improved practice around families’. It considers risk factors for disguised compliance, recognising disguised compliance and learning for improved practice. 6.3.9 Over the period of this review there were a number of TAF meetings, CP conferences and Core Group meetings, and for these meetings to be effective it is important to ensure that the relevant people are invited and attend. At the learning event professionals expressed concern that key professionals who worked with the family were not always invited to meetings, and therefore did not attend or provide information that was required. For example CGL, and some health professionals including the GP. As well as having the required professionals in attendance, meetings should have clear aims and objectives and those attending must understand the purpose of each meeting, their role at the meeting, what the expected outcomes for the children are following the meeting and what their role is in the 23 Laming, Lord (2003) The Victoria Climbié inquiry. Report of an inquiry by Lord Laming. Cm 5730, London: TSO. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 14 plan devised at the meeting. All actions need to be SMART (specific, measurable, achievable, realistic and timely) and reviewed regularly with the family. A focused plan which involves all the relevant professionals and the family, including the children where possible, should be the aim. 6.3.10 Meetings should also invite professionals to state if they disagree with any part of the plan. Professional challenge is a fundamental professional responsibility and should be seen as a sign of good professional practice and effective multi-agency working. Any professional who has voiced their concerns and still does not agree with the plan for a child should escalate their concerns using the policy for resolving professional disagreements. It was acknowledged by the IRO at the review conference prior to Billy’s accident that the CP plan had been ineffective and that the concerns had not been addressed and there had been no reduction of risk. New timescales were set, but no contingency plan was made for if there continued to be a lack of progress. 6.3.11 There was a significant range of information available to agencies who were involved with the family at the time, particularly following assessments and through the various multi-agency meetings (TAF, Strategy, ICPC and Core Groups). There was evidence of good joint working such as the school, road safety officer and the family practitioner supporting Billy, and health professionals working closely together and sharing relevant information both when Sibling 3 was born and when Billy had his accident. Children’s Social Care also worked closely with hospital staff when Billy was admitted following his accident. 6.3.12 In contrast to this, the agency reports and professionals at the learning event recognised that each agency held information that others were not aware of such as the School Nurse did not initially know about Billy’s behaviour concerns and was not aware of the early help support or meetings, the Police held historical information about Father and Mother’s partner, and the school were not aware that there were working agreements in place regarding the children’s contact with Father. The GP had been notified about CP meetings, however there was no evidence that they considered whether there was any relevant information held on their system that might contribute to the CP Plan even though all the family records were linked. Not all professionals were aware of the CAF/TAF meetings or core groups, and plans (both early help and child protection) were not updated and shared regularly. It is important that professionals see the significance of the information they hold, through good information sharing and thinking about who might hold or need to be aware of information. Learning: Plans need to be: Outcome focused SMART Involve all relevant agencies Consider and involve all the children, parents and relevant wider family Empower professionals to challenge if a plan is not working. (It is good practice to invite professional challenge, as a standing agenda item, at Conferences, Strategy Meetings and Core Group meetings.) Professionals need to identify when parental cooperation with a plan is superficial. Consideration then needs to be given to the impact of this limited engagement on the children. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 15 Professionals need to be curious about information held by other agencies and proactive in sharing information that may improve the understanding of a child’s lived experience. 6.4 Parental Drug Misuse 6.4.1 It is well recognised that the misuse of drugs can have an adverse impact on parenting capacity. The links between the misuse of drugs and neglect are strong, as is denial, chaotic lifestyle, manipulation of professionals and involvement in criminal activity. Amphetamines can make people feel alert, confident and full of energy and can reduce appetite. But it can also make people become agitated and aggressive and can cause confusion, paranoia and even psychosis (Source: NHS England). There are substantial research studies and national guidance through Serious Case Reviews, the NSPCC, the Social Care Institute for Excellence, the Department of Health, and the National Institute for Care and Excellence, which show the effect parental drug misuse can have on the physical and emotional wellbeing of children. 6.4.2 It was not known or suspected until the birth of Sibling 3 that Mother was misusing drugs. It is standard practice for Midwives to ask about mental health and drug use (prescribed or illicit), which was done in the case, but Mother did not identify or confirm anything, even though she had identified to other professionals the use of a prescribed relaxant which she said was for managing stress and sleeplessness. Even when Sibling 3 was clearly very unwell in hospital Mother continued to deny substance misuse. The hair strand test showed a high-medium result indicating regular use and it was only then that Mother acknowledged that she took amphetamine. No professionals had seen any obvious signs of Mothers amphetamine use so could not prepare for any problems arising at Sibling 3’s birth when the baby could have been withdrawing from exposure to narcotics. Neither could professionals offer any support nor drug treatment programmes for Mother when she was pregnant. With hindsight however, Mother’s care of Billy shows that she was not managing prior to her pregnancy with Sibling 3. Even following the birth of her youngest child, Mother had consistently denied misusing drugs. Neither Mother nor her partner appeared to fully accept responsibility or recognise the need to change. 6.4.3 From the outset Mother had informed CSC and early help that she suffered from anxiety, stress and a poor pattern of sleeping. The GP was seeing Mother monthly and reviewing her prescribed medication, however, there was no evidence that the GP considered the impact on her parenting or the children themselves (Think Family)24. The GP didn’t discuss this with any other professional, and other practitioners did not seek consent from Mother to discuss the case with her GP. Hindsight leads to the possibility that Mother may have been using her prescribed relaxant to manage her ‘come down’ when using amphetamines. This should be considered when a patient is being prescribed this particular medication. 6.4.4 No specialist assessment was undertaken of Mother’s mental health, even when she told professionals that her use of amphetamines was largely due to her low mood and a reliance on amphetamines to motivate her. Although Mother was appropriately referred for bereavement counselling. The commissioners of Public Health services in Middlesbrough have contributed to the review and have stressed the importance of staff from all agencies promoting and valuing the importance of early and sustained engagement in lifestyle and 24 Think Family is a whole family approach taken from Think Chid, think parent, think family: a guide to parental mental health and child welfare (social care institute for excellence 2009 (updated 2011). STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 16 behaviour services (including substance misuse and mental health services) rather than waiting until families are at crisis point. 6.4.5 Once her drug misuse was identified, Mother was referred to the drug and alcohol service. An assessment undertaken revealed amphetamine use daily. The assessment did not consider the following however: information related to physical or mental health examination of risks and triggers exploration of protective factors impact on the children (the limited assessment was entirely adult focussed) where drugs were stored, where the children were when drugs were purchased, and the impact on the family finances This was due to the practice in the agency at the time and Mother’s limited engagement with the service. This was not adequately challenged by the agency and information was not shared about the lack of detail and rigour in the work being undertaken. Change, Grow, Live (CGL) have improved since the time being considered by this review and they now encourage parents to engage in group work and provide a specific parenting capacity assessment, which would have been helpful in this case. 6.4.6 Professional curiosity and challenge is extremely important when assessing risk to children when there is a concern about parental drug misuse. Living in a household where a parent or carer misuses substances may not mean a child will experience abuse or neglect but it is a significant risk factor. An analysis of 175 serious case reviews from 2011-14 found that 47% of cases featured parental substance misuse (Sidebotham et al, 2016). There was no evidence to suggest that CGL used professional curiosity, sufficiently challenged Mother, or fully explored her drug use and its impact on each of the children in the household. The wider professional group also accepted Mother’s version of the impact of her drug misuse and did not adequately triangulate it with what they were seeing (Mother was stated to display little or no affection or nurture once the children were no longer babies, she showed a disregard for the children’s safety, had noticeable mood swings and an apparent lack of emotion about her children). There were also concerning features in the children’s behaviour. When working with parents who misuse substances, professionals need to understand what is happening in the home and consider the day to day life of all family members through the child’s eyes. It is only then that they can provide effective support, interventions and challenge. It is unclear what, if anything, the children knew about Mother’s drug misuse. 6.4.7 There are a number of substance misuse risk assessment models available for professionals to use such as SCODA (Standing Conference on Drug Abuse), which if used in this case could have enabled a fuller risk assessment of the drug misuse, Mother’s behaviours, and its impact on the children, and ultimately whether Mother was able to function as a parent in the medium to long term. Learning: Professionals need to understand and consider the day to day life of all family members through the child’s eyes when working with parents who misuse substances. This will enable effective support, interventions and challenge. STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 17 The use of a formal assessment tool, such as SCODA, is of benefit. Any such assessment should be shared with all agencies involved and be updated regularly. A parents self-report of their drug taking must be viewed with respectful caution. 6.5 Neglect 6.5.1 This was a case of child neglect. Neglect is the ongoing failure to meet a child’s basic needs and is the most common form of child abuse. Sometimes this is because a parent does not have the skills or support required, and sometimes it’s due to problems such as mental health issues or drug and alcohol misuse. Neglect features in 60% of serious case reviews and is the most common criteria for a child protection plan.25 6.5.2 Identifying and assessing child neglect is difficult and monitoring progress over time, or lack of progress, can be complex, yet this is crucial for making the right decision about a child’s welfare. The NSPCC have published interagency guidance that sets out the risk factors associated with neglect. ‘Neglect: learning from serious case reviews’.26 The key messages for agencies and professionals are: Be clear with parents about what needs to change and by when. Parents should be respectfully challenged when they fail to follow formal agreements When there’s no long term positive change, the lead professional should co-ordinate support and services. Doing this will help agencies work effectively together Warm relationships between parents and children shouldn’t override concerns about neglect Maintain focus on the best interests of the child rather than the immediate needs of a parent who may be dominant or very needy Improvements to poor home conditions should be regularly reviewed, especially if the family is unlikely to sustain changes 6.5.3 In many ways this was not a ‘classic neglect case’ as the children were reported to be clean and tidy and there was no concern about the state of the home (other than a report of messy children’s bedrooms in January 2017). However the lack of supervision, the emotional detachment of Mother observed both with the children and when the children were discussed with her, the low attainment of Billy and Sibling 1 and 2 at school, poor school punctuality, and incomplete immunisations, were signs of both physical and emotional neglect. There are many forms of neglect and in this case it was predominantly supervisory and emotional neglect. Neglect was not considered in this case until the identification of Mother’s substance misuse however, and the focus was then predominantly on Sibling 3. Neglect was again considered following Billy’s accident when a criminal investigation was carried out by the Police. The Crown Prosecution Service declined to prosecute, but significant harm due to neglect was accepted in the care proceedings in respect of all the children. 6.5.4 There is little evidence that neglect was considered in early assessments, although a number of indicators were present over the review period such as the consistent lack of supervision of the children, the children on occasions being reported as being hungry, Mother failing to follow advice and being distracted by other priorities. Although efforts by a number of 25 Action for Children 2013 26 Neglect: learning from case reviews. Summary of risk factors and learning for improved practice around neglect NSPCC 2014 STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 18 professionals were put in to support Mother she didn’t perceive there was a problem and she did not accept that she needed additional support. Although it does appear that there were periods when the children did receive care that was appropriate and when Mother’s functioning as a parent was adequate, professionals need to be aware of the multi-faceted risk to children caused by neglect and the cumulative impact. Practice in neglect cases can focus on individual episodes or issues of concern, with a failure to step back and look at patterns of parenting and the impact on children on care that dips just above and then below ‘good enough’ on a regular basis. To ensure that any assessment considers cumulative risk there should be a re-examination of each incident or issue so as to assess whether a multitude of factors, when considered together, constitutes significant cumulative harm.27 6.5.5 A chronology should be compiled for each child, which is shared between professionals to ensure that the whole picture is known and considered. Understanding the child’s history over time enables the impact of care that is inconsistent to be known and critically analysed. 6.5.6 Professionals at the Learning Event were able to reflect that plans were too vague, appeared to address the symptoms but not the underlying causes, and not sufficiently focussed on what needed to change. There was limited historical information in regard to Mother’s own history and whether she had experienced neglect and/or poor parenting. There was no assessment of Mother’s cognitive ability or full understanding of her emotional difficulties. As professionals focussed on individual episodes there was a failure to step back and look at patterns of parenting and the impact on the children. Middlesbrough are now using the neglect assessment tool known as the Graded Care Profile 2 (GCP2). The Graded Care Profile (GCP) scale was developed in 1995 as a practical tool to give an objective measure of the care of children across all areas of need where there are concerns about neglect. The second version of the tool, known as ‘GCP2’ was developed to improve on GCP with the core principles of GCP remaining the same. GCP2 is a reliable and valid assessment tool in aiding practitioners in the assessment of child neglect. Middlesbrough Council are in the process of introducing Signs of Safety28. It is hoped that this will have a positive impact on assessments and will enable a holistic and detailed holistic view of the family. It supports professionals to focus on child safety, partnership with parents, identifying strengths that lead to safety, safety planning, and development of safety networks. 6.5.7 Professionals at the learning event highlighted the benefits of management oversight and reflective supervision when dealing with complex families, and cases of neglect. High-quality supervision and management oversight has long been viewed as a fundamental and integral element of social work practice’ (DCSF, 2009:29) and it is increasingly important to other professionals. Direct work with children and families can be highly rewarding as well as complex, stressful and emotionally demanding. There was a mixed picture of how well supervision was accessed and used in this case. There were occasions when advice was taken but advice is not the same as reflective practice. The school do not provide safeguarding supervision to their early help staff, as there is no current statutory responsibility to do so. One health agency discussed the family at one safeguarding supervision session. Early Help recognised that safeguarding supervision was limited at the time, and the social worker had received three safeguarding supervision sessions which was below minimum 27 The terms ‘cumulative risk’ and ‘cumulative harm’ were first identified by Bromfield and Higgins in Australia in 2005 who defined cumulative harm as ‘the effects of patterns of circumstances and events in a child’s life which diminish their sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or layers of neglect.’ 28 A safety and solution orientated approach to child protection case work (Andrew Turnell and Steve Edwards 1999) STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 19 expectations and there was no focus on the family history or the cumulative effect of neglect. Reflective supervision would have offered robust challenge and critical reflection, would have looked at evidence and risks, and would have provided support to professionals. Learning: In neglect cases, professionals may become reactive to incidents rather than considering the child’s lived experience over time. Neglect is damaging to children as its impact is cumulative. Good quality plans and reflective supervision is key to effectively recognising and challenging neglect. 7. Conclusions and recommendations 7.1 It is important to also learn from the good practice identified during the course of this review. Good practice across a number of agencies has been acknowledged throughout the report. A wide range of services and professionals were available to support the family and many of those professionals displayed considerable commitment to improving the care the children were receiving. This included good multi-agency working immediately following Sibling 3’s birth, and a timely and appropriate multi-agency response to Billy’s accident. 7.2 Partner agencies of the MSCB and those individuals working with the family have taken responsibility for this case and are prepared to learn lessons. Their involvement in this SCR has been invaluable. 7.3 The professionals involved wanted the best for this family and worked hard to support them. The 2016 Triennial Analysis of SCRs is clear that for many of the children considered in a SCR, ‘the harms they suffered occurred not because of, but in spite of, all the work that professionals were doing to support and protect them.’ As shown however, the support provided was often as a reaction to a crisis or event and there was insufficient focus on targeting and supporting the individual needs of the four children. Earlier consideration could have been given to whether the neglect they were suffering was a child protection concern that required a time focused plan and assessments of the parent’s capacity to change. There was limited challenge of the Mother to change her lifestyle or to understand her own life experiences and how that impacted on her ability to care sufficiently for her children. 7.4 Professionals and organisations need to reflect on the quality of their services and learn from their own practice and that of others. While a serious case review allows this to happen, it should be a regular part of working in a role where safeguarding is part of the job. Effective and accessible safeguarding supervision is essential if staff are to be helped to put in practice the critical thinking required to understand cases holistically, complete analytical assessments and provide effective interventions.29 7.5 This SCR has considered an individual case, and has identified learning which is relevant both to this specific case, and to the wider system. At the time this review was being completed another SCR on a child to be known as Alex was also being undertaken. The Alex case found learning in regards to parental drug misuse, neglect and planning which was similar to the learning identified here. The publication of the Alex case will be delayed due to on-going parallel proceedings, however the learning should be widely disseminated, along with the learning from this case. 29 Working Together to Safeguard Children- HM Government 201 STRICTLY CONFIDENTIAL - SCR Billy – version 6 FINAL 20 7.6 There have been changes made within partner agencies of MSCB since the work in this case was undertaken, that will have a positive impact on safeguarding children in Middlesbrough. Details of these changes will be included in the MSCB response to this SCR. 7.6 The recommendations made below are intended to add value to the single agency recommendations and are linked to the learning established in this review. Recommendation 1: The MSCB to seek assurance from partner agencies that the learning from this review is being rigorously promoted, in a timely way. Recommendation 2: The MSCB to consider how it can ensure that plans: consistently capture the voice of the child and the child’s lived experience with meaningful analysis include the engagement of all of the relevant professionals invite challenge from those who have concerns about the effectiveness of the plan Recommendation 3: The MSCB to request assurance from partner agencies providing early help about arrangements for reflective supervision for their practitioners. Question for the Board: How can the MSCB ensure that the impact on children of parental substance misuse is appropriately considered in multi-agency assessments and plans? |
NC52533 | Death of 5-month-old girl from sudden unexpected death in infancy (SUDI) in February 2020. Learning includes: when becoming aware of service history in another area agencies should proactively seek historic information to inform their current work; earlier identification of carer support issues and young carer support issues for families triggered by what is known in medical processes; and raise awareness of bereavement support for local professions involved in safeguarding. Recommendation includes: to seek assurances by the provision of evidence that graded care profiles are being undertaken consistently and that they are having an impact on the identification and reduction of neglect; clear guidance on the role of the lead professional; raise practitioner awareness, to include this case as an example of where a trauma-informed approach could have resulted in a more asset based approach to some of the issues (e.g., the behaviour of M6, and the issues of School attendance) in workforce development products and training; and consider the issue of carer support and impact of having an unwell child born into a family that already requires support as a wider partnership and develop an action plan to respond.
| Title: Local child safeguarding practice review: Hallie. LSCB: Wigan Safeguarding Children’s Partnership Author: R. Bolton Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review Hallie Review Author: R Bolton, Social Worker, Business Manager Wigan Safeguarding Children Partnership. Local Child Safeguarding Practice Review Hallie Wigan Safeguarding Children Partnership Introduction: 1.1 The Local Child Safeguarding Practice Review was triggered by the death of a five month old baby girl, known for the purposes of this report as Hallie on 28 February 2020, which was notified to the National Child Safeguarding Practice Review Panel by Wigan Council Children’s Social Care department on 3 March 2020. At that stage police investigations were continuing. 1.2 At around 05:45 on the 28 February 2020, Hallie was found in her cot not breathing and lifeless. Tragically, despite prompt medical attention Hallie could not be revived. The Sudden Unexpected Death in Childhood process commenced, and it was within this initial investigation that concerns about the material conditions in the property, and where Hallie had been sleeping were raised. This, along with the history of Hallie’s family with Children’s Social Care agencies, prompted the CSINs notification and pursuant Rapid Review. Coronial investigations concluded with a recording of Hallie’s death having unexplained natural causes. 1.3 Hallie was the youngest daughter of her mother and father, with three slightly older siblings. All had resided together in a council rented property since 2015. The older children all attended the same local community primary School. 1.4 The review has been undertaken using a systems methodology and root cause analysis, building from the Rapid Review undertaken in March 2020 where initial learning considerations were raised. Due to the ongoing investigations at that stage both from a Police and Coronial perspective, and the impact of the Covid pandemic on all agencies it was not possible to progress with information gathering from agencies at that time and the Local Child Safeguarding Practice Review process effectively commenced in April 2021. 1.5 From the Rapid Review Key areas for further learning were identified and these were developed into themes for Terms of Reference for the report: • What the Hallie case tells us about the response to neglect strategically and operationally in practice, and what improvements can be made? • Whether the Thresholds of Need operating over the preceding period leading up to Hallie’s death was appropriately applied, and if so if they are assistive to practitioners and preventative of harm? • What learning can be taken from the Hallie case relating to practice within partner agencies? • Does Hallie’s case provide assurance of the quality and operation of the ‘front door’ (known as the Multi Agency Safeguarding Team) into services, including at early help level. • Was the initial and subsequent support afforded to Child’s family good quality, and does it present opportunities for learning? 1.6 A LCSPR Panel was formed comprising representatives of the following agencies: Lead Reviewer Learning and Improvement Officers, Wigan Safeguarding Partnership Deputy Headteacher, Primary School AD/Designated Nurse Safeguarding Children and LAC, Wigan Borough Clinical Commissioning Group. Service Lead, Children’s Social Care Detective Constable, Greater Manchester Police Detective Sergeant, Greater Manchester Police Case Review Unit Specialist Safeguarding Nurses, Wrightington Wigan and Leigh NHS Foundation Trust Deputy SENCO and Designated Safeguarding Lead, Primary School 1.7 A Practitioner Learning event took place on 9 May 2021. 1.8 An interview between the review author, the Deputy headteacher of the School, and parents took place in April 2021. 2. Summary and Brief Chronology 2.1 Hallie’s mother and Father are both originally from another borough in Greater Manchester before moving to Wigan in 2013. Hallie’s mother has considerable involvement with Children’s Social Care in that borough prior to her becoming an adult, in terms of neglect and as an identified victim of child sexual exploitation in the period 2005-11. Hallie’s mother described to the author that she used to spend a lot of time associating with older men from a particular community in that borough, and that it was Hallie’s father, who is 17 years her senior, who in her words saved her from that lifestyle and helped her settle down. 2.2 Hallie’s mother and father’s first child, a son, was born in 2011 when Hallie’s father was 17 years old, followed by another son 2 years later in 2012 and a daughter one year after in late 2013. There was then a gap of 6 years before Hallie was born. 2.3 Of note is that Hallie’s siblings were subject to Child Protection Plans under the category of neglect at the time the family moved to Wigan, transferring as active cases to Wigan in July 2013. The Child Protection Plans remained open for a period of 2 months before being closed and the case stepped down to the Gateway (now Start Well) early intervention service. Commentary: Within the limitations of access to the social care records from 2013 and staff having moved onto new roles there is little evidence to outline the reasons stepping down to a lower tier of intervention. Hallie’s Mother reflected on this period in interview with the author, saying that she knew when the children were on Child Protection Plans, she needed a new start or she would lose the children, so she came to Wigan and ‘got the case closed in 3 months.’ 2.4 The benefit of detailing all the information transferred to Wigan from the original borough at this point some seven years later is limited. However, it is suggested that even if there was information provided about Hallie’s father previous history of trauma, its use in any assessment that followed is not evident and the period in which Hallie’s mother and father could have got to know services in Wigan was very short before the move to Gateway. 2.5 From the period of 2013 – 2018 there were 5 other contacts to Wigan Council Children’s Social Care relating to concerns for welfare for the children, domestic abuse, neglect, and poor home conditions. None of these contacts prompted re-opening the case at a Child Protection level, with the rationale being given that the family were being supported by the Gateway level of services. 2.6 In that period the primary services that Hallie’s parents and siblings were accessing health visiting services, due to the close ages of the children, and towards the latter end of that period they began to have contact with school as Hallie’s older siblings entered the school. 2.7 Hallie’s mother and father’s interactions with school were frequent since the children commenced attending there. The school is in an area with high social deprivation and can resource a comprehensive pastoral support programme, and there was frequent contact between the family and the workers offering support. Some of this support was very ‘practical’ in terms of assisting with School pick up and drop off, sometimes providing food to the children via the school breakfast club. 2.8 The main interaction between school and the family was via Hallie’s mother. Over the period from 2018 onwards school report that there were various occasions where their interactions with Hallie’s mother led to her becoming verbally aggressive either when challenged or when she felt aggrieved that something was unfair in relation to her children. Hallie’s mother has reflected on this when interviewed by the author and has stated that she ‘says what she thinks’ and sometimes it causes trouble. Commentary: Against the backdrop of Hallie’s mother’s own experiences of abuse and neglect it is perhaps not difficult to envisage that one of the consequences of this is that she had found it difficult to develop positive verbal reasoning and communication skills, and what professionals may see as ‘appropriate’ behaviours to respond to what she may perceive as challenges to her abilities to parent her children. There had never, apparently, been a reflective look at Halle’s mother’s history and in the absence of this her behaviours were pathologized rather than being trauma-informed. 2.9 Throughout the review process, school provided evidence of their previous concerns relating to the siblings of Hallie and how they had contacted Social Care to make referrals in relation to the observed neglect of the siblings. There was (and is, under a renewed offer) an Early Help framework in place but this was not utilised by the School. In understanding the possible reason why this was not used, the School reflected in the Learning event that their experience at the time was that as they have a strong pastoral support offer they have a high threshold for looking for external support on cases, and that when they made referrals it was at a stage where they felt they had not been able to achieve progress at that initial level. The school at the time did not hold the view that the facilitation of an Early Help process would have given them scope to deal with the issues surrounding Hallie’s mother and father as they do not have access to the ‘adult’ agencies working with the family. 2.10 There is a lack of information or knowledge throughout the chronologies available to the Local Child Safeguarding Practice Review about Hallie’s father. Typically, the information in primary health records and health visiting records, concentrates heavily on the behaviours of Hallie’s mother and those of Hallie and her siblings. There are occasional recordings in relation to Hallie’s father around him working and this creating childcare pressures for Hallie’s mother and of him sometimes being the one bringing the children to School but there is little evidence of curiosity leading to improved richness of the information. Commentary: This, as time goes by, creates availability bias and confirmation bias rather than focussing on finding the missing information and it becomes the accepted position that not much is really known about Hallie’s mother, nor is there attempts particularly to engage him. The issue of ‘hidden men’ is recurrent in case reviews, and this review, along with recent research in this area1 are cause for Wigan Safeguarding Children Partnership to further review and update the workforce development approaches that are ongoing on this issue. 2.11 Hallie was born 28th Sept 2019 spontaneously at home slightly premature at 35 weeks gestation, so she and her mother were conveyed to hospital. She made positive progress on the neonatal unit establishing feeding and temperature control and returned home with her parents within around 72 hours. 2.12 Health visiting commenced soon after Hallie’s return home, and notably the Health Visitor involved (HV1) who had worked with the family almost continuously over the last 5 years was re-allocated to the case. Hallie’s mother considers this as an area of great strength as she already had a trusting relationship with HV1 and that HV1 was the one consistent person who she would talk to. There was also involvement by lthe Neo Natal Outreach team from the hospital trust due to Hallie having spent time on the neonatal unit. 2.13 Records seen by the Review Panel evidence that for the following 3-4 weeks there was a good level of communication between professionals involved, albeit that at times there is a lack of analysis. There was increasing evidence of care needs not being consistently met, and this is well documented in the Neonatal Outreach record however at no point was there evidence of measures such as the Graded Care Profile being used to document neglect. The Safeguarding Team in the hospital trust have responded by facilitating mandatory neglect and Graded Care Profile Training to the children’s workforce in the trust in August 2020. 2.14 Over the period covering Hallie’s birth and early life there is an absence of the use of any assessment tools to scale the concern about the evident neglect. It would be expected that the Graded Care Profile would be used, but whilst there are recordings of the observed issues there is little to lift these into a more objective form where progress could be similarly measured. The lack of embedding of the Graded Care 1 ‘The Myth of Invisible Men’ National CSPR, Sept 2021. Profile Tool use across agencies that form Wigan Safeguarding Children Partnership is an ongoing concern being progressed by training and quality assurance processes. Commentary: Whilst nappy rashes are not uncommon, there is no improvement over a 3 week period when advice on management was given. In this period there is recording by the same professional about the poor state of the home but there is no evidence of consideration of whether Hallie’s physical condition was possibly being due to her not being afforded sufficient care, and a lack of analysis until the final visit on the 25 October. 2.15 The neonatal outreach team closed the case on 25 October, however as a point that evidences good practice, they contacted the duty health visitor (DHV) on the team that HV1 worked to enquire whether their concerns about home conditions on the 25 were present in the Health Visiting Record. The neonatal outreach nurse was told that there were no concerns documented, and that she should make a referral to social care if she had concerns. The DHV then later noted that there were indeed some concerns noted on earlier case records from the return home visit by HV1 but decided not to contact the neonatal outreach nurse with this update as she felt that the Neonatal Nurse should make the referral to Social Care Multi-Agency Safeguarding Team (MAST) based on her own professional judgement of the concerns she had observed. Commentary: The primary issue here is that prioritising the safety and wellbeing of Hallie was lost in the process. Whilst the Neonatal Nurse had clearly some concern and could have contacted the MAST to discuss them and potential response, she sought to consolidate her view first by contacting her HV colleague. This was not, in effect necessary but the Local Child Safeguarding Practice Review Panel considered it reasonable to share information at this stage. Nonetheless, on doing so she was then given incorrect information that would have lessened the concerns she held. The DHV then within a few minutes on further review noted that the information she had given was either incomplete or incorrect. The thorough review the DHV undertook was expected practice, however the decision to not then recontact the Neonatal Nurse to correct her earlier information was unsafe if we refocus the issue on Hallie’s safety. The recorded reason given that the neonatal nurse should still refer based on her own concerns is irrelevant when, at that stage, the neonatal nurse did not possess the most relevant information on which to base a decision. This practice episode is not something that the Local Child Safeguarding Practice Review Panel consider to be symptomatic of a wider system, it is purely professional decision making mistakes which are best approached through the existing systems of support and supervision. 2.16 Hallie was unwell over the 5 months of her life, having repeated presentations to hospital due to respiratory problems and apnoea. In December 2019 and January 2020, she was twice resuscitated by either Ambulance staff or A+E doctors after 999 calls. On a further 3 occasions she had been presented to A+E unwell by her parents and over the course of her short life she had been admitted for observation on a total of 5 occasions. Hallie had been seen by numerous doctors, including two consultant Paediatricians the day before she died in a clinic appointment. At the time of her death Hallie was undergoing extensive assessments in relation to metabolic problems (weight maintenance and feeding were difficult for her), genetics investigations as well as the respiratory problems. Commentary: Hallie’s health was a known factor that was both chronic and occasionally acute over her short life. As covered in 2.13 the impact of neglect on this was missed. Section 3 Themes raised by the review into the death of Hallie: 3.1 The role of the Lead Professional, impact on Thresholds and understanding of neglect: What can be observed in this case is that HV1 was, through no formal procedure, acting supportively in a role that would be considered as being the Lead Professional in an early help approach. However, the case was not being managed through a structured process which would have brought professionals together to review risks and progress at regular points and would have applied governance. In effect, what was occurring was those various professionals e.g., HV1, school, Outreach nursing were all trying to manage the safeguarding issues as they were presented to them rather than collaboratively. Where the concerns are around neglect, shared professional understanding is crucial as it requires objective reflection, but these opportunities were missed in this case and created a passive case management model. Resultantly, the Local Child Safeguarding Practice Review Panel’s view is that opportunities to trigger the case into a Child Protection Response were missed. The evidence for this is that despite there not being any sudden downturn in the home conditions, when Social Care intervention was triggered in January 2020 there was decisive action taken in terms of facilitating a deep clean of the property and outside area, and in replacing Hallie’s bedding. However, what this also raises is that this was being facilitated by a Children’s Support Worker under a tiered response and was practically focussed – it produced improvements to the material nature of the home, but there is a lack of evident oversight from a Social Worker who may have applied more of a thresholds of neglect oversight of the issues. Learning and Recommendations: At the time of Hallie’s death work was ongoing to review and redesign the Wigan Safeguarding Children Partnership Thresholds document for professionals and following the Covid Pandemic, which started in March 2020, this was completed and rolled out across the workforce. This may have addressed the key points that Hallie’s case highlights but there is a need for a recommendation in relation to this area to avoid any kind of confirmation bias (Kirkman, Melrose 2014).2 2 “Clinical Judgement in Decision-Making in Children’s Social Work” Kirkman and Melrose, Dept of Education 2014. Recommendation 1 For Wigan Safeguarding Children Partnership to seek assurances by the provision of evidence from and Start Well, CSC, Health and wider partners that Graded Care Profiles are being undertaken consistently. Recommendation 2: For there to be clear guidance produced by Wigan Safeguarding Children Partnership on the role of the lead professional. Recommendation 3: For the new 2021 Thresholds framework, including lead professional role and implementation to be quality assured via a multi-agency Wigan Safeguarding Children Partnership process in early 2022, with specific audit enquiry points included in relation to this case. 3.2 Cases transferring into the area and adopting a trauma informed approach. Hallie’s case evidences the impact that vulnerable individual families or individuals moving from one area to another has on the spectrum of agency involvements there to support them and this is well understood in the context of ‘Troubled families’ 3. On moving to Wigan, the long and involved history of Hallie’s mother with statutory agencies through her childhood during which she had been a victim of child sexual exploitation and her mental health support needs were not relayed as she did not have active involvement at the time, and understandably she and Hallie’s father wanted a new start. In context, when Hallie’s mother started to have contact with agencies in Wigan she would not have perhaps considered what they did not know about her and she told the author this; she had been so familiar with having professional involvement throughout her life she thought they might know more than they evidently did. In 2013 when Hallie’s mother came to Wigan, there had not been investment in developing a trauma informed approach4 and therefore whilst there is abundant evidence of practitioners and professionals interacting with Hallie’s mother over 2013 – 2020 in a compassionate, supportive manner the professional understanding and reflection of how Hallie’s mother may be presenting trauma related behaviour was less apparent. There is similar learning regarding the impact of trans-generational parental trauma and abuse forming parts of historic case reviews in the borough5 and the embedding of a truly trauma informed approach across agencies is a key priority for Wigan Safeguarding Children Partnership over 2021-22 and a trauma informed approach is being developed and embedded. 33 “Troubled families: Vulnerable families experiences of multiple service use” Blackwell, 2012 4 “Trauma informed social work practice” Levenson, NASW Press, 2017 5 Child T (2021 Unpublished) and Child F+G (2017, Wigan SCB). Learning and recommendations: Hallie’s mother and Father move into the borough in 2013 is not captured in current information systems so it is not possible to comment on whether there were missed opportunities to transfer information. However, a situation arises where when Hallie’s mother comes into first contact with Wigan agencies there is no evidence of attempts to build an understanding of her background. Current Greater Manchester Safeguarding Procedures detail case transfer processes which have improved greatly since 2013, however what this case shows is a little more nuanced as it was not a live case. When becoming aware of service history in another area agencies should proactively seek historic information to inform their current work. Recommendation 4: To raise practitioner awareness, Wigan Safeguarding Children Partnership should include this case as an example of where a trauma-informed approach could have resulted in a more asset based approach to some of the issues (e.g., the behaviour of Hallie’s mother, and the issues of School attendance) in workforce development products and training. 3.3 Impact of an unwell child being born into the family: Hallie was a baby with poor health, and an emerging picture of her needs was evolving as medical investigations took place. It was felt that Hallie would have had long term, enduring additional needs and whilst these were not diagnosed specifically by the time of her passing it is evident from the number of emergency admissions that she was very unwell and therefore vulnerable. The Local Child Safeguarding Practice Review Panel considered whether systemically we apply a strengths based, early intervention approach to situations like this; i.e. whilst health providers take the lead in those diagnostic processes do we collectively consider impact on the welfare and wellbeing of the siblings and parents in relation to assessment of the impact of any additional caring needs and supporting the family through the transition to looking after a very unwell child with emerging long term difficulties. The view was that there could be earlier identification of carer support issues and young carer support issues for the family triggered by what was known in the medical processes. Recommendation 5: For Wigan Safeguarding Children Partnership to consider this issue at a future executive meeting and identify any prospective improvements that can be made. 3.4 Bereavement Support: Through this Local Child Safeguarding Practice Review both Hallie’s mother and father were spoken to by the lead reviewer. Whilst not within the scope of the lines of enquiry for this review, both reflected in those sessions the disjointed way in which they had been offered support following Hallie’s death. Hallie’s mother had had to go via her GP to access long distance support from the bereavement team at a tertiary children’s hospital, and Hallie’s father said he had never been offered any support at all. Wigan Safeguarding Children Partnership has a well-developed Bereavement Strategy and this case offered learning for a couple of key points around local professional awareness, as for example Hallie’s mother did not have to access support via her GP it could have been a self-referral etc. There is no separate recommendation for this point but the learning has been fed into the Wigan Safeguarding Children Partnership Bereavement Support Group who are undertaking a mapping exercise of referral routes into various supportive local agencies. Section 4: Summary of Recommendations: Recommendation 1 For Wigan Safeguarding Children Partnership to seek assurances by the provision of evidence from and Start Well, CSC, Health and wider partners that Graded Care Profiles are being undertaken consistently and that they are having an impact on the identification and reduction of neglect. Recommendation 2: For there to be clear guidance produced by Wigan Safeguarding Children Partnership on the role of the lead professional. Recommendation 3: For the new 2021 Thresholds framework, including lead professional role and implementation to be quality assured via a multi-agency Wigan Safeguarding Children Partnership process in early 2022, with specific audit enquiry points included in relation to this case. Recommendation 4: To raise practitioner awareness, Wigan Safeguarding Children Partnership should include this case as an example of where a trauma-informed approach could have resulted in a more asset based approach to some of the issues (e.g., the behaviour of M6, and the issues of School attendance) in workforce development products and training. Recommendation 5: For Wigan Safeguarding Children Partnership to consider the issue of carer support and impact of having an unwell child born into a family that already requires support as a wider partnership and develop an action plan to respond. |
NC51286 | Death of a premature 9-week-old baby girl in June 2017 from unascertained causes. Mother had fallen asleep with Child Y and when she was awoken by her 7-year-old daughter, Child Y was not breathing. Child Y was of African-Caribbean ethnicity. Mother had history of mental health difficulties, and reported being sexually abused as a child in the West Indies, and learning difficulties due to a childhood accident. Mother and Child Y's four siblings were known to Children's Social Care Services and Police; NSPCC referral in 2016. History of violence within relationships with Fathers 1 and 2, and private law dispute about residence arrangements with Father 1. A Family Assistance Order was made in 2015. Allegations of physical abuse and online sexual exploitation involving Siblings 1 and 2 and Father 1 lead to a Children's Social Care assessment. Social workers concerned about Mother's parenting; risks of co-sleeping with Child Y were discussed on several occasions. Five children (including Child Y) and Mother were living in the two-bedroom flat, which health visitors noted were poorly decorated and sparsely furnished. Police observations at the time of Child Y's death showed that the home environment was dirty and smelly, with no suitable sleeping place for Child Y. Learning includes: the need for raised and constant professional curiosity; learning about invisible men; a greater willingness to escalate issues if agency responses appear insufficient; effective record keeping. Recommendations include: policies and guidance should be amended to require midwives and health visitors to enquire about, observe and record, where and in what a baby is/is to be sleeping.
| Title: Serious case review: Child Y. LSCB: Lewisham Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lewisham Safeguarding Children Partnership Serious Case Review Child Y Author: Fergus Smith 1st June 2018 Contents 1 INTRODUCTION 1 1.1 ‘Trigger incident’ & reason for serious case review 1 2 MOTHER’S BACKGROUND 5 2.1 Childhood & previous relationships 5 3 PERIOD OF REVIEW: 2016 – CHILD Y’S DEATH 6 3.1 Introduction 6 3.2 Concerns about the well-being of child Y’s siblings 6 3.3 Awareness of & initial response to child Y pregnancy 13 4 RESPONSE TO TERMS OF REFERENCE, CONCLUSIONS & LEARNING 23 4.1 Response to terms of reference 23 4.2 Conclusions 27 4.3 Learning 28 5 RECOMMENDATIONS 29 5.1 Introduction 29 5.2 Lewisham Safeguarding Children Board 29 5.3 Lewisham Clinical Commissioning Group 29 5.4 Lewisham Children’s Social Care 29 5.5 Lewisham & Greenwich NHS Trust 29 CAE 1 1 INTRODUCTION 1.1 ‘TRIGGER INCIDENT’ & REASON FOR SERIOUS CASE REVIEW 1.1.1 Mother’s account of the trigger incident is that she had lain down on a double bed with her 9 week old baby (referred to in this report as ‘child Y’) and fallen asleep. She was awoken by her 7 year old daughter who noticed blood coming from the baby’s nose. An ambulance was summoned and transported child Y to hospital. Resuscitation attempts which had begun at the home and continued en-route to hospital were unsuccessful and child Y was declared deceased at 14.11 on 10.06.17. 1.1.2 Child Y (a female of African-Caribbean ethnicity) had been born at 32 weeks gestation, spent 22 day in the Neonatal Unit at Lewisham Hospital, primarily to establish feeding, and had then been discharged to the care of her single mother who was by then living with 4 other children in a 2 bedroom flat. During child Y’s stay in hospital, mother had been seen to share a bed and had been advised on more than one occasion that this could be risky because such an immature baby cannot maintain its airways. 1.1.3 Post mortem examinations revealed no specific cause, natural or unnatural to account for the death, which appears to be ‘Sudden Infant Death Syndrome (SIDS)’1. 1.1.4 A ‘rapid response meeting’ of the ‘Child Death Overview Panel (CDOP)’2 was convened on 15.06.17 and details about mother’s complex social history discussed. A recommendation was made that a serious case review (SCR) should be undertaken. That recommendation was ratified on 12.10.17 by the independent chairperson of Lewisham’s Safeguarding Children Board on the basis that the required criteria for completing a SCR (reproduced in paragraph 1.2.1) were satisfied. 1.1.5 The Department for Education (DfE), regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE)3 were informed of the above decision and this review was undertaken between November 2017 and March 2018 in accordance with the terms of reference reproduced in section 4. Following approval by Lewisham’s Safeguarding Children Board (LSCB) a copy of this report is being sent to the NPIE and DfE. 1 SIDS is defined as the death of an infant older than 7 days and less than 1 year of age that remains unexplained after review of the clinical history, circumstances of death and negative post-mortem examination; it is a sub-set accounting for about 80% of the larger total of ‘sudden unexpected death in infancy’ (SUDI) – 20% have a clear cause such as an infection or criminal conduct. 2 Each Local Safeguarding Children Board (LSCB) is responsible for ensuring that a review of the death of any child ordinarily resident in its area is completed by a CDOP which may (as in this case) alert the LSCB chairperson to its view that a serious case review may be required. 3 The NPIE was established by central government in 2013 in order to advise Local Safeguarding Children Boards on the initiation and publication of serious case reviews. CAE 2 1.2 PURPOSE, SCOPE & PROCESS OF THE REVIEW 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died or has been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. A SCR is not concerned with attribution of culpability (a matter for a criminal court), nor the cause of death (the role of a Coroner). 1.2.3 The period of review was from 01.01.16 to child Y’s death on 10.06.17 though issues and events of particular relevance prior to 2016 have also been considered. An independent report was commissioned from Children Act Enterprises (CAE) Ltd (www.caeuk.org). On the basis of material supplied (a merged chronology of agencies’ contacts and self-critical individual management reviews), lead reviewer Fergus Smith would: Collate and evaluate it Conduct consultation / learning events with relevant professionals and Develop for consideration by the serious case review team a narrative of agencies’ involvement and an evaluation of its quality, conclusions and recommendations for action by the LSCB, member agencies and (if relevant) other local or national agencies FAMILY & PROFESSIONAL INVOLVEMENT 1.2.4 Attempts were made at face to face contacts, to involve mother in this review. She declined to participate and made it clear that she was opposed to its completion. An early briefing event for involved professionals was convened when the purpose and process of the SCR was explained and queries resolved. 1.2.5 The aims of involving staff at the above initial and at a planned second event were to ensure the accuracy of information within the report, to amend or clarify provisional conclusions and to encourage acceptance and application of the learning that was emerging. In the event, there was insufficient response amongst involved practitioners for a second event and the learning from this review is being incorporated into the Safeguarding Children Board’s ongoing training and development programmes. CAE 3 PANEL MEMBERSHIP Lead reviewer (chairperson) Lay representative from the Lewisham Safeguarding Children Board (LSCB) Consultant Community Paediatrician & Designated Doctor Lewisham Clinical Commissioning Group (CCG) Designated Nurse Safeguarding & Looked After Children for Lewisham CCG Options & Advice Manager Strategic Housing Borough of Lewisham Safeguarding Children’s Adviser Lewisham & Greenwich NHS Trust Named Midwife Lewisham & Greenwich NHS Trust Named Nurse Lewisham & Greenwich NHS Trust Quality Assurance Manager Lewisham Children’s Social Care Service Manager Access, Inclusion & Participation Lewisham Service Manager for Safeguarding & Reviewing Hackney Representative of Metropolitan Police Service Representative of London Ambulance Service + Interim Safeguarding Children Board Business Manager SOURCES OF INFORMATION Lewisham Clinical Commissioning Group (GP Services) Lewisham and Greenwich NHS Trust Queen Elizabeth Hospital (midwifery, neonatal and health visiting services) Lewisham Children’s Social Care (responding to referrals and liaison with Hackney Children’s Social Care) Hackney Children’s Social Care (responding to referral, supporting a Family Assistance Order and liaison with Lewisham) School attended by sib.3 and sib.4 Metropolitan Police Service (responding to earlier reported offences and the SCR trigger event) London Ambulance Service (LAS) (emergency response to trigger event) Children & Family Court Advisory and Support Service (Cafcass) (a letter summarising its involvement) CAE 4 IMMEDIATE FAMILY (APPROXIMATE AGES AS AT DATE OF Y’S DEATH) Father of Sib.1 & 2 35 Mother 34 Age 34 Sib.3 10 Child Y 9 weeks Father of Sib.3 & 4 38 Sib. 4 7 Sib. 1 15 Sib. 2 13 Father of Child Y ? dob ? CAE 5 2 MOTHER’S BACKGROUND 2.1 CHILDHOOD & PREVIOUS RELATIONSHIPS 2.1.1 Child Y’s mother has reported being sexually abused by a family member as a 6 year old child back in the West Indies. She has also reported (though no medical / psychological confirmation has been traced) that as a result of an accident in childhood, she has some learning difficulties, in particular with reading and writing. 2.1.2 It is understood that mother arrived in the UK in 1999 when she was 16 years of age. In 2002 she became pregnant with sib.1 and went on to have a second daughter sib.2, both by ‘father 1’. 2.1.3 Mother’s relationships with father 1 (and to a lesser extent with the father of her next 2 children) were volatile. Mother initiated numerous allegations of violence by father 1 toward her, or one of their daughters. Mother and father were though, consistent in declining to provide witness statements to support any potential prosecutions. 2.1.4 Observations of officers attending the various reported incidents suggest that mother was at times the instigator of violence and often exaggerated or invented allegations. Mother’s mental health was observed by attending police officers to be fragile. 2.1.5 Mother and father 1 split up and re-united on an unknown number of occasions and finally parted in about 2015 (by which time mother had borne 2 more children by ‘father 2’). Mother’s allegations against her ex-partner continued throughout a prolonged private law dispute about residence arrangements and into the period of review described in section 3 below. Information supplied by the Children and Family Court Support and Advisory Service (Cafcass) confirms that a ‘Family Assistance Order (FAO)4 had been made on 06.11.15. 2.1.6 In late 2015, the court had determined that the girls should be resident with their father with alternate weekend and half of school holidays with mother. The court’s direction for sib.1 was that she was to have contact with her mother ‘at father’s discretion’. Sib.2 appeared to be ambivalent and on occasions (sometimes it seems at her mother’s request) made false allegations against her father or exaggerated typically adolescent grievances. This pattern of behaviour continued and is analysed in more detail in the period under review. 2.1.7 The numerous contacts with mother and father 1 and father 2 in the decade preceding the review period is that Police responses were prompt, proportionate and complied with Metropolitan Police Service (MPS) guidance. 4 A FAO is issued under s.16 Children Act 1989 as amended by Sch.3 para. 56 Adoption and Children Act 2002 and s.6 Children and Adoption Act 2006; it is a means of providing for up to 12 months, social work support to families experiencing difficulties after separation or divorce; the court conveys a duty on a CAFCASS or a local authority social worker to befriend, advise and assist anyone named in the order (often in relation to facilitating and monitoring contact with a child/ren). CAE 6 3 PERIOD OF REVIEW: 2016 – CHILD Y’S DEATH 3.1 INTRODUCTION 3.1.1 This section contains an account with some italicised commentary about professional standards of the services provided during the review period. Section 4 offers a response to each element of the review’s terms of reference and summarises overall conclusions and learning. 3.2 CONCERNS ABOUT THE WELL-BEING OF CHILD Y’S SIBLINGS 3.2.1 Information provided by school refers to an incident in mid-January 2016 when mother was thought to be homeless and sib.3 (then aged 8.5) was described by staff as ‘struggling with anger issues’ and ‘not always attending school’ (the attendance rate of sib.3 and sib.4 was approximately 90% - a level considered unacceptable by the local authority). MOTHER’S REFERRAL TO CHILDREN’S SOCIAL CARE 3.2.2 Mother attended Lewisham Children’s Social Care on 15.02.16.She reported concerns about father’s care of her two elder daughters who lived with him (following private legal proceedings the previous year) in Hackney. The response given by the ‘advice & information worker’ was that mother should seek legal advice and no further action was taken. Mother’s confusion about her legal status (she wrote that she did not hold parental responsibility, though she did) and a difficulty in reading and writing was noted. Information emerging from this review indicates that mother’s concerns included her claim that sib.1 (age 13) had previously lived through domestic violence and of sib.2 (age 11) was being ‘molested’ by her ‘violent and aggressive’ father. Comment: on the basis of what was alleged, a referral to Hackney Children’s Social Care should have been initiated; in spite of a subsequent re-design and reported increase in capacity of the service (heavily overloaded at the time) a precautionary recommendations had been made in section 5. NSPCC REFERRAL TO CHILDREN’S SOCIAL CARE 3.2.3 2 days after mother’s expression of concern and prompted by mother providing similar allegations to the NSPCC a formal referral from that agency was sent to Hackney and (for information) to Lewisham Children’s Social Care. This referral suggested mother’s reference to father ‘sexually molesting’ his elder daughter, might refer to him talking about menstruation. Mother had also claimed that the girls were not resident with her only because she had been made homeless in 2015. On receipt of this referral, the Lewisham MASH team manager TM1, determined that no further action (NFA) was required of her agency. Comment: insofar as the allegations related to the children living in Hackney and that its Children’s Social Care Service was known to have been alerted, the management decision was proportionate to the available information. CAE 7 3.2.4 Hackney’s response, having gained the consent of their father, was to meet both elder girls alone and separately at school. Sib 1 (aged 13) refuted all aspects of the referral and said that she had chosen not to see her mother. She claimed that her sister sib.2 (aged 11) who saw their mother every weekend was ‘brainwashed’ by her. Sib.1 reported that when living with her mother she had been obliged to complete household chores and look after her younger siblings. She also indicated that her mother ‘made things up’. 3.2.5 Sib. 2’s responses were significantly different. She reported father to be violent and wanted to live with their mother. She acknowledged though, that mother had asked her to say that father hit and molested her sister. Comment: Hackney’s response was thorough; the complexities of the family situation were already becoming apparent. ON-LINE SEXUAL EXPLOITATION 3.2.6 Whilst mother’s allegations were being investigated, sib.2 revealed to Police that her elder sister had been sending explicit images and videos of herself to older men. With father’s co-operation, officers arranged a forensic examination of the child’s laptop and confirmed contacts as described, with 2 adult males in America. Interpol was alerted and no further action was taken by the Metropolitan Police. ALLEGATION OF ASSAULT BY SIB. 2 3.2.7 On 29.02.16 sib.2 accompanied by her mother, attended Lewisham Police station and alleged an assault by her father (a slap on the upper arm). Sib. 2 said that she wanted to live with her mother. Father had meanwhile reported his daughter as ‘missing’ and later characterised the event as a further example of his ex-partner seeking to get the court order determining residence with him, to be altered. Strategy discussion 3.2.8 A strategy discussion was held between the Child Abuse Investigation Team (CAIT) DS1 and SW1 in Hackney Children’s Social Care and a decision made that father’s admitted slap of his daughter did not reach the threshold for a prosecution and that a single agency investigation would suffice. 3.2.9 On the basis of there being no evidence to support mother’s allegations, a decision would be made on the 01.03.16 that no further action was required of the Police CAIT and that a Children’s Social Care assessment would begin. CAE 8 Sib.2 ‘Emergency Department’ presentation 3.2.10 The precise timing of events is uncertain, but on 01.03.16 sib. 2 (presented by whom was unrecorded) attended the Emergency Department (ED) at University Hospital London (UHL). She complained of symptoms (soreness of a small contusion to one of her shoulders) which she suggested were linked to the reported assault by father. Her living arrangements as noted by staff, were that she lived with her father during the week and her mother at weekends. 3.2.11 The incident was intended to be referred to the internal safeguarding meeting, by means of a completed CAF and the GP informed. Comment: records do not confirm that the attendance was debated at the safeguarding meeting on 03.03.16, nor is there evidence that Children’s Social Care was directly notified either via the completed CAF or by phone; this represented a missed opportunity for better multi-agency recognition of the family dynamics and a more accurate risk assessment. A recommendation is included in section 5. Assessment of need 3.2.12 At a visit made by Hackney’s assessing social worker SW2 on 01.03.16 sib. 1 expressed a wish to remain with her father and cited difficulties if she were to be resident with her mother, e.g: Being less required to attend school Having to complete excessive chores Being hit with a belt ‘weekly’ Excessive and embarrassing religious rituals (drinking and ‘anointing’ with oil) 3.2.13 Sib. 2 who was spoken to alone, acknowledged some positive aspects of living with her father but felt less favourably treated than her sister. She expressed a determination to move to her mother. The social worker’s record indicated his view that school attendance and behaviour were likely to deteriorate if sib.2 moved back to her mother. Though neither child reported violence between their parents, they both spoke of an incident in which their mother threatened their step-father with a knife and recalled that the Police had been involved. The description of maternal care raised implications for the younger siblings which were recognised and triggered actions described below. Comment: the social worker’s concerns and responses were, on the basis of known information, justified. CAE 9 3.2.14 On 02.03.16 both parents were seen separately. Father complained of the difficulty of maintaining contact because his ex-partner moved around so much. Mother expressed her belief that it was inappropriate for teenage girls to be cared for by a male. Later on 10.03.16, Lewisham Children’s Social Care was alerted by Hackney’s SW2 to the need to assess mother’s parenting of her younger children, citing: Mother taking money from the children when she had seen them for contact Trying to influence the children to make false allegations against their father (including sexual misconduct toward sib.1) and seeking an intrusive and un-needed medical examination An allegation by sib. 1 that her mother had last year smashed her mobile phone and poured oil on her to rid her of (presumably bad) ‘spirits’ 3.2.15 Lewisham’s TM2 required further enquiries to be made and on 22.03.16 spoke by phone with Hackney’s SW2 who had met the Lewisham-based children as part of his work. He indicated that: The August 2015 s.47 enquiries had concluded that father had not acted unlawfully Hackney had no ongoing concerns about father’s parenting Hackney’s concern was focused on mother’s mental health and its impact on her care of the children living with her Sib.2 spoke warmly / positively about her mother whilst sib. 1 had declined any contact for some 5 months 3.2.16 After a final home visit, SW2 indicated the case in Hackney would be stepped down to the ‘Family Support Team’. Lewisham’s TM2 later determined the reports from Hackney did not meet the local threshold for an assessment. She discussed this with SW2 who was completing a S.7 welfare report5 for private legal proceedings. He agreed to re-refer if his contact raised new, or reinforced current concerns. Comment: SW2’s current involvement offered a level of reassurance; however, (and allowing that no confirmation has been found that they were actually included in what was shared with Lewisham) some of the earlier issues identified by the older girls coupled with existing knowledge about mother would have justified an attempt by Lewisham to engage her, obtain consent for further checks and to explore the younger children’s lived experiences; the response suggests a higher threshold for a response may have been applied in Lewisham. 3.2.17 Mother registered sib.3 (aged 9) and sib.4 (aged 6) with ‘GP Practice 1’ in Lewisham on 14.03.16. A further visit to the older girls’ father reinforced SW2’s view that he was capable of meeting their needs. 5 Under s.7 Children Act 1989 a court may ask the local authority to complete and submit a report on any aspect of a child’s welfare; this typically arises as in this case, in the context of parental disputes about residence or contact. CAE 10 2ND SET OF ALLEGATIONS BY MOTHER 3.2.18 On 29.03.16 in a phone call with mother, an unnamed Lewisham duty social worker tried but was unable to get mother to consider whether she was encouraging, or actually asking her daughters, to initiate false rumours about her ex-partner. Comment: a justified attempt; the value of records is diminished if it is not possible to define which professional made them. 3.2.19 During the same conversation mother reported that she had called Police in August 2015 in the belief that sib. 2 whilst on the phone to her half-brother had been assaulted by her father. Mother claimed this daughter had reported being beaten until she vomited blood and had been refused access to a hospital. Mother claimed to have had no feedback following Police involvement. Comment: this had been investigated by Police and Hackney Children’s Social Care; sib.1 had refuted the account offered by sib.2 and mother – an example of mother’s tendency to imagine, exaggerate or invent (with the additional risk that the example she was setting would be followed by sib.2). 3.2.20 Mother refuted the allegation about anointment for religious reasons and went on to link alleged domestic abuse by her elder daughters’ father with her depression and referred to being ‘in and out of hospital’. She alleged her elder daughters had not been registered with a GP and spoke of sib.2’s episodic breathing problems. She referred also to the criminal record of her ex-partner for violence in 2003. The record of this phone conversation refers to mother ‘being irrational though not abusive’ throughout and constantly yelling. Mother acknowledged lifelong involvement with child protection and care services. The conversation was ended by the duty social worker who judged that it was not going to be possible to derive further useful information. Comment: a discussion of this significance should not be conducted by phone; the call nonetheless highlighted a range of reasons to be concerned about mothers care of dependent children which should have been followed up. 3.2.21 The report submitted by Lewisham Children’s Social Care identified scope for improving co-ordination on its IT system, of emails, records of phone conversations and ensuring duplication of relevant information across the case records (when relevant) of siblings. The agency has reported the initiation of corrective action, though a cautionary recommendation has nonetheless been included in section 5. 3RD SET OF ALLEGATIONS BY MOTHER 3.2.22 On 06.04.16 mother alerted Police to an image on Instagram of sib.2 (then 13) holding a large knife. She again emphasised her fear of her ex-partner and did not want officers to attend his address for fear of repercussions. Mother declined an appointment offered and was advised to contact Children’s Social Care (whether Hackney or Lewisham is unclear) because it was understood that the agency was already involved. CAE 11 3.2.23 Lewisham TM2 completed on 08.04.16, a record of her decision (and its rationale) of ‘no further action’ by Lewisham with respect to mother’s latest allegations. Hackney would contact again if a planned visit to the younger children in Lewisham revealed any further or new concerns. Comment: the decision and (helpfully) its associated rationale were justified. 3.2.24 A week later (on 13.04.16) sib.3 (aged 8) and sib.4 (aged 7) were each seen alone during a home visit by Hackney’s SW2. The former described being religious, singing songs, reading the bible and praying. In addition he described doing chores around the house which ‘he enjoyed’. His sister reported that he also ‘did cooking and cleaning’. Sib.4 identified her mother’s favourite pastime as praying and reported being smacked on the hand with her mother’s open hand if naughty. Comment: given the reported level of age-inappropriate exploitation, it is unsurprising that sib.3 had also reportedly accidentally burned his sister’s leg whilst boiling water for noodles; a scar on his hand said to have been caused by a mop was also noted though how that old injury had (or was said to have) occurred was not captured in records. 3.2.25 At the same home visit, a lack of bedding on the bunk beds was noted. Mother’s assertion that it was being washed was accepted and her account that the children preferred to sleep with her left unexplored. 3.2.26 Mother identified a large family network in Enfield, though no detail was sought or provided (more curiosity and follow-up might have generated useful support). She also reported having been ‘bright’ before a childhood accident (an account later repeated to a health visitor). Mother proposed consulting her GP for her acknowledged illiteracy. RENEWED CONCERNS FROM HACKNEY 3.2.27 On 29.04.16 Hackney’s SW2 emailed Lewisham’s Emergency Duty Team (EDT). Based upon his direct work with sib.1 and sib.2, he was concerned about mother’s parenting. Hackney was, he reported, seeking a medical examination to clarify whether there was evidence of physical abuse of sib.1 whilst with mother (‘weekly belting’). Sib.1 had reported similar mis-treatment of sib.3 and sib.4. SW2 also reported that mother was at times, using an unidentified person whom she had known for only 2 months to care for her children. Comments: these allegations (with the exception of the unknown caregiver where the nature of his concerns are not stated) and references to historic domestic abuse were essentially repeats of those previously reported in March. 3.2.28 SW2 sought a ‘needs assessment’ of sib.3 and sib.4. The initial response of TM4 was focused on the reference to mother’s use of an unfamiliar caregiver and concluded that more information e.g. results of the checks completed for the s.7 welfare report being completed for private law proceedings, would be required of the referrer before Lewisham’s threshold for an assessment was met. CAE 12 3.2.29 The proposed response was ratified by TM2 who noted that mother had previously indicated an unwillingness to have Children’s Social Care involvement (she had reported having been in care herself and having an antipathy toward social workers). It has been reported that the ‘no further action’ response would have been relayed back to Hackney by ‘Business Support Staff’ and that no further request for agency involvement was received. Comment: setting aside the uncertainty about what was actually fed back to Hackney (Lewisham has been unable to locate a record of it), TM2 had on 08.04.16 suggested that SW2 get back in touch if concerns remained; from the perspective of the involved children, there remained unresolved allegations of use of a belt etc. 3.2.30 At about this time GP Practice 1 received a request for information to support a ‘S.17 assessment’ of the siblings in the care of mother. Comment: Hackney was undertaking a S.7 report, not a S.17 assessment, responsibility for which (if one was being completed) would fall to the borough in which children lived; it may be that the Practice was unfamiliar with s.7 and mis-recorded the request. 3.2.31 School 1 has described a minor incident at school on 13.05.16 when sib.3 (rising 9) rolled up some paper like a cigarette and said he was smoking ‘weed’. This was apparently discussed with his mother. COMPLETION OF HACKNEY’S ASSESSMENT & FINAL COURT HEARING TO DETERMINE RESIDENCE OF SIB.1 & 2 3.2.32 The conclusion of Hackney’s assessment was that the allegations against the older girls’ father were unsubstantiated and his care was good. The case was stepped down to the Family Support Team. Mother’s inability to focus on anything except her determination that her elder girls be returned to her care was made clear. A final court hearing was, following mother’s representations, put back until 27.07.16. 3.2.33 There was a further incident on 22.06.16 when sib. 2 was reported to the Police by her father not to have returned home from school and was later found at her mother’s home. She described being shouted at but not hit, by her father the day before and was very resistant to returning to him. Police did return her to her father and completed a Merlin notification to Children’s Social Care. 3.2.34 At the final court hearing on 27.07.16 an application by mother for a change of residence for sib.2 was dismissed. The existing Family Assistance Order (FAO) made in November 2015 was extended until 26.01.17 so that Hackney could try to assist the parents with contact arrangements. On 01.08.16 Hackney’s SW3, some days ahead of a deadline to report to the court on progress, sought from Lewisham information about any parenting course in the borough that mother might attend. CAE 13 3.2.35 The above communication seems to have been mistaken for a request to confirm whether mother had been on such a course. An email reply was sent to Hackney 4 days later from Lewisham’s MASH confirming the dates of earlier referrals to Lewisham (March and April). Comment: the response to the question from Hackney (which was itself not entirely clear), indicates that it was misunderstood; the report submitted to the serious case review also identifies a systemic weakness in how such contacts are captured in Lewisham and a recommendation is made in section 5. MOTHER’S REQUEST FOR LEARNING DISABILITY ASSESSMENT 3.2.36 On 15.09.16 mother consulted GP1 and sought an assessment of her cognitive capacity. She referred in particular to her difficulties in reading / writing and was referred to a ‘Mental Health Learning Disability Team’. The referral was turned down later that month with a suggestion that the GP re-direct the referral to IAPT6 (though this source is not known to offer the form of assessment required and requested). Comment: the rejection of the referral was unfortunate. Some insight into mother’s learning needs could have helpfully informed professional expectations of her ability to cope with parental challenges; the need for certainty about where such assessments may be undertaken is believed to be of national significance and justifies a recommendation in section 5 that the LSCB alert NHS England. 3.3 AWARENESS OF & INITIAL RESPONSE TO CHILD Y PREGNANCY 3.3.1 On 04.10.16 mother presented at A&E complaining of abdominal pains and revealed a positive pregnancy test some 3 weeks earlier. 3.3.2 During October 2016 father was increasingly concerned about events at the girls’ school and community, and associated bullying. His previously good level of engagement has been described as diminishing from this point. In late October mother called Police twice to report what appeared to be a neighbourhood dispute about noise levels. This was reported to have been resolved without any formal action. 3.3.3 GP3 was consulted by mother on 25.10.16 and initiated an ante-natal referral which referred to her history of sexual abuse, domestic violence, a daughter who had been subject to a child protection plan in 2004 and mother’s depression during 2005. The GP did not take the opportunity to initiate a safeguarding referral and the concerns mother alluded to were not coded in a manner that would facilitate immediate identification from the summary page of the primary care record. 6 The IAPT programme began in 2008 and is focused on treatment of adult anxiety disorders and depression in England. CAE 14 3.3.4 Whilst a ‘vulnerable child in the family’ code was later added to mother’s medical records, it was not added to those of sib.3 and sib.4, rendering recognition of need / risk less easy at subsequent GP presentations. 3.3.5 On 01.11.16 school 1 report that sib.3 was clearly upset though unable to clarify why. The special educational needs co-ordinator (SENCO) liaised with SW2 from Hackney Children’s Social Care who reported his 2 unsuccessful attempts to prompt acceptance of a referral by Lewisham Children’s Social Care. Comment: it is unfortunate Hackney did not escalate its justifiable concerns. 3.3.6 At a further GP consultation on 03.11.16 this time with GP3, mother was issued with a form to excuse her from seeking work. It cited awaiting an assessment by the learning disability team, ‘severe learning disability’, ‘dyslexia’ and pregnancy. Comment: the referral for an assessment by the learning disability team had already been rejected, though mother may not at this stage have been informed of that. Aside from pregnancy, the descriptions (severe learning disability and dyslexia) went beyond the knowledge base / competence of a GP. 3.3.7 A midwife MW1 saw mother at GP Practice 1 on 07.11.16 and recorded risk factors as ‘previous social services involvement, past domestic abuse, learning disability, and 2 older children living (for unknown and unexplored reasons) with their father’. Mother refused to provide details of a man to whom she claimed to be married, who lived ‘far away…and who was awaiting ‘immigration status’. Mother also referred to her own mother (child Y’s grandmother) having a ‘learning difficulty’. With her consent, a referral was made that day (presumably on the basis of mother’s self-reports – the CAF was completed later) to the Midwifery Safeguarding Meeting and Lewisham’s Children’s Social Care MASH. Comment: in the light of mother’s responses (some of which were untrue, lacking credibility or misleading e,g. ‘no social worker involvement since 2006’) a good deal of relevant information had been obtained by the midwife whose response to what she was told, was sensitive and prompt. 3.3.8 At the routine ‘maternity safeguarding meeting’ on 11.11.16 (it is uncertain whether a social worker was present) it was noted that mother’s childhood experiences had not been explored at the booking appointment and that she had not referred to the (anyway incorrect) ‘fact’ provided by the GP that her eldest child had been subject of a child protection plan in 2004. The outcome of the discussion was that the ‘safeguarding midwife’ MW2 would, in consultation with MW1 complete a CAF. This was done by 16.11.17 CAE 15 3.3.9 There is no evidence that the Health Visiting Service was (as intended) sent the completed CAF by Midwifery. The later ‘targeted’ ante-natal visit suggests though, an awareness of additional needs prompted by her awareness that a CAF was going to be completed. Neither health visitor nor midwife followed up with either involved borough. The ‘Maternity Safeguarding Pathway’ now requires a copy of each maternity safeguarding notification to be sent to health visitors and GPs via secure email, so no recommendation has been made. 3.3.10 At a further consultation with GP5 on the same day, mother reported that her visa allowing her presence in the UK, was due to expire in January 2017. She was advised that she could seek a supportive letter from the Practice and she did so in December. On 16.11.16 MW1 completed and submitted a CAF to Children’s Social Care. Comment: the implications of mother’s immigration status had been largely un-explored though Lewisham’s Children’s Social Care had noted that mother had been and was no longer of ‘no recourse’ status, claimed at that time to ‘have recourse to public funds’ and was hence in receipt of Benefits. 3.3.11 Lewisham Children’s Social Care TM1 authorised on 18.11.16, a formal response to the Midwifery referral and receipt of the completed CAF. ‘Information and advice’ about children’s centres including one for adults with learning difficulties was provided. MW1 has no memory of receiving confirmation of Children’s Social Care’s response and no record of such feedback has been traced. The view held in Lewisham was that the involvement of the court in ongoing residence-related private law proceedings and Hackney’s work was sufficient. No further information or escalation of its concerns was initiated by Midwifery where MW1 had assumed that the named midwife routinely followed up any CAF referrals). The absence of such ‘follow-up’ unintentionally reinforced a view in Social Care that it needed to take no additional action. Comment: mother was known to be functionally illiterate and to have significant learning and mental health difficulties; some allegations against her were serious and SW2 who had met all the children had explicitly recommended an assessment; Lewisham’s response took insufficient account of known history; its response again raises questions about the threshold being applied. ANTE-NATAL CARE & OTHER SIGNIFICANT EVENTS 3.3.12 At a ‘Targeted’ Ante-natal Health Visiting’ meeting on 13.12.16 the case was allocated to HV1 with a view to offering ante-natal contact. An appointment letter was sent for a visit on 20.02.17. Comment: mother’s illiteracy, though known to agencies did not prompt the use of alternative / supplementary methods of communication; the formal ‘vulnerable ante-natal pathway’ required a visit within 4 weeks of a referral. CAE 16 3.3.13 Sib.1 and sib.2 were by early 2017, displaying some intimidatory behaviours toward other pupils and school was having difficulty in getting their father to attend and discuss the issue. On 10.01.17 bullying by sib.1 was sufficiently serious to prompt by Police a ‘First Instance Harassment Warning’ and for the school to require her to sign an ‘Acceptable Behaviour Contract’. Father failed to attend a ‘Team Around the Child’ meeting on 25.01.17 and concerns about sib.1’s use of social media continued. 3.3.14 At the planned home visit on 20.02.17 HV1 explored mother’s background and was told of previous abusive relationships and that Children’s Social Care involvement had been a function of her having ‘no recourse to public funds’. Mother reported that the Home Office had now granted her ‘leave to remain’. She attributed the fact that her elder daughters lived with their father to her previous homelessness. 3.3.15 HV1 noted the flat to be sparsely furnished though tidy. She identified no hazards. Required equipment for the baby was discussed (though it is unclear whether suitable sleeping arrangements were actually confirmed) and a genogram completed (an expectation in targeted health visiting cases). Mother’s self-reported learning difficulties remained un-explored. 3.3.16 There were also unexplored discrepancies between mother’s accounts of her relationship with child Y’s father in the maternity safeguarding record and that noted by HV1, with the former referring to a supportive man and the latter to her having asked him to leave because of verbal and emotional abuse. Comment: neither Health or Social Care records in either borough refer to the father of child Y (father 3) ever having been resident; ‘father 2’ and father 3’ are essentially invisible – a recurring challenge for professionals working with anxious and avoidant families. 3.3.17 Mother again attributed involvement of Children’s Social Care during her relationship with father 1 as being about her lack of recourse to public funds and referred (inaccurately) to one of her 2 elder daughters having been subject of a child protection plan. The extent and impact of mother’s apparent learning difficulty / disability remained unexplored and represented a missed opportunity to better appreciate the extent to which they might impact on parenting. 3.3.18 HV1 agreed to review the situation at 36 weeks gestation and asked whether mother might wish to join the ‘Maternal Early Childhood Sustained Home (MECSH) visiting programme7. Completion of a maternal mood assessment revealed no concerns. Comment: the accuracy of mother’s account remains uncertain; HV1’s records have been described as concise and accurate, though mother’s response to the appropriate offer made, remains unknown. 7 MECSH is a structured programme of sustained home visits for families at risk of poorer maternal and child health and development outcomes. CAE 17 3.3.19 At a midwifery appointment on 23.02.17 mother reported having ‘separated’ from her husband and linked this to verbal abuse. JOINT INVESTIGATION OF FURTHER ALLEGATIONS 3.3.20 On 05.03.17 mother presented her elder daughters to Hackney Police station where they described an alleged assault by their father on Christmas Eve. They also referred to a number of other incidents when their father had been drunk and acted in an aggressive manner. STRATEGY DISCUSSION 3.3.21 Following a strategy discussion on 06.03.17 between DS2 and TM3, it was agreed that the allegations would be jointly investigated and that the girls could meanwhile remain with their mother. Father appeared to be accepting of the girls’ stay with his ex-partner, though did later that month query how this could be reconciled with the court-ordered arrangements for residence. 3.3.22 When mother was seen by MW1 at GP Practice 1 on 13.03.17 she reported the fact that her daughters were now with her and went on to register her 2 younger children with the Practice. Mother was not asked when her daughters had joined her, though it seems likely that it had occurred since her last contact with MW1 in February. 3.3.23 A social worker met with both girls together on 15.03.17 and Achieving Best Evidence (ABE) interviews were completed on 17.03.17 when the girls offered comparable accounts. Sib.2 reported to the Hackney social worker that her mother claimed that their father was a gang member (something not identified in the report supplied by Police). Father reluctantly agreed to ‘child protection medicals’ which were finally completed on 27.03.17. Comment: sib 1 in a further ABE interview on 16.07.17 would admit that she had been coerced by mother and sister into making her allegations; sib.2 would also admit over the summer that their mother had persuaded them to exaggerate some occasional smacks inflicted by their father. By that time though, over 6 months had elapsed which (as a matter of law) precluded the possibility of any potential prosecution for common assault. 3.3.24 HV1 was informed on 27.03.17 by the midwife that sib.1 and sib.2 had returned to their mothers’ care as a result of allegations against father of physical abuse. Police were said to be involved. Neither the midwife (who was new to community-based work and unaware of any such expectation) nor health visitor shared this information with either local authority Children’s Social Care. This was an example of insufficient professional curiosity and represented a missed opportunity. 3.3.25 Following an interview under caution on 05.04.17 the criminal investigation of allegations against father were passed to the Crown Prosecution Service (CPS). CAE 18 BIRTH OF CHILD Y & POST- NATAL SUPPORT 3.3.26 In response to a 999 call on 08.04.17 mother was transported to Lewisham Maternity Unit where child Y was born prematurely (by caesarean section) later that day and subsequently transferred to the neonatal unit (NNU). Though its origin and recorder remains unclear, some biographical information was captured in the hospital’s paper records and some intention (which remained unfulfilled) was expressed to seek further information about mother’s social situation. Comment: it is important that the origin of information (which may or may not be accurate) as well as the involved professional are clearly recorded. 3.3.27 Mother returned home after 3 days at which point it is unclear what proportion, if any of the previous concerns about mother and family were recognised by ward staff. A post-natal phone appointment was arranged for 21.04.17 and child Y remained in the NNU. Mother’s post-natal discharge summary was uploaded to the electronic record and a copy sent to the GP on 11.04.17. The summary contained no reference to the concerns identified by Midwifery or NNU staff or the referral to Children’s Social Care. Comment: this was a missed opportunity to recognise and respond across agencies to a significant level of established social need. 3.3.28 Research during the course of this review has confirmed that MW1 completed a visit to mother on 12.04.17 (child Y was then 4 days old) and on 18.04.17 (day 10). She subsequently asked Community midwives to visit on 02.05.17. 3.3.29 In response to what or whom is unrecorded, but on 19.04.17 the neonatal consultant provided a letter advocating the need for a warm, clean and dry environment for a pre-term baby with an increased risk of respiratory diseases. During the course of the SCR, it has been deduced that this may have been prompted by a ‘notice of intention to evict’ received by mother on 21.04.17. 3.3.30 HV3 applied (by phone) a standard test8 for possible depression on 21.04.17 and found no cause for concern. A home visit was to be made once child Y was home. Comment: though good practice to check on emotional well-being, a new birth visit should be completed (in hospital if not at home) within 7-14 days post-delivery. There appears to have been no curiosity with respect to the result of the referral to Children’s Social Care, about which the health visitor should have been aware. 8 The ‘Whooley’ questions for depression are 1. During the last month, have you often been bothered by feeling down, depressed or hopeless? (YES/NO); 2. During the last month, have you often been bothered by little interest or pleasure in doing thing? (YES/NO)…….YES to one or both questions is take as a positive screen for depression (Whooley et al, 1997). CAE 19 3.3.31 Following a GP consultation the day before, on 22.04.17 sib.2 was seen at A&E complaining of chronic ankle pain. Whilst there, she reported physical abuse of her sister. This (appropriately) prompted the examining doctor to contact Hackney Children’s Social Care where confirmation of the residence arrangements and reassurance about the girls’ safety was provided. A&E records capture mother’s claim to be homeless and to have experienced past domestic abuse. 3.3.32 At a neonatology meeting on 24.04.17 it was reported that no safeguarding concerns had been identified whilst child Y was an in-patient and that staff were aware of mother’s background. 3.3.33 The day after the above meeting at a ward round by the consultant, the need to clarify the outcome of the Midwifery Service CAF supplied to Children’s Social Care and to explore mother ‘rooming in’ (i.e. staying with her baby) was identified. NNU staff consequently made contact with Lewisham’s MASH. On the paper records used, names, roles are unclear (a recurring problem in hospital records seen). 3.3.34 Whilst acknowledging the liaison with Lewisham’s MASH as good practice, the report supplied to this serious case review evaluated the NNU’s level of understanding of recorded safeguarding concerns / social history as insufficient e.g. it is uncertain whether staff were aware of the return to mother of her elder daughters. 3.3.35 On 27.04.17 an unidentified doctor (once again the signature is illegible) was told that the response to the CAF had been that a referral to a Children’s Centre was to be made. This was accepted without challenge. On 28.04.17 mother was offered advice and shown a DVD about basic life support (BLS) but said she was too tired to complete the practical aspect thus leaving it uncertain what she had actually understood. She was advised about the risks of co-sleeping and appropriate ways to maintain the optimum temperature for child Y. 3.3.36 Mother disclosed to the NNU nurse Children’s Social Care involvement with sib.1 but was apparently too upset to elaborate. She confirmed her separation from the father of child Y and referred to a ‘church sister’ who was looking after her other children whilst she ‘roomed in’. Comment: curiosity about the ‘church sister’ and the reasons for Children’s Social Care involvement would have been helpful (together with the earlier example of not following up mother’s reference to having extended family in Enfield, this offers an example of insufficient professional curiosity). CAE 20 CHILD Y’S DISCHARGE HOME 3.3.37 After 6 ‘high dependency’ and 7 ‘special care’ days, child Y was discharged on Sunday 30.04.17 (a Bank Holiday weekend). A discharge summary was sent to the GP Practice (and by 03.05.17 was uploaded to ‘child records’ and thus available to the Health Visiting Service). In addition to plans for ongoing medical support, safeguarding issues were included and some (inaccurate) information brought forward from obstetric notes. On 02.05.17 a phone call was anyway made to the Health Visiting Service to confirm the discharge and request regular weighing of child Y. Comment: that otherwise useful liaison and request for weighing could usefully have been completed prior to the discharge of child Y; such notifications are now completed by email thus rendering it unnecessary to formulate any recommendation. 3.3.38 A community midwifery visit was completed on 02.05.17 (by a midwife other than MW1 – no signature was provided). Mother was breast-feeding and apparently managing well in ‘temporary housing’. On 03.05.17 sib.1 and sib.2 (newly registered patients) were mistakenly coded by the GP Practice as being ‘subject to child protection plans’. Comment: all professional records should be attributable to the individual who generated them; the mislabelling at the Practice suggests that either GP5 and/or administrative staff may need to be briefed on the precise meaning of a child protection plan. 3.3.39 HV2 visited on 08.05.17 but mother was not at home and was seen instead on 11.05.17. On 09.05.17 child Y was brought by her mother to a paediatric ophthalmology clinic (the results of which became available only after the death of child Y). 3.3.40 At her visit on 11.05.17 HV2 had concerns, but not about mother’s parenting. Mother reported that her elder daughters were present (not at school) because, following abuse by their father, they were living with her. She refused to name child Y’s father. The impact of mother’s self-declared learning difficulties were discussed. A report to this serious case review by school 1 referred to a listless and unwell sib.4 (then aged 10) saying at school the day before ‘mum says I will be in trouble if I don’t stay in school’ and ‘mum has a new baby.’ 3.3.41 Mother denied using drugs, alcohol or tobacco. The risks of co-sleeping were discussed (as they had been whilst child Y in hospital) and mother advised to consult her GP as soon as possible to obtain a further formula prescription. HV2 left mother a list of tasks to be completed and she intimated that the children could help her read them. CAE 21 3.3.42 Amongst her comprehensive observations of the accommodation, HV2 noted that the flat was poorly decorated, sparsely furnished and that during the visit, mother had killed what may have been a cockroach. ‘Baby equipment’ was noted in the living room, though it is uncertain whether this included somewhere suitable for child Y to sleep (in view of the co-sleeping at the time of death, a relevant issue). Comment: 5 children including a vulnerable baby were living in this 2 bedroom flat; whilst self-evidently less than ideal, it is understood such a situation is not unusual and would not constitute ‘overcrowding’9; the need for health visitors and midwives to be inquiring about sleeping arrangements is recognised by the inclusion of a recommendation is section 5. 3.3.43 Though raised in the ante-natal period, the option of joining the MECSH programme was not re-visited. Nor does it seem that the CAF completed by the Midwifery Service and passed to Children’s Social Care had been supplied to or anyway informed responses of the Health Visiting Service. In the knowledge that her older children helped their mother to read, a list of baby-related issues that needed to be raised with the GP was formulated and left. Mother reported that her elder girls had a social worker and that due to his abuse of them, their father was in Police custody. Comment: if the health visitor had made contact with Children’s Social Care, she would have learned that mother’s account was inaccurate and a further example of well-established behaviour patterns; depending upon children to interpret for a semi-literate parent is not good practice. 3.3.44 At what may have been a chance encounter on 12.05.17 at the GP practice (mother was there in her own right), HV2 undertook to source a pram, though did not explore further how mother was coping without one. She observed that child Y was being cared for by sib.1 (aged 14). 3.3.45 Later that week an enquiry made of mother by Hackney Children’s Social Care about the elder girls’ non-school attendance elicited the information that she was unhappy with the school, resentful of local services and of the behaviour of the girls’ father. Next day father attended the office in Hackney to express his concern about a deteriorating level of school attendance. Father later (25.05.17) reported to Hackney that sib.1 was unhappy about her mother’s plan to change her school but was scared of saying so. 3.3.46 Mother failed to bring child Y for a cranial ultra-sound scan on 02.06.17. The apparently standard response was a note (directed toward whom is not stated) stating …’please review the clinical situation and advise if this is still required’. Comment: the consequences of such an unclear and rigid policy will be experienced by the child patient rather than the parent, and requires re-thinking. 9 See House of Commons Library BRIEFING PAPER Number 1013, 14 November 2016 ‘Overcrowded Housing (England)’ see http://researchbriefings.files.parliament.uk/documents/SN01013/SN01013.pdf CAE 22 3.3.47 At an appointment on 09.06.17 with GP6 name mother mentioned housing and visa problems (she had previously claimed to have been given a right to remain in the UK). Child Y received her initial immunisations on the same day. TRIGGER INCIDENT & OBSERVED ENVIRONMENT AT TIME OF DEATH 3.3.48 At 13.22 on 10.06.17 a 999 call was received to report a 2 month old female not breathing and with blood coming out of her mouth and nose. Child Y was transported to hospital where after further unsuccessful attempts to resuscitate her, life was pronounced extinct. A post-mortem examination suggested natural causes and in consequence the Coroner’s Office discontinued its investigation. 3.3.49 Police observations of the environment in which the family were living were markedly different to those captured about a month before by the health visitor. The most significant issues recorded on the day that child Y died were of an excessively high temperature, cockroach infestation, a very dirty and smelly environment, no available food and no indication of a suitable sleeping place for child Y (a ‘Moses’ basket was being used to store clothes). 3.3.50 It may be that, in consequence of the pressure of all 5 children, the environment had deteriorated rapidly from the ‘acceptable’ condition observed a month earlier. Equally, it may be that the police officer was more critical in his assessment. CAE 23 4 RESPONSE TO TERMS OF REFERENCE, CONCLUSIONS & LEARNING 4.1 RESPONSE TO TERMS OF REFERENCE WAS PROFESSIONAL AWARENESS SUFFICIENT TO RESPOND EFFECTIVELY TO: Needs and lived experience of the children Needs of mother? Cultural, identity and other diversity issues within the family Potential indicators of abuse (e.g. mental health, drugs, alcohol, domestic abuse) 4.1.1 Hackney’s SW2 had very appropriately sought and distinguished between the views of both sib.1 and sib.2 during the thorough enquiries prompted by the NSPCC referral of February 2016. 4.1.2 In spite of the efforts expended by Hackney, it is not entirely certain that the (historical?) allegations made by sib.1 of mother’s use of a belt were entirely resolved. Had Lewisham responded differently to mother’s initial allegations or to the liaison initiated by SW2 in March and April 2016, the ‘lived experience’ of sib.1, 2, 3 and 4 might have become clearer. 4.1.3 Setting aside issues of sib.3’s school attendance and associated comments the child made to school staff, some observations of family circumstances also raise questions about the children’s ‘lived experience’ e.g: The extent to which mother was depending upon her then 8 year old son to clean and cook and look after his younger sister (as well as the credibility of his enjoyment of praying) The lack of bedding accepted in April 2016 (the record made by Police on the day of child Y’s death, suggests that the children and in particular child Y, may latterly have had nowhere suitable and safe to sleep The impact of what was recognised in both boroughs as (at best) exaggerated allegations about father’s conduct (immediate anxiety / confusion for the children and setting an example (which sib.1 and sib.2 later followed) 4.1.4 The needs of mother (in particular potential mental health needs) were recognised by Hackney as of significance in terms of her capacity to look after her children. There remains doubt about the precise detail shared by SW2 with TM2 in Lewisham. It does though seem that by default, rather than design, Lewisham assumed that unless or until an explicit allegation emerged from the private law proceedings (which were themselves essentially limited to the narrower issues of residence and contact), or SW2 presented more compelling evidence, the borough’s threshold for assessment was not reached. CAE 24 4.1.5 The unsuccessful attempt in late March 2016 by the Lewisham duty social worker to encourage mother to recognise the direct and indirect impacts on her children that exaggerated allegations were having, provides evidence that staff were mindful of the problem. Mother’s histrionic responses proved sufficient on that occasion, to close down this justified line of enquiry. 4.1.6 Perhaps of central importance (without a formal assessment it was not possible for involved professionals, nor the serious case review panel to form a conclusive view) was mother’s level of cognitive ability and associated capacity to parent a large and growing family. 4.1.7 No agency identified any concerns about drugs or alcohol and no evidence has been located to suggest that they should have done. All were told of mother experiencing domestic abuse though the comprehensive record supplied by the Police (much of it pre-dating the review period) as well as accounts offered by her children suggest that she may have as often been a perpetrator. WERE HISTORICAL FACTS KNOWN OR TAKEN SUFFICIENTLY INTO ACCOUNT: Parents’ history Any previous involvement of either parent with Adult or Children’s Services 4.1.8 Whilst Hackney Children’s Social Care worked directly with the father of sib.1 and sib.2 and clearly recognised his historical and current capacity to be a ‘good enough’ parent, other agencies captured very little about fathers 1, 2 or 3. This was in part a result of mother’s refusal to divulge information, in particular the name of child Y’s father (whom she described as her ‘husband’ and whose identity she disclosed to Police only after child Y’s death). It was also a function of an insufficiency of professional curiosity and recognition of the relevance of such men either as a source of support or because of a need to evaluate the risk they might pose. 4.1.9 Mother’s reference in April 2016 to a large family network in Enfield remain unexplored though could (if accurate) have been the source of much needed support. Her reference to a lifelong and unwelcome involvement of social workers (as well as her histrionic behaviours during the aborted phone conversation in March 2016) might usefully have prompted more reflection on mother’s personal history. CAE 25 4.1.10 Whilst there was a level of consistency in mother’s reports of her childhood and associated accidents and abuse, there existed no easy or obvious way (she having apparently entered the UK aged 16) of confirming or challenging what was reported. Some of her assertions having been recorded in good faith, were shared with other agencies and became accepted as ‘fact’: A childhood accident that had left her with lifelong learning difficulties (encapsulated by some agencies as ‘illiteracy’ and by others as ‘dyslexia’) Sib.1 having been subject of a child protection plan in 2004 A series of relationships in which she had been the ‘victim’ 4.1.11 With respect to issues that may be described as diversity-related, Lewisham records offer evidence of some exploration of mother’s erstwhile precarious existence as someone with ‘no recourse to public funds’ (NRPF). The extent to which the man described as mother’s husband (child Y’s father) was relevant to her or his wish to remain in the UK remains uncertain. WERE POLICIES & PROCEDURES EFFECTIVE? Did practice accord with ‘Working Together to Safeguard Children 2015’ Local multi-agency policies and procedures Did actions accord with assessments and decisions made Were appropriate services offered or provided or relevant enquiries made in the light of assessments Were records systematically reviewed to evaluate and assess risk 4.1.12 Hackney’s response to the NSPCC referral of mid-February 2016 was thorough. It and the response to sib.2’s allegation of an assault by her father were proportionate and justified. The Police response to the on-line exploitation of sib.1 confirmed between those 2 sets of allegation was also the right one. 4.1.13 The alleged physical abuse by mother referred to first in March 2016 seems to have been marginalised in the subsequent exchanges between boroughs. 4.1.14 In October 2015 Hackney would have been justified (based upon London-wide agreed procedures) in escalating its view that Lewisham Children’s Social Care should complete an assessment of mother’s parenting of the younger children. Uncertainty about the Lewisham’s threshold criteria then and now justifies a precautionary recommendation for consideration by what is understood to be a current strategic ‘MASH Steering Group’ charged with ensuring lawful and effectives responses to contacts by other agencies and individuals. CAE 26 4.1.15 The joint investigation of the further allegations raised by mother in March 2017 was somewhat delayed because of the birth of child Y and by default rather than intention, ended (contrary to the views of the court in private law proceedings) with the elder girls becoming and remaining resident with their mother. 4.1.16 There were latterly examples of actions not following agreed policies / protocols e.g. compliance with ‘vulnerable ant-natal pathway’ or timing of the new birth visit. 4.1.17 All actions taken by operational staff appear to have been supported by relevant managers and although there were inadequacies such as a lack of signature in several health records or a failure to obtain further necessary information necessary (each specified at relevant places) none resulted in any adverse result to child Y or her siblings. WAS QUALITY OF WORK GOOD ENOUGH? Voice of the children Information sharing Thresholds for intervention Record keeping Managerial oversight (first-line & senior) Were there deficiencies due to organisational capacity (resources, staffing, other underlying systemic issues) Professional disagreements 4.1.18 As noted elsewhere, the voices of child Y’s siblings (and at minimum, sleeping arrangements for child Y) could have been explored more. SW2 was careful to recognise and seek the views of each child he met, but the account by the 8 year old sib.3 of his positive enjoyment of chores and praying (and his sister’s account of his culinary responsibilities) are surprising and were worthy of further enquiry. 4.1.19 As stated above, the allegation of sib.1 of her mother’s use of a belt as well as the professional concerns about mother’s mental health shared by Hackney, ought to have been explored and were unintentionally overlooked in the several exchanges between involved boroughs. 4.1.20 No indications emerge of any reluctance to share information between agencies though several examples where this was not achieved in a timely or effective manner have been identified. An inability to identify the author of several (mostly health) records diminishes their value. 4.1.21 Lewisham Children’s Social Care has acknowledged that some of its response were constrained by the then structure and level of demand. It is clear that Lewisham’s threshold for intervention was higher than Hackney’s. The SCR panel was concerned to ensure that the current threshold criteria are appropriate and consistently applied and has in consequence developed a recommendations within section 5. CAE 27 4.2 CONCLUSIONS 4.2.1 This serious case review highlights the challenges for all involved professionals of distinguishing between the majority of victims of domestic abuse whose experiences go under-reported or insufficiently recognised and a proportion whose allegations about adult on adult or parent on child assaults, are fabricated or exaggerated. 4.2.2 Police and Hackney Children’s Social Care (as well as the court in the private law s.8 Child Arrangements Order proceedings) succeeded in drawing that distinction. 4.2.3 Whilst it was to a degree shaped by its responsibility of discharging the extended Family Assistance Order, the threshold for intervention by Hackney Children’s Social Care was lower than that applied by its equivalent in Lewisham. 4.2.4 The need for greater certainty about mother’s cognitive ability and any associated deficit in parenting ability was, helpfully, recognised and the attempt by the GP to respond to mother’s request for an assessment a welcome one. The failure of the attempt illustrates what is believed to be a more widespread gap in the portfolio of services required to safeguard and promote the welfare of children. 4.2.5 Health Services had expended significant efforts in advising mother on how to minimise the risks of SIDS. A less ready acceptance of mother’s reassurances about sleeping arrangements would have been desirable. The fatal event itself (setting aside an increased level of risk associated with bottle-feeding and excess room temperature) was unpredictable and unpreventable by any actions that might reasonably have been taken by involved professionals. CAE 28 4.3 LEARNING 4.3.1 Transcending responses provided to the individual elements of the terms of reference and the broad conclusions of the review, the more general learning points (the first 5 emerge often in serious case reviews) are that: The case offers several examples of the need for raised and constant professional curiosity (and respectful uncertainty about parental assertions) – it remains a matter of debate to what extent insufficiency of such curiosity is a function of overload / lack of time to reflect on observations, or about the individual professional Recorded personal history is a critical source of evidence in evaluating presenting circumstances There are significant benefits in identifying and learning more about ‘invisible men’ (potentially sources of support as well as risk) There should be a greater willingness to challenge / escalate issues if agency responses appear insufficient or are not confirmed The need to maintain effective record keeping (ensuring identification of author and when relevant, legibility of writing) is vital in complex multi-agency work There remains a need to further promote amongst parents an understanding of what research has revealed about sudden infant death and how to reduce risk CAE 29 5 RECOMMENDATIONS 5.1 INTRODUCTION 5.1.1 The following recommendations are those considered to be of most strategic significance and may require further multi-agency negotiation. 5.2 LEWISHAM SAFEGUARDING CHILDREN BOARD 5.2.1 The LSCB should alert NHS England to the widespread absence of any commissioned arrangements which enable GPs to refer-on for a diagnosis of a learning disability and the extent to which it is impacting or may impact, on future capacity to provide safe and good enough care to dependent children. 5.3 LEWISHAM CLINICAL COMMISSIONING GROUP 5.3.1 The involved GP practice should be reminded of the relevant ‘Read Codes’ for capturing and distinguishing ‘vulnerable’ children and those ‘subject of a child protection plan’. 5.3.2 A briefing based upon the findings of this serious case review should be circulated to Practice managers and the GP safeguarding leads. 5.4 LEWISHAM CHILDREN’S SOCIAL CARE 5.4.1 The ‘MASH Steering Group’ should take all necessary steps to ensure the current threshold for incoming contacts is lawful, consistently applied and known to and accepted by all relevant local and London agencies. 5.4.2 A review should be completed of how / where records of phone calls, emails and ‘walk-ins’ are stored so as to standardise expectations. 5.5 LEWISHAM & GREENWICH NHS TRUST 5.5.1 The Trust should take all necessary steps to ensure that referrals to the internal safeguarding meeting: Result in the required debate Are recorded on the relevant IT system and (In cases where a referral is made to Children’s Social Care) that an acknowledgment of that referral and the agency’s proposed response is kept 5.5.2 If a midwife initiates a MASH referral, s/he should inform the relevant GP and Health Visiting Service. CAE 30 5.5.3 All midwifery staff should upload letters and document safeguarding concerns to ‘ICare’ (its database). 5.5.4 An audit should be completed of all Emergency Department attendances ‘rag-rated’ red (urgent) to ensure that they are being discussed in a timely manner at the ‘ED safeguarding meeting’. 5.5.5 Policies and guidelines should be amended to require midwives and health visitors to enquire about, observe and record as a matter of routine, where and in what a baby is / is to be sleeping. 5.5.6 All community midwives should have the opportunity to meet with their team leaders for a ‘one to one’ every 3 months so as to ensure that, in addition to advice and guidance from the Maternity Safeguarding Team, there is management oversight of complex cases. 5.5.7 All midwives rotating out to community work should complete a ‘one to one’ session with a member of the Maternity Safeguarding Team so as to ensure that the midwife understands the ‘safeguarding pathway, how to escalate concerns and is confident about utilising the consultancy function of that team. Overview child Y draft 3 01.06.18 GLOSSARY / ABBREVIATIONS ABBREVIATION MEANING BLS Basic life support LSCB Lewisham Safeguarding Children Board CAF Common assessment framework CAIT Child Abuse Investigation Team CAMHS Child & Adolescent Mental Health Service CDOP Child Death Overview Panel EMIS A patient database accessible to many primary care practitioners IMR Individual management review LSCB Local Safeguarding Children Board MECSH Maternal Early Childhood Sustained Home visiting programme NICU Neonatal Intensive Care Unit NSPCC National Society for Prevention of Cruelty to Children NPIE National Panel of Independent Experts SCR Serious Case Review SIDS Sudden Infant Death Syndrome SUDI Sudden Unexpected Death in Infancy UHL University College Hospital London |
NC52189 | Historical sexual abuse of an adolescent girl. In 2016, prior to Faith's 18th birthday, Faith disclosed that she had been sexually abused for several years by a neighbour, and that her mother had been aware this was happening. There were several domestic incidents involving police and neighbours at the family home. Faith's step-father was violent and Mother had issues with alcohol. Faith was excluded from school and looked after by two foster parents, before moving to residential care. A retrospective health review identified that as a child Faith had been seen by health practitioners with symptoms suggestive of sexual abuse. Ethnicity and nationality not stated. Findings include: over many years the signs and indicators that Faith had been sexually abused were not recognised and acted upon and her voice was not heard; assessments and plans were limited in their analysis of the history of both parents, the dynamics of relationships within the family and relevant health information; there was no clear plan to give Faith a permanent safe home and the legal framework was not used effectively. Recommendations include: develop a multi-agency whole family approach to work with complex families; seek evidence from Children's Services that the cause of placement breakdown is analysed and that findings are incorporated into ongoing planning for the child; ensure that all practitioners have the required knowledge and skills and confidence to recognise and respond to child sexual abuse within the family including hearing the voice and lived experience of the child.
| Title: Serious case review “Faith”. LSCB: Medway Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Medway Safeguarding Children Board Serious Case Review “Faith” Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd January 2020 Page 2 of 32 Contents 1 INTRODUCTION ........................................................................................................... 3 2 THE REVIEW PROCESS .............................................................................................. 4 3 SUMMARY OF FINDINGS ............................................................................................ 5 4 FAMILY BACKGROUND .............................................................................................. 7 5 FAITH’s CARE HISTORY ............................................................................................. 7 6 SUMMARY OF AGENCY INVOLVEMENT ................................................................... 8 7 FAITH’S EXPERIENCE AS A CHILD AND YOUNG PERSON .................................. 17 8 SUMMARY OF OPPORTUNITIES TO PROTECT FAITH .......................................... 18 9 FINDINGS & RECOMMENDATIONS ......................................................................... 20 10 SUMMARY OF RECOMMENDATIONS ...................................................................... 30 11 APPENDIX ONE: DETAILS OF LEAD REVIEWER AND PANEL MEMBERSHIP .... 31 12 APPENDIX TWO: REVIEW QUESTIONS .................................................................. 31 13 APPENDIX THREE: DOCUMENTS SUBMITTED TO THE REVIEW ......................... 32 Page 3 of 32 1 INTRODUCTION This report is about “Faith”1 who, as a child and young person, had contact with several organisations in Medway. This serious case review was commissioned following a retrospective review of Faith’s health records in December 2016. The health review identified that as a child Faith had been seen by health practitioners with symptoms that may have been indicative of sexual abuse and that there appeared to have been a failure of multi-agency responses to indicators of risk throughout her childhood. The apparent failure to protect had first been identified by the nurse for looked after children in January 2016, just prior to Faith’s eighteenth birthday and Faith had confirmed to the nurse that she had been sexually abused by a neighbour for a number of years and her mother had been aware that this was happening. The nurse made Children’s Social Care aware of this disclosure. Although there has been no prosecution of any offender, there are many occasions when the possibility that Faith was being sexual abused should have been acted upon. A referral was made to Medway Local Safeguarding Children Board in March 2017 for the case to be considered for a multi-agency review or audit as Faith’s experiences have had a serious adverse impact on her emotional and mental health and it was believed that there were lessons that could be learned about the way that agencies work with suspected sexual abuse. Following further discussions, in August 2017 the decision was made that the case met the criteria for a serious case review2 as a child had been seriously harmed and there was cause for concern as to the way in which the authority, their Board partners or other relevant persons had worked together to safeguard the child. It has been the aim of the panel to include Faith in the process as much as she wished to do so, and this review has been driven by Faith’s wish to understand what happened to her and why she was not protected. We hope that this review will, to some extent, help her with this wish and in order to provide enough information for Faith it has been necessary to provide a certain level of detail that might not be usual in a published report. It has also meant that events some years ago have been explored in more detail than might be the case in other reviews. The review team have been very grateful to Faith for contributing to the review and for her insight into events throughout her life. This has provided important information which has greatly influenced the conclusions of this review. This review has not been completed within expected timescales. This is primarily due to challenges in gathering non-recent information as well as trying to ensure maximum collaboration with Faith and the practitioners involved. 1 Faith is a pseudonym agreed with the subject of this review. 2 As set out in Working Together to Safeguard Children (2015) Page 75 Page 4 of 32 2 THE REVIEW PROCESS An independent lead reviewer was commissioned in October 2017 to work with a panel of senior professionals within Medway in order to carry out the review. The panel was chaired by a senior police officer. Further details of the lead reviewer and panel members are set out in Appendix 1. At the start of the review, all organisations who had worked with Faith were asked to provide a summary chronology of their involvement from the time of Faith’s birth through to 2016 when the referral was made to Children’s Social Care regarding Faith’s experience of sexual abuse. Individual chronologies were received from: Medway Council Youth Offending Team Medway Council Children’s Services Medway Council IRO Service Medway NHS Foundation Trust Child and Adolescent Mental Health Services (CAMHS) - Sussex Partnership Medway Community Healthcare GP’s Kent Police Secondary School 1 Secondary School 2 Primary Schools x 3 Independent Special school Residential Placement 1 Residential Placement 3 Residential Placement 6 Medway Foster Carer Placement The panel considered these chronologies and identified questions that should be considered by the serious case review. These questions are set out in appendix two of this report. The panel also identified further written information that would assist the review and all documents considered by the lead reviewer are set out in appendix three. Practitioners who had known Faith were invited to speak to the lead reviewer in order to assist the review in understanding what had influenced practice decisions at the time. It has not been possible to speak to all who knew Faith as, due to the passage of time not all could be traced or were available. However, sufficient numbers have been available to provide the review with a degree of assurance that the panel’s understanding of the factors influencing practice is credible. The information provided by Faith herself has also been invaluable in helping the review to reach its findings and recommendations. Following a review of all the information the lead reviewer agreed a draft of the report with the panel which was then shared with all those who had contributed to the Page 5 of 32 review including Faith. Faith told the review that she wished for the full report to be published in order to make sure that everyone understood what could have been done differently and how services need to improve. The report was agreed by Medway Safeguarding Children Board in May 2019. Constraints Understanding what happened and why it happened when Faith was a very small child has been hampered by gaps in records and the fact that many staff are no longer working for the organisation concerned. Primary school records for two of the schools attended by Faith contain very little information from that period and the independent special school records are minimal. Records within the Hospital Trust are available but have not helped to explain issues raised by this review and whilst Children’s Social Care records are reasonably comprehensive, they do not identify clearly the rationale for all of the decisions made. The review has identified a specific problem with obtaining non-recent GP paper records and has not been successful in doing so despite the best efforts of Medway Clinical Commissioning Group. These records are managed on behalf of NHS England by a private company and the review has been informed that this company are unable to process the application because the patient is registered with a GP and this can only be done through the GP practice. The GP practice have also not been able to obtain the records and the review has heard that the system for obtaining non-recent records is one that frustrates many GPs in their day to day practice. A recommendation regarding this issue is therefore included at the end of this report. The final review question requested by the panel was for this report to identify what is happening now across the partnership to improve practice in similar situations and are there further improvements that need to be made? It is not the purpose of a serious case review to audit current practice, but the panel felt that due to the non-recent nature of much of the information in this review, comment should be made on where practices have changed. Comment is made within the findings, but this should not be taken as a comprehensive review of current practice; any such review will need to be carried out by the local partnership, taking account of the findings of this review. 3 SUMMARY OF FINDINGS The overall conclusion of this review is that Faith was let down by a safeguarding system that failed to recognise signs and indicators of abuse and to take action to protect her as a small child. This system is made up of organisations and individuals who work within local and national policies and guidance. Although there are examples of poor individual practice this took place within an overall context of organisational systems which did not provide the checks and balances that are needed to ensure that children are kept safe from harm. Managerial oversight and Page 6 of 32 supervision of individual practice did not provide sufficient scrutiny and challenge, particularly within social care, and organisational systems did not identify where processes failed, for example the delay in responding to a GP referral to the paediatrician. There was information available to agencies and individual practitioners when Faith was a small child that should have been explored more systematically and the possibility that Faith was being sexually abused considered more thoroughly. Actions taken were not in line with procedures or professional knowledge at that time. Although professional knowledge and confidence in recognising and working with child sexual abuse should now have increased, a relatively recent study by the Children’s Commissioner found that there are still challenges in working with child sexual abuse within a family environment,3 and called for the practice of professionals in identifying children who are being sexually abused to be strengthened. The Commissioner’s finding is relevant in this case. Practitioners need to understand the barriers that might prevent children from talking openly about their experiences and find creative ways to engage with them. Children’s behaviour needs to be understood as a form of communication and in this case the potential that Faith’s change in demeanour as a small child might be indicative of sexual abuse could have been explored more fully. The human response to Faith as a troubled child was not apparent and her behaviours meant that she became the problem to be managed, rather than there being a sufficient level of understanding of the factors that might be causing her behaviour. This could have included a greater focus on the family dynamics and the needs of individual adults and children within the family. As a result, the system continued to fail Faith as she grew up and her behaviours became defined as problematic and challenging, rather than being understood as a response to her experiences within her family. As a result, practitioners paid insufficient attention to the complexity of her family relationships and how these continued to affect her even though she was living away from home. Contact arrangements with her family were not clearly specified and monitored and there was no clear plan as to how to best work with Faith and members of her family to achieve a permanent solution. Underpinning this is the need for practitioners to be able to work with layers of complexity and need within families. A recent study4 noted that parents involved in care proceedings experienced entrenched and serious violence, drug and alcohol addiction or sexual abuse, often over many years and mostly in the context of poverty and deprivation. Faith’s situation was no different. In such circumstances, practitioners need to be able to move beyond simple solutions and one key message 3 Children’s Commissioner (2015) Protecting children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/Protecting-children-from-harm-executive-summary_0.pdf 4 Trowler, I (2018) Care Proceedings in England: The Case for Clear Blue Water. University of Sheffield and Crook Public Service Fellowships. Page 7 of 32 is the need for professionals to be able to work confidently with families where there are multiple issues. Many changes have taken place in work with children and families since the events set out in this review. Most notably, care planning for looked after children in Medway is more structured and there would for example be a formal assessment of any family member who wished to care for a child. Police practices have changed with more emphasis on listening to children and there is a sexual abuse pathway in place to assist practitioners when this is a concern. There is however no room for complacency and much more that can be done to make a positive difference to the lives of children who may be in a similar situation to Faith. The findings and recommendations of this report set out where further work needs to be done by those agencies with responsibility for protecting children. 4 FAMILY BACKGROUND Faith’s mother had two children from a previous relationship (known in this report as Half Sibling 1 and Half Sibling 2). Faith is the oldest child of her mother and father’s relationship and has two younger siblings. There is little on record regarding Father and Mother’s history. Faith told the review that her mother’s first partner was in the armed forces and she lived with him overseas where her oldest children were born. On returning to the UK she started a relationship with Faith’s father. Investigations for this review have found that Father had 17 convictions for 41 offences between 1970-2007, several suspended sentences and six terms of imprisonment. The most recent term of imprisonment was in 1999 when he received a two-year sentence for drug offences. From Faith’s perspective this is important information that should have been taken into account and, although the information is mentioned from time to time in the records, it was not always explored in assessments relating to the children in the family. 5 FAITH’S CARE HISTORY Faith was accommodated under Section 205 for two periods of time and moved through several placements. These were as follows: Placement Dates Type of Placement Education 5 Section 20 Children Act 1989 requires the Local Authority to provide accommodation for a child where: (a) No person has parental responsibly for them. (b)They have been lost or been abandoned. (c) The person who has been caring for the child is prevented permanently or not, from providing him or her with suitable accommodation or care. Page 8 of 32 Foster Carers 1 May 2010 – Sept 2010 Foster Carers 2 Sept 2010 – June 2011 Secondary School Period in Care ended, and Faith lived with her sister and then her father Secondary School Residential Placement 1 November 2012- Feb 2014 A local Authority placement in Medway Secondary School Independent Special School (July 2013 – Feb 2014) Residential Placement 2 Feb 2014 – May 2014 Out of Borough Therapeutic placement Out of county school Residential Placement 3 Aug 2014 – Jan 2015 Local 16+ accommodation Left education Residential Placement 4 Jan 2015 Out of Borough residential home Residential Placement 5 October 2015 Local semi-independent accommodation Residential Placement 6 December 2015 Supported independent accommodation 6 SUMMARY OF AGENCY INVOLVEMENT When Faith was a small child the agencies with most involvement with her family were police and health practitioners. Police involvement was primarily as a result of neighbourhood disputes, allegations of domestic violence involving Faith’s parents and drug related offences. In April 2004 (when Faith was six) there was an allegation of sexual assault committed by Faith’s father towards his fifteen-year-old niece. Children in the family were spoken to by a police officer and a social worker and said all was well. There was no further action due to lack of evidence as the victim did not want to proceed. This episode should now be understood in the light of Faith’s submission to the review which speaks of the difficulties for a young child in talking to professionals when told by their family not to say anything. The Children’s Social Care assessment noted that Faith had been taken to the GP on several occasions and that a GP (a locum) had made an urgent referral to the Community Paediatric Department highlighting physical symptoms that could be Page 9 of 32 indicative of sexual abuse. It also contained information about Faith’s sexually explicit behaviour at school which was beyond that expected of a six-year-old. However, the final analysis failed to take this into account in reaching the conclusion that there was no evidence that Faith could have been harmed. In the referral to the hospital, the GP had highlighted social problems including Mother’s alcohol abuse and asked for advice on “this very delicate situation as she may be at risk”. This referral was sent to the community paediatricians rather than directly to the hospital paediatricians, but this does not explain why the hospital did not pick up the referral until nineteen months later. This was not acceptable, and the Hospital Trust has been unable to provide the review with a full explanation as to why this delay occurred. The specific sequence of events at that point is set out in Paragraphs 9.8 and 9.9 of this report. The locum GP was proactive in recognising possible risks within the family, but this became lost due to the referral being framed as a request for advice from a medical colleague rather than a child protection referral to Children’s Social Care and a request for a medical under child protection procedures lack of involvement by specialist medical practitioners such as the Named or Designated doctors who could have given advice to the GP lack of a timely response from the paediatric department at the hospital The concerns of the GP and the school were not understood by Children’s Social Care in relation to the allegation of sexual assault made against Faith’s father and other information known to the police about the family within the community. By the age of nine, Faith’s primary school identified that she had gone from a bright and happy child to one who was “weak and unable to concentrate”. The school made a referral to Children’s Social Care which also highlighted continuing disputes with neighbours and that Faith had reported being tied up by a neighbour and that her mother had been stabbed. An initial assessment by Children’s Social Care resulted in no further action; the reason being that the neighbour had moved out and the home situation had calmed down. There was insufficient consideration given as to why Faith’s family had failed to protect her. There was a further referral from the police two months later following an allegation that Father had assaulted Mother. This resulted in a child protection conference and Faith and Sibling 1 and 2 were placed on the child protection register under the categories of physical and emotional abuse. The plan from this conference was a series of tasks with little evidence of how these would improve the safety and wellbeing of children in the family. At a review child protection conference three months later, the situation was described as much improved although there was no report from the school to give information about the family from their perspective. It was acknowledged that three Page 10 of 32 months was a short time to be sure changes could be sustained and a further conference was convened a month later when it was agreed that Faith would receive counselling at school and the child protection plan should be discontinued. The family transferred to the local family and social support team for on-going monitoring and support. Following this, there was an allegation of domestic abuse and numerous allegations and counter allegations between the family and the neighbours with police records noting that two families between them were responsible for reporting around 50 crimes against each other. The case was closed to Children’s Social Care and child in need meetings continued at Faith’s school. By this stage it was clear that this was a complex family with multiple needs, and it is unlikely that monitoring and low-level support would facilitate enough change. An outcome focused plan which took account of the needs of adults and children within the family and had clear measures for success would have been more likely to succeed in improving the life chances of Faith. Faith started secondary school in September 2009 and in November 2009, when she was eleven, there was a “child protection referral” from housing as Mother had left the family home taking Faith with her. This referral is significant as it quotes information that the social worker had given to housing that “father is a great influence on the children”. Inaccurate information was also quoted as the referral noted that the previous referral was due to Mother’s drinking rather than domestic abuse. At this point it appears that Father was seen as a resource and any information to the contrary was not considered. An Initial assessment started. At this time Faith was apparently moving between her Mother and Father’s address; torn between her parents and noted to be extremely distressed. Faith’s school alerted the social worker and on a visit to the home Father was noted to be aggressive to Faith. Arrangements were made for Faith to stay with her half-sister (Half Sibling 1) who by now had a baby and had moved out of the family home. In December 2009, a child protection conference took place and Faith and her two siblings were made subject of a plan. The main issues highlighted within the social work report were Mother’s alcohol use and Father’s violence and cannabis use. Meanwhile, Father had applied for a Residence Order and an Interim Order was made in respect of all three children which stipulated that Faith was to remain with Half Sibling 1. At the final court hearing the social worker supplied a Section 7 report6 to the court which did not support Father’s application for a Residence Order for either Faith or her siblings. The social worker preparing the report had referred to concerns about Father’s capacity to parent, but the court decided to grant a Residence Order for the two younger siblings although not for Faith who remained 6 A Section 7 assessment and associated report derives its name from Section 7 Children Act 1989 which empowers the court to ask a Cafcass Officer to report to the court on matters relating to the welfare of the child in order to help the judge make a safe decision. Page 11 of 32 with her half-sister. Soon after this the social worker responsible for Faith changed and it seems that some of the misgivings about Father were not seen in the same light from that point forwards. In May 2010 concerns about Faith increased and she was accommodated by the Local Authority (with her parent’s permission) moving into a placement with Foster Carers 1. Faith was clearly distressed at leaving her half-sister and there were several instances of her going missing from care. Social workers responded to concerns about Faith by removing her from the family environment. Although the section 7 report had begun to question the assumptions about family dynamics and relationships, the impetus to deepen this understanding became lost with a change of social worker and the focus of work with Faith became unclear. When she was accommodated there had been no placement planning meeting, and this was the beginning of a pattern that continued throughout Faith’s time in care whereby there was no clear plan for family contact that was understood by all parties involved. Whilst in this placement, in June 2010, Faith was admitted to the paediatric ward with medical problems. Her foster carer told the nurses for looked after children that Faith had gone to an aunt after school and the aunt was a “convicted paedophile”. The nurses referred to Children’s Social Care who decided not to hold a strategy meeting but to refer to the NSPCC to address Faith’s emotional needs. The next day the nurse for looked after children again contacted Children’s Social Care to express the concerns of the paediatrician, but at this stage still no further action was taken as it was the view of Children’s Social Care that the medical problems were self-inflicted. There were more episodes where Faith went missing from the foster carers and was admitted to hospital having taken an overdose. Social work records note that just prior to this she had made a partial disclosure regarding sexual abuse by a male known to the family when she was age 9 and 11 but she did not want to discuss further. She was assessed by CAMHS7 as having “no mental health problems and low risk of completed suicide”. The day after discharge she was again readmitted with an overdose, Foster Carers 1 could no longer cope, and Faith moved to a new placement with Foster Carers 2 (via a private fostering agency). In August 2010, there was a review child protection conference and all three children’s names were removed from a plan. It seems that due to concerns about Faith’s emotional wellbeing, a report was commissioned from a private psychiatrist. This review has been unable to establish unequivocally why the terms of reference for this assessment stated that no enquires should be made of Faith in respect of the issue of sexual abuse. It is the view of Children’s Social Care that the most likely reason was that the concerns were about emotional wellbeing, there had been no disclosure from Faith of sexual abuse and questions regarding possible sexual abuse would be seen as leading or “fishing for information. This is discussed further in paragraph 9.4. The conclusions of the 7 Child and Adolescent Mental Health Service Page 12 of 32 psychiatrist showed the characteristics of a child who had been subject to significant traumatic experiences. The report recommended in-depth therapeutic work. A looked after child review noted that the plan was for Faith to remain with her current foster carer but to return home to her father “maybe after Christmas”. During this period, it is not clear what work was being done with Faith and her family to underpin a plan for her to possibly return home to her father. Faith was undoubtedly torn about where she wished to live, was worried about her siblings and “voted with her feet” many times by returning to family members, but there does not seem to have been any plan of work which addressed the complexities of the family circumstances. In March 2011 a new social worker was allocated and in May 2011 Faith’s foster placement ended abruptly due to the foster carers separating and Faith moved in with Half Sibling 1. This prompted a move of school. There is note of an e-mail exchange between the social worker and the Independent Reviewing Officer8. The social worker informed the Independent Reviewing Officer that the family had effectively “de-accommodated” Faith as she had chosen to leave the foster placement and the family were happy for her to live with her half-sister. The Independent Reviewing Officer reminded the social worker that the plan should have been ended with a review. She also requested that the social worker looked at previous child protection records due to concerns regarding sexual abuse. (There is no evidence that the social worker did this). The email also refers to files not being available due to an office move and due to files not being available, the social worker could not tell the Independent Reviewing Officer why the psychiatrist had been instructed not to discuss sexual abuse. There was some additional confusion as the social worker also suggested that the case would be managed under child in need but subsequent recording of visits to Faith at her half-sisters are referred to as “LAC visits” (i.e. visits to a child who is still in the care of the local authority). At this stage of work with Faith there seems to have been a loss of focus by Children’s Social Care, exacerbated by a change in social worker and the new worker not having access to all the relevant information due to restructuring of teams within the department. In June 2011, Children’s Social Care records note that she was no longer a looked after child and from this point Faith began regular meetings with a practitioner from CAMHS. Faith spoke to the special educational need’s coordinator at school about her worries concerning her siblings who were living at home with her father. She described recently staying with her father and her father receiving death threats and being attacked and she was extremely scared and guilty about leaving her siblings. The school appropriately shared this information with Faith’s social worker and the 8 Independent Reviewing Officers ensure the care plans for children in care are legally compliant and in the child's best interest. Page 13 of 32 school’s Police community support officer. When followed up by the social worker, there were inconsistencies between Faith’s and Father’s version of events and no further action was taken. There were further concerns at school regarding self-harm, possible sexual activity, verbal and physical aggression which resulted in a five-day exclusion from school. At a professionals meeting held at school (attended by the social worker), concerns were expressed that Faith’s behaviour had escalated rather then settled since living with her sister and it was agreed that an application for a Special Educational Needs statement would be made. In July 2011, Father presented at the social work office with Faith as the living arrangement with her half-sister had broken down. He agreed to keep her whilst the local authority looked for another placement, but no placement was found, and Faith remained with Father. Contact with her mother was to be supervised although there was no court order to back this up. This sequence of events is an example of Faith feeling that she was not being listened to. She expressed concerns about the environment at home, but her Father’s account was believed and then she was returned to his care when she needed accommodation. In September 2011, Faith who was still living with Father, moved back to the school she had been attending prior to her move to her half-sister. In-school counselling was arranged via CAMHS but she attended none of the six sessions. From November 2011 through to January 2012, there was continued contact with the community CAMHS practitioner. Faith found that her mother was pregnant again and self-harm led to a hospital admission. The GP was informed but there is no record of any follow up. There was a CAMHS risk assessment on the ward with a plan for follow up by the CAMHS practitioner. From February through to May 2012, Faith continued to see the CAMHS practitioner regularly and it is clear that her behaviour was difficult to manage at school. The CAMHS worker brought to the attention of the social worker the recommendation from the previous psychiatric assessment that Faith should receive therapeutic input and suggested that this was still relevant. There is mention within the records of Faith having supervised contact with her mother. In July 2012 there was an updated core assessment. All of Faith’s challenging behaviours are attributed to parental substance misuse and domestic abuse within the family during her early childhood. There is no mention of sexual abuse or assault as part of her experience. At this point Faith had had the same social worker and manager for four years. In November 2012 Faith was accommodated again due to 'high levels of stress' in the family". She was reportedly violent towards her younger siblings. She was accommodated at a Local Authority home and from the start she gave the staff the Page 14 of 32 impression that she had a volatile relationship with her father and wanted to single handedly “save” her mother. In December 2012, a residential worker called the Police concerned that Faith was being taken to a 50-year-old male’s home by another female four years older than her. Police informed Children’s Social Care. In Medway in 2012, professional knowledge about child sexual exploitation was in its infancy but at the very least this episode should have triggered a response that was more proactive in exploring the risks that Faith was being exposed to. It would have been most appropriate for this response to be led by her social worker. This did not happen. There were concerns from the school due to cut marks on Faith’s arms and over the Christmas period she attended hospital complaining of pain and headache and had two black eyes and reported falling and hitting her head when drunk four days earlier. She was discharged to the care of GP. In January 2013, Faith reported to a member of residential staff that she had been raped by her mum's friend as a nine-year-old and memories had been triggered as she had recently seen the man in the local area. She said this had led to her self-harming and that her mum knew but did nothing. This was reported to the Police and Faith told the Police that she was sexually assaulted but because her statements were conflicting, no further action could be taken. In relation to the wider network, around this time Faith had three assessment sessions with CAMHS psychotherapist. There is also an admin entry in the GP records (she had possibly changed GPs as a result of moving into residential care) providing further detail of Faith’s medical history, but this was not complete and did not include allegations of rape. This was the second specific allegation by Faith, and it is interesting that this was made soon after moving away from the family into residential care. The response by agencies is discussed more fully in Finding One. What is clear is that the GP service was not fully aware of the details of Faith’s history and could not take this into account in any contact they might have had with her. In February 2013, Faith was noted by the residential unit to be self-harming and worried about her mother’s health. She assaulted another female resident, was arrested and admitted the assault for which she received a reprimand. At the March 2013 LAC review Faith was noted to have settled reasonably well but there was then a report of “aggressive and violent behaviour” at school and later in the month Faith lost her work experience placement. There followed reports of altercations with residents in the home and from June – August 2013 there were more episodes of Faith being missing from the unit and on the majority of occasions she was with her mother. In September 2013, Police received a call from a previous member of staff to the residential home expressing concerns regarding her and another female resident Page 15 of 32 being sexually exploited and specifically that Faith's mother was an alcoholic and would meet up with older males when Faith was with her. He was concerned these issues were not being addressed. A referral was submitted to Children’s Social Care and there is no evidence of any response by Faith’s social worker to this information. Also, in September, Faith was a victim of an assault from a fellow male resident who was arrested and charged. Faith presented at the local hospital emergency department with chest/abdominal injury and was discharged with advice and reassurance. There was no documented record of contacting Children’s Social Care. In December 2013, due to changes in the CAMHS service the practitioner who had been seeing Faith regularly since approximately 2011 left the department. From Faith’s perspective this felt like a very sudden departure. In the first months of 2014, there were concerns about increasing self-harm, but no female therapist was available at CAMHS at that time9. Along with other residents Faith ingested bleach and it was decided to move her to an out of Borough therapeutic home for young people. Faith did not settle in the therapeutic placement and at the end of April left to live with Half Sister 2. In June 2014, Faith and her half-sister were homeless and placed in a guest house. In July they were given temporary accommodation but were evicted two weeks later due to concerns about their behaviour. In August, Faith moved to a home for young people age 16+. She was reported missing twice within the first month and was also arrested for assault. In September 2014, concerns about Faith increased with reports of attempted robbery, assault and increased contact with her mother including the possibility that she was being sexually exploited. (This was referred to in the records as possible involvement in “prostitution”)10. At the end of September, a multi-agency strategy discussion was held, Faith had been missing for a week and there is a record that the social worker was considering secure accommodation. In October 2014 Faith returned to the placement and refused to talk to the Police. She was allocated to a student social worker from the YOT team and the nurse for looked after children (who had a good relationship with Faith) planned a health assessment. Faith pleaded guilty to a robbery charge and was bailed until November. Concerns increased regarding Faith’s contact with her mother and the possibility that she was involved in “prostitution and drug running”. These concerns were discussed at a professionals meeting and it was agreed that the accommodation provider would be requested to report Faith missing if she was absent from the premises without providing an address that could be checked by Police. 9 A female therapist became available in April after Faith had moved out of Borough and the case was closed to CAMHS. 10 In 2014 this was an outdated term to use. Page 16 of 32 In November 2014, records of the youth offending team and Children’s Social Care note concerns that Faith was pre-occupied with her mother’s needs. There was a report of a domestic violence incident between them indicating a volatile relationship. The Police requested a strategy meeting and agreed that the social worker should arrange a multi-agency meeting focused on keeping Faith safe. On 12th November Faith was cautioned for battery committed on 15th August 2014. Faith continued to be missing from placement returning with new boots and her eyebrows waxed – it was unclear where she had got the money from but there continued to be no formal assessment of risk relating to any form of exploitation. In December 2014, Faith continued to go missing from the placement and was served with a 28-day notice to leave. At her review there is a note of concerns regarding sexual exploitation and her father is recorded as believing that she should be in secure accommodation. In January 2015, Faith was reported missing 20 times. There are also records of violent behaviour within the accommodation with Faith being both perpetrator and victim. Faith moved to a residential children’s home out of Borough. In March and April 2015, Faith was reported missing three times and the residential home contacted the looked after children team, concerned that she was having unsupervised contact with her mother and father. There were also reports that she was using drugs and missing appointments with the youth offending team worker. From August to September 2015 there were various attempts by the Youth Offending Service to engage with Faith to no avail and a final warning letter was sent. Finally, a planning meeting took place at the end of September. Concerns increased about Faith’s health and wellbeing and she was moved in October 2015 to local 16+ accommodation, followed two months later by a move to local semi-independent living in the local area and registered with the local GP surgery. During subsequent visits by her worker from the youth offending team, Faith spoke openly about various incidents in her childhood which the worker recorded as “horrific”. It was at this point that the nurse for looked after children began a health history in preparation for Faith leaving care and uncovered the safeguarding concerns that led to this serious case review. From 2013 onwards, the focus of work with Faith was mainly on containment. Her worker for the youth offending team did work hard to develop a relationship and understand the causes of her behaviour but by this time Faith could not trust those she viewed as authority figures. She did develop a reasonably positive relationship with the nurse for looked after children possibly due to her being seen as part of health provision rather than an authority figure. It is during this period that the failure to recognise what had happened to Faith and Page 17 of 32 respond positively when she made allegations can be seen to have resulted in an approach which could not meet her overall needs. The worries that her relationship with her mother could be linked to Faith being sexually exploited were recognised but not adequately assessed or addressed. 7 FAITH’S EXPERIENCE AS A CHILD AND YOUNG PERSON Much of the information for this section has been provided by Faith and we are extremely grateful that she has been willing to contribute to this review. Although it has been painful for her to talk about her life, she has said that she hopes her story will prevent other children and young people going through the same experiences. Faith’s early memories are of a home life where there was a high level of violence and numerous disputes with neighbours and others in the community. The disputes between neighbours involved the children and Faith remembers being tied to a lamppost, petrol being put through the letter box and a car set on fire. She remembers the Police being aware of what was happening, but nothing changed. She remembers social workers coming to the house, but they did not ever see her outside the home. She could not say anything about her life in front of her parents as they had told her to lie. As well as information gained directly from Faith, a review of the records shows that there were occasions when at the time she told people what life was like for her or there were descriptions of her circumstances, these should have made professionals think more carefully about her circumstances. The record of the child protection conference in March 2008 gives a good picture of Faith’s life at that time. It documents a little girl who was bright and could be in the top group of school, but her emotional state was preventing this and she was having difficulty coping with the work. She was often late for school, not always very clean and appeared to have an ongoing infection and frequently asked to go to the toilet during class. Homework was not always completed, and she did not take books home with her as they were not returned. Again, the child protection conference in December 2009 had information about a girl who was extremely distressed and torn between her parents. The conference heard that she had described witnessing severe domestic incidents between her mother and father, including her father holding a knife to her mother and punching one another. She had also described being hit by her father with a leather slipper in the past causing severe bruising to the back of her legs. She had said 'he's marked me loads of times'. She also said that her mother would drink from the moment she got up until she went to bed but was with a new partner and was getting better. She also said that she had no friends at school because whenever they would knock at her house her Dad would tell them to 'f**k off'. At age 11 Faith was able to articulate that her parents were as bad as each other and she did not know who she wanted to live with. At this point she told social workers that her mother and father had told her to lie to social workers so the case would be closed. Page 18 of 32 Faith’s view is that by the time she was taken into care it was too little too late and I am not sure I even know what family means. She remembers being glad to be out of the home but unhappy in care. Her view now is at least strangers were treating me like crap – it is different when it is your mum and dad. In her first placement she felt she was treated differently to the carer’s own child, did not feel part of the family and the foster carers had not been fully prepared for what to expect. She remembers feeling unhappy at her second carers and at this point took an overdose. By the time that Faith was in residential care her distress was evident through self-harm and behaviour that became labelled as “challenging”. By this time Faith feels that she was punished for her behaviour rather than anyone recognising how she was feeling. Faith valued her relationship with the CAMHS practitioner but at that time felt that she could not speak to her openly as she did not want the practitioner to dislike her and opening up might have made the practitioner view her differently -I would have lost her as a friend. It was upsetting for Faith to lose her contact with the CAMHS practitioner when the service restructured, and she was unhappy that another female therapist could not be found. She also felt that the LAC nurse was the other person who really cared - It is about someone being real. Throughout her adolescence Faith desperately worried about her family, had a volatile relationship with her parents and felt torn between them. She feels that during her time in the first residential placement she felt there was something wrong with her, was out of control and at that time I did not know what I was capable of doing. She now feels that she should have been put into secure accommodation at that point. From the perspective of staff in the residential unit Faith’s behaviour was “off the chart” but so was the behaviour of all the young people in the unit at that time. Looking back, Faith feels very angry that more effort was not made to help Half-Sister 2 look after her. She desperately wanted to be with her family and felt let down by her social worker. After she and her half-sister were evicted, and she moved into another residential home she remembers her social worker saying she would “phone on Tuesday” to see what could be done but no call came. Her half-sister often says, “I am still waiting for that Tuesday.” This is a very important significant contribution to this review, reminding practitioners of the importance of always keeping children and families fully updated about decisions that are being made. Practice should be about “working with” rather than “doing to” children and their families. Faith remains very vulnerable and although therapy has been offered at the time of writing she has not felt able to access this therapeutic help. 8 SUMMARY OF OPPORTUNITIES TO PROTECT FAITH Although much of the practice outlined above will have changed, and the agency responses to this review will identify specifically where service improvements have been made, it is important to be clear where there were opportunities to do things Page 19 of 32 differently. The following aims to identify pivotal points where alternative practice decisions could have made a difference and should provide a baseline for agencies to measure how far current practice addresses the deficiencies in the past. Age of Faith Five – Seven At the point that the locum GP referred to a paediatrician, there was a 19-month delay before an appointment was given and a lost opportunity to explore the risks outlined in the GPs referral. The gynaecologist examining Faith did not have information about the wider family and the GPs concerns about risk. Nine Faith’s change in behaviour at school and allegation of being tied up by a neighbour should have been assessed more thoroughly by Children’s Social Care. Twelve The misgivings of the social worker who did not support Father’s application for a Residence Order, became diluted once the Residence Order was granted in respect of the younger siblings. One underlying cause was likely to have been a change of worker at this point. Twelve Children’s Social Care did not follow expected procedures following (a) a referral from the paediatrician that Faith had contact with an aunt who was a “convicted paedophile” and (b) subsequent disclosure by Faith of sexual abuse by a male known to the family. Twelve There was a lost opportunity to explore the possibility that Faith had been sexually abused at the point a report was commissioned from a psychiatrist who was asked not to make enquiries about sexual abuse. Thirteen A newly allocated social worker did not take the advice of the Independent Reviewing Officer and review previous child protection records. This seems to have been within the context of a department undergoing a great deal of change with previous records not being easily available. Fourteen An updated core assessment did not include any information about previous concerns regarding sexual abuse or physical assault in her early years. Fourteen A second disclosure of sexual abuse could have been investigated and assessed more thoroughly by Police and Children’s Social Care. The Police were not aware of a previous disclosure made when she was age twelve as this had not been passed to the Police by Children’s Social Care. Fifteen Allegations that Faith may have been sexually exploited were not properly investigated by police or Children’s Social Care. Sixteen Further allegations of sexual and criminal exploitation were not properly investigated. Page 20 of 32 9 FINDINGS & RECOMMENDATIONS Finding One: Over many years the signs and indicators that Faith had been sexually abused were not recognised and acted upon and her “voice” was not heard. Although this review has had the benefit of hindsight, there was information known to professionals at various points in Faith’s life that should have resulted in recognition that she may have been/was being sexually abused. This was important in relation to protecting her when she still lived at home, understanding her behaviour and vulnerabilities as a young person and considering any risks to siblings remaining within the household. Once she left home it is clear that Faith worried about her siblings and this was partly why she would return home frequently when in care. Understanding behaviour, trauma and vulnerability This was a complex family situation with concerns about neglect, violence and alcohol and drug use; factors which are explored further in Finding 2. This complexity appears to have obscured a focus on potential sexual abuse, and as Faith grew up her behaviour was generally seen as the problem, rather than the manifestation of previous trauma and distress. There were exceptions when trauma in her past was recognised and discussed, but this fell short of specifically identifying and naming sexual abuse. For example, the youth offending worker told the review that her focus was on working with a young person who had been traumatised and to prevent her being further criminalised. The lack of in-depth consideration of the possibility of sexual abuse was particularly notable in the report by the psychiatrist in September 2010 which noted that she showed the characteristics of a child subject to significant traumatic experiences. This psychiatrist is a known expert in the field of sexual abuse and in the introduction to the report notes that it was his opinion that she may have been the victim of sexual abuse but in carrying out the assessment he had been asked that there should be no direct enquiries of her in respect of the issue of sexual abuse11. As explained in 6.17 above, a possible explanation for this directive was that no disclosure had been made, and questions about sexual abuse could be seen as a “fishing” exercise. If this was the reason, it confuses criminal standards of evidence gathering with a need to protect her from harm and understand all the interlocking factors in Faith’s life that were affecting her wellbeing. From age 14 onwards the main indications regarding sexual abuse related to Faith’s behaviour and vulnerability to exploitation by others. There is some evidence of concerns about her mother’s part in this, but Faith’s loyalty to her mother and desire to look after her would have made this very hard to address. 11 Report of independent child psychiatrist September 2010 Page 21 of 32 School can be an environment where young people may feel able to talk about abuse. The school were aware that she was vulnerable and although her behaviour was at times hard to manage, they understood her disruptive behaviour as a way of avoiding facing up to things. They did not at the time speak about sexual abuse although they were aware this was possible. The secondary school had a copy of the psychiatrist report which noted that the psychiatrist had been asked not to make direct enquiries about sexual abuse and therefore assumed that it would be damaging to discuss this openly. They also assumed that Children’s Social Care “knew what they were doing” and were relieved that CAMHS were involved as so many of their pupils had problems accessing a CAMHS service. Medical indicators of sexual abuse There were opportunities to focus on sexual abuse as a result of medical symptoms as a young child. At this stage, Faith remembers hoping that doctors would realise what was happening as she could not say anything directly about life at home as she had been told to keep quiet by her parents. She also remembers staring hard at professionals hoping that they would realise that something was amiss. The earliest opportunity to identify medical symptoms that may have been indicative of sexual abuse was in March 2004 when Faith was aged six. The locum GP who saw her at this stage identified a combination of potential risk factors (social and medical) and specified these concerns in a referral letter to the community paediatrician. Although this should have been sent directly to the hospital paediatricians the Health Trust has been unable to explain why the letter was not passed to the correct department and it took a chasing letter from the same GP practice to prompt an appointment 19 months later. The paediatrician who saw Faith in clinic at this time was working as a neonatologist. The review has queried why a doctor specialising in newborn babies saw Faith but has been informed that this doctor was a suitably qualified paediatrician who had a specialist interest in neonatology. The neonatologist correctly took advice from the designated doctor and checked with the safeguarding team in the hospital who, at that point, had no record of Faith. It was appropriate that the neonatologist referred to a gynaecologist, but the original letter from the GP was not included in the papers and the gynaecologist only saw a letter from the neonatologist saying there were “no psychosocial problems”. In this context sexual abuse did not form part of the “differential diagnosis”12. When Faith was referred to the gynaecologist at age 10, the gynaecologist was not aware that she was subject of a child protection plan and having spoken to her parent wrote in the records “no worries about abuse”. There was a further opportunity for the gynaecologist to consider Faith’s symptoms within a social context when the education welfare officer wrote asking whether her symptoms could result in her 12 This is the process of differentiating between two or more conditions which share similar signs or symptoms. Page 22 of 32 missing school. However, since there had been no other concerning factors this did not trigger any further queries by the gynaecologist. The following month the gynaecologist’s secretary received a request from the school nurse for copies of the letters in the file to “inform the child protection plan”. This was dealt with as an administrative matter and the gynaecologist remained unaware of any concerns by other professionals about the risk to Faith. Today the process would be that any such request should be made via the hospital safeguarding team and the expectation would be that they would make direct contact with the consultant. Gynaecologists are primarily focused on care of adult women, although some may have an interest in treating children and this episode highlights the importance of gynaecologists who see children having good safeguarding knowledge and access to the right information. Two issues have been identified through discussions with practitioners: 1. The advisability of pre-pubescent girls being seen jointly by a paediatrician with links into child safeguarding networks alongside a gynaecologist. 2. The possibility that some children may be seen by gynaecologists (for example in emergency clinics) who have not completed level 3 safeguarding training. Responding to disclosures Although there is an argument for using the term “allegation” rather than “disclosure”, this report uses the term disclosure as, from Faith’s perspective she was disclosing to professionals what had happened to her. The first direct disclosure of sexual abuse was when Faith was age 12. Just prior to this she had been admitted to hospital with physical problems and the hospital became aware that she may have had contact with an aunt who was a known sex offender. The paediatrician asked Children’s Social Care to investigate but the management decision was that since there had been no disclosure the problems could have been self-inflicted, and no further action was needed. Children’s Social Care have not been able to give an explanation to the review as to the reason behind this decision, but it seems that again the lack of a “disclosure” seems to have been influential in the case. Less than two weeks later Faith disclosed to her social worker that a male known to the family had forced her to have sex on two occasions when she was aged nine and 11. Just after this disclosure she was re-admitted to hospital having taken an overdose of tablets found at her foster carers. She was seen by a CAMHS worker and cleared for discharge. Although there is reference to the need for a strategy discussion with the Police there is no evidence that this happened, and the lack of Police contact was queried by the named nurse at the hospital. The social worker assured them that the Police had been contacted but Faith would not speak to them and he/she would “sort it out in the Page 23 of 32 community”. There is no record of any contact in the Police records and it seems that the social worker became diverted by Faith taking a second overdose and the need to find a new fostering placement as the carer did not feel they could cope with her any more. The social work focus was on managing the most current crisis rather than taking a look at the whole picture and working within expected child protection procedures and processes. There is no evidence of any social work managerial oversight that picked up on the deficiencies in response and it is of concern that at this point no consideration was given to possible risks to other children who remained in the household. The lack of police knowledge of this first disclosure is significant as, when Faith was fourteen, she made her second direct disclosure of sexual abuse in childhood and the police investigation did not take this into account. On this occasion she told a residential worker she had been raped by the older brother of her friend. The family concerned were also known to her mother. This disclosure was investigated and an ABE13 interview undertaken but there was no further action due to the number of discrepancies in Faith’s account. The quality of the police investigation has been subject to an internal investigation and areas for improvement identified, although it is unlikely that there would have been a realistic chance of prosecution even if these improvements had been made. What is more pertinent is that even though prosecution may have been unlikely based on the available evidence, the possibility that Faith had been subject to sexual abuse as a child should have been more firmly integrated into the assessments and plans for her going forward. Discrepancies in her account should have been understood in the context of a child living in a chaotic environment and the impact that this would have had on her at the time and her recall of events. A review of previous Children Social Care records would have found that the referral made by her school in 2007 and described in paragraph 6.5 above was around the time she alleged the rape took place. It is important to reflect on Faith’s comments about who she felt tried to help her. She valued the relationship with the nurse for looked after children and CAMHS practitioner although this type of CAMHS contact would not be available today. The CAMHS service has moved from a pastoral holistic treatment model to a clinically based mental health interventions model and it is impossible to judge whether this would have made a positive difference to Faith at that time and prompted her to talk openly about any experience of being sexually abused. What is known is that the ending of the relationship was abrupt as the worker left when the service was transferred to another provider and there were insufficient female therapists to allocate Faith a worker when she needed it. 13 An Achieving Best Evidence (ABE) interview is an interview of a vulnerable victim or witness carried out under Ministry of Justice Guidance https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf Page 24 of 32 The overriding impression was that the possibility Faith had been/was being sexually abused rumbled below the surface within the professional network. At times the concern became more acute, but any planned action soon became overridden by another apparently more pressing crisis. At this distance in time it is hard to fully understand what was driving professional responses although it is possible that there was a view that there would be insufficient evidence to bring anyone to court. This may have been the case but at no time did child care plans set out the possibility that Faith had been abused and what response was needed to meet her needs. Discussion with professionals during this review has raised the question of how confident practitioners feel in discussing the possibility of sexual abuse either with children themselves or in forums such as child protection conferences. The review has heard that this may still be a current problem and that staff development activities need to focus on developing confidence in listening, responding and not being embarrassed. Even though at the time there may have been reservations about what could be done in relation to relatively non-recent allegations of abuse it is hard to understand why there was not a more coherent approach to concerns that Faith was being sexually exploited, her mother may have been involved and that this was linked to drugs and possible criminal exploitation. The first national guidance on child sexual exploitation had been published in 2009, four years before there were significant concerns about Faith and this should have influenced the way professionals responded. The sexual abuse pathway within Medway should now provide a framework for working more effectively with situations where there are concerns about sexual exploitation. Further consideration now needs to be given to the effectiveness of work where there is also a concern that criminal exploitation is also a feature of the young person’s life. More recently, Kent police have recognised the need to improve their response to children and developed an approach to their work in line with the national strategy for child centred policing. The Kent police child centred policing plan contains a section specifically on the voice of the child and in January 2019 the police reporting structure changed in order to make sure that the voice of the child is captured within records. Recommendation One Partner agencies in Medway should review their staff development activities in relation to child sexual abuse and sexual exploitation to ensure that all practitioners have the required knowledge, skills and confidence to recognise and respond to child sexual abuse within the family including hearing the “voice” and lived experience of the child. Recommendation Two Consideration should be given by Medway Hospital to pre-pubescent girls being jointly Page 25 of 32 seen by a gynaecologist and a paediatrician (or a relevant specialist children’s practitioner). Best practice would be a joint paediatric/gynaecologist clinic for these patients. Recommendation Three All partner agencies should promote the use of the sexual abuse pathway in cases of sexual abuse and sexual exploitation, emphasising the use of the Sexual Assault Referral Centre (SARC), and make sure that the pathway is embedded into day to day practice. Recommendation Four All partner agencies should work together to consider the effectiveness of recognition and response in situations where criminal exploitation may feature in a young person’s life. Finding Two Assessments and plans were limited in their analysis of the history of both parents, the dynamics of relationships within the family and relevant health information. There is little evidence that assessments and plans explored the family history, dynamics of relationships and any discrepancies in accounts given to professionals. This meant that assessments lacked depth and did not fully analyse the experience of children in the family, any risks they may face and the needs of individual family members. Responses to the family including child protection plans therefore did not take account of the complexity of needs and work with the whole family to improve the lives of the children including Faith. For example, information obtained for this review shows that Father had a significant criminal history including a two-year prison sentence for drug related offences after the birth of Faith. Some (but not all) aspects of this were known but were not given sufficient attention when considering the overall dynamics of the family and their interactions with the local community. In face to face conversations, Father minimised his criminal history, although at the time of his application for Residence Orders further information from Faith and her half-sister indicated that he had not been entirely honest. Father’s response may have been understandable, but his account was not challenged and explored further in the context of the known neighbourhood disputes and reports of family violence. The section 7 report at the time of Residence Order application did question Father’s capacity to care for his three children and argued against an order being made. However, once the Order was agreed in respect of the two youngest children the focus moved away from his capacity to parent. A new social worker took over Faith’s case and work with the family from this point seemed based on the premise that Faith’s mother was the main problem. It is likely that the reality was more complicated than that. This social worker (and manager) worked with Faith for several years and there is little evidence that any alternative hypotheses were considered. Further assessments and plans would have benefited from an analysis Page 26 of 32 of a chronology which set out the history of both parents, their relationship and the experiences of all the children in the household. Such an analysis may have helped to understand the cause of any specific risks to the children and focus services more clearly on protecting Faith from harm and working with the family system. Faith feels strongly that practitioners should have been more curious about the relationships within the family and to have asked questions about why her older half sibling wished to leave home and move in with her birth father at the age of 13. A common thread from discussions with Faith and those who worked with her is her strong loyalty to all her family and her wish to help and protect her siblings and her mother. There is no indication that this was properly understood and addressed or that the system provided any structured help to Faith’s mother, thus putting a burden of responsibility on Faith. Many of Faith’s episodes missing from care were linked to her making contact with her mother. If more attempt had been made to work with Faith’s mother, it is possible (but by no means certain) that her knowledge of the sexual abuse experienced by Faith would have come to light. The recent call for more focus on real partnership working with families and sophisticated services that address the needs of the whole family is of relevance here.14 Assessments were limited in their knowledge and use of health information. There is little evidence of social workers contacting health professionals for information and similarly not all health professionals would have been aware of concerns within Children’s Social Care. The full extent of GP understanding at this time has not been possible to explore further as records from the time have not been available to the review. The review was informed that this is still an issue today with health visitors not being asked for information when a child and family assessment is taking place and nurses for looked after children not being invited to strategy meetings for children who are looked after by the local authority. There is also a current concern that integration of health information is more problematic because Named Nurse15 and health safeguarding access to the social work database (Framework i) has been removed as a result of GDPR16. In respect of current systems Children’s Social Care have informed the review that systems are set up to link all past involvement, information and concerns about a child. Agency checks are now described as more thorough with the introduction of a Multi-Agency Safeguarding Hub (MASH) and information sharing agreements being in place. Given the concerns expressed by health colleagues above, this is an area that needs further attention in order to understand the differing agency perspectives. 14 Trowler, I (2018) Care Proceedings in England: The Case for Clear Blue Water. University of Sheffield and Crook Public Service Fellowships. Page 7. 15 All providers of NHS funded health services should identify a dedicated named doctor and a named nurse for safeguarding children. Named practitioners have a key role in promoting good professional practice within their organisation and agency, providing advice and expertise for fellow practitioners, and ensuring safeguarding training is in place. 16 General Data Protection Regulation Page 27 of 32 Recommendation Five Partner agencies should work together to develop an agreed multi-agency whole family approach to work with complex families. This approach should include expectations regarding information sharing and understanding and working with the root causes of adult issues that are affecting parenting capacity. Finding Three There was no clear plan to give Faith a permanent safe home and the legal framework was not used effectively. When she was accommodated, planning lacked focus, did not manage family contact and there were missed opportunities to explore the meaning of her behaviour, particularly at times of placement breakdown. There is an overwhelming sense that throughout Faith’s time accommodated by the local authority, practitioners struggled to provide the professional and human response that was needed when working with an extremely troubled child. It is questionable as to whether section 20 voluntary accommodation provided the structure and stability that Faith needed. Part of the problem (as identified in Finding Two) was that the risks within the family environment had not been properly analysed, adequate help had not been provided in a very complex family situation and the potential for long term change not addressed. Although accommodated, family dynamics continued to adversely affect Faith and she bounced between family members with her unrelenting focus being on trying to look after her mother with her father threatening to reject her when she and Mother had contact. The independent reviewing officer during the time was concerned that section 20 was not appropriate and that the required consent from Mother had not been obtained. At that time there was no culture within the department of independent reviewing officers escalating any concerns and their focus became keeping the placement stable to prevent Faith going home. The independent reviewing officer was also aware that the social worker was struggling to keep Faith on board, and it seems that in trying to keep Faith engaged there was a lack of structure to her contact with her parents. Contact was driven by Faith (and her father) rather than an analysis of what would be best for her wellbeing. Since voluntary accommodation meant that her parents could remove her from care at any time, the focus seems to have been on not “rocking the boat” and consequently no one looking after Faith had a clear framework for managing contact and absences from care. There are three alternative possibilities here. One is that greater efforts should have been made to support Faith’s half-sister to look after her- this is what Faith feels should have happened although the records would suggest that there were serious concerns about the potential risks. The second is that section 20 should have been underpinned by more structured planning, work with the whole family and greater Page 28 of 32 challenge to Faith’s parents when they seemed to disrupt the placement or thirdly, a recognition that Faith was likely to have most stability via a legal order. The independent reviewing officer did ask the social worker on more than one occasion whether legal advice had been sought and was told that it had but the threshold was not met. There is no record of any such advice being sought from the legal team. What is clear is that there is a notable absence of the effective use of disruption meetings within the local authority at the point of placement breakdown. This would have provided an opportunity to reflect on the underlying causes of the breakdown and plan next steps, including whether a legal planning meeting should be convened and whether any kind of court order was needed to protect her, including the use of secure accommodation. Although Faith feels that secure accommodation17 should have been considered when she was in the first residential placement, it seems that people who knew her at that time did not feel that she was at the most serious end of the spectrum in terms of behaviour and would not have met the legal threshold. Later, when there were concerns about her involvement in the supply of drugs and risk of sexual exploitation the need for a legal order could have been considered but there is no evidence that any kind of structured thinking or planning took place to determine whether or not this was the right route for her. There are strong views about the use of secure accommodation. Martin Narey in his review of residential care18 commented on this and the wide variation in the use of secure accommodation between local authorities. He noted: Some senior social work managers pride themselves on never, or very rarely, resorting to secure use because they consider that to do so, is somehow morally wrong, and that a child is being essentially imprisoned without due process. I believe that means that the benefits of a secure placement are sometimes overlooked by commissioners. (page 30). Another factor is the knowledge that there is a shortage of secure places with a court in 2018 declining to make an order after no suitable placement could be found19. The Department for Education’s response to the Narey review including funding to increase capacity may prevent concerns about availability influencing assessments in the future. If a secure accommodation order had been granted this would have been for up to three months in the first instance and then for periods of up to six months on 17 Under section 25 Children Act 1989 a secure accommodation order can be made where: a) A young person has a history of running away, is likely to run away from any other kind of accommodation and if he runs away is likely to suffer significant harm; or b) If the young person is not kept in secure accommodation he is likely to injure himself or other people. 18 Residential Care in England Report of Sir Martin Narey’s independent review of children’s residential care, July 2016 19 http://www.communitycare.co.uk/2018/10/16/judge-bemoans-distorted-market-young-peoples-secure-accommodation/ Page 29 of 32 subsequent application to the court. From Faith’s perspective this would have given her the space and stability to engage in therapeutic work. It is not clear whether any of the above concerns affected thinking in Medway. The impression is that the most likely explanation is that decisions were affected by a more fundamental lack of effective assessment and plans that were not always informed by all relevant information. For example, Faith’s allegation of rape made in January 2012 was not included in the social worker’s report for the Looked After Child review. It is important to note that the review has been told that the planning process today would be different than it was when Faith was accommodated, and the Safeguarding Children Board will need to be assured that this is the case. Understanding the causes of placement breakdown should have included a focus on the impact of early experiences on Faith’s behaviour and whether her therapeutic needs were being adequately met. Agencies were possibly lulled into a false sense of security because a CAMHS worker was involved and the working context was not one where a multi-agency approach to providing child mental health services was everyday practice. There is evidence that Faith’s school tried to provide support but there was no planning across services that could have integrated the work of CAMHS, the school and social work services. Children’s Social Care have informed the review that the local authorities Legal Gateway reviewing system now reviews and provides management overview and planning in all cases where a child is accommodated under Section 20. All such children have specific plans where timescales are agreed, legal advice is sought and pre proceedings planning starts. Had this been in place for Faith, improved planning may have provided an opportunity to focus on her need for stability and clarity in expected contact with her family. Recommendation Six Medway Safeguarding Children Board should seek evidence from Children’s Services that legal planning is used at an early enough stage and that this provides the framework for thorough assessments and ongoing work with the child and their family. Recommendation Seven Medway Safeguarding Children Board should seek evidence from Children’s Services that the cause of placement breakdown is analysed via disruption meetings and that findings are incorporated into ongoing planning for the child. Recommendation Eight Partner agencies should establish a multi-agency approach to the provision of therapeutic services to children and young people and that this approach should clarify roles and responsibilities and at a minimum involves schools, health and social work services. Recommendation Nine NHS England should review the system for accessing both electronic paper and archived primary care records in order to ensure that it is fit for purpose in assisting GPs in their current practice and also any required statutory reviews. Page 30 of 32 10 SUMMARY OF RECOMMENDATIONS Recommendation One Partner agencies in Medway should review their staff development activities in relation to child sexual abuse and sexual exploitation to ensure that all practitioners have the required knowledge and skills and confidence to recognise and respond to child sexual abuse within the family including hearing the “voice” and lived experience of the child. Recommendation Two Consideration should be given by Medway Hospital to pre-pubescent girls being jointly seen by a gynaecologist and a paediatrician (or a relevant specialist children’s practitioner). Best practice would be a joint paediatric/gynaecologist clinic for these patients. Recommendation Three All partner agencies should promote the use of the sexual abuse pathway in cases of sexual abuse and sexual exploitation, emphasising the use of the Sexual Assault Referral Centre (SARC), and make sure that the pathway is embedded into day to day practice. Recommendation Four All partner agencies should work together to consider the effectiveness of recognition and response in situations where criminal exploitation may feature in a young persons life. Recommendation Five Partner agencies should work together to develop a multi-agency whole family approach to work with complex families. This approach should include expectations regarding information sharing and understanding and working with the root causes of adult issues that are affecting parenting capacity. Recommendation Six Medway Safeguarding Children Board should seek assurance from Children’s Services that legal planning is used at an early enough stage and that this provides the framework for ongoing work with the child and their family. Recommendation Seven Medway Safeguarding Children Board should seek evidence from Children’s Services that the cause of placement breakdown is analysed via disruption meetings and that findings are incorporated into ongoing planning for the child. Recommendation Eight Partner agencies should establish a multi-agency approach to the provision of therapeutic services to children and young people and that this approach should clarify roles and responsibilities and at a minimum involves schools, health and social work services. Recommendation Nine NHS England should review the system for accessing both electronic, paper and archived primary care records in order to ensure that it is fit for purpose in assisting GPs in their current practice and also any required statutory reviews. Page 31 of 32 11 APPENDIX ONE: DETAILS OF LEAD REVIEWER AND PANEL MEMBERSHIP Jane Wonnacott was appointed as an independent lead reviewer by Medway Safeguarding Children Board to carry out the review and write this report. Jane is a qualified social worker with over twenty years’ experience of conducting Serious Case Reviews and is the author of over one hundred reports. A panel was made up of senior professionals and was appointed to work with the lead reviewer. Members of the panel were: Detective Superintendent (Chair until January 2019) - Kent Police Named Nurse for Safeguarding - Medway Community Healthcare Head of Safeguarding - Medway NHS Foundation Trust Area Manager, Kent - NELFT Designated Safeguarding Nurse for Children and Families - NHS Medway Clinical Commissioning Group Detective Chief Inspector (Chair from January 2019) - Kent Police Head of Safeguarding and Quality Assurance – Medway Council Principal Social Worker, Children’s Services – Medway Council Virtual Head Teacher, Children & Adults services, Medway Council Learning and Development Officer, Child Death Review Co-Ordinator - Medway Safeguarding Children Board Business Manager - Medway Safeguarding Children Board Project Support Officer – Medway Safeguarding Children Board 12 APPENDIX TWO: REVIEW QUESTIONS 1. Why were the early signs of child sexual abuse not recognised and acted upon across the partnership and are there lessons for practice today? 2. What were the barriers (individual and cultural) that stopped professionals from hearing the voice of the child/young person and acting to protect her when allegations had been made and/or there was evidence of abuse? 3. What do practitioners understand their powers and responsibilities are in relation to information sharing, how effective was communication and partnership working across the partnership, and how did this impact on the safety and wellbeing of the child/young person? 4. How far were the child/young person’s overall health needs met, how effective was communication across the health community? 5. Were there any barriers that prevented practitioners from following up and challenging responses to referrals? Page 32 of 32 6. What does this case tell us about how effectively professionals engage with young people whose behaviour is described as “challenging and work with them to understand the meaning of their behaviour? 7. What were the barriers that prevented the child protection and legal processes from safeguarding the child, promoting her wellbeing and achieving permanence? 8. What is happening now across the partnership to improve practice in similar situations and are there further improvements that need to be made? 13 APPENDIX THREE: DOCUMENTS SUBMITTED TO THE REVIEW Children’s Social Care assessments Child Protection Conference Minutes Psychiatric assessment List of schools attended CSA pathway Section 7 Report from Children’s Services Serious Incident Report Kent Police – Investigation Review |
NC048276 | Death of a 4-day-old girl (ZBM) in December 2014. Mother (CB) was under observation on a maternity ward for babies whose mothers have complex medical needs. CB left hospital unannounced carrying ZBM and subsequently took her own life and that of ZBM. CB had a history of mental health problems, was known to health services previously and had been taking anti-psychotic medication to stabilise her condition. CB became pregnant in April 2014 and had an on-off relationship with her partner throughout pregnancy. In May 2014 CB called police to report partner for domestic abuse but later withdrew the allegation. CB reported stopping medication mid-November 2014. Ethnicity or nationality of the family is not stated. Learning includes: the complexity and range of services that work with pregnant women with mental health problems makes it difficult to coordinate multi-organisational working; the positive strategy of long-term engagement with service users in mental health services can create difficulties when balancing the needs of a pregnant service user against the needs of the unborn child; the practice of service users being asked to relay complex information about their treatment or condition verbally to other agencies makes it more likely that this information will be incorrectly relayed or not shared at all, placing the unborn child and service user at increased risk of vulnerability. This report does not make recommendations to the Bristol Safeguarding Childrens Board about what actions should be taken in response to the findings of this review.
| Bristol Safeguarding Children Board Serious Case Review Can the Bristol Safeguarding Boards be assured that services to support new mothers with mental health needs are sufficient to ensure that their needs and the wellbeing of their unborn/new-born baby are safeguarded? Julie Pett and Sarah-Jane Leatherland 6/4/2017 1 | P a g e S e r i o u s C a s e R e v i e w Contents 1. Introduction .................................................................................................................................... 2 1.1. Why this case was chosen to be reviewed ............................................................................. 2 1.2. Summary of case ..................................................................................................................... 3 2. Methodology ................................................................................................................................... 4 2.1. A systems based approach ...................................................................................................... 4 2.2. Review team ........................................................................................................................... 4 2.3. Structure of the review process .............................................................................................. 5 2.4. Parameters and mandate ....................................................................................................... 5 2.5. Sources of data ....................................................................................................................... 5 2.6. The nature of the findings ....................................................................................................... 7 2.7. Methodological comment and limitations ............................................................................. 8 3. The Findings .................................................................................................................................... 9 3.1. Introduction ............................................................................................................................ 9 3.2. Appraisal of professional practice in this case – a synopsis ................................................... 9 3.3. In what ways does this case provide a useful window on our systems? .............................. 14 3.4. Finding 1 ................................................................................................................................ 16 3.5. Finding 2 ................................................................................................................................ 19 3.6. Finding 3 ................................................................................................................................ 22 3.7. Finding 4 ................................................................................................................................ 26 3.8. Finding 5 ................................................................................................................................ 30 3.9. Finding 6 ................................................................................................................................ 35 3.10. Finding 7 ............................................................................................................................ 37 3.11. Finding 8 ............................................................................................................................ 40 3.12. Learning at the fringes ...................................................................................................... 43 3.12.1. Learning from the SCR process ......................................................................................... 43 3.12.2. Isolation of GPs from Midwifery Services ......................................................................... 43 3.12.3. Observation on Maternity Wards ..................................................................................... 43 3.12.4. Observation on withdrawal symptoms ............................................................................. 44 3.13. Conclusion ......................................................................................................................... 44 4. Glossary of Terms .............................................................................................................................. 45 2 | P a g e S e r i o u s C a s e R e v i e w 1. Introduction 1.1. Why this case was chosen to be reviewed 1.1.1. Serious Case Reviews are about learning lessons for the future. They make sure that Safeguarding Boards get the full picture of local systems and processes, including what happened and why. This allows all partner organisations involved to work more closely together to develop and improve their services and practice. 1.1.2. Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children states that: “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children”. (HM Government 2015, 4:7) 1.1.3. Statutory guidance requires serious case reviews (SCRs) to be conducted in such in a way which: “Recognises the complex circumstances in which professionals work together to safeguard children. Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Is transparent about the way data is collected and analysed. Makes use of relevant research and case evidence to inform the findings”. (HM Government 2015, 4:11) 1.1.4. It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: “There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Families….should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process”. (HM Government 2015, 4:10) 3 | P a g e S e r i o u s C a s e R e v i e w 1.1.5. The Care Act 2014, implemented 1st April 2015, requires the Safeguarding Adults Board (SAB), to arrange a Safeguarding Adults Review (SAR) where a case gives rise to concerns about the way in which local professionals and services work together to safeguard adults at risk. CB’s death occurred prior to the requirement of a statutory adult’s review, and because Bristol LSCB was undertaking a statutory SCR for ZBM, Bristol SAB agreed not to carry out a SAR but to take note of any Findings relating to the death of CB that could have implications for adult services. Bristol City Council Adult Social Care provided a representative to the review team so that learning could be shared with Bristol SAB throughout the review process. 1.1.6. NHS England also recognised the benefit in reducing the number of reviews conducted, and funded a Perinatal Mental Health Specialist as a member of the Review Team in the place of conducting a separate Mental Health Homicide Review 1.2. Summary of case 1.2.1. CB was diagnosed with a thyroid condition whilst at school. Her father died quite suddenly when she was 15 years old and CB had a history of low mood from that period, developing psychosis from her late teens. She continued to have intermittent relationships with her partner, mother and sister. CB was admitted to a Mental Health Hospital in December 2010 and began to take an anti-psychotic drug which stabilised her condition. She lived for some time in supported housing after her hospital discharge, and finally moved to a private flat in central Bristol. 1.2.2. CB was referred to the Community Mental Health Early Intervention Team in 2011 and continued to engage with this service. CB discussed becoming pregnant with her GP practice during late 2013, and in April 2014 became pregnant. She was initially ambivalent but decided to continue with the pregnancy. CB was in an ‘on-off’ relationship with her partner throughout this time. In May 2014 she began her Community Ante-Natal appointments and initially chose Hospital 1 to give birth, although later changed her mind and eventually chose Hospital 2. CB also had intermittent contact with the local specialist Mother and Baby Unit. 1.2.3. When CB was 14 weeks pregnant in May 2014 she contacted the Police accusing her partner of domestic abuse and a referral was made to Children’s Social Care First Response, although CB later withdrew the allegation. After responding, Police and Children’s Social Care First Response took no further action. 1.2.4. In July 2014 at 22 weeks pregnant, CB transferred from the Community Mental Health Early Intervention Team to the Assessment and Recovery Team. She continued to access Community Midwifery, and a Health Visitor made initial contact with CB to follow up concerns raised by the midwifery team. 1.2.5. In mid-November 2014 at 39 weeks pregnant, CB told her midwife that she had stopped taking her medication the week before, although she then told other professionals that she had been reducing for five months. 4 | P a g e S e r i o u s C a s e R e v i e w 1.2.6. CB had her first ante-natal appointment with an obstetrician with an interest in mental health at Hospital 2 in late November 2014, and she gave birth to a healthy baby named ZBM there on 28th November 2014. 1.2.7. CB and ZBM remained at Hospital 2 for observations on a maternity ward which offers increased support, monitoring and observation of babies who have mothers with complex medical needs, prematurity and mothers’ use of substances both prescribed and recreational. CB was subsequently seen by the Mental Health Liaison Team at various points during her admission from 28th November 2014, and agreed to restart her medication by 2nd December 2014. She refused the dose offered, so never restarted her medication. On the evening of the 2nd December 2014 CB left the hospital carrying ZBM and subsequently took her own life and that of ZBM. 2. Methodology 2.1. A systems based approach 2.1.1. A systems approach in SCRs is focused on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the underlying issues that are influencing practice more generally. It is these underlying patterns that count as ‘findings’ or ‘lessons’ from a case, and addressing them will contribute to improving practice more widely. 2.1.2. Qualitative research methods are required in a systems approach, and data comes from structured conversations with involved professionals, case files and contextual documentation from organisations. 2.2. Review team 2.2.1. The Serious Case Review was carried out by a Review Team led by two Independent Lead Reviewers. Collectively, the role of the review team is to undertake the data collection and analysis, and author the final report. Ownership of the final report lies with the LSCB as commissioner of the case review. Sarah-Jane Leatherland Independent Lead Reviewer Julie Pett Independent Lead Reviewer 2.2.2. The review team was made up of senior representatives from different agencies. Review team members did not have any relationship to the case being reviewed; they were independent and are detailed below: Detective Inspector, Protect Investigations, Avon & Somerset Constabulary Designated Safeguarding Children’s Nurse, Bristol Clinical Commissioning Group Safeguarding Adults Lead Adult Social Care, Bristol City Council Service Manager Children’s Social Care Bristol City Council (BCC) Consultant Social Worker, Children’s Social Care Bristol City Council (observer for professional development). 5 | P a g e S e r i o u s C a s e R e v i e w Independent Head of Midwifery, Associate Director of Nursing, Yeovil District Hospital NHS Foundation Trust Independent Consultant Perinatal Psychiatrist, Leeds and York Humber NHS Foundation Trust 2.3. Structure of the review process 2.3.1. When using a systems model, gathering and making sense of information about a case is a gradual and cumulative process. Over the course of this review the Review Team met seven times, including three meetings with the Case group and a day and half of sessions to present the emerging analysis. Attendance at all meetings was good, and the Review Team also accepted comments via email and by phone to ensure as inclusive an approach as possible. 2.4. Parameters and mandate 2.4.1. In line with qualitative research principles, reviewers endeavour to start with an open mind so that the review is led by the evidence discovered through the process. A research question is used in place of terms of reference to avoid a prescriptive focus. 2.4.2. The review team and LSCB agreed the following research question: Can the Bristol Safeguarding Boards be assured that services to support new mothers with mental health needs are sufficient to ensure that their needs and the wellbeing of their unborn/new-born baby are safeguarded? 2.4.3. The period under review was April 2014 to December 2014. However, in order to provide context the Review Team also looked at the history of CB’s involvement with services prior to these dates. 2.5. Sources of data 2.5.1. The systems approach requires the review team to learn how those involved in a case saw things at the time and explore ways in which the context may have influenced their work. This is known as the ‘local rationality’ and requires those involved to play a major part in the review, analysing how and why practice unfolded the way it did and highlighting the broader organisational context. Data From individual conversations 2.5.2. The Review Team conducted structured conversations with the following members of staff (the ‘Case Group’). At least two members of the Review Team were involved each time: Care Coordinator EI Team Mental Health Trust Care Coordinator Recovery Team Mental Health Trust Community Midwife, Hospital 2 Consultant, Hospital 2 Consultant Social Worker, Children’s Social Care Detective Constable, Police Force 6 | P a g e S e r i o u s C a s e R e v i e w Director Children’s & Families Hospital 2 General Practitioner Head of Midwifery, Hospital 2 Health Visitor Mental Health Liaison Consultant, Mental Health Trust Mental Health Liaison Nurse, Hospital 2 Mental Health Liaison Nurse, Hospital 2 Pregnancy Advisory Service Nurse Advisory Service Lead Nurse Pregnancy Advisory Service Doctor Specialty Doctor. Mother and Baby Unit, Mental Health Trust Team Manager, First Response, Children’s Social Care Team Manager, Mental Health Trust Ward Sister Hospital 2 Further clarification about commissioning arrangements in Bristol was provided in a conversation between a reviewer and the Programme Director from NHS Bristol Clinical Commissioning Group. Data from documentation 2.5.3. The following documentation was available for the review team: Electronic CSC records GP records Maternity Ward records RCA Documents already completed by Health Trusts Nice Guidelines Working Together to Safeguard Children Versions 2013 and 2015 Agency Reports to the Coroner Preventing Further Death reports – Coroner New born baby records Community maternity records Audit of Social Care First Response Decision Making June 2016 Clarification of queries following analysis of this documentation was received from Hospital 1, Children’s Social Care and from the Mental Health Trust. The voice of the child 2.5.4. ZBM was unborn for the majority of the time period under review, and newly born at the time of her death, so it is difficult to hear the voice of the child. From the individual conversations and case group meetings ZBM was described as a healthy term baby (born at 42 weeks gestation), and there are many references to breast-feeding. 7 | P a g e S e r i o u s C a s e R e v i e w 2.5.5. From the ante-natal care provided there is nothing to suggest that in pregnancy there were any concerns about ZBM’s growth or development, which suggests that her mother was careful of her own physical health and that of the unborn child. 2.5.6. ZBM’s Father and maternal Grandmother described her as ‘beautiful’ and ‘perfect’, and that she was content both in the care and handling by her mother and father. 2.5.7. From the evidence available ZBM was well fed and cared for and attended to by her Mother and Father in the hospital setting, and was a contented baby. Data from family 2.5.8. The lead reviewers met with CB’s partner (ZBM’s father) and mother at the start of the review and then with her sister and mother again towards the end of the review process to inform them of the draft Findings. It was helpful to learn that professional’s experiences of CB mirrored that of her family. The family’s input has meant that the Review Team were able to gain an understanding of both their and CB’s experience of the multi-agency system. Their view has profoundly influenced the Findings within this Review and we would like to thank them for their candour and honesty. They helped us to understand a little about what CB was really like as an individual. Unfortunately ZBM’s Father was not available towards the end of the review, and so the lead reviewers were unable to share the draft findings with him. 2.6. The nature of the findings 2.6.1. A serious case review plays an important part in efforts to achieve safer and more effective systems. Consequently, it is necessary to understand what happened and why, and go further to reflect on what this reveals about gaps and inadequacies. The case acts as ‘a window on the system’ (Vincent 2004: 13). 2.6.2. Case Review findings therefore say something more about the Board’s area/agencies and their usual patterns of working. The Review Team has selected findings that focus on the systemic patterns of working that most urgently need tackling for the benefit of children and their parents – and these may not be the issues that appeared most critical in the context of this particular case. 2.6.3. Some agencies have already identified learning and developed recommendations and action plans, or resolved issues. This review will not duplicate their work. Changes and developments made as a result of learning identified in this case include: The review of ward layout and security undertaken and changes to prevent women leaving the ward unchallenged implemented at Hospital 2. A review of perinatal mental health has been undertaken by Mental Health and Midwifery Commissioners and Providers and plans made to commission community perinatal services in Bristol A review of Mental Health Services by Mental Health Commissioners has taken place There has been a change in practice within the Pregnancy Advisory Service regarding contact with mental health services and domestic abuse specialist services. 8 | P a g e S e r i o u s C a s e R e v i e w There has been a change in practice within the Mental Health Trust Recovery Team regarding cover of caseload when care coordinators are on leave There has been a change in practice around the support of service users who have a part time Care Coordinator in the Mental Health Trust Improved access so appropriate staff in obstetric staff and midwives teams can access mental health records. 2.7. Methodological comment and limitations 2.7.1. Most professionals involved in the case engaged fully in the review process. The review has benefited from their openness and willingness to speak candidly about the systems in which they work. The review acknowledges that some practitioners were unable to participate fully in the review process, and values the contribution that those practitioners were able to make. 2.7.2. This case has been subject to a number of different investigations and reviews including the Coroner’s Court. The effect of practitioners reliving their work and involvement in this case may have impacted this review. The Review Team also acknowledges that the case has had a significant emotional impact on all of the practitioners involved in the case and the process of multiple reviews has compounded this. 2.7.3. Although two people were identified from Avon and Wiltshire NHS Mental Health Trust to join the Review Team, neither were able to engage with the full SCR process. This meant that it was difficult for the rest of the Review Team to pursue some lines of enquiry and / or understand day to day practice within mental health services in Bristol. This may have impacted on overall learning from this Review. 9 | P a g e S e r i o u s C a s e R e v i e w 3. The Findings What light has this case review shed on the reliability of our systems? 3.1. Introduction 3.1.1. In the systems methodology, findings are presented as a series of ‘Problems and Puzzles’ i.e. the multi-agency issues for consideration and local prioritisation, rather than recommendations. The member agencies are asked to note the findings of this report and to take ownership of the learning. This report does not seek to recommend to the Safeguarding Children’s Board what actions should be taken in response to the findings of this review, nor tell member organisations how to embed the learning from this review into their practice. 3.1.2. The findings are intended to be the start of a process of change where the Safeguarding Board and member organisations work together to effect systemic improvements that will support and protect children and adults from abuse or neglect in the future. 3.2. Appraisal of professional practice in this case – a synopsis 3.2.1. The serious case review has found that examples of expected and good practice were demonstrated by individual professionals across the review period. In addition there are examples of professionals who have worked to the best of their ability considering their prior experience and the limitations of the systems in which they operate, as identified in this report. 3.2.2. Throughout the review timeline professionals appeared to be more focused on the needs of the adult (Mother) rather than the unborn child. This is explored in Finding 1. Opportunities were missed for professionals to be supported to identify and tackle child protection issues, and this is discussed in Finding 2. 3.2.3. Health Professionals did not routinely consult a pharmacist for information to clarify the use of medication during pregnancy and breast-feeding as part of their practice. This practice would be supported through casework support and supervision, as discussed in Finding 2. 3.2.4. CB attended her GP practice in April 2014 with her partner because she was pregnant. CB had not met this GP before and appropriate care was given resulting in a referral to the mother and baby unit (MBU). 3.2.5. CB contacted the Pregnancy Advisory Service (PAS), which contacted the GP. The GP provided CB with an opportunity to meet alone to discuss her concerns about the pregnancy. Information about CB’s involvement with the PAS was not shared with other professionals during the case, and was therefore not interpreted as a potential risk factor by any of the professionals involved. At the time, the PAS did not routinely contact the Mental Health Service about a patient. This practice has now changed and when the PAS are aware that a patient has a history of severe and enduring mental health, a mental health practitioner is routinely contacted. 10 | P a g e S e r i o u s C a s e R e v i e w 3.2.6. In early pregnancy the concerns for CB were firstly the risk of mental health relapse during pregnancy or post-delivery, and secondly the effects of her medication on her baby. A joint contact by MBU Specialty Doctor and Care Coordinator provided advice on both these issues as would be expected, and also offered a planned admission to the MBU around the due date. At this time the key primary care professionals were proactive and established a good communication network. 3.2.7. On 2nd May 2014 CB attended her first appointment with a Community Midwife, accompanied by her partner, having decided to continue with the pregnancy. Ante-natal assessments were completed at this time including identification of CB’s mental health needs, and the support being provided by MBU and the Care Coordinator. The Community Midwife appropriately notified the Health Visitor of CB’s pregnancy, and midwifery care continued throughout. CB’s compliance with scheduled midwifery appointments was variable. However, because she had ‘regular contact’ with midwives this was not perceived to be a risk factor, or as a possible indicator that her mental health could be deteriorating. 3.2.8. The MBU initially remained in contact with CB on an informal basis. Whilst this practice had the best of intentions, this later confused other professionals involved with CB, leading to a number of assumptions being made by a range of professionals as to the level of support that was being provided to CB, and who was 'leading the case management'. CB’s choice to withdraw from the MBU was not communicated to other professionals involved in the case, and so some professionals assumed that MBU remained involved. This is discussed more fully in Finding 7. 3.2.9. In May 2014, when CB was around 14 weeks pregnant, she made a 999 call to the police with an allegation of domestic abuse, and the police attended her flat. Police fully investigated the allegation and completed a DASH (risk) assessment in accordance with local procedures. After investigation, the Police assessment did not meet the thresholds for referrals to either children's safeguarding services or adult safeguarding services. Whilst there is some evidence of communication between Police and Mental Health Services, this was limited, and no plan was made to inform other health professionals such as the Midwife and GP. 3.2.10. At this time, a “request for help form was completed” [by the Midwife] “following advice from child protection nursing team”. The Review Team noted that this is the sole reference to any specific Health child protection professional, i.e. named professional, within the case before CB left the hospital ward with ZBM, and this is discussed in Finding 2. Professionals lost focus on the unborn child, allowing barriers to communication and information sharing to restrict their practice, which is discussed in Finding 1. 3.2.11. From June 2014 onwards professionals began to be concerned about CB’s mental health. Key professionals found it difficult to therapeutically challenge CB, which is explored further in Finding 4. 11 | P a g e S e r i o u s C a s e R e v i e w 3.2.12. Communication continued between the Community Midwife and the Mental Health Team, however there was over reliance on obtaining information through CB. This is explored in Finding 7. A lack of analysis and lack of a multi-agency meeting coupled with CB’s variable engagement resulted in key professionals being unable to identify the inconsistencies in the information that CB was sharing with different professionals. This is discussed in Finding 8. 3.2.13. Furthermore, professionals used every day language and shorthand to describe CB’s severe and enduring mental health condition across agencies, which provided a further distortion to the overall picture of the case, creating misunderstanding of the risks involved. This is discussed in Finding 6. 3.2.14. CB had remained with the Mental Health Early Intervention Team much longer than was usual, which was a person centred approach. Mental health professionals carefully considered the transfer of CB and eventually an appropriate time for transfer to the Recovery team was identified. It is unclear what consideration was given to the impact of her pregnancy on her mental health and the skills needed to support her in this period of significant change. Finding 1 examines the tension between the strategies of long-term engagement with the service user with the needs of the unborn child. 3.2.15. A Care Programmed Approach (CPA) review was held in July 2014 with both Care Coordinators when CB was 22 weeks pregnant. The impact of the pregnancy did not seem to be an indicator for more specialist oversight of CB’s care, or for involvement of the medical clinician. The lack of a visible mental health medical lead or a review of CB and her medication except for the involvement of the MBU is worth further consideration and will be explored in finding 4. 3.2.16. The CPA review provided a detailed plan with regard to CB’s mental health needs but the plan was overly ambitious given their caseload, specifying fortnightly contact between the new Care Coordinator and CB. A weakness within this plan was that no other professionals (e.g. GP, midwife, health visitor, psychiatrist) involved in CB’s care were invited to attend or contribute to the plan and decision-making. Whilst this was the practice in Bristol at the time, this means that key professionals that should have contributed to the plan were omitted. Having a lead clinician as discussed in Finding 7 would have supported the planning and decision making at this point. 3.2.17. Following this review meeting professionals relied on CB to accurately inform Midwifery of the transfer to the recovery team. Adult Mental Health puts their service users at the centre of their care and in charge of information flow. This case has indicated systems need to be reviewed when the adult is pregnant or caring for children. 3.2.18. The GP received a copy of the care plan and noted the change in medication dose. CB continued to collect her medication giving no indication she was altering her own doses. There was no further contact between the GP and CB, or between the GP and any other services including midwifery services. The isolation of the GP and lack of interaction with midwifery is discussed in Learning at the Fringes. 12 | P a g e S e r i o u s C a s e R e v i e w 3.2.19. In August 2014, when CB was 25 weeks pregnant, CB and her original Care Coordinator had their final contact which was a positive experience and clearly demonstrated that CB was progressing from a mental health perspective. 3.2.20. The co-located Midwifery and Health Visiting teams had “loads of discussions” about CB and so the Health Visitor commenced ante-natal contact with CB as expected. Whilst co-location can improve inter professional and inter-agency working, there is limited evidence of the Midwife and Health Visitor working together, or having a common recorded text of discussions. 3.2.21. The Health Visitor assessment recognised a possible safeguarding risk, reported by CB, relating to “unsupervised access to the baby by CB’s partner”. Attempts by the Health Visitor to extend CB’s support network were thwarted as CB declined, but this did not trigger a concern about a potential increased level of risk. An agreement that the Care Coordinator and Health Visitor would contact each other about further concerns was unrealistic, as this was dependent on each professional being able to identify a concern, and there was no plan to have any regular contact between them at any time. 3.2.22. In response to concerns by the Health Visitor, the Care Coordinator appropriately attempted to address the challenges of some aspects of CB’s Birth Plan but stepped back in the face of CB’s unwillingness to acknowledge these. Following a discussion with her named Midwife about a home birth being unsuitable, Midwifery care continued to be provided by the midwifery team, but with the named midwife withdrawing from direct contact. This was reasonable practice. The difficulties practitioners face in challenging assertive service users is explored in Finding 4. 3.2.23. A number of professionals attempted to make referrals to Children’s Social Care ‘First Response’ but were unable to articulate their concerns sufficiently to meet the threshold for services and identify a clear need for social work involvement. This resulted in missed opportunities for a pre-birth assessment to be undertaken. Professionals had a misunderstanding of the role of Children’s Social Care First Response, as discussed in Finding 5. 3.2.24. In late October 2014, when CB was 36 weeks pregnant, a professionals meeting was held between the Midwife, Health Visitor and Care Coordinator. This had taken some time to organise, and was limited to the professionals that “knew about each other”. Whilst a multi-agency professionals meeting is expected practice, this failed to involve any medical practitioner (CB had not been seen by a Mental Health Physician since August 2014), and no invitation was given to a manager, supervisor, named professional, safeguarding team, or children’s social care. This was the only multi-agency professionals meeting held during the period under review. Barriers to effective information sharing are discussed in Finding 3. 3.2.25. When CB failed to attend an appointment with the MBU and Care Coordinator towards the end of October 2014 due to her confusion about the venue, a further urgent appointment was made, although this had restricted time. The focus at this meeting was about the strategies CB should use to bond with her baby as CB told them she now planned to bottle-feed. CB was 37 weeks pregnant, and even though it was known that she frequently 13 | P a g e S e r i o u s C a s e R e v i e w changed her mind there was not an alternative/contingency plan post-delivery, with the sole plan being admission to the MBU. 3.2.26. Midwifery care continued, and suddenly CB changed her plans from delivering her baby at Hospital 1 to Hospital 2. A referral to a Consultant Obstetrician was made because of CB’s additional health needs, and she was seen on 11th November 2014 at 39 weeks pregnant. Neither Maternity Hospital had access to RIO (mental health recording system) so the information available was limited. CB indicated she was still taking her medication. 3.2.27. On 19th November 2014 the Community Midwife emailed the Consultant Obstetrician with concerns about relapse as CB had disclosed to her that she had stopped taking her medication. There was confusion about the language being used across agencies - see Finding 6. A final referral was made to Children’s Social Care ‘First Response’, whilst appropriate maternity care was being planned and provided. The organisational practice of generating “green paperwork” (an internal vulnerability alert system for hospital teams) was not commenced in midwifery at this point. 3.2.28. Children’s Social Care ‘First Response’ accepted the referral on 19th November 2014 and transferred the case to the hospital team, notifying the referrer by letter. At the time ZBM was born the midwifery service at Hospital 2 were unaware that CB and ZBM were an open case at Children’s Social Care, and so did not notify them of ZBM’s birth. 3.2.29. CB delivered her baby (ZBM) on 28th November 2014 and they were both transferred to a maternity ward which had higher staff-patient ratios, and allowed for closer observation of the baby’s anticipated medication withdrawal. This ward specialised in observing women and babies for withdrawal from substance misuse. Appropriate midwifery care was provided, and on 29th November 2014, the “green paperwork” was commenced. CB presented as affectionate towards her baby and commenced breastfeeding. Ward staff were concerned about CB’s mental health condition and made an internal hospital referral to the Mental Health Liaison Team, who provided a mental health assessment of CB. The Mental Health Liaison Team had discussions within their team. Over the next 36 hours 5 team members continued to assess and monitor CB, including staff being “doubled up” to ensure continuity and that there was a plan in place. At this point the Mental Health Liaison Team accessed the community mental health records via RIO. CB was physically fit for discharge but it was appropriate that she remained on the ward for observation. 3.2.30. The reason for CB’s and ZBM’s admission to the ward remained unclear, with different professionals thinking it was for different reasons. One reason was for observation of ZBM because of the potential risks of CB’s medication, which is discussed in Learning on the Fringes. Professionals remained in contact with CB undertaking their individual roles, but there was no overview of the case, which may have prompted contact with the social care team or a review of the outcome from the social care referral 10 days earlier. Professionals were concerned about CB’s well-being, but were not concerned that she posed a risk to ZBM, which was reasonable given their observations of the interaction between CB and ZBM and wider family support. Clinical findings showed ZBM was thriving. 14 | P a g e S e r i o u s C a s e R e v i e w 3.2.31. CB was visited by her partner on the evening of 2nd December 2014, who described CB as affectionate to ZBM. CB fell asleep during this visit, which prompted her partner to leave the ward, allowing CB to rest and informing staff that she was asleep. There was a system for controlling entry to the ward but mothers and their babies were allowed free access throughout the hospital. Each maternity unit can decide on the level of security as appropriate. This allowed CB to leave the ward with ZBM unnoticed and unchallenged. Since this incident ward security has been reviewed and improved, and the ward has also had a reconfiguration of the reception area for improving the patient experience. 3.2.32. Once the maternity ward staff noticed that CB and ZBM were missing there was a quick response by the maternity ward staff who contacted the police. 3.2.33. This case highlights that “Safeguarding is everybody’s business”, in that CB was able to walk outside at night, in unsuitable clothing, carrying a new-born baby, in a public place, unchallenged by anyone. 3.3. In what ways does this case provide a useful window on our systems? 3.3.1. This case, as all cases, has many unique aspects. These include both the local well-known place where CB chose to end her life and that of ZBM as well as the age of ZBM when she died. 3.3.2. The Review Team had to set aside these unique aspects and use the case to provide a ‘window on the system’. This provided an opportunity to explore multi-agency interactions and the common dilemmas and tensions staff face when they are required to determine whether to support or intervene in the lives of children (including unborn children) and their mother. 3.3.3. Both the Case Group and the Review Team felt strongly that it should be noted that professionals are working in increasingly pressured environments with limited resources, yet being required to deliver services with ever-higher expectations. Within this climate, both supervision and information sharing become a particular challenge and feature in a number of the Findings below. The review team have prioritised eight findings for the Boards to consider: 3.3.4. Finding 1 The positive strategy of long-term engagement with service users in Mental Health Services has the unintended consequence of creating difficulties when balancing the needs of a pregnant service user against the needs of the unborn child. 3.3.5. Finding 2 Although Bristol health professionals have access to safeguarding support and supervision; the model of support is inconsistent. This means the possible risks to an unborn child may not be recognised compared to the more immediate needs of the adult. 15 | P a g e S e r i o u s C a s e R e v i e w 3.3.6. Finding 3 Current practice does not identify a lead clinician across services that work with vulnerable adults, including those who are pregnant. This means that case management for service users with complex needs lacks coordination. 3.3.7. Finding 4 Some professionals may feel intimidated by unpredictable and hostile service users, and become less confident in using their skills and expertise to challenge whilst maintaining support and engage the service user. This impact can be compounded if the service user presents as verbally assertive and challenging. 3.3.8. Finding 5 Professionals in Bristol are inconsistent in their ability to provide Children’s Social Care First Response with a referral that articulates their concerns clearly enough to meet the threshold for a service. Children’s Social Care First Response does not consistently provide feedback as to why a referral does not meet the threshold for social care, leading to inaction by referrer and First Response. 3.3.9. Finding 6 Common terms used professionally to describe a service user’s health may have different connotations depending on the professional setting. If they are taken at face value by other professionals this will have a direct impact on practice and decision-making. 3.3.10. Finding 7 The practice of service users being asked to relay complex information about their treatment or condition verbally to other agencies makes it more likely that this information will be incorrectly relayed or not shared at all. This places the unborn child and service user at increased risk of vulnerability. 3.3.11. Finding 8 The complexity and range of individual services that work with pregnant women with mental ill health across Bristol makes it difficult to coordinate multi-organisational working. 16 | P a g e S e r i o u s C a s e R e v i e w 3.4. Finding 1 The positive strategy of long term engagement with service users in Mental Health Services has the unintended consequence of creating difficulties when balancing the needs of a pregnant service user against the needs of the unborn child. Introduction 3.4.1. For adults with severe and enduring mental health conditions the therapeutic relationship with professionals is allowed to develop over time because it is recognised that the service user will remain with services long term. Usually this is positive and appropriate. However the approach may not be effective when working with a pregnant woman because of the relatively short timescale of pregnancy coupled with the increased risks to both the mother’s and baby’s wellbeing. How did the issue manifest in the case? 3.4.2. In April 2014, CB was technically already overdue to be transferred from the Early Intervention Team (EI) to the North Bristol Recovery Team (A&R) when she became pregnant. The successful therapeutic relationship with her Care Coordinator had developed over time and had supported CB to remain in the community rather than requiring a hospital admission, for over three years. 3.4.3. Consideration was given for CB to remain with the Early Intervention (EI) Team but because she had already outstayed the timescale for this service it was agreed to transfer CB to the Recovery Team at this point. 3.4.4. A Care Programme Approach (CPA) Review meeting was held on 15th July 2014 (when CB was 22 weeks pregnant) between both Care Coordinators and CB, and a Care Plan was agreed. The care plan focused on the adult needs and not on any issues related to pregnancy and mental health. 3.4.5. The first meeting between CB and her new Care Coordinator took place on 12th August 2014 at CB’s flat. The new Care Coordinator raised a number of concerns around CB’s home birthing plan, such as the practicality of a home birth, but CB disputed her view and was unhappy about the discussion. The Care Coordinator did not make a future appointment but left it to CB to arrange a subsequent appointment, as would be the usual care plan for the majority of service users. This approach did not take into consideration the changing needs CB would have as the pregnancy progressed or reflect how CB would review their birth plan / home birth. 3.4.6. Later an appointment was made by CB after prompting by CC2 for 24th September 2014, but CB did not attend. 3.4.7. There were increasing concerns about CB’s mental well-being raised by midwifery to the Care Coordinator, who discussed these with Midwifery and the Health Visitor as well as the Mother and Baby Unit Specialty Doctor and CB’s mother. 17 | P a g e S e r i o u s C a s e R e v i e w 3.4.8. The Care Coordinator made a number of attempts to contact CB and spoke to her on 8th October 2014. Further attempts to speak to CB following her failure to attend a further appointment on 21st October 2014 were made. Finally, CB was seen by the Care Coordinator and MBU Specialty Doctor on 28th October 2014, some two and a half months after the meeting in August 2014. What makes it underlying rather than an issue particular to the individuals involved? 3.4.9. During the individual conversations three mental health professionals said that the aim of their role was to develop and maintain a therapeutic relationship over time. This means amongst other things that service users decide how regularly they meet their Care Coordinator and are encouraged to actively manage their own symptoms. This generates a decrease in clinical care and promotes self-management. This strategy was confirmed by the experience of the Review Team. 3.4.10. Mental health professionals do not routinely work with women who become pregnant so there will always be a proportion of mental health workers that will have never worked with a pregnant woman. For example, neither Care Coordinators nor the Team Manager had worked with pregnant women previously although they were aware of the post-pregnancy risk of relapse in maternal mental health. 3.4.11. It is not unusual for adult service users to miss or decline appointments, but as caseloads in the A&R Team are much larger compared to the EI Team there is less flexibility for A&R Care Coordinators to reschedule visits quickly. 3.4.12. The A&R Case Coordinator in this case for example had a Case Load of 23 while working half time compared to the full time EI Care Coordinator with a Case Load of 15. The reason for this is partly due to the differences in the focus of each team. The Early Intervention Team aims to intensively work with younger people who have had a first psychotic episode over a relatively short time period. Only a minority of service users are then transferred to the Recovery Team which works with service users who require longer term support. 3.4.13. Some other agencies such as Midwifery have the flexibility to transfer face-to-face contact with the service user, if there is likely to be disengagement, to another practitioner within the team, whilst maintaining responsibility for their care. For the Recovery Team with only the Care Coordinator as sole point of care, this is not possible, although service users are able to access Crisis support. 3.4.14. However, since this case in 2014, there has been a positive change in practice within Bristol Mental Health Services so that part-time Care Coordinators receive support from a staff member graded at Band 4, which is a ‘support worker’ role, more junior to the Care Co-ordinator. What is known about how widespread or prevalent the issue is? 3.4.15. Current Mental Health practice nationally uses a Recovery methodology to give service users control over their own care. The Care Programme Approach (CPA) provides a framework for effective mental health care for people with severe mental health problems. 18 | P a g e S e r i o u s C a s e R e v i e w 3.4.16. The introduction of the National Service Framework for Mental Health in 1999 saw the development of specialist teams to provide targeted services within tight criteria, e.g. individuals experiencing their first episode of psychosis in Early Intervention (EI) Teams. The lower caseloads and additional services offered to EI service users has proved in the main successful, with typically only 20% of EI Service users moving on to long term recovery teams and the majority returning to the care of their GP. 3.4.17. However, Gilburt, H. et al., 2014 (Service Transformation: Lessons from mental health. London: The Kings Fund), identifies that nationally this increase in specific services has created an unmet need among some individuals with long-term care needs. For example, there is an assumption that there will be time to develop the therapeutic relationship and this strategy is pursued because Recovery Teams do not have the capacity to be as flexible as the more intensive service provided in Early Intervention. 3.4.18. Parental mental ill-health is recognised as one element of the ‘toxic trio’ within child protection. This includes perinatal mental health (Ofsted 2010; Brandon et al 2012), Ofsted (2010) Learning lessons from serious case reviews 2009 – 2010, Manchester: Ofsted). 3.4.19. The Strategic Clinical Network Report, Perinatal and Infant Mental Health Care in the South West: Improving Care Pathways, (June 2015) states that: “Because the support network for women with perinatal mental health issues is complex and involves many agencies, there is an even greater need for each agency to be constantly alert to the safeguarding needs of the unborn child or infant. This thread should run through all care planning” 3.4.20. Nationally there is little consistency of approach although multi-disciplinary perinatal pathways have been developed in some parts of the country, for example in Dorset and Leeds. In Bristol, a multi-agency perinatal pathway will be developed as part of the commissioning process for the new community perinatal service currently being commissioned. What are the implications for the reliability of the multi-agency child protection system? 3.4.21. Mental health professionals support people with a severe and enduring mental health conditions by developing strong relationships with service users over time. This is appropriate for the majority of service users; however, this approach does not match the relatively short time scale of a pregnancy. 3.4.22. The impact of the mother’s mental health on both mother and baby combined with the limited time scales to make assessments and implement care packages to improve parenting outcomes requires a different approach to developing the therapeutic relationship in order to mitigate risks to mother and baby. 19 | P a g e S e r i o u s C a s e R e v i e w Finding 1 Issue for consideration by the board The positive strategy of long-term engagement with service users in Mental Health Services has the unintended consequence of creating difficulties when balancing the needs of a pregnant service user against the needs of the unborn child. Summary For adults with severe and enduring mental health conditions the therapeutic relationship with professionals is allowed to develop over time because it is recognised that the service user will remain with services long term. Usually this is positive and appropriate. However this approach may not be effective when working with a pregnant woman as there are varying degrees of disconnect between timescales of the adult and the unborn child. This leads to possible increased risks to both the unborn child and mother’s well-being. Questions for the Board and Organisations How can practitioners be supported to focus and intervene with the safeguarding needs of the child (including an unborn child) whilst at the same time support the needs of the mother? How should the Board monitor the implementation of the Perinatal and Infant Mental Health Care in the South West: Improving Care Pathways? 3.5. Finding 2 Although Bristol health professionals have access to safeguarding support and supervision; the model of support is inconsistent. This means the possible risks to an unborn child may not be recognised compared to the more immediate needs of the adult. Introduction 3.5.1. Reflective supervision is one of the key factors that improves decision-making and drift in cases. The lack of structured safeguarding supervision in all health services can have implications for service users and their children as it is difficult for a single professional to prioritise and articulate complex layers of risk without support, especially where practitioners are newly qualified, lack experience in a specific area of clinical practice or carry high caseloads. The challenge is to ensure that staff are able to reflect and recognise the cases they need help and support with when they are busy. Providers of services need systems in place to monitor that staff are being supported in their work around safeguarding. This is especially important when staff are working with new client groups e.g. pregnancy in mental health teams or mental health in midwifery teams. Effective supervision enables staff to develop clear thinking about a case. How did the issue manifest in the case? 3.5.2. Although CB was discussed at the Mental Health Trust Multi-disciplinary Team’s (MDT) meeting early on during the period under review there is no documented evidence that she was ever discussed at 1:1 sessions by any staff even during periods when professionals had safeguarding concerns e.g. when CB alleged domestic abuse or when referrals were made to First Response. 20 | P a g e S e r i o u s C a s e R e v i e w 3.5.3. Several staff from different health disciplines told the Review Team that they felt intimidated by CB yet there does not appear to be a system in place to reflect on both the clinical and safeguarding needs for CB. If there was, it does not appear to have been used. 3.5.4. It is notable that discussion with a Lead Professional for Safeguarding occurred only once during the period under review, on 16th June 2014. The next entry for a safeguarding professional is not until 3rd December 2014 after CB and ZBM had gone missing from the ward. 3.5.5. In addition although “concern” was raised in the referrals to Children’s Social Care there was a lack of clarity between whether concerns were about CB's relationship with her partner, her mental health, her ability to care for a baby, risk to the baby from her partner and/or the relationship. This lack of a full assessment would have benefited from a full discussion which includes decision and actions and is documented in the patient’s records and shared appropriately. 3.5.6. Nobody seemed to be able to be clear about this and develop a coherent referral; supervision may have assisted this. What makes it underlying rather than an issue particular to the individuals involved? 3.5.7. During conversations and at the follow-on meeting on 11th April 2016 the Case Group told the Review Team that supervision is variable across services. In no health organisation is there a system to review all cases in a caseload in a systematic way over time. In all health organisations practitioners rather than supervisors self-select cases. 3.5.8. In contrast, embedded supervision review processes exist within the Police e.g. Crime Review Structure, and within Children’s Social Care where there is a full case load review with the first line manager (usually consultant social worker in Bristol). In addition there is weekly data shared with the first line manager, unit coordinator and service manager which highlights areas of drift e.g. assessments not completed on time. 3.5.9. Of course, unlike Social Care, Health is a universal service, and caseloads tend to be correspondingly higher. Supervision is in place in high risk areas, and practitioners are supported to raise concerns when they identify them. However, this approach to self-selection does have its own subsequent risks. This case indicated there may be a varied approach to staff accessing safeguarding support and supervision. It would also be important to recognise if there are any barriers to staff seeking out support, advice and supervision. 3.5.10. Where supervision occurs, most agencies rely on a mixture of one-to-one clinical and/or line management meetings between supervisor and supervisee, or discussion of cases in team meetings. However, cases are self-selected for supervision and for discussion at Multi-Disciplinary Team meetings. 21 | P a g e S e r i o u s C a s e R e v i e w 3.5.11. For example, health visiting has always had structured supervision. The Clinical Commissioning Group monitor Health Visitor (HV) and School Health Nurse supervision, which is 1:1 every 4 months, and reviews the CP/CIN/ and UPP cases and any cases the HV has raised in the last 4 months so they can discuss this in a reflective way. It is positive that there is now some evidence of structured supervision being instigated in other settings. Community Midwifery Teams in Hospital 2 began monthly ‘group’ supervision with the named professional in April 2016. What is known about how widespread or prevalent the issue is? 3.5.12. Supervision can take a variety of forms. Supervision may include informal or ad hoc case discussion, one-to-one clinical reflection on cases, group supervision, observation of practice, or direct instruction of activity. Bishop (2007), NMC (2016). 3.5.13. In addition there are a number of specialist social care child systems available e.g. Signs of Safety (Turnell 1999) which is primarily based around child protection but can be used effectively to address risk assessment during supervision. At the time the case unfolded, the Signs of Safety model in Bristol was in the early stages of implementation and not consistently embedded in practice across all agencies. The provision of Multi-agency training had commenced at this time. 3.5.14. The Review Team are aware of the proactive use of specialist safeguarding staff being used as a resource by practitioners routinely in Health organisations nationally, as defined in their statutory roles, which includes supporting staff with casework, and safeguarding supervision. (HM Government 2015, RCPCH 2014). 3.5.15. A system of structured supervision could help staff escalate their concerns about capacity and case load waiting. For universal services, however, this may not be realistic such as with Health Visitors having caseloads from 150 to 350 and being unable to transfer or discharge due to being a universal service. Instead services need to balance the risks and ensure staff have the tools to identify patients who may be at risk rather than undertake supervision of every case. What are the implications for the reliability of the multi-agency child protection system? 3.5.16. When staff hold case responsibility in isolation it means that potential safeguarding risks are not articulated or shared and practice cannot be supported to improve. There are also implications for how confident and supported staff feel when managing complex and challenging cases. 3.5.17. Across health organisations there is no process for reviewing every service user on an individual professional’s caseload. This system results in an over reliance on that individual professional to identify issues and concerns to their line manager. This issue is exacerbated if a practitioner is inexperienced or new to a role, or working outside their usual sphere of professional competence, e.g. adult mental health professionals working with pregnancy and midwives working with women with severe and enduring mental health conditions. 22 | P a g e S e r i o u s C a s e R e v i e w 3.5.18. In addition, service users perceived to be stable or without complex needs can receive less input from the multi professional team and less support, which in turn reduces opportunities to identify any deterioration. Failure to discuss all service users in supervision could also prevent the identification of those who are indeed stable and well enough to be discharged from individual caseloads. Of course cases, being considered for closure or transfer should routinely be discussed in supervision, to ensure that all safeguarding assessments have been completed and the required action taken. Finding 2 Issue for consideration by the board Although Bristol health professionals have access to safeguarding support and supervision; the model of support is inconsistent. This means the possible risks to an unborn child may not be recognised compared to the more immediate needs of the adult. Summary Supervision provides an opportunity for individual practitioners to discuss safeguarding issues in a reflective way with a more experienced practitioner to ensure care and treatment plans are appropriate and effective, and include all relevant professionals and agencies. This can also provide the gateway for escalation, where practitioners are unsuccessful in their care plan to access additional services. The absence of safeguarding team involvement for advice, support and supervision can result in missed opportunities to identify the less obvious safeguarding cases which require supervision and support for case management. Questions for the board and organisations How can the Board support member agencies to improve the overall consistency of their child protection supervision? Is the Board assured that models of supervision used lend themselves to best practice? How can the practice of consulting with safeguarding teams be embedded systematically? 3.6. Finding 3 Current practice does not identify a lead clinician across services that work with vulnerable adults, including those who are pregnant. This means that case management for service users with complex needs lacks coordination. Introduction 3.6.1. Across Services working with children there is a culture both of identification of a lead professional to oversee the management of the case and of holding multi-agency and multi-agency disciplinary professional’s meetings, even when a case does not meet the Child Protection threshold. However in adult services multi-agency meetings rarely happen and a lead professional is rarely identified. It follows that this is unlikely to occur when the adult has an unborn child. 23 | P a g e S e r i o u s C a s e R e v i e w 3.6.2. Of course, staff in adult services do discuss cases and share information with other agencies but rarely identify a lead clinician or hold professionals meetings except where the adult meets Safeguarding Adult thresholds. This is because when service users have capacity there is an expectation that they will lead and coordinate their own care. This is the case even when the service user is pregnant. This means that different combinations of committed staff are aware of each other’s perspective, but not necessarily the entire picture. Therefore the implications of the situation may not be completely understood by all the professionals involved in the case, which in turn limits the strategies that might be applied. 3.6.3. A clear definition of who is responsible for a woman’s mental health and maternity care once perinatal mental illness is diagnosed or likely would encourage a more focussed coordinated plan of care. How did the issue manifest in the case? 3.6.4. In this case some professionals assumed that the Mental Health Care Coordinator was the lead professional whilst others assumed it was the MBU Doctor, and still others the GP. 3.6.5. Verbal communication about CB was frequent, e.g. between the Health Visitor and Midwives who were co-located. Staff told the Review Team they verbally discussed concerns and actions ‘constantly’. Often this was positive because professional care could be amended instantly. Staff clearly worked well together discussing concerns and CB’s maternity needs. Some professionals kept comprehensive records of their own actions; However, any decisions or agreed actions were not evident, shared, or not clearly stated in all professional records. This meant that gradual changes in CB’s mental health or repeat behaviours could not easily be identified by practitioners and articulated to others. 3.6.6. As CB did not meet the criteria for accepted multi-agency adult pathways (e.g. MARAC, Safeguarding Adults, MAPPA), no mechanism existed to direct and support the frontline professionals within the case. No referral was made to the safeguarding vulnerable adult’s team even when CB alleged domestic abuse, as she did not meet the threshold criteria. 3.6.7. The CPA Meeting between CB and Care Coordinators on 15th July 2014 was a missed opportunity to involve other professionals working with CB such as the GP, Midwife and Health Visitor and agree an appropriate lead professional. This would have also been an opportunity for services to understand how each other operate and the boundaries around their roles. 3.6.8. In addition there were several examples of drift within the case as no one was taking the lead, or checking back and reviewing as to what should be happening, e.g. during August and September 2014 when CB had been discharged from the Mother and Baby Unit at her request. 3.6.9. The only multi-agency professionals meeting that took place was between Health Visitor, Midwife and MH Care Coordinator on 22nd October 2014, and resulted with only one action, which was to refer to Children’s Social Care’s First Response, although it was unclear what risk the team had identified or what actions they had wanted from Children’s Social Care. There were no recorded decisions about a coordinated approach to care for CB and 24 | P a g e S e r i o u s C a s e R e v i e w her unborn child, or plan if Children’s Social Care did not accept the referral and it was unclear what the expected outcome of the referral was. 3.6.10. Professionals agreed discharge from hospital would be delayed until a safe plan was in place, but this did not take account of CB requesting early or self-discharge. No contingency plan was ever created for the care and support of CB and ZBM. The offer of a place on the MBU was the only plan devised by agencies despite CB’s stated reluctance for admission, and her known aversion to inpatient hospital treatment. 3.6.11. A clear plan of mental health care and the care plan for her as a mother with child was only going to be completed at the point of discharge when the baby was born. What makes it underlying rather than an issue particular to the individuals involved? 3.6.12. During both the individual conversations and at the Case Group Follow on Meeting on 11th April 2016, the Case Group told the Review Team that they did initiate multi-agency professionals meetings when required. For example, midwifery services provided several examples of this happening recently, which is a positive step. However, multi-agency professionals meetings still appear to be relatively rare and are inconsistent in their use. In addition the examples provided by the case group were initiated at a manager rather than front line level, or when it was a statutory requirement e.g. under Safeguarding Adults procedures. These only provide a short-term opportunity for care planning and not a long-term model. 3.6.13. The review team sought to understand why this was so. There is no multi-agency care-planning pathway to provide a forum and process for consistent information sharing, planning and decision making involving all agencies over the longer term. What is known about how widespread or prevalent the issue is? 3.6.14. The absence of an agreed multi-agency pathway for decision making and case planning in cases known to a number of agencies who work with adults is not unique to Bristol. 3.6.15. In contrast to adult services, during child protection procedures services working with children routinely conduct multi-agency meetings as evidence gathering, and to gain an overview of the case management. This takes place across services in case legal intervention is required to protect the child. This has been embedded in practice for some time, following the Victoria Climbié Inquiry (Laming 2003). Legal intervention is rarely considered in Adult Social Care, and consequently there is no practice of analysing patterns of behaviour or of building evidence running alongside case management. This leads to very few multi-agency strategy or professionals’ meetings taking place. 3.6.16. The Care Act 2014 was available during the period under review, but was not implemented until 1st April 2015, and so a SAR was not a statutory requirement at the time. 3.6.17. One of the most profound implications of the Care Act for Adult Services is around preventative services. Under the general principle of ‘Promoting Wellbeing’, The Care Act 2014 Guidance 1.13 c. states the important principle of “the importance of preventing or 25 | P a g e S e r i o u s C a s e R e v i e w delaying the development of needs for care and support and the importance of reducing needs that already exist.” The Guidance also states that “At every interaction with a person, a local authority should consider whether or how the person’s needs could be reduced or other needs could be delayed from arising”’ 3.6.18. Mental Health services for mothers and children are widely acknowledged to be inconsistent and inequitable across the country yet more than one in ten women will suffer from a perinatal mental illness, spanning from adjustment disorders and stress through to chronic serious mental illness and postpartum psychosis. 3.6.19. Recognising this, the South West Mental Health and Dementia Strategic Clinical Network and the South West Maternity and Children’s Strategic Clinical Network jointly led a review of perinatal and infant mental health services. (Perinatal and Infant Mental Health Care in the South West: Improving Care Pathways, June 2015). 3.6.20. The Review made a number of recommendations including: “Clear referral processes at any stage during the perinatal period when there is a history of mental illness, a mental wellbeing problem is suspected or there is the sudden acute onset of mental ill health” And developing a care plan for each service user which: “Incorporates a clear definition of who is responsible for a woman’s mental health and maternity care once perinatal mental illness has been diagnosed or suspected” The implementation of these recommendations would mitigate risk for women with a diagnosed mental health need who are pregnant. What are the implications for the reliability of the multi-agency child protection system? 3.6.21. The lack of a clear pathway leaves the service user and their unborn child more vulnerable. A robust system requires both single and multi-agency coordination, and the lack of a recognised multi-agency framework makes it more likely that single agencies will work in isolation and ‘compete’ rather than work together to provide a package of support and care. 26 | P a g e S e r i o u s C a s e R e v i e w Finding 3 Issue for consideration by the board Current practice does not identify a lead clinician across services that work with vulnerable adults, including those who are pregnant. This means that case management for service users with complex needs lacks coordination. Summary Not agreeing a ‘lead’ professional prevents any one professional being able to see the whole and emerging picture and removes the opportunity for coordinating services. Professionals meeting in non-statutory forums to share information and make interagency plans of support would provide early help and support to children, including unborn children and their families. A professional overseeing the whole case management would be able to identify at an early stage where services users and families may not be sharing information or attending services consistently. Questions for the board and organisations How can the Board support staff to ensure that coordination of care in different services complement each other? How does the Board ensure that the relevant multi-agency professionals are involved in complex cases with full engagement across partner agencies? Questions for the Bristol Safeguarding Adults Board. Is the Board assured that the principles underpinning the Care Act 2014 are being consistently and effectively applied in Bristol to women who are pregnant or a parent? How can a culture of multi-agency working, including multi-agency professionals meetings, be established in Bristol? 3.7. Finding 4 Some professionals may feel intimidated by unpredictable and hostile service users, and become less confident in using their skills and expertise to challenge whilst maintaining support and engage the service user. This impact can be compounded if the service user presents as verbally assertive and challenging. Introduction 3.7.1. Some professionals can find it difficult to work with service users with unpredictable behaviour and may find it more difficult to challenge the service user’s thinking if the service user is making unwise or unsafe choices. Leaving the important issues unchallenged could be interpreted by the service user as implicit agreement with their decision. Undesired behaviour can become more entrenched and therefore more difficult to manage by both that individual professional and other professionals that follow. 3.7.2. By assuming that articulate and assertive service users are less vulnerable than others, professionals can underestimate risk factors that impact upon those users and their unborn child or children. This paralyses a professional’s ability to utilise their skills, tools and expertise and potentially leaves the service user and their unborn child / new-born baby more vulnerable. 27 | P a g e S e r i o u s C a s e R e v i e w How did the issue manifest in the case? 3.7.3. The practitioners who worked with CB described her as unpredictable in her mood and behaviour. For example one professional described CB’s sudden change in mood as ‘turned on a sixpence’ and that she was ‘quite angry and strong’ She was sometimes ‘very hostile’ to other professionals and her engagement with services was variable. 3.7.4. Discussions with family members confirmed that CB was ‘unpredictable’ and could be volatile and challenging. They tried to maintain contact with CB but it was difficult at times. The family did not always confront CB as a way of maintaining their contact with her because it was ‘as CB would allow’. This strategy was mirrored by professionals, who at times were advised by family members how they could engage CB. 3.7.5. When a mental health professional attempted to discuss possible child protection issues with CB, the professional described the experience as; ‘It was as if the shutters went down’. It was difficult – ‘I was in her home she had a way of gazing …quite fierce.’ 3.7.6. When confronted with this unpredictability or hostility many professionals ‘backed off’ from the confrontation, leaving the issue for another time or other professional to handle without a clear documented plan of how to address these issues. 3.7.7. This was compounded by what Case Group members described as CB’s intelligence and assertiveness. One professional described CB as ‘middle class’, ‘articulate’. This made it more difficult for professionals to identify the potential risk. 3.7.8. When challenged by professionals CB was able to counter their suggestions with cogent arguments. For example, CB declined offered support from the local children’s centre and the Health Visitor accepted CB’s argument that she had lots of friends with young babies so did not require further support. 3.7.9. Professionals also found it hard to shift CB’s views, such as when a Midwife challenged CB’s desire to have a home water birth because of impracticality due to her crowded small 3rd floor flat. The Midwife did not pursue this challenge, believing there was time during the pregnancy for CB to change her mind. Although there was time to do this it led to a number of changing birth plans and no assessed obstetric mental health support until days before CB delivered. 3.7.10. In fact CB’s mental health and the consequent risks to the unborn child should have been the priority alongside her desire for a home birth. This fundamental issue was not prioritised by professionals to be consistently tackled together. CB’s mental health which was longstanding added an extra layer of uncertainty which did not appear to be reviewed in a coordinated fashion. If a clear multi-agency approach had been taken there may have been an analysis, and consideration of whether this mother’s fluctuating ability to cooperate may increase the risk to the child. 28 | P a g e S e r i o u s C a s e R e v i e w What makes it underlying (rather than an issue particular to the individuals involved)? 3.7.11. At the case group follow on meeting the Case Group agreed that when working with challenging behaviour or views that you had to ‘pick your battles’. Whilst the Review Team accepted that sometimes this is a valid approach, there was an underlying assumption that sometimes difficult issues could be left to someone else to tackle or they appear to resolve over time (whereas in reality they remain hidden). Instead less important issues are tackled. 3.7.12. This may mean that unchallenged risky decisions could become more entrenched and therefore more difficult to manage in the future. Finding 2 shows how supervision can support staff when working with people with unpredictable behaviour and aggression. What is known about how widespread or prevalent the issue is? 3.7.13. Professionals working with adults who have capacity must respect service user entitlement to make informed decisions about their care even if these are considered to be unwise. There is an art to being persuasive but not being coercive, which is not an easy skill for professionals to develop and use. However, when the service user is pregnant, using this skill becomes even more difficult for the professional as the service users’ unwise or unsafe decision will have an impact on the unborn child. Concentrating on the service users’ decision can result in side-lining or distracting the professional, and therefore reducing the focus on the rather more fundamental issue of safeguarding the unborn child. 3.7.14. If professional relationships lack openness and are coupled with professionals feeling intimidated (even though the professional may not recognise this) this can result in professionals maintaining a self-protection mode (T Morrison 2009). Professionals do not challenge the smaller issues which results in the avoidance and inability to challenge more risky issues such as safeguarding in the future. Overall, this results in the unborn child/ new born baby and the service user being at greater risk of harm and increases their vulnerability. 3.7.15. Professionals can “become emotionally battered by clients, colleagues and systems” (Fletcher 1978). In effect professionals can make an inappropriate response, for example inadvertently colluding with the service user. This is a phenomenon well documented since 1990 as “professional dangerousness” (Litchfield 2013, Calder 2016). “Professional dangerousness” is when professionals involved in child protection work can behave in a way which either colludes with or increases the dangerous dynamics. Objectivity can be lost, and service users and their children are at increased risk. One protective mechanism for professional dangerousness is recognised to be supervision (Morrison 2010; DfE 2015) which is discussed in Finding 2. 3.7.16. There have been many studies of societal stereotypes showing that professionals and non-professionals judge some people as vulnerable but not others (Gilburt et al [2012]). This is linked to a human tendency to associate some types of people with some attributes more than others. Hostile, assertive or articulate people are less likely to be perceived as at risk in the absence of other obvious attributes. 29 | P a g e S e r i o u s C a s e R e v i e w What are the implications for the reliability of the multi-agency child protection system? 3.7.17. Challenging unpredictable and hostile people is hard, and staff require a high level of skill and support to do so. It is even harder if this is compounded by the service user being verbally assertive and challenging. 3.7.18. The consequences are that the service user’s beliefs could become more entrenched and therefore more difficult to manage. By not challenging assertive service users, professionals in Bristol are not adequately assessing risk factors that impact upon those users and their children. 3.7.19. In pregnancy this is made more difficult because there is not always time for someone to come around to an idea because other services may need to be involved. Finding 4 Issue for consideration by the board Some professionals may feel intimidated by unpredictable and hostile service users, and become less confident in using their skills and expertise to challenge whilst maintaining support and engage the service user. This impact can be compounded if the service user presents as verbally assertive and challenging. Summary Where professionals lack confidence in challenging service users they are inclined to avoid the confrontation, which results in inadvertent collusion. This makes it more difficult for professionals to then make challenges in the future on the issues that really matter, especially in relation to safeguarding the unborn child. Although professionals attempt to support the client in an open and therapeutic relationship, they are inadvertently practicing professional dangerousness through lack of a fully open relationship with the service user. Professional challenge is made more difficult when service users are verbally assertive. Questions for the board and organisations How can professionals be supported to work openly with all service users even if the service users present as verbally assertive and challenging, whilst maintaining a focus on the unborn child / baby? 30 | P a g e S e r i o u s C a s e R e v i e w 3.8. Finding 5 Professionals in Bristol are inconsistent in their ability to provide Children’s Social Care First Response with a referral that articulates their concerns clearly enough to meet the threshold for a service. First Response does not consistently provide feedback to explain why a referral does not meet the threshold for social care, leading to inaction by referrer and First Response. Introduction 3.8.1. Laming (2003), said that practitioners’ responsibilities do not end at the point of referral to children’s social care, but ends at the point where their professional concern is resolved. In Bristol, professionals instead tend to default to making a referral to Children’s Social Care First Response when presented with child safeguarding or protection concerns rather than taking action themselves. Professionals use the referral to Children’s’ Social Care as false reassurance that action has been taken, and appear to lack understanding that this doesn’t discharge their own professional responsibility to take action – either directly with the service user by themselves, or through escalation procedures when their desired outcome is not achieved. 3.8.2. If these concerns do not meet the Children’s Social Care First Response threshold criteria (as outlined in the BSCB Threshold Guidance), the perception is that the concern has been rejected, when in reality a decision has been made about service eligibility threshold. The referring service does not always understand why the referral does not meet the threshold for services and so does not change their practice to ensure that future referrals meet the threshold criteria. Rather than addressing the concerns proactively themselves and then providing Children’s Social Care First Response with further evidence, the consequence is inaction and the risks to the unborn / child are not assessed or managed. How did the issue manifest in the case? 3.8.3. During the period under review different agencies made referrals regarding CB and ZBM to Children’s Social Care First Response on three occasions. Professionals in this case were unable to articulate their concerns succinctly or effectively, so Children’s Social Care First Response interpreted referrals as ‘no new information’ or ‘the same referral’. Although Children’s Social Care First Response did clarify with MH Case Coordinator in one instance, they did not contact the original referrer. 3.8.4. When Children’s Social Care First Response did not progress a referral, professionals from other agencies also did not clarify with Children’s Social Care First Response why the referral did not meet the thresholds for services. Professionals accepted the decision of no further action by Children’s Social Care, and did not consider using the Escalation Policy despite their concerns. 31 | P a g e S e r i o u s C a s e R e v i e w 3.8.5. When CB disclosed that she had stopped taking her medication, just prior to birth, Children’s Social Care First Response did progress the referral from midwifery and transferred the referral to the hospital social work team, where the case was unallocated but managed by their duty system. Children’s Social Care First Response informed the referrer by letter dated 19th November 2014, however there is no evidence that this letter was received by the referrer or that the information was passed to the maternity ward. The ward therefore did not notify or involve the social work team in their care and treatment of CB and ZBM post-delivery as they had no knowledge that children’s social care were involved, and CB and ZBM were not going to be discharged in the immediate future. What makes it underlying (rather than an issue particular to the individuals involved)? 3.8.6. Many professionals in the Case Group demonstrated a lack of understanding of the role of Children’s Social Care First Response as they were unable to state what they wanted Children’s Social Care First Response to do, both at the time, and at the subsequent case group meetings. 3.8.7. There was a perception raised in the Case group that Social Care thresholds are high and cases are rejected without notification and limited clarification e.g. GPs are rarely contacted. 3.8.8. Professionals understood that all contacts with Social Care First Response were referrals, yet Social Care perceived some of these to be contacts for information sharing. The review team felt this perception was one that needed addressing, as it may be a barrier to staff accessing help and support. 3.8.9. A huge volume of contacts is taken by Children’s Social Care First Response - about 1800-1900 a month. These range from Domestic abuse notifications, information sharing where families have a known social worker, requests for information from other services e.g. LA or legal teams and actual concerns from professionals. 3.8.10. During the period December 14-November 2015 the numbers of contacts varied from between 1700 and 2200 a month. Of these, 200 (10.5%) were sent to Referral Units, 400 (20%) to the Threshold Decision Unit, 500 (26%) were queries to open cases with 800 (42%) no further action. Some of these contacts may have been classed as information sharing between agencies, particularly if the family identified had involvement with Children’s Social Care; however a large proportion were referrals from other agencies that did not meet the threshold for assessment by Children’s Social Care. 3.8.11. This was a substantial amount of professional time used for no purpose. However, the lack of effective feedback means individual professionals from other agencies do not then learn how to construct an appropriate referral and articulate their concerns to meet Children’s Social Care thresholds, as per the Bristol Safeguarding Children Board threshold guidance. A recent audit of 20 random referrals (of which outcomes were selected as 25% referral to Early Help, 25% referral to Social Work and 50% No Further Action) by CSC First Response in June 2016 identified that in all cases referrers were given appropriate feedback. In the cases where there was no further action most of these involved advice and guidance being given before closing. In 16 cases there were follow up enquiries. There were extensive enquiries 32 | P a g e S e r i o u s C a s e R e v i e w on 1 case. In the other 4 referrals a decision was made that comprehensive information had been provided with the referral, the case was referred on directly to the social work unit as clear risk identified and in 1 case the family member refused permission for the FR advisor to contact the school. In 4 cases there were follow up calls to members of the family. In 5 cases there were follow up calls to the referrer to clarify the referral and gain further information. This would evidence that feedback is given. 3.8.12. In addition, professionals at the Follow on Meeting were unclear both within and across services of how to follow escalation policies when their referrals are rejected, which may link to Finding 2 regarding use of Safeguarding Leads. 3.8.13. In April 2016 Bristol Clinical Commissioning Group undertook a Quality Assurance Review of Health Referrals to Children’s Social Care First Response. This provided a snapshot audit of two weeks’ worth of health referrals to Children’s Social Care First Response. It showed the quality of the referral generally remained variable and the level of cases for ‘no further action’ remained high. The report highlights some notable improvements from one acute health trust, which has instigated a quality assurance framework and this has improved the quality of the referrals and social care accept these with limited challenge. 3.8.14. However, the current referral process lacks consistency, as referrals can be made by phone or on a web based form. The web-based form cannot be saved by the referrer to add to their clinical records, making agency records incomplete. Having more than one route for the referral process leads to confusion for the referrer about the decision-making and action or otherwise by Children’s Social Care First Response. 3.8.15. Professionals and services referring to Children’s Social Care First Response perceive that they are not consistently provided with feedback about whether their concern is being accepted or does not meet the threshold for services, and what actions are being taken by Children’s Social Care although this is not evidenced through the small audit discussed above. 3.8.16. Although Children’s Social Care First Response have clear criteria for thresholds agreed by all partner agencies, this is not consistently understood by professionals in other agencies, especially by those working in areas with few safeguarding concerns, where referral to Children’s Social Care First Response is not part of their everyday practice. What is known about how widespread or prevalent the issue is? 3.8.17. The Munro review part 1 (2010) recognised that professionals need to make expert judgements about when to make a referral and getting the right balance can be difficult. However if social workers have too many referrals there is a risk that some cases may be missed or assessments delayed because of the volume. Health Professionals can support social care by undertaking the best assessment they can based on the contact they have with the family. 3.8.18. Since Baby P there has been a huge increase in referrals to Children’s Social Care nationally. A national study of children born in 2009-10 suggests up to 150,000 pre-school children were reported over fears of abuse or neglect, most unnecessarily. Only 25% of referrals were 33 | P a g e S e r i o u s C a s e R e v i e w formally investigated while 10% led to protection plans, the study said. The University of Central Lancashire report by Professor Andy Bilson said staff were wasting time. (http://www.bbc.co.uk/news/education-36377293 [25.5.2016]) 3.8.19. This is in contrast to the longer term overall downward trend in referral rates in Bristol as shown in the tables below: 3.8.20. This downward trend is despite the fact that over the last decade Bristol has seen the fourth largest growth in the number of under 5s nationally. Bristol’s 82,800 children currently make up almost 19% of the total population, i.e. one in every five people living in Bristol is aged under 16. The number of children in Bristol is likely to continue to grow, with a projected increase of 17,400 children (0-15 year olds) between 2012 and 2037, an increase of 21.6%. (Ref: The Population of Bristol October 2015-Key population trends in the Bristol Local Authority area). 3.8.21. The increase in population, even with the downward trend of referrals, will continue to exert pressure on Children’s Social Care First Response resources. 3.8.22. Nationally there is an issue whereby thresholds between agencies are inconsistent, and in particular between ‘health’ and social care. When interagency professionals make poorly constructed referrals to Children’s Social Care First Response and the referral is not accepted, there is a perception from the referring frontline professional that referrals are “rejected”. Whilst local audits demonstrate this is not the case, the perception remains for frontline practitioners in other agencies. Within the case group meeting there was evidence of professional apathy developing which has the potential for poor interagency relationships. (Ward-Smith, Peggy. "Professional apathy: avoiding and preventing this chronic work condition). 424 0100200300400500600700Number of Referrals received by month No. of ReferralsLinear (No. of Referrals) 34 | P a g e S e r i o u s C a s e R e v i e w What are the implications for the reliability of the multi-agency child protection system? 3.8.23. At an individual level, professionals avoid the frustration of perceived rejection and inaction by Children’s Social Care First Response by inaction themselves, leaving unborn children at risk. 3.8.24. An inefficiency of working is created for all professionals and services involved as too many safeguarding referrals of poor quality continue to be generated. This causes an increased workload for all practitioners and services through the duplication of work, and lack of learning. 3.8.25. There needs to be improved standards across all professionals’ assessments and referrals to Children’s Social Care First Response with an improved response from them to articulate why referrals have not been accepted. This learning approach is proactive and reduces barriers and perceptions. Children’s Social Care First Response do not consistently explain to professionals why a referral does not meet the threshold for social care which can result in the service user being left without a service from either agency. Finding 5 Issue for consideration by the board Professionals in Bristol are inconsistent in their ability to provide Children’s Social Care First Response with a referral that articulates their concerns clearly enough to meet the threshold for a service. Children’s Social Care First Response does not consistently provide feedback as to why a referral does not meet the threshold for social care, leading to inaction by referrer and First Response. Summary Professionals making referrals have difficulty in consistently articulating their concerns about a case in a manner that will ensure progression of the referral from children’s social care First Response. Frontline workers in children’s social care First Response are constantly trying to manage the resulting high proportion of poorly constructed referrals, so the situation is cyclical, generating duplication of work for all services. The perception of referral and rejection by frontline professionals can result in professional apathy and poor interagency relationships, which can damage rather than build a culture of interagency working, and neither agency learns or develops to improve the situation. Questions for the board and organisations How does the Board monitor the quality of referrals to children’s social care? How can the Board assure itself that the quality of feedback on referrals is appropriate and received by the referring agencies? How is the Board assured that front line practitioners across all agencies have a clear understanding and working knowledge of the BSCB threshold guidance? How is the Board assured that referring agencies continue to hold responsibility for referrals that do not meet the First Response threshold and take appropriate steps, including escalating where necessary? 35 | P a g e S e r i o u s C a s e R e v i e w 3.9. Finding 6 Common terms used professionally to describe a service user’s health may have different connotations depending on the professional setting. If they are taken at face value by other professionals this will have a direct impact on practice and decision-making. Introduction 3.9.1. The use of shorthand terms by professionals to describe complex or specialist symptoms or treatment internally within agencies is common. These casual phrases are, in effect, jargon, but may not be understood as such by other agencies who take them at face value. This problem is exacerbated when they are recorded by practitioners in other agencies as the shorthand version without the qualifying explanation of what that phrase or word really means. 3.9.2. The potential to misunderstand a shorthand description would be alleviated if multi-agency meetings networking and working practices were held as standard as other professionals would be more likely to receive the full description. How did the issue manifest in the case? 3.9.3. There were a number of different words commonly used to describe different aspects of CB’s health. For example, the use of the word ‘well’ was used by a variety of professionals. In each case it meant something different. 3.9.4. The GP used the term ‘well’ to describe CB’s general physical health whereas ‘well’ in midwifery terms meant that CB’s pregnancy was progressing normally. 3.9.5. For Mental Health practitioners ‘well’ meant CB was managing the symptoms of her illness such as her ‘hearing voices’, i.e. CB having auditory hallucinations, but functioning in the community. However, even when the use of the term was explained during discussion with other professionals only the term ‘well’ was recorded. This was then later interpreted and understood as well in the sense that CB was free of symptoms of mental ill health. 3.9.6. As a consequence, decisions were made based on inaccurate analysis of the information available and caused drift in the case. One example of this was when the Care Coordinators’ view of CB’s mental health - that she was ‘well’ - was accepted by Children’s Social Care First Response in August 2014. This also impacted on the length of time between concerns being raised by Midwifery and Health Visitor about CB’s Mental Health during August 2014 before a professional’s meeting in October 2014. 3.9.7. In this case if a full description from a mental health worker of exactly what was meant by “well” had been provided, this may have given a more full understanding to all involved and impacted on practitioners assessment of the case. 36 | P a g e S e r i o u s C a s e R e v i e w What makes it underlying rather than an issue particular to the individuals involved? 3.9.8. The confusion caused by use of shorthand terms used as jargon was evident both across agencies and professionals, examples being Midwifery, Children’s Social Care First Response, and Health Visiting. 3.9.9. During their individual conversations several members of the Case Group explained that Mental Health had described CB as ‘well’ but were unable to define what this meant in Mental Health terms. Other examples of words that were misinterpreted across agencies were ‘recovering’ and ‘stable’. The Case Group continued to debate this question during the Case Group ‘Follow On’ Meeting. 3.9.10. Professionals are busy and cannot always write up discussions verbatim, but often use accepted shorthand. When they or another team member return to their records there is a reliance on the way that information was recorded. This means that decisions are made on limited information, placing the unborn child and service user at increased vulnerability. What is known about how widespread or prevalent the issue is? 3.9.11. All professionals use shorthand terms which may mean something specific or particular to that profession in addition to the common usage. There have been many studies on the barriers to communication between patients and clinicians caused by use of medical terms or jargon. However, the Reviewers have been unable to find any studies around the use of simplified or shorthand terms as a barrier between professionals. The Review Team speculated that the increased use of everyday terms by clinicians may actually be in response to attempts to communicate better with patients, although this Finding shows the opposite effect. What are the implications for the reliability of the multi-agency child protection system? 3.9.12. When agencies think they understand the language used by another agency but do not and act accordingly, this leaves service users and unborn children at increased risk and vulnerability. 3.9.13. Whilst the decision practitioners make at face value appears appropriate, there is an inherent flaw, as the decision is based on a misunderstanding of the actual current situation. Service users may then not be deemed eligible for assessment or service provision from other agencies such as Children’s Social Care. 3.9.14. It also means that professionals may defer to those seen as experts without exploring possible risks to the unborn child. 37 | P a g e S e r i o u s C a s e R e v i e w Finding 6 Issue for consideration by the board Common terms used professionally to describe a service user’s health may have different connotations depending on the professional setting. If they are taken at face value by other professionals this will have a direct impact on practice and decision-making. Summary Professionals communicate with a range of individuals on many levels. Communicating with a range of service users and professionals at the same time, simple, everyday phrases are used with service users and professionals, and subsequently recorded in a manner that does not provide a clear picture of the current situation. Using everyday language with other agencies can give a false impression of the situation, with decisions and practice then based on that false impression. This results in the unborn child and service user being placed at increased risk of vulnerability, and in some circumstances this can prevent the service user and unborn child meeting the threshold for assessment or service provision. Questions for the board and organisations How can the Board encourage professionals to use precise language to explain their concerns to other agencies in order to ensure common understanding? 3.10. Finding 7 The practice of service users being asked to relay complex information about their treatment or condition verbally to other agencies makes it more likely that this information will be incorrectly relayed or not shared at all. This places the unborn child and service user at increased risk of vulnerability. Introduction 3.10.1. It is common practice for adult service users to be asked to pass on information about their condition to other agencies as this allows the service user to remain in control. However, it does raise the risk of the service user misinterpreting that information, restricting the amount of information shared, or even not sharing any information. This is even more likely if the service user has complex conditions or when difficult decisions have to be made. 3.10.2. This is exacerbated when there is no lead clinician to provide oversight and leadership. How did the issue manifest in the case? 3.10.3. Over the course of her pregnancy, different professionals entered into discussion with CB about use of her medication, particularly about the pros and cons of use when pregnant and subsequently when breast feeding. This information was sometimes passed directly between professionals but often shared only via CB herself. 3.10.4. CB’s discussions with the Mother and Baby Unit Specialty Doctor about the use of medication in pregnancy and when breast-feeding were necessarily nuanced and complex. 38 | P a g e S e r i o u s C a s e R e v i e w 3.10.5. The Specialty Doctor had consistently informed CB that not much was known about the risks of taking her medication in pregnancy. She had also consistently told CB that it was safer to continue with the medication as the risks to baby were greater if CB relapsed. As CB had agreed to bottle feed, their discussion on 28th October 2014 focused on alternative strategies to bond with her baby when bottle feeding rather than on the effect of medication on the baby when breastfeeding. This appointment was added to the Clinic because CB had missed her planned appointment. 3.10.6. As time was tight at the meeting the case notes sent to the Maternity Hospital had limited detail. CB told the midwives that medication could not be used when breastfeeding and this was her explanation for stopping her medication. 3.10.7. It is notable that it was not until CB had given birth to ZBM that any professional contacted a pharmacist to confirm the safety of her medication on ZBM when breastfeeding or otherwise. 3.10.8. The Review Team speculated that CB was exhibiting disguised compliance with regard to her medication particularly as she subsequently revealed that she had not been taking it for five months. Outside the period under review CB had previously demonstrated a pattern of coming on and off medication but this risk does not appear to be part of any risk assessment or referral. What makes it underlying (rather than an issue particular to the individuals involved?) 3.10.9. At the case group ’Follow On’ meeting different professionals continued to offer conflicting accounts about what CB had told them about the safety of the medication during pregnancy and whether it was safe to breastfeed or not. 3.10.10. This showed that the issues around the decision to continue taking a drug or not are complex and difficult to interpret. There is often a balance to be made between differing or conflicting factors. Risks are often difficult enough to interpret and articulate by the clinician themselves let alone by service users or other professionals. 3.10.11. There is a risk when professionals are busy with increased workloads that this can impact on clinical records, letters and information sharing. 3.10.12. Patients may alter their medication in an attempt to have control over their condition. If this is a possibility then this needs to be part of any risk assessment to the unborn. What is known about how widespread or prevalent the issue is? 3.10.13. There is no definitive answer about the safe use of the medication in this case as clinical trials are limited about the risks posed by pregnancy and breast feeding. The patient information leaflet from the manufacturer of CB’s medication states that the risks must be weighed and the decision made by the clinician. Service users with the capacity to do so will also weigh up the risks themselves. 39 | P a g e S e r i o u s C a s e R e v i e w 3.10.14. The practice of encouraging adult service users to take control of their illness and self-manage their treatment and information sharing with other professionals is an important part of service user recovery and maintenance. Within Children’s Health services information may be shared by parents about their child with other professionals. In general however, unlike Adult Services, practice includes both multi-agency meetings and written communication directly between professionals to share information about decision making or treatment regime. This provides a safety mechanism to ensure that information is routinely shared, and assists professionals in identifying when discrepancies may occur, whether or not these are intentional on the part of the parent. 3.10.15. Disguised Compliance is a term used by professionals to describe families who appear engaged with the work of professionals and services, but in reality are not working in partnership. “‘Disguised compliance’ involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention”. (NSPCC 2010) 3.10.16. “Sometimes, during cycles of intermittent closure, a professional worker would decide to adopt a more controlling stance. However, this was defused by apparent co-operation from the family. We have called this disguised compliance because its effect was to neutralise the professional’s authority” (Reder et al (1993) 3.10.17. This can often be difficult for workers to recognise or deal with and is a recognised barrier to achieving good outcomes for children. Disguised Compliance is a term that is frequently used within Children’s Services but is not actively and comprehensively considered and understood. Adult Services rarely encounter the phenomenon. 3.10.18. Numerous Serious Case Reviews and research papers, since the 1990s, have identified the need for Disguised Compliance to be recognised by professionals as a potential factor in the relationship between agencies and families. What are the implications for the reliability of the multi-agency child protection system? 3.10.19. The common practice of service users being asked to pass on information to other professionals they are working with is appropriate and reasonable when information is simple and unambiguous, and relates solely to the service user. However, extrapolating this practice to include the passing of complex or nuanced information is unrealistic even if the service user wishes to do this and has the capacity to undertake this role. When this practice also includes an unborn child then the impact of this method of information sharing by the service user leads to increased risks to the unborn child / children. 40 | P a g e S e r i o u s C a s e R e v i e w Finding 7 Issue for consideration by the board The practice of service users being asked to relay complex information about their treatment or condition verbally to other agencies makes it more likely that this information will be incorrectly relayed or not shared at all. This places the unborn child and service user at increased risk of vulnerability. Summary The practice of encouraging adult service users to take control of their illness and self-manage their treatment and information sharing with other professionals is an important part of service user recovery and maintenance. However, this can lead to increased risks to unborn children if the service user makes decisions that affect the unborn child. This is in contrast to children’s health services where there are routine governance processes in place to avoid the misinterpretation of information relayed by service users or professionals, which provide additional safeguarding measures to the child. Whilst it is recognised that the unborn child has no legal ‘rights’ until birth and is independent of the mother, the actions the service user takes prior to birth can impact on the unborn child both in utero and post-delivery. Professionals do have a statutory duty to consider the needs of the child, including pre-birth. Questions for the board and organisations How can the Board be assured that the correct balance is established between service user control and independence of their treatment, with the needs of the unborn child remaining paramount? 3.11. Finding 8 The complexity and range of individual services that work with pregnant women with mental ill-health across Bristol makes it difficult to coordinate multi-organisational working. Introduction 3.11.1. Adult Services are often difficult to navigate because of the layers of specialisms that are not clearly understood by professionals even within their own agencies. This is compounded when agencies seek to plug the gaps in services themselves. This is particularly evident in Bristol because NHS England specialist commissioning for tertiary and specialist services and local Clinical Commissioning Groups for the provision of local services often commission the same providers. How did the issue manifest in the case? 3.11.2. The Mother and Baby Unit (MBU) was not commissioned to provide community perinatal services and was working with CB informally. This confused other professionals and agencies, as some thought that a MBU Doctor was the lead clinician and expected direction from this perceived lead for CB, and so did not take the lead themselves. At the same time other professionals assumed that the GP was the lead clinician. 41 | P a g e S e r i o u s C a s e R e v i e w 3.11.3. This was made even more confusing to agencies because CB initially chose to have her baby at Hospital 1 (which is on the same site as the MBU) and then suddenly changed to Hospital 2 in mid-November 2014 just before she was due to give birth. 3.11.4. Further evidence of specialists working in isolation is shown from when CB attended a consultation for her thyroid condition at Hospital 1 and there appeared to be no consideration on the impact of her mental health on her pregnancy. What makes it underlying rather than an issue particular to the individuals involved? 3.11.5. At the Case Group follow on meeting the Case Group confirmed that they did not understand what other services do, and often which service or agency to contact when a service user had other needs. For example, there are lots of different specialisms and teams within Mental Health services that other professionals did not understand but other agencies lumped them all together as ‘mental health’. It was considered by the Case Group even more difficult in Bristol because of the consortium of many different organisations which sit within the ‘Bristol Mental Health’ Service banner. 3.11.6. Within Bristol there are two Maternity Hospitals, each with a Midwifery led maternity unit (i.e. one in each trust) and two Community Maternity Teams providing services. Whilst this is in accordance with providing patient choice through giving women the opportunity to choose which hospital (or home birth) to deliver their baby, and includes the ability for women to change their mind during pregnancy about the place of delivery of their baby, this situation confused both Case Group and some Review Team members. 3.11.7. There should be consistency in standards in maternity provision across both services in Bristol. This case has highlighted a systems issue which needs resolving. What is known about how widespread or prevalent the issue is? 3.11.8. “Adults’ care needs are often multiple and interrelated with other needs….[and] therefore part of a complex system of related public services and forms of support. How well services meet adults’ needs depends on all parts of the system working together” (National Audit Office Adult Social Care in England Overview Report 2014) 3.11.9. Locally it is positive that the Multi-Agency Protocol around Mental Health is currently being refreshed. It is also positive that Commissioners have identified the complexity of services as an issue in Bristol and it should be noted that a review of Mental Health Services in Bristol is due to start shortly, which should help to clarify the roles and responsibilities of the different services available. 3.11.10. Community Perinatal Services are currently being commissioned by Bristol Clinical Commissioning Group at a cost of £368K pa. At the time of writing (July 2016) recruitment is underway for an interim service. The system remains complex, as multiple services are provided for women from other areas who deliver in either Hospital 1 or Hospital 2 as commissioners in these areas have made separate arrangements. This development is not without risk, as the range of services will be delivered according to post code rather than 42 | P a g e S e r i o u s C a s e R e v i e w clinical need, and has the potential to leave providers at increased risk of managing complex cases in different pathways according to patient geography. 3.11.11. Nationally it has been recognised that perinatal care is not consistent across the country. In March 2016 the Government announced that over the next five years an additional £290m will be allocated to the care of women who experience mental ill health during the perinatal or antenatal period. The funding by NHS England is focusing on increasing inpatient beds. In the South West agreement has been given to a further inpatient unit in Torbay and it is hoped that the MBU unit in Bristol will have increased capacity. What are the implications for the reliability of the multi-agency child protection system? 3.11.12. Investing in acute care (inpatient units, and crisis resolution and home treatment teams) or targeting services by risk management over services for clinical benefit can address the needs of individuals in crisis, but will not stop the crisis from occurring. However, if professionals are unable to navigate the system effectively because services are too complex or unwieldy this leaves service users and their children vulnerable. Finding 8 Issue for consideration by the board The complexity and range of individual services that work with pregnant women with mental ill health across Bristol makes it difficult to coordinate multi-organisational working. Summary The complexity of services in Bristol means that practitioners may be unable to navigate the complex system effectively. This is compounded when some services attempt to plug gaps on an informal case by case basis. Service users and their unborn child are placed at a greater vulnerability than if there were no service being provided at all, as a ‘false reassurance’ is provided to other professionals and agencies. Questions for the board and organisations How will BSCB seek assurance from the BSAB that any changes to the mental health services address the concerns raised? How will BSCB and BSAB know that professionals are able to navigate the adult mental health systems they work in? How will BSCB, BSAB and CCG work with neighbouring boards to promote consistency of service provision for women with health risks that may impact on safeguarding children. 43 | P a g e S e r i o u s C a s e R e v i e w 3.12. Learning at the fringes 3.12.1. Learning from the SCR process 3.12.1.1. As well as the Findings described above, the Review Team consider that there was learning from the review process itself that the Boards should note in order to improve any future review processes, including the impact of multiple reviews and the timing of reviews. This discussion will be presented to BSCB in a separate learning document, as this learning is beyond the scope of the SCR. 3.12.1.2. There were also some single agency issues noted that are detailed below as impacting on the multi-agency system. 3.12.2. Isolation of GPs from Midwifery Services 3.12.2.1. GPs in Bristol have a limited role in ante-natal care. This reflects the national approach which is that pregnancy is normal for women and should only be medicalised if there are known health issues. Although the rationale is understandable –i.e. pregnancy is not an illness and should not be treated as such, this was surprising to some members of the Review Team from outside of the Bristol area. When pregnant women have complex medical conditions the GP as the primary carer should be included in the discussion and decisions around the women’s care, and this is especially necessary as they will be managing the mother and baby after delivery. GPs are notified of all pregnancies but there does not appear to be any current system for a direct review between midwives and GPs in these complex cases. The Review Team suggests that there should be a review of any current pathways or guidance that improves the communication between midwifery and GP services, and that a pathway be developed; There needs to be a structure in place that requires communication between the midwifery team and the GP, and other relevant professionals involved in the care of pregnant women where there are other medical conditions including mental health conditions. 3.12.3. Observation on Maternity Wards 3.12.3.1. One of the reasons given for admitting CB and ZBM to a maternity ward that specialises in patients whose babies require increased observation due to prematurity, the mother’s medical condition or a mother’s drug use(both medically and substance misuse), was for observation of ZBM’s withdrawal from medication following delivery. Staff continued observation of ZBM for withdrawal of substance abuse rather than medication, even though CB had informed them that she had not been taking her medication for some time. 44 | P a g e S e r i o u s C a s e R e v i e w 3.12.3.2. It is unclear if the assessment tool used to consider ZBM’s withdrawal symptoms addressed the symptoms specific to the anti-psychotic medication CB had been prescribed. ZBM did not show any signs of withdrawal based on the form used on the ward. 3.12.3.3. The Review Team suggests that there is a process or policy where staff liaise with the pharmacy team to know what symptoms they should be observing when mothers are on medication that may impact on a new born baby. This information should be in place prior to delivery and form part of the birth plan. If there is a risk of withdrawal then an appropriate assessment tool relevant to the medication prescribed or used by the mother should be with the birth plan prior to delivery. 3.12.4. Observation on withdrawal symptoms for all agencies 3.12.4.1. Expert advice should be sought in order that professionals recognise what withdrawal symptoms look like for a range of medications and substances as part of a robust pre-birth plan. 3.13. Conclusion 3.13.1. This review has identified that there are a number of significant systemic issues, outlined above, which has provided a window on the system which demonstrates how difficult it is for professionals to work with challenging services users, and within areas of practice that are less familiar to them. This review highlights how easily adult issues and needs can override the paramountcy of the child or unborn child. 45 | P a g e S e r i o u s C a s e R e v i e w 4. Glossary of Terms ASC Adult Social Care BSCB Bristol Safeguarding Children Board BSAB Bristol Safeguarding Adult Board CiN Children In Need CMHT Community Mental Health Team CP Child Protection CC Care coordinator CCG Clinical Commissioning Group CSC Children’s Social Care CSW Consultant Social Worker, Hospital Team EI TM Early Intervention Team, Mental Health Trust First Response Front door for Children’s Services in Bristol FPN Family Planning Nurse, Pregnancy Advisory Service GP General Practitioner HV Health Visitor MARAC Multi Agency Risk assessment Conference MAPPA Multi Agency Public Protection Arrangements MBU Mother & Baby Unit MHL Mental Health Liaison Service MW Community Midwife PAS Pregnancy Advisory Service SA Safeguarding Adults SAR Safeguarding Adult Review SHN School Health Nurse SW Social Worker |
NC043742 | Findings from an anonymised review into an incident found to have met the statutory requirements for a serious case review. Generalised findings reflect those from an Ofsted inspection in November/December 2012, which found overall local child protection services to be inadequate. These include: focus on the parents' needs over the child's; insufficient supervision; inconsistent application of policies and procedures; professional optimism; poor quality assessments; and insufficient professional challenge. Makes various recommendations, covering: Isle of Wight Safeguarding Children Board, children's services, schools, The Children's Society, GPs and Isle of Wight NHS Trust.
| Title: Report of findings from a serious case review. LSCB: Isle of Wight Safeguarding Children Board Author: Moira Murray Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. REPORT OF FINDINGS FROM A SERIOUS CASE REVIEW ISLE OF WIGHT SAFEGUARDING CHILDREN BOARD Independent Reviewer Moira Murray August 2013 Prepared for publication by Alan Bedford, November 2013 2 Local Safeguarding Board (LSCB) Chair’s Foreword The national guidance ‘Working Together to Safeguard Children 2013’ requires LSCBs… ‘when compiling and preparing to publish reports (to) consider carefully how best to manage the impact of publication on children, family members and others affected by the case. Following advice from medical sources, independent safeguarding experts, I have decided that it can only be appropriate to publish the findings of a Serious Case Review (SCR) in this form- which looks at lessons learned and no detail from the case that was studied. The LSCB fully supports the national guidance that every effort should be made to publish full SCRs but also recognises that it has a duty of care to mitigate risks that may identify vulnerable children. It has been necessary to provide limited information about the purpose of the review and terms of reference to ensure that the case cannot be recognised. A safeguarding consultant, Alan Bedford, was commissioned to anonymise the findings from the SCR, and prepare this report which can be published. I am satisfied that this Report, which is supported by the SCR independent reviewer, is true to the findings approved by the LSCB. A number of the findings echo those made by Ofsted in their ‘Inspection of local authority arrangements for the protection of children: Isle of Wight’ ( January 2013) http://www.ofsted.gov.uk/local-authorities/isle-of-wight This also assisted the decision that a findings only report could be published as there was no need for case detail to establish some of the key conclusions. Child protection arrangements on the Island are currently monitored by an independent Improvement Board, overseen by the Government and the IOWLSCB is committed to ensuring that close scrutiny is given to ensuring necessary improvements are put in place in line with the findings of this SCR and the Ofsted judgement. New management arrangements commenced in September 2013 when Hampshire County Council took over the running of children’s services on the Island. I was appointed as the new Independent Chair of the LSCB in October 2013. Maggie Blyth, Independent Chair, Isle of Wight Safeguarding Children Board November 2013. 3 CONTENTS Foreword 1. Introduction 2. Findings 3. Conclusion 4. Recommendations Appendix One Recommendations from Agency Management Reviews 4 1. INTRODUCTION 1.1. Background to the Review: The Isle of Wight Local Safeguarding Children Board (LSCB) concluded that the circumstances of the case concerned met the statutory requirements for a Serious Case Review. It commissioned an independent reviewer Moira Murray ( an independent social work consultant) to prepare the report from agency reports, under the oversight of a Panel which was independently chaired by Phil Green (who works with the training and development agency Reconstruct). The process followed the guidance then in force, Working Together to Safeguard Children (2010). As can be seen from the Foreword, it was not possible following extensive advice to publish a traditional SCR, and so this Report focusses on the Findings. 1.2 Terms of Reference: The purpose of a serious case review as set out Working Together (2010) is to: • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • Improve intra- and inter-agency working and better safeguard and promote the welfare of children. 1.3 In addition to the standard questions that were listed in Working Together there were case specific terms of reference which focussed on the quality of assessment of risk, the response to the risks concerned, and the degree to which there was evidence of professional challenge and robust questioning of other agencies assessments of family capacity. 1.4 Review Process: The Panel had an independent chair, and members from the involved agencies, and the designated nurse for safeguarding who produced an overview of all the health contributions. Individual Management Review (IMR) reports were received from the involved health and social care agencies: The Isle of Wight Council (children’s social care), the Isle of Wight NHS Trust (comprehensive community and secondary health care, and the Isle of Wight CCG (for primary care/GP) and the children’s centre. They were written by staff who had not been involved in the case. 1.5 There were a number of delays in the production of IMRs, and some lack of consistency in Panel attendance from Children’s Social Care, but enough information was collated to understand the issues and identify learning. The SCR Panel considered how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible, under LSCB monitoring. 5 1.6 Anonymity: For the reasons described in the Foreword, this report does not talk about the specific case. 2. FINDINGS 2.1 The SCR findings, of necessity, cannot go into specific detail, but are generalised to maintain the focus on findings rather than family. A few findings (of which agencies are aware) cannot be described as that would reveal identifying detail. 2.2 In January 2013 Ofsted published a report, following an inspection in November/December 2012, into Local Authority arrangements for protection children. It reached the following conclusions which were largely found in this case- which is not surprising since the case was essentially in the period studied by the Review. Ofsted found the overall child protection services inadequate (‘a service that does not meet minimum standards’) and summarised a number of key areas for improvement • Not all children and young people get the right help from social workers when they need it to help them be safe. • Sometimes social workers are slow to sort problems out for children and they are not always good at understanding all the things that need to change before a child will be protected. • Some of the managers have not been able to understand or put right things when there are delays or when the social worker doesn’t understand the problem properly. • When social workers look at the problems in a family they sometimes give too much attention to what the adults say and do not think hard enough about what might be best for the child. Sometimes this means the plans they make won’t work and things don’t get better. • Social workers do not always get the chance to talk to their managers about the children there are working with and how well they are doing as a social worker. • Managers don’t always have the right information about all the work that is being done with children. This means that they find it hard to sort out problems and make improvements to all the work that they are in charge of. 2.3 Most of these characteristics were seen in this case. In the full Ofsted report the following more specific points were made that were also seen in this case: • Significant weaknesses and systemic failures in core child protection business • Services being delivered by Children’s Services First Response Unit …were found to providing inadequate responses to children in need of 6 protection, with some decisions which exposed children and young people to the risk of harm • The ‘clear and relevant’ threshold document (for when referrals should be accepted) was not consistently being applied, with a variable response to referrals • Professionals from other agencies reported experiencing delays and a lack of responsiveness from First Response when raising concerns about children • Too many cases were kept at the ‘contact’ stage that should be escalated to ... initial assessment, and cases which met the threshold for child protection enquiry were not escalated • Some cases were closed or ‘stepped down’ inappropriately , relying on other agencies to carry undue risk • A number of assessments seen by inspectors had overly optimistic conclusions that did not sufficiently reflect risk or the child’s journey in terms of the use of historical information and prognosis for positive change. Too many risk assessments do not consider patterns of behaviour, family history or previous events and as a result risk is assessed based on one specific incident rather on a comprehensive overview. • The majority of assessments seen are of poor quality, lacking sufficient analysis of risk and indicating a lack of understanding of risk factors. • The LSCB was also said to be underdeveloped 2.4 By listing these findings from Ofsted, it prevents this report from illustrating its own findings too much, and thus put anonymity at risk. The list of findings above and the findings from this SCR relate to 2012 and before 2.5 Appraisal: The SCR concluded that there was good practice on the part of certain agencies, notably health visiting, mental health services, the named midwifery safeguarding advice, and the children’s centre. (Children’s centres were also praised by Ofsted).
The health visitor was exemplary in monitoring the baby’s development and acted appropriately in getting the right medical intervention when this was of concern. In overall terms, these agencies were aware of risks to the children involved and shared them with Children’s Social Care. 2.6 However, in face of very poor responses from Children’s Social Care, the SCR found that other agencies should have been more challenging and escalate their concerns about inaction, or for example ensuring a thorough assessment during pregnancy. It was also concluded that all agencies could have given more thought ‘to what it was like to be a child in that family’ (given the range of social and health risk factors. 7 2.7 Children’s Social Care is criticised by the SCR for the following reasons, some of which echo the Ofsted findings above • A reluctance to accept the implications of the risk factors regularly presented by the mother, either for her or future children • The full range of risks in the extended family, and from the history, were either not considered or given sufficient credence. Children’s Social Care is best placed to bring together the whole picture • Deciding that the case needed dealing with at the CAF level, rather than responding to the seriousness of the concerns as a ‘child protection’ case • The CAF assessment was, as a result, led by another agency worker who would not have been trained to assess the level of risk involved • When Children’s Social Care did agree to do an assessment it was not done in time to impact on some key decisions around the baby concerned • Nor was it properly multiagency as required • The Review concluded that there was a reluctance in Children’s Social Care to engage with mental health professionals • An assessment of mother to be and family’s capacity with a new child was resisted until too near birth • When an initial child protection conference was eventually thought necessary on by a social work manager on the baby who was failing to thrive, there was no Strategy Meeting with Police or any other agency first as is good practice, and the Conference was arranged for over three weeks’ time. By that time it was too late to have any impact on protecting the baby • There was a very serious failure by managers in Children’s Social Care to review and account for decisions in the First Response Unit, and subsequently in the short term unit. 2.8 There were also general lessons, such as one seen in numerous SCRs about undue professional optimism despite considerable non-compliance with advice, and which is often unabated by subsequent events which would challenge such optimism. There was optimism (which stems from a natural desire to help families be successful) despite physical and emotional home conditions which might suggest a different conclusion and for example about a young parent’s ability to take on new responsibilities given past social and health concerns. 2.9 A variation of this was that, probably out of a commitment to self -determination and respecting client wishes, a young mother’s self-assessment of capacity and service need was followed by social care, to the detriment and exclusion of the views of other professionals who had been involved with the family. 8 2.10 A specific aspect of learning from the Review was the need for reflective supervision which encourages professional curiosity when faced with non-engagement/disguised compliance from families. Such reflective supervision should ensure that managers recognise the need to escalate child protection concerns that are not acted upon by statutory agencies. Whilst certain aspects of reflective supervision were evident in the practice of some agencies, it was not in others. There was, however, no escalation of child protection concerns by agency managers to their counterparts in Children’s Social Care, when safeguarding referrals were rejected by the First Response Team. In the case of Children’s Social Care there was no indication that any form of reflective supervision took place, as supervision was team focussed. 2.11 The Review looked at whether there were organisational difficulties which would put these findings in context. It describes approaches to the organisation of children’s care on the Island that appears to have had an adverse effect on the ability to protect children. This is covered in the Ofsted inspection report. There appears to be no other capacity or organisational concerns highlighted in this SCR, except that the programme of recruitment to build capacity in health visiting numbers in line with national policy. 3 CONCLUSION 3.1 It is apparent that there were opportunities for early intervention by Children’s Social Care. It is also apparent that the need for such intervention was recognised by some of the agencies involved in the review. However, the requests for early intervention were not acted upon until very late in the review process. Agencies need to follow up requests with a poor response more vigorously. 3.2 The Serious Case Review has recognised that there was good practice on the part of certain agencies, most notably mental health, midwifery safeguarding advice, the health visiting and the Children’s Centre. These professionals recognised the safeguarding concerns presented by the family. They were also persistent in bringing such concerns to the attention of Children’s Social Care. 3.3 If Children’s Social Care had recognised the need for early intervention, in the form of targeted support for the family, within the framework of child protection, then the outcome may have been different. 3.4 Most of the findings of the SCR were issues found by Ofsted in their 2012 inspection. Strong action was recommended by Ofsted. 9 4. SCR RECOMMENDATIONS These are the recommendations from the SCR. (The recommendations from the agency IMRs are reproduced in Appendix 1). It is acknowledged that some of these recommendations have been implemented since the completion of the Serious Case Review. The recommendations are for the Board to pursue Isle of Wight Local Safeguarding Children Board 4.1 That the LSCB develops and publishes an agreed Threshold document for referrals to Children’s Social Care, which accords with the requirements of Working Together to Safeguard Children (DfE 2013) 4.2 That the LSCB must be satisfied that each partner agency has an agreed escalation procedure in place that clearly indicates what action should be taken when safeguarding children referrals are deemed not to meet the threshold for intervention by Children’s Social Care. Such procedures are to comply with the 4LSCB Escalation Policy. 4.3 That the LSCB considers undertaking a ‘deep dive’ audit (which includes the participation of multi-agency partners) of the Duty and Assessment team, which has replaced the First Response Team to ascertain: • The timeliness and quality of information provided in pre-birth assessments/child in need/section 47 assessments and in the case of teenage mothers whether an assessment has been completed in respect of the mother and the unborn child • Whether child protection concerns are adequately assessed at the time of referral; • Where a decision to ‘step down’ a child in need case to the status of a CAF is appropriate. 4.4 That the LSCB ensures that future training for professionals includes the messages from research concerning safe sleeping for babies. 4.5 That the LSCB recommends that multi-agency meetings should always be held in cases where there are concerns from professionals of non-organic failure to thrive, which result in hospitalisation and there are subsequent admissions for the same reason. To be monitored by audit. 4.6 That the learning from this review is disseminated to multi-agency partners in a timely and meaningful way, so as to promote reflective learning and encourage best practice. 10 Appendix 1 Recommendations from Agency Individual Management Reviews (IMRs) These are reproduced from the agency IMRs submitted to the Review, with adjustment for this Report where necessary to ensure anonymity of family detail. The agencies and the LSCB are clear on the full wording of the actions concerned. The recommendations are listed by IMRs 1. Isle of Wight Council Children’s Social Care 1.1 Storage of information related to service users to be simplified so that electronic recording is easily accessed. 1.2 Adoption of a consistent approach to how cases are allocated to Consultant Social Workers. 1.3 Initial child protection conferences to be allocated in a timely fashion to meet legislative standards. 1.4 Ensure the voice of all relevant children in cases is heard, recorded and acted upon. 1.5 Ensure the CAF process is suitably quality assured 1.6 Ensure that thresholds are agreed, understood and applied consistently 1.7 The Council is working on this recommendation 2. Education 2.1 All schools to have a standard recording policy Records should include a bullet point chronology of significant events, record actions and outcomes with clear timelines for review. 2.2 When pupils are absent from school in excess of 15 days for illness a referral is made to the Local Authority so that a clear plan can be made to ensure a child is provided with an effective education in line with their health needs 2.3 Schools to have identified Pastoral Support processes for children with additional needs with senior leadership ownership and oversight. 3. The Children’s Centre 3.1 All Conversations/actions that take place must be recorded in case files as per policy (Case Recording & Records Management policy-July 2010). 3.2 The Children’s Centre staff should challenge other agencies including Children’s Services where appropriate. 11 3.3 A review of criteria for distribution of ‘well done certificates’ 3.4 A process to be embedded in order for incomplete actions to be addressed. 3.5 Completed Risk Assessments to be fully evidenced in files prior to any home visits/outings/lone working 4. Primary Care (GP) IMR (recommendations for the NHS) 4.1 To undertake a training needs analysis to benchmark progress with delivery of safeguarding children training and updates to GP practices and their staff. 4.2 To ensure that GP practices and their staff have access to updated safeguarding children policies, guidance and research (including READ code information). 4.3 To promote an understanding of the need for GPs, Nurse Practitioners and Practice Nurses to consider the impact of parental/carer difficulties (on children in the household and make referrals accordingly. 4.4 To require registration details to include information of who is living in a household, in relationship to cooperating with Serious Case Review investigations. Where members of a household are registered at a different practices, to seek consent for information sharing in line with legislation and guidance. 5. Isle of Wight NHS Trust 5.1 Quarterly meeting set up with (specified) Safeguarding Children Leads in mental health to promote/review/challenge multi agency risk assessments. 5.2 Clinical Review in CCAMHS Education Forum of National Clinical Practice Guideline Number 78 National Institute for Health & Clinical Excellence, 2009, Chapter 9. 5.3 Need for Health Staff to have further training in faltering growth. 5.4 Need for Staff to have further training in (a specific issue) from this case 5.5 Ambulance - All minors attending hospital by ambulance should be accompanied by their care giver. 5.6 A&E - Accident and Emergency Unit needs to ensure that if they see a pregnant mother who has abdominal pain and bleeding that they liaise urgently with Maternity Staff (Accident & Emergency) 5.7 Maternity – (specified medication) levels should be promptly measured so that preventative treatment can be given in a timely manner. 5.8 Safeguarding - The IOW Trust policy of Safeguarding is out of date and needs updating. 5.9 Health - TAF minutes should be available to Health Staff and action plans monitored. 12 5.10 Health Visiting - There is a need to improve the offer of universal antenatal health visiting contacts. This has also been raised in a previous partnership review action plan. 6. The Health Overview Report 6.1 That the newly appointed Named GP for the IOW undertakes a safeguarding children audit of all IOW GP practices as a baseline for future learning and development. The audit tool should be derived from the RCGP & NSPCC Toolkit. Support in this activity should be provided by the Wessex Area Team/CCG Safeguarding Leads 6.2 That the NHS England Wessex Area Team reviews the specification for health visiting services to ensure this includes an antenatal contact by the Health visiting service as per the Healthy Child Programme (Department of Health, 2011); 6.3 That the NHS England Wessex Area Team work with local partners and the Department of Health to commission the Family Nurse Partnership programme for the IOW; 6.4 This recommendation is being pursued by the NHS END |
NC047181 | Admission to hospital emergency department of 7-week-old baby Thomas with an unexplained head injury on 25 December 2014. Thomas was subject to a Child Protection Plan set up pre-birth on 3 September 2014, due to a high risk of neglect. A schedule of expectations was in place, triggered by risk factors including: mother's previous child with another partner removed for adoption in 2014; mother and partner's (Thomas's father) history of drug and alcohol misuse and personal neglect; partner's father had a history of violence and petty criminality and had been assessed as lacking capacity in November 2014 having sustained a brain injury in an accident. Mother was noted to be caring for Thomas appropriately during scheduled visits by agencies; unannounced visits in late December failed as the social worker could not gain access to the home. Failure by mother to attend appointments agreed to as part of the schedule of expectations and delays by agencies in following up missed appointments. Professionals and agencies had an over-optimistic approach to the management of the family. The Core Group practice did not reflect the pivotal role in multi-agency support for recognised at risk families and was ineffective in keeping Thomas at the centre of decision making. Members of multi agency team were not always engaged with the safeguarding process. Absence of co-operation by parents was not acted upon. Legal processes and thresholds were not challenged despite the instinct that the decision to keep Thomas with the family at birth was wrong. Sets out key findings using the root cause analysis investigation process, focussing on a multi-agency approach which encourages team reflection and collaborative working. Recommendations include: putting the child as the focus of the child protection process; review of the Core Group structure to include formal terms of reference, core membership and standardised agenda; review of communication systems between agencies; training offered to professional agencies involved in safeguarding very young children to help them recognise disguised co-operation.
| Title: Serious case review: CN12 ‘Thomas’: root cause analysis report. LSCB: Devon Safeguarding Children Board Author: Palladium Patient Safety Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW CN12 ‘THOMAS’ 2 Root Cause Analysis Report By 2015 www.palladiumpatientsafety.co.uk 3 Executive Summary Background: Following the admission to hospital of a 7 week old infant who was the subject of a Child Protection Plan with a head injury for which no accidental explanation was provided, a serious case review was commissioned in May 2015. The purpose of the review was to explore the effectiveness of the multi-agency working practices in safeguarding this infant and identify systems that would benefit from improvement. Palladium Patient Safety were commissioned to undertake the serious case review using a Root Cause Analysis methodology. The investigation involves a review of all the available information and evidence with staff from all of the agencies involved with this child and family. The Root Cause Analysis investigation process concentrates on examining system and process failures. The recommendations are identified in collaboration with the staff from all agencies to reflect a front line perspective of potential solutions. This approach allows those involved to reflect on the incident as a multi-disciplinary team and identify personal and team learning to be shared within their primary area of practice. Lessons Learned: The multi –agency teams involved in the care of this child recognised the importance of child protection and used the processes detailed in local and national policies. Their self-reflection noted they could have used challenge more effectively. However the opportunity for a holistic view of the situation for these ‘at risk’ families is not assisted by lack of shared communication processes and opportunity to review cases as a multi-disciplinary team. This is explored in depth in the discussion section of the report Conclusion: There were opportunities to identify a fuller picture of the whole family risks at the antenatal stage which may have influenced scrutiny of the family behaviours in the post-natal period. It is unclear whether this would have prevented the specific injury – details of which are not fully established 4 Contents Executive Summary ................................................................................................................................. 5 Background and consequences of the incident ...................................................................................... 6 Scope of the Serious Case Review .......................................................................................................... 7 Timescale ............................................................................................................................................ 7 Lines of Enquiry ................................................................................................................................... 7 Questions to be addressed in the Serious Case Review ......................................................................... 8 Process ................................................................................................................................................ 8 Involvement and support of the parents ............................................................................................ 9 Agencies who had contact with baby/family ...................................................................................... 9 Notable Practice identified by Root Cause Analysis meeting attendees and report author .................. 9 Mapping and Analysis of the Incident .................................................................................................. 10 Source materials ............................................................................................................................... 10 Rationale for use of a timeline .......................................................................................................... 10 Development of tabular timeline for ‘Thomas’ ................................................................................ 10 Care and Service Systems Failure Analysis ........................................................................................... 11 1. Care system failures identified by the review meeting attendees ................................................... 11 2. Service system failures ...................................................................................................................... 11 Contributory factors analysis ................................................................................................................ 12 3. Summary of the Contributory Factors .............................................................................................. 12 4. Root cause(s) identified by multi-agency incident review meeting attendees and report author .. 14 5. Lessons Learned identified by multi-agency review meeting attendees and report author ........... 15 6. Discussion .......................................................................................................................................... 16 Question 1: Was every service involved in the safeguarding of ‘Thomas’ playing their full part? ...... 16 6.1 Core Groups ................................................................................................................................ 16 6.2 Risk Assessment and Safeguarding ............................................................................................. 17 6.3 Documentation and Systems ...................................................................................................... 18 6.4 Appraisal of Family Behaviours ................................................................................................... 18 6.5 Opportunities for Multi Agency Communication ....................................................................... 19 6.6 Insight and Human Factors ......................................................................................................... 20 Human Factors Checklist ................................................................................................................... 20 Question 2: Was the safeguarding service offered to ‘Thomas’ based on a clear understanding of the needs of the baby?................................................................................................................................ 21 6.7 Core Purpose of Child Protection Plans ...................................................................................... 21 5 6.8 Information Gaps ........................................................................................................................ 21 6.9 Enforcement of the Schedule of Expectations ............................................................................ 22 Question 3: Was the plan to protect the baby effective? .................................................................... 23 6.10 Baseline Assessment ................................................................................................................. 23 6.11 Response to Further Information ............................................................................................. 24 Question 4: Could the injury to ‘Thomas’ have been prevented? ........................................................ 24 7. Overall Recommendations for Devon Safeguarding Children Board ................................................ 25 8. Arrangements for sharing learning as agreed with Root Cause Analysis review team .................... 26 9. Other opportunities for sharing the learning to be considered ....................................................... 26 6 Background and consequences of the incident A 7 week old baby, ‘Thomas’ presented to the local Emergency Department having sustained a serious head injury on the 25th December 2014. The exact time frame and cause of the injuries remain unclear. There were a number of adults who had care of ‘Thomas’ whilst at a family party on this date. A Police investigation was completed. An update of the criminal investigation on the 27th May 2015 confirmed: ‘The case has not met the criminal threshold so there will be no further action in this respect. There is still a finding of fact to take place and this may reveal further information which requires investigation, however at this stage the criminal case is not proceeding’ At the time of the injury, ‘Thomas’ was the subject to a Child Protection Plan. This had been set up pre-birth on the 3rd September 2014. The basis for the Child Protection Plan was the high risk of neglect and the terms of the Child Protection Plan were - ‘unborn baby subject to a Child Protection Plan – Neglect’. Working Together to Safeguard Children1 describes neglect as: ‘The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing or shelter (including exclusion from home or abandonment); protect a child from physical and emotional harm or danger; ensure adequate supervision (including the use of inadequate care givers); ensure access to appropriate medical care or treatment. It may include neglect of, or unresponsiveness to, a child’s basic emotional needs’ In addition to the Child Protection Plan, a further level of protection had been put into place under the Public Law Outline. This took the form of a ‘Schedule of Expectations’ which is a written agreement outlining what the parents needed to do or stop doing in order to keep ‘Thomas’ at home. This was triggered because there were a substantial number of risk factors identified and known by partner agencies for ‘Thomas’. 1 Working Together to Safeguard Children, Department for Education, 2013 www.education.gov.uk/aboutdfe/statutory/g00213160/working-together-to-safeguard-children 7 The following risk factors for the family had been identified by multi-agency risk assessment2 leading to the Child Protection Plan: The mother had a previous child in 2011 with another partner and this child was removed for adoption in 2014. The mother had a history of substance abuse and personal neglect. The mother’s partner and father of ‘Thomas’ had a history of violence and petty criminality The mother’s partner had sustained a brain injury in 2014 as a result of an accident and been assessed as lacking capacity in November 2014. The mother’s partner had a history of substance abuse and personal neglect. Following reporting of the injury to ‘Thomas’ sustained on 25/26th December 2014, the Serious Case review sub group agreed that ‘Thomas’ had suffered significant harm. In addition there were concerns about the effectiveness of the multiagency arrangements in place to protect him. Scope of the Serious Case Review Timescale The review covers a 16 week period from 3rd September 2014 to 25th December 2014. This reflects the commencement of the Child Protection Plan for the unborn baby to the date when the serious head injury was identified. The report author reviewed all information provided by the various agencies either side of these dates and decided to include additional information. In particular, information relating to the past history of the father of ‘Thomas’ was included in the final scope of the review. Lines of Enquiry The terms of reference of the review were agreed at the outset and include questions described in Devon Safeguarding Children Board2 along with the specific areas of enquiry for ‘Thomas’. 2 South West Child Protection Procedures http://www.online-procedures.co.uk/swChild Protection/ 8 Questions to be addressed in the Serious Case Review 1. Was every service involved in the safeguarding of ‘Thomas ‘playing their full part? 2. Was the safeguarding service offered to ‘Thomas’ based on a clear understanding of the needs of the baby? 3. Was the plan to protect the baby effective? 4. Could the injury to ‘Thomas’ have been prevented? The agreed purpose of the review is to establish what lessons can be learned about local practice and working together, and to identify some recommendations for change. The overall aim is to improve inter-agency working and better safeguard and promote the welfare of children. Process The Serious Case review sub group elected to undertake an independent review using a systems process. Use of an independent investigation process is supported by many patient safety academics and will ‘help to build an open culture that learns from errors and corrects them’3. Palladium Patient Safety (report author) were commissioned to conduct the investigation because of their expertise in use of the investigation methodology selected. The methodology selected is a well-tested investigational approach in healthcare using a toolkit known as ‘Root Cause Analysis’. Use of the Root Cause Analysis toolkit encourages an analytical approach throughout the investigation and will help establish ‘what happened, how it happened and why it happened from the perspective of human performance and the performance, or under performance of systems and processes designed to support the delivery of safe and effective care’.4 The Root Cause Analysis process used by the report author focusses on a multi-agency approach which encourages team reflection and collaborative working. It promotes the process of sharing learning. By using a multi-agency approach, the teams involved in working with ‘Thomas’ are given an opportunity to collaboratively identify where local systems and processes may have failed to function in the best interests of ‘Thomas’. The Root Cause Analysis approach allows them to actively work together using brain storming/writing and analysis tools to identify improvements to reduce the risk of recurrence. 3 Macrae C and Vincent C ‘Learning from failure: the need for independent safety investigation in healthcare’ Journal of the Royal Society of Medicine; 2014, 107 (11) 439-443 4 Dineen M ‘Six Steps to Root Cause Analysis’; www.consequence.org.uk 9 Contributions to the Root Cause Analysis process were provided by representatives of the following teams: Children’s Social Care. Health Visiting. Midwifery Services. Primary Care. Involvement and support of the parents Mother and Father of baby have been contacted twice by letter by the Devon Safeguarding Children Board Business Unit to ascertain if they would like to contribute to the Serious Case process. No response has been received from them to date. Contact and support has been offered and maintained to the family by the local authority and partner agencies. Agencies who had contact with baby/family Details of the agencies involved in ‘Thomas’ and his family include: Children Social Work, Adult Mental Health Services (Devon), Midwifery, Health Visiting, Drug and Alcohol Services – Devon, Devon & Cornwall Police, General Practice and South Western Ambulance Service. The following agencies confirmed they had no contact with the baby/family: Torbay Council – Children’s Services. Notable Practice identified by Root Cause Analysis meeting attendees and report author 1. Devon Safeguarding Children Board commissioning an independent review is suggestive of an open and just culture creating an environment where ‘causes of serious events can be established and lessons widely learned’5 2. The case is being viewed as an opportunity to learn by partner agencies and there is an undertaking from all agencies to share any learning widely. 3. Individual practitioners tried to work to the best interest of ‘Thomas’. 4. Concerns about the welfare of the unborn baby were recognised when the pregnancy was declared to maternity services and a Multi-Agency Safeguarding Hub referral was made by Midwifery Services to the local authority in compliance with Working Together 2015. 5. Mother was noted to be caring for ‘Thomas’ appropriately during the scheduled visits by various agencies and they wished this to be recognised. This was different to behaviour noted with her previous child. 5 ‘Investigating clinical incidents in the NHS’, Health Select Committee May 2015 10 6. All of the attendees at the Root Cause Analysis meeting and the General Practitioner’s interviewed have current knowledge of safeguarding responsibilities and processes. They are either up to date with their safeguarding training at the appropriate level; or booked on an update course. 7. The General Practitioner practice evidenced rapid response following flagging of increased risk profile of ‘Thomas’ at the General Practitioner visit on the 22nd December 2014. Their internal flagging system on patient records was effective. Mapping and Analysis of the Incident Source materials In addition to using a tabular timeline and referencing policies for the agencies involved for the review, other documents referenced were: Single agency reports. Chronological timeline developed by Devon Safeguarding Children Board. General Practitioner meeting summary records. Acute hospital attendance records for ‘Thomas’ Root Cause Analysis meeting summary records. Rationale for use of a timeline A chronology of events is essential to a robust investigation. There are several methods of displaying the information such as using a narrative chronology, or tabular timeline. With any method selected by an investigation team the timeline must demonstrate: Clarity of information Sufficient level of detail especially at critical stages in the storyline Notable practice Missing information and/or gaps in systems and processes Development of tabular timeline for ‘Thomas’ The original chronological timeline was collated by the Devon Safeguarding Children Board team with contributions from the agencies involved with ‘Thomas’ and displayed in Excel spreadsheet format The timeline was transferred into a tabular timeline format by the report author During the Root Cause Analysis meeting the attendees read through the tabular timeline and updated the information displayed referencing their professional records, baby and family records with additional information to ensure the timeline was an accurate reflection of the events leading up to the end date of the investigation The Root Cause Analysis review meeting attendees and report author used the visual display of the timeline to identify and analyse: 11 Gaps in the services Opportunities to improve liaison between partner agencies and between the family and partner agencies Care and Service Systems Failure Analysis The multi-agency attendees at the Root Cause Analysis review meeting were separated into two groups and asked to analyse the contributory factors to assess which factors could be separated into ‘Care systems failures’ or ‘Service systems failures’. The notable practice factors are documented on page 9. The review team and report author had the advantage of retrospective insight and acknowledged that factors may not have been so apparent at the time of occurrence. The report author has added to this list generated by the minutes of the round table discussions during the Root Cause Analysis review meeting. The issues raised and the impact of the care and service systems failures are explored in more depth in the discussion section of the report. Recommendations to reduce the risk of recurrence are considered in the discussion section of this report on page 16. 1. Care system failures identified by the review meeting attendees 1.1 Risk assessments were delayed, incomplete and not monitored effectively 1.2 The management of parental behaviours was prioritised over Thomas’s needs 1.3 Communication between agencies was constrained by location and resources 1.4 The Core Group did not function effectively and not all of the agencies who could have contributed to the assessment of risks were present at the meetings 2. Service system failures 2.1 Alerting Systems, Information Technology and Information Governance do not work together so that it was impossible for all of the agencies to have a clear picture of all of the risks relating to ‘Thomas’. 2.2 Staffing related issues impacted on the day to day management of the Child Protection Plan. 2.3 Staffing related issues such as supervision, staffing levels, and managing absence impacted on the day to day management of the Child Protection Plan. 2.4 Multi-agency professional training and education is not sufficiently joined up which reinforces a silo working approach. 12 Contributory factors analysis A fundamental part of a Root Cause Analysis investigation is to identify the contributory and causal factors that contributed to the occurrence of the incident, and/or specific events along the incident pathway. Recommendations for addressing these contributory factors are included in the discussion section of this report on page 16. 3. Summary of the Contributory Factors 3.1 Baby and family factors: 3.1.1 ‘Thomas’ was subject to a Child Protection Plan having been assessed as at risk of neglect. 3.1.2 There was a history of the mother having a previous child adopted due to neglect. 3.1.3 There was a history of both mother and father misusing drugs and alcohol. 3.1.4 Multiple risk factors including a comprehensive history of offending with regards to the father were not known at the time of the Child Protection Plan being put into place, and were not taken into account during further reviews. The net result was that not all of the agencies were aware of potential for harm from the father for ‘Thomas’. 3.1.5 The Police were not routinely involved in Core Group meetings so were not able to contribute information current to the family. 3.1.6 The midwifery and health visitor teams noted concerns as the mother was prioritising the father’s needs over ‘Thomas’ after he was born. Although during visits ‘Thomas’ appeared to being cared for well, the opportunity to gain access to the family residence was managed by the mother so it was not always easy to see the family in normal circumstances. 3.1.7 Several attempts to make unannounced visits to the home in late December failed as the duty social worker could not gain access. 3.1.8 There were delays in following up failure to attend appointments agreed as part of the Schedule of Expectations. The Mother failed to attend many appointments she had agreed to as part of the Schedule of Expectations citing many reasons for this and there were delays by agencies in following up the missed appointments. The drift with apparently little challenge focussed on the needs of the parents over Thomas. 3.2 Communication factors: 3.2.1 The midwife who made the original referral to the MASH did not receive feedback that the referral was received. 13 3.2.2 The MASH process was reported by the General Practitioner to be ‘cumbersome’ and difficult to obtain advice when reporting on to the system. This is a critical system for the child protection process. 3.2.3 There are multiple forms of written and electronic communication which are only accessible by the teams using them, which results in a lack of joined up working and duplication. 3.3 Team working and human interaction factors: 3.3.1 Midwives recognised that when a named midwife is not free to attend a Core Group meeting, apologies are sent when in fact a representative should be sent to ensure continuity in communication. 3.3.2 When ‘Thomas’ was first seen at the General Practitioner surgery he was reviewed by a trainee who was not aware of the family history. A senior opinion was sought regarding the family and the senior General Practitioner noted the parents smelt of alcohol. As Thomas was not registered with the surgery at the time of the appointment, the General Practitioner was not aware that this may have been a cause for concern. This should have been recognised as a concern whether Thomas was registered with that surgery or not as a child should not be in the care of inebriated parents. 3.3.3 During the Root Cause Analysis review meeting, it was recognised that the Independent Reviewing Officer could have challenged the decision not to remove ‘Thomas’ at birth. 3.3.4 Team factors also included a lack of shared understanding from all agencies involved about risks to ‘Thomas ‘and follow up plans. 3.4 Education and training factors: 3.4.1 The review meeting attendees felt that there was a gap in skills for the analysis of risk. 3.4.2 The training programmes available for child protection do not consistently use a simulation approach involving all agencies. 3.5 Equipment factors: 3.5.1 The review meeting attendees suggested that there were inherent risks associated with multiple information technology, recording and working systems in use across the services. 3.6 Task factors: 3.6.1 There was a delay in setting up the Initial Child Protection Conference 3.6.2 The review meeting attendees felt that the assessments completed did not appear to reflect the complete picture of the family circumstances for all agencies. 3.6.3 Multiple delays in referring the father to the appropriate adult services due to his reluctance to engage meant that there was never a complete picture of the risk factors associated with him and his failure to engage with services was allowed to drift unchallenged. 14 3.7 Environment and Location Factors: 3.7.1 The family were awaiting a house move and there were concerns about where they were living. The family were therefore able to use being out of town or lack of buses as a reason for being late or cancelling appointments as they had no reliable transport 3.8 Organisation & Agencies: 3.8.1 The review meeting attendees felt that a protection plan for a new born needs to be in place from 34 weeks gestation not left until the baby is due as was the case for ‘Thomas’. 3.8.2 The hospital discharge planning meeting should have been arranged prior to delivery – although this is often difficult to do given the unpredictability of labour. In this situation the Mother had an admission which suggested that she may go into early labour and so the discharge planning meeting process could have been triggered. 3.8.3 The Core Group membership is decided at the Initial Child Protection Conference and this is frequently open to change. The General Practitioner, Police, the relevant Adult Services and Recovery Intervention Service did not attend the Initial Child Protection Conference which was an opportunity for vital risk factors for ‘Thomas’ to be shared. 3.8.4 There is currently no standardised membership for the Core Group and attendance inconsistent with multi-agency contributions sporadic and information is being missed as was the case with ‘Thomas’. 3.8.5 The General Practitioner did not appear to have been invited to the Initial Child Protection Conference and this team felt that this was a missed opportunity. 4. Root cause(s) identified by multi-agency incident review meeting attendees and report author The aim of a root cause analysis investigation is to identify and confirm agreed root cause(s). A root cause analysis as defined by Prof Charles Vincent (Imperial College) is ‘Not just a retrospective search for root causes, but an attempt to look into the future’ 6 Despite many individuals working to the best interests of ‘Thomas’, the review meeting attendees felt that the local child protection establishment of a lead professional in a position to have the ongoing full picture and keep the child at the centre of the decision was deficient. The reasons for this may be linked, in part, to changes in the allocated social workers during this period. It is unclear from the discussions who became the lead social 6 Vincent, Charles. ‘Patient Safety’. Page 111; 2006. Elsevier 15 worker for ‘Thomas’ after this date. This event also coincided with the Christmas holidays and the Health Visitor also being away on annual leave. Continuity was inevitably adversely affected by these factors. A number of contributory factors for this system failure include systems design, cross agency working and communication. 4.1 The agencies had an incomplete picture of the parental risk factors from the pre-birth assessment, in particular the father due to lack of engagement of adult social services. As a result they failed to respond to escalating risk factors relating to the father. 4.2 Professionals and agencies adopted an over-optimistic approach to the management of the family. The primary factor was that the team wished the parenting of ‘Thomas’ to be successful following previous family history of adoption. This was compounded by a reassurance by the ‘perceived engagement’ demonstrated by the family and the observations of ‘positive mothering’. 4.3 The legal processes and thresholds were not challenged despite the instinct that the decision to keep the baby with the family at birth was wrong which resulted in the baby remaining with his family. 4.4 The Core Group was ineffective in keeping ‘Thomas’ at the centre of the decision making. 5. Lessons Learned identified by multi-agency review meeting attendees and report author 5.1 Safeguarding risk assessments need to be proactive, dynamic, and accurate and kept up to date with current risk factors in order to be effective. They are the key tool for recording assessment of the family. They need to reflect clarity of decision making and actions taken and focus on supporting the needs of the child not the adults. 5.2 Oversight of the risk assessment needs to be led by an individual and effective governance beyond the initial risk assessment. As an example, why was the legal decision not to remove the baby at birth, which with hindsight was considered to be a contributory factor, not challenged by the Core Group? 5.3 The Core Group remit and efficient function should reflect a more assertive approach to keep the child and their risks at the centre of the care. 5.4 The professionals lost situational awareness and their decision-making was distorted by over optimism and a failure to employ professional curiosity with regards the mother. As an example, they failed to question the significance of the historical concerns and listen to their ‘professional gut feelings’ regarding the past history of domestic violence by the father and the deteriorating parental behaviour. 5.5 All agencies involved need to acknowledge and voice concerns, escalate them promptly and appropriately and challenge decisions made on behalf of a child that 16 are considered incorrect or inappropriate. The Core Group is the opportunity for all agencies to hear and reflect on the impact of these concerns for the child. 6. Discussion Working Together to Safeguard Children 2015 states that effective safeguarding in every local area should be underpinned by two key principles: Safeguarding is everyone’s responsibility: for services to be effective each professional and organisation should play their full part; and A child centred approach: for services to be effective they should be based on a clear understanding of the needs and views of children. Following the Root Cause Analysis meeting discussions, review of the timeline, and the evidence available to the reviewers, the report author provides the following answers to the questions posed in this report. Question 1: Was every service involved in the safeguarding of ‘Thomas’ playing their full part? Working Together 2015 (point 16, page 9) states that: ‘No single professional can have a full picture of a child’s needs and circumstances and, if children and families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action’. 6.1 Core Groups 6.1.1 The Core Group status and use in practice does not reflect the pivotal role in multi-agency support for recognised at risk families and therefore it was not possible for all of the agencies to play their full part in the safeguarding of ‘Thomas’. 6.1.2 The title of the meeting implies that it is a core part of the child protection system locally. However during the discussions it was established that Core Groups do not have standard terms of reference, membership or quorum. The Core Group is primarily administered, facilitated and attended by members of the Social Work team. The Core Group does not fulfil its primary function as the core source of information and management of Child Protection Plans for individual children. As a result, the relevance of the meeting is not recognised or prioritised across all the agencies. 17 6.1.3 Agencies were either not invited to attend Core Group meetings or were unable to attend as it was not seen as a priority or chose not to attend meetings as they did not know the family. Frequently they had to send apologies due to workload. The lack of attendance of key agencies reduces the opportunity to share risk information across health and social care agencies involved in a Child Protection Plan. This was observed in the case of ‘Thomas’. 6.1.4 The report author recommends, as a minimum, that the first Core Group meeting attendance should include contributions from all relevant agencies including the appropriate Adult Services, General Practice and Police to provide a good baseline assessment of the key risks. 6.2 Risk Assessment and Safeguarding 6.2.1 There appeared to be an over reliance on the Social Work team to complete the necessary assessments for children with a Child Protection Plan. ‘Working Together’ clearly states that safeguarding is everyone’s responsibility and there is a need for every professional to accept responsibility for identifying and sharing any risk factors to children. In this case there were several opportunities for risks associated with the father to be followed up more vigorously across the agencies. 6.2.2 As an example, it was recognised that the failure to invite the appropriate Adult Services to Core Group meetings resulted in significant information regarding the father being missed. 6.2.3 The discussions during the Root Cause Analysis review meeting suggest that some members of the multi-agency team were not always actively engaged with the safeguarding process. The General Practitioner’s acknowledged that ‘they have longer term relationships with many families and can provide background and context to a Child Protection meeting’. They expressed a desire to attend meetings in person or virtually but the opinion of the Root Cause Analysis review meeting attendees suggested that, in practice, this a rare occurrence and General Practitioner’s regularly did not attend Core Group meetings despite being invited to attend. The General Practitioner’s stated that they fully recognised the importance of child protection meetings and would ‘try to attend if they saw the family and had information of relevance for the Child Protection review. They were less likely to attend if they had no direct contact with the patient or follow up meetings’. Copy minutes were of the initial Core Group meeting were held on file for the mother. 6.2.4 When the family presented at the surgery in December and ‘Thomas’ was registered for the first time, he was seen by a General Practitioner trainee who did not know the family. An appropriate secondary review by a senior General Practitioner took place but they also did not know the family, the safeguarding issues nor the fact that ‘Thomas’ was subject to a Child Protection Plan. As part of the incident review, both reflected that if they had been party to this information features of the assessment during the appointment, for example the fact that the father was noted to be smelling of alcohol, may have influenced 18 the follow up review of ‘Thomas’. If the General Practitioners were encouraged to be actively involved in Core Group meetings every time then the risk of missing this information would be reduced. 6.2.5 Midwifery felt that they made significant attempts to be involved in safeguarding processes but these attempts were not helped by communication systems across health and social care which did not work well together. As a result they often did not know when Core Group meetings were taking place, they did not receive the minutes from the Core Group meetings or they were delayed. So they were not kept up to date with the current progress for a family or changes in risk factors. In this case it would appear that not all of the agencies had up to date information regarding the risks pertaining to this family. The core source of information on Care First lacked information regarding risks of the father and his escalating behaviours. 6.3 Documentation and Systems 6.3.1 There are a variety of paper and electronic records and care systems in use within the region and none of them apparently interface. The net result of this system variation is that red flags and vital information about risks cannot be easily shared. So despite serious attempts to play their full part often agencies were thwarted in their attempt to share information regarding the family. As an example it was disclosed during the Root Cause Analysis meeting that the baby had been returned to the mother who was now resident in a Mother and Baby Unit. Many of the agencies in attendance were unaware of this. 6.3.2 Multiple systems increase the chances of an individual or family more easily navigating their way around a system unmonitored, and by use of disguised co-operation assuring agencies of compliance with agreed plans. The professionals in the Root Cause Analysis review meeting did not consider the family were deliberately manipulative but acknowledged their ‘over-optimism’ for the mother to do well with this baby may have impacted on certain decisions. 6.3.3 The policies from all of the agencies referenced during the Root Cause Analysis meeting are current and reference the relevant safeguarding requirements. The report author notes some of the policies run to multiple pages. This puts the risk of key information being difficult for staff to access and follow. This is a general observation and there is no indication of any adverse impact on the management of ‘Thomas’. 6.4 Appraisal of Family Behaviours 6.4.1 The report author suggests the ‘emotional dimension of working with children and families lead to a distortion in the reasoning because of the unconscious impact it has on where attention is focussed and how information is interpreted’.7 As an example, the excuse of attendance at hospital appointments preventing meeting with Social Workers could not 7 Munro E LSE. ‘The Munro Report of Child Protection: Final Report – A child centred system’. 2011 19 readily be challenged without confirmatory communication between agencies. The mother consistently failed to make appointments (RISE/SPLITZ) required as part of the Schedule of Expectations. 6.4.2 The agencies were playing their full part but were persuaded by the parental behaviour and distracted by the family chaos. Brandon et al recognise this as a common phenomenon in safeguarding children cases. “Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents ...engineered the focus away from allegations of harm, children went unseen and unheard.”8 The report author noted documented examples of complete absence of co-operation by parents. This did not appear to be acted upon and the potential additional risk for ‘Thomas’ recognised. James Reason in ‘Managing the Risks of Organisational Accidents9 states ‘ The pursuit of safety is not so much about preventing isolated failures, either human or technical, as about making the system as robust as practicable in the face of its human and operational hazards’ (1997). 6.4.3 It is the opinion of the report author that the Child Protection Plan had been put in place due to potential risks of ‘Thomas’ being subject to ‘neglect’ based on previous family history. Observation of the mother and ‘Thomas’ together concentrated on whether she was caring for him and feeding him. This she appeared to be doing when professionals were allowed access. The report author suggests that if the risk factors regarding the recent criminal history for the father had been known when the Child Protection Plan was put in place then it may have taken into account the fact that ‘Thomas’ was at risk of physical harm. If the Police had attended the Core Group meetings this would have increased the opportunities for information regarding this to be shared. 6.5 Opportunities for Multi Agency Communication 6.5.1 The General Practitioners, Social Workers and Health Visitors present at the Root Cause Analysis meeting observed that changes in health and social care services that had evolved nationally over the past five years regarding service provision may have reduced the 8 Brandon M et al. ‘Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious cases 2003-005’. Research Brief DCSF RB023 (PDF) London: Department for Education and Skills. 9 Professor James Reason Managing the Risks of Organisational Accidents. Ashgate Publishing 1997 20 opportunity for professional communications; for example the Health Visiting service now deliver their service predominantly in Children’s Centres reducing the opportunities for formal and informal communication with some other key agencies. 6.5.2 These changes were considered to have reduced the chances of sharing vital information between different agencies. Section 47 of the Children’s Act sets out the requirement of all agencies to communicate vital information citing ‘’a statutory gateway to data sharing’. 6.5.3 Some of the attendees lacked confidence in challenging decisions made in legal meetings. The report author understands work is underway regarding this. It is recommended that a trial of a simulated training programme which includes all of the agencies involved in children’s safeguarding could be set up to test issues raised by case studies such as these in a safe environment. 6.6 Insight and Human Factors 6.6.1 All agencies appeared to be working with the best intentions towards the family but were no helped because the communication systems between them did not interact making it virtually impossible to verify what the parents were telling them and to accurately assess the factors in the family life which would have presented an additional risk to ‘Thomas’ at birth. 6.6.2 Effective use of human factors understanding and theory involves a mix of these elements in order for teams to undertake their key function as effectively as possible and avoid unreasonable expectation of ‘human perfection.’ This is as relevant to those involved in Safeguarding Children as in other high-risk industries: Human Factors Checklist Recognition of the need for clear communication between all those involved Availability and use of well-designed and effective tools to support the core function Clear sense of shared purpose for the core function and respect for each team member’s role. An endorsement of the agreed process to support the core function with no acceptance of ‘work-around’ A flat hierarchy with the ability to challenge decisions. An emphasis on constant improvement and shared learning. Leadership who set a high standard whilst also provide meaningful support to their teams 21 Question 2: Was the safeguarding service offered to ‘Thomas’ based on a clear understanding of the needs of the baby? 6.7 Core Purpose of Child Protection Plans 6.7.1 In the opinion of the report author the Child Protection Plan outlined what should have happened to keep ‘Thomas’ safe. This was over-ridden by consideration of the needs of the parents. The actions towards the parents were all well-intentioned but did not place ‘Thomas’ at the centre of the care. Working Together 2015 (point 20, page 9) states that ‘Effective safeguarding systems are child centred and that failings in safeguarding are too often the result of losing sight of the needs and views of the children within them, or placing the interests of the adult ahead of the needs of the children’. The analysis of the professionals at the Root Cause Analysis review meeting was that this was the biggest failing of the safeguarding processes in this case. The professionals agreed they became distracted by the chaotic lifestyle, the behaviours and the varying needs of both parents and inadvertently put these above the needs of ‘Thomas’. 6.7.2 The lack of opportunity for the agencies to meet and share information reduced the chances of the team benefiting from shared ‘faint signals’. These are described by Ron Westrum10 as ‘symptomatic events, suspected trends, gut feelings and intelligent speculation’ concerns about the parents which in turn reduced the resilience of a team. 6.7.3 The pre-birth assessment took too long to complete once on notice of the pregnancy of a second child considering the first baby had been placed for adoption as a result of neglect. The agencies were aware of the pregnancy in April 2014; and yet the Child Protection Plan was not put into place until September 2014. 6.8 Information Gaps 6.8.1 The result of the delay regarding risk assessment was that vital information regarding the father of ‘Thomas’ was not mapped out or gathered, shared and discussed openly by the multiagency team. 6.8.2 The review group attendees described their professional behaviour as ‘over-optimistic’ based on an overwhelming desire and empathy for the mother to manage the baby well this time as she had another child adopted in 2013. Several agencies observed the mother had been caring for ‘Thomas ‘appropriately and they were very confident that things would be better this time. The report author considers the focus was on whether ‘Thomas’ appeared to be neglected. It was completely appropriate for the Social Worker and Health Visitor to be observing for signs of neglect as an indication that the mother was reverting to her 10 Hollnagel et al, ‘Resilience Engineering – Chapter 5 A typology of Resilience Situations’; page 55; 2006. 22 previous behaviour. She did appear to be looking after ‘Thomas’ well. The desire to support the mother so she could make a success of her parenting is understandable. It was recognised that this may have blurred the more critical analysis of the family situation and overridden suspected underlying risk factors. Professor Eileen Munro confirms that this is a risk for the social worker who cannot help but become deeply involved with a family.11 6.8.3 There was little consideration given to the behaviour of the father in the weeks prior to the injury. He had been arrested by the Police only weeks before and this factor did not trigger a review of the family situation and reassessment of the risk factors for ‘Thomas’. If the risk factors for the father had been more openly discussed by the agencies involved in the Child Protection Plan the report author suggests that this desire to support the mother may have been interpreted differently. 6.8.4 The supportive approach was further compounded by the fact that some practitioners lacked significant historical information and knowledge regarding the parents including the ‘toxic trio’ of substance abuse, alcohol overuse and domestic violence and a history of petty crime. There was not a widely shared knowledge regarding father’s history and risk factors and therefore it was not possible for an accurate assessment of the risks he presented based on partial information. Significant factors such as when the family did not attend appointments and were not at home for scheduled visits should have been communicated across all the agencies involved and should have triggered a more robust response. 6.8.5 The failure of children’s services to engage with adult services in order to find out more about the father’s background and current situation was recognised as significant. 6.8.6 Observations were made regarding the mother’s focus on the care of the father and caused concern for many of the agencies but not acted upon. As an example, the mother making tea for the father a few hours following delivery of ‘Thomas’. This behaviour triggered the midwives to discuss this with the social workers as they felt it was inappropriate. It was considered to be of concern but it was never enough to trigger a more robust response to the management of the Child Protection Plan as the planned visits by any agency had failed to gain access to the family by mid-December. 6.9 Enforcement of the Schedule of Expectations 6.9.1 The mother agreed to engage with various agencies such as RISE/SPLITZ as part of the Schedule of Expectations. Her lack of compliance with elements of the Schedule of Expectations was documented on several occasions and discussed at supervision sessions with the Social Work team but never acted upon. It is not clear what the difference ensuring she attended her appointments would have made on the outcome for ‘Thomas’ but it is an 11 HM Government Department of Education. The Munro Review of Child Protection: Final Report – A Child Centred System. 2011 Professor Eileen Munro LSE 23 example of the way the behaviours of the parents were allowed to drift by the agencies managing the Child Protection Plan. RISE offers a wide range of services that ‘takes an abstinence-based recovery-focused approach for people with high-risk lifestyles’12 Information from the shared care single agency reports suggests that she was asked to attend RISE for hair strand testing to establish whether she was still using cannabis. Her non-compliance with this requirement of her Schedule of Expectations appears not to have been enforced. Her non-attendance at a RISE meeting was flagged to her verbally on many occasions by several of the agencies including the Family Support Team but not acted upon. The focus was how the mother felt about attending or not attending RISE and not what would happen to ‘Thomas’ if she didn’t comply with the monitoring service offered by them. The attendees at the Root Cause Analysis review meeting concluded that allowing the compliance with requirements of the Schedule of Expectations to drift did not meet a required safeguarding standard. The subsequent failure to further risk assess this non-compliance resulted in a failure to keep ‘Thomas’ at the centre of the assessment and should have been recognised as a ‘flag’ for increased risk. However the report author accepts that this form of support is offered on a voluntary basis and leaves the agencies in a difficult position. The social work team and Family Support Worker made frequent attempts to encourage the mother to keep to the conditions of the Schedule of Expectations but she failed to comply Question 3: Was the plan to protect the baby effective? 6.10 Baseline Assessment 6.10.1 The attendees at the Root Cause Analysis review meeting felt that initially an appropriate Child Protection Plan had been put in place on the 3rd September 2014, and communicated with relevant agencies; and that it summarised the initial needs and risks to ‘Thomas’. 6.10.2 The pre-birth assessment was not completed in a timely manner for the circumstances. The midwifery team had completed a MASH referral in April 2014. There was no further action regarding the child protection for ‘Thomas’ until June; and the Child Protection Plan was not put in place until September 2014. Vital time to collect and share information regarding the increasing parental risk factors was lost. 6.10.2 There were regular Core Group meetings to monitor the plan and discuss the family. However the Core Group meetings were not attended by all of the relevant agencies. This 12 Social Care and Health; https://new.devon.gov.uk/adultsocialcareandhealth/health-and-wellbeing/alcohol-and-drug-misuse/ 24 significantly contributed to a lack of information about the father relevant to the Child Protection Plan for ‘Thomas’. There was a lot of local knowledge regarding the reasons for and circumstances of a previous child who had been adopted. 6.11 Response to Further Information 6.11.1 It was noted that further assessments should have been prompted by changing risk factors for the baby linked to the demonstration by the father of some more risky behaviours such as the disturbance in October 2014 which involved him being arrested and charged. 6.11.2 Information was missing from the Child Protection Plan for ‘Thomas’. The impact of organisation risks associated with Information Governance was noted by all the agencies. At the Root Cause Analysis review meeting the attendees expressed a desire to share local documentation about the individual parents. However there was a perception that the Information Governance requirements of their originating organisations would override the ability to share information. The restrictions, if correct, significantly reduce the opportunity for information sharing; but could be mitigated if all agencies attended the Core Group meetings. 6.11.3 The report author suggests there is too great an emphasis on the Social Worker to arrange and administer the Core Group meetings and subsequently implement all of the elements of the Child Protection Plan. There was a passive approach from other agencies to the purpose of the Core Group. Although other agencies did engage with the plan in this case but it would appear that there is a strong reliance on individual practitioners’ professionalism and tenacity and not a consistent approach across the agencies. Currently it is possible to ‘opt into’ Core Group Meetings where an ‘opt out’ standard is more appropriate. 6.11.4 The Child Protection Plan that was in place was not robust enough to survive the test of a change in team member, sudden loss of a senior social worker and the impact an extended seasonal holiday would have on the Social Work service. 6.11.5 The report authors recognise that the outcome for ‘Thomas’ suggests that the plan put into place for him was not effective. However, it is difficult to see how any aspects of the plan might have anticipated or prevented the injury to the child in December 2014. Question 4: Could the injury to ‘Thomas’ have been prevented? 6.12.1 Despite the setting up of a Child Protection Plan for ‘Thomas’ before his birth within the first 6 months of his life he sustained a serious injury requiring hospital admission and specialist assessment. 25 6.12.2 The report author considers that the specific mode of injury – details of which remain unclear - could not have been prevented unless the child was living away from his family at the time of injury. 7. Overall Recommendations for Devon Safeguarding Children Board This review provides valuable learning for all the agencies involved as it largely reiterates best practice principles. The seven specific recommendations were identified by the multi-agency team who had responsibility for ‘Thomas’ and the report author. The report author recommends that serious consideration should be given to their implementation as actions in a form that suit the needs of the various teams and services involved in safeguarding children in Devon. 7.1.1 The child should be the focus of the Child Protection process and the needs of the adult should not be considered over those of the child. A series of questions that can be asked during Core Group meetings to prompt this should be developed. As an example ‘does this decision truly reflect the safeguarding requirements of this child at this time and does it anticipate future risks?” 7.1.2 Effective review of serious safeguarding incidents needs to be conducted promptly and involve all members of the multi-agency teams referring to all relevant documentation. 7.1.3 The Core Group structure, process and administration should be reviewed. A formal Terms of Reference, core membership and standardised agenda should be established taking into account the contributory risk factors for this investigation. The Core Group needs to be supported by an administrative team to ensure meetings run efficiently and outputs are circulated in a timely manner. 7.1.4 Review of communication systems between agencies both paper and electronic regarding children’s safeguarding to reflect ‘Working Together’ and allow agencies to effectively share information to the benefit of the child assessed to be at risk. ‘Read only’ access to core documentation should be considered to some users. 7.1.5 Professional agencies involved in safeguarding very young children such as Police, Midwifery, Health Visiting, Social Work and General Practitioners, should be offered training to help them recognise and resist attempts by families to hide the risks for children (and pre birth infants) subject to Child Protection Plans and to help them adopt a confident risk focussed challenge to legal advice. Training events should be based on simulated and realistic 26 case studies involving all partner agencies to test local safeguarding processes, enhance ‘professional curiosity’ skills and learn together. 7.1.6 Develop alternative opportunities to improve the communication between General Practitioners, Health Visitors and Social Workers to promote team working between all agencies involved in the safeguarding of children. 7.1.7 Risk assess staffing levels, staff supervision and support systems currently in place to ensure full involvement in child protection processes and in particular, individual and teams ability to escalate issues of professional concern. Staffing levels need to be sufficiently flexible to cope with seasonal variation and demand. 8. Arrangements for sharing learning as agreed with Root Cause Analysis review team 1. Review group attendees to reflect on outcome of Root Cause Analysis process during personal supervision sessions. 2. Review group attendees to share learning widely within local teams. 3. Publication of the Serious Case Review Root Cause Analysis report. 9. Other opportunities for sharing the learning to be considered 1. Devon Safeguarding Children Board to share with board members and appropriate sub-group members. 2. Devon Safeguarding Children Board to ensure all partner agencies receive a copy of the report and are requested to disseminate and brief all staff on the findings of the review and actions. 3. Development of local scenario based simulation training programme using a scenario with similar factors. 4. Lessons learned shared in various media such as team newsletters, emails, case history summaries. 5. Review improvements introduced following Serious Case Review using audit methodology. Annette Marshall Nicky Henderson Palladium Patient Safety 16th November 2015 |
NC52427 | Death of a 12-year-old child by suicide in 2020. Learning includes: wider consideration of issues relating to children electively home educated (EHE), children from the Jehovah's Witness faith, child and adolescent mental health services (CAMHS) and triage arrangements and information sharing in tertiary hospitals. Recommendations include: consider how to engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the safeguarding children partnership on the effectiveness of those arrangements; the local authority EHE team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included; engage with the Department for Education in the development of local guidance for schools on children electively home educated; request the National Safeguarding Practice Review Panel considers the recommendations from the Independent Inquiry into Child Sexual Abuse (IICSA) report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level; alert the National Child Safeguarding Practice Review Panel, and contact all child death review leads, to raise awareness of the need for child death review processes requiring referrals to the coronial process to be explicit about any potential safeguarding concerns.
| Serious Case Review No: 2022/C9517 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Local Child Safeguarding Practice Review Child A 2 CONTENTS Item Page 1. Introduction 3 2. Process for conducting the review 4 3. Family History and Agency involvement 5 4. Family views 6 5. Findings & analysis - School’s responses to children of Jehovah’s Witness faith and Elective Home Education - Elective Home Education arrangements - Jehovah’s Witness faith and safeguarding arrangements - Information sharing from tertiary hospitals 8-12 6. Analysis and Recommendations 13 3 1 Introduction 1.1 A Local Child Safeguarding Practice Review (LCSPR) was commissioned following completion of a Rapid Review process, submitted to the National Child Safeguarding Practice Review Panel in July 2020. The Rapid Review requires all agencies to undertake a review of their records and to submit a timeline, analysis and summary of agency involvement. This review involves the tragic death of a 12 year old child, referred to as Child A in this report, by hanging. 1.2 The case was referred to the Safeguarding Children Partnership’s Case Review Group (CRG) as the tertiary hospital, where the child had been treated and subsequently died, had raised some safeguarding concerns. These related to Child A’s weight, access to food, parental presentation and concerns shared by parents in relation to a sibling who had previously self harmed and described suicidal ideation. 1.3 As a result, there was a joint Section 47 child protection investigation undertaken by the Local Authority and Police. This took place and ran concurrently to the early stages of this Practice Review. The outcome of this investigation was that there were no child protection concerns, but sibling was assessed and began to receive a Child and Adolescent Mental Health Service (CAMHS). 1.4 The CRG and Independent Reviewer were unable to evidence any concerns regarding abuse/neglect relating to Child A through the review process. However, it was agreed by the CRG that this review offered a broader opportunity to use the lens of this family to consider any local or national learning around safeguarding for children electively home educated and from a particular faith. This was because Child A was electively home educated as was the sibling and the family were also a member of the Jehovah’s Witness faith. 1.5 Therefore, this review has been undertaken in a proportionate way to ensure the key learning is identified to support improvements in policy and practice. It is deliberately not detailed about the family but provides a brief summary of the family circumstances and key agencies’ engagement with the family. 1.6 The purpose of a LCSPR, as confirmed in the current statutory guidance, Working Together to safeguard children 2018: Chapter 4 is clear that the focus is on learning, not holding individuals or agencies to account. 4 2 Process for conducting the LCSPR 2.1 The CRG acted as the review Panel and first met in October 2020 to discuss the Rapid Review learning and scope the Terms of Reference (TOR). The Independent Reviewer attended this meeting. The Independent Reviewer is an independent safeguarding consultant, experienced Local Safeguarding Children Board and Serious Case Review (SCR) Panel chair and SCR/LCSPR reviewer, fully independent of the commissioning Safeguarding Children Partnership and its partner agencies. 2.2 It was decided that sufficient detail had been provided by all agencies into the Rapid Review process, so agency reports were not requested. However, it was agreed it would be helpful to request that the schools attended by both children be asked to consider their involvement and their responses to children from the Jehovah’s Witness community. In addition, it was thought useful to inform both the Section 47 assessment process and the practice review to understand the Jehovah’s Witness faith community and their safeguarding arrangements to inform the local Safeguarding Children Partnership. Consequently, an expert was commissioned to provide information to specific questions developed by the Reviewer and the Panel. 2.3 The Terms of Reference initially set out the following areas, which were felt to require further focus: • The safeguarding implications of Elective Home Education (EHE) for children and the effectiveness of the current system to identify any concerns. • How much do practitioners understand the EHE arrangements /policies/operational delivery? • To consider how mainstream schools respond to /adapt to the inclusion of children who are Jehovah’s Witnesses and any learning for the wider school/education community. • The potential impact of the family’s religion as Jehovah’s Witnesses and how this is responded to by the Safeguarding System. • How effective are the safeguarding policies of the Jehovah’s Witness organisation and how would potential concerns around parenting be managed/responded to? • To consider the learning from other published SCRs/LCSPRs, which have involved children home educated, and any wider national learning and the impact for learning for the commissioning Safeguarding Children Partnership. 5 2.4 The CRG then met in January 2021 and considered the expert opinion on safeguarding arrangements in the Jehovah’s Witness faith and the reports prepared by the schools and agreed further actions to be undertaken by the Reviewer. At the March 2021 CRG meeting, it became clear at this meeting that there were additional issues identified in relation to the tertiary hospital and how information about their safeguarding concerns had been fed into the differing statutory processes. As a result, the CRG formally requested an agency report from the tertiary hospital to address specific issues identified through the practice review process. 2.5 Following the discussion on the school’s reports, it was decided it would be helpful to meet practitioners in order to progress the learning from this review process and to understand the issues facing front-line practitioners in relation to elective home education and the opportunities and challenges about the ‘system’. A meeting was therefore held with the Reviewer and four practitioners from the Local Authority Elective Home Education team and the Safeguarding in Education team in February 2021. 2.6 The contribution of family members is an important part of the review. It was agreed that both parents of Child A would be informed of the review and invited to contribute their thoughts and experiences on all agencies that had been involved with the family. The reviewer kept the family informed of progress by letter and then made contact in June 2021 and was able to have a helpful lengthy virtual meeting with Mother. 3. Family History and Agency involvement 3.1 The family are White British and comprised of parents, Child A and sibling. The family are Jehovah’s Witnesses and the children were electively home educated. The family had only been known to Children’s Social Care through it’s “front door” following a referral by the General Practitioner to CAMHs in relation to the older sibling in January 2020. There was concern around low mood, incidents of self harm and suicidal thoughts. The assessment concluded that the CAMHS threshold was not met and sibling was signposted to a counselling service, the local college counselling service and the provision of a number of “apps”. 3.2 The older sibling became electively home educated from the end of Year 7 and Child A from the end of Year 5. They had routine contact with the Local Authority home education service. This comprised annual phone calls to discuss and agree education provision was suitable, the offer of attendance at a Drop In and a Home Visit if requested by the family. A Home visit was not requested, and 6 the education of the children was deemed suitable. Therefore, the contact with this family didn’t include face to face contact or home visits. Child A sibling had begun to attend a local college on a one year part time home education programme. The college also provided counselling and high levels of support. 4. Family Views 4.1 The reviewer had a very helpful discussion with mother who was able to identify a number of areas of learning although generally her overall experience of local agencies was very positive. However, she felt that access to CAMHS for Child A sibling was not the most constructive experience in January 2020 as the assessment was done over the phone and sibling had felt unable to disclose the detail of their suicidal ideation. Sibling was signposted to other support services but then was fortunate enough to receive excellent counselling and support from the local college. 4.2 Mother also identified the lack of NHS services/counselling for parents of children who have died to support their mental health. The Child Death review nurse helpfully facilitated this service from local charities but that seemed to be purely good fortune that they were flexible enough to offer a service. Mother described the current support from CAMHS and the Adult counselling service as very positive. 4.3 Mother reflected on their experience at the tertiary hospital, where Child A was admitted and died. This was clearly a highly distressing period and occurred during the Covid pandemic, which obviously impacted on the family and the service. However, her reflection was informed by the positive experience they had received as parents when Child A had been a very seriously ill baby at another tertiary hospital. At that time she said they felt nurtured and supported and this contrasted significantly from the experience at the tertiary hospital where Child A died. 4.4 Both parents received the medical notes from the tertiary hospital, which were released by the Coroner’s office. They were very concerned at the statements included in the notes around their presentation and Child A’s weight, which had not been shared with them directly. Mother felt the staff were influenced by the initial Police and Children’s Social Care investigation and that their experience with some of the staff made sense when she had subsequently read the medical notes. They had been allocated a Liaison Officer from the nursing team but although father had found that helpful, Mother said she felt the interaction appeared judgemental and punitive. 7 4.5 Mother described the statement made by nursing staff that the parents had been “absent” and not with Child A but described the “instruction” from nursing staff apparently at the request of Children’s Services that one parent needed to return home and remain with sibling. Ironically mother said this meant sibling had to leave their friend’s home where sibling felt nurtured and return home to where the incident had taken place, which caused distress. This also coincided with the hospital Covid policy at that time for only one parent to be present on the ICU. Mother felt alone and unsupported, there was no food outlets open in the hospital, so she had to go outside to find food. Mother stated the notes described her spending little time with Child A but she felt that nursing staff were always with Child A and she felt “often in the way”. Mother said she had however had a more positive experience with some nursing staff. She wondered if they might have been short staffed due to Covid but said that the ICU itself was not near capacity. 4.6 A significant point made by mother was that both parents were asked, once it was confirmed that there was no likelihood of survival for Child A, if they would agree to organ donation. They considered but decided against it based on what they believed would be Child A’s wish. Mother then described being told almost immediately that they would then turn off the life support and that the room they had been using to sleep in would be no longer available to them. On reflection Mother felt that might explain what she felt to be a judgemental atmosphere. Mother described being told information and trying to absorb that to share with her husband and felt that her reactions were then judged as not demonstrating emotion. Overall mother described a significant lack of compassion. 4.7 Mother described the local Police/Children’s Social Care involvement as very positive, compassionate and non-judgemental. She described the child death review nurse as a “lifesaver” who had helped them navigate their way through the processes/systems and provided significant emotional support. 4.8 In discussion around the decision to electively home educate the children, mother was positive about all the schools attended by the children and how they had positively “accommodated” their Jehovah’s Witness faith. Mother described sibling as having difficulties for some years with concentration and they hoped it would improve over time. However there had not been improvement by the end of Year 7 and decided that home education might be beneficial and better suited. This was a positive experience for sibling who was then was able to join a programme at a local college enabling sibling to spend 2/3 days a week in college. This structure has been very beneficial for sibling. 4.9 Mother stated that they had then discussed removing Child A from school to home educate and had initially planned to do this at end of primary school and 8 had discussed this with the Head. They thought that there was no real advantage to waiting and so removed Child A at the end of Year 5. Mother stated Child A was not socially isolated but had only one real friend at school but a number of children from the Jehovah’s Witness faith were home educated locally and there was a great deal of contact with those children. Child A was functioning a year ahead academically. Mother described the support from the Local Authority as also being a positive experience with supportive contact and advice and had no comments about areas of improvement. 4.10 Mother wanted to make the point that although at the inquest, the cause of Child A’s death was suicide, the Coroner had explained in court this was a relatively new requirement to come to a conclusion on the “balance of probabilities”. If this inquest had taken place previously, it would have had a likely outcome of an “open verdict”. Mother’s view was confirmed by the assessment undertaken by Children’s Social Care that suicide intention was not clear. 5. Findings School responses /arrangements for children from the Jehovah’s Witness faith 5.1 Agency reports were requested from all three schools attended by the children and they provided reports and analysis facilitated by an independent consultant, which were thorough, helpful and reflective. Specific questions were developed by the CRG and the Reviewer and addressed key questions of how were the schools aware of, and sensitive to, the needs of children of Jehovah’s Witness faith in their work, and knowledgeable about the child’s faith and the implications of this in terms of inclusion and access. 5.2 The summaries in the report broadly identified that practice had been robust but in terms of improvement, it would be helpful to create systems for better communication with specific faith groups and improve staff understanding of specific beliefs and practices. Their proposals included all schools to promote open discussion with parents and child at the point of admission and introduce individual planning for children from specific faiths and to develop and promote child -focussed feedback on their lived experience as a child of a specific faith at the school. It was identified that when a child leaves a school to become electively home educated and the school do not have the opportunity to gather the child’s views and wishes directly, this should be seen as a potential additional vulnerability alongside any additional vulnerabilities such as isolated lifestyle, family systems or faith with the EHE service. 9 5.3 All the schools were clear they had significant concerns around the current systems in place regarding home education. One school concluded “It allows children to become invisible and removes avenues of support for their parents. With the current increase in EHE across the country, alongside the increase in mental health concerns we need some robust adaptations made to legislation and support available if a decision is made to educate at home. We would welcome the opportunity to support these actions”. Elective Home Education (EHE) in the local area 5.4 Following receipt of the agency reports, the Reviewer met with representatives of the Local Authority Elective Home Education Team and the Safeguarding in Education team to consider the findings. This was an opportunity to reflect on the school’s reports, current arrangements and consider opportunities for improvement. A number of actions were identified to help raise the profile of elective home education within schools, to update the existing Elective Home Education policy to be clearer and more explicit about roles and responsibilities and expectations, to ensure multi-agency pathways were clear, to develop guidance and to consider better ways to hear the child’s voice. 5.5 Action was subsequently taken to raise the profile and understanding of EHE with all Designated Safeguarding Leads (DSL) in schools including the independent sector which included devising enhanced training, which is now embedded in DSL training and the link to the online ‘off-rolling’ form is included in this training. The EHE Team have also sent an update through the twice-weekly Covid schools message board. In addition, the EHE team created and shared a template exit letter for schools to use with parents, which very clearly signposts to EHE services, and responsibilities. 5.6 The Reviewer provided comments on the EHE Policy, which have been incorporated into a revised Policy published in March 2021. This included a clearer definition of responses from the EHE team when children are classified as vulnerable/non vulnerable. Work is ongoing on how to include the potential social isolation of children into the “vulnerable” criteria. 5.7 Two working groups were established, one focussing on developing pathways of communication between the EHE team and Health (GP/paediatrics/dentistry/School Health) and social care. Training and resources for all frontline practitioners across these services is being developed to ensure the right information about potentially hidden children is identified and shared. 5.8 The second working group is focussed on working with headteachers from primary, secondary, special and independents schools to co-devise a guidance document for schools on EHE processes which ensure best practice in 10 safeguarding EHE children. The EHE team is keen to work in partnership with school leaders to create a workable document which ensures consistent practice and gives clear pathways of communication and clear definition of processes for informing and updating the EHE team about children who off roll from school to EHE, and communication with parents. The Reviewer has raised this work with the National Panel and suggested it might be helpful to have Department for Education (DfE) representation on this working group. DfE has subsequently confirmed their agreement to joining the working group. 5.9 In order to address concerns around how to better hear the child’s voice in the process of children becoming home educated, the initial parent pack sent out to parents has been redesigned, with a young person voice section at the top. Routine reports have also been recalibrated to put a young person voice section at the top to support the changes in culture/relationships/parental trust by making explicit the belief that the voice of the child should be heard. In addition, the educational psychology service has allocated time to support with the development of an EHE young person voice. Additionally, work to develop an exit interview for/by schools with children, is ongoing. 5.10 The Local Authority has made good progress from a sound base on developing its local response to elective home education. The national focus on elective home education and the current perceived legislative restrictions to enable these children to be known about and seen continues and has been recently a specific focus of work for the National Child Safeguarding Review Panel. Work was commissioned to consider safeguarding referrals of children electively home educated and the outcome has been shared with the Secretary of State and Children’s Commissioner. The Education select committee have also undertaken an inquiry in 2021 to which the national panel provided evidence. There are therefore recommendations in this review both locally and nationally. Jehovah’s Witness Faith 5.11 There was no evidence that there were safeguarding issues in relation to Child A, the subject to this review, related to their faith. However, the review provided an opportunity to consider the effectiveness of the safeguarding arrangements in the Jehovah’s Witness faith and if there was a need for local or national improvement. 5.12 The CRG commissioned an “expert” report on the Jehovah’s Witness faith and with the Reviewer developed specific questions for which responses were received. The Reviewer also undertook an analysis of the current worldwide Safeguarding Policy used within the Jehovah’s Witness faith (Dec 20). 11 5.13 Neither of these documents provided the Reviewer or the CRG with assurance around the process of response to referrals, the checks/training of leaders/staff and the management of safeguarding referrals and allegations. The reviewer therefore undertook to research the national work currently being undertaken in relation to the Jehovah’s Witness faith by the Charity Commission and the national Independent Inquiry into Child Sexual Abuse (IICSA). 5.14 The Reviewer wrote to and had helpful discussions with the lead investigator from the Charity Commission. The Charity Commission investigation has been ongoing since 2014 and they provided evidence to the IICSA in 2020 of their concerns primarily around safeguarding policies and procedures. They have commissioned a number of independent safeguarding reviews of arrangements within the Jehovah’s Witness faith. The delay in their investigation has been mainly due to a number of lengthy Judicial Review legal challenges from the Jehovah’s Witness faith, two of which are still ongoing. It appears unlikely that this investigation will be resolved in the near future. 5.15 The current national Independent Inquiry into Child Sexual Abuse (IICSA) was established in 2015. It undertook a thematic inquiry in 2020 into the “current child protection policies, practices and procedures in religious institutions that have a significant presence in England and Wales including non-conformist Christian denominations, the Jehovah’s Witnesses, Baptists, Methodists, Islam, Judaism, Sikhism, Hinduism and Buddhism“. The public hearing into this investigation concluded in August 2020 and an investigation report was published on 2/9/21. 5.16 The IICSA Inquiry involved up to 2 days of specific focus on the Jehovah’s Witness Faith in 2020. There were around 48 documents submitted, which mainly included statements on behalf of the Jehovah’s Witness faith setting out their policies and other statements in response including from the Police and victims in individual cases. 5.17 Statements were provided to the Inquiry of a number of individual cases where there was evidence of deliberate decisions by a number of Elders to not refer a case of child sexual abuse and of delay by Elders in referring cases of the suspected abuse of children. Statements describe the Jehovah’s Witness safeguarding policy/procedure as “confused” as Elders are not “required” to report abuse to statutory authorities and can compromise Police positions by talking to parents. This review is concerned that the Jehovah’s Witness safeguarding policy does not provide assurance or sufficiently clear guidance to members of the Jehovah’s Witness faith and this is impacting on children not receiving sufficient safeguarding and protection from abuse/neglect. 5.18 The IICSA Inquiry was published on 2/9/2021. It is very detailed in outlining current arrangements and their concerns about the Jehovah’s Witness faith’s 12 safeguarding arrangements. It reflects the issues already highlighted in relation to safe recruitment, safeguarding training and responding to allegations of abuse. The Report makes two recommendations, the first in relation to child protection policy, procedures and training: “All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and survivors. The policy and procedures should be updated regularly, with professional child protection advice, and all organisations should have regular compulsory training for those in leadership positions and those who work with children and young people.” The Report concludes that broader issues will be addressed in the IICSA Inquiry final report in 2022. 5.19 The Reviewer also contacted the National Child Safeguarding Practice Review Panel to request further information on whether they are aware of other SCRs/LCSPRs or Rapid Review processes involving children from the Jehovah’s witness faith. The response was that this had not been identified as an issue so far in the work of the Panel. Information sharing - Tertiary Hospital 5.20 Through the process of this review, concerns became apparent at the inconsistent and at times inaccurate information shared by the tertiary hospital into the different statutory processes, which follow the sudden unexpected death of a child. The CRG decided at its meeting in March 21 to request an Individual Management Review (IMR) from the tertiary hospital. The IMR was received in early May and there was a consensus that the IMR report did not fully address the questions posed. There was limited analysis of the issues and no learning identified for the tertiary hospital. As a result, CRG did not feel assured on the effectiveness of the tertiary hospital processes to share information with other agencies and the impact this may have on decision making. They wrote again to the local Safeguarding Children Partnership in May 21 to request further analysis of the key points identified by the Safeguarding Children Partnership and the resulting learning for the tertiary hospital. 5.21 CRG were primarily concerned that there didn’t appear to be a collective shared and agreed view from all the health practitioners involved in the care of Child A about their concerns of potential abuse/neglect. There was evidence of contradictory statements specifically about the child’s weight. The medical opinion on whether Child A was malnourished or just of slight build was unclear and, as the child was not weighed at any point or subject to a post mortem examination, there was no evidence. 13 5.22 The response from the tertiary hospital in July 2021 appears to have recognised that there was learning to be gained from this incident and they have identified six areas of specific learning. One specific local learning relates to the need to ensure that when referrals from the lead clinician following a child death are made into the Coronial process that there is an explicit requirement for the clinician to state if there any safeguarding concerns. This is to enable the Coroner to make an informed decision on the need to undertake a post mortem or any other specific actions. The Safeguarding Children Partnership have recognised that it would be helpful for this to be a national learning and recommendation from this Review. The Safeguarding Children Partnership have also strongly suggested that the local Clinical Commissioning Group Designated Nurse and Designated Doctor monitor progress against these areas of learning. 6. ANALYSIS and RECOMMENDATIONS The death of Child A is desperately sad and tragic for the family and this review, and local multi-agency investigations, have not identified any concerns around abuse or neglect. However, the death led to a decision to undertake this review which has enabled wider consideration of issues relating to children electively home educated, children from the Jehovah’s Witness faith, CAMHS triage arrangements and information sharing in tertiary hospitals and has developed proposals for local and national learning. 1. The Safeguarding Children Partnership consider how they can engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the Partnership on the effectiveness of those arrangements. 2. The Local Authority Elective Home Education team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included. 3. The Safeguarding Children Partnership engage with DfE in the development of local guidance for schools on children electively home educated. 4. The Safeguarding Children Partnership to request the National Safeguarding Practice Review Panel considers the recommendations from the IICSA report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level. 14 5. The Clinical Commissioning Group Designated Nurse and Designated Doctor support the tertiary hospital to consider the learning and review their arrangements to share information with other agencies. 6. The Safeguarding Children Partnership seeks assurance from CAMHS regarding the robustness of the triage of CAMHs referrals. 7. The Clinical Commissioning Group consider the current commissioning of bereavement services to parents following the death of a child to enable a consistent and appropriate response to the need. 8. The Safeguarding Children Partnership should alert the National Child Safeguarding Practice Review Panel and contact all Child Death Review Leads to raise awareness of the need to ensure that all Child Death Review processes require referrals into the Coronial process to be explicit about any potential safeguarding concerns. Alex Walters June 2022 |
NC044932 | Death of a 3-year-old Somalian boy, Child H, and serious injury to his 2-month-old brother, in March 2013. Father has been charged with Child H's murder and his surviving siblings have been taken into care. Family had previously been separated by civil war in Somalia and spoke minimal English. Significant history of domestic abuse including an incident leading to mother spending three months in a women's refuge. Issues identified include: insufficient attention paid to past incidents of domestic abuse; professional focus on the emotional impact on children of living with domestic abuse, not on the increased risk of physical harm; lack of reassessment of the family's situation despite indicators of increased risk of harm including overcrowding and new and stressful family relationships; and inadequate range, availability and quality of interpreters. Uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Lambeth Safeguarding Children Board.
| Title: Serious case review: Child H. LSCB: Lambeth Safeguarding Children Board Author: Sally Trench and Ghislaine Miller Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lambeth SCR Child H Confidential Final Report 1 Lambeth Safeguarding Children Board Serious Case Review Child H Authors: Sally Trench and Ghislaine Miller SCIE Lead ReviewersLambeth SCR Child H Confidential Final Report 2 Index Title Page 1. Introduction 4 1.1 Why this case was chosen to be reviewed 4 1.2 Succinct summary of case 4 1.3 Family composition 5 1.4 Time frame 5 1.5 Methodology 5 1.6 Reviewing expertise and independence 6 1.7 Specialist advice 7 1.8 Methodological comment and limitations 8 1.9 Structure of report 8 2. Findings: What light has this case review shed on the reliability of our systems to keep children safe? 9 2.1 Introduction 9 2.2 What is it about this case which makes it act as a window on practice more widely? 9 2.3 Appraisal of practice in this case: a synopsis 11 2.4 Summary of findings 14 Findings in detail 16 2.5 Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed. 16 2.6 Finding 2. Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies? Where they are not, inaccurate judgements are more likely to go unchallenged. 20 2.7 Finding 3. The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. 24 2.8 Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to 27 Lambeth SCR Child H Confidential Final Report 3 be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. 2.9 Finding 5. A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. 31 2.10 Finding 6. The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the Family Support and Child Protection Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing, even in situations where an urgent response is required. 35 3. Conclusion 39 References 41 Appendix 1: The SCR Process in detail 43 Appendix 2: Glossary 52 Appendix 3: Statistics on domestic violence 54 Appendix 4: Lessons already learnt and changes implemented to improve practice 56 Lambeth SCR Child H Confidential Final Report 4 1. Introduction 1.1 Why this case was chosen to be reviewed Lambeth Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the following criteria: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died; ... and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (Working Together to Safeguard Children, 2013:68) 1.2 Succinct summary of case The case concerns a Somali family living in Lambeth. They had previously lived in Somalia, where they had two older daughters, and later a son, Child H, who was born in 2009. The parents were separated for many years due to the civil war in their country. They were reunited in London in early 2011 when Mother joined Father in a shared house with members of his extended family. All three children remained in Africa at this time; the parents did not know where the two elder children were, and Child H stayed with relatives in Ethiopia. Professionals became involved because of the pattern of domestic violence and abuse that quickly emerged in the relationship between Mother and Father. This included supporting Mother, in late 2011 when she was heavily pregnant with Sibling 1, to leave the family home after a serious assault, and to live for three months in a women’s refuge in another London borough. After the baby was born, professionals remained involved because the parents reconciled and Mother returned to Lambeth, where both later denied the history of domestic violence. The baby was made subject of a Child Protection (CP) Plan based on an assessment of the risk of further violence, and professionals endeavoured to work with the parents on the implementation of that plan. During this year, Mother quickly became pregnant again. Just before her next child (Sibling 2) was due to be born, Father brought back their three year old Child H from Ethiopia. In January 2013, therefore, the family had grown to three children, aged three years and under. All the children were now subject of Child Protection Plans. In early March 2013, at the age of two months, the youngest child suffered a serious injury, and was admitted to hospital in a neighbouring borough. A week later, his 3-year old sibling died of injuries received whilst in the care of Father. Lambeth SCR Child H Confidential Final Report 5 1.3 Family Composition Family member Age in March 2013 Father 42 Mother 40 Child H Aged 3 ½ at death Sibling 1 14 months Sibling 2 2 months The parents’ two older children did not join the family in Lambeth, and their whereabouts are unknown. 1.4 Timeframe The SCR analyses professional practice between February 2011 (Mother’s arrival in the UK) and 11th March 2013 (date of Child H’s death). 1.5 Methodology Statutory guidance requires SCRs to be conducted in a way that: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. (WT 2013: 67) The following principles should underpin all reviews: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and Lambeth SCR Child H Confidential Final Report 6 sensitively. This is important for ensuring that the child is at the centre of the process. (WT 2013: 66-67) In addition, SCR reports should “…be written in plain English and in a way that can be easily understood by professionals and the public alike” (WT 2013: 70) To help ensure that this report is accessible to all readers, a guide to acronyms and terminology is provided as Appendix 2 of this report. Lambeth LSCB has chosen to use the Learning Together systems model, developed within the Social Care Institute for Excellence (Fish et al., 2008) to comply fully with the requirements of Working Together 2013. The Learning Together review process is based on the following key principles: 1. Avoid hindsight bias. In order to understand why people acted as they did, it is important to avoid hindsight bias – judging their actions from the standpoint of knowing what happened later, when it is easy to see which bits of information were significant and which were irrelevant. Therefore this systems model seeks to understand the experience and the reasoning of the workers and managers who were working with the family at the time, in particular, to explore what sense they were making of the case, and the contributory factors in the work context that were influencing their practice at the time; 2. Provide adequate explanations. The model requires reviewers to appraise and explain decisions, actions and inactions in professionals’ handling of the case, and to view performance as the result of interactions between the context and what the individual brings to it. 3. Move from individual instance to the general significance. The case provides a ‘window on the system’, finding out whether weaknesses visible in the management of an individual case are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi-agency CP system. 4. Produce findings and questions for the Board to consider. Some findings lead to the simple recommendation of a new rule or specific action; others may require the Board to consider how to balance identified needs with other demands on agencies’ resources. 5. Analytical rigour. Qualitative research techniques are used to underpin rigour and reliability, alongside a very open process so that others can see how conclusions were reached. Full details of this review process are contained in Appendix 1 of this report. 1.6 Reviewing expertise and independence Lead Reviewers The SCR has been led by two independent, experienced and accredited SCIE Lead Reviewers, Sally Trench and Ghislaine Miller. They both have extensive Lambeth SCR Child H Confidential Final Report 7 experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework, and have received training and accreditation in the SCIE Learning Together model. Neither has any previous involvement with this case, or any previous or current relationship with Lambeth Council or partner agencies. The Lead Reviewers have received supervision from SCIE as is standard. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. Review Team This comprised 9 senior managers from the multi-agency services involved with the family. Their role was to provide a source of high-level strategic information about their own agencies, as well as professional expertise in their fields. Together with the Lead Reviewers, they collected data about this case, including a review of agencies’ records, and produced and agreed the content of this report. Full involvement of practitioners The second important group taking part in the case review was 25 front-line professionals and first-line managers who had worked with the family in different capacities. They provided a detailed picture of what happened in this individual case, and also their knowledge of the systems as a whole, to help us understand whether practice in this case had been typical or otherwise. To elicit their involvement and experiences of this case, members of the Review Team held individual conversations with the Case Group professionals. The Case Group also attended two multi-agency meetings to contribute to the analysis and findings from the Review Team and Lead Reviewers. 1.7 Specialist advice The Lambeth LSCB Manager arranged for specialist input about Somali history and culture to support the interpretation of professional practice in this case. A half-day’s training was provided for the Review Team (and a shorter session for the Case Group) by the Somali Development Group, a voluntary organisation based in Bristol. This training provided an extremely useful insight into a range of historical, religious, and cultural aspects of Somali life and experiences, including The effects of the 20 years-plus civil war and displacement of family members The role of men/fathers in family and community life Conversely, the often subservient role of women and children The common use of khat as a drug and its effects The Review Team are conscious that the somewhat traditional picture that was being provided would not apply to all Somalis living in London, nor to all Somalis in their own country. In relation to our case, it helped in bringing cultural sensitivity to how professional practice was appraised. For example, it gave an insight into the intervention by the ‘Somali community’ regarding Mother’s reporting of domestic violence. In particular, it suggested that Mother’s situation must have been extreme and desperate for her to flee the Lambeth SCR Child H Confidential Final Report 8 marital home (November 2011), thus seriously flouting family and community norms. The representative from the Somali Development Group was also helpful in matters such as advising against the use of male interpreters with women in Mother’s circumstances (something which had happened uniformly in this case, due to the lack of available female interpreters). 1.8 Methodological comment and limitations 1.8.1 Participation of professionals Child H’s death was a shock to staff who had been working with the family, and has caused them much distress and grief. Thus, engaging constructively in the SCR process in this context has inevitably been challenging and often painful for the staff involved. Nonetheless, they have participated very responsively in individual conversations and group discussions, where they have recalled their decision-making and actions in the case. The Lead Reviewers and the Review Team have been impressed throughout by the professionalism, knowledge and experience the Case Group have contributed to the review and their capacity to reflect on their own work so openly and thoughtfully in this SCR. Several Case Group members have remarked that it has been a positive experience to contribute to learning from the tragedy. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report. 1.8.2 Missing perspectives of the parents and children Police have advised that the status of the parents as alleged perpetrator and witness in criminal proceedings ruled out the possibility of their participation in the SCR. This means that a critical perspective is missing from this case review. The SCR has not been able to benefit from the parents’ input regarding what worked well in their engagement with professionals, what issues made it harder for them to engage with efforts to support them in their care and protection of their children, or how they managed their interactions with the workers. After the criminal proceedings are concluded, the parents will be asked whether they are willing to meet with the Lead Reviewers to give their views about these issues. Should this be possible, an addendum to this report will be provided, to reflect any further learning. Child H’s two remaining siblings are too young to make it feasible to gain their perspectives or experiences. 1.9 Structure of report The next chapter (Chapter 2) of this report begins with a summary of what happened in the case. It identifies four distinct phases in professional contact with the family and presents judgements on the way the work was done in each phase. This leads on to a presentation of the six priority findings. Each finding concludes with some key questions that the finding raises for the LSCB and Lambeth SCR Child H Confidential Final Report 9 member agencies. It is the responsibility of the LSCB to decide how best to respond to the findings, with the aim or reducing the recurrence of poor practice. The questions are intended to support their considerations. 2. Findings: What light has this case review shed on the reliability of our systems to keep children safe? 2.1 Introduction Statutory guidance requires that SCR reports ‘…provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence (WT 2013: 71). These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong.’ (2013: 65) This section firstly explores the ways in which features of this particular case are common to other work that professionals conduct with children and families, and therefore how this one case can provide useful organisational learning to underpin improvement. Next, a synopsis of the appraisal of practice is provided for the reader. This sets out the view of the Review Team about how timely and effective the interventions with Child H and his family were, including where practice fell below expected standards. Where possible, it provides explanations for this practice, or indicates where these will be discussed more fully in the findings. Finally, this section discusses six priority findings that have emerged from the SCR. The findings explain why professional practice was not more effective in protecting Child H in this case. It also outlines the evidence that indicates that these are not one-off issues, but underlying patterns – which have the potential to influence future practice in similar cases. We also consider what risks they may pose to the wider safeguarding of children. 2.2 What is it about this case which makes it act as a window on practice more widely? 2.2.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews (SCRs) states: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together, 2013:66) Lambeth SCR Child H Confidential Final Report 10 2.2.2 Lambeth Safeguarding Children Board (LSCB) identified that the SCR of this tragic case held the potential to shed light on particular areas of practice: How well are we currently working with Somali families in Lambeth, including those who have been affected by civil war and forced migration, as well as those where there is domestic violence (DV)? How well does the system of Child Protection Plans, Conferences and Core Groups operate to keep children safe, especially when parents are resistant to this involvement? How well do partner agencies work together, including the core CP services, in responding to suspicious injuries to small children and babies? 2.2.3 This case epitomises the difficulties that professionals face in their efforts to safeguard and protect children in situations where there is domestic violence and abuse between parents. This is relatively straightforward if the violence is admitted and the abused partner wants to separate from the violent partner with a clean break. However, it is in the nature of domestic violence that the victim often returns to their violent partner – through fear, ambivalence, and/or conflicting loyalties toward their children and the partner. Pragmatic, social and cultural issues also influence the victim’s decisions – in particular, when they are dependent on their partner for the right to remain in the UK. Despite the threat of continuing future violence, there may be other benefits to returning to the relationship: avoidance of the stigma from family and the community; an attempt to integrate in the community; the need for social companionship; and financial and practical support. Understanding these competing priorities and conflicting loyalties adequately to assess the risk of potential harm to the children involved is a complex and challenging task for professionals. It is one made more difficult by the uncertainty about risk and danger that characterises this field of work. The available research evidence base provides indicators, but is not able to underpin absolute predictions of which partners will go on to harm their children. Domestic violence does not happen in isolation; families are often facing other, very real challenges and disadvantages. In this case, these were associated with endeavouring to hold a family together in a context of forced migration and separation due to civil war. All these different issues compete for workers’ attention, as they bring their professional competence to bear on making sense of a situation and the implications for the safety and wellbeing of the children involved. The case therefore raises vital questions about how effectively our child protection system is working to provide a timely and effective response to children living in situations of domestic violence, in a context of migration where family members, both adults and children, have been separated by civil war and later reunited. The scenario is even more challenging for professionals to handle if, as in this case, there were no known recurrences of domestic violence incidents. Lambeth SCR Child H Confidential Final Report 11 Specifically, this case held a number of complex challenges which safeguarding agencies working in Lambeth and other neighbour boroughs encounter regularly, in the following common areas of practice: Working with domestic violence, with parents who either minimise or deny violence, and who resist efforts to assess risk from a violent male. Working to address historical domestic violence, and the risk of future occurrences, during a period in which there are no known incidents. Considering the impact of domestic violence on children – what is the nature of the risks? Working with families from a community (in this case, Somali) characterised by a culture of family privacy and male authority. The complexity of the work is frequently compounded by the adults’ and children’s minimal spoken English. Responding to an urgent child protection incident in the midst of multiple competing demands, and the importance of ensuring timely and effective communication across agencies. The dynamics at play between professionals (both in and outside formal meetings), the issues of professional practice and accountability, and the pivotal roles of supervision and management oversight. 2.3 Appraisal of practice in this case: a synopsis The response of professionals to the family falls into four distinct phases over a total period of almost two years: 1. Professional responses to the violent assaults on Mother by Father, including during her pregnancy with Sibling 1 (spring 2011 to early 2012) 2. Professional responses after the birth of Sibling 1 when Mother returned to Father (winter 2012) 3. The longer term work with the family that followed (spring 2012 to winter 2013) 4. The injury to Sibling 2, the death of Child H and the response of professionals (early spring 2013) The quality of practice varied during these phases: the responses to incidents in phase 1 and the initial response after the birth of Sibling 1 were appropriate and of high quality. However, professionals appeared to struggle to a greater extent with the longer term work with the family – in particular how to address domestic violence issues during a period when there were no known violent incidents, and when both parents denied the past domestic violence which had been fully recorded and was known to have happened. Finally, responses following the injury to Sibling 2 showed poor information transfer between teams and agencies, and the subsequent Section 47 investigation following the injury to Sibling 2 was not conducted in line with statutory guidance. Lambeth SCR Child H Confidential Final Report 12 The different phases of involvement are discussed in more detail below and the explanations provided in the findings are signposted. Phase 1 – professional responses to violent assaults on mother In spring 2011, before Mother’s pregnancy with Sibling 1 was known, she reported a violent assault by Father. Police dealt appropriately with the attack on Mother at home, after which she withdrew her allegations against Father. Later in the year, when Mother was in the third trimester of her pregnancy with Sibling 1, professionals responded promptly and efficiently to the crisis situation following a further violent attack on Mother, including threats to kill Mother and unborn child, after which she fled the family home. She was subsequently supported to separate from her partner and keep her unborn child safe. A multi-agency risk assessment conference (MARAC) was part of this planning, reflecting the very high risk of harm to Mother. Later, when Mother decided to reunite with Father in Lambeth, the cross-borough work was done well to make this return as safe as possible by continuing the protection of Mother and (now) baby. Phase 2 – professional responses following the birth of Sibling 1 Sibling 1 was born in January 2012. Following this, practice was initially good. Professionals made concerted efforts to equip Mother with knowledge about the risks, to support her not to return to her husband's household, as well as handling the transfer of the case from a neighbouring London borough effectively. A Core Assessment of Mother and baby was then conducted back in Lambeth, making the appropriate recommendation to hold an Initial CP Conference, with a parallel plan for a legal planning meeting (a meeting led by the Children and Young People’s Service (CYPS), with legal advisers, to consider whether there should be family court proceedings to protect a child). The fact that the legal planning meeting did not take place was a missed opportunity to explore levels of risk, and possible options for intervention. Phase 3 - Longer term work with the family After the birth of Sibling 1 in January 2012, a period of long term work with the family began. At this point, both parents denied that the previous domestic violence incidents had occurred. During this time, the Review Team judged the response of professionals to have been less rigorous and authoritative than would have been expected. This was in large part due to professional focus being on the present rather than exploring past incidents to minimize the chance of their future recurrence. Therefore, no known current incidents of DV left professionals falsely reassured about the levels of risk to the children, and with the view they had nothing to work on. This is explained further in Finding 4. The relevance and influence on the family of their specifically Somali experiences (e.g., of their civil war and the long separation of family members, plus the role of the local Somali community in relation to the family and the dominance of male partners) which had initially been explored, was not pursued further – despite the fact that it was reported that ‘community elders’ had taken a role in mediating between the parents regarding the domestic violence. Lambeth SCR Child H Confidential Final Report 13 The 9-month period after the Initial CP Conference for Sibling 1 saw major changes in the family household including Mother’s pregnancy and later the birth of Sibling 2, and the arrival of 3 year old Child H from Ethiopia (where he had been staying with friends or relatives) with what appeared to be bruises to his face and marks on his body. The changes for the family included significant overcrowding and new and stressful family relationships – not least the management of three small children aged 3 years and under. All of these were indicators of increased risk of harm to Mother and the children. However, professionals did not undertake the re-assessment of the situation that was indicated by the family’s changed circumstances. Father, in particular, remained an unknown quantity and did not participate in any exploration of risk or of his personal history. The professional response was hindered by the fact that, while knowledgeable about many facets of domestic violence, those working with the family were not all sufficiently aware of the evidence base about the increased risk of physical harm to the children at this time. This is discussed further in Finding 1. At Core Groups and CP Conferences, there was a gradual sense of things going well for the family, and an optimistic feeling that progress was being made, when in reality the CP Plans were not being fully implemented. The lack of any further known violent incidents (Finding 4) was compounded by a lack of challenge and debate about the sense that the network was making of developments in the family, either through individual professional supervision or a healthy culture of multi-agency debate and challenge. This is explored further in Finding 2. When Child H arrived in the UK, his facial injuries were observed by various professionals, including a Health Visitor; a Social Worker, who advised that the parents should take him to be examined by the GP; and later a Midwife who contacted the family’s SW regarding her concerns. A Section 47 investigation was not carried out, as would have been expected for a child with unexplained injuries. The Conference Chair saw this as unsatisfactory and requested an urgent CP medical. Phase 4 – Injury to sibling 2 and professional response In March 2013, Sibling 2, who at that point was two months old, was admitted to hospital with a broken femur, an extremely serious and unusual injury in a child of that age. The subsequent child protection responses were poorly co-ordinated and, in some important respects, did not adhere to statutory guidance. The sharing of information regarding Sibling 2 was delayed at an early, critical stage. In A&E, the electronic ‘flag’ system for children on CP Plans was missing the relevant list of names from Lambeth, and then direct information about the family was not available from the Emergency Duty Team (EDT) for several hours. The reasons for this are discussed further in Finding 6. No appropriate interpreting arrangements were available which meant a significant delay in hearing the parents’ explanation for the baby’s injury. Interpreting arrangements are discussed further in Finding 3. This left A&E Lambeth SCR Child H Confidential Final Report 14 and ward staff with little information to guide their assessment of risk. Despite this, the initiative of the Named Nurse in producing a list of actions early the next morning was helpful and appropriate. Information from social care EDT about the ‘suspicious injury’ was not picked up quickly by the social work team on the following day (Finding 6 also examines how information is handled in out of hours services). The subsequent Section 47 investigation, led by the Family Support and Child Protection Team (FSCP), where the case was allocated, did not proceed in line with the guidance in Working Together and the London CP Procedures. The Police were not immediately contacted for a Strategy Discussion. Instead the Social Worker (SW) visited parents in the hospital and interviewed them, with the Paediatric Registrar. The Strategy Meeting was not successfully convened until two days later, allowing the passage of time to imply a lack of urgency, and for opportunities for evidence to be contaminated or missed. There was no consistent FSCP manager providing oversight and guidance for the investigation through the next few days. Once Sibling 2 was admitted to a hospital ward, there was a shared view that he was in a safe place. Social and health care professionals and the police (once they became involved, at the Strategy Meeting) failed to make a link with ongoing risk to the two siblings who were now in the sole care of Father. There was no home visit to check on their circumstances, apart from one made by the Health Visitor upon her return from leave later in the week, which found no one in. A risk assessment was required of Father’s ability to care for the children in Mother’s absence, but this did not happen. The delayed Strategy meeting focused on the likely cause of the injury to Sibling 2. However the conclusions as to whether the injury was non-accidental were unclear, for reasons explored further in Finding 5. The discrepant histories of the incident given by the parents received insufficient attention, and the necessary challenge and skepticism from the members of this Strategy Meeting were not apparent. Consequently, the risks to all the children were wrongly downgraded, despite other evidence to suggest that risk of harm to the children was high. Although there was significant additional evidence to suggest physical abuse and neglect, this was not acted upon in the absence of a certain medical opinion. The following day, Sibling 1 and Child H underwent CP medical examinations by a Community Paediatric Consultant. These were conducted, although the booked interpreter did not turn up (a problem already noted in this case), using Father as the spokesperson for his children. It was clear that the medicals needed to go ahead without further delay. However, given that Father was the possible ‘person of concern’ in the situation, arrangements should have been made for Child H (Sibling 1 being pre-verbal) to be spoken to alone with an interpreter at the soonest possible opportunity. Child H was brought into A&E exactly a week after his younger sibling’s admission to hospital. He was pronounced dead an hour later. Lambeth SCR Child H Confidential Final Report 15 2.4 Summary of findings The Review Team has prioritised 6 findings for the LSCB to consider. They relate to four of the six categories of underlying patterns (see Appendix 1). Finding Category Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed. Multi-agency working in longer term work Finding 2. Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies? Where they are not, inaccurate judgements are more likely to go unchallenged. Human reasoning: cognitive and emotional biases Finding 3. The current range, availability and quality of interpreters is problematic; for planned work, it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. Management systems Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. Multi-agency working in long term work Finding 5. A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. Multi-agency working in response to incidents and crises Finding 6. The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required. Multi-agency working in response to incidents and crises Lambeth SCR Child H Confidential Final Report 16 This is a finding for Children’s Social Care. The Review Team considered carefully whether the ineffective management of the Section 47 investigation represented a pattern of working in the individual FSCP Team, and possibly more widely. We were reassured that it was not in two ways: 1) the team in question has been reorganized and now has new managers in place, and 2) an audit has been carried out by the Quality Assurance service, looking at the conduct of Section 47 investigations across all CSC teams. This found that formal CP procedures are understood and followed well in teams, whilst acknowledging variations in the individual skills and experience of workers. Lambeth CSC have said there will be a closer look at those teams where there are a low number of Section 47 investigations, to check that practice remains alert and correct in carrying out this statutory duty. Findings in detail This section represents the main learning from this case review for the LSCB and partner agencies. Each finding is set out in a way that illustrates: How does the issue feature in this particular case? How do we know it is not peculiar to this case? What can the Case Group (those who worked with the family) and Review Team (the senior managers from each agency appointed to help with this case review) tell us about how this issue plays out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice? How prevalent is the pattern? What evidence have we gathered about how many cases are actually or potentially affected by the pattern? How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national? What are the implications for the reliability of the multi-agency child protection system? The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, and other documentation from agencies, and from relevant research evidence. Six priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. The remainder of this section discusses the six findings. 2.5 Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed. Lambeth SCR Child H Confidential Final Report 17 There is clear research evidence of the increased risk of physical harm to children from men who are violent to their female partners (e.g. Stark and Flitcraft, 1996; Bowker et al, 1998) as illustrated in the blue box below. Yet a feature of this case was how little this knowledge base informed professional practice. Concerns about physical harm focused on the mother, not the children. How did the issue feature in this particular case? The professionals involved with the family told us, and case records showed, that they did not consider there to be a risk of physical harm to the children as a result of living with a father with a recent history of violence toward his wife. This was true for all phases of the case. When Child H first arrived in the country with what appeared to be bruising to his face and marks on his body, there was no Strategy Meeting. The professionals who saw him shortly after his arrival did not question whether Father had caused the injuries, despite knowing that Child H had been in Father’s care for several weeks, and that Father had previously assaulted Child H’s mother. One professional, the Midwife, after seeing Child H on a home visit, contacted the family’s SW about her concerns. It was not until the CP Conference (almost two weeks after Child H was initially seen by the SW), that a CP Medical was requested, by the Conference Chair. At this Conference, Child H, and then new baby Sibling 2, were made subject to CP Plans, under the category of Emotional Abuse. The history of domestic violence did not prompt professionals to ask questions about the likelihood or otherwise that Father would physically harm the children. At a critical point in the case, after Sibling 2 was admitted to hospital, professionals in the hospital and in the FSCP Team told us they had not considered that the other two children might be unsafe left in the care of Father. Their decision-making, including all those at the Strategy Meeting held in the hospital, assumed a benign view of Father’s ability to provide adequate care of them. No assessment of Father’s ability to look after the children adequately was conducted, including the risks he might pose to them as an adult with a history of violence. At other key periods too, professionals focused entirely on the risks to Mother of violence from Father. This was so at the beginning of the case when Mother and baby (Sibling 1) left the women’s refuge and returned home to live with Father. Consequently, many professionals told us that they were utterly shocked and bewildered at Child H’s death, and found it hard to believe that it had happened. Lambeth SCR Child H Confidential Final Report 18 What is the evidence base about domestic violence and risks to children? UK: In 40-70% of cases where women are being abused, the children are being directly physically abused themselves (Stark and Flitcraft, 1996; Bowker et al, 1998). USA: In families experiencing parental domestic abuse there is an overlap of between 30 and 60% in rates of physical abuse for the children. (e.g., Barnett et al, 1997). In a national survey of over 6,000 American families, researchers found that 50 percent of men who frequently assaulted their wives also physically abused their children (Edleson, 1995). The routine co-occurrence between adult domestic violence and both physical harm and neglect of children is underlined in a study of the characteristics of parents and partners (Hartley, 2002/2009). Australia: Similar findings, noting significantly increased risk to children of physical abuse in homes where there is a violent male, emerge from several studies of varying sizes. Until recent years, this was poorly recognised, and the risk of violence from adults was regarded separately from the risks of physical harm to children (Tomison, 2000). How do we know it is not peculiar to this case? When exploring what lay behind this lack of recognition of the risks to the children in more detail, it became clear to the Review Team that staff across agencies were unaware of the body of available research evidence on the risks to children of domestically violent parents. In their individual conversations and discussions at the joint review meetings, members of the Case Group without exception said they made no connection between domestic violence between adults and an increased risk of physical violence to children. This contrasts with the risk of emotional abuse, which they recognised more confidently in relation to children living in a household where there is domestic violence1. This suggested to the Review Team that the issue was not an anomaly of professional handling of this particular case, but something that would potentially influence how professionals handled other cases where there is violence between the parents. What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 1 Children living in households where DV is happening are now identified as “at risk” under the Adoption and Children Act 2002. From 31 January 2005, Section 120 of this act extended the legal definition of harming children to include harm suffered by seeing or hearing ill treatment of others. This would include witnessing domestic abuse. Lambeth SCR Child H Confidential Final Report 19 The volume of victims and their families referred to and known to all agencies, with domestic violence as a feature of their lives, is rising year on year. Available statistics suggest this is as true nationally as it is in Lambeth2. In Lambeth alone, last year almost 400 children were estimated to be living in households affected by the most serious levels of domestic violence – which are subject to MARAC processes. The number of cases potentially affected by this finding is therefore very significant – see Appendix 3 for further details. It is clear that domestic violence is prevalent in terms of numbers, locally and widespread around the UK. What has been less easy to discover is exactly how widespread is the lack of professional awareness about the increased risk of physical harm to children who are living with a violent adult. The broader experience of Review Team members locally suggests that the tendency to focus on the emotional impact on children of living with domestic violence has developed with the increased priority given to the topic and associated training within Lambeth, across London and nationally. This has generally been encouraged and considered a positive development. The Review Team confirmed that the correlation of domestic violence with physical abuse of children is a standing feature of LSCB-delivered training in Lambeth on domestic violence. However, it has not previously been known that this aspect is becoming lost in practice. What are the implications for the reliability of the multi-agency Child Protection system? A safe system requires professionals who are knowledgeable about the research evidence base in their field, so that they can draw on this to inform their practice. Given the growing number of families known to be experiencing domestic violence from an adult male partner, it is increasingly important that professionals have an up-to-date understanding of the available evidence about this area of work. This case has demonstrated that some aspects of the evidence base are well known, especially the potential for emotional abuse of children. Yet the SCR process has also identified that other aspects of evidence are as yet unfamiliar: specifically, consistent research evidence about the increased risk of physical harm to children who are living with a violent adult is not informing practice. This means that physical risks to children may not be reflected in assessments and plans, increasing the chances of children being left at risk of harm. Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed. All agencies promote and expect evidence-informed practice from their workforces. The training programmes run by Lambeth LSCB aim to support 2 The revised Children in Need Census from April 2013 will collect this data nationally for children known to social care. Lambeth SCR Child H Confidential Final Report 20 this by equipping professionals with up-to-date knowledge about CP. This case review has found that currently, not all professionals in Lambeth and neighbour boroughs demonstrate a confident and clear understanding of the evidence base in relation to risks of physical harm to children in households where there is domestic violence between adults. This means that physical risks to children may not be reflected in assessments and plans, increasing the chances of children being left at risk of harm. Without a better understanding of these risks, we can expect the possibility that professionals across partner agencies will miss the physical risks to children, which will be higher when a child is in the sole care of the violent adult. Issues for the Board and member agencies to consider: Is the Board surprised by this finding? The correlation of domestic violence with physical abuse of children has been a feature of LSCB-delivered training in Lambeth on DV for a long time. Is the effectiveness of training routinely evaluated? Are there alternative mechanisms for improving workforce awareness of the evidence base in this area? To what extent is evidence-informed practice really supported across different agencies? Do member agencies know how it is promoted and prioritised in their work places? How readily accessible to staff and managers are summaries of the research evidence base in this area? Is the use of research evidence routinely reinforced and supported through the professional hierarchies and supervisions/management practices? How would the multi-agency partnership be able to evidence a better awareness of risks in this area? 2.6 Finding 2. Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies? Where they are not, inaccurate judgements are more likely to go unchallenged. It is widely recognised that in working with families to safeguard children, the sense that professionals make of information they receive and how they use it will inevitably and necessarily be vulnerable to common errors of human reasoning (Munro, 1999). As Munro (2008) notes: ‘Psychological research has shown that people are very bad at policing their own biases. Social workers need regular critical supervision to ensure that their biases are not distorting their assessments.’ Two key ‘checks and balances’ to help review judgements are professional supervision and a culture of mutual challenge in multi-agency working. The aim of supervision is to provide a fresh, and often more senior, perspective on cases, and to allow reflection and challenge of practitioners’ thinking and Lambeth SCR Child H Confidential Final Report 21 decisions where necessary. Similarly, the multi-agency network should function in such a way that thinking and decisions are challenged and tested. However, a number of features and episodes in this case raised important questions about how well these more routine mechanisms for providing critique and challenge worked in this case and are working more generally. How did the issue feature in this particular case? This case had a number of perplexing features for professionals, including the ongoing denial of past violence by Father against Mother – something which was known to have happened. Added to this was the general impression received by all professionals, even those who met the parents only briefly, that these were pleasant and attentive parents. As time went by, and there were no further known DV incidents, professionals felt reassured. The lack of both good quality supervision within agencies and multi-agency discussion and challenge meant that these responses persisted in an unhelpful way. This was true, even when the family’s circumstances changed considerably (with the arrival of Child H and a new baby shortly after), in a way that meant greater stress for the crowded family unit. The Child Protection Conference Chair appeared to fulfil a significant ‘supervisory’ role, by reminding parents and professionals alike of the level of violence that had been inflicted on Mother previously. She questioned why this evidence was not being given greater prominence, and rightly pointed out that the parents’ denial threw continuing doubt on their honesty and openness with professionals. Thus, she represented the principal voice of caution against and challenge to the positive view of the parents. She was supported in this within CP Conferences by the SW’s recommendation that the children continued to require CP Plans. In contrast to this, the quality of the SW’s individual supervision meant that the need for ongoing assessment of risk was not identified and acted upon. The Review Team would have expected professional supervision to explore the specific relationship workers form with parents and children, and how this affects what information they receive, how they interpret it and how they use it; this was particularly important for supervision of the main Social Worker. However, the supervision of this case in the FSCP team changed hands three times during 11 months, and the amount of time allocated to it was minimal. Conversations with the Team Manager and Deputy Team Manager demonstrated that this case was regarded as low risk and going reasonably well. The formal supervision on this case in the 3 month period leading up to the death of Child H amounted to 35 minutes in total. A similar picture held true for the Health Visitor’s safeguarding supervision, where a reassessment of risks was not considered. The Review Team would also have expected to see stronger challenge and debate among the professional network, to voice and explore differences in professional opinion. Core Group meetings, happening more regularly than Child Protection Conferences, would have been the appropriate forum for this. But as with supervision, in this case that was largely lacking. Lambeth SCR Child H Confidential Final Report 22 How do we know it is not peculiar to this case? As part of the case review process, the Review Team asked the Case Group about where challenge usually comes from. The answer received was: ‘Oh, the CP Conference Chair does that’. This suggests that the supervision arrangements and multi-agency discussions evident in this particular case are not atypical of usual practice. This is supported by a recent internal audit of supervision within CSC, which found that this was an area requiring further development and strengthening. Practice was found to be variable and inconsistent, with some workers receiving good and regular supervision, and others not. In a number of cases reviewed, there were missed opportunities for reassessment, which supervision should have picked up. What numbers of cases are affected, and how widespread are they – local, regional, national? Supervision does not feature in the work of all professional groups. However, for the core agencies in the field of child protection (social care, health and police), it is a critical part of their work, and so is relevant to a large number of cases. There is evidence to suggest that a lack of adequate supervision is a problem at a national level. As noted by Brandon et al. (2008) in a review of serious case reviews: ‘Scrutiny of the 47 reviews revealed a number of concerns about poor supervision to front-line workers, especially social workers. Staff in education, health and the voluntary sector were also found to need access to support, supervision and in particular to child protection advice. In some of these sectors supervision may be less of a priority than in children’s social care and therefore less likely to take place.” (2008:92) Within the agency context of high workloads, emotionally charged work, changing organisational structures and legislative imperatives, the critical aspects of the supervisor’s role are most vulnerable. It has been demonstrated in research that in such a ‘turbulent environment’3 both supervisors and supervisees may be prone to endorse each other’s approach rather than using supervision as an opportunity to challenge and question assumptions. Such endorsements can seem like a supportive way forward in what feels like an unmanageable situation. It has been noted elsewhere (Rushton and Nathan, 1996) that, given time and resource constraints, case management aspects of supervision often supersede the important activities of reflecting on, and challenging, judgements and decisions. There are a considerable number of multi-agency meetings, including Strategy Meetings in crisis CP work (investigations of incidents), and in the ongoing meetings (Conferences and Core Groups) for the monitoring and management of CP Plans. This is a national structure, and is supported by statutory guidance. The ability of these groups to fulfil the function of 3 Hughes and Pengelly (1997) Lambeth SCR Child H Confidential Final Report 23 respectful and rigorous challenge is relevant both locally and around the country. We were unable to find evidence about the quality of functioning of these groups locally or elsewhere. What are the implications for the reliability of the multi-agency child protection system? Our multi-agency safeguarding systems are intended to have checks and balances within them to guard against the known fallibility of individual judgements and decisions. In particular, individual supervision and multi-agency meetings are designed to work as mechanisms for ensuring that judgements are examined and challenged, to help ensure that individuals and groups do not get drawn into inaccurate or biased patterns of thinking. If these mechanisms are not working well, this leaves individual professionals and the multi-agency team around the child, vulnerable to falling into well-known ‘traps’ of human reasoning such as failing to reassess judgements in the light of new evidence, or being drawn into parental versions of events (Munro, 1999). This can, in turn, lead to poor decision-making at both an individual and group level. Finding 2. Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies? Where they are not, inaccurate judgements are more likely to go unchallenged. It is widely recognised that in working with families, the sense that professionals make of information they receive and how they use it will inevitably and necessarily be vulnerable to common errors of human reasoning (Munro, 1999). We also know that we are unable to police our own cognitive biases; hence, creating safe systems requires building in mechanisms that take this into account. Two key ‘checks and balances’ are professional supervision and multi-agency discussions about the case, each bringing fresh eyes and challenge to the process. This review suggests that these mechanisms are currently not working well enough in all cases, leaving professionals vulnerable to falling into well-known ‘traps’ of human reasoning, which in turn lead to poor decision-making. Issues for the Board and member agencies to consider: What is known within the LSCB about the provision of supervision in agencies? Do agencies have a structure for the regularity of supervision and a template for what it should cover? Are agencies clear about what aspects of supervision do get prioritised and what overlooked? How would an improvement in practice in this area be known about? Lambeth SCR Child H Confidential Final Report 24 What training is available for safeguarding supervisors, newly in role? How well do key multi-agency meetings support respectful challenge to colleagues and respectful uncertainty to parents? What are the chairing arrangements for key CP meetings? Are these fit for purpose? Are Chairs of Strategy Meetings, CP Conferences and Core Groups regularly acting as ‘devil’s advocate’, in order to challenge assumptions and views of individuals and the network of professionals working with the family? Do they encourage respectful but open debate? 2.7 Finding 3. The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. Gaining an accurate understanding of children’s experiences, wishes and feelings, and parents’ perspectives is a crucial task of child protection work. It is made particularly challenging when families do not speak English. Here, the availability of independent and timely interpretation services is key. This case has highlighted difficulties in achieving timely access to interpreters, both in the long-term management of meetings and contacts, and in acute circumstances. They resulted in various episodes of inappropriate and unsafe practice. In discussing these episodes, members of both the Review Team and Case Group were taken aback that they had occurred, and how they had impeded effective investigation of actual and potential physical injuries to the children involved. How did the issue feature in this particular case? The need to use interpreters was a key feature of this case. Both parents had Somali as their mother tongue. Father, who had lived in the UK for some years, was able to speak and understand some English, to a ‘workable’ level. Mother, however, knew practically no English when she arrived in London. As time went on, she appeared to acquire some English language skills, but these remained very limited. She required an interpreter for all interactions with professionals. Child H similarly spoke no English when he arrived in London; it was his first time in the UK. We give just two illustrations below, the first concerning communication with Child H as a potential child victim of physical assault, the second concerning communication with his parents as potential perpetrators of an assault on his brother, Sibling 2. The first illustration relates to Child H’s arrival when he was observed to have apparent bruising to his face. There was no Section 47 investigation, although he was considered at the Review CP Conference for Sibling 1, which Lambeth SCR Child H Confidential Final Report 25 took place two weeks later. There, the CP Conference Chair requested that Child H should have an immediate CP medical examination. An interpreter was booked for the medical examination but did not arrive, meaning that Father – the possible ‘person of concern’ – acted as the child’s interpreter and spokesperson. This effectively gave the child no independent voice, as would be expected in a CP medical. These circumstances were repeated at two later CP medicals for Child H and Sibling 1, when the booked interpreter again did not turn up. The second illustration relates to the professional response to the injury to Sibling 2 in the A&E department at a hospital in a neighbour borough. When Sibling 2 – a two-month old baby – was presented by the parents with a broken femur, medical staff needed to elicit the parents’ explanation of what had happened as quickly as possible. To do this, they used a female cousin of Father to translate for Mother, via telephone. As with Child H, this use of a family member minimised the likelihood that she would feel able to speak openly about what had happened. While there were arrangements available for the usual telephone interpreting service in A&E at the time, the paediatric staff described two issues that deterred staff from using it. Firstly, at that time the location of the two phones was on the busy reception desk, which afforded no confidentiality. Secondly, it was normal to experience delays in getting a service. How do we know it is not peculiar to this case? Input from Case Group members made it evident that the problems described above are common, rather than impinging only on this one case. We learned from Case Group and Review Team members that all agencies, perhaps with the exception of the police, struggle to obtain consistent interpreters who can offer a high standard of service for this very complex work. There are different contract arrangements across agencies for interpreting services. Rather than a generic problem of timely access to them, however, Case Group members described how it is far easier to ensure a consistent and reliable service for planned work than for emergency or urgent work. The reasons for this included a scarcity of trained interpreters and a lack of choice (e.g., of gender of the interpreter), particularly in minority languages. One example given by a member of the Case Group was that there is only one Vietnamese interpreter for the whole of her borough, and this person is therefore engaged and busy for several months in advance. Participants described the systems as operating in favour of booking interpreters for blocks of time – for example, for ongoing work with a family, CP Conferences and Core Groups. The result is that there are fewer interpreters free, and rarely at the exact time required, in matters such as urgent CP investigations – including A&E presentations, Section 47 interviews and child protection medicals, and out-of-hours activities generally. What numbers of cases are affected, and how widespread are they – local, regional, national? How many cases require interpreters and are therefore potentially affected by this issue? Lambeth, like many London boroughs and towns and cities elsewhere in the UK, is ethnically very diverse. It is consistently in the top 10% Lambeth SCR Child H Confidential Final Report 26 for numbers of international migrants annually (see 2011 Census Headlines). Those with English as their first language in the borough have fallen from 76.2% of the population in 1992, to 51.5% in 2012. The Review Team have not been able to access data about how many child protection investigations in Lambeth involve children and/or families who require interpreters, but have estimated that these are likely to be a considerable number. How widespread is the difficulty in accessing interpreters when needed? The Review Team have not found any hard data on this question but as described above, input from the Case Group indicated that the difficulties of access are widespread across Lambeth, including the lack of a choice in the gender of the available interpreter. These challenges are likely to be shared by other local authorities in London and around the country where there is a high degree of diversity, but the Review Team do not have any formal data on this. What are the implications for the reliability of the multi-agency Child Protection system? Communication with children and their family members is vital to safeguarding and child protection work. In a multi-cultural borough and city, it is inevitable that communication will need to be enabled and supported by high quality, independent interpreting services for a variety of different languages. Given the nature of the work, such services need to be accessible in a timely fashion for both planned and unscheduled, emergency work. However, this finding shows that such a situation does not always exist in Lambeth agencies, nor in the hospital where this family presented. The current range, availability and quality of interpreters is variable for planned work, but for urgent child protection referrals and other emergency presentations, such as children with injuries to A&E, the situation is worse, with services routinely struggling to have reliable access to good quality interpreters. This makes it less likely that critical risk assessments in these circumstances, and decisions based on these, will be of an adequate quality to support this complex work. It leaves room for poor understanding on both sides and, in some cases, for parents to mislead professionals about what has happened. Finding 3. The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. Good quality interpreters, available in a timely way, are an essential part of a safe system for working with vulnerable families from a variety of ethnic backgrounds, especially so in a borough as diverse as Lambeth. This review has found that an overall scarcity results in a general booking-up of good interpreters, and a lack of availability in emergency or urgent matters such as CP interviews, CP medicals, and Lambeth SCR Child H Confidential Final Report 27 presentations to A&E. This significantly undermines the reliability with which we can expect the multi-agency child protection system to function, representing a barrier to the ability of professionals to communicate effectively with children and parents alike and leaving children therefore potentially at greater risk of harm. Issues for the Board and member agencies to consider: Is the Board aware of these areas of difficulty in interpreting services? What does the Board think about the impact on CP work, especially urgent CP work? Is this an acceptable situation? What are the obstacles to improving this situation (including funding)? Is there any London-wide action which might be helpful – e.g., commissioning across boroughs? Is the Board aware of how needs assessments for interpreting services are carried out and whether they are adequate? Have Board agencies previously shared information about how their various contracts and interpreting services are working – and how they are monitored? What are the options for tackling the deficits found in this case review? How well does contract monitoring identify when things are going well, need improvement, or have made improvements? Is change needed to the information collected and analysed? Language Line is used by a number of agencies on a regular basis. Is there guidance about those circumstances when this would not be sufficient – e.g., when it is important to get other cues from a child or adult by a face-to-face interaction? 2.8 Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. Child protection work requires that professionals attempt to predict the future, gauging the current harm and risks to children. In cases of domestic violence, this involves working with parents to explore previous incidents in order better to understand the causes and triggers of violence and their significance for minimising ongoing risks and potential future incidents. This case has highlighted a tendency among multi-agency professionals to give greater weight to whether domestic violence is known to be currently occurring, than to what historical incidents of domestic violence reveal about risk now and in the future. This creates difficulties for maintaining professional Lambeth SCR Child H Confidential Final Report 28 confidence and skills to implement aspects of child protection plans that concern domestic violence, when the main issue of concern appears to be ‘absent’ or have ceased. The result may be a false perception of decreased risks when, without professionals achieving an understanding of the causes and triggers of the violence, actual levels of risk may still be high. Even where workers are aware that risk is still present, cases can become ‘stuck’, with professionals unclear about how to effect change. How did the issue feature in this particular case? Sibling 1 was placed on a CP Plan, which was later amended to include the two other children. This was designed to protect the children via two parallel approaches: family support to both parents, and actions to address the domestic violence in the family. There was a requirement for Mother to engage with and receive protective advice from the specialist DV service, GAIA. It was also stipulated that ‘There should be no further DV or argument that gets physical at all, and not around Sibling 1’. The contingency statement in the Core Group records suggested that, should the family not comply, legal action would be considered. The family engaged well with the family support elements of the plan, but not with the actions relating to domestic violence. For example, Mother refused to attend the GAIA service as required. During this time, there were no further known incidents of domestic violence. As the immediacy of the previous incident receded, and no further incidents came to light, most professionals were reassured and felt that there was a declining basis for taking robust action with the family, and maintaining a focus on domestic violence within the multi-agency group. As more time elapsed since the original domestic violence incident, increasingly those working with the family were of the view that there was no reason to keep the children on CP Plans – even though little was actually known about the parental relationship and father’s propensity to violence. This case had a feature which proved particularly difficult for professionals to manage: the parents’ contention that there had never been any violence between them. Professionals knew that this was untrue, given the history recorded by Police, hospital and the women’s refuge staff, but were unsuccessful in engaging either parent in a more open exploration of past history and future risk. In exploring what lay behind the insufficient and ineffective engagement with the history of domestic violence and ongoing risk for the family, the Review Team discussed the difficulty posed by the parents’ complete denial of past or present violence. Input from CSC highlighted how this denial, and refusal to discuss DV, was compounded by the fact that no further violent incidents came to light after the parents had reunited. This is a common circumstance in working with DV cases, where further real or potential incidents of violence remain a secret kept by both perpetrator and victim (and sometimes their children as well). All this suggests why it became more difficult, and perhaps seemed less relevant, to challenge the parental denial of the original violent incidents, or Lambeth SCR Child H Confidential Final Report 29 indeed the ongoing issue of risk. As more time passed from the incident of Mother fleeing DV, the impact of this event reduced. The reaction of professionals suggests that, rather than relating simply to a skills deficit, the underlying issue related more to how violence was being conceptualised (as incidents or process) and the implications for how risk was understood. How do we know it is not peculiar to this case? The Review Team and Case Group recognised a familiar pattern in how professionals had responded to this case in relation to assessing the risk of domestic violence. Any number of SCRs have demonstrated how difficult it is for professionals to challenge parents who appear compliant (‘deceptive compliance’). Where there is, added to this, an ongoing denial of current domestic violence, workers struggle to maintain an active and alert assessment of potential future incidents, their causes and triggers, and thus the ongoing risk to parent/victims and children. Participants in this review explained how such a focus on known current DV is encouraged by the courts who gauge levels of risk relative to actual rather than potential occurrences. Where there are no further reported incidents, the evidence for insisting on completion of required actions by the parents, or moving into the court arena, is perceived by CSC and partner agencies as becoming weaker with every passing Conference. Over time, professional partners tend to feel reassured when there is no further known domestic violence, and when children are seen to be doing well and parents appear to be caring. In the absence of known incidents of violence, the basis for enforcing the plan or any contingency actions appears to diminish – even though actual levels of risk are unknown and can remain high. Indeed, options for formal intervention (e.g., via court proceedings) become increasingly limited. The Review Team considered carefully how well professionals’ skills and experiences prepare them for working effectively in this complex area, and we acknowledged that there are different levels of skill among staff. But it seems that the common circumstances of denial in DV cases – combined with no further known incidents – continue to present a challenge very widely to workers and their managers, as to how to engage parents and assess risk appropriately. As noted above, there was an additional complicating factor in this case, which was the Mother’s recanting of her original experience of DV. There are some similar features in the work with chronic neglect cases, where purposeful intervention can be difficult to sustain – until a current ‘incident’ occurs, to which protective action by organisations can be attached. What numbers of cases are affected, and how widespread are they – local, regional, national? This finding relates to the professional tendency to assess levels of risk to children as being determined by whether domestic violence is known to be occurring currently in a family, rather than on understanding of whether and how it may happen in a potential future scenario. As discussed in Finding 1, domestic violence is prevalent and widespread in the UK (see figures in Lambeth SCR Child H Confidential Final Report 30 Appendix 3). In Lambeth, last year almost 400 children were estimated to be living in households affected by the most serious levels of domestic violence. This suggests a relatively large number of cases may be affected by this issue. We have not been able to ascertain how widespread the tendency is for professionals to focus on actual current domestic violence incidents, rather than the causes and triggers of past and potential future incidents. What are the implications for the reliability of the multi-agency child protection system? A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. However, this finding draws attention to the way in which professional responses to domestic violence in families are functioning less well to act pre-emptively on behalf of children. Whether domestic violence is known to be currently occurring in a family tends to determine the perceived levels of risk to children and the need for purposeful engagement with parents, leaving the causes and triggers of past and potential future incidents poorly understood. This case suggests a common bias in professional handling of domestic violence cases whereby the present is given more weight than the past. So domestic violence cases in which there is no known recurrence of incidents tends to lead to a perception of decreased risk and diminishing need for the implementation of domestic violence-related interventions. Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. However, this finding draws attention to the way in which professional responses to domestic violence in families are functioning less well to act pre-emptively on behalf of children. Whether domestic violence is known to be currently occurring in a family tends to determine the perceived levels of risk to children and the need for purposeful engagement with parents, leaving the causes and triggers of past and potential future incidents poorly understood. This case suggests a common bias in professional handling of domestic violence cases whereby the present is given more weight than the past, and parents’ denials are insufficiently challenged. So domestic violence cases in which there is no known recurrence of incidents tend to lead to a flawed perception of decreased risk and a scaling-down of concern and appropriate action. Lambeth SCR Child H Confidential Final Report 31 Issues for the Board and member agencies to consider: Does the Board recognise this as a familiar pattern? How can professionals be supported to maintain a focus on domestic violence when there is no known recurrence during professional involvement? What kind of information needs to be collected to let the Board know whether improvement has been made in this area? What is the ‘minimum’ kind of risk assessment of a perpetrator which is needed to support an effective CP Plan? And how should this be expressed in CP Plans in a consistent way? How can the multi-agency network be helped to move ‘stuck’ cases on in a way that reduces risk of harm to children? 2.9 Finding 5 – A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. The multi-agency safeguarding network needs to be able to work and communicate together effectively in response to acute child protection incidents. The process for managing and conducting Section 47 inquiries and criminal investigations involves social care, police and medical professionals (and possibly others, depending on the case). Together, they must plan and undertake the tasks required to investigate how and when the injuries might have occurred, who might have caused them, and to ensure the children’s immediate and longer term safety. This is a complex exercise, given that different professionals bring their own skills, experience and specialist knowledge to the table, with the lead child protection agencies (children’s social care and Police) in charge of directing the Section 47 process. How the investigation was conducted following the presentation of Sibling 2 to A&E has drawn attention to norms related to communication between health, social care professionals and police that provide the latent conditions for errors and mistakes to occur in this critical process. How did the issue feature in this particular case? Following Sibling 2’s presentation at A&E with a serious physical injury, a delayed Strategy Meeting was held. The purpose of the meeting was to share information and views about risk and to determine what further investigation needed to be carried out. Yet in the event, the focus was predominantly on the medical view of the physical injury to Sibling 2. Lambeth SCR Child H Confidential Final Report 32 Input from the Case Group highlighted that practitioners involved in the meeting were left with very different ideas of what had been said and meant by colleagues. Critically, those from health and those from children’s social care and police left the meeting with discrepant understandings of whether the causation of Sibling 2’s injury was accidental or non-accidental (NAI). The baby’s Consultant Orthopaedic Surgeon thought he had articulated that the cause of the injury remained uncertain. However, non-medical colleagues took the surgeon’s input to mean that ‘on balance the injury was accidental’. Yet at the time neither ‘side’ was aware of the discrepant understanding. The emphasis placed on the medical view of the injury in the meeting also distracted from other important areas of risk assessment that should have been discussed, including the inconsistent explanations by the parents, progress in corroborating their explanations, and ongoing risks to the other children. How do we know it is not peculiar to this case? It became an important part of the Review team’s Task to get underneath this issue. Discussions within the Review Team and Case Group confirmed the view that, within CYPS and the Police, the quest for certainty from medical colleagues about how a physical injury has occurred is very strong. This is understandable, as their possible options to protect a child at risk in such circumstances rely on the clarity and precision of evidence which can, for example, be produced in court. Participants felt this was more so in relation to physical injuries, than in relation to cases featuring suspected sexual abuse or unacceptable levels of care. Discussion among the Review Team also confirmed the clash between this need for categorical explanations from medical colleagues on the part of social care and police staff, with the norms of medical professionals themselves. Input from participants shed light on the way the medical view was articulated by the surgeon in this case, and how this is standard. The baby’s Consultant Orthopaedic Surgeon had explained that ‘the injury could be consistent with the parents’ story’. He, like Health members of the Review Team, would understand this statement as leaving the causation of the injury open. They would see it as a step in the process of ‘differential diagnosis’ – a principle of which is that ‘anything is possible until it is ruled out’. However, non-medical colleagues took the surgeon’s statement to mean that ‘on balance the injury was accidental’. A Review Team member from Health summed up the clash neatly: “In my experience, this is quite a common pitfall in strategy meetings and is a generalisable finding. It arises because doctors don’t fully understand that social workers and police are listening for a clear opinion on which to plan the rest of the investigation (and if they don’t hear it they may feel unable to proceed) and because social workers and police don’t appreciate they may be listening to a discussion of ideas rather than a finished opinion. In practice, getting to an opinion is an iterative process – that involves some people checking out the history, others requesting more specialist help or further investigations. It’s about tolerating (and planning for) uncertainty to allow this process to happen”. Lambeth SCR Child H Confidential Final Report 33 The experience of Review Team members was that the more experienced health professionals are in the field of child protection, the better they are at bridging the gap in expectations, by explaining the steps in a differential diagnosis and advising caution as appropriate. What numbers of cases are affected, and how widespread is the pattern – local, regional, national? It is likely that numerous cases present the problem of assessing whether injuries raise child protection concerns or not. Child protection referrals coming into CYPS and CP work involving partner agencies are very high, and have risen significantly over recent years. The table below refers to the number of S47 investigations (many of which are a response to ‘incidents’ of physical harm) in Lambeth and nationally for the last three years of available statistics. Year Lambeth UK UK rate per 10,000 children 09/10 402 89,300 81.1 10/11 561 111,700 101.1 11/12 729 124,600 109.9 Source: Department for Education We also have indicative evidence that the confusion between medical and other types of evidence regarding the existence of abuse is not restricted to Lambeth. Recent SCRs around the country have identified similar practice, where alternative explanations of physical harm have either been misleading or too readily accepted (e.g., Daniel P, Keanu W, Victoria C). This and another Learning Together review, in a different part of the country, have identified exactly this issue: a tendency for the multi-agency team to await a certain judgement of non-accidental injury before taking protective action. In these systems reviews, we have been able to go further by exploring the underlying patterns and reasons for how professionals from different agencies approach such tasks in different ways and with different understanding. What are the implications for the reliability of the multi-agency child protection system? Physical injuries to children which are known from the outset to be non-accidental are the exception rather than the rule. It is more common that the causation of physical injuries is open to a range of discrepant explanations. A safe system therefore requires reliable means whereby different professionals can bring their respective expertise to bear on planning and undertaking the tasks required to investigate how and when the injuries might have occurred, who might have caused them, and to ensure the child and siblings’ immediate and longer term safety. A pattern whereby a quest for certainty from social care and police runs alongside a norm among health colleagues of keeping all possibilities on the table until they are discredited, without either side realising the difference, creates potential accident opportunities. It represents a barrier to effective communication and collaboration in this challenging and critical area of work. Lambeth SCR Child H Confidential Final Report 34 Finding 5. A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks for a child in child protection investigations. Child abuse does not come ready labelled as such. This is as true for physical injuries sustained by a child, as it is for the presentation of emotional or behaviour problems. It is usual that there are different but equally plausible explanations for the causes which can include non-accidental injury inflicted on a child. A safe system therefore requires child protection investigations that bring the knowledge of different professions to bear on this challenging task. This finding highlights a pattern that affects the reliability with which child protection investigations will function, due to a mismatch between social care, police and medical professionals’ expectations about the process of communication. Social care and police staff look to medical staff to provide categorical explanations of the causes of physical injury, while it is standard for medical professionals to provide a more nuanced account of possibilities. All parties remain unaware of the mismatch, increasing the likelihood that past and future risks for the children concerned will be poorly understood and acted on. Issues for the Board and member agencies to consider: Is this a known problem to the Board? If so, how widespread is it considered to be? Is this an area of practice which is addressed in any current training/policies/procedures? What might the role of the Chair be in Strategy Meetings and CP Conferences to support improvement (e.g., at the end of the meeting, summing up what has been understood and agreed, and listing the consequent decisions)? What might the role of the hospital and/or community Named professionals be to support improvement? Should the named nurse and doctor have a particular role to play where there is i) uncertainty about causation of a suspicious injury and/or ii) disagreement among medical and nursing staff about the causation of a suspicious injury? Does the Board think there might be any particular constraints in trying to improve practice in this area? How would the Board know if there had been improvement in this area of multi-agency practice? Lambeth SCR Child H Confidential Final Report 35 Some thoughts about training: Use of role play – e.g., of Strategy Meeting in such cases Examples of cases where there is/remains uncertainty about the causation of an injury Presentations by nurses/doctors to other professionals regarding what constitutes uncertainty about an injury and why Presentations by Social Workers and Police to medical colleagues regarding the full range of risk factors which can lead to decision-making in a case (and vice versa). 2.10 Finding 6. The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required. This is a finding for Children’s Social Care. In all cases, but particularly in urgent child protection matters, the timely and accurate exchange of information, within and across agencies, is essential for safe working in this complex area. At nights and week-ends, different systems are in operation and there are generally fewer staff to handle the work. It is vital that the systems for requesting and passing on information are as efficient and reliable as possible. This case has highlighted two particular weaknesses in how the out-of-hours processes are routinely working. These relate to a) norms about how requests for information are prioritised; and b) processes whereby day time staff pick up messages from the previous night. How did the issue feature in this particular case? In this case there were two distinct instances of the vulnerabilities referred to in this finding. When Sibling 2 presented at A&E with a serious physical injury, the system that would usually have worked to inform A&E staff that the child was on a Child Protection Plan was temporarily missing an up-to-date electronic list of Lambeth children’s names. This was a brief gap, but in this instance it had the effect of slowing down the momentum in identifying risk to the children. In this instance, this was particularly significant because the parents had (falsely) told hospital staff that they were not known to CSC. The Review Team noted the vital role played by such information and flagging systems, given that decisions about safeguarding children (e.g., to send them home from hospital with parents) often have to be taken urgently. A request for information was therefore sent to the Emergency Duty Team in Lambeth. Given the acute nature of the presentation, this information was required very promptly. Instead, there was a delay of six hours before EDT’s Lambeth SCR Child H Confidential Final Report 36 reply was received. This meant that Sibling 2 had moved from A&E to the orthopaedic ward before details about the family and the existence of a CP Plan for the children were provided to the hospital. This first instance was compounded the following morning when the record of the EDT Social Worker’s discussion with the hospital was not picked up by the allocated Social Worker in the daytime team, or anyone else in her team in a timely way. This meant that the SW was unaware of the advice that this was a child protection matter, to be shared urgently with the Police Child Abuse Investigation Team (CAIT). She first learned about Sibling 2’s injury and the concerns of the doctors at midday the day after he had initially presented at A&E. How do we know it is not peculiar to this case? As part of the case review process, those involved explored the extent to which these two instances were unique to this case, or representative of more routine processes and practices. In relation to the delay in responding to A&E’s requests for information, the Case Group and Review Team members, including members of the EDT, confirmed that lengthy delays in response to requests for information out of hours are common. The telephone operator who answers the initial request for a data check is unable to supply information herself. She/he is based in a call centre and does not have access to CYPS’s electronic database so is unable to ascertain whether a client is known or whether a child is subject of a CP Plan. She/he must pass the request to the sole EDT social worker on duty. This gives the first indication of the underlying nature of this issue, and therefore the likelihood of its reoccurrence. As well as shedding light on the process of response of EDT, input from the Case Group and Review Team also helped explain norms about how different information requests are prioritised by EDT workers. Working alone, the EDT social worker must prioritise between referrals that come in throughout the night. Input from participants gave a picture of a reasonably standard hierarchy of urgency that is used, whereby an adult mental health assessment or the emergency placement of a child, take precedence over requests for ‘routine data checks’ – which is how the first call from the hospital was regarded. As the former often require a long time to complete, this can then leave a response to a request for data checks waiting for several hours, as we saw in this case, regardless of the severity of the injury to a child. The standard use of this hierarchy of response will therefore make it less likely that physical injuries to children will routinely be treated as a matter of urgency. In relation to the delay to the daytime staff picking up messages from the previous night, participants in the case review process also described what lay behind this delay and therefore the likelihood of the problem recurring in other cases. Participants explained that the EDT passes information to the daytime team by loading its record of what occurred during the night or week-end directly onto Framework, the service’s electronic database – as happened in this case. Lambeth SCR Child H Confidential Final Report 37 The system vulnerability arises from the fact that in the FSCP Teams there is no routine and reliable system to ensure that the EDT records on Framework are picked up at 9am every day. Social Workers do not always come to the office first thing; they may be out on a home visit, or at a meeting; indeed, they may be sick or on holiday, and whose responsibility is it to check Framework on behalf of the whole team every morning is unspecified. The result is poor reliability in how emergency information gets received into the team. This leaves the only safeguard in place being the possibility that either the EDT worker or the other participant, such as the hospital in this case, will follow up with a phone call to the day time team, which does not happen routinely. What numbers of cases are actually or potentially affected? Participants in the case review process considered that the number of cases where the timeliness of information-sharing and response following a presentation to services out of hours is likely to be significant both in Lambeth and beyond. We were unable to identify any formal data in the timeframes but anecdotally A&E departments in hospitals are very busy places at night and week-ends, and thus the potential need for information regarding children and their safety can be correspondingly high. Anecdotally too, the flow of information from the EDT into the daytime FSCP teams happens on a regular basis and in considerable volume. Allocated clients – children and families – form a large proportion of the out of hours workload, and all these EDT transactions have to be provided to the daytime teams at 9am Monday to Friday. We have not been able to ascertain absolute numbers. How widespread is the pattern – local, regional, national? Here too, hard data have proved hard to access but the Review Team thought it is common for EDTs in inner-London boroughs to experience heavy demand and be staffed by a single worker on duty out of hours, and thus to be forced to prioritise some requests and deprioritise others. We have not found any research that would shed light on whether the logic used by EDT staff in Lambeth of giving low priority to responding to requests for routine data checks relative to other demands, is common. The Review Team would hope and expect that requests for data checks concerning the presentation of a baby with physical injuries would automatically rank as high priority, but has not been able to ascertain whether across London or nationally this is indeed the case. Input from Children’s Social Care has indicated that the lack of a system for routinely retrieving at the start of the day information logged by EDT is not a feature of all social care teams. The Review Team were told that in the Referral and Assessment Team, the ‘front door’ of the CYPS service, unlike in the FSCP Teams, there is an established system for retrieving all EDT referrals every morning. This is done by a duty worker whose job it is to do this at 9am promptly. Where the referral concerns a family already known, the information is passed on to the allocated worker in the appropriate team. Lambeth SCR Child H Confidential Final Report 38 What kind of risk does this pattern introduce to the safe and reliable functioning of our system? A safe system for protecting children needs as reliable a response out of hours as during the normal working week. Yet, at nights and week-ends, CP Police and CYPS emergency services operate on a fraction of the staff who carry out their duties during the working week. At the same time, they regularly work with risky and urgent situations, and they must be able to refer information onwards in a timely and effective way. The two systems vulnerabilities found in this pattern demonstrate how relaying and picking up EDT information can be affected a) by the lower priority given to responding to ‘normal data checks’ and b) the unreliable practice in retrieving urgent EDT information at the earliest moment – 9am on the next working day. These vulnerabilities mean that important information about children and families may not be shared in a timely way, and therefore will not inform crucial professional responses. Finding 6. The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required. This is a finding for Children’s Social Care. The need for timely and effective help to children is not restricted to office hours of the working week. A safe system therefore needs the out of hours services to work reliably for children who present at nighttimes, weekends and over holiday periods. This case has highlighted two patterns that undermine the reliability with which information is provided to and received from the Emergency Duty Team in Lambeth. These are a) by the lower priority given to responding to ‘normal data check’ requests by the Emergency Duty Team and b) the lack of a system in the FSCP Teams for routinely retrieving, at the start of the day, information logged by EDT the preceding night. Both have the effect of inhibiting the timely flow of urgent information, leaving professionals in various services (but often health settings) less able to make proper assessments of risk, and children remaining in potentially unsafe situations. Issues for the Board and CYPS to consider Is this a known problem – within CYPS? Within the LSCB? Lambeth SCR Child H Confidential Final Report 39 Does the Board/CYPS agree that these are critical systems flaws? Is it acceptable that out of hours services have to wait several hours for a simple piece of information, such as the existence of a CP Plan? What has been done already to consider how to improve a timely and effective flow between out of hours and daytime services? Can we learn from good systems in EDTs and CYPS teams in other London boroughs? Are there particular problems getting in the way – e.g., lack of access to the CYPS database by the operator taking requests for information? Would it be possible for the EDT operator to be able to answer simple questions such as ‘subject to CP Plan’ – without recourse to the social worker on duty? What would constitute an improvement in both these vulnerabilities and how would the Board know there had been an improvement? Are there any resource issues which come into play? 3. Conclusion The tragic death of three-year old Child H has resulted in a number of legal steps. His father has been charged with his murder, and his trial is scheduled for early 2014. His surviving siblings have been removed into the care of Lambeth Council. This review has identified a number of factors which affected the work of the professional safeguarding children network with Child H’s family. It has analysed the judgements and actions of those involved in the case, and the reasons for these. It has also analysed what this case has told us about weaknesses and vulnerabilities in the multi-agency child protection system. A key part of this story remains unknown. The perspective of the parents, who remained secretive about many things in their contact with agencies and professional staff, has not been captured. Unfortunately, the ongoing criminal justice process has meant that there has not yet been an opportunity to interview Mother and Father. Without their insights and information, the understanding of the family and how they worked with professionals remains incomplete. It is not known yet whether the parents will be willing to contribute to the review in some way after the criminal trial has concluded. In a ‘systems’ case review, the individual case acts as a window on the local systems, so that broader learning can emerge. Through this case, six priority findings have been identified, relating to: Professional understandings of the risk of physical harm to children living in families where there is domestic violence between partners The role of supervision and multi-agency groups in reflecting on and challenging judgements Lambeth SCR Child H Confidential Final Report 40 The quality and availability of interpreters, particularly in emergency situations The challenge of tackling domestic violence when it has occurred in the past and there is no reoccurrence Differential understandings between health and social care of the role and meaning of medical opinion in determining likely cause of injuries, and subsequent actions, and Information sharing between Emergency Duty Teams and other teams and agencies. The LSCB is presented these findings and associated questions to consider as they decide how best to respond, as a way forward to strengthen and develop the work of the multi-agency network in Lambeth and hospitals in neighbouring authorities. Lambeth SCR Child H Confidential Final Report 41 References Barnett, O., Miller-Perrin, C., Dale, R.D., Family Violence across the Lifespan: An Introduction, Sage Publications, 2010 Bowker, L. H., Arbitell, M., McFerron, J. R., ‘On the relationship between wife beating and child abuse’, in K. Yllo & M. Bograd (Eds.), Feminist perspectives on wife abuse (pp.90-113), Sage Publications, 1988. Brandon, M., Thoburn, J., Lewis, A., Way, A., Safeguarding Children with the Children Act 1989, London: The Stationery Office, 1999 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., Black, J., Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews, 2005 – 07, University of East Anglia/DCSF, 2009 Edleson, J.L., Peled, J., Jaffe, P.G. (Eds), Ending the cycle of violence: Community responses to children of battered women, Sage Publications, 1995 Farmer, E. and Owen, M., Child Protection Practice: Private Risks and Public Remedies, London, HMSO, 1995 Fish, S., Munro, E., Bairstow, S., SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2008 Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Hartley, C.C., ‘The Co-occurrence of Child Maltreatment and Domestic Violence: Examining Both Neglect and Child Physical Abuse, Child Maltreatment, 2002; 7; 349, and Sage Publications 2009 (http://www.uk.sagepub.com/pricefamchnge4e/study/articles/06/Hartley.pdf) Hughes, L., and Pengelly, P., Staff supervision in a turbulent environment: managing process and task in front-line services, London: Jessica Kingsley London CP Procedures, 3rd Edition, 2007 Lord Laming, The Victoria Climbie Inquiry Report, The Stationery Office Limited, London, 2003 Munro, E., ‘Common Errors of Reasoning in Child Protection Work’, Child Abuse and Neglect, Vol 23, No 8: 745-758, 1999 Munro, E., ‘A systems approach to investigating child abuse deaths’, originally published in The British Journal of Social Work, 35 (4), pp. 531-546, Oxford University Press, 2005 Munro, E., ‘A systems approach to investigating child abuse deaths [online]’, London: LSE Research Online, 2007 Munro, E., ‘Lessons learnt, boxes ticked, families ignored’, The Independent, 16th November 2008 Lambeth SCR Child H Confidential Final Report 42 Ofsted, Learning Lessons, taking action: Ofsted’s evaluation of serious case reviews 1 April 2007 – 31st March 2008, Reder, P., Duncan, S., and Gray, M., Beyond Blame: Child Abuse Tragedies Revisited, Routledge, 1993 Reder, P., and Duncan, S., Lost Innocents: A Follow-up Study of Fatal Child Abuse, London: Routledge, 1999 Regan, L., ‘Children and Domestic Violence: Its Impacts and Links with Woman Abuse’ paper presented at the Impact of Domestic Violence on Children Conference, London, October 2001 Rushton, A., and Nathan, J., “The Supervision of Child Protection Work”, The British Journal of Social Work, Vol 26 (3): 357-374 SCIE At a Glance 01: Guide to Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2008 Stanley, N., Children Experiencing Domestic Violence: A Research Review, Dartington: Research in Practice, 2011 Stark, E., and Flitcraft, A., Women at risk: domestic violence & women’s health, Sage Publications, 1996 Tomison, A., ‘Exploring family violence: Links between child maltreatment and domestic violence’, Issues in Child Abuse Prevention, no. 13: Melbourne: Australian Institute of Family Studies, 2000 Topping, A., “Domestic violence figures are disturbingly high, says charity”, The Guardian, 7th March 2013 www.womensaid.gov.uk: Home/Domestic Violence A-Z/Children Working Together to Safeguard Children, DCSF, 2010 Working Together to Safeguard Children, DfE, 2013 Lambeth SCR Child H Confidential Final Report 43 Appendix 1 – Methodology 1. This SCR has used the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires all SCRs to adopt a systems methodology. 2. The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3. Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4 The basic principles – the ‘methodological heart’ – of the Learning Together model – are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 2.4 Typology of underlying patterns 2.4.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection Lambeth SCR Child H Confidential Final Report 44 systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category. 1. Anatomy of a finding For each finding, the report is structured to present a clear account of: How the issue manifests itself in the particular case In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated in the Anatomy of a Learning Together Finding (below). Lambeth SCR Child H Confidential Final Report 45 1.5 Review Team and Case Group 1.5.1 Review Team The Review Team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, and so on. The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review. The two Lead Reviewers in this SCR are both accredited to carry out SCIE reviews, and have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework. Neither has any previous involvement with this case, or any previous or current relationship with Lambeth Council or partner agencies. Lambeth SCR Child H Confidential Final Report 46 Ghislaine Miller, SCIE independent Lead Reviewer Sally Trench, SCIE independent Lead Reviewer Interim Assistant Director Looked-after Children and Corporate Parenting Lambeth Children and Young People’s Service (CYPS) Consultant Paediatrician and Named Doctor for CP and Safeguarding St. George’s Hospital (SGH) Nurse Consultant, Designated Nurse CP NHS Lambeth Clinical Commissioning Group (CCG) Consultant Paediatrician and Designated Doctor for Safeguarding, NHS Lambeth CCG Trust Named Nurse, Safeguarding Children Guy’s and St. Thomas’ NHS Foundation Trust Head of EYFS and Childcare Early Intervention and Targeted Lambeth CYPS Review Officer Band L SC&O 21(2) Crime Academy & Review Group Metropolitan Police Quality Assurance Officer Lambeth CYPS Head of Service for Quality Assurance and LSCB Board Manager Lambeth CYPS 1.5.2 Case Group The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 25 Case Group professionals, and received transcripts of 3 further conversations which were held with members of the dental practice. Lambeth SCR Child H Confidential Final Report 47 Health: GPs (x2) Consultant Paediatrician (Emergency Medicine), SGH Paediatric Registrar, SGH Consultant Orthopaedic Surgeon, SGH Consultant Community Paediatrician, Guy’s and St Thomas’ NHS Foundation Trust Named Nurse, SGH Midwife, Guy’s and St. Thomas’ NHS Foundation Trust Health Visitor, Guy’s and St Thomas’ NHS Foundation Trust Health Visitor, Guy’s and St Thomas’ NHS Foundation Trust CYPS: Head of Service, CPFS Teams, CYPS Lambeth Deputy Team Manager (x2), CP&FS Team, Lambeth Team Manager, CP&FS Team, Lambeth Social Worker, CP&FS Team, Lambeth Deputy Service Manager, Locality Team, Westminster Senior Safeguarding Coordinator, Lambeth Adult and Community Services CP Conference Chair Team Manager, EDT Sessional Social Worker, EDT Early Years and Education: Head Teacher, Primary School Outreach Worker, Children’s Centre Nursery Teacher Metropolitan Police: Police Constable, Child Abuse Investigation Team (CAIT) Police Constable, Community Safety Unit Police Constable, Domestic Violence and Hate Crime Unit (by telephone) The case review received copies of conversations undertaken by NHS London, with: Dentist Receptionist, dental surgery Practice Manager of the dental surgery Lambeth SCR Child H Confidential Final Report 48 1.6 Structure of the review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The Review Team form the ‘engine’ of the process, working in collaboration with Case Group members who are involved singly in conversations, and then in multi-agency ‘Follow-on’ meetings. The sequence of events in this review is shown below. Date Event 23.04.13 Scoping meeting between Lead Reviewers, LSCB Chair and Manager 13.05.13 Introductory meeting for the Review Team 23.05.13 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of. 14, 17, 18 and 28.06.13 Four days’ conversations with members of the Case Group (individual sessions of about 1.5 hours with each member of the Case Group; normally conducted by two members of the Review Team) 26.06.13 1) Half day training for the Review Team, provided by the Somali Development Group 2) Review Team analysis meeting (1) 01.07.13 Review Team analysis meeting (2) 15.07.13 First Follow-on meeting (Review Team and Case Group) In this meeting, the group works together on identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case appraising the practice in these KPEs considering what was affecting the work/workers at the time (the ‘view from the tunnel’) NB, In the spirit of learning, the Designated Nurse and Designated Doctor from SGH were invited to this and the second Follow-on meeting as observers. 24.07.13 Review Team analysis meeting (3) 29.07.13 Lead Reviewers’ updating presentation to LSCB Executive Group Lambeth SCR Child H Confidential Final Report 49 09.08.13 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group are provided with a draft report which sets out the emerging underlying patterns and findings, and are asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 09.08.13 Review Team analysis meeting (4) 15.08.13 Quality Assurance: supervision session for Lead Reviewers with SCIE (Dr. Sheila Fish) 06.09.13 Review Team meeting (5) – to consider the draft final report 10.09.13 SCR Sub-Group meeting – to consider the draft final report 26.09.13 Meeting with LSCB Board Chair, DCS, and (previous) Interim DCS. Request for report to be revised and to then agreed by Review Team. DfE informed by LSCB Chair of delay in completion of report. 6.12.13 Final meeting of the review team TBC LSCB meeting – to consider the draft final report TBC Final report, fit for publication, to be submitted to Department for Education (DfE) 1.7 Scope and terms of reference 1.7.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored. In this SCR, we noted and explored the questions (Para 1.1.2) which Lambeth SCB had posed as of particular interest. 1.7.2 The time frame for the SCR was decided as follows: February 2011 (Mother’s arrival in the UK) to 11th March 2013 (date of Child H’s death) 1.8 Sources of data 1.8.1 Data from practitioners Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team. Two Follow-on meetings in which members of the Case Group responded to the analysis of the case and gave feedback about accuracy and fair representation of their views. In relation to the emerging findings, the Case Group were asked to comment on whether Lambeth SCR Child H Confidential Final Report 50 these were underlying and widespread/prevalent. In other words, could we draw conclusions about whether, and in what way, this case provides a ‘window on the system’? Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed. 1.8.1.1 Key Practice Episodes and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ and thence into a selection of Key Practice Episodes (KPEs) which enable us as reviewers to capture the optimum learning from the case. These KPEs are significant points or periods in relation to how the case was handled or how it developed. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time. 1.8.1.2 Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in this SCR. The tragic circumstances of the child’s death have meant that the process has been a very painful one for most if not all members of the Case Group. Nonetheless, they have participated very responsively in individual conversations, which have recalled their role in the child’s story, and in group discussions which have at times been very difficult and challenging. Several have remarked that it has been a positive experience to contribute to learning from the tragedy. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network, and has allowed us to capture the learning which is presented in this report. 2 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: The records of the agencies in the case, which were then translated into an integrated chronology Referral and information records (CYPS) Transfer summary (CYPS) Minutes of meetings: CP Conferences, Core Groups, MARAC Reports for CP Conferences CP Plans and Written Agreements Core Assessment (CYPS) Detailed records of CP home visits (CYPS) CP Medical report for MA (6th December 2012) Lambeth SCR Child H Confidential Final Report 51 Record of outcome of S47 Enquiries March 2013 Record of Strategy Discussions March 2013 Detailed records from EDT, 4/5 March 2013 Detailed records of Brother 2’s hospital admission and care Email correspondence of CYPS managers regarding the incidents in March 2013 CP Medical reports for MA and Brother 1 (8th March 2013) In addition, the Lead Reviewers read the SCR Panel minutes of 26.03.13, and a briefing document drawn up for consideration at that meeting, including draft Terms of Reference. 1.8.3 Data from family, friends and community 1.8.3.1 As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. In this review, the status of the parents as perpetrator and witness in criminal proceedings has ruled out the offer of conversations with them at this time. It is hoped that at a future point, it will be possible to engage both parents in a dialogue about their experience of working with agencies. Lambeth SCR Child H Confidential Final Report 52 Appendix 2 – Guide to terminology Acronyms used and terminology explained 1. Statutory guidance requires that SCR reports ‘…be written in plain English and in a way that can be easily understood by professionals and the public alike.’ (2013: 70) Writing for multiple audiences is always challenging. An appendix (Appendix 2) on terminology aims to support readers who are not familiar with the processes and language of safeguarding and child protection work. 2. Lambeth LSCB and SCIE are both keen to improve the accessibility of SCR reports and welcome feedback and suggestions for how this might be improved. 3. Acronyms A&E Accident and Emergency Department (hospital) CSC Children’s Social Care CYPS Children and Young People’s Services DTM Deputy Team Manager DV Domestic violence ED Emergency Department FSCP Family Support and Child Protection Team GSTT Guy’s and St. Thomas’ Hospital Trust HV Health Visitor IDVA Independent Domestic Violence Agency LSCB Local Safeguarding Children Board LT Learning Together MARAC Multi Agency Risk Assessment Conference SCIE Social Care Institute for Excellence SGH St. George’s Hospital SW Social Worker TM Team Manager 4. Terminology Children Act 1989: When local authority social care services work with a family, the principal legislation underpinning their powers and duties is the Children Act, 1989. One particular section of the Act is referred to throughout this report: section 47. Lambeth SCR Child H Confidential Final Report 53 S47: This sets out the duties of Police and CYPS to respond to any report that ‘a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm.’ Under these circumstances, enquiries must be made to decide on action needed to safeguard or promote the child’s welfare. Strategy Meeting: This is the meeting (or sometimes telephone discussion) which initiates the s47 process. The first action after a child protection referral has been received is for CYPS to make contact with the Police and to set up a Strategy Meeting to plan who will do what in carrying out the enquiries for this child/ren. Formal Child Protection Procedures: Child Protection Conferences, Core Groups and Child Protection Plans are ‘regulated’ by statutory guidance (Working Together, all editions). They are the multi-agency formal procedures for identifying, assessing and planning for the protection of children who reach the threshold of ‘at risk of significant harm’. Under the umbrella of the LSCB, the CYPS service is responsible for convening and supporting these arrangements. The CYPS social worker is designated as the ‘key worker’ for the children on Child Protection Plans. Court orders: The act gives other powers to the courts – to make protective orders of various kinds, including an Emergency Protection Order (s44) – and powers to the local authority to apply for such orders. Police have the power (Police Protection) without an order to remove a child who is in immediate risk of significant harm to a place of safety. Details of how a S47 investigation, or enquiry, is to be carried out are found in Working Together, all editions. Lambeth SCR Child H Confidential Final Report 54 Appendix 3 - Statistics on domestic violence National data: Figures reveal that ‘…13,500 people – 80% of them women – reported domestic violence to Citizens Advice last year. There were 3,300 reported incidents between October and December 2012, an 11% increase on the same period the previous year.’ (Topping, 2013) In the same Guardian article, Home Office figures are quoted which state that last year 1.2 million women experienced DV, including sexual violence, from their partners. Women’s Aid.org.uk: Research shows that domestic violence can affect one in four women in their lifetimes, regardless of age, social class, race, disability or lifestyle. Domestic violence accounts for between 16% and one quarter of all recorded violent crime, and for 10% of emergency calls. In any one year, there are 13 million separate incidents of physical violence or threats of violence against women from partners or former partners. (Home Office, 2004; Dodd et al., 2004; Dobash and Dobash, 1980; Walby and Allen, 2004) Statistics about domestic violence: Incidence and prevalence of domestic violence: General In 2011/12, 7.3% of women (1.2 million) and 5% of men (800,000) report having experienced domestic abuse. 31% of women and 18% of men have experienced domestic abuse since the age of 16 years. This amounts to 5 million women and 2.9 million men. In 2011/12, the police reported nearly 800,000 incidents of domestic violence. There has been a 65% increase in the number of domestic violence prosecutions between 2005/06 and 2010/11 and a corresponding 99% increase in number of defendants convicted. Despite this, domestic violence conviction rates in the five years to 2011 stood at just 6.5% of incidents reported to police – though a much higher proportion of around 70% of those charged. Women are much more likely than men to be the victim of multiple incidents of abuse, of different types of domestic abuse (partner abuse, family abuse, sexual assault and stalking), and in particular of sexual violence. Lambeth statistics: include various indicators that reflect the level of DV: Referrals to CYPS with DV as a factor: 19% Number of CP plans with DV as a factor: 61% Total number of calls in the past year to national DV helpline from Lambeth residents: 1,696 calls (30,424 calls from London as a Lambeth SCR Child H Confidential Final Report 55 whole). Calls from Lambeth were the third highest in London after Croydon (1747) and Lewisham (1699) The table below gives the Lambeth MARAC referrals from 2007 to the present. These show a continuing rise in the numbers of referred victims who are regarded as ‘at high risk of serious harm or death’, and who have become the subject of protection plans formulated at the MARAC meetings. Date Period No of victim referrals Number of associated children Apr 07 – Mar 08 47 59 Apr 08 – Mar 09 156 171 Apr 09 – Mar 10 307 328 Apr 10 – Mar 11 341 400 Apr 11 – Mar 12 286 361 Apr 12 – Mar 13 396 388 Rolling 12 month Aug 12 – July 13 408 391 Lambeth SCR Child H Confidential Final Report 56 Appendix 4 - Lessons already learnt and changes implemented to improve practice across agencies This Appendix details actions already taken which are relevant to four of the six priority findings. Finding 1: A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed. LSCB: Has endorsed and rolled out the Barnardo’s risk assessment tool which does specifically look at the risks to the children of direct physical abuse. CYPS: Since this review, the CP Conference Chairs have been asked to review the categorisation of children on CP Plans and stress the correlation.between DV and physical abuse in the conference and risk assessment. GSTT: GSTT have undertaken training for community practitioners re routine enquiry and use of Barnardo’s risk assessment in March/April 2013. SGH: An action plan was developed following a Learning Improvement process in response to this case. This included the following changes: o Risk assessment tool introduced to A&E for use when NAI is one possible explanation for the presenting complaint (more detail in action plan). o Lead consultant for child safeguarding, particularly for the more medical aspects, e.g., interpretation of injury, for each specialty identified. o Lead consultant to be identified and notified on admission whenever child safeguarding concerns are raised. o Ward team to assess risks in respect of the child’s safety on the ward when NAI is a possibility and implement appropriate measures, e.g., positioning child close to nursing station, restricting visitors. Finding 3: The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. SGH: Phones used for Language Line (and other confidential purposes) in the A&E department have been moved into two side rooms. Finding 4: Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further Lambeth SCR Child H Confidential Final Report 57 in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. CYPS: Is moving towards the full-scale implementation of the Signs of Safety model which will strengthen the quality of risk assessment, make concerns more easily understood by parents, and will frame CP Plans in a way that is more outcome-focussed. Finding 5: A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. CYPS: Following the incident, guidance has been reissued within CYPS to social work teams about the requirement to record on the day the key findings and actions arising from a Strategy Meeting, and give those to the attendees on the day. This was audited and found to be happening in the cases seen. SGH: An action plan was developed following a Learning Improvement process in response to this case. The changes are outlined above, under Finding 1. |
NC52838 | Summarises key findings and learning points from cases of intra-familial sexual abuse (IFSA), including sibling sexual abuse. Learning points include: acting on early concerns, using the Strengths and Needs Form; remaining alert to the possibility of all types of bias including unconscious gender bias and female abusers; awareness of how practice can be influenced by family social status; considering the viewing and sharing sexual images online in the context of family history and response to trauma; effective communication, with practitioners both sharing and seeking information, and using clear language; using available tools to identify different types of IFSA, for example a multi-agency chronology; ensuring that assessments consider and include the whole family and that all children in the family have been seen individually and had their voices heard; analysing parental motivations and capacity as part of risk assessments; reflecting on the impact of inter-generational abuse on parenting capacity and the need for practitioners to be trauma aware; understanding practitioners confidence levels around specific types of IFSA, especially sibling sexual abuse; consideration of what additional support may be needed when ending work with a family if parents are vulnerable; encouraging fathers to be included and participate in discussions; the impact of Covid-19 on families and service delivery; and the need to update the national practice of categorising abuse in the child protection process when there are multiple risk factors, for older children, or where there is intra-familial (sibling) abuse. Recommendations are embedded in the learning points.
| Title: Intra-familial sexual abuse (IFSA): a thematic review of Oxfordshire local child safeguarding reviews. LSCB: Oxfordshire Safeguarding Children Board Author: Oxfordshire Safeguarding Children Board Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Intra-familial sexual abuse (IFSA): A Thematic Review of Oxfordshire Local Child Safeguarding Reviews This thematic review considers IFSA, including sibling and intra-family sexual abuse and highlights key practice issues found in Oxfordshire learning reviews. It links with national research & other learning reviews. The review gives an overview of findings and learning for building confidence & strengthening practice when working with situations of IFSA. Key findings Finding one: Professional curiosity and unconscious or conscious bias “It was not seen” • Practitioners should remain curious in their practice and consider all possibilities when working with children and their families. In the cases reviewed, there were examples where practitioners were not questioning enough in their practice, where self-reported information was taken at face value and where unconscious or conscious bias may have led to assumptions being made • Professionals must access specialist Sexual Abuse training to be able to understand harmful sexual behaviours and risk indicators between siblings and in families and know the indicators to consider the likelihood of sexual abuse Finding two: Information sharing and working together to gain a full picture/history • Important historic information was not consistently shared across the safeguarding system, leading to assumptions being made about who knew what and what information had been shared • Crime records by the Police need to be clear, consistent and use the appropriate terminology when detailing sexual abuse. In one Review when sharing information with Children’s Social Care the relevance of what was being shared was not recorded appropriately • Agency records need to show all key information concerning each child and adult in the family, evidencing that they have each been spoken to. In one Review the Police and CSC had not spoken to the other children in the family and this impacted on risk being assessed/known • It can be a professional and system challenge to have a ‘collective memory’ as practioners will change and so it is imperative that all relevant/key points are recorded on systems to show a child’s story over time and in chronological order Finding three: The need for practitioners to be trauma aware when understanding Inter-generational patterns of abuse o Research Key messages from research on intra-familial child sexual abuse has shown that there are clear links between inter-generational abuse and how this might impact on parenting capacity • Adverse childhood experiences (ACEs) and responses to childhood trauma : One parent’s behaviours weren’t recognised as a response to trauma but instead were seen as being attachment seeking - including sexualised behaviour, sharing of sexual images and being vulnerable to sexual exploitation Finding four: Understanding individual children’s worlds in their families and hearing their voice • Remember - behaviour is a way of a child communicating their distress • Each child in the family needs to be seen and spoken to when assessing risk Finding five: Working with families to understand barriers and enablers • In one Review it was evident that the parental social status shaped professional interactions and outcomes for the children due to assumptions made and a fixed view taken 2 • Working in a whole family systemic way when there are worries of sibling sexual abuse is important • In one review little work was done with the father – valuable information could have strengthened the findings Finding six: Impact of the covid-19 pandemic • The COVID-19 pandemic, subsequent lockdown and change in service delivery meant children were not being seen as regularly and parental vulnerabilities, e.g., stress, distress, feelings of loneliness and isolation increased. Strengths in Practice • In one case the Family Nurse Partnership (FNP) was a consistent, supportive and child focussed presence, there was evidence that the parent was benefitting from input and the children were developing appropriately. FNP identified that parent’s mental health was deteriorating, that the children were exhibiting signs of distress in their behaviour, sought advice and made attempts to get additional help • In some situations, referrals to Children’s Social Care were comprehensive, including parent’s family history, experiences of abuse, sexual exploitation, self-harm and experiences of care • There were a number of examples where practitioners ensured that face to face meetings were held with families and that information was shared well across partners • In one review, professionals involved clearly had concerns that children were being abused and pursued different specialist and social work assessments to establish evidence • There were high levels of involvement across agencies to support families through children in need and child protection plans • In some of the situations reviewed, there was strong evidence of appropriate information sharing across partnerships and some good examples of working together • In some of the reviews, the views of the children were clearly recorded in assessments • There was expertise seen in CAMHS specialist provisions of the partnership regarding sibling sexual abuse • In one review there was evidence of good transitional arrangements when a child reached 18 years old Practitioner Learning points to build confidence and strengthen practice • Keep a constant focus on the child and their lived experiences • Try and build a connection with each child in the family so as to understand their lived experience and hear their voice • Understand the relationship and dynamics between siblings – remember observational skills as part of your analysis • There are likely to be barriers and enablers to understanding a child’s world – unpick these carefully with the family and professional network and in supervision Early intervention: • Act on early concerns, using the Strengths and Needs Form (S&NF), https://www.oscb.org.uk/early-help-forms-tools formerly the Early Help Assessment (EHA) to better understand what is going on and to decide the best way forward. • If you are not confident in using the assessment, EHA training is available, or you can seek support from your LCSS link worker or Designated Safeguarding Lead (DSL) Unconscious bias: • Practitioners must remain alert to the possibility of all types of bias including ‘unconscious gender bias’. Whilst the sexual abuse of children by women, especially by mothers of their own young children, is rare; 3 practitioners must recognise that some females do abuse and be alert and seek specialist advice and supervision when considering the differences in offending behaviours, victim profiles and personal characteristics in male and female offenders: Centre of expertise on child sexual abuse (CSA Centre): research, resources and training • Be aware of how practice can be influenced by family social status when working with differing social class, professional status, and academic qualifications Viewing and sharing sexual images online: • When parents with a history of familial sexual abuse report that they are sharing sexual images, practitioners should consider the context and implications of early childhood trauma, and question whether the parents behaviour has an impact on their parenting and risk to children. • There was evidence of sharing of explicit images, in at least two of the cases reviewed, both with and without consent. This behaviour can be viewed as common practice by young people and was not considered by professionals in the context of family history and response to trauma Information sharing and effective communication: • Double check that ALL key information has been shared with relevant professionals – it can be easy to miss significant things when there are competing demands • Check out information with the family • Effective communication requires practitioners to both share and seek information, and to use clear language to avoid any misinterpretation • See and note behaviours as potential evidence of child sexual abuse. Be specifc and detailed in your recording of what you observe in a child / what a child tells you or retracts / what they may draw / interactions and dialogue with siblings / parents and wider family dynamics • Consider whether you have spoken to everyone you need to, that all involved agencies have contributed to assessments and that you are sharing relevant information to strengthen your analysis Use of available tools to identify different types of IFSA: • Use available tools to support your practice, and to contribute to effective assessments and plans , for example a multi-agency chronology (MAC) can provide a good insight into the child’s life Assessments: • Ensure that assessments consider and include the whole family, e.g., who is in the family, do you have a genogram and what are the family members’ needs, family background? Does your assessment consider the child’s social context? • Have all the children in the family been seen individually and their voices heard? • Keep a firm focus on potential risk, reflect on existing evidence and assessment, re-assess risk factors and triggers, and use escalation between agencies when risks are not reducing despite intervention • Make sure you analyse parental motivations and capacity as part of your risk assessments Manager Learning points to strengthen oversight and direction in formal/informal supervision • When working with parents / families where there have been generational patterns and cycles of abuse and childhood trauma, robust supervision and management oversight is essential to enable practitioners to reflect on the impact this might have on parenting capacity and risk to children • Safeguarding supervision and management conversations should be both supportive and challenge practitioners’ thinking, and a chronology of events/multi-agency chronology completed to indicate patterns or areas of concern • When ending work with a family, or stepping down a service, supervision, management, and safeguarding advice should enable reflection, to help practitioners see the wider context along with family history to ensure the decision-making is safe and proportionate for the child • Understand practitioners’ confidence levels around specific types of IFSA and especially sibling sexual abuse as there can typically be a lack of professional awareness and awkwardness in practice 4 pag • Consideration of what additional support may be needed when ending work with a family, or when a plan is to be stepped down if parents are especially vulnerable, for example care experienced young parents to ensure a think family approach • Consideration should be given to whether teenage parents, in particular ‘Children We Care For’ should be identified as needing more focussed support and interventions that acknowledge trauma and potentially greater safeguarding risk • Training and resources must support practitioners’ knowledge and understanding of sexual abuse, including female abusers and abuse of infants and sibling sexual abuse • All agencies need to ensure they understand the nature of risk, and a shared language which enables effective discussion, assessment, and intervention in relation to the use of the internet and social media as a platform for child abuse • All agencies should ensure that when working with parents with a history of sexual abuse, or they understand the family history, trauma and responses to trauma. This must be an integral part of the assessment of parenting capacity and risk • Child Protection Conferences need to provide robust scrutiny, bring balance and avoid over optimism • Categorising the nature of abuse at a Child Protection Conference should not prevent wide ranging discussion of all the risk factors. Participants should remain mindful that for many children, the risk may reflect more than one category • Whilst the pre-birth assessment is led by Children’s Social Care, it is imperative that all agencies with both knowledge of the family and the issues impacting on them, participate and contribute • The role of the Leaving Care Personal Assistant (PA) needs to be well understood by other agencies across the Partnership and must be fully integrated into any partnership working • The impact of the COVID-19 pandemic on families and service delivery should be evaluated and used to inform future planning • Practitioners should consider how fathers can be included and participate in discussions/ meetings regarding their children and services should be designed to enable their involvement National learning The national practice of categorising abuse in the Child Protection process is out of date and does not work well when there are multiple risk factors, for older children, or where there is intra-familial (sibling) abuse. As per a reccomendation from one case review - a letter on behalf of Oxfordshire Safeguarding Children Board (OSCB) has been sent to the Department for Education (DfE) asking for a review of the categories of risk, to ensure it reflects current safeguarding practice and is fit for purpose. If you do one thing…… learn the signs and indicators of child sexual abuse, Children are unlikely to tell anyone that they are being abused and particularly if this is between brothers/sisters Remember that behaviour is talking for a child Stubborn challenges: • The need for robust supervision and management oversight • Interpreting information in a way that supports existing theories and beliefs • Over - optimism • Continuous sharing of information and effective communication across the network • Use of chronologies to indicate patterns of behaviour and areas of concern 5 Did you know? The following links offer useful further information and guidance: • Centre of expertise on child sexual abuse (CSA Centre): research, resources and training o Key messages from research on intra-familial child sexual abuse o Signs and indicators template o Communicating with children guide o Supporting practice in tackling child sexual abuse film series o Helping education settings identify and respond to concerns o Supporting Parents and Carers Guide • OSCB training; including OSCB Generalist and Designated Safeguarding Lead Courses, and themed courses, e.g., Digital Safeguarding, Domestic Abuse, Healthy and Unhealthy Sexual Behaviours training • OSCB online procedure manual: o Child Protection Conferences o Information sharing • Multi-agency practitioner’s toolkit: o Professionals only meeting guidance o Guidance on chronologies o Safeguarding conversations poster Sibling Sexual Abuse • BBC radio 4 podcast. Sibling Abuse – the last taboo? • Understanding sexualised behaviour in children | NSPCC LearningAd·https://learning.nspcc.org.uk/ Download the SSA report (PDF, 1.6MB) Other guidance / resources • The National Child Traumatic Stress Network: Creating trauma informed systems |
NC51228 | Death of an infant in November 2017 from injuries linked to being shaken three months earlier. Father was convicted of murder. Charlie was the youngest of three children and lived with mother and father. Father had history of significant domestic abuse in a previous relationship and violence towards his sister and partner. GP records showed that he sought support for anger issues in 2004. Father suffered a significant brain injury from a fall at work in December 2015; he was supported by various services; Mother became his primary carer. In June 2017 Sibling 1 made disclosures at school about Father being angry and rough play indicative of risk to injury. Call made to Multi Agency Safeguarding Hub; children's social care stated that threshold was not met for a Family and Child Assessment. Mother declined Early Help support. On the day of the incident Charlie was left in the care of Father along with Sibling 2; he suffered significant injuries linked to being shaken. Learning includes: professional curiosity may lead to a fuller understanding of the lived experiences of children; accurate recording of assessments is vital for understanding risk; when children talk about their lived experience there should be adequate credence given; information held by agencies that indicate risk to children should be shared regardless of how or why that information is known. Recommendations include: specific programmes of activities to improve and embed a culture where Think Family and authoritative practice and supervision become the norm in practice considerations.
| Title: Serious case review case 7: Charlie (assigned pseudonym): overview report. LSCB: Walsall Safeguarding Children Board Author: Karen Rees Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Walsall Safeguarding Children Board Better Together for Children www.wlscb.org.uk Serious Case Review Case 7 Charlie (Assigned Pseudonym) Overview Report Author: Karen Rees Presented to Walsall Safeguarding Children Board (WSCB) 3rd October 2018 2 CONTENTS 1 Introduction 3 2 Circumstances leading to the review 3 3 Methodology 3 4 Reviewer 5 5 Process and Scope 5 6 Parallel Processes and Family Engagement 5 7 Background Prior to Scoping 6 8 Key Phases 6 9 Thematic Analysis 14 10 Good Practice 27 11 Conclusion and Learning 27 12 Recommendations 29 Appendix 1: Terms of Reference (Redacted for publication) 31 Appendix 2: Pathways to Harm, Pathways to protection 35 3 1. Introduction 1.1. This Serious Case Review is undertaken following a referral to the Serious Case Review Sub Group on 21/09/2017 related to a childcare incident in August 2017. 1.2. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. 1.3. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: abuse or neglect of a child is known or suspected; and either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.4. The request for a Serious Case Review was agreed by the Independent Chair of the WSCB on 26/09/2017 2. Circumstances Leading to the Review 2.1. Charlie was the youngest of three children and lived at home with parents and siblings. Charlie was left in the care of Father along with Sibling 2. Mother and Sibling 1 were absent from the home. Whilst in the care of Father, Charlie suffered significant injuries that are presently being linked to shaken baby. 2.2. Charlie was initially cared for in the Intensive Care Unit at the Local Children’s Hospital on life support. Charlie’s long term prognosis was poor and medical professionals indicated that Charlie would not survive the injuries. Following consent from the family, the life support was discontinued in November and Charlie died. 2.3. Father had previously suffered a significant brain injury as a result of an industrial accident. This resulted in him being disabled with a support and rehabilitation plan implemented; he was supported by various services. 3. Methodology 3.1. Working Together to Safeguard Children 20151 does not prescribe a fixed methodology for Serious Case Reviews, but states that reviews should be conducted in a way in which; 1 HM Government (2015) Working Together to Safeguard Children 4 recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 3.2. This serious case review used a mixed methods approach based on systems methodology. Agency Review Reports were requested from the agencies that had provided services to Charlie and the family. Agency Review Reports and other written reports were received from: Local Authority Adult Social Care Clinical Commissioning Group (CCG) Area A on behalf of GPs Hospital Trust Area A (Health Visiting, Inpatient and community midwifery post-delivery, ante natal outpatients, Community Rehabilitation Services to Father, Accident and Emergency) Hospital Trust Area B (Accident and Emergency, Hospital Midwifery) Hospital Trust Area C (Specialist Health Services to Father) Mental Health Trust Local Authority Children’s Services (Children’s Social Care and Education) Police Ambulance Service Housing Privately Funded Specialist Epilepsy Nurse for Father Privately Funded Occupational Therapist/Case Manager for Father (NB Area A denotes area of residence, whilst Areas B and C denote alternative local authority areas) 3.3. Members of the panel, practitioners and their line managers, report authors and safeguarding leads came together for two Practitioner Learning and Reflection Workshops (PLRW). Attendees at the first PLRW had an opportunity to review all the Agency Review Reports prior to and during the day. The PLRW also included group work whereby attendees identified areas where learning had occurred. The second workshop enabled a review of the emerging themes, learning and recommendations. In keeping with Working Together 2015 guidance, the PLRWs ensured full engagement from agencies who had provided services to the family. This was to enable an understanding of the systems that practitioners were working within with a view to ascertaining why practitioners practiced in the way that they did and how they made decisions. 5 4. The Reviewer 4.1. Karen Rees is an Independent Safeguarding Consultant with a nursing background. Karen worked in safeguarding roles in the NHS for a number of years. Karen is completely independent of WSCB and its partner agencies. 5. Process and Scope 5.1. Full Terms of Reference and Project Plan were agreed at a meeting of the Serious Case Review Sub Group on 9 November 2017 and are attached as Appendix 1. The review has considered agency involvement with Charlie, siblings and parents from September 2014, (the start of the school year just prior to Mother’s pregnancy with her second child), until the date of the serious childcare incident. 6. Parallel Processes and Family Engagement 6.1. At the time of conducting this review there was an open coroner’s inquest and ongoing criminal investigations. The Coroner was made aware of the Serious Case Review. As the criminal proceedings progressed to charges, the coroner closed the case. 6.2. Due to the ongoing investigation, Police asked that the family were not approached at that stage. This decision was respected and therefore arrangements to meet with the family were not possible until after the conclusion of the criminal processes. The family were therefore informed about the review in writing and sent a leaflet about the method of conducting the review including the use of family records. 6.3. The criminal proceedings concluded with Father being convicted of murder. Mother and Father were then invited to contribute to the review. Father cancelled the appointment; Mother was not at home for a pre-arranged meeting. As it was not possible to engage with the parents, there are some gaps in information and therefore the review does not contain family perspectives of the lives of themselves or their children and the services that they received. 6.4. For the purposes of this review, the family will be known in the following way: Family member To be called Mother of Charlie Mother Father of Charlie Father 1st Child of Mother/Stepchild to Father Sibling 1 2nd Child Sibling 2 6 7. Background Prior to Scoping Period 7.1. Information available to the review would indicate that Mother and Father had been in a relationship for about 5-6 years at the time of the incident. Father has two children from a previous relationship. Mother has one child from a previous relationship (Sibling 1). 7.2. The Police provided some historical information to the review that reflected significant domestic abuse perpetrated by Father in a previous relationship and evidence of violence towards his sister and partner. GP records indicate that Father sought support for anger issues in 2004. In 2012 Father self-referred to Primary Care Mental Health services but did not meet the criteria for services and was discharged. 7.3. Mother was seen once in mental health services for anxiety and depression in 2013. This was attributed to her mother’s house being burgled and that Mother lived on her own with a child (Sibling 1). 8. Key Phases 8.1. For the purposes of this review the children’s story will be highlighted using relevant information in key phases that inform the areas for analysis in section nine of this report. Relevant information from the Agency Review Reports was extracted and discussed in the PLRW seeking to understand the multiagency working and learning. Key Phase 1: September 2014- August 2015 (Birth of Sibling 2) 8.2. During this phase, Sibling 1 was attending School 1. There were no concerns expressed with attendance, behaviour or academic ability. 8.3. The family were living in private rented accommodation; records suggest that Mother and Father had their own tenancies initially. 8.4. In December 2014, Mother booked for antenatal care at the GP Practice. At the home visit by the community midwife that followed, it was noted that parents were living together with Sibling 1. No risks or concerns were identified. Routine domestic abuse enquiry was undertaken at various points with no disclosures made. Ante natal care was noted to be shared between Area A Hospital Trust community midwifery services and Area B Hospital consultant and midwifery staff. 8.5. In May 2015, Father attended his GP stating that he had difficulties controlling his temper. He indicated that he was affected by issues from his childhood. He advised the GP that he had been violent and aggressive in the past. He reported that his partner was supportive. The GP referred Father to Primary Care Mental Health Services. It is confirmed that Mother and children were registered at the same practice as Father. 8.6. Father was seen by Primary Care Mental Health Services from the Mental Health Trust at the GP practice in June 2015. Mother accompanied him to the appointment. It was noted that Mother was pregnant at the time of this consultation although the name of Mother is not recorded. The 7 information disclosed by Father led to a discussion of treatment options with a suggestion of contact with an external counselling service for support with anger management. 8.7. Following this consultation, Father was discharged by Mental Health Services. No risks were identified and no information was shared with any other services. This will be subject to further analysis in section nine of this report. 8.8. Mother attended all her ante natal appointments and was seen on a self-referral basis for varied concerns during pregnancy. None of these concerns were reported to be out of the ordinary. Pregnancy progressed well. Sibling 2 was born following a planned induction of labour for medical reasons (attributed to pelvic girdle pain that is not an uncommon pregnancy complication). Key Phase 2: August 2015 (Birth of Sibling 2) - Pregnancy Booking Charlie (August 2016) 8.9. Mother and Sibling 2 were discharged the day after the birth. No risks or concerns were identified. 8.10. Routine post-natal care was undertaken at home by the community midwives. Routine maternal mental health screening did not highlight any concerns. Community midwifery services handed over care to the health visiting service within the same Hospital NHS Trust (Area A). 8.11. The health visitor undertook the new birth visit in line with the Healthy Child Programme (HCP)2. Father was not present at this visit. Details of family members were recorded. No risks or concerns were identified. Routine domestic abuse screening was undertaken with no disclosures made. The level of service identified that was required to meet the needs of the family was Universal i.e. indicating that there were no additional needs; the family required routine screening appointments only. 8.12. Sibling 2 was seen with Mother by the health visiting service on two further occasions. The first was for the follow up visit secondary to the new birth visit, the second was for the 6-8 week check at home. Nothing of note was recorded and the family remained subject to Universal level of intervention. It is noted that the required routine maternal mental health screening was not undertaken at this visit. 8.13. Sibling 2 was not brought for the routine introduction to solids appointment in early December 2015 (pre-Father’s accident). 8.14. The family moved into a social housing tenancy in October 2015. A welcome visit was made by a housing officer after ten days; no welfare or safeguarding concerns were noted. 8.15. It was noted that neighbour disputes started soon after the family moved but appeared to be of a ‘tit for tat’ nature with both the family and neighbour reporting concerns about noise and disruption. One of the concerns was the neighbour reporting that he heard a baby crying and verbal 2 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk 8 abuse being shouted at the baby. This was at the time that Father was in hospital. The housing officer visited to investigate on the same day but there was no reply. Father was still in hospital when the visit took place six days later. At this visit it was noted that the baby was in the bouncer, was content and had no visible marks. The property was clean, warm and well ventilated. The disputes appeared to be ongoing until the family moved in May 2016. 8.16. Father sustained a traumatic brain injury from a fall at work in early December 2015; he remained in Area C Hospital until the end of January 2016. He was referred to Area A Hospital’s Community Neurological Rehabilitation Team (CNRT)3 for follow up. He also remained under the care of a Neurologist at Area C Hospital. 8.17. It is recorded in GP records in December 2015 that Grandmother was looking after the baby (Sibling 2) as Father was in hospital in a coma following a fall at work. 8.18. In April 2016, Sibling 2 was seen at clinic for a 9-12 month review as per HCP. No concerns were noted with health or development. There is no evidence that Mother’s mental health was assessed as would be standard at this appointment. It is not recorded that there was any knowledge of the circumstances of Father’s injury at this appointment. 8.19. CNRT noted concerns related to Father’s condition and that Mother had become his carer. Concerns related to behaviour change as a result of his brain injury and that he was displaying angry outbursts of a verbal and occasionally physical nature. Both parents stated that there was no physical violence to her or the children. How this information was shared and with whom will be subject to further analysis in section nine. In May, sessions with a clinical psychologist commenced to include support with anger and irritation. 8.20. In May 2016, the family were rehoused on medical grounds due to Father’s brain injury. 8.21. In June 2016, an ambulance was called as Father had slurred speech. Father was conveyed to Area A Hospital where he complained of head pains. Father was admitted and underwent tests and observations. CT scans of his head showed no changes. Father demanded to be discharged the following morning. 8.22. It was also in June that Mother contacted Adult Social Care to request psychiatric support for Father. This was declined as it was not the role of Adult Social Care; Mother was appropriately signposted to the GP. 8.23. In July, an ambulance was called for Father who was fitting. He was conveyed to Area A hospital. It was noted that Father had a pre-arranged consultation with a neuro clinician a few days later and he was discharged. 3 Community Neurological Rehabilitation Team consists of a multidisciplinary team of a range of professionals to offer rehabilitation and support services dependant on a patient’s assessed need. 9 8.24. At the end of this phase, an Independent Occupational Therapist (OT) Case Manager received a referral from the solicitors and insurers related to Father’s injury claim. This was to provide input around Father’s rehabilitation needs. This was in addition to the input being received from NHS services. The extent of the understanding of this role and the dimensions it added will be analysed further in section nine. 8.25. Sibling 1 had moved school in February. Neither School 1 or 2 appeared to have knowledge of Father’s brain injury and reported no concerns during this phase. 8.26. It is of note that all the professionals working with Father, knew of his status as a Father and many had contact with the children in the course of their work. Key Phase 3: August 2016- Birth of Charlie (March 2017) 8.27. In August 2016, Mother attended an antenatal booking appointment with the community midwife at the GP surgery. Father was in attendance. Mother and Father were asked about family health and there was no information given about the brain injury and any impact. There were no risks identified at this contact. 8.28. In September, the Community Midwife undertook a home booking visit. Father was present. At this visit, Mother stated that her occupation was a full-time carer for Father. There is no entry in the records to indicate that this was explored further. 8.29. During this phase, it was arranged that taxis could be funded through the injury claim in order that parents could get to appointments. 8.30. In October 2016, an Independent Epilepsy Nurse was funded through the injury claim as it was recognised that there was currently no NHS provision available. The Epilepsy Nurse visited the family on several occasions and supported them in managing childcare safely as well as other aspects of epilepsy management. 8.31. In November, Father suffered a further seizure. On this occasion he recovered whilst the ambulance crew were in attendance and he remained at home. 8.32. This phase is characterised with significant involvement from the CNRT offering support and rehabilitation to Father and increasing notes in records regarding the nature of Father’s anger and frustration. 8.33. When Mother’s maternal mental health was assessed by the community midwife, it is reported that she expressed that she was stressed and answered ‘yes’ to both Whooley questions4. The patient 4 The Whooley Questions (see below) are used as a screening tool for major depressive disorder. A no response to both questions (negative test) essentially rules out depression, and a yes response to one or both questions (positive test) identifies virtually all persons who may benefit from further evaluation. 1) During the past month, have you often been bothered by little interest or pleasure in doing things? (Yes/No) 10 held records record this as ‘stressed’; in the electronic records ‘anxiety’ is ticked. There was no further action recorded regarding this. At a later appointment this no longer appeared to be a feature. 8.34. Two episodes in this phase indicate the ongoing stress for Mother. In October, she complained about the current midwife and requested a change. In December, Mother was reported to be angry and agitated at the time it took to book the next hospital appointment whilst at the GP surgery. There was no further exploration of this recorded. 8.35. In December, letters within the GP records for Father from Area A Hospital and Area C Hospital indicate ongoing concerns. These indicated anger and frustration that included displays of physical aggression albeit no reports of direct violence against persons. 8.36. The Independent OT case manager referred Father to Adult Social Care for a Care and Support Assessment. Father’s needs were assessed not to be significant from an Adult Social Care perspective. Needs were mainly noted to be housing and financial. Adult Social Care were informed by the Epilepsy Nurse that there were significant concerns regarding safety in the home because of the number of seizures Father was having. There was an indication that Mother could not leave him on his own and he needed 24-hour monitoring. 8.37. In November, Sibling 2 was seen in the paediatric assessment unit at Area B Hospital for a rash. During questions about family health, Father was reported to be well. There was no mention of Father’s brain injury or epilepsy. Also in November, Sibling 1 was admitted to Area B Hospital for an elective tonsillectomy. 8.38. In December, Mother presented with Sibling 2 in Accident and Emergency at Area B Hospital with a tiny bruise and scratch mark in the ear. The injury was reviewed by a paediatric consultant and no safeguarding issues observed. Sibling 2 was diagnosed with acute tonsillitis. 8.39. None of these attendances resulted in knowledge of Father’s condition or the stressors that were present for Mother. 8.40. In mid-January, Adult Social Care social worker referred Father for an assessment for Continuing Healthcare funding. The assessment took place two weeks later. It was noted that as part of this assessment Father required constant support and supervision in terms of his own needs. This assessment documents anger due to tiredness, that Father is not able to look after the children on his own, that he feels a burden and was very low in mood. This assessment did not include his role as a Father, it was purely to assess his need for any further funded healthcare. The impact of this and origin of these stated issues is further analysed in section nine. 2) During the past month, have you often been bothered by feeling down, depressed or hopeless? (Yes/No) http://whooleyquestions.ucsf.edu/content/home accessed 23 April 2018 11 8.41. The day before the CHC assessment, Adult Social Care contacted Children’s Social Care to inform them of the circumstances the family were in and to seek support for getting Sibling 1 to school. Sibling 1 was still attending school in the previous area following their house move. Support was declined as there were no additional needs in respect of Sibling 1. Children’s social care have no record of this contact. The continued difficulty in getting Sibling 1 to school eventually resulted in funding of Taxis through the injury claim. This was arranged by the Independent OT in addition to the already agreed use of taxis for appointments. Adult Social Care were not advised of this. During the CHC assessment it was agreed that the Adult Social worker would contact Children’s Social Care to update them. There is no record that this second contact took place in either Adult Social Care or Children’s Social Care records. If it did take place and was not recorded, there was no ensuing action from Children’s Social Care. 8.42. Adult Social Care provided Telecare services and signposted Father for support services from Headway5. A carers assessment commenced for Mother, but this was never completed. Adult Social Care supported an application for rehousing and school transfer for Sibling 1. 8.43. During the final stages of Mother’s pregnancy with Charlie, the Independent OT arranged for private funding for the family to pay for two days per week additional childcare (nursery and then subsequently a childminder) for Sibling 2. This was in order to reduce the burden of childcare and replace the support Father would have given if not for his brain injury. 8.44. In February, there is a record that the health visitor attempted an antenatal visit as required by the HCP. It is not known if this was a booked appointment but there was no reply at the address. There was no record that this visit was rescheduled. 8.45. Area B Hospital maternity records indicated that labour was to be induced in this pregnancy due to social reasons. There is no further indication as to why this was. Community midwifery services in Area A were not aware of this information. Once labour had been induced, Mother asked if things could be speeded up as she was concerned for Father as exhaustion could be a factor for seizures. This information did not feature in the discharge summary. Key Phase 4: March 2017 (Birth of Charlie- Date of Incident (August 2017) 8.46. Charlie was born following the planned induction and was well at birth. Mother and Charlie were discharged the following day. 8.47. The community midwife carried out a routine post-natal visit the day after discharge and reported no concerns. A physical assessment of Mother and Charlie was undertaken. Emotional well-being was reported to be normal. A further contact was made on day 5 at the GP surgery. No concerns were reported and emotional well-being was again noted to be good. Mother did not attend a further planned appointment at the children’s centre. This was the day after the family moved. An appointment was left with Father but this contact did not take place. 5 Headway is a registered charity that supports people affected by brain injury to improves their lives 12 8.48. When Charlie was nine days old the family moved to a privately rented bungalow. When housing attended the previous tenancy to prepare it for re letting, they found two doors internally had been damaged. The housing report for this review indicated that photographic evidence confirmed that the doors appeared to have been punched (at a height consistent with an adult rather than a child). This information was not shared with any other agency. 8.49. The health visiting service received the birth notification in a timely manner. There were difficulties arranging the new birth visit as the family had just moved, were busy settling in to the new home and stated it was not convenient to have the health visitor there. Due to the change in address, the health visitor handed over to a new health visiting team and the new birth visit was undertaken on day 15 (one day outside of recommended timescale for the visit). 8.50. At the new birth visit parents and both siblings were present. Health for both parents was reported and recorded as good. The Whooley questions were asked with a negative response from Mother. The domestic abuse routine enquiry undertaken when Father was out of the room resulted in no disclosures. The result of this visit was that health visiting care plan would be as per the Universal Service with the next contact being at 6-8 weeks. 8.51. The 6-8 week home visit appointment was not carried out; the health visitor was met on the doorstep as Charlie was reported to be asleep and generally unwell. The appointment was rearranged for three days later at the clinic. Mother reported that she had changed Charlie’s milk feed on advice of the GP as Charlie had been vomiting after feeds. 8.52. Although Adult Social Care had an open case for Father, there was little activity in this phase. The social worker had been off sick and left, leading to the case awaiting reallocation. The carer’s assessment in respect of Mother was closed as it was not completed. The family did not make any contact with Adult Social Care requesting any further support. No contact was received from any other agency requesting further input for the family. 8.53. In this phase, the GP received further letters from the Psychologist in the CNRT detailing the circumstances of concern at home. This related to the ongoing anger and frustration and detailed issues where Father had indicated a wish to end his life. Father had declined respite care. There were also reports in this phase that parents had stated that they had had enough of all the different professionals involved and that they just wanted to be left alone. They felt that they had enough support from the Independent OT. 8.54. The GP followed up this information with a review appointment. Father denied any current thoughts of suicide and declined the offer of support from a community psychiatric nurse. 8.55. As a result of the ongoing concerns that Father’s rehabilitation was not progressing, alongside about the difficulties consistency in engagement from the family, there was consideration of a multi-disciplinary team (MDT) meeting. This meeting took place in May. The meeting was attended by the Independent OT, the Independent Epilepsy Nurse and the Psychologist. The focus was related to the role of Mother as carer, to set rehabilitation goals and identifying seizure and medication management. Minutes of the meeting were sent by the Independent OT to those involved. The Area 13 A hospital does not have a record of the minutes. Anger and frustration at the level that it was being discussed in letters and in notes was not discussed at this meeting. 8.56. In June, Sibling 1 (aged 8 ½ years) arrived at School 3 (where he had moved two months previously), crying. Sibling 1 disclosed that Father had been throwing coins towards Sibling 1’s head as a result of asking for money for a school trip. Sibling 1 went on further to disclose that Father often gets angry when they play fight and that the punches can be really hard and that it hurt. Sibling 1 stated that Father only stops when he gets bored. On making time to listen to Sibling 1 further in a ‘Time to Talk’ session, Sibling 1 made significant disclosures regarding various aspects of home life that included arguments between parents and anger in Father that made Sibling 1 feel scared. Sibling 1 also disclosed that Father hurts Mother and says mean things to her. Sibling 1 gave more details of other rough play that was indicative of risk of injury to the children in the home. Sibling 1 asked that Father was not told about what had been disclosed to school. 8.57. As a result of this information a call was made to the Multi Agency Safeguarding Hub6. The response from Children’s Social Care was that the threshold was not met for a Child and Family Assessment and Mother should be offered Early Help support. When school staff spoke to Mother she declined Early Help stating that they had lots of help and support. Mother was seen to respond appropriately to Sibling 1 and hugged and provided reassurance. Prior to this incident, Sibling 1 had not mentioned anything to School 3 about Father’s brain injury or fits; they had no knowledge of this. School 3 continued to undertake well being checks and monitored Sibling 1 for signs of abuse or distress. None were noted. School 3 took no further action regarding the threshold decision by Children’s Social Care or to speak to any other professionals that Mother had indicated were supporting them. 8.58. The Epilepsy Nurse visited in this phase and continued to offer advice to Father about safe childcare e.g changing Charlie’s nappy on the floor and feeding sitting on the floor. He was also advised not to bath the children but to top and tail only. There is no record of any communication with the health visitors or midwives regarding this advice or the reasons for the epilepsy nurse involvement. 8.59. In July, an ambulance was called for Charlie who was reported to be vomiting blood. The ambulance crew found all physical examinations to be normal and conveyed Charlie to Area A Hospital Accident and Emergency. The GP received information from Accident and Emergency that Charlie was transferred to the Urgent Care Centre following triage, suggesting that this was not a critical emergency. The outcome of this attendance is recorded on GP records as ‘discharged with advice’. This was not known to the health visiting team as information is not shared from these attendances with the paediatric liaison service or the health visitors. 8.60. In August, Charlie was in the care of Father and collapsed. Injuries identified were consistent with having been shaken. Charlie was transferred to the regional intensive care unit where life support was maintained. A decision was made that the Charlie could not survive the injuries and life support 6 Multi-agency safeguarding hubs Multi-agency safeguarding hubs are structures designed to facilitate information-sharing and decision-making on a multi-agency basis often, though not always, through co-locating staff from the local authority, health agencies and the police. 14 was withdrawn three months later and Charlie died. 9. Thematic analysis 9.1. By analysing the agency review reports and using the information gathered at the Practitioner Learning and Reflection Workshops, it is possible to identify areas where there is learning that can lead to recommendations and improvement. 9.2. It was stark in this case how much information was known to those working with Father and Mother as his carer. All of those working with the children as their focus, had no knowledge of the situation and difficulties that the family had found themselves in following Father’s Accident in December 2015. 9.3. It was very difficult to find the voice of the child in the many reports that were received or at the PLRW’s and therefore leads to the first area for analysis. THE VOICE OF THE CHILD IN ASSESSMENT AND UNDERSTANDING RISK Opportunities for hearing the voice of the child: Children’s workforce 9.4. Due to information not being known to midwifery services and the health visitor, Father’s anger and later accident did not feature in the assessment or understanding of risk by these practitioners in either pregnancy. The family were identified as requiring universal services only. The domestic abuse questions were asked of Mother by both midwifery and health visiting staff and no disclosures were made. 9.5. This routine enquiry regarding domestic abuse was good practice and shows evidence that learning from previous SCRs in the locality appear to have been applied. 9.6. The information regarding the outcome of primary care mental health services assessment in May 2015 was recorded in the GP records for Father. Fathers’ records are not routinely accessed by community midwives during ante natal and post-natal services within GP practices. 9.7. Midwives stated that the reason that fathers’ records are not accessed is that it is the Mother that is their patient and not the Father. Consent to access fathers’ records is cited as an issue. It can be seen from the work of the Fatherhood Institute7 and in advice to midwives from the Royal College of Midwives8 that full and meaningful engagement with fathers should be encouraged. This is because of the positive impact not only on fathers, but on mother and baby. Consent can be gained to access and document in fathers’ records. Most fathers would see this as positive inclusion in whole family ante natal care. In this case, Father was registered at the same practice. This may be more of a challenge where a father is not registered at the same practice. If inclusion of Father and recording 7 The Fatherhood Institute. http://www.fatherhoodinstitute.org/ Accessed 25 May 2018 8 Reaching out: Involving Fathers in Maternity Care https://www.rcm.org.uk/sites/default/files/Father%27s%20Guides%20A4_3_0.pdf Accessed 25 My 2018 15 in Father’s records had been routine, the midwifery service would have become aware of the brain injury to Father. Fathers who decline consent to be included could invoke a professional curiosity as to why that may be and in some cases, identify potential risk factors. 9.8. The assessment of maternal mental health, during second pregnancy, was not robust. Mother had answered positively to the Whooley questions which may have been indicative of how things were at home. This was within the period following Father’s accident. This information was not effectively documented and therefore was not available to those undertaking maternal mental health assessments in the post-natal period. The actual recording of the answers to the Whooley questions was not obviously apparent within the records. However, the patient held records state that mother was stressed and the electronic records indicate anxiety was present. It is not clear why neither of these issues led to further assessment and support. The Area A Hospital Trust have evidenced this as learning and made single agency recommendations regarding this. 9.9. In the ante natal period for Charlie, the issue of the agreed induction of labour for social reasons and the ensuing request to speed things up so that Father did not get tired, was not known to community midwifery. This was because it was not recorded in the shared patient held midwifery notes. This had only been recorded in the obstetric notes of Area B Hospital. 9.10. Community midwifery services in Area A and hospital midwifery services in Area B have traditionally shared information across their services via email communication and within the maternal patient held records. There is a recent development of the installation of new records software at Area B Hospital that will enable Area A midwifery services access to view all electronic hospital notes. The improvements to communication and the efficacy of this will form part of WSCB assurance seeking recommendations from this review. 9.11. When the community midwifery service then asked about maternal mental health in the post natal period, it was reported to be good. It is not clear why this had changed. The author would suggest that as there was no action on disclosure antenatally, there was not much mileage in disclosing anything further as it did not lead to further questioning or understanding. 9.12. It is also clear that Mother told community midwifery services that she was a full-time carer to Father. This did not elicit any further questioning about what this meant and any impact this would have. The Area A Hospital Trust have not been able to identify why this was. It is possible that a culture of professional curiosity is not embedded this is discussed later. 9.13. There was a further attendance that may have been suggestive of requiring further exploration and possible support. In December 2016 Mother attended Accident and Emergency with Sibling 2. The presenting condition was regarding a bruise in the ear. It was felt by all at the PLRW that this was not a usual concern to be presented at an emergency department. Although procedures were followed and a paediatric opinion was sought, there was no documented exploration of why Mother had been so concerned about such a tiny mark to cause her to present Sibling 2 to Accident and Emergency. This may have been a further missed opportunity to hear the voice of the child. 16 9.14. In terms of understanding what these incidences would mean for any children in the household and any impact on them, practice did not consider the voice of the child. These missed opportunities to apply professional curiosity may have been the reason that those professionals did not know of the situation regarding Father’s injury and epilepsy. Child focussed professionals did not know about the large number of professionals working with Father and Mother from half way through Key Phase 2. 9.15. It does have to be acknowledged, however, that on being asked about family health on several occasions post Father’s accident, there was no information made available to professionals by Mother or Father. 9.16. There was one very clear indicator of the lived experience of the children and the voice of the child. In June 2017 Sibling 1 made clear disclosures regarding what constituted physical child abuse and domestic abuse and violence. School 3 responded appropriately and gave time to listen to what Sibling 1 was saying. When this was referred to Children’s Social Care through the MASH, it was seen as an advice call. The call is not documented by Children’s Social Care and therefore it is not possible to understand why a direct disclosure of abuse and violence by an 8-year-old child was not subject to any further assessment. 9.17. It could be argued that even if it was felt that the threshold for Child and Family Assessment by Children’s social care was not met, the issues that were disclosed could have been subject to some agency checks. That may well have alerted the GP that the issues that were recorded in Father’s records were having a direct impact in the home and on the children. Sibling 1 was not a child who had ever disclosed at previous schools about Father’s brain injury or epilepsy. This then, was out of character. It is important to note that at the time of the disclosure, Sibling 1 had only been at School 3 for five weeks. School 3 listened and offered very good care after Sibling 1 chose to tell them what was happening at home. The impact of not being heard by and responded to by the system to effect change and protection may well have prevented any further disclosure. 9.18. When spoken to by school staff, Mother played down what was happening and staff saw her respond appropriately to Sibling 1. In the context of any domestic abuse she may have been experiencing, this would not be an unexpected response. 9.19. The previous contact by Adult Social Care about the difficulties Mother was experiencing in managing childcare were also not documented by Children’s Social Care, so this further piece of the jigsaw did not add to the picture that was emerging. 9.20. School 3 recognise that they could have done more to challenge the Children’s Social Care response. They could have searched out more information from Mother when she indicated that there were many professionals supporting them. This could have led to further information being shared. Education services have made appropriate recommendations to address this in their own agency review. 9.21. The previous information regarding Father’s historic violence was only known by the Police. The issues related to a previous relationship and would not have been flagged to those working with the 17 family in the timeframe for this review. It is the case, however, that if the referral regarding Sibling 1’s disclosure had resulted in any background checks, then this evidence would have come to light and would have led to a different understanding of risk. Opportunities for hearing the voice of the child: Adults’ workforce 9.22. This then moves us to thinking about how those working with the adults heard the voice of the child and understood risk to the children in their assessments of the adults. 9.23. The first time that there is an indication of risk to children by those assessing Father is in June 2015 in the first key phase. Sibling 1 was six years old and Mother was seven months pregnant with Sibling 2. Father had attended the GP practice with concerns over managing his anger. Having been duly referred to Primary Care Mental Health Services he was seen and assessed. 9.24. This assessment appointment took place at the GP practice. Father was accompanied by Mother and it was understood by the mental health worker that she was pregnant. The severity of depression was recorded from the completed questionnaire as low. Disclosures were made, however, of significant anger and that Father indicated he knew he was capable of harming himself or others when he loses his temper and it gets out of control. It is further documented that there were no safeguarding concerns. Although the record indicates that his partner’s baby was due soon, there was no recording of Mother’s name. 9.25. The outcome was for referral for an external counselling service that was funded by commissioners for those with a GP in the locality. It is not known if this service was accessed by Father. It is not recorded how the financial pressures that were also disclosed were going to be supported or if any advice was given regarding this possible trigger for his symptoms. The practitioner who undertook the assessment is not able to recall the consultation. 9.26. The Mental Health Trust has recognised this as an issue for their services. This assessment does not consider the voice of the child and no other checks or balances were made regarding what was being disclosed. There was information in the GP records regarding historical anger issues and the previous attendances regarding this. Had this been known, the current presentation may have been viewed differently. 9.27. Since this time there are new procedures within the Mental Health Trust that include undertaking checks within their agency to ascertain any history. There is now an electronic system for reporting and flagging concerns that links to seeking safeguarding advice. There is also a system of professionals meeting where there may be concerns for unborn babies. These meetings are attended by the safeguarding midwives. Had this system been in place at the time, the Mental Health Trust have indicated that this family would have been discussed. 9.28. Clarity was sought at the PLRW regarding the assessed need of Father. This was to try and understand the impact that this would have had on Mother as his carer, as well as being a mother of a growing family. It is apparent that there were no physically assessed needs in that he was able to manage activities of daily living. The independent OT has informed the review that Father was not 18 one to be involved in housework before the accident and therefore it was not a requirement to re teach him skills. There was an indication that it was more about motivation to undertake tasks post injury that was the issue. Father had lost confidence in himself and required support to go out of the house. 9.29. Tensions appeared to increase after the seizures started. Father could no longer drive and Mother did not drive. There was significant information in the CHC assessment regarding Father’s needs that indicated that risk to the children and the baby that was due within six weeks needed to be assessed. Issues such as anger, not being able to care for the children alone, feeling a burden and low in mood may have had an impact on Mother’s ability to cope, Father’s mental health and well-being as well as possible risks to the children. 9.30. There is no clarity in the recording of the CHC assessment as to why it was recorded that Father could not care for the children alone. i.e. whether it was Father and/or Mother who had stated that Father could not care for the children alone. A review of what is documented as well as discussion with the assessor, has resulted in knowledge that it was discussed but not who had stated it. 9.31. It was issues of this nature though, along with the fear of seizures happening resulting in either injury to himself or the children that led to the decision, possibly by Mother, that Father could not care for the children on his own. No professional documented any assessment that stated that Father should not be left alone with the children because he was a risk. Records do indicate that, as he struggled to manage his own care, he would not be able to provide adequate care for his children on his own. This issue may become clearer when the author is able to speak to parents. 9.32. Adult Social Care attempted to get support for Mother from Children’s Social Care. Mother was struggling to get Sibling 1 to School 2. The whole family had to travel some distance to school on a bus as Mother could not drive and could not leave Sibling 2 alone with Father. This referral was rejected and is not recorded by Children’s Social Care. Adult Social Care were not given any advice as to how to proceed. When there may have been evidence that there was recognition of the need to support the family further during the CHC assessment, there is no record of a call to Children’s Social Care. There is therefore no evidence that any information from the CHC assessment was shared with Children’s Social Care. If it was, it did not result in any action or advice from Children’s Social Care. Notwithstanding this, it is a hypothesis from this review, that largely, the issues that parents presented to adult workers were seen in terms of meeting Father’s needs. The impact on children living within these circumstances, both historical and current was not seen as a possible risk. 9.33. Adult Social Care did not contact the school to see if there was any support that the school could give. Mother was seven months pregnant at this point, but Adult Social Care did not contact either the GP, the community midwife or the health visitor. This was another missed opportunity for adult and children’s workers to share information. 9.34. The CHC assessor contacted the GP during the assessment process; it does not appear that the GP shared any historical information related to violence or aggression. 19 9.35. Adult Social Care has identified that as a negative response was received from Children’s Social Care, on the day before the CHC assessment, they took that to mean that there was nothing further that could be done. There were two issues here. Firstly, Children’s Social Care did not offer any further advice and guidance to Adult Social Care about other options for family support that they might try. Secondly, there was information within the CHC assessment that was significant. With the negative response from Children’s Social Care and the further information from the CHC assessment, Adult Social Care could have made use of the Thresholds Guidance9 to identify what level the needs of the children were at. This may have prompted contact with school, health visitor GP etc. These were the professionals who would be supporting children below the threshold for Children’s Social Care interventions (i.e. at levels 1-3). This has led to a single agency recommendation by Adult Social Care regarding training and use of the Thresholds Guidance. 9.36. Further indicators of risk for the children were missed due to the incomplete carer’s assessment for Mother. It has been stated that Mother was ambivalent to the assessment and gave different responses regarding her needs. This lack of engagement from Mother, meant that the assessment was not completed and was closed as a piece of work. The author would argue that it is possible that Mother may have been more engaged with the assessment if there had been more contact with the social worker. The case was left unallocated when the social worker went off sick. Had Mother understood what the outcomes might have been and had an opportunity to build a relationship with the social worker, she might have engaged more. This may well have had a positive impact on the children. One of the stated reasons for not having more involvement was the belief by the social worker that the Independent OT was undertaking the lead role. 9.37. The Independent OT informed the review that the role was regarding the rehabilitation of Father and does not have the statutory duty to undertake a carer’s assessment as identified within the Care Act 2014. That responsibility lies with the Local Authority Adult Social Care. The communication issues here are discussed in the next section. 9.38. Adult Social Care now have regular ‘share meetings’ at GP practices and this would be an opportunity to discuss cases of this nature. Had this been in place at the time it may have led to wider information being shared with the health visitor and/or midwife. The Local Authority are also in the process of producing a Corporate Safeguarding Policy (Adult and Children). This will cover all directorates in the council and will ensure that everyone has access to information regarding referral and escalation pathways. The policy will also reference Thresholds Guidance for safeguarding children. 9.39. As more information was being disclosed to professionals working with Father, no one spoke to Sibling 1 to understand any impact on him. Books and information were given to Father to read to Sibling 1 regarding a parent with a brain injury. There was also work planned with Sibling 1 by the 9 MULTI - AGENCY THRESHOLD GUIDANCE Identifying Need and Analysing Risk when working with Children in Walsall available at http://westmidlands.procedures.org.uk/assets/clients/6/Walsall%20Downloads/Multi-agency%20threshold%20guidance%20(PDF%201MB).pdf accesssed 26 April 2018 20 Epilepsy Nurse regarding seizures; parents declined this stating that they did not want Sibling 1 to be upset. 9.40. There did not appear to be an understanding of the impact of living in an environment of constant stress and displays of aggression would have on young children or the risk that could ensue from this. Moreover, the unpredictable nature of Father’s outbursts must have been very difficult for the children and Mother. 9.41. It is noted that some of those working with the adults did not have information related to the level of aggression e.g. the Independent OT has stated that there was knowledge of frustration and irritability but not of any physical aggression that is seen in the Psychology reports. Further issues related to how this was understood and communicated will be discussed later in this review. 9.42. Father did indicate to one of the psychologists, that he had previously had some anger issues but stated that this was of a verbal nature and was minimised by Father. It is of note, however, that the problems being presented were largely considered by most professionals working with Father to be new and out of character for him. This may go some way to explaining the inability to understand risk. There was a degree of empathy being applied by those working with Father and trying to support him to rehabilitate back to his pre-accident demeanour. What they were not aware of, was that Father had historic anger issues, some of those being significant violence to others. 9.43. Those whose primary focus were the adults, knew of Sibling 1 and 2 initially and then of the pregnancy and birth of Charlie. Whilst only some of those professionals were aware of the level of anger that was being displayed, none of them knew that anger was not a new issue post brain injury and that in fact, this was documented in GP records back as far as 2004. 9.44. In sessions with the CNRT and at appointments with the neurology service at Area C Hospital, issues and concerns related to anger and frustration were being disclosed. These services did not consider that there was enough concern or evidence that the children were at risk and therefore did not share this information. Several reasons were put forward for why this was the case. As there had been no reports of violence against the children the risk was not recognised. There was concern expressed that it was important to keep the professional relationship with the parents and that to share that information may cause parents to disengage. 9.45. Housing staff also had indicators of the stress that the family were under. Whilst Father was in hospital after his accident, housing received a report of an adult shouting at a baby. When they visited, there were no safeguarding concerns noted and therefore information was not shared. The significance of Father’s hospitalisation was not fully understood and the information was not shared with those that may have been able to offer assessment and further support. 9.46. Housing staff also had more evidence of possible violence when they reported that doors needed repair due to adult punch marks. This was not shared with any other agency, because its significance was not recognised. Housing services have made a recommendation about this issue in their agency 21 review report. 9.47. There is very clear research regarding the impact of witnessing domestic violence on children and this is now accepted in all professional fields as child abuse10. Domestic abuse cannot be ruled out in this case despite the non-disclosures by Mother. Sibling 1 indicated this in his disclosure at school. As Mother denied this when challenged it would have been very difficult to evidence and support. It is less clear in research and less well understood by some professionals, of the impact of other displays of irritability and aggression. There is some research11 to suggest that displays of anger appear to be stressful for young children and that if that anger becomes physical then the level of stress increases. 9.48. The GP practices involved from when Father’s accident occurred had comprehensive information detailing the behaviour that Father was displaying and that was causing issues at home. This did not lead to any understanding of the impact this was having on any children and any risk. All family members were registered at the same practice throughout the period under review. The GP practice also had some information that this aggression was not unique to post Father’s accident. The reasons for the previous referral from the GP to the mental health team, along with the outcome was documented within the GP records. This was not shared with others. 9.49. The reasons cited that the GP practice did not assess the impact of the information that they were in receipt of, was that none of the letters indicated that the GP was required to do anything with this information. The author would challenge this as the GP practice was the only place that had details that this patient was a father who was displaying historic and current anger. This should have been recognised and information should have been shared. It was argued by the author of the GP Agency Review, that it would not be possible with the number of patients and time constraints to have acted on this information without a clear mandate to do so from those sharing the information. Those who wrote the letters had indicated that they would have a professional respect for the GP and would not always add instructions to their letters unless it be for a change of medication. 9.50. It is, however, the case that all those who knew this information had responsibility to share it. It appears that there are misconceptions regarding roles. The GPs have acted as passive recipients of information. Those writing letters have assumed that GPs will act on the information that they receive. It is indefensible to not understand the risk that was apparent and to at least have a conversation with the health visitor. The Children Act 1989 established that the welfare of the child is paramount and that it is everybody’s responsibility to safeguard children. 9.51. When the family transferred to a new GP practice in April 2017, they transferred as a family. On receipt in the new practice the records are read by the practice manager and any important issues are flagged to the GP. Any specific problem is coded and added to the electronic record. Records do not flag family links unless there is an identified risk (e.g. domestic abuse) therefore each record is viewed in isolation. This is a significant task as many records are copious. There does need, however 10 NSPCC Domestic Abuse https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/domestic-abuse/ accessed 26 April 201 11 Cummings, E. M., Zahn-Waxler, C.& Radke-Yarrow, M. (1981) Young Children's Responses to Expressions of Anger and Affection by Others in the Family. Child Development. Vol. 52, No. 4 pp. 1274-1282 22 to be a robust system of the new practice understanding the issues of new patients. Without this in place the risks regarding what may not be known to the new practice are considerable. Single agency recommendations have been made regarding this issue. COMMUNICATION AND COORDINATION 9.52. When there are many services working with a family it is important that each service recognises the number of other services and professionals involved, as well as their roles and responsibilities. It is also important that the care being delivered is done so in a coordinated way. 9.53. Many of the services offered to the family were health services or services allied to health. A unique feature of this case was that some of the services were being privately funded through Father’s injury claim against his employers. It was not until all the agency review reports were received that it began to become clear how many professionals were involved. Indeed, when initial reports were received it was clear that there were other services that agency review authors had not initially known about. 9.54. This leads to consideration of how services can work together more effectively. It is a fact that there could have been more professional curiosity at several points by those whose primary focus was the children. This has been explored in the previous section. Opportunities for coordinated support in children’s workforce Learning Point 1: Application of Professional curiosity may lead to a fuller understanding of the lived experiences of children Learning Point 2: Accurate recording of assessments is vital for understanding risk Learning Point 3: Professionals undertaking assessments in the ante natal and post-natal periods benefit from actively engaging with Fathers accessing and recording in records. Single Agency Recommendation. Learning Point 4: Where midwifery and/or health visiting services are divided across organisations, effective use of shared records is vital to ensure relevant and timely information sharing. Learning Point 5: When children talk about their lived experience there should be adequate credence given. Learning Point 6: The impact of the system not acting on what a child has disclosed may prevent further disclosures. Learning Point 7: Those being asked for advice should signpost and advise next steps Learning Point 8: Defensible decision making can only be evidenced by recording decisions. Learning Point 9: The 1989 Children Act principle regarding the welfare of the child being paramount must be adhered to by ALL professionals. Learning Point 10: Information held by agencies that indicate risk to children should be shared regardless of how or why that information is known. 23 9.55. It could be argued that as parents did not share any information when being asked about family health by the child focussed professionals, it was not overtly obvious that Father had health issues and was being seen by a multitude of professionals. Those child focussed professionals did not recognise Father as a man who required full time care or had the issues that were being discussed in assessment of his needs in the adult focused services. 9.56. Opportunities to understand that there was more to this family than was being presented are linked to those opportunities for application of professional curiosity discussed previously. If there had been more enquiry of the family at various points, then those professionals may well have considered other levels of service and support. Frameworks for communication and coordination are aligned to the level of need of a child and family. These are set out in the WSCB Thresholds Guidance IBID. Had the level of need been assessed using all the information that was knowable, it may have led to an Early Help single agency response at level two or a multi-agency early help offer at level three according to the WSCB Thresholds Guidance. 9.57. If the disclosure made by Sibling 1 had led to a Child and Family Assessment by Children’s Social Care or an Early Help Assessment, then the above frameworks would have been applied. Children’s Social Care did not feel that this met the threshold for level four and therefore was not opened for assessment; Mother declined Early Help. This should have triggered a challenge and possible escalation. 9.58. It has been identified in a previous SCR in the locality, that the Thresholds Guidance is clear regarding a parent refusing an Early Help offer. This should be discussed and considered as to whether the needs of the child would escalate which would then result in a referral to Children’s Social Care. 9.59. As it was, this did not happen and therefore the opportunity for coordinated support was missed. One of the reasons that this did not happen was highlighted at the workshops. Staff from School 3 indicated that they have many children who make disclosures in their setting. This has led to the employment of a full-time family support worker. They have the facilities to support families and children. Sibling 1 was being monitored and supported. They also saw a positive response from Mother and this lessened their concerns. School staff indicated that they may not always get that reaction from parents so this again added to their reassurance that all was well. This meant that escalation and challenge to Children’s Social Care was not seen as necessary. Opportunities for coordinated support in Adult’s workforce 9.60. The reasons for not identifying risk in the adult workforce were discussed in the previous section. There were several opportunities to identify frameworks for communication by those working with the adults. Even without the complexity of any risk to the children, there were many professionals working with the adults that required more robust communication. 9.61. Adult Social Care perceived that the Independent OT was the main coordinator of care and therefore did not take a lead role. The Independent OT states that this was a misunderstanding and that was not what the role was about. There needed to be more communication regarding these two roles 24 that may have led to a clearer understanding of roles and responsibilities. The MDT meeting discussed below would have been an ideal opportunity to rectify this misunderstanding. 9.62. The Independent OT stated that there was no working relationship formed with the CNRT Psychologist as the practitioner left the post just after the OT became involved. The CNRT records do not indicate any contact between those two professionals at this time. It is of note that the Independent OT stated that this changed when a new psychologist became involved. The CNRT records indicate that it was five months after the new psychologist became involved before contact was made by the Independent OT. This was because the Independent OT believed there to be a gap in service and that the post remained vacant. In fact, the gap was two months. Much of this information sharing from the OT was undertaken via email and telephone conversations. This information is recorded in CNRT and other records. It is therefore not easy to understand why the Independent OT was not aware of the level of physical aggression that was known to the Psychologist. The independent OT and the Independent Epilepsy Nurse saw no evidence of children who were at risk and did not have the benefit of the information that was known to others working with Father. 9.63. The Independent OT wrote regular reports to update the GP. These are not filed within the GP record despite a consent form signed by Father being evident. It has not been possible to understand why these reports are not available in the records. The Independent OT has stated that reports were sent to the GP. The GP practice has no record of these reports. 9.64. The MDT meeting that was convened was for a limited purpose. There needed to be an earlier consideration of this meeting to include the GP, Adult Social Care, the independent practitioners as well as those from both Hospital Trusts (A and C). Use of the MDT meeting framework would have meant a much earlier sharing of information and clarity regarding information that all held. It is known that parents were presenting different issues to different professionals. This would have been an opportunity for the agreement as to who was going to be a key worker for the adults. 9.65. This framework would also have aided an understanding of the different roles that professionals were undertaking. The Independent Epilepsy Nurse and OT have indicated that they often struggle to be accepted as part of the MDT in cases where they have been instructed as part of an injury claim. These professionals offer a service that is privately funded through the injury claim but offer a professional service to the clients. It is in everyone’s best interests for all professionals to work effectively together, however they are commissioned. In fact, these professionals were having contact and supporting the whole family throughout their involvement. 9.66. It is possible that with all the information gathered, there would have been a better understanding of the complexities and the possibility of including the children’s workforce in the sharing of information. 9.67. It has been discussed earlier in this review that there was an issue of concern by some that there is a potential for people to disengage if information is shared. There is an acceptance now that, in this case, there should have been advice sought by CNRT from the hospital safeguarding leads. This would have enabled supporting information sharing in a way that would not alienate the family. It 25 was important for those professionals to understand the paramountcy principle in the Children Act and that the welfare of the children overrides any concerns regarding adult engagement. It is acknowledged that there were mixed messages by Mother who at times indicated that they were getting lots of help and support and at others that they were not getting the help they needed. This needed further exploration and understanding and could have resulted in finding help that was acceptable to parents. It was known that Mother was struggling and asking for help on some occasions from some professionals. Think Family 9.68. Whilst the frameworks above (Thresholds Guidance and MDT meetings) were not applied for the reasons stated, what was required was a whole ‘Think Family’ approach. This further framework could have provided a more coordinated approach across those working with the parents and the children. 9.69. The Think Family framework12 was originally identified as a useful toolkit when working in cases where parental mental health was an issue. It has been recognised that this framework is useful when it is identified that any issues affecting parents result in services working with adults (e.g. physical health, learning disabilities etc.). This framework recognises that no parent or child exists in isolation and that when an issue affects an adult it has an impact on the child and vice versa. 9.70. Think Family approaches can support all those offering services to each member of the family to think about the services as a whole family intervention. This ensures that information regarding service levels and interventions are shared. The model recognises that there may be risks and vulnerabilities in families who have additional needs but also that there are often protective and resilience factors that can be built on. This framework, if used, could have included an assessment of the role Mother played as a carer to understand if this provided protective and resilience factors or if in fact this was an added stressor. The needs of both parents would have been considered by use of a Think Family approach. 9.71. In this case, it was of concern that those working with the children had no knowledge of the brain injury and seizures that Father was experiencing and the cited anger and frustration. A Think Family approach would ensure that all services working with various family members were in touch with each other. Services could then be offered cognisant of all the other services. This would ensure that there was no duplication of, or gap in support being offered to the family. More importantly, the family themselves would be very clear on who was undertaking what role, where their support was coming from and who was coordinating that support. Identification of strengths and resilience factors would also have helped the family as well as professionals to realise where the positive aspects lay. 9.72. Using a whole family approach could have led to wider MDT meetings that would include the children’s workforce alongside those working with the adults. It could be argued that this might have 12 SCIE 2014 Think child, think parent, think family: a guide to parental mental health and child welfare http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf 26 commenced as far back as Father’s discharge from hospital. 9.73. It is recognised that it would be unusual to include those working with a child and family in the discharge of an adult. This case, however, was unusual in the complexities that the family were facing. At the very least it would have shown the family that their needs were being considered and that they were receiving a coordinated and seamless approach to having those needs met. 9.74. A recent SCR in the same locality identified that Think Family approaches are not well embedded in Walsall. Further recommendations are therefore made within this review. Professional curiosity and authoritative practice: The role of supervision 9.75. A clear theme that has emerged within this review is the lack of application of professional curiosity. This theme though, is broader than that. 9.76. Previous studies regarding learning from SCRs, the more up to date Triennial Analysis of Serious Case Reviews13 and Lord Laming in his review into the death of Victoria Climbié14, have indicated that it is important to maintain a respectful uncertainty of parents. It is suggested that it is possible to do this without affecting the professional/patient/client relationship. 9.77. It is noted in these documents that serious case reviews often feature families that are of a complex nature with multiple vulnerabilities that emerge over several years. SCRs also often feature cases where the children and family are being seen by multiple professionals in multiple settings across different localities. This SCR has all those features. 9.78. In order to ensure that assessment is able to be comprehensive, robust and is child centred, professional curiosity is needed whilst maintaining a healthy scepticism of the issues that are being presented. Sidebotham (2013)15 identified that this is only possible if professionals are able to adopt authoritative practice. This authority comes from competence and confidence whilst practising. It requires empathy to keep the child at the centre whilst considering the needs of the parents. This then necessitates humility from professionals who are willing to accept the limitations that they may have in their knowledge and skills to seek advice, supervision and guidance. 9.79. Agencies therefore need to promote a culture of authoritative practice and provide the systems and mechanisms of training advice and supervision. In this case, it can be argued that there were no ongoing overt child protection concerns leading to a lack of seeking of advice and support. In agencies where those cultures are in place and there is clear support and mechanisms for robust supervision and training in child protection, these skills are transferrable to all practice. This supports practitioners to apply the skills that are needed to sift through the myriad of information. This may have enabled professionals to see that Charlie and siblings were at risk of harm and required protection. 13 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education 14 The Lord Laming, (2003), The Victoria Climbié Enquiry 15 Sidebotham, P. (2013) Authoritative Child Protection. Child Abuse Review, 22(1): 1-4 27 10. Good Practice 10.1. This case featured a plethora of good practice from knowledgeable and dedicated practitioners that have been included in the body of the report where appropriate. Further good practice was identified as follows: In the main agencies followed their own procedures. Those working with Father ensured the GP was appraised of the issues and progress. Domestic abuse routine enquiry appeared to be well embedded in health visiting and midwifery services. Action contained within a letter to the GP regarding Father’s needs were followed up with a consultation with Father. There were elements of good record keeping in several services. Adult Psychology Services and Independent OT arranged a MDT meeting. Concerns regarding the family from Adult Social Care and School resulted in contact with Children’s Social Care. The family were supported with housing needs by various professionals. There was a key worker in school for children and time set aside for children to talk. GP records show aspects of the voice of the child in documenting how sibling 2 appeared when presented at the practice. 11. Conclusion and Learning 11.1. Charlie was the youngest of three children whose Father had suffered a brain injury fifteen months before Charlie was born. Father was a man who had struggled to manage his anger and had a history of violence to others. This was not known to the majority of professionals working with the family. Those that knew of his current anger issues largely attributed them to his brain injury. It is fair to say Learning Point 11: Application of Thresholds guidance ensures that services are offered according to level of need. Learning Point 12: Professionals need to ensure that Thresholds are applied effectively. Decisions that appear to be at odds with what guidance states must be challenged. Learning Point 13: Where there are many professionals involved, there is a benefit from ensuring MDT meetings take place at the earliest opportunity and are inclusive of all professionals involved. Learning Point 14: ‘Think Family’ frameworks ensure that the needs of the whole family are considered in light of what is known by all. Think family frameworks prevent professionals working in isolation. Learning Point 15: Effective supervision and training can support a culture of authoritative practice. Learning Point 16: Children and families benefit from inclusion of all health and social care professionals in communication and coordination of support regardless of how they are commissioned. 28 that there is every possibility that his anger and frustration became more intense as a result of his injury and ensuing seizures. This was, however, not a man who became angry following a brain injury but man with anger and violence issues in his past who went on to suffer a brain injury. 11.2. What Charlie and his siblings needed to stay safe, was a comprehensive package of support that was coordinated and communicated to all involved with the family. Charlie needed to have parents supported to offer the best care that they could in the circumstances. The effects and impacts of the stressors on them needed to be understood by thorough ongoing and dynamic assessment of need. Risk needed minimising by assessment of vulnerabilities; resilience factors needed recognising and increasing. 11.3. By using the Terms of Reference and the model put forward in the Triennial Analysis of Serious Case Reviews (depicted in Appendix Two), it is possible to draw conclusions and learning in terms of ‘Pathways to Harm and Pathways to Protection’ 11.4. The events leading up to the injuries to Charlie are unknown by professionals and therefore it is difficult to identify exactly which focus might have provided more insight into Pathways to Harm. 11.5. In terms of Pathways to Harm model, it can be identified that the background context of Charlie’s family was initially one where Father had a history of anger and violence. They were initially a couple with an older child of Mother’s from a previous relationship expecting their first baby together. What is very clear is that the vulnerabilities increased as time progressed. Father’s accident happened when Sibling 2 was four months old. From that time, mother became a carer and vulnerabilities for the children increased. Charlie was then born which created increased pressure to manage Father with his anger issues and a new baby. Application of systems to aid prevention and protection related to these vulnerabilities was required. 11.6. The thresholds for intervention were not fully understood and applied. This was because the full extent of the vulnerabilities had not been assessed therefore risk was not understood across those working with either an adult or a child focus. The identified level of need remained at Universal (Level 1) rather than Early Help Additional Support (Level 3) or Complex Needs (Level 4). 11.7. The system of a whole ‘Think Family’ approach was not applied by any professionals. This too has preventative and protective factors within it as it encourages all those working with both adults and children to offer a coordinated service and a sharing of information. Those working with the adults did not understand the whole family approach and therefore worked independently of those offering services to the children. 11.8. This review found that there was a wealth of information about Father and the struggles that Mother was reporting but very little information about the children. The focus within this family was very clearly on the adults and not the children for the reasons that this review has identified. 11.9. Most of those working with the children as their focus were not aware of the head injury to Father and therefore could not effectively assess the vulnerabilities. In part, this was because parents did not disclose anything regarding Father’s health to those professionals. 29 11.10. Vulnerabilities were not discussed in a multidisciplinary forum. This meant that all professionals had elements of information that they knew but that were not known to everyone else. Had information been shared in a coordinated manner it is possible that the risks and vulnerabilities may have been viewed holistically. This may then have led to a multi-agency package of support to wrap around the family. This package should have had the needs of Charlie and siblings as the central focus i.e. provision of safe and effective care from both parents. 11.1. Professionals did not display authority in their practice when considering the needs of the children, this led to a lack of professional curiosity, empathy to seek the voice of the children and ultimately the services offered to the family remained at the wrong level to deliver the protection from harm that Charlie and siblings needed. 12. Recommendations 12.1 This Serious Case Review has identified several learning points. WSCB will include all of these learning points with a synopsis of the case in their ongoing learning and improvement briefings. These will provide valuable information for use in training and supervision as well as a topic for agendas within individual safeguarding committees and wider workforce briefings. 12.2 The issues raised within this Serious Case Review are similar to those found in a previous SCR in Walsall and that are also found nationally. WSCB therefore need to understand more deeply how these issues can be embedded in practice. 12.3 Two other Area LSCBs have agencies that were involved within this review. WSCB will need to ensure that relevant learning is shared with those Boards 12.4 Issues regarding Thresholds and associated decision making are being addressed in ongoing work related to improving and enhancing the Multi Agency Safeguarding Hub processes and responses. Further recommendations are therefore not made here. 12.5 The main themes that arise appear to be ones of the culture within organisations regarding two main areas: Think Family Authoritative Practice and Supervision In order that the learning can be addressed both of these areas need specific programmes of activities to improve and embed a culture where these become the norm in practice considerations. Activities on both of these areas need to cover the Child and Adult Workforce who work with families. Elements should consist of: 1. Ensuring Guidance is available, up to date and relevant 2. Mandatory Safeguarding Children training is Multi Agency and includes Think Family and understanding of authoritative practice. 3. Supervision in agencies evidences supportive respectful challenge of these areas. (Multi-agency Safeguarding Supervisor Training should be considered) 30 4. Ongoing safeguarding audit programmes of Board and within agencies include these issues. 5. Appreciative enquiry is used to identify good practice both at Board and within single agency safeguarding/board meetings/staff meetings (as relevant to each agency). 31 Appendix One: Terms of Reference and Planning Document 1. Introduction The request for a Serious Case Review was agreed by the Independent Chair of WLSCB on 26/09/2017. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Serious Case Reviews and other case reviews should be conducted in a way in which : recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Working Together Chapter 4 para 11, March 2015) 2. Case summary Charlie is the youngest of three children and lived at home with parents and siblings. Charlie was left in the care of father along with one sibling. Mother and other sibling were absent from the home address. Whilst in the care of father Charlie has suffered significant catastrophic injuries that are presently being linked to shaken baby. Charlie was initially cared for in the ICU and was supported on life support. long term prognosis was poor and medical professionals indicated that CHARLIE would not survive the injuries. Following consent from the family, the life support was discontinued on and Charlie died. Father is being treated as a suspect in relation to this investigation. Father had previously suffered a significant head injury as a result of an industrial accident that resulted in him being disabled with a support and rehabilitation plan implemented and supported by adult social care. 3. Scope of the Review The review will consider agency involvement with Charlie, siblings and parents from September 32 2014, (the start of the School Year just prior to mother’s pregnancy with second child), until the date of the serious childcare incident, unless there is specific relevant information post incident. 4. Methodology This Serious Case Review will be undertaken using a hybrid methodology that will analyse the complex circumstances that practitioners work in and provide opportunities for shared learning and lead to improvements in the way in which agencies understand their roles and responsibilities and work together to promote the safety and well being of children. Agencies will be asked to review their own involvement with the family and to produce an Agency Review Report. This will be followed by the sharing of the written material in order that learning can be shared in and analysed taking into account the view of the professionals that were involved at the time. This process will involve 2 round table Practitioner Reflection and Learning Workshops to ensure practitioner and first line manager involvement in the review. This methodology takes into account the requirements in Sec. 1 above. 5. Areas of consideration to be addressed by all agencies: Agencies will be required to use the Agency Review Report Template provided. The report should be written for publication without the need for redaction. In addition to the scoping period, agencies are asked to provide any relevant background information that they consider will be important in setting the context for the later family situation. a. Please critically evaluate the quality of known information, assessments and decision making. Was the risk to Charlie fully understood and acted upon? How was the family history incorporated into assessments (including any knowledge of domestic abuse)? b. Please analyse the actions taken and the support that was put in place for the family following the accident to Father. c. Please comment on the assessments that were undertaken in relation to father as a parent and partner? What support network was there to support the family and how was this assessed and understood? d. What preparation, assessment and planning was undertaken during the pregnancies in the scope of this review? How well was this communicated to other professionals? e. Please comment on assessment, planning & support regarding the implementation of the rehabilitation for Father. How were the needs of the children incorporated into these plans? f. Did practice within your service meet the required standard in this case? (Please expand on your answer providing evidence). g. Please comment on liaison between professionals and record keeping in the case generally. h. Please identify examples of good practice, both single and multi-agency. 6. Agency Review Reports are required from the following organisations/agencies: Hospital NHS Trust Area A: 33 o Health Visiting o School Nursing o Midwifery o Other hospital Departments e.g. Out patients and A & E in respect of Charlie, parents and Siblings. o Any service associated with Father’s healthcare and rehabilitation post-accident. General Practitioner (via Clinical Commissioning Groups) for siblings and parents The Mental Health NHS Trust The Metropolitan Borough Council o Children’s Social Care o Children’s Centres/Early Help o Education o Adult Social Care Police Housing Ambulance Service Occupational Therapist and any other professionals appointed by Injury Solicitors 7. Family Engagement An important part of a Serious Case Review is the involvement of family members so that their thoughts and viewpoints can be incorporated both to the review itself and any learning. The Board will need to consider the appropriate point at which to inform the family of the review that takes into account the current circumstances. The overview author will make contact with relevant family members once authorised. The family will be offered feedback at the end of the Serous Case Review process. 8. Overview Author Walsall Safeguarding Children Board have commissioned Karen Rees, an Independent Safeguarding Consultant from 402k Consultancy Ltd. to undertake this SCR 9. Timeline for Review (NB Due to severe weather the first Workshop had to be reconvened hence delays ensued) Safeguarding Board decision and commissioning discussion 26 September 2017 Scoping Meeting 9 November 2017 Letters to Agencies/Authors etc. 14 November 2017 Authors’ Briefing 1 December 2017 Agency Reviews submitted to WSCB 15 February 2018 Quality Assurance of Agency Reviews by Lead Reviewer 16-18 February 2018 Agency Reviews distributed 19 February 2018 Practitioner Learning and Reflection Workshop (Whole Day) 2 March 2018 19 April 2018 34 1st Draft of Overview Report Distributed to all attendees 6 April 2018 17th May 2018 2nd Review Learning and Reflection workshop (½ Day) 19 April 2018 (AM) 24 May 2018 V2 Overview Report Distributed to all attendees 27 April 2018 8 June 2018 Comments on V2 latest by 4 May 2018 15th June 2018 Version 3 to SCR Sub Group members TBC Final Draft Overview report presented to SCSIC Subgroup and/or LSCB (arrangements tbc) 26 September 2018 35 Appendix Two: Pathways to Harm; Pathways to Protection |
NC046637 | Death of a 16-year-old girl on 16 November 2013 at a hostel where she was living. Coroner recorded the cause of death as hanging but returned a 'narrative' verdict as it was unclear whether Child W intended to take her own life. A significant number of professionals were supporting her at the time including social workers, hostel staff and substance misuse and mental health services. W was removed from her birth family at 7-years-old because of physical abuse and neglect. She was adopted at 10-years-old with her younger brother. Adoptive parents struggled to cope with her and her sibling's behaviour and requested support from professionals. Prior to her death, W had left her adoptive home following a breakdown in relations. Other concerns included an unsuccessful contact meeting with birth father; self-harm; and substance misuse. W was also the victim of an alleged rape. Findings include: Child W was assessed as needing "intensive therapeutic support" following her early childhood experiences and attachment issues but this support was not provided. Recommendations include adoption support plans need to clearly detail how and by whom therapeutic needs will be met; attachment needs of adopted children should form part of specialist therapeutic services in local commissioning arrangements; and local authorities should ensure that staff are clear about local guidance and support for homeless 16 and 17-year-olds.
| Title: Serious case review: Child W: overview report. LSCB: Hull Safeguarding Children Board Author: Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW Prepared under Chapter 4 of ‘Working Together to Safeguard Children (2013)’ Child W Report of the Hull Safeguarding Children Board following consideration of a review independently led by: Reconstruct Ltd December 2015 2 Contents 1. Introduction 2. The Approach to the Review 3. Time Period 1: September 2004 – July 2013 4. Time Period 2: July 2013 – November 2013 5. Findings, Developments and Recommendations Appendix 1: SCR Review Panel Membership Appendix 2: Brief Description of Services Appendix 3: List of Abbreviations 3 1. Introduction 1.1 The circumstances which led to a Serious Case Review 1.1.1 Child W was 16 years old when she died. On 16th November 2013, she was found, by a worker at the hostel in which she was living, on her knees in the bathroom, with her head facing forward and a ligature around her neck. ‘999’ was called and an ambulance transferred her to Hull Royal Infirmary. All attempts at resuscitation were unsuccessful and Child W was declared dead shortly after. 1.1.2 An inquest into Child W’s death was held in March 2014. The coroner accepted the pathologist’s conclusion as to the cause of death as ‘hanging’ and accepted that the toxicology reports were negative. On the balance of probability the coroner returned a ‘narrative’ verdict. This verdict reflects the conflicting views of those who gave evidence at the inquest. It means that it is unclear as to whether or not Child W intended to take her own life. 1.1.3 Child W was born in Barnsley in 1997. She experienced a very difficult and troubled early childhood, which led to her removal from her birth family when she was 7 years old. After a period in foster care, Child W and her younger brother were placed for adoption with carers in Hull. Child W was formally adopted when she was 10 years old. 1.1.4 In the months leading up to her death, Child W had left her adoptive home and was living in hostel accommodation in Hull. She had been the victim of an alleged rape. A significant number of professionals and services in Hull were involved during this period in helping and supporting her. 1.1.5 Given all of these circumstances, the Independent Chair of Hull Safeguarding Children Board decided that a Serious Case Review into Child W’s death would be undertaken. 1.2 Family Background 1.2.1 Child W was the second daughter of her birth parents. She also had a younger brother. All three children were made subject to Interim Care Orders in October 2004 and a decision was taken by Barnsley Metropolitan District Council (MDC) that it was no longer safe for them to live with their birth parents. 1.2.2 Child W and her younger brother were initially placed with local Barnsley foster carers before moving to live with carers in Hull in July 2006. These carers had been approved as adoptive parents by Hull City Council in February 2006. They initially fostered Child W and her brother with a plan for adoption. Child W and her brother were legally adopted by the Hull carers in August 2007. 4 1.3 Child W 1.3.1 During the course of this review, people who knew Child W have been keen to share their memories of her. The words used to describe Child W, her character and personality, are strikingly similar, from those who knew her best and those whose contact with her was more fleeting: she was popular, caring, keen to help others and always defending the ‘underdog’. Child W was well liked by her peers and by the adults who knew her. 1.3.2 Child W’s parents describe her as being able to ‘fit in’ and make friends from across a very broad range of social backgrounds: she delighted in describing her family context as “posh” in contrast to her early childhood in Barnsley but she was always charming and polite and “fitted in everywhere”. 1.3.3 From an early age, Child W wanted to pursue a career in a caring profession because she wanted to help others. Primarily she wanted to become a medic in the army. 1.3.4 Teachers at Child W’s secondary school describe her as having a “cheeky but playful” attitude towards school life and that she liked nothing better than to have a “good debate”. Her caring outlook was further shown in her need to “ensure justice for anyone wrongly accused”. 1.3.5 Child W’s school report for the academic year 2011/12 (her year 10) described a confident member of the tutor group keen to volunteer for tasks. She volunteered as a ‘Reader Leader’ and her tutor described her as being “very supportive of her peers and always willing to help”. She was described in this report as being “an outstanding ambassador for the school” 1.3.6 During her childhood and early teenage years in Hull, Child W engaged with a wide range of voluntary and community sector services and activities, including the Guides, the Army Cadets and, from October 2013, the Warren. 1.3.7 The Army Cadets describe her as a popular cadet who enjoyed band, camps, swimming and keeping herself fit by running. She is described as a talented musician, playing the drums and flute, and taking charge of the flute section. When she stopped attending the cadets in May 2013 without explanation, her place was kept open for her in the hope that she would return. 1.3.8 Child W took part in various activities at the Warren, including craft work and music, and was described as being a popular member of the Warren community. After her death young people at the Warren organised a ceremony to celebrate her life. 5 1.3.9 Child W also formed strong and positive relationships with the adults who were helping her during the last few months of her life, including her social worker and project workers at Hostel 2. Workers at the hostel fondly recall the many hours they spent with Child W helping her with her homework, applying make-up, buying her beauty products comforting her when she needed it. They describe her as always wanting to be cuddled by staff. 1.3.10 They describe her as having an infectious smile and laugh; as being bright and bubbly, and, when in good spirits, vibrant and full of life. Child W lived at the hostel during a particularly troubled period in her life. Not surprisingly staff also found her to be quite emotional and that her behaviour could be erratic at times. 1.3.11 Their overriding memories of her however are of a young person who put other people before herself; who was fiercely loyal to those she cared about, often putting their needs before her own and; as someone who would do her utmost to cheer up anyone who was sad. Child W had lots of friends and was instantly liked by people who she met. 1.3.12 Her parents too describe her capacity to make people feel valued: this capacity was illustrated after her death amidst the plethora of tributes and messages posted on Facebook by the significant number of young people who genuinely considered themselves to be Child W’s “best friend”. 1.3.13 It is apparent that Child W’s character and personality were such that she had a powerful positive impact on those who knew her: her family, friends and the adults who tried hard to help her. This also explains why all those who knew her were so profoundly affected by her tragic death. 6 2. The Approach to the Review 2.1 Statutory guidance requires Serious Case Reviews (SCRs) to be conducted in a way that: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. 2.2 Under the guidance, Local Safeguarding Children Boards (LSCB) may use any learning model which is consistent with the principles. 2.3 The Hull Safeguarding Children Board (HSCB) commissioned Reconstruct Ltd to provide Independent Lead Reviewers for this review. Agencies provided individual chronologies of events, which were combined into an integrated chronology. This was used to help inform an initial scope and focus for the review. 2.4 A ‘review panel’ of senior professionals representing the agencies that were or had been involved with Child W and her family, and other members of the HSCB Serious Case Review sub-committee, was established (see Appendix 1). 2.5 The panel agreed that the main focus of the review should be on establishing any learning from the way in which local services and professionals had worked together to help and support Child W from March 2012 until her death in November 2013. 2.6 It was also agreed, however, that it would be important to consider the impact, and practice issues, of Child W’s early childhood experiences, placement and subsequent adoption in Hull (2006-07), since this provided an important context to understanding her needs and vulnerabilities. 2.7 The panel agreed that the review should tell the story of Child W’s life and journey through the helping services, from the perspective of those who knew her, and to draw out any learning for the LSCB about the way in which agencies need to work for the future. Specifically, the initial focus would be on: The impact of her adoption and the level of support offered to her and to her family to make this placement a success given her family history; The impact if any of her adoption status on the help she received and the perception of her needs and risks held by professionals; 7 The response from professionals to her family when things began to escalate from March 2012 up until the point of her death, including the sharing of information and how this informed practice; The joint police investigation into her rape allegation and the level of support offered to her, plus the way in which risk to her was assessed from this point, including whether CSE protocols were considered; The role of the voluntary sector and the thresholds and protocols for their support to and safeguarding of vulnerable young people. 2.8 The review panel agreed that the Independent Reviewers would carry out an “independent investigative review” using the principles of appreciative enquiry. The process involves asking open ended questions in order to gather facts and opinions and to understand the context in which people were working and made decisions at the time. 2.9 The independent reviewers: Met with the key professionals and had direct access to agency records Met on three occasions with Child W’s adoptive parents at the start of the review Produced draft reports and carried out further investigations as the review progressed Facilitated a ‘learning event’ on 16th July 2014 which was attended by most of the practitioners and managers involved in the review Attended several additional meetings with the HSCB Independent Chair and senior Board members, to discuss the development and final shape of the report. Produced a further draft report for consultation at the end of October 2014. 2.10 This report was initially considered by the HSCB Serious Case Review sub-committee on 3rd November 2014. It had been received by the Board shortly before this meeting. It was agreed that members of the review panel should be asked to provide comment on the draft. 2.11 The draft report and the feedback from panel members were considered in more depth by the SCR sub-committee on 14th January 2015. Members agreed that the independent reviewers had helpfully identified the key learning from Child W’s death. 2.12 As the review progressed and the key learning was identified it became clear that the original main areas of focus (paragraph 2.7 above) needed to be adjusted somewhat, and, in particular, to draw out some of the wider local ‘systemic’ learning about how the partnership as a whole responds to the needs of vulnerable young people in a coordinated way. 2.13 The HSCB SCR sub-committee agreed that it would be helpful to re-structure the report in order to better draw out the learning, by focusing on ‘Areas of Significant Practice’ and also in order that the final report: 8 Would not harm the welfare of any children, young people or vulnerable adults involved in the case; Presented a more rounded picture of Child W, as she was known to her family and to the people who tried hard to help her; Adequately reflected the complexities of living and working with vulnerable young people, in a way which enabled a critical analysis of practice. 2.14 The report still relies extensively on the work of the independent reviewers and includes the lessons learned and conclusions which they helpfully drew out in their analysis. It has been restructured to address the concerns and issues outlined above. 2.15 The death of this young person has been the subject of considerable local publicity in which she has been identified. Her parents have been clear that they do not wish her identity to be disguised in any way in this review. In earlier drafts she was referred to by her given name. 2.16 After careful consideration of the potential immediate and longer term impact however, HSCB took the decision to uphold standard best practice by not using ‘given names’ because of its duty of care to protect information about individuals who could be identified and who have not given permission for that information to be shared. 2.17 HSCB recognises that, for a range of complex reasons, it has taken longer than it ought to finalise a report for publication. There is learning for the Board as a whole about process and methodology. Chapter 5 of the report identifies systems and practices which have improved over the period of time covered by the review, specific improvement actions linked directly to learning from Child W’s death and plans for ‘system-wide’ improvements explicitly informed by this learning. 9 3. Time Period 1: September 2004 – July 2013 3.1 ASP 1: Child W’s Adoption and Post-Adoption Support (August 2007 – August 2010) 3.1.1 Child W and her siblings were placed on the Child Protection Register by Barnsley Local Authority in September 2004. The registration category was neglect. Child protection agencies in Barnsley were concerned that Child W was experiencing physical abuse and neglect and that she had attachment dysfunction and delayed social and emotional development. 3.1.2 In October 2004 an Interim Care Order was made and Child W and her younger brother were placed with local short term foster carers. A full Care Order was made in June 2005, when Child W was 8 years old. She did not return to the care of her parents. 3.1.3 In November 2005, Hull Children’s Social Care commenced a home study assessment on a female couple who wanted to become adoptive parents. During the assessment process, the couple attended a regional inter-agency adoption event held in Wakefield and expressed an interest in being considered as adoptive parents for Child W having read her profile at the event. The couple were approved as adopters by the Hull Adoption Panel in February 2006. 3.1.4 In the meantime, Barnsley Children’s Social Care had commissioned an assessment by an NSPCC psychologist of Child W and her younger brother’s attachment and therapeutic needs. The assessment identified the need for intensive therapeutic input to their placement in recognition of the children’s previous experiences and their attachment difficulties. The assessment also identified a positive attachment between Child W and her brother, supporting a plan for them to be placed together. As a first step, the Hull carers agreed to care for both children, with a view to adoption. 3.1.5 Barnsley Children’s Social Care was pursuing permanency for Child W and her brother and assessed the Hull couple as specific foster carers, with a plan for adoption. The assessed need for specialist attachment and therapeutic work was clearly considered and discussed between Barnsley and Hull during this period. However, there is a record of an email from a Hull social worker to Barnsley, in April 2006, stating that the specialist support assessed as likely to be required would not be available in Hull. 3.1.6 In June 2006, the Hull couple were approved as foster carers for Child W and her brother by the Barnsley Fostering Panel. The children were placed in Hull in July 2006, four weeks after they were first introduced. It appears from records, and from the accounts of the Hull couple, that the planned timescale for the placement was accelerated as the 10 children’s existing foster carers were going on holiday and were unable to take both children with them. 3.1.7 A Looked After Children (LAC) Review was held on 20th July 2006. The NSPCC in Barnsley had ceased direct work with the children but provided a report detailing their observations and recommendations for the review. They subsequently (27th July 2006) wrote to the Hull couple, confirming an offer of ‘one-off consultation’ in relation to attachment theory and confirming their understanding, from the Barnsley social worker, that support would be provided by a Hull based agency. Given the email of April 2006 (paragraph 3.6 above) the basis of this understanding is unclear. 3.1.8 Child W and her brother were matched by the Barnsley Adoption Panel in October 2006. The minutes of the Barnsley Adoption Panel at which the match was made state that the Hull couple were aware that “therapeutic services are available in Hull but do not feel that these are needed at the moment”. The couple sought a commitment that these [therapeutic] services would be available if needed. According to the minutes, this was incorporated in the Adoption Support Plan. 3.1.9 The Adoption Support Plan (prepared for the Adoption Panel in October 2006) states that the “NSPCC will identify any future therapeutic needs as part of their work with Child W”. However, as above, the NSPCC had concluded its detailed assessment and finished its work with the children by July 2006 (at the latest). The need for “intensive therapeutic input” had already been assessed. 3.1.10 The support plan did clearly state Barnsley’s commitment to working with the carers to “identify the most appropriate resources” once therapeutic needs [have] been identified and also stated that enquiries had been made with both statutory and non-statutory resources depending on Child W’s changing therapeutic needs. The plan confirmed Barnsley’s financial responsibility for three years post placement to meet any additional costs as a result of therapeutic need. 3.1.11 A Placement Order was made in April 2007 and an Adoption Order in August 2007. Until the Adoption Order was made, the children remained looked after children to Barnsley MDC. In May 2007, a social worker in Hull recorded some concerns about how the Hull carers were coping with the children. This worker was then not able to attend the subsequent statutory review, which concluded that the placement was progressing well, albeit, that some behavioural difficulties were noted. 3.1.12 The ‘Annex A’ report prepared as part of the Hull carer’s application for an Adoption Order recommended that the order be made. The report was jointly compiled by social workers from Barnsley and Hull. The closure summary on the Barnsley Children’s Social Care records, which was completed following the making of the Adoption Order in August 2007, states that “at present, the adoptive parents do not feel 11 the need for any additional support either for themselves or the children”. 3.1.13 Child W’s adoptive parents were reminded that the responsibility for post-adoption support in the first three years following the making of the Adoption Order (i.e. up to August 2010) rested with Barnsley MDC, the placing authority. 3.1.14 In practice, this meant that the agreed contact arrangements with Child W’s birth family (two indirect contacts per year, or exchange of cards and letters, and one direct contact per year with birth parents) were managed and supervised by the Barnsley Adoption Team. 3.1.15 The fostering allowances which had been paid to the family ended upon the making of the Placement Order in April 2007. The family report that this placed additional stress on them as a result of the time and cost involved in travelling to Barnsley for support. There is evidence that there was some local Hull provision of services to the family (beyond universal support) during this period in response to specific incidents and identified need (see 3.2) 3.1.16 This included some Child and Adolescent Mental Health Service (CAMHS) support for Child W’s younger brother which commenced in July 2008 and had concluded by May 2009, when, according to a letter sent by the service to the Barnsley Adoption Team, the adoptive parents had “not identified any further need for CAMHS involvement”. 3.1.17 There are no records during this period of any additional requests for help and support made by the family to Barnsley MDC. There is no requirement under adoption regulations for local authorities to provide formalised, ongoing post-adoption support or to periodically review progress, and so the responsibility for seeking additional support was vested in the adoptive parents. 3.1.18 At the end of Barnsley’s period of statutory responsibility for the provision of post-adoption support, there was no active, ongoing support provided by them to the family and, therefore, nothing to be ‘handed over’ to Hull. Barnsley continued to manage the contact between Child W, her brother and their birth family beyond this period. Analysis 3.1.19 Recent Government sponsored research1 into adoption disruption found very low overall rates of disruption. The factors identified as being the most significant in increasing the risk of disruption were: the child’s age at the time of disruption; older age at placement; a longer than average waiting time between placement and securing the 1 ‘Beyond the Adoption Order: challenges, interventions and adoption disruption’. Research Brief April 2014. Julie Selwyn, Dinithi Wijedasa and Sarah Meakings – University of Bristol School for Policy Studies, Hadley Centre for Adoption and Foster Care Studies. 12 Adoption Order. Teenagers were found to be ten times more at risk of experiencing disruption compared with children under the age of four. The majority of young people whose placements disrupted had been abused and neglected by their birth families. Most adoptions disrupted during the teenage years. 3.1.20 Child W was eight years old when she became looked after, nine when she was placed as a looked after child with the Hull carers who became her adoptive parents, and ten years old when the Adoption Order was made in August 2007. The childhood experiences of abuse and neglect which led to her becoming looked after and which created assessed difficulties for her in making positive attachments, coupled with her age at placement, created the conditions for a higher than normal likelihood of adoption disruption in later years. 3.1.21 Child W’s placement with the Hull carers, as foster carers with a view to adoption, was clearly planned. Barnsley Children’s Social Care assessed and approved the couple as specific foster carers for Child W and her younger brother. However, the eventual speed of their placement appears to have been a response to events, which may well have limited the opportunity for proper preparation and for the children’s wishes and feelings about the placement to be fully taken into account. In the circumstances however, the decision to expedite their placement in Hull, rather than to seek an alternative short-term placement with other carers, appears reasonable. 3.1.22 Given her childhood experiences and attachment difficulties, Child W was assessed as likely to need “intensive therapeutic input” to support the development of positive attachments and a successful adoptive placement. The most experienced of carers were likely to be presented with challenges in managing behaviour and responding to emerging needs. 3.1.23 The Hull couple were clearly committed to providing a loving and caring home, on a permanent basis, for Child W and her younger brother. They were also aware of the outcome of the psychological assessment and the issues which might arise in caring for the children. Neither had previous parenting experience, nor access to an extended support network which might have given more resilience to the placement. 3.1.24 The eventual disruption of Child W’s adoption (May/June 2013) was not inevitable. However, the apparent optimism about the placement was misplaced without firm and robust arrangements in place for the provision of skilled and specialist therapeutic work on attachment. 3.1.25 Neither of the adoptive parents was identifying a need for additional support up to and beyond the making of the Adoption Order in August 2007. Like many parents, there is some evidence to suggest an understandable desire on their part to show that they were ‘coping’ and 13 that seeking additional external support might be interpreted by professionals as a failure on their part. 3.1.26 Nevertheless the onus was on the professionals to ensure that Child W and her brother received the specialist support and intervention they required. Whilst the Adoption Support Plan confirmed the commitment of Barnsley MDC to provide financial support (for 3 years post-adoption) to meet the therapeutic needs of the children, the plan is insufficiently clear and specific about how such support would be obtained. The Plan (prepared for the Adoption Panel in October 2006) states that the “NSPCC will identify any future therapeutic needs as part of their work with Child W”. In fact, by that time, the NSPCC had concluded their work with her and clearly articulated their assessment of what would be needed in the future to meet her needs. 3.1.27 Given the detailed assessment provided by the NSPCC, the “intensive therapeutic input” assessed as being needed, should have been specified, identified and made available with a clearer description of what Child W and her brother needed and how her adoptive parents could support this, rather than being somewhat vaguely described as being available as and when the need arose (i.e. in response to subsequent behavioural issues which might arise). The conclusion of the review is that the lack of therapeutic work, pre and post-adoption, significantly limited the capacity of the adoptive parents, and subsequently of agencies, to meet Child W’s emerging and long-term needs. 3.1.28 It should also be recognised that the adoption practice being assessed here took place in 2006 and 2007. The passage of time has meant that few of the individual practitioners, or their managers, have been available to contribute directly to the review. Adoption legislation and practice also changed in 2006, so the framework within which decisions were taken and plans developed for Child W was relatively new. 3.1.29 Given the more recent national focus on adoption, and further additional practice guidance and legislation, adoption practice has undergone significant change in the intervening years. In particular, the understanding of the post-adoption support needs of adoptive families, including the provision of appropriate therapeutic services to help children recover from damaging early experiences, has been a focus of recent government initiatives. Nevertheless, this review recommends that the two LSCBs (Barnsley and Hull) take steps to ensure that the lessons learned are understood in the context of current practice. Finding 1: Adoption Support Plans need to clearly and explicitly detail how, and by whom, any assessed therapeutic needs in respect of children placed for adoption will be met. 14 Finding 2: The attachment needs of children placed for adoption should form part of the specialist therapeutic services in local commissioning arrangements. 3.2 ASP 2: Support for Child W from Hull agencies as problems emerged in the family (up until May 2013) 3.2.1 A diary note in Child W’s Children’s Social Care (CSC) file (November 2008) indicates that she was visited at school by a social worker and police officer, following some concerns having been raised about how her adoptive parents were managing her younger brother’s behaviour. 3.2.2 During the joint police and social worker visit to see her at school Child W is recorded as saying that she was sad because she didn’t like having two mums and that she and her brother would like to have a mum and dad. 3.2.3 There is no referral, strategy discussion or manager decision record on CSC files in relation to this visit, and therefore nothing to indicate that it was conducted as part of a section 47 enquiry (Children Act 1989) and the source of the referral is unclear. 3.2.4 Child W was, however, seen in school so it would appear that she may have shared her concerns at school and that the school may subsequently have made the referral. Humberside Police has no record of this visit, or of any strategy discussion, on their systems. The CSC record indicates that Child W was advised to raise any further concerns with her teacher. There is no record of this on her brother’s file, nor any record of these concerns having been discussed with her adoptive parents. 3.2.5 Between January 2011 and November 2012, there was a more significant level of involvement with the family by local professionals. The primary focus of this involvement was on providing the family with help and support in meeting Child W’s younger brother’s needs. A series of multi-agency meetings was held and there were recorded concerns that his adoptive placement was breaking down. 3.2.6 There is evidence that the situation at home was having a significant impact on Child W. In January 2011, for example, Children’s Social Care records report her as “struggling to cope”. In February 2011, she disclosed at school that the situation at home was upsetting her. She also sprayed deodorant on a wound and her mother confirmed to the school that she had done this before. The school had a consultation with a Common Assessment Framework Coordinator and also made a referral to the Barnardos’ Sibling Support Group. Child W started to attend sibling support groups in May 2011. 15 3.2.7 At this time, both children are recorded as requesting to go into care. There was professional discussion about a potential adoption breakdown. A core assessment of Child W’s younger brother was initiated. Support was managed by the Hull Adoption Team together with a Locality (Social Work) Team. Respite provision was requested by the family for the younger brother and the Marlborough Family Support Team provided outreach support and activities to the family. 3.2.8 Child W is only occasionally referenced in the notes of the multi-agency meetings held during this period. For example, there is a note on the records (23rd June 2011) that she had been told on Facebook that her father had died (he hadn’t) and, on 15th September 2011, the social worker recorded a list of issues she was facing, related to the wider issues within the family. 3.2.9 There is very little reference in the records to work being carried out directly with Child W, despite the evidence that she was being adversely affected by the home situation. 3.2.10 In November 2011, Child W’s parents requested help and support specifically for her via the Community Support Team worker who was already working with her brother. Child W had complained that she was being bullied by a pupil from another school. Her parents are recorded as feeling that they were “failing as parents” and were also concerned that Child W had begun stealing from home and damaging things. There had also been a request from Child W’s older sister for contact with her. On 13th January 2012, the social worker recorded a concern that the adoptive placement was “breaking down”. 3.2.11 A range of services and support were considered and offered to Child W and her family over the next few months. In addition to ongoing support provided by the Community Support Team Worker, Child W received support from the Rights and Participation Project (RAPP), a service providing advocacy and support to children and young people in need, or at risk, in Hull. At the project, she was involved in activities such as drama and music. Her parents describe this as being an enjoyable experience for her. 3.2.12 In March 2012, the police attended the family home because Child W had climbed out on to the roof and threatened to jump. Her parents had confiscated her mobile phone and ‘grounded’ her for a month. The police officers who attended persuaded Child W to climb down and concluded that her behaviour was “attention seeking” and that she had no real intention to harm herself. Her adoptive parents emailed the Community Support Worker about the incident and Humberside Police notified Children’s Social Care. The police referral to Children’s Social Care indicated that the officers who attended had a discussion with Child W and her parents together, once she had come down from the roof. It is recorded that Child W had stated that she wanted either to go into care or to live with her birth father. 16 3.2.13 The response to the email from Child W’s adoptive parents was not immediate as the worker was on leave when it was sent. He responded to the email on his return and offered to meet with Child W so that she had someone to speak to about her feelings. Child W’s mum responded by saying that Child W had subsequently apologised for the incident and confirmed that she did not want to live with her birth father. 3.2.14 Child W’s case was closed to the Community Support Team on 11 May 2012. The closure records indicate that this was because her parents had informed the worker that she was no longer interested in speaking to him, but that she knew that there were people and agencies she could speak to if she chose to. The supervision record states that while the case would be closed, the fact that the Community Support Team continued to support her brother meant that Child W’s needs could continue to be overseen. 3.2.15 On 16th March 2013, the school’s Child Protection Coordinator observed that Child W was upset due to unpleasant texts being sent by a former boyfriend. She also showed a teacher a cut which she had made to her arm. The school contacted Children’s Social Care for advice and they advised Child W’s parents to contact the Police if the texts continued and to discuss her self-harming with the family GP. The school also advised that they would make the school nurse aware of her self-harming. There is no record of any further support provided or sought in relation to this incident. 3.2.16 This incident on 16th March 2013 is the single incident of concern noted in relation to Child W between March 2012 when she climbed onto the roof at home (paragraph 3.2.12) and the end of May 2013. Neither were there any additional requests or referrals for support made during this period. 3.2.17 The evidence is somewhat contradictory about what Child W’s life was like during this period. On the one hand, her parents describe deteriorating relationships between themselves and Child W, and state that she was spending more and more time away from the family home, although she was never reported to the Police as missing from home during this period. 3.2.18 On the other hand, Child W’s school attendance record was excellent, and well above average, in Years 9, 10 and 11 (she had 100% attendance in Year 11 between September 2012 and May/June 2013 and is recorded as being late on only 5 occasions). With the exception of the one incident in March 2013, the school observed no cause for concern about Child W or her health and development and this was supported by her excellent attendance record during this period. She also attended to sit all of her (GCSE) examinations in May/June 2013. She did not reach her predicted grades as, in the view of the school 17 she sometimes failed to fully apply herself, but she did achieve pass grades in both BTEC Health and Social Care and Applied Science. 3.2.19 During this period Child W regularly attended the Cadets, having joined in 2009. She continued to do so until May 2013 at which point her attendance stopped without explanation. Her place at the Cadets was kept open for her in the hope that she would return. Leaders at the Cadets observed no indications that Child W was emotionally troubled. At the same time (May 2013) Child W received a letter from the Army notifying her that her application to train as a medic had been rejected. This was a significant blow to her hopes and ambitions. Analysis 3.2.20 Records indicate that professionals were aware that the situation at home at the time was having a significant negative impact on Child W. It would have been helpful, and good practice, for her needs to have been separately and specifically assessed as a child in need under section 17 of the Children Act 1989 at this time, so that she could have been provided with support to address her individual and thoroughly assessed needs, including work to strengthen her attachment to her parents. 3.2.21 As early as November 2008 (the joint visit by a police officer and social worker to see Child W at school) she was recorded as being sad and saying that she and her brother wanted a mum and a dad. This recorded sadness may have given an indication of the impact of her early childhood experiences on her capacity to make secure attachments and that this had been insufficiently explored at the point of placement or subsequently. This was an opportunity to explore Child W’s ‘sadness’ with her more thoroughly which was missed. 3.2.22 Professionals appear to have accepted the view that the incident in March 2012, when Child W threatened to jump from the roof at home was “attention seeking behaviour”, linked directly to sanctions imposed by her parents in response to her behaviour. On the basis of the information available to them and the situation which they found, this was a reasonable judgement for the attending police officers to reach. Neither the attending police officers, nor indeed her parents, viewed this incident as one which required immediate follow-up by Children’s Social Care. 3.2.23 In their email to the Community Support Worker, Child W’s parents said that they were not sure “how serious” she was about living somewhere else, but felt that they should make the worker aware. By the time the worker responded, on his return from leave, Child W had apologised and changed her mind. The offer to meet with her alone and discuss her feelings with her was an appropriate and proportionate response. 18 3.2.24 Nevertheless, the review has found that, whilst support was provided to Child W for some of this period, there was an insufficient focus on assessing her individual needs, alongside the understandable primary professional and family focus on her brother. Finding 3: There should be an holistic approach to assessment which captures and reflects the needs of the whole family in the process. 3.3 ASP 3: The response of agencies as Child W’s needs escalated and her Adoptive Placement broke down (9th July 2013) 3.3.1 On 30th May 2013, Child W was taken to Hull Royal Infirmary Accident and Emergency Department by ambulance having been involved as a pedestrian in a road traffic accident. She told a member of the ambulance crew that she had been smoking cannabis. Subsequently she gave nursing staff at the hospital differing accounts of how the accident had happened. Child W was with her boyfriend at the time of the incident. Yorkshire Ambulance Service staff contacted the Children’s Social Care Emergency Duty Team about the incident. Children’s Social Care subsequently made contact with Child W’s parents who are recorded as being concerned that she was “associating with the wrong crowd” 3.3.2 On 2nd June 2013, Child W was allegedly raped by an older man who was a friend of her boyfriend. She did not report this rape at this time, either to her parents or to professionals. She subsequently made a disclosure about the rape to a social worker on 9th July 2013 (see separate section relating to rape allegation, 4.4 ) 3.3.3 Child W was arrested by the Police on 3rd June along with a group of other young people on suspicion of being involved in arson and burglary of a house next door to where her alleged rape had occurred. Whilst in custody, during a private consultation with her solicitor, Child W threatened to kill herself. She was put in a ‘camera cell’ pending her interview and release from custody. The Hull Youth Justice Service provided an Appropriate Adult. The worker noted old self-harm cuts to Child W’s arms and made a referral to the Children’s Social Care Emergency Duty Team (EDT). Child W also reported a numb right arm and pain in her right leg from the road traffic accident. She was released from custody on police bail to return on 27th June 2013. 3.3.4 Child W’s parents told the EDT that the situation at home had become “untenable” due to her mixing with young people who were involved in criminal activity. She was spending time away from the family home and repeatedly telling her parents that she did not want to live at home. 3.3.5 They made direct contact with Children’s Social Care Central Duty Team (CDT) on 4th June 2013 and the CDT alerted the Adoption Team of this contact. An Adoption Team Social Worker visited the family on 19 18th June. This visit was originally arranged for 11th June but was rearranged due to the sickness absence of the worker. 3.3.6 Child W’s parents described their concerns about her lifestyle and the impact of her behaviour on their health and on her brother. They stated that Child W did not want to live at home and that she only returned home to collect clothes. They wanted some “distance” between themselves and Child W. It was agreed that a request for support would be made to the Integrated Looked After Children (ILAC) Team. Child W was not at home at the time of this visit. 3.3.7 As agreed, on 20th June 2013 the Adoption Team Social Worker discussed Child W with a Team Manager in the ILAC Team who agreed to consider her at an allocation meeting early the following week. On 26th June 2013 the Adoption Team social worker was advised to seek help and support for Child W from the Community Support Team. As she was neither looked after nor a care leaver, she did not fall within the remit of the ILAC Team. 3.3.8 In the meantime Child W had presented herself at a police station on 22nd June 2013 saying that she was “blacking out and fainting”. An ambulance was called and she was checked over before being collected and taken home by her mother. 3.3.9 On 23rd June 2013, Child W’s parents made contact with the Emergency Duty Team. Child W had left home on crutches to stay at a friend’s house. Her parents were concerned that she was at risk of further injury. They were advised to report her as missing and EDT undertook to alert the Adoption Team in the morning. 3.3.10 On 27th June 2013 a Community Support Team worker went to the police station in an attempt to meet Child W, having noted that she was due to answer her bail on that day. The CST worker was unaware that her requirement to attend the police station to answer her bail had been cancelled as a ‘no further action’ decision had been taken in respect of her initial arrest. 3.3.11 Having not managed to meet Child W, the CST Worker decided to make an ‘impromptu’ visit to the family home, in the hope of meeting her and her parents there. There was no-one at home. The worker left some housing leaflets and forms for Child W with a neighbour and close family friend and a message for her parents on their answer phone. Analysis 3.3.12 The initial response of the Hull Adoption Team to the request for help made by Child W’s parents was timely. An initial appointment was offered within 5 working days, although this was delayed for a further 5 working days due to sickness absence. 20 3.3.13 Having met with her parents (18th June 2013) it is apparent that the Adoption Team social worker felt that colleagues in other teams/services within Children’s Social Care would be better placed to provide the help and support which Child W might need, and, in particular, the potential need to find alternative accommodation for her. 3.3.14 Within a further 7 working days the Community Support Team had agreed to offer help and support and a CST worker attempted to make direct contact with Child W. This attempted contact with her at the police station shows an enterprising and swift response from the worker concerned. 3.3.15 Unhelpfully, the internal conversations between the Adoption and ILAC Teams and the Adoption Team and Community Support Team are reflected in case records as “referrals”, whereas they more accurately reflected professional conversations focused on identifying the most appropriate source of help and support for Child W. These conversations, albeit concentrated within little more than one working week, reflect a degree of professional uncertainty at the time as to the specific role and remit of various different teams. 3.3.16 Given Child W’s status as an adopted child, the Adoption Team was the first point of contact in seeking help and support. It could be argued that this status led to a delay, albeit a short one, in accessing the help and support which her circumstances and needs warranted, with the Adoption Team effectively acting as ‘brokers’ for the family. 3.3.17 The records indicate a real sense of professional uncertainty about how best to respond to Child W’s needs: the post-adoption social worker felt that the issues were not adoption related, whilst other teams saw adoption as a ‘complicating factor’. A joint approach across services at this point might have been the most helpful response. Finding 4: The needs of children and young people must be at the centre of decision making about the provision of support, and service or organisational boundaries should not act as a barrier to children, young people and families accessing the most appropriate help and support according to those assessed needs. 21 4 Time Period 2: Child W’s admission to Hostel accommodation (9th July 2013) to her death on 16th November 2013 4.1 Narrative 4.1.1 Child W first visited the Targeted Youth Service (TYS) offices in Hull City Centre on 2nd July 2013. She stated that she was homeless. Staff discussed options with her and she agreed to return home as her parents had not said that she couldn’t return there. On 8th July 2013, she presented at a local police station saying that she was homeless. Child W had returned earlier than planned from a week long holiday with her boyfriend and her parents were away for the weekend. After liaising with the Children’s Social Care Emergency Duty Team and with her parents, the police took Child W to stay overnight with a friend. 4.1.2 On 9th July 2013, Child W visited the Targeted Youth Support (TYS) Team offices in Hull City Centre. She stated that she did not want to return back home to live with her parents. Her parents were contacted and confirmed that she could return home. However, they felt that she needed to be found alternative accommodation as their relationship with her had deteriorated. A place was obtained for her at Hostel 1, a local young people’s hostel. Child W was allocated a social worker who worked in the TYS team. 4.1.3 From 9th July 2013 until her death on 16th November 2013 Child W lived in young people’s hostel accommodation in Hull. In addition to the staff at both of the hostels in which she lived during the period, her TYS social worker and other TYS colleagues, a wide range of other professionals and agencies were involved in providing help and support to her. 4.1.4 There were also a number of personal relationships which Child W was trying to make sense of and sustain during this period: an important relationship with her boyfriend, a young care leaver from a neighbouring authority; her relationships with her parents and brother, which had become strained but remained significant to Child W; and her relationship with her birth family. 4.1.5 Child W’s relationship with her boyfriend has been described by professionals as a mutually loving one. It was also a highly intense one. Professionals were concerned at times that Child W was too easily influenced by her boyfriend and there are frequent examples of her giving him money to cover debts he had accrued. 4.1.6 His eviction from Hostel 2, at which they were both living in October 2013, clearly angered and upset Child W and led to a particularly unsettled period, during which she rarely stayed overnight at the hostel. 22 4.1.7 The breakdown in this relationship, and the consequent events of 2nd and 3rd November 2013, led directly to the decision that Child W could no longer live at Hostel 2. On 15th November 2013, in a meeting with her social worker, Child W was clearly upset because she had heard via Facebook that her boyfriend had started a relationship with someone else. 4.1.8 It is also clear during this period that Child W wanted to rebuild a more positive relationship with her adoptive parents and with her brother, although she consistently stated that she did not feel ready to return home to live. Her parents felt that some ‘distance’ between them was needed, although they continued to agree that she could return home if she wanted to. 4.1.9 The records indicate that Child W’s relationships with her adoptive parents were “up and down” during the period, but she was also comforted at difficult times by being able to talk to them and receive reassurance that they still loved her. 4.1.10 According to hostel records, Child W spoke with her brother on 7th October 2013, and was upset about how that conversation had gone. This same day she harmed herself with a razor at the hostel, and she later told hostel staff that “everything with her brother”, in addition to recent contact with her birth father, her childhood experiences, problems with her adoptive parents and the court case, had caused her to do it. 4.1.11 Notes of a meeting on 29th October 2013 between Child W, a senior hostel worker and social worker, confirm that she wanted to restore a good relationship with her brother describing this as essential for them both. Child W met her brother, in the company of other young people, earlier on the day she died. Her parents report that this was a positive meeting. 4.1.12 On 26th September 2013, Child W’s birth father made contact with her. This was in response to her making contact with him to see if the information in her “letter for later life”, prepared for her as part of the adoption process, was true. Child W was said by hostel staff to be “overwhelmed with excitement” at the prospect of meeting her birth father, as she had questions for him and wanted to know if the “rumours” about why she was taken into care were true. Hostel staff advised her against this meeting and sought advice from her social worker. 4.1.13 Despite the concerns of the professionals and of her parents, she was determined to meet her birth father and did so on 1st October 2013. The records show that this visit did not go well and that Child W was upset about it. She told hostel staff that her birth father was drunk and kept calling her by her older sister’s name. She told staff that she didn’t think she would be seeing him again. 23 4.1.14 There are extensive records detailing Child W’s daily life and her various contacts with agencies during this period. For the purposes of this review, and the learning which can be derived from it, it is helpful to consider key themes and issues, as areas of significant practice, which facilitate an overall analysis and understanding of service provision and practice. The main learning and findings relate to the wider ‘systems’ of support to vulnerable young people, and these are captured as part of the ‘over all analysis and learning’ (section 4.10). Where there are more specific findings these are included after the analysis for the relevant ‘area of significant practice’. 4.1.15 However, there are a number of key events which help to provide an overall context to Child W’s life during this period: 9th July 2013: Child W went to live at Hostel 1. She also disclosed to her TYS social worker that she had been the victim of rape. 12th July 2013: A telephone strategy discussion took place between Children’s Social Care and Humberside Police and a section 47 enquiry was initiated. 17th July 2013: The social worker facilitated a ‘mediation meeting’ with Child W and her parents. 6th August 2013: Child W met with a police officer and her social worker to complete the pre-interview assessment in respect of the rape allegation. 7th August 2013: Child W was formally given a place at Hostel 2, having ‘moved herself in’ over the previous weekend. Her boyfriend was living at the same hostel. 20th August 2013: Child W was interviewed by the Police, with her social worker present, on DVD about the rape. 23rd August 2013: The alleged perpetrator of the rape was arrested by the Police, charged and remanded in custody. 26th Sept 2013: Child W’s birth father made contact with her. 1st October 2013: Child W had an ‘unsuccessful’ face-to-face contact with her birth father. 7th October 2013: Child W received treatment at Hull Royal Infirmary Accident and Emergency Department having self-harmed with a razor. 7th October 2013: Child W visited her social worker and agreed to a referral for a full health assessment, CAMHS assessment and to see the Housing Options Worker to explore alternative accommodation options. 24 18th October 2013: Child W’s boyfriend was evicted from Hostel 2. A primary mental health screening telephone assessment took place between the social worker and a CAMHS health liaison worker. 22nd October 2013: Child W’s boyfriend was given accommodation at another hostel run by the same organisation as Hostel 2. 25th October 2013: An application for supported lodgings for Child W was approved and potential carers identified. 28th October 2013: Child W met the supported lodgings carers but decided against taking up this placement. 29th October 2013: A meeting took place between Child W’s social worker and a senior member of hostel staff of Hostel 2 in the context of concerns that the hostel could no longer meet Child W’s escalating needs. A behavioural contract was agreed. 30th October 2013: Child W saw a Refresh substance misuse service worker, who commenced a comprehensive assessment of her substance, sexual and emotional health needs. 2nd November 2013: Child W’s relationship with her boyfriend ended. 4th November 2013: Child W was evicted from Hostel 2. A place was found for her back at Hostel 1. 11th November 2013: Child W saw her Refresh worker. The risk assessment was updated. She then attended an appointment with a CAMHS worker for assessment. 13th November 2013: Child W was informed that the Plea and Case Management Hearing scheduled to take place that day for the alleged perpetrator of the rape had been adjourned. 15th November 2013: Child W contacted the manager of Hostel 2. He confirmed that he would hear her appeal against her eviction from the hostel on 19th November 2013. 16th November 2013: Child W was found by a worker at Hostel 1 on her knees in the bathroom, with her head facing forward and a ligature around her neck. 4.2 ASP 4: Social Work Help and Support for Child W. 4.2.1 As soon as Child W made direct contact with TYS on 9th July 2013 she was allocated an experienced and qualified social worker. This same worker remained her social worker for the remainder of her life. 25 4.2.2 There is substantial evidence from the various records and from the conversations with practitioners that Child W had a positive relationship with her social worker, regularly seeking her help, advice and support and asking for the social worker to support her at various key times (for example, the pre-interview assessment and DVD interview in relation to the rape allegation and Child W’s CAMHS assessment). 4.2.3 The social worker made consistent and persistent efforts to help and support Child W and there is evidence of close liaison with other agencies, in particular with Hostel 2, and of referrals to CAMHS, supported lodgings, health services, the post- adoption team (for a sessional worker ) seeking support for the presenting issues. At points, the social worker was also in daily contact with Child W, one of many young people on her caseload. 4.2.4 It is also noteworthy that Child W and her boyfriend were frequent visitors to the TYS team and not always to seek support with current ‘crises’. This indicates that she felt comfortable and ‘connected’ to the service. There is also evidence that she received responsive ‘ad-hoc’ support from the wider team when she made unplanned visits to the service and her social worker was not present to see her. 4.2.5 In consultation with her line manager, the social worker initiated the conversations with Children’s Social Care Central Duty Team and Humberside Police which led to a telephone strategy discussion on 12th July 2013 and a decision to initiate a section 47 enquiry into the allegation of rape. As part of this decision-making process, the social worker confirmed that she would undertake a Core Assessment of Child W’s needs in accordance with procedures. The core assessment was not completed within the 35 day timescale pertaining at the time, and indeed, had not been completed by the time of Child W’s death in November 2013. Analysis 4.2.6 The assessment process represented an important opportunity to fully and comprehensively assess Child W’s needs, and indeed risks, by bringing together information from a range of sources and to inform a clear plan for her, which might have identified the range of agencies and services providing help to her and the respective roles and responsibilities of those involved. 4.2.7 It is a feature of this period in Child W’s life that there were many different services involved in responding to her needs and providing help, but that , at no time was there a multi-agency meeting convened to coordinate support and agree one coherent plan. This meant that the risks associated with her lifestyle were not explicitly discussed in a multi-agency context and nor, therefore, was the collective involvement of different practitioners reflected upon in a way which might have 26 promoted better joint working, to provide greater continuity of support and to mitigate risk. 4.2.8 A clearer structure for management oversight of the case would have meant that a coordinated plan, alongside reflective discussion about the progress of the core assessment, was more likely to happen, and where relationships or communication between agencies were not working well this would more likely have been exposed and addressed. Supervision records between the TYS Manager and the social worker from 14th November 2013 indicate a discussion about the need to revisit the section 20 (Children Act 1989) accommodation issue, the fact that Child W’s needs showed that she would require long-term support and an agreement that it would be helpful to convene a professionals meeting to share information and coordinate support. 4.2.9 The meeting was convened to take place the following week, by which time Child W had died. Such a meeting could, and might helpfully, have been triggered by key incidents and processes (e.g. the strategy discussion, the core assessment, her eviction from Hostel 2) or at any point in time as her needs escalated and the number of agencies involved in her life multiplied. 4.3 ASP 5: Consideration of Child W’s Legal Status 4.3.1 When Child W first presented as homeless, Children’s Social Care sought advice from their legal department as to whether she should be accommodated under section 20 of the Children Act 1989. This advice was sought in the context of the ‘Southwark Judgement’ (Law Lords, May 2009), case law which obliges a local authority to provide accommodation and support to homeless 16 and 17 year olds, and to treat such young people as ‘looked after’, unless, based on an initial assessment, the child is not “in need” in the local authority’s judgement. 4.3.2 There is no doubt that Child W would have been assessed as “in need” as intended by the judgement and legislation and in accordance with the local HSCB thresholds of need guidance. Analysis 4.3.3 The legal advice provided appears to be that, since her parents were not saying that she could no longer live at home, Child W was not in fact homeless. Nevertheless she was found hostel accommodation having effectively made herself homeless by refusing to return home to live. In this context, the issue of accommodation under section 20 should have been explored with her parents and with Child W herself. 4.3.4 As Child W was aged 16 at the time, her agreement to be accommodated under S 20 CA 1989, and to become a ‘looked after 27 child’, would have been needed. Since there is no evidence that this option was explored with her, it is not helpful to speculate as to whether or not she would have wanted to become a ‘looked after child’. 4.3.5 It is also difficult to envisage how such a step might materially have affected the arrangements made for Child W’s accommodation. Becoming ‘looked after’ would have opened up the possibility of a placement for her either in foster or local residential care. Subsequent attempts to persuade Child W to take up a supported lodgings placement made it clear that she did not want to live with another family and it seems likely that she would have had similar reservations about any proposed foster placement. It is also unlikely that placement in a local children’s home would have better met Child W’s needs at the time, indeed, given her lifestyle and her overriding desire to be with her boyfriend, such a placement might have exacerbated risk. It was clear, from the outset that Child W wanted to live in hostel accommodation and, specifically, Hostel 2, at which her boyfriend was living. 4.3.6 However, had the issue been fully explored with Child W, as it ought to have been under the legislation, and had she asked to be looked after, this would have afforded her the additional formality of the looked after process through the structure in planning and independent reviewing which this entails. 4.3.7 It is important to reflect too, that whilst LAC status for Child W might, in itself have provided a clear regulatory framework within which multi-agency planning would have occurred, it was by no means a necessary pre-condition for such joint planning to happen. Finding 5: The Local Authority should ensure that it agrees and produces for staff clear local guidance on the interpretation and application of the ‘Southwark Judgement’. 4.4 ASP 6: The response of agencies to the allegation that Child W had been raped 4.4.1 Child W’s TYS social worker first contacted the Police and Children’s Social Care Central Duty Team about her allegation that she had been raped on 10th July 2013. The telephone strategy discussion which led to the decision to initiate a section 47 enquiry, led by the Police, took place on 12th July 2013. A Vulnerable Witness Officer (VWO) in the police was identified to lead on this on 15th July. The officer spoke to Child W on the same day and arranged to visit her on 18th July 2013. 4.4.2 Several appointments to see Child W were missed by her and attempts to contact her on mobile numbers she had left proved unsuccessful. On 30th July 2013 the VWO did make contact with Child W on a mobile phone number and arranged to meet her on 6th August 2013. Child W 28 subsequently asked her social worker to attend the meeting with the police and this was agreed. 4.4.3 The pre-interview assessment was completed at this meeting on 6th August 2013. Child W decided that she did not want to proceed immediately to DVD interview, although the interview suite had been booked in case, and this took place, again with her social worker accompanying her, as arranged on 20th August 2013. 4.4.4 On 23rd August 2013 the alleged perpetrator was arrested by the police, interviewed, charged with the rape of Child W and remanded in custody. Child W was informed of the outcome. 4.4.5 The Officer in the Case subsequently visited Child W on 23rd September 2013 to provide her with a personal update on the investigation and progress of the case and then provided her with a further progress report later in October 2013. In the meantime, her parents received a letter from the Humberside Young Witness Service on 6th September 2013, offering support for Child W should the rape allegation proceed to trial, informing them of the plea hearing date (Plea and Case Management Hearing) and confirming that the defendant had been remanded in custody. 4.4.6 Child W received a letter on 8th November from the Witness Care Unit informing her that the plea hearing would take place on 13th November 2013. On 13th November 2013, her social worker was advised that the plea hearing had been adjourned until 27th November 2013. Child W was angered and upset about the delay when she was told of it by her social worker. Analysis 4.4.7 The investigation into the rape allegation was conducted sensitively and at Child W’s pace. Appropriate measures were taken to ensure that she was as comfortable as possible, including a positive response to her request to be accompanied by her social worker. The completion of a pre-interview assessment prior to the DVD interview follows the best practice expected under Achieving Best Evidence. 4.4.8 Understandably, Child W was extremely anxious about the criminal proceedings and became more anxious and frustrated as scheduled hearing dates approached and there were successive adjournments with no progress being made. Her anxiety about the case was explicitly linked, by those caring for her at the time, to her subsequent self-harming behaviour (7th October 2013). 4.4.9 Child W’s social worker discussed accessing counselling for her when she first commenced working with her. At this stage Child W was adamant that she did not wish to speak with anyone. There is no evidence in the records that her potential therapeutic needs in relation 29 to the rape were further explicitly explored so that appropriate counselling might have been arranged had she wanted it. 4.4.10 Had the initial strategy discussions included health colleagues, it is possible to imagine that a full assessment of Child W’s health needs, including the need for any pre-trial therapy, might have been agreed as part of the assessment and enquiry process. 4.4.11 Consideration has been given during the course of this review as to whether or not Child W was a victim of Child Sexual Exploitation and, if so, whether there were missed opportunities before the alleged rape to identify potential vulnerability. No information was known to professionals immediately prior to the alleged incident (2nd June 2013) which ought to have led to an assessment of her vulnerability to CSE. Neither has any evidence emerged to indicate that she had been groomed by her alleged assailant. Finding 6: Health professionals should be routinely involved in section 47, Children Act 1989 strategy discussions, as set out in ‘Working Together 2015 and in local Hull Safeguarding Children Board procedures. 4.5 ASP 7: Child W’s accommodation needs and the role of the hostels Hostel 1 (9th July – 7th August 2013 & 4th – 16th November 2013) 4.5.1 During her initial stay at Hostel 1, Child W was absent for 14 of 28 days and nights. Most often when she was absent from the hostel she was staying with her boyfriend’s mother in Bridlington. 4.5.2 On 10th July 2013, the day after she moved in, she was issued with a ‘reviewable notice’ (a warning) by hostel staff for smoking cannabis on the premises. A week later hostel staff made a referral to the Refresh substance misuse service on Child W’s behalf. 4.5.3 Child W returned to live at Hostel 1 following her eviction from Hostel 2 on 4th November 2013. The admission process was carried out by the Housing Options Worker (a member of the TYS team), with Child W’s social worker also present. 4.5.4 Child W was allocated a female link worker and an external male advocate to assist her with her planned appeal against her eviction from Hostel 2. Child W’s parents report her phoning them on an almost daily basis at this time, expressing her distress about the eviction, and at overhearing comments which she interpreted as meaning that she was “beyond help”. 4.5.5 Hostel daily records, recorded in a communications log and email handovers, confirm that Child W spent most of her time away from the hostel and also indicate a complicated relationship with her boyfriend. 30 4.5.6 Child W was returned to the hostel by the police in the early hours of 16th November, having called at a Police Station saying that she and a friend were being followed by a man. According to hostel records she slept until about midday then left the hostel and went into town to meet up with the boyfriend of another hostel resident and with her brother. The hostel worker made a routine room check and observed nothing unusual in her room. 4.5.7 According to the worker, Child W returned to the hostel in the early evening, asking the worker if she could use the hostel phone, saying “it’ll be the last time, I promise.” The worker now thinks the comment may be significant. After the call Child W told the worker that she was going to meet her boyfriend the following day. She looked upset. She then went upstairs. 4.5.8 The hostel worker later went to ask Child W if she had taken the cigarettes of another resident. Child W was having a bath. She answered the worker and sounded quite cheerful. The worker went back downstairs to prepare for handover with his colleague. 4.5.9 A female resident then came downstairs to say that she had been on Facebook and read that Child W was in town talking to a woman. The hostel worker thought this strange and so went to check on Child W. Child W was still in the bathroom. She had been in there for about forty minutes, which was not unusual. The worker knocked repeatedly on the bathroom door but got no answer. He spoke to his colleague who also got no response from Child W. This worker unlocked the bathroom door and found Child W on her knees, having hanged herself with a dress tie. The Police and Ambulance Service were called. Child W was taken to hospital where she was pronounced dead. 4.5.10 The workers at Hostel 1 who were interviewed as part of this process were totally shocked and deeply affected by Child W’s death. They had not observed anything in particular that would help explain her actions on that evening. Hostel 2 (7th August – 4th November 2013) 4.5.11 From the day of her admission to Hostel 1, Child W was determined to obtain a place at Hostel 2. She was a frequent visitor and had got to know some of the staff because her boyfriend was living in this hostel. Whilst visiting Hostel 2 on 16th July 2013, Child W completed a self-referral and gave hostel staff the name of her social worker to approach for a reference. 4.5.12 Staff at Hostel 2 contacted Child W’s social worker for a character reference on 16th and 17th July 2013. The social worker said that: she had only recently met Child W and did not yet know her well; Child W was highly vulnerable due to her emotional wellbeing and risk of sexual 31 exploitation; and, she doubted that, given these concerns about Child W’s vulnerability, a mainstream hostel would be suitable for her. 4.5.13 The referral was rejected at this point: there was professional consensus that Child W’s support needs were too high for the hostel, coupled with concerns about the impact on her should her relationship with her boyfriend break down whilst they were living under the same roof. 4.5.14 On Saturday 3rd August 2013, Child W was staying as a guest at Hostel 2. She persuaded staff that her permanent admission had been agreed with her social worker and was allowed to move herself in. 4.5.15 It is not entirely clear from the respective records on precisely which date her place at the hostel was confirmed. It is apparent that Child W’s vulnerability and her suitability for the hostel were discussed. The outcome of the discussions was an agreement, which had been reached by 7th August 2013, that Child W would be allowed to stay, but that she would need to comply with the hostel terms of tenancy, that she would be closely monitored and that, if her relationship with her boyfriend within the hostel became an issue, she would need to move elsewhere. 4.5.16 This decision reflects the hostel’s general willingness to do their best to help and support vulnerable young people and a level of realism and pragmatism: Child W had seldom stayed at Hostel 1 and it was likely that she would be more settled at Hostel 2, which was her preferred placement. 4.5.17 During August 2013, there is evidence of good communication between hostel staff and Child W’s social worker and the Housing Options Worker. The main focus of concern in relation to Child W at this time centred on her relationship with her boyfriend, which staff observed could be controlling at times, and on managing her money. The social worker also agreed to liaise with Child W’s boyfriend’s pathway worker and to undertake some protective behaviour work with Child W. 4.5.18 Child W had the same link worker for the duration of her stay at Hostel 2 and took part in regular ‘Star Links’ updates on 23rd August, 22nd September and 29th October 2013. ‘Star Links’ sessions contributed to Child W’s support plan which was reviewed every three months. The ‘Star Links’ records provide a helpful insight into what Child W’s life was like at any one time and it is clear that she enjoyed the sessions and contributed fully to them. 4.5.19 The session conducted with her on 23rd August 2013, recorded ‘no issues’ in relation to Child W’s emotional well-being and confirmed her long-term goals as: to find a suitable college course; to find suitable accommodation; and to work on her relationship with her parents. In 32 relation to accommodation, Child W is recorded as considering a joint tenancy with her boyfriend in the future, but not feeling ready yet for that big commitment. 4.5.20 Hostel records indicate that an ‘inter-agency support planning meeting’ took place on 28th August 2013 between a senior member of hostel staff and the Housing Options Worker. According to these records, the senior member of hostel staff expressed concern about the lack of progress in finding Child W accommodation more suited to her support needs and discussed the need to develop an “easing out plan”. 4.5.21 There are no available notes of this meeting and no record of it on social care files. This is one of a number of examples of discrepancies in the records of the two agencies (Hostel 2 and Children’s Social Care). There is no record, either, of this discussion in the summary of Child W’s ‘Daily Diary and Risk Management Plan’ emailed by the hostel to the Housing Support Worker in October 2013. 4.5.22 The hostel records indicate that a further ‘inter-agency support planning meeting’ took place on 7th September 2013. These were regular meetings which took place between the senior member of hostel staff and Housing Options Worker to review the progress of all (Hull) young people living at the hostel. There are no notes of the meeting, but the hostel daily diary records continue to note visits from the police regarding the court case, problems with her benefits, Child W giving her boyfriend money and low attendance at college. 4.5.23 Child W’s next ‘star links’ session took place on 22nd September 2013. She is recorded as saying that she liked doing the ‘star links’ as it “shows you how well you are doing.” This session confirmed that she was happy at the hostel and not feeling ready for a move on at present. Child W also said that she was feeling under pressure at the moment due to the pending court case and said she would speak to her social worker about getting some counselling. She said that she was feeling more positive and attending college. Child W reported smoking cannabis on a regular basis but didn’t feel this was a problem. She also said that she had good friends who she could talk to but that things were “a bit up and down” with her Mum. 4.5.24 On 6th/7th October 2013, Child W self-harmed at the hostel by scraping her left arm with a razor (see section 4.6). 4.5.25 In response to this incident of self-harm, the hostel re-assessed Child W’s support needs from “low” to “high”. Further discussions took place between the hostel and Child W’s social worker. The social worker agreed to pursue a supported lodgings placement for Child W and to seek sessional work support for her. The outcome of the conversation, at this time, was that Child W did not need to move out of the hostel immediately, but that a ‘move on’ to more suitable accommodation needed to be arranged. 33 4.5.26 Child W’s boyfriend was evicted from the hostel on 17th October 2013 for persistent breaches of hostel policy. Her boyfriend told a TYS worker that Child W had attempted to self-harm as a result of this. Child W visited the TYS offices on 18th October 2013. She was clearly upset and angry about her boyfriend’s eviction from the hostel and threatened to self-harm. A discussion took place with her about supported lodgings, alongside efforts to rebuild her relationship with her parents. 4.5.27 Records indicate that Child W was agitated and unsettled over the weekend (19th and 20th October 2013), repeatedly asking hostel staff if her boyfriend could be re-admitted to the hostel, packing her belongings ready for moving out on the Monday (21st October) and staying out overnight on 20th October at the house of a friend of her boyfriend. 4.5.28 On 21st October 2013 Child W visited the TYS offices and told a worker that she had packed her belongings and that she wanted to leave the hostel and move to a flat with her boyfriend. Records indicate that she turned down supported lodgings saying that she did not want to live in another family situation. She threatened several times that she would harm herself if she didn’t get her own way. Child W calmed down and her parents were contacted and said that she could return home. Eventually she agreed to return to the hostel and to consider supported lodgings. Hostel records show that the TYS worker spoke on the phone with a senior member of hostel staff who confirmed that Child W’s place at the hostel was still available for her. 4.5.29 On 22nd October 2013, hostel management agreed to offer Child W’s boyfriend a place at another hostel. It is clear from the records that this decision was taken primarily as a means of supporting Child W and settling her down. 4.5.30 On 23rd October 2013, her mum contacted the hostel to express concern about Child W’s emotional well-being. Child W is reported as telling her mum that “she has had enough and wants to end it all”. Child W spent the night away from the hostel with a longstanding friend from school. 4.5.31 She did not sleep at the hostel on 25th, 26th or 27th October 2013. When she returned to the hostel on 28th October, the hostel worker who had last seen her on 25th noted that she appeared to have lost weight, and looked pale, tired and dishevelled. 4.5.32 On 29th October 2013, a meeting took place between Child W, a senior member of hostel staff and the social worker. Child W was due to start a new course with Inspiring Youth on 4th November. All agreed that she continued to have difficulty in budgeting. Child W confirmed that she would like her social worker to identify a sessional worker for her. She 34 also said that she would like to restore a good relationship with her brother which she felt was essential for both of them. Concern about her weight loss was discussed. Child W said that she wanted to go to the gym and that she liked to do the Saturday morning run in East Park. She reported that she had not self-harmed for some time (since 7th October) but “understood why she does it.” 4.5.33 The social worker drew up a written agreement (described in the hostel records as a ‘behaviour contract’) which outlined the expectations of the social worker, the hostel and Child W and which all parties signed. It was agreed that this would be reviewed in four weeks’ time. 4.5.34 Child W and her link worker had a further ‘star links’ session later on 29th October. The records refer to the meeting (4.5.32) and that the Housing Options Worker would complete a ‘move on’ form for Child W in January (2014) if her behaviour “continues to improve”. The record confirms that Child W was receiving physiotherapy to build the muscle in her leg. Child W reported feeling under less pressure at the moment and said that she was looking forward to starting her new college course the following week. She also said that she was now engaging with a Refresh substance misuse worker and reported that things were going a little better between her and her Mum. 4.5.35 Over the weekend (2nd & 3rd November 2013) Child W fell out with her boyfriend over money and the relationship came to an end. It is clear from the hostel records that she and her boyfriend repeatedly rang each other and that Child W was in and out of the hostel over the weekend, arguing and shouting with her boyfriend. At one point, the hostel’s resident’s phone was unplugged by a hostel worker because Child W’s boyfriend was frequently ringing it. Child W needed, and received, comfort and support from workers over the weekend, which was given, including in the form of cuddles. 4.5.36 On 4th November 2013, having been informed by hostel staff of the events of the weekend, the senior member of Hostel 2 asked for an urgent meeting with the Housing Options Worker prior to meeting jointly with Child W. Child W’s social worker was not available to meet. Both decided that Child W’s support needs were too high for Hostel 2. A ‘notice period’ of two weeks was agreed, to enable time for Child W to be found more suitable accommodation. 4.5.37 Child W joined the meeting in a state of high agitation. According to the hostel records she made repeated threats to harm herself, was shouting, pacing the room and flailing her arms about. She is recorded as saying that no one in her life cared about her. She was asked to leave the room. 4.5.38 It was decided that she could not return to Hostel 2. Child W was upset with the decision and refused to consider returning to her adoptive 35 home. She did agree to go back to Hostel 1 and was taken to Hostel 2 to collect her belongings and on to Hostel 1. Her up to date Risk Management Plan was emailed to the Housing Options Worker by Hostel 2’s Deputy Manager. Analysis 4.5.39 Hostel accommodation was never seen as being the most appropriate option, best suited to meeting Child W’s needs. The preferred option was for her relationships with her adoptive parents to be sufficiently restored to enable her to return home to live in the longer term. 4.5.40 Given that she was unwilling to return home to live, and her parents felt that some “distance” was needed, her social worker discussed supported lodgings with her at her first meeting with Child W and her parents on 17th July 2013. Child W did not want to consider this option and it is clear that she was determined that she wanted to live at Hostel 2. 4.5.41 It was not until 21st October 2013 that Child W agreed to consider a supported lodgings placement. An application was swiftly made and approved on 25th October 2013. A potential carer was identified for her and she was taken by her social worker to meet the carer on 28th October 2013. Child W turned down the placement. 4.5.42 Initially she said that this was because the placement was too far away from where her boyfriend was living. Later, she told her social worker that she did not want to live in a family environment, due to previously being in care and the breakdown of her relationship with her adoptive family. Child W said that if things didn’t work out for her in a hostel then it wouldn’t hurt as much as it would in a family home. 4.5.43 It is clear that Child W formed important and supportive relationships with staff at Hostel 2 who nurtured her at a time in her life when she needed it most. Case records inevitably fail to capture a full picture of these relationships, although there is evidence in the ‘star links’ work that Child W was happy at the hostel. For example, staff helped her with her coursework, applied make up, bought her beauty products and comforted her when she needed it. 4.5.44 The hostel had shown, despite reservations from the outset that Child W’s needs were too high for it to meet given the staffing ratio, that it was willing to work with her, and continue to do so, with a ‘move on’ plan, even as her needs escalated during October 2013. The decision on 22nd October 2013 to offer Child W’s boyfriend a place at another hostel owned by the same company is an example of the hostel continuing to focus on how best they could continue to support Child W despite her increasing support needs. 36 4.5.45 The events of the weekend (2nd & 3rd November 2013) and Child W’s responses during the meeting on 4th November 2013 were judged to demonstrate that Hostel 2 could no longer meet her escalating needs. This decision, in the context of Child W’s high and escalating support needs, is understandable. 4.5.46 Nevertheless, the decision clearly upset her and she immediately started to ask about an appeal against it. Her eviction came at a time when her court case as a victim of an alleged rape was approaching and she had just ended an important relationship with her boyfriend. Her distress will have been compounded by comments which she is said to have overheard and which she is reported by her Mum as interpreting as meaning that she was “beyond help”. 4.5.47 Child W’s re-admission to Hostel 1 recorded that an assessment of her vulnerability had been completed, but this was not on file or received by the hostel. Child W’s risk management plan, completed by Hostel 2, and emailed to the Housing Options Worker, was not passed on to Hostel 1. The document contained considerable information which might have assisted Hostel 1 in supporting Child W. 4.5.48 The information on the hostel file focused on Child W’s substance use, personal circumstances and likely support she would receive from CAMHS, via the mental health assessment which was due to be undertaken on 11th November 2013, and from her social worker. 4.5.49 There was no needs assessment of Child W created by Hostel 1, other than a support plan focusing on ‘my way forward’ aims. The staff team report having had no training in self-harm or in recognising suicidal ideation, assessing risk or child sexual exploitation in the previous 12 months. There was no evidence of daily link worker sessions and there had been no formal supervision of staff for the previous 12 months. 4.5.50 There are important lessons to be learned about the range and type of accommodation available in Hull to vulnerable young people, the extent to which such accommodation is supported to meet the needs of vulnerable young people and the need for protocols, as part of local commissioning arrangements, setting out clear expectations for sharing information with, and between, hostel providers which is needed to help meet the needs of young people. 4.5.51 This learning is explored further in the ‘overall learning and analysis’ (section 4.10) and reflected in ‘Finding 8’. 4.6 ASP 8: Child W’s emotional health and the response of professionals 4.6.1 There are a number of instances known to professionals when Child W either harmed herself or made threats to do so: in February 2011 (spraying deodorant on an old wound); March 2012, the incident on the roof at home; March 2013, a cut to her arm and 3rd June 2013 when in 37 police custody. None of the known incidents of self-harming behaviour resulted in more than ‘superficial’ injury. 4.6.2 At her first meeting with her social worker in July 2013, Child W told her social worker that she had previously self-harmed when she had split up with a boyfriend. 4.6.3 There are no further records of self-harming behaviour or of Child W making threats that she would harm herself until 7th October 2013 when she self-harmed by scraping her upper arm with a razor. 4.6.4 The incident took place at Hostel 2. Child W took herself to the local Hull Royal Infirmary Accident and Emergency Department for treatment. According to hostel records her injury was superficial. Child W is recorded as saying that she had harmed herself because of “everything: her brother and meeting with her Dad (birth father) and all the bad things that happened when she was younger and the problems she has got with her parents and the court case coming up”. 4.6.5 Hostel staff immediately informed Child W’s social worker of the incident. Child W had an appointment with the social worker later that day. This incident prompted the hostel to reassess Child W’s support needs from ‘low’ to ‘high’. 4.6.6 The hospital sent a discharge summary to Child W’s GP surgery on 8th October 2013. The description of ‘upper arm injury’ did not state that the injury was self-inflicted and did not, therefore, alert the GP of any need to follow it up. 4.6.7 Child W and her social worker talked about the self-harming later on 7th October 2013. Child W told her social worker that she had no intention to end her life, but that she wanted to feel pain. She agreed to a referral to the Child and Adolescent Mental Health Service (CAMHS) for assessment. This was an appropriate response to this incident. The CAMHS referral was made on 11th October 2013. 4.6.8 On 18th October 2013, a telephone mental health screening assessment took place between Child W’s social worker and a CAMHS health liaison worker. The assessment concluded that there was no immediate risk, but that an appointment within 10 days was required. There was no available appointment within this timescale. An appointment was made for 11th November 2013, after 16 working days. 4.6.9 On 11th November 2013, Child W, accompanied by her social worker and sexual health worker, attended for her CAMHS assessment. The CAMHS worker carried out a screening assessment using the ‘Strengths and Difficulties’ Questionnaire. The conclusion of the assessment was that there was no immediate suicide risk but that Child W would be referred into the CAMHS self-harm pathway. It was 38 agreed that contact would be made with the TYS social worker to progress this further by the end of the week (16th November 2013). 4.6.10 The assessment took place outside of the expected timescales (16 working days instead of the target of 10). CAMHS waiting times are a feature of the service nationally, and have been a feature locally too for many years. However, Child W did not experience an extensive delay in being assessed. 4.6.11 The CAMHS worker was not aware that Child W had asked to see a female worker and had said that she would be uncomfortable talking to a man. 4.6.12 On 15th November Child W met her social worker. The recording for this date refers extensively to her boyfriend and Child W saying that she was “fed up” and that she couldn’t be “bothered with anything anymore”. The social worker spent time with her, encouraged her to contact her mum and helped her to arrange her appeal against her eviction, and feels that Child W left the meeting in a much more positive frame of mind. 4.6.13 The following day on 16th November 2013, Child W died. Staff at the hostel had not noticed anything in relation to her behaviour or mood prior to this, which might have given rise to concern. Analysis 4.6.14 During this period (9th July – 16th November 2013) there is one recorded incidence of Child W self-harming (7th October 2013). This incident appropriately triggered a referral to CAMHS for more specialist assessment. There were a number of occasions on which she threatened to hurt herself, when stressed or as a means of trying to persuade adults to accede to her requests. Her parents also expressed concern about her emotional well-being to professionals on several occasions. On each such occasion, however, Child W subsequently saw professionals and provided reassurance that she did not intend to self-harm and did not have any suicidal thoughts. 4.6.15 Child W made threats to self-harm to a number of different workers and it would have been very difficult for any worker to assess how serious these threats were, or how much risk there may have been of suicide, particularly as her actual recent self-harm had involved relatively minor cuts and scratches (March 2013 and October 2013). This difficulty will have been compounded by the fact that none of the staff in contact with her, other than the CAMHS worker, had received any specific training in recognising the risk factors or in ‘Youth Mental Health ‘First Aid’. 4.6.16 In the consultation for the development of Hull’s ‘Emotional Health and Wellbeing Strategy’, professionals fed back that it was “hard to spot the 39 difference between ‘normal’ teenage behaviour and a teenager with emotional health needs”. 4.6.17 Adolescence is known to be a time of extreme emotional turmoil, and of physiological changes2 which make it difficult for teenagers to make sense of their world. For teenage girls this is compounded by hormonal changes which produce mood swings, impulsive behaviour, and physical symptoms. They often rebel against and withdraw from the care and influence of the adults who would protect them and develop intense relationships which produce equally intense emotions when these go wrong. They are struggling to make sense of who they are at a point when they are physiologically not well equipped to do so. 4.6.18 The presence of strong familial bonds and flexibility in parental care and control is crucial in enabling this process to happen in a positive way, and these factors were not present for Child W. Her emotional turmoil would have been magnified by her attempts to make sense of her abusive childhood and her relationships with her birth and adoptive families. Her “letter for later life” from her adoption social worker explaining the circumstances of her coming into care was found in her possessions at the hostel. 4.6.19 Child W had been in a highly intense relationship with her boyfriend which had recently ended. Her behaviour in response to this (attention-seeking, distressed, demanding of staff time and energy) contributed directly to the decision to evict her from Hostel 2 as her support needs could no longer be met there. Whilst this was an understandable decision, nevertheless it had the effect of adding to Child W’s emotional turmoil at the time. 4.6.20 At the time of writing this report, six teenagers (including Child W) have taken their own lives, whether deliberately or not, across Hull and the East Riding of Yorkshire in the last 2-3 years. In Hull, there has been a noticeable increase in the numbers of children and young people attending accident and emergency having self-harmed. Local schools, both primary and secondary, also report a significant increase in self-harming behaviour and general concerns about teenage emotional well-being. 4.6.21 The links between self-harm and suicide are not straightforward. Self-harm is defined as “intentional self-injury or self-poisoning, irrespective of type of motivation or degree of suicidal intent”3. This reflects the often mixed nature of intentions associated with self-harm and also the fact that suicidal intent is a dimensional rather than unitary 2 Raising Girls S Biddulph Harper Publications, 2013 3 Hawton K, Harriss L, Hall S, Simkin, S., Bale E, Bond A. Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics. Psychol. Med 2003; 33: 987-96 and National Institute for Health and Clinical Excellence (2011). Self-harm: longer-term management CG133. National Institute for Health and Clinical Excellence: Manchester 40 phenomenon - many young people who self-harm do not go on to kill themselves, and have no intention of doing so. 4.6.22 This can lead some professionals to underestimate the impact of other risk factors, and of the impulsivity which is a feature of many young people, particularly those who have had challenging and abusive backgrounds, and who are struggling with poor self-esteem. 4.6.23 Given this complexity, and given Child W’s previous pattern of behaviour, it would not have been possible for any of the professionals involved in supporting her to have predicted the outcome and neither will it ever be known whether or not Child W intended to take her own life. Finding 7: Practitioners working with young people need to have a good understanding of adolescent development. Access to training, advice and consultation for professionals and families regarding children and young people’s emotional health and wellbeing needs to be clarified as the current strategy has not yet been fully delivered or achieved. 4.7 ASP 9: The response to Child W’s health needs and issues (excluding emotional health) 4.7.1 Child W was taken to Hull Royal Infirmary on 30th May 2013 having been struck by a vehicle. She had injured her leg. She attended the accident and emergency department on 30th August 2013 for advice about her knee, but did not wait to be seen. A letter was sent to her GP which highlighted missed appointments. Child W missed many of her appointments for physiotherapy on her knee, including on 9th and 23rd October and 6th November 2013. 4.7.2 She attended Hull Royal Infirmary, accident and emergency department on 7th October 2013, having cut her upper arm with a razor and received treatment for the wound. The hospital discharge letter to her GP did not describe the injury as having been self-inflicted. 4.7.3 Between 30th September and 12th November 2013, there are five recorded instances of Child W accessing ‘walk in’ medical help for a variety of health complaints and tests. Analysis 4.7.4 The lack of a fully coordinated, joined up multi-agency approach, such as might have been achieved via a professionals meeting, meant that the health services with whom Child W had been in episodic contact over the last few months of her life, had no opportunity to share information about that contact, or to put her visits and health needs into any broader context. These health records were not, therefore, pulled together at any point. 41 4.8 ASP 10: Help provided to Child W in relation to her substance use 4.8.1 Child W was first referred to the Refresh young people’s substance misuse service by staff at Hostel 1 on 17th July 2013, following being given a warning at the hostel the previous week for rolling a cannabis joint on the premises. She was interviewed and an initial referral/risk assessment completed, but she declined support at this time. 4.8.2 It is clear from Hostel 2’s records that Child W continued to use cannabis on a regular, and sometimes daily, basis but that she didn’t consider this to be problematic. On 19th September 2013, the hostel daily diary records Child W as being sick and under the influence, having taken a legal high. This is the first recorded instance of her using other substances, most probably Mephedrone (M-CAT). She was advised about the dangers. 4.8.3 On 17th October 2013, Child W self-referred to the Refresh substance misuse service. On 30th October 2013, her allocated Refresh substance misuse worker started a comprehensive assessment of her substance, sexual and emotional health needs, focusing on Mephedrone (M-CAT) reduction, sexual and physical health. 4.8.4 Child W had an unplanned meeting at Refresh on 8th November. She told her worker that she was having difficulty relaxing and said that this made her feel vulnerable. She agreed with her worker that they would practice relaxation techniques at the end of their sessions. On 11th November, Child W saw her Refresh worker and the assessment was updated. She scored high on substance misuse, neglect, vulnerability and mental health. 4.8.5 When Child W saw her worker on 13th November 2013 she told her that she had not used M-CAT since 8th November 2013. Analysis 4.8.6 There is evidence in the respective records of communication between Child W’s Refresh worker and her social worker, and that they saw Child W together on at least one occasion. Concern about her continued drug use was one of the issues which influenced the decision to arrange a professionals meeting. This decision was taken shortly before Child W died (para. 4.2.8). 4.9 ASP 11: Support for Child W in meeting her training and further education needs 4.9.1 In May 2013, as she was taking her GCSE examinations, Child W received a letter informing her that her application to train as a nurse in the army had been rejected. On 23rd April 2013, she had previously accepted the offer of a place on a child care course at Hull College. 4.9.2 On 22nd August 2013, Child W’s social worker helped her to obtain her GCSE results from school. She had obtained D’s and E’s in her 42 GCSEs and had passed her BTEC Health and Social Care and Applied Science. The school offered her support in the future in discussing her next options. 4.9.3 On 28th August 2013, Child W did not attend an appointment at college, as she had decided that the course she was due to start was not what she wanted to do. The hostel records state that her social worker would help find her a more suitable course. 4.9.4 Arrangements were made for Child W to switch to a Business Administration course at Hull College. On 6th September 2013 she was given a grant to buy stationary and clothing for the course. The hostel records indicate that her attendance at college was inconsistent, with many daily entries showing that she did not attend. 4.9.5 On 29th October 2013, she is recorded as looking forward to starting a new course (with ‘Inspiring Youth’) on 4th November, as she had not been enjoying her previous course. In the event, Child W never did start this course. 4.9.6 Child W met twice with the duty worker at the Connexions Service on 14th November 2013. She said that she had no money and was advised that she needed to enrol at college in order to receive her benefits. Child W explained that the antibiotics she had been prescribed were ‘wiping her out’ and that this was why she had not attended. Arrangements were made for her to go into college on Monday (19th November 2013). She was given a ‘mega-rider’ for the bus. Analysis 4.9.7 Arrangements were made for Child W’s future learning via the Risk of NEET (Not in Education, Training or Employment) indicator process (RONI) managed through the Connexions Service. She received personalised outreach support from a Connexions worker and the service tried to support her to attend college and to communicate with other services as required. 4.9.8 In the context of what was going on in her life at the time, however, particularly from October onwards, it is not surprising that Child W found it difficult to attend college on a regular basis or give attendance the priority she may have wished. 4.9.9 Greater overall coordination of the help and support being provided to Child W would have also assisted both the college and Connexions service to tailor their particular provision and responses to her individual and changing needs and circumstances as part of one agreed support plan. 4.10 Overall Analysis and Learning 4.10.1 All of the practitioners who were interviewed and took part in this review were deeply affected and saddened by Child W’s death. 43 4.10.2 There is clear evidence that many who worked most closely with her cared about her as a young person, and worked hard to build positive relationships and trust with her - and were also very concerned about the risks associated with her lifestyle and created by her experiences. They wanted her to be safe and did what they could to encourage her to stay safe. At some points contact with key staff was on a daily basis. This was good practice. 4.10.3 There is also ample evidence that Child W built positive and supportive relationships with key adults in her life: this included staff at Hostel 2 and her TYS social worker. There is evidence too that she found many of the services which she used, and the staff working in them, accessible, welcoming and ‘young person friendly.’ When she called at services ‘on spec’ and her allocated worker was not available to see her, there is also good evidence that other staff were willing to provide help, support and advice. The approach of workers and the ‘feel’ of services, as experienced by Child W and others, form part of an approach and value-base which must continue to form the basis of any local redesign of support services for vulnerable young people. 4.10.4 Practitioners also wanted much more for Child W: to help her to get her life onto a more secure and stable footing and realise her full potential; to obtain permanent, suitable accommodation; to resume training or education or employment and; to improve her physical and emotional health. To this end many professionals showed persistence and determination and did not stop trying to help, despite the challenges. These qualities and skills too need to be recognised as central to the learning from Child W’s death and informing what improvement might look like. 4.10.5 Work with vulnerable young people is an area of specialism in its own right. This review has highlighted the difficulties some young people face in accessing services. It has highlighted the need not just to improve the quality and range of accommodation options, but more fundamentally, the need to ensure that accommodation and support are provided in a much more seamless way, and in the context of a clear framework for practitioners and an explicit, value-based approach for working with young people. 4.10.6 There are arguably resource and capacity issues which can leave young people more vulnerable than in the past. Practitioners taking part in this review highlighted from their perspective the impact of ‘cuts’ in funding of services for this group of children. 4.10.7 There is a strong history of good multi-agency working with young people in Hull; however, as services have been reduced the different elements of an integrated model of working with young people have fragmented, and the relationship between different parts of the system and respective roles and responsibilities has not been made sufficiently 44 clear. The effect of this has arguably been that staff are more likely than before to be working in isolation. 4.10.8 It may well be the case that, in the context of budget cuts across the public sector, there has been an insufficient focus locally on how to remodel services for young people across the partnership to ensure that needs can be met. It is, therefore, essential that the local partnership comes together to understand what life is like for this group, listens to them and makes a joined up response accordingly. 4.10.9 It is widely recognised that ‘mainstream’ systems of help and support, including child protection systems, can sometimes inhibit the kind of person-centred engagement work that is needed to build the confidence of young people and draw them back into mainstream services. Vulnerable young people may often have had negative experiences of professionals and/or harmful relationships with adults. They will also often be coming into contact with a range of different agencies - voluntary, community and statutory. Their networks of support can be fragmentary and transient. 4.10.10 This kind of work needs to be recognised in the workforce development of the partnership as a valued and important part of the range of provision that can help keep young people safe, requiring a particular set of skills and values. 4.10.11 In addition, training, awareness-raising and guidance on self-harming behaviours in young people are needed for practitioners across the partnership. With the sole exception of the CAMHS worker, none of the staff in contact with Child W had any training in recognising the risk factors associated with self-harm. It is, by its very nature, extremely difficult to understand the factors which contribute to death as the result of deliberate self-harm. Knowledge of the broad risk factors provides a context for assessment but the same risk factors can be applied to large numbers of troubled young people who do not die as a result of deliberate self-harm. The literature also suggests that deliberate self-harm is frequently characterised by impulsivity, which provides a further challenge in terms of keeping young people safe. 4.10.12 Despite the best efforts of many staff across the partnership, communication between individuals and agencies was not always as good as it needed to be. Whilst professionals from different agencies did communicate, and did meet, there was no multi-agency meeting convened for the purpose of coordinating information, including understanding risks and strengths, and drawing up an agreed plan. This meant that the risks associated with Child W’s lifestyle were not explicitly discussed in a multi-agency context; nor therefore was the collective involvement of different practitioners reflected upon in a way that might have promoted better joint working between agencies and practitioners. This might have reduced the number of interfaces Child W had to negotiate at times and rationalised roles between 45 practitioners which, importantly, may have simplified things for her. It might also have helped Child W to feel that all the adults working with her were giving consistent messages about how they could help. 4.10.13 A clearer structure for management oversight of the case would have meant that a coordinated plan was more likely to happen, and, where relationships or communication between agencies was not working well, this would more likely have been exposed and addressed. Work with vulnerable young people must operate within a clear framework and must be continuous with the wider system of help and safeguarding. Child W’s needs were at no point considered within a risks framework. This is also an area for development and learning. 4.10.14 There is a balance to be struck between the capacity for self-determination of a young person, and the advice, support and accommodation options presented to them based on their needs as assessed by the adults who have a duty to safeguard and promote their welfare. A future framework for working with young people should include how the assessment of housing needs is carried out, together with the responsibilities of respective agencies in addressing the needs of this group. 4.10.15 Many of the professionals involved in the review considered that many young people remain at an unacceptable level of risk in the city through homelessness and that there are seldom sufficient adequate places for them to stay. 4.10.16 The review has highlighted a skills gap and also a need for clarity about some key procedures and protocols to ensure that admission and exit processes are fair and consistent and that risk management is robust. Above all, there need to be realistic expectations of the capacity of hostel staff in managing high levels of need for some young people. This issue, the provision of supported accommodation for young people, needs to be addressed in the context of a wider review of services for this age group. 4.10.17 Child W’s determination got her to the hostel that she wanted to be at. It is clear that other options were discussed with her and it is difficult to see how this might have been different. The status of ‘s.20’ would have afforded the added formal structure of the looked after children reviewing process, but it would only have been a protective factor had Child W chosen to cooperate with it. It would, however, have provided a framework within which practitioners came together to review Child W’s care and placement. 4.10.18 Child W’s experience also highlights the need for clear post-adoption support arrangements, particularly when arrangements cut across different local authority areas. There is a need for post adoption support to be better understood in its own right and in relation to 46 safeguarding services and other engagement services for young people. Older young people may find youth support and engagement services more relevant to them depending on their age and circumstances - each young person needs to be assessed in their own right and services need to talk to each other, and with the young person, about the best way of working with them. Agencies can spend too much time talking to each other and deciding whether a young person is eligible or has an entitlement to a particular service, rather than meeting to decide who is best placed to work with each individual. This might usefully form part of the overall framework and approach. 4.10.19 Child W’s experience informs us that the design and commissioning of services, whether accommodation or support services, must be more closely integrated with the overall framework of support for young people and reflect the needs and views of young people in the city. Finding 8: There is a need for a fundamental, ‘whole system’ review of support arrangements for vulnerable young people in Hull, which captures the learning identified in this review. 47 5. Findings, Developments and Recommendations 5.1 Adoption Practices and Post-Adoption Support Finding 1: Adoption Support Plans need to clearly and explicitly detail how, and by whom, any assessed therapeutic needs in respect of children placed for adoption, will be met. 5.1.1 The adoption and post-adoption support issues addressed in this review (Chapter 3, section 3.1) date back to a period between 2006 and 2010. The review has made reference to the heightened national focus on adoption since that time and to the changes in statutory guidance which have had an impact on adoption practices. 5.1.2 The adoption practice issues and learning from this review relate specifically to Barnsley local authority, since it was they who placed Child W for adoption and carried the responsibility for providing post-adoption support for three years after the making of the Adoption Order. 5.1.3 There is evidence that Barnsley Adoption Services have undertaken significant improvements since the time when Child W and her brother were first placed. The most recent Ofsted report notes that social workers work well with people wanting to become carers (both foster carers and adoptive parents) and provide them with good support after they are approved to care for children. 5.1.4 Ofsted also found that there has been a good focus on developing adoption support in Barnsley through the appointment of a dedicated worker. Detailed adoption support plans are routinely developed to enhance adoptive placements. These include emotional support packages through CAMHS for parenting support for adopters and access to specialist counselling services for children 5.1.5 Whilst it was Barnsley which placed Child W for adoption, this review has been commissioned by the Hull Safeguarding Children Board (HSCB) and so it is appropriate and necessary for the HSCB to seek assurances from Hull City Council about the current quality of adoption practices and provision of post-adoption support. 5.1.6 The Board is assisted in this regard by the findings of the recent Ofsted ‘Inspection of services for children in need of help and protection, children looked after and care leavers’. The inspection took place in November and December 2014 and the report was published in February 2015. 5.1.7 Adoption performance overall was judged to ‘require improvement’. This judgement related primarily to the timescales within which children are placed for adoption after entering care and to the arrangements for monitoring the progress of children with a plan for adoption. 48 5.1.8 The performance in Hull on numbers of children placed for adoption was judged by inspectors to be ‘good’. The adoption panel was assessed as being chaired well, and the panel minutes and recommendations found to be clear and appropriate. However, inspectors found that the quality of child permanence reports received by the panel was too variable, citing examples which had not included all risk issues, or recorded history well. 5.1.9 The quality of prospective adopter reports and matching reports seen by inspectors were judged to be good, containing clear analysis and detail. Adoption disruption rates in Hull were found to be low and all of the adopters spoken to reported that a suitable match was made. The inspectors also found post adoption support to be a strength of the local authority. Adopters spoke positively about adoption support and were aware how to access this now and in the future. Recommendation 1: Hull and Barnsley Safeguarding Children Boards should assure themselves that adoption processes, and arrangements for post-adoption support, are now good, including the need for handover arrangements, should there be ongoing involvement of the placing authority at the end of the three year statutory period. In relation to older children in particular, the way in which post-adoption support services are accessed and provided in collaboration with other relevant services should also be set out. By: 31st March 2016 5.2 Access to specialist therapeutic services to address attachment needs Finding 2: The attachment needs of children placed for adoption should form part of the specialist therapeutic services in local commissioning arrangements. 5.2.1 The recent Ofsted inspection (para. 6.1.4 above) acknowledged that Hull local authority had recognised the need for consistent and readily available psychological support for looked after children, and that, “in the absence of targeted health commissioned service” had employed two psychologists. This had enabled a focus on attachment issues for young people, a greater understanding of behavioural issues and is helping to support the needs of looked after children. In addition, the inspectors saw examples of the local authority buying packages of support for young people with specific complex needs, and that this was helping to improve outcomes. 5.2.2 However, both the Ofsted, and the simultaneous Care Quality Commission (CQC) inspection found that looked after children were insufficiently prioritised for mental health services, with relatively few receiving direct support from the Child and Adolescent Mental Health 49 Services (CAMHS). Ofsted found that CAMHS was not delivering the agreed ‘targeted and dedicated specialist service’ for children in care. Some young people were waiting too long to access the service and their needs were going unmet. 5.2.3 These findings translated into a CQC recommendation for access to CAMHS for looked after children to be improved. This review has identified that Child W did not receive the specialist therapeutic help that had been identified as being needed for her, either whilst she was still looked after by Barnsley local authority, or subsequently, post-adoption. Whilst this was never specifically sought for her, nevertheless doubts were expressed at the time as to whether it would have been available if requested. 5.2.4 Local partnership work to improve access to specialist CAMHS services for looked after children, including in relation to attachment, should extend to include children who have been adopted and, in respect of whom, therapeutic need extends beyond the adoption itself. The HSCB has established clear mechanisms to oversee progress in improving access to CAMHS for looked after children. Recommendation 2: The emotional and mental health needs, including those relating to attachment, of children placed for adoption, and those who have been adopted, should be prioritised by commissioners of therapeutic services By: 31st March 2016 5.3 Assessing the needs of whole families Finding 3: There should be an holistic approach to assessment which captures and reflects the needs of the whole family in the process. 5.3.1 The review identified that, during the period from November 2008 – May 2013, when there was significant professional involvement with the family, there was an insufficient focus on Child W’s needs as an individual. 5.3.2 In January 2014, Children’s Social Care implemented a new model for the delivery of social work services in Hull, based on a systemic approach to social work practice. Under the new model, small teams of social workers, known as ‘pods’ were established, led by a Consultant Social Worker. The model is based on each Pod operating as a ‘learning system’ with shared workload, regular reflective group discussion about ongoing assessments and work, and access to clinicians to support the work. 5.3.3 The new model was still in its relative infancy at the time of the inspection, but inspectors still identified, as one of the local authority’s 50 strengths, that recent assessments were of increasing good quality with a strong focus on the voice of the child. They also found many examples of good direct work with children and well developed social work relationships with children and families, “characterised by social workers and their managers who know the needs of children well.” 5.3.4 The systemic approach to practice is increasingly embedded. A significant investment has been made in training and development of social work staff. The approach places emphasis on the quality of the work with children and families, looking at whole family dynamics and explicit consideration of risk and the specificity of risk in relation to individuals. 5.3.5 The use of genograms and other tools to help understand the experience of all children and adults in the immediate and extended familial network is emphasised. Weekly reflective meetings are designed to provide visibility to cases to the wider pod and oversight by the CSW, as well as provide support and challenge to the hypotheses upon which the interventions are based. 5.3.6 The reflective meetings also include clinicians who work to help understand and challenge the dynamic between the practitioner/agency and family and explore how this has a bearing on effecting change. Work is also increasingly focused on specific goals designed to effect and monitor change. Change to reduce risk and sustain families is the premise for involvement, with constant reflection and review. Since the Ofsted inspection greater emphasis is placed on the ‘risk’ elements of assessments and plans and the oversight of CSW’s and managers 5.3.7 Notwithstanding these developments, Children’s Social Care will need to ensure that this particular element of learning is clearly communicated to the ‘frontline’ and features as part of routine reflective discussion and supervision. Recommendation 3: Managers in Children’s Social Care should ensure that this specific learning is clearly communicated to frontline practitioners and reflected in work with children and families. By: 31st January 2016 5.4 Service Provision Finding 4: The needs of children and young people must be at the centre of decision making about the provision of support, and service or organisational boundaries should not act as a barrier to children, young people and families accessing the most appropriate help and support according to those assessed needs. 51 5.4.1 Since the commencement of the Serious Case Review considerable work has been undertaken to re-shape services. Some of this work and the evidence of improved practice are described above. Others are described in relation to ‘Finding 8’ below. 5.4.2 It is nevertheless acknowledged that a more fundamental ‘whole system’ review of partnership arrangements for the provision of help and support to vulnerable young people is needed. One of the key principles underpinning service re-design must be that children and young people can access the right service, at the right time and in the right place, and that their legal status or history does not act as an unnecessary barrier for them. Recommendation 4: Hull Safeguarding Children Board should ensure that this key principle is reflected in the development of a new local multi-agency framework for the integrated support of vulnerable young people. By 30th June 2016 5.5 Assessing the need to accommodate homeless 16 & 17 year olds under section 20, Children Act 1989. Finding 5: The assessment of ‘homeless’ 16 & 17 year olds should always include consideration, with them and their families, of the potential for accommodation under section 20, Children Act 1989. 5.5.1 The local authority has produced a draft protocol clearly describing its legal responsibilities under the Children Act 1989 and Housing Act 1996. More importantly the protocol describes the way in which different services should work together to assess the needs of young people who are at risk of homelessness or who are in housing need. 5.5.2 The protocol now needs to be refined, agreed and implemented in order to achieve greater clarity and consistency, and better outcomes for 16 and 17 year olds in need of accommodation. Recommendation 5: The Local Authority should ensure that it agrees and implements for staff clear local guidance on the interpretation and application of the ‘Southwark Judgement’. By 31st January 2016 5.6 Strategy Discussions under section 47, Children Act 1989 Finding 6: Health professionals should be routinely involved in s 47 strategy discussions as set out in ‘Working Together 2015’ and local HSCB child protection procedures. 52 5.6.1 The involvement of health professionals is assisted by the co-location of the health safeguarding team with the Police and Social Care decision-makers. This means that there is increasing involvement of health professionals in s47 discussions. This needs to become more embedded and forms part of the post inspection improvement work to establish a multi-agency early help and safeguarding hub. Recommendation 6: Hull Safeguarding Children Board should receive regular reports in relation to the involvement of health professionals in section 47 strategy discussions and the impact of this on the quality of decision-making and planning. From: January 2016 onwards 5.7 Adolescent emotional and mental health and wellbeing Finding 7: Practitioners working with young people need to have a good understanding of adolescent development. Access to training, advice and consultation for professionals and families regarding children and young people’s emotional health and wellbeing needs to be clarified as the current strategy has not yet been delivered or achieved. 5.7.1 Since Child W’s death considerable work has been undertaken to improve the range of services and increase early intervention in relation to the emotional and mental health and wellbeing of children and young people. The development of the Children and Young People’s Mental Health and Wellbeing joint commissioning strategy and associated delivery plan, overseen by the Children, Young People and Families Board has identified gaps in provision particularly at a universal and targeted/early help level. 5.7.2 These gaps have been addressed by: Extensive consultation with children, young people and parents, as well as stakeholders and partners, and learning from examples of good practice in other areas. Mapping existing good practice locally and identifying areas of development and improvement at a universal and targeted/early help level (traditionally known as tier one and two). The development and implementation of a multi agency workforce development and training plan, which will: o Provide staff with information on evidence based approaches which promote protective factors and support children and young people’s emotional health in Universal & Targeted/Early Help settings. o Enable skills development and capacity building in Universal and Targeted/Early Help services that support children, young people and their families/carers. 53 o Increase the numbers of brief interventions undertaken in Universal and Targeted/Early Help services to initiate and support behaviour change or improvement. o Improve partnership working though shared and consistent training, knowledge and practice. 5.7.3 In its first year, 67 practitioners were trained in Youth Mental Health First Aid .They were from a range of agencies: 43 from Hull City Council, including social workers, youth workers and early help practitioners; 13 were from the voluntary and community sector; and 11were from other agencies such as health, schools and police. 5.7.4 This year this training is being delivered to all children’s homes staff in addition to being offered to a range of agencies as previously. Additional thematic training is being developed including self-harm training and bereavement training. In addition CAMHS are piloting training with youth justice and Refresh workers which will equip them to undertake emotional health assessments, enabling them to refer appropriately and improve early access to specialist CAMHS where needed. 5.7.5 Other developments have included: Piloting of a range of universal and targeted provision across schools, community and family for young people aged 10-14 (HeadStart). The development of digital tools for young people including an app which provides information and support and enables young people to access appropriate online support (designed with young people) (2014). Improved publicity of existing local and national services for teenagers via a Z card (designed with young people). The development and implementation of a counselling framework in 2014. The framework has 4 providers who deliver counselling for children and young people aged 5-19 who are LAC, have social care involvement, are accessing substance misuse services or who are a young offender. Counselling can be accessed within 28 days of referral although this is usually quicker. The commissioning of a community based counselling service for 10-19 year olds who do not fit into any of the cohorts described above. This service launched in September 2015. Counselling will be accessed within 28 days of referral. The development of a 0-19 delivery model for universal and targeted/early help services which is being finalised and will include provision to address gaps identified in consultation with children, young people and other stakeholders, including: o One to one support for young people e.g. mentoring and support to build confidence and reduce social isolation as well as improve engagement in services e.g. youth services; 54 o Targeted group work on key issues e.g. bullying, anxiety and stress or with key groups e.g. NEETS or boys and young men, BME communities; o Increased capacity needed to provide effective parenting support (e.g. one to one and group work). This includes support for parents in identifying and supporting their young people on emotional health issues but also work to improve parenting skills and support parents with mental health issues which impact on the family. 5.7.8 All of these issues/needs relate to those children and young people who do not currently meet the CAMHS threshold but who, without interventions at the universal/early help stage, could end up needing that service. Recommendation 7: Hull Safeguarding Children Board should support, monitor and challenge the development and implementation of the emotional and mental health and wellbeing action plan and accompanying workforce development plan. Effective from May 2015 and on a half yearly basis 5.8 Helping and supporting vulnerable young people in Hull Finding 8: There is a need for a comprehensive, ‘whole system’ review of support arrangements for vulnerable young people in Hull, which captures the learning identified in this review. 5.8.1 Since the SCR commenced much work has been undertaken to improve services. This has taken place against a backdrop of various needs to reshape services. Some of this work, and, in particular the development of new models of working within Children’s Social Care and the work on emotional and mental health and wellbeing has been described above. 5.8.2 The systemic approach is being extended into work in targeted youth including the youth justice service and work with young people at risk of CSE. 5.8.3 Change has taken place in respect of the safeguarding oversight of vulnerable young people. There is now a stronger alignment between Targeted Youth Support and Children’s Social Care and this has now been in place for some time. 5.8.4 This has strengthened the management oversight of the safeguarding of vulnerable young people to ensure informed decision making about risk management, based on assessment. Where appropriate, CSC lead fully on the assessment and will assume case responsibility in some cases; in others cases although the lead is CSC, targeted youth 55 remain involved to ensure specialist input in areas such as benefits and supported accommodation is given, yet the safeguarding element continues from CSC providing input into the assessment and the continuing work. 5.8.5 Work is underway to consider options for extending the provision of post-16 accommodation in the city to meet a range of needs. This work includes undertaking an analysis of gaps and consideration of how a broader range of options can be provided locally. This important work needs to be taken forward in the context of the more fundamental ‘whole system’ review of partnership arrangements for supporting vulnerable young people. 5.8.6 Ofsted found that recent commissioning work has already resulted in the provision of new accommodation, including a one to one 24-hour facility for young people with the most complex needs and that the work to increase the range and choice of suitable accommodation has led to improvements, enabling needs to be met in the majority of cases. 5.8.7 Other examples include: o Targeted youth work that sees considerable work to prevent young people’s homelessness and proactive approaches to resolve and reconcile issues with young people and families or carers. o The preventing family breakdown pod- DfE funded Innovation project to support families who are in crisis. o The learning from this review being considered and reflected in the current re-commissioning of Public Health 0-19 nursing services. 5.8.8 Whilst the service developments described represent welcome progress, nevertheless they do not yet fully capture learning from this review, and Child W’s experiences of service provision. There remains a need for the local partnership to come together to more fundamentally review arrangements, to ensure that the benefits of a fully integrated approach are maximised. 5.8.9 As the SCR process developed, it became clear that the learning implied a need to review the whole system of help and support to vulnerable young people. This learning, which is captured in section 4.10 of the report, was formulated into a recommendation made in March 2015 to the HSCB in advance of the completion of the review. The review of the system of support of vulnerable young people has been initiated by the Hull Children, Young People and Families Board which will oversee the development of a framework for services. 56 5.8.10 The review will take a ‘whole system’ approach, reflecting changes that have already been made in working with younger children and families locally in re-designing the system of social care and early help and promoting a systemic practice model in working with vulnerable young people. 5.8.11 It will provide a comprehensive overview of services which will take into account current and ongoing work to transform, remodel and improve services for vulnerable young people and their families. Critically, the review will engage closely with vulnerable young people ensuring that their views and experiences will help to shape service provision, so that the value-base, ‘feel’ and accessibility which Child W often experienced is reflected in future design. 5.8.12 All of the key learning from this review will be reflected in the new framework. The HSCB will monitor the progress of the review, to assure itself that it is being undertaken and that the final outcome captures relevant learning. It is anticipated that the review will be concluded by 30th June 2016. . Recommendation 8: That Hull’s Children, Young People and Families Board (HCYPFB) undertakes a comprehensive review of provision for vulnerable young people in Hull, and develops a framework for working with them By: 30th June 2016 Recommendation 9: That Hull Safeguarding Children Board seeks assurances that the learning highlighted by this review is embedded within the new framework. Recommendation 10: That Hull Safeguarding Children Board reviews its threshold of needs guidance as it relates specifically to teenagers, as part of the development of a new framework for this work locally. By: 30th September 2016 57 Appendix 1: Members of the Serious Case Review Panel: The Serious Case Review panel for this case, comprised members of the HSCB Serious Case Review Sub-Committee, as follows: Paul Dyson, HSCB Independent Chair (Chair of Panel) Neil Colthup, HSCB Manager Manager, Hull Safeguarding Adults Board City Safe and Early Intervention Manager, Children, Young People & Families Service, Hull City Council Designated Nurse for Safeguarding Children, NHS Hull Clinical Commissioning Group Head of National Probation Service, Humberside (Hull and East Riding Local Delivery Unit) City Safeguarding Children Manager, Children, Young People & Families Service, Hull City Council Project Coordinator, East Riding Voluntary Action Services Designated Doctor for Safeguarding Children, NHS Hull Clinical Commissioning Group Chief Superintendent, Humberside Police Cathy Eccersley, Child Death Review Coordinator, HSCB HSCB Professional Practice Officers 58 Appendix 2: Brief Description of Services Hostel 1 (between July-November 2013) Hostel 1 comprised of 3 shared flats, each with two bedrooms, a shared living area, kitchen, toilet and bathroom. Child W had her own room with a lockable door. All other services were shared. The service provided bedding and towels, an iron, vacuum cleaner, tumble drier, television, DVD player and a communal lounge. Residents prepared and purchased their own food. The conditions of occupancy were via a licence agreement. At the time, the length of stay in the hostel was aimed at being approximately ten days. The service was managed by a Client Services Manager. The staff team comprised three support staff and three night staff. The manager was supervised by a Business Contract Manager. The hostel was staffed 24 hours a day, supported by an on call system which could arrange additional back-up cover. There is no legislative framework governing staffing levels in hostels. The hostel operated a link worker system and had the capacity to provide one to one support for clients. Staff provided housing related support, but relied on referral to external agencies to access more specialist support, such as counselling or in relation to substance misuse issues. Hostel 2 (August-November 2013) Hostel 2 is one of three in Hull managed by a local project. The manager of this hostel has responsibility for two of the three hostels. . The staff team comprises of 13 full-time and three part-time staff working across the three sites. The hostel mission statement describes a facility which provides “temporary board and lodgings in homely surroundings and provides support and assistance to residents in enabling them to find or regain their place in mainstream society”. Its vision is to “identify residents’ needs, build self-esteem, listen, consult, advise, encourage, counsel and support. The project will provide a warm, secure, comfortable and homely environment”. The criteria for admission (in July 2013) were ‘medium to low dependency’. The hostel has 12 single bedded units. Child W had her own bedroom with a lockable door. All other facilities were shared. Residents were provided with cooked food. The conditions of occupancy were via a Licence Agreement and Resettlement Contract. At the time, the length of stay in the hostel could be up to 18 months. 59 All residents were allocated a link worker and had a ‘risk management plan’. Link worker sessions took place every three weeks and formed a support plan known as ‘Star Links’. The support plan was reviewed every three months. The staffing complement within the project allowed for only one member of staff to be on duty at any one time, giving a 1:12 ratio of staff to young people. Children and Young People’s Services (Hull City Council) A number of different teams and services are referred to at various times. For the period from 2011-2013, these included: The Central Duty Team (CDT) This was the single point of contact/referral for children at risk of significant harm. The team undertook initial assessments in respect of referrals, before transferring children and families to Locality Social Work Teams, where longer term social work support was assessed as being needed. Emergency Duty Team (EDT) The EDT was the point of contact with Children’s Social Care outside of normal office hours. Locality Social Work Teams There were three locality Social Work Teams. These teams provided social work help and support to children subject to Child Protection Plans, Children in Need and to children who were looked after where no permanency decision had yet been reached. Integrated Looked After Children (ILAC) Team This team provided social work help and support to children who were looked after in the long term. The team was also responsible for recruiting and supporting local foster carers and for managing local children’s homes. The Adoption Team This team provided a range of adoption services: assessment of adoptive parents; matching children with adoptive parents; providing post-adoption support. Community Support Teams (CST) There was a CST linked to each locality social work team. The role of the CST’s was to provide help and support to children and families where there was need but the need did not meet the threshold for social work support. Marlborough Family Support Team This is a team which works flexibly, including out of hours, to provide support to families to prevent breakdown which 60 would necessitate children becoming looked after. The team is able to access/provide short break and respite looked after placements as part of packages of family support. Targeted Youth Support (TYS) Targeted Youth Support (TYS) provides early interventions and crisis support to young people (aged 16 -18) and families. The Access and Support Team provides a universally accessible duty service. The Housing Options Team provides housing advice and support 61 Appendix 3: List of Main Abbreviations Barnsley MDC Barnsley Metropolitan District Council CAMHS Child and Adolescent Mental Health Services CDT Central Duty Team CSC Children’s Social Care CSE Child Sexual Exploitation CST Community Support Team EDT Emergency Duty Team HSCB Hull Safeguarding Children Board ILAC Integrated Looked After Children Team LAC Looked After Child LSCB Local Safeguarding Children Board NSPCC National Society for the Prevention of Cruelty to Children SCR Serious Case Review TYS Targeted Youth Support (Service) VWO Vulnerable Witness Officer |
NC51567 | Death of an 11-month-old girl in October 2017. Female C was babysitting Baby T when she became unwell. Ambulance services were called and Baby T was taken to hospital; was found to have sustained a head injury. Later transferred to Great Ormond Street Hospital, where she died. Female C convicted of manslaughter and sentenced to six years imprisonment. Mother was an asylum seeker and reported imprisonment, religious persecution, physical abuse and rape. Had two other children by a different father in Vietnam and had suffered post-natal depression. Mother had no English language skills and relied on interpreters when meeting professionals. Mother and Baby T were moved accommodation by Home Office several times. Mother began working illegally and paid Female C to babysit Baby T. Learning themes include: decisions made by Home Office about Mother's claim for asylum and asylum support; effectiveness of Home Office asylum seeker support services and 'mainstream' health and social care services; impact of frequent moves of Mother and Baby T; use of interpreting services in supporting Mother and Baby T; 'lived' experience of Baby T; indications of trafficking or exploitation concerns and agency responses; 'hidden males'. Mother and Female C were Vietnamese. Recommendations include: remind practitioners about policy and practice in respect of modern slavery; ensure that advice to parents on caring for crying and sleepless babies is accessible in all community languages; Home Office to ensure pregnant asylum seekers and asylum seekers with young children are referred to local primary care service at the point of first contact.
| Title: Baby ‘T’: serious case review (SCR): report. LSCB: Redbridge Local Safeguarding Children Board Author: David Mellor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Redbridge Local Safeguarding Children Board (LSCB) BABY ‘T’ SERIOUS CASE REVIEW (SCR) REPORT Published 14 January 2020 2 Contents No. Section Page 1 Introduction 3 2 Terms of Reference 4 3 Glossary 6 4 Case Summary 8 5 Mother’s Views 28 6 Learning Themes 32 7 Findings and Recommendations 58 8 References 69 Appendix A SCR Process and Panel Membership 72 3 1. Introduction 1.1 On 5th October 2017 a child who will be referred to in this report as Baby T died in Great Ormond Street Hospital (GOSH), London after sustaining a head injury. The child was eleven months old. Her mother was a Vietnamese asylum seeker and she and Baby T had been placed in the London Borough of Redbridge whilst mother’s asylum claim was considered by the Home Office. (Her mother was granted leave to remain in the UK in May 2019). On the day she died Baby T became unwell whilst in the care of another Vietnamese female who had applied for leave to remain in the UK and who lived in the neighbouring London Borough of Barking and Dagenham. This person, who will be referred to in this report as Female C, was convicted of the manslaughter of Baby T in July 2019 and sentenced to six years imprisonment the following month. 1.2 Redbridge Local Safeguarding Children Board (LSCB) agreed to conduct a Serious Case Review (SCR) on the grounds that Baby T had died and abuse was suspected. The progress of the SCR was delayed for a time by the need for specialist medical reports to contribute to the pathologist’s report and inform the criminal investigation and Coronial proceedings. 1.3 The SCR was commissioned under the 2015 Working Together statutory safeguarding children guidance. Since the SCR was commissioned the Children and Social Work Act 2017 has been enacted. This legislation abolished LSCBs and placed the responsibility for multi-agency safeguarding arrangements on three ‘safeguarding partners’ – the local authority, the police and the Clinical Commissioning Group. Locally to Redbridge, the partners have established a single set of arrangements across Barking and Dagenham, Havering and Redbridge – the BHR Safeguarding Partnership. As stated above, this SCR was commissioned, and has been completed, under the 2015 statutory guidance. 1.4 The LSCB commissioned David Mellor to be the independent reviewer for this SCR. David is a retired chief police officer and former independent chair of safeguarding children and adults boards who has seven years’ experience of conducting SCRs and other statutory reviews. He has no connection to Redbridge or any of the agencies involved in this case. A SCR panel was established to oversee this review and membership of this group and a description of the process by which this SCR was carried out is shown in Appendix A. 1.5 An inquest into the death of Baby T will take place in due course. 4 1.6 The members of Redbridge LSCB wish to express heartfelt condolences to the family of Baby T and to thank her mother for her contribution to, and engagement with, the SCR. 2.0 Terms of Reference 2.1 In respect of Baby T and her mother, the SCR will consider events from October 2015, when it is understood that Baby T’s mother arrived in the UK, until the death of Baby T on 5th October 2017. In respect of the carer, the SCR will consider events from August 2013, when she first arrived in the UK, until the death of Baby T. 2.2 The purpose of the SCR is to identify any lessons which can be learned about how practitioners and agencies worked together and separately in the case of Baby T. 2.3 The overall focus of the SCR is on the extent to which practitioners and agencies appreciated and sought to mitigate the potential risks to Baby T arising from being the infant child of an asylum seeker who had mental health issues, who was quite isolated, who had limited access to resources, and was liable to be moved at short notice from one part of the country to another. 2.4 At the outset it was agreed that the following issues would be particularly relevant to explore: Whether vulnerabilities on the part of Baby T’s mother and/or Female C were identified and addressed by the relevant immigration authorities. The liaison, if any, between the relevant immigration authorities and health, social care, and any other relevant agencies in those areas in which mother was placed pending consideration of her asylum application; and in areas in which Female C resided after her arrival in the UK. The communication, if any, between agencies in different areas as mother and Female C moved from one location to another. The involvement of relevant health and welfare agencies, if any, with both mother and Female C, and its effectiveness. Whether there were any warning signs of vulnerability or risk, in relation to either or both mother and Female C, which could have been picked up but were not. 5 Whether there are any indications or concerns about trafficking in relation to mother and/or Female C, and how any such indications have been responded to. The extent to which language, cultural and ethnic identity issues were understood and responded to in the way national and local agencies worked with mother and the carer. The accommodation provided for mother and Baby T in Redbridge, who else was living there, and any risks associated with those arrangements. Any relevant issues relating to the accommodation secured by Female C. If appropriate, the SCR will make recommendations to both national and local agencies. 6 3.0 Glossary Asylum seeker - a person who has claimed asylum under the 1951 United Nations Convention on the Status of Refugees on the ground that if they are returned to their country of origin they have a well-founded fear of persecution on account of race, religion, nationality, political belief or membership of a particular social group. They remain an asylum seeker for so long as their application or any appeal against refusal of their application is pending. Cognitive behavioural therapy (CBT) is a talking therapy that can help clients manage their problems by changing the way they think and behave. It is most commonly used to treat anxiety and depression but can be useful for other mental and physical health problems. Immigration & Asylum Act 1999 Section 95 support to asylum seekers for people seeking asylum in the UK, who lack the means to support themselves, are entitled to support while the Home Office is processing their asylum application. This support is called Section 95 (s95) support. Asylum seekers must apply for this type of support on a specified application form and it can take several weeks for the Home Office to process this request. Section 98 support to asylum seekers, also provided under the Immigration & Asylum Act 1999, is a form of temporary support which is provided to asylum seekers who appear to be destitute and who are awaiting a decision on their application for Section 95 asylum support. A decision on a request for Section 98 (s98) support should be made before the end of the working day on which the application is received. Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events. Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt. They may also have problems sleeping such as insomnia and finding concentration difficult. These symptoms are often severe and persistent enough to have a significant impact on the person's day-to-day life. Refugee is a person who has fled their country of origin and is unable or unwilling to return because of a well-founded fear of being persecuted because of their race, religion, nationality, membership of a particular social group or political opinion. An asylum seeker whose claim for asylum or subsequent appeal against initial refusal has been successful is classed as a refugee. 7 National Referral Mechanism (NRM) is the mechanism through which the National Crime Agency’s Modern Slavery Human Trafficking Unit (MSHTU) collects data about victims of human trafficking or modern slavery and ensures that they receive the appropriate support. This information contributes to building a clearer picture about the scope of human trafficking and modern slavery in the UK. 8 4.0 Case summary Baby T and her mother 4.1 On 7th June 2016 mother telephoned the Home Office to say that she wished to claim asylum in the UK. Basic details were taken from her and arrangements were made for her to attend a full screening interview at the Home Office Asylum Screening Unit (ASU) in Croydon the following day. A Vietnamese interpreter was present for this interview during which mother disclosed that she had entered the UK illegally on 27th October 2015. She also disclosed that she was four months pregnant with Baby T. She said she had met Baby T’s father after her arrival in the UK and he had been supporting her since that time. She said she was living at a private flat in Hackney (address 1), adding that she felt safe there. Mother was given temporary admission to the UK and advised that she had until 22nd June 2016 to state the grounds on which she should be allowed to remain in the UK. She was advised that she would be contacted by a case worker to discuss her asylum claim (This discussion was to have taken place on 28th November 2016 but mother was unable to attend – paragraph 4.23). She was also provided with a letter advising her on how to claim financial support during her asylum claim. Mother was told to report again on 16th June 2016. 4.2 During the interview mother disclosed that she had two children aged five and three who were living with her father in her home village in Vietnam. She said that she had last seen them in 2014 and had had no contact with them since leaving Vietnam. She said that she and her husband and father-in-law had been arrested and detained in prison. She added that she had escaped after her father bribed a prison guard. She said that her husband and father-in-law had died. 4.3 Mother reported to the ASU on 16th June 2016 as directed. Thereafter her reporting frequency was changed to fortnightly and she next attended the ASU on 30th June 2016. She was next required to report to the ASU on 28th July 2016 and monthly thereafter. Mother had been noted to have a legal representative on 24th June 2016. 4.4 On 4th July 2016 Homerton University Hospital midwifery received a Hackney GP referral in respect of mother. Because the GP referral contained limited information, mother was referred to the community midwife in the first instance rather than being triaged directly to the public health midwife who case managed vulnerable pregnant women. 9 4.5 On 19th July 2016 mother attended a booking appointment with the community midwife who conducted an assessment which identified that she had complex social needs and was referred on to unspecified ‘appropriate professionals’. 4.6 On 19th September 2016 mother was seen by the public health midwife and disclosed concerns more fully than during previous appointments. The midwife made a referral to Hackney Children’s Social Care in which she stated that mother had entered the UK as an asylum seeker ‘eleven months ago’ after spending a year in prison in Vietnam. Mother was said to have been asked to leave her current accommodation in the UK where she was staying with a friend. (It is understood that Baby T’s father left mother at this time and no longer provided financial support). A First Access Screening Team (FAST) social worker then spoke to mother and advised her to contact the National Asylum Support Service (NASS) helpline as she could be eligible for housing as an asylum seeker. Mother was further advised to ‘return back’ to Hackney with documentation from the Home Office if she was unable to receive support. Mother’s case was then closed to Hackney children’s social care on the grounds that mother was likely to be eligible for asylum support. (Hackney FAST is the equivalent of Multi-Agency Safeguarding Hubs (MASH) in other boroughs and is the single point of contact or ‘front door’ for children and families services.) 4.7 On 22nd September 2016 mother’s requirement to report at the ASU was suspended until 26th January 2017 due to her pregnancy and monthly thereafter. It was considered that there were no safeguarding concerns as mother was said to have her own accommodation and the support of the unborn baby’s father, although, unknown to the Home Office, this situation had recently changed (see previous paragraph). 4.8 On 29th September 2016 mother’s midwife referred her to the Hackney Multi-Agency Team (MAT) for support with her asylum application and obtaining housing and food vouchers from the Home Office. MAT is a children’s centre Multi-Agency Team meeting, attended by a virtual team of practitioners from different agencies, who work together to coordinate and monitor family intervention, in order to prevent fragmented service delivery. The MAT monitored mother’s case whilst she was living in Hackney and became concerned that she was socially isolated and lacked a support network. 4.9 On 5th October 2016 mother expressed reservations about accepting Home Office asylum support as she was worried about leaving both the Vietnamese community she had been living amongst and the established relationship she had with her midwife. She also expressed concern about the possibility that she could be sent to stay anywhere in the UK. The following day the midwife visited mother in 10 company with an interpreter to discuss her options. They relocated to a safe space to have the conversation because mother said she felt afraid owing to the alleged inappropriate behaviour of the person who owned the property in which she was staying. Mother decided to access asylum support. 4.10 On 7th October 2016 mother was assisted by Migrant Help, which offers vulnerable migrants, including asylum seekers, advice and support to successfully apply for asylum support. At this time mother was homeless and was said to have become reliant on strangers for food and essentials. The Home Office dealt with the request for emergency accommodation quickly as mother was heavily pregnant and homeless. She was provided with initial accommodation under Section 98 of the Immigration and Asylum Act 1999. This is temporary accommodation when an asylum seeker is destitute. She was taken to emergency overnight accommodation at address 2 which is a hotel. 4.11 The following day mother was moved to a room in address 3 in Croydon which is operated by Clearsprings Ready Homes, a provider of accommodation services to the Home Office. Vietnamese interpreters and a telephone translation service were available there. Migrant Help workers are also based at the address. Mother was referred by Migrant Help workers to the Rainbow Health Centre in Croydon which is a one stop health clinic for refugees and recent migrants to the UK. It is understood that no concerns were highlighted to Clearsprings in respect of mother or her unborn child at this stage. 4.12 On 10th October 2016 the Hackney public health midwife contacted the safeguarding maternity team at Croydon University Hospital to hand over care of mother and her unborn baby. Two days later, contact took place between a Hackney health visitor and her counterpart in Croydon to advise of mother’s transfer. On the same date a family support worker from Hackney MAT referred mother to Croydon Early Help service. 4.13 On 13th October 2016 mother had a new registration consultation at the Rainbow Health Centre. The specialised midwife for vulnerable and marginalised women is based within this health centre and she saw mother for a booking appointment the following day. A detailed assessment of her maternal, obstetric, social and psychological history was undertaken. It was documented that mother did not have a previous history of mental illness nor were there any current mental health concerns. Interpreting services would have been used to facilitate this assessment although it is not clear whether this was face-to-face or via Language Line. 11 4.14 On 18 October 2016, mother was helped by Migrant Help to apply to the Home Office for a maternity grant of £300. This was initially refused in error by the Home Office but subsequently granted (7th November 2016) after mother was supported to appeal. On the same date Croydon maternity services saw mother for booking in respect of her pregnancy. 4.15 On 20th October 2016 Croydon Early Help service referred mother to the Parent Infant Partnership (PIP) which supports attachment and child development in the first 1001 days of a child’s life. The service has a therapeutic parent/infant offer, keyworker support and intensive and nurturing group work through a Mellow Parenting offer. Mellow Parenting is a charity which designs and supports the delivery of parenting programmes (see reference (1)). Mother was allocated a key worker. 4.16 On 21st October 2016 the Home Office received an application from mother for longer term asylum support (accommodation and financial) under Section 95 of the Immigration and Asylum Act 1999 and this was granted on 2nd November 2016. 4.17 On 25th October 2016 the PIP key worker began attempting to contact mother by text, using Google Translate, which proved unsuccessful. However, the receptionist at address 3 was able to assist the key worker in arranging a home visit for 31st October 2016 when the PIP key worker visited with an Early Help Best Start senior practitioner. It was identified that the focus of the work would be to support mother to prepare for the imminent birth of her baby (expected due date was 7th November 2016). Mother was noted to have limited items in preparation for the baby’s arrival apart from some clothing given by the Vietnamese community in Hackney. The use of Google Translate again proved unsatisfactory and it was decided that an interpreter would to be used for all future visits. The referral of mother from Hackney had not been accompanied by an assessment and due to the relatively short time mother resided in Croydon no Early Help assessment was completed. 4.18 On 4th November 2016 the Croydon PIP key worker made a visit to mother in company with an interpreter. The focus of the work was to support mother to prepare for the birth of her baby and ensure that she could access help within the community. 4.19 On 7th November 2016 mother was admitted to the maternity ward of Croydon University Hospital in labour and she gave birth to Baby T in the early hours of the following morning by spontaneous vertex delivery (normal delivery). The baby was in good health with no concerns reported. Her weight was 3390 grams (7lb 7oz). Mother and Baby T were discharged home during the late afternoon. The discharge 12 address was initially documented as address 1 but later the same evening this was corrected to address 3. On the same date mother received the £300 maternity grant from the Home Office in the form of a token for her to cash in her local post office within 10 days. 4.20 During November and early December 2016 the Croydon PIP key worker made five weekly visits to mother and Baby T. An interpreter was present for two of these visits. 4.21 On 22nd November 2016 a health visitor visited mother and Baby T at address 3 for a new birth visit but was unable to complete the visit as health visiting administration had booked a Mandarin interpreter rather than a Vietnamese interpreter. (The new baby review/visit should take place between 10-14 days after birth. The Croydon health visitor made the uncompleted new birth visit on the fourteenth day after Baby T’s birth). 4.22 On 23rd November 2016 the health visitor had a chance meeting with mother at address 3 whilst seeing another client. Mother had left Baby T on the edge of a bed whilst she was sorting washing in a hallway. The health visitor requested the staff at address 3 to supply mother with a Moses basket as soon as possible. Clearsprings has advised this review that baby items such cot/Moses basket, feeding bottles, sterilizer, baby wipes, nappy bags, nappies and baby formula are supplied on the birth of the child. It is not known why mother has not previously been supplied with a Moses basket. Mother was advised not to leave the baby unattended unless in a Moses basket. A Vietnamese guide to co-sleeping and video were provided to mother. 4.23 On 28th November 2016 mother did not attend an asylum interview with the Home Office as she and Baby T were unwell. 4.24 On 29th November 2016 the health visitor was able to achieve the new birth visit with the assistance of a Vietnamese interpreter. A strengths and needs assessment was completed but from subsequent examination of the responses it appears that the questions and/or answers may not have been adequately interpreted as for example mother is recorded as saying that she was not isolated and had a stable family environment. Mother disclosed a previous history of postnatal depression with her two previous children which was reported to have been self-managed which was inconsistent with an earlier assessment (paragraph 4.13). 13 4.25 The ‘Universal Plus’ health visiting service was to be provided to mother and Baby T ‘due to (unspecified) accommodation issues’. The health visiting service in England provides three levels of service as follows (2): Universal: health visitor teams ensure that every new mother and child have access to a health visitor, receive development checks and receive good information about healthy start issues such as parenting and immunisation. Universal Plus: families can access timely, expert advice from a health visitor when they need it on specific issues such as postnatal depression, weaning or sleepless children. Universal Partnership Plus: health visitors provide ongoing support, playing a key role in bringing together relevant local services, to help families with continuing complex needs, for example where a child has a long-term condition or additional concerns such as safeguarding, domestic abuse and mental health problems. Standard practice for ‘Universal Plus’ should have been another visit at six weeks postnatal but this did not occur and there was no further contact between the Croydon health visitor and mother and Baby T. 4.26 On 7th December 2016 the Home Office wrote to mother to advise that they had been unable to make a decision on her asylum claim within the six months since her original claim. The delay in determining mother’s asylum claim was attributed to her having recently given birth. The Home Office were to review her case in three months. Mother took the Home Office letter to Migrant Help which referred her to a law centre where a solicitor obtained a more detailed account of her life in Vietnam, which was shared with her Croydon PIP key worker. Mother disclosed to the solicitor that she had been persecuted because she practiced the Hoa Hao Buddhism religion. She said she had been arrested in 2014 for distributing leaflets promoting the Hoa Hoa faith with her husband. She said that her husband had been tortured by the authorities which had caused his death. Mother disclosed that she had been beaten and instructed to work in the fields. She had also been imprisoned. Mother said that after her husband died, her parents were worried about her safety and her father made arrangements for her to flee Vietnam (bribed the authorities to enable her to get out of prison). It was not considered safe for her children to accompany her out of Vietnam. 4.27 She had travelled via Laos then a flight to France before entering the UK on a lorry. She had met a Vietnamese woman who had let her stay with her and the woman’s sister from October until December 2015. She then met a man, described as an agent, who had taken her to Hackney where she met the father of her child. She said that he had been kind to her and provided her with accommodation and 14 financial and ‘moral’ support. He had assisted her to claim asylum but later left her. Mother said she had tried to contact him but was unable to get through to him. She did not know why he had left her. Mother said she had delayed claiming asylum because she had been under the control of the agent. She said that she continued to practice her religion although the lack of a temple meant that she could only practice at home. She said that she could not return to Vietnam as she believed that she would be ill-treated and persecuted. 4.28 The Home Office Country Policy and Information Note on Vietnam: Ethnic and religious groups (March 2018) states that Hoa Hoa Buddhism is one of 14 religions which hold full government recognition in Vietnam but many followers refuse to join the government sanctioned Hoa Hoa organisation. Unregistered Hoa Hoa groups are monitored and harassed by the authorities and leaders have been sentenced to lengthy terms of imprisonment (3). 4.29 On 9th December 2016 the Croydon PIP key worker made a weekly visit to mother and Baby T (no interpreter). The PIP key worker found that mother had left Baby T in her room with a male neighbour whilst she went to get breakfast. The key worker advised mother that it was dangerous to leave her baby with a stranger. ClearSprings have advised this review that they were not informed of this concern. 4.30 On 12th December 2016, mother told Migrant Help that she had received a letter from the Home Office advising that she was to be dispersed to West Drayton in the London Borough of Hillingdon on 19 December 2016 to access her longer term accommodation and financial support under Section 95 (paragraph 4.16). Migrant Help gave mother a ‘dispersal briefing’ but the move was cancelled as Home Office policy was not to disperse a mother and baby before the baby is six weeks old. Baby T would have been one day short of six weeks old on 19th December 2016. 4.31 However, the Home Office decided to disperse mother and Baby T to Cardiff on the same date (19th December 2016). This was not intended to be a permanent dispersal. There was a shortage of bed space in London and so it was decided to move mother and Baby T to Cardiff temporarily until permanent accommodation could be sourced nearer to London. The Home Office Healthcare Needs and Pregnancy Dispersal Policy states that ‘for the purposes of this policy, the late stages of pregnancy will be defined as normally running from six weeks before the estimated date of delivery until a clinician has signed off on the postnatal checks. The latter will usually be around six weeks after birth, unless there have been complications’. Therefore, mother and Baby T were moved a day earlier than stated by policy although it is unclear why the move to Hillingdon was postponed and the move to Cardiff approved. 15 4.32 On 15th and 16th December 2016 the Croydon PIP key worker made visits to mother and Baby T in company with an interpreter prior to their forthcoming relocation to Cardiff. During the period in which she supported mother and Baby T, the key worker carried out the following work: Helped mother prepare for the baby’s birth by sourcing a moses basket, baby bath, a range of clothing, toys and a buggy; Liaised with the Salvation Army who donated items such as breast pads, clothes for mother, and toiletries; Collected food from food bank and delivered this to the family; Delivered donated Christmas gifts from local charity; Referred the family to a Croydon solicitors which specialises in Legal Aid immigration services, and attended appointments with mother; Liaised with other professionals including health visitor, interpreter, solicitor, local charities and temporary accommodation receptionist; Provided mother with advice on co-sleeping; Provided information about baby clinic and ESOL (English for Speakers Of another Language) classes; and Supported mother at her meetings with Migrant Help, a charity supporting asylum seekers, refugees and victims of human trafficking and modern slavery. 4.33 On 19th December 2016 mother and Baby T were moved to address 4 in Cardiff where they stayed until 4th January 2017 before being moved to address 5 in Cardiff which is around twelve minute’s walk away from address 4. These addresses were linked to Cardiff Section 98 initial accommodation. Mother’s Croydon PIP key worker contacted Cardiff Social Care to inform them that mother and Baby T had moved to their area and the following day completed a multi-agency referral form to enable the family to continue receiving support. 4.34 On 21st December 2016 mother took Baby T to a Cardiff GP practice as she was concerned that the child had an eye problem. Baby T was examined and found to be well. Mother said that Baby T had not yet had a BCG vaccination (for TB) and an appointment for this was to be arranged. (BCG appointments were arranged for April and May 2017 which mother did not attend as she had left Cardiff by that time.) 4.35 The following day the Cardiff MASH received the referral from Croydon which raised a number of concerns about mother and Baby T including mother’s vulnerability, isolation, loss experienced in Vietnam which she had fled for fear of her life, lack of English, very limited resources and need for support and guidance in caring for Baby T. Reference was made to her following a traditional Vietnamese 16 approach to parenting including co-sleeping. The MASH noted that mother had been allocated a health visitor, as a result of a referral from Clearsprings, which was also the provider of mother and Baby T’s initial accommodation in Cardiff. The MASH health safeguarding nurse advisor contacted the health visitor to advise that mother may need additional support and to make a further referral to children’s social care if any safeguarding children concerns arose. The case was then closed to Cardiff Children’s Services. 4.36 On 6th January 2017 mother and Baby T attended a clinic for routine eight week health screening and immunisations. Baby T appeared healthy and no concerns were apparent. The level of health visitor service provided to mother and Baby T in Cardiff was the ‘universal’ Healthy Child Wales Programme. As with health visiting in England, there are three levels of health visitor service which are ‘universal’ – the core minimum intervention offered to all families, regardless of need, ‘enhanced’ – additional interventions based on the assessment and analysis of resilience and identification of additional need and ‘intensive’ – further interventions, built upon ongoing assessment and analysis of greater need. 4.37 On 12th January 2017 Cardiff and Vale University Health Board requested health visitor records for mother and Baby T from Croydon Health Services but these were not transferred to Cardiff until 10th February 2017, by which time mother and Baby T had left. 4.38 On 13 January 2017, Migrant Help spoke to mother’s PIP key worker in Croydon and referred her to Oasis, a charity which helps refugees and asylum seekers in Cardiff, and the Welsh Refugee Council. 4.39 On 18th January 2017 mother and Baby T were permanently dispersed to address 6 in Ilford in the London Borough of Redbridge which is a large 8 bedroom property allocated to mothers and children and operated by Clearsprings. On arrival, mother was provided with a starter pack, kitchen pack, cleaning pack and baby pack. Migrant Help continued to offer support to mother which was mostly liaison with the Home Office. Their last contact with mother was on 16th May 2017 to resolve an issue relating to her financial support. In her contribution to this review, mother said that there were four mothers and their children sharing in address 6 (paragraph 5.15). 4.40 On 2nd February 2017 mother presented at Ilford Medical Centre and was given a new patient questionnaire to complete in respect of herself and Baby T. The questionnaire was in English but mother was able to obtain informal interpreting assistance and return the completed questionnaire a few days later. She provided 17 details of her previous GP practice in Croydon from which her medical records, and those of Baby T, were obtained on 9th and 3rd March 2017 respectively. 4.41 On 6th February 2017 mother contacted her Croydon PIP key worker to tell her that she and Baby T had moved to the London Borough of Barking and Dagenham. Her key worker asked for her new address and identified that it was actually in Redbridge. The key worker then contacted Redbridge Homestart and completed an Early Intervention Panel referral form in respect of mother and Baby T. 4.42 On 8th February 2017 mother saw a practice nurse at Ilford Medical Centre for a new patient assessment. No interpreter was present. Nothing of note was said to have been recorded including ‘no family history’. 4.43 On 15th February 2017 the referral made by the Croydon PIP key worker was discussed by the Redbridge Early Intervention Panel, which considers and co-ordinates all requests for early intervention and agrees relevant support and intervention for the child and their family through multi-agency discussion and decision making. The referral stated that mother was a Vietnamese asylum seeker who was described as ‘very isolated and vulnerable’ and was allocated to an Early Intervention family support worker to complete a Common Assessment Framework (CAF) and Neglect Toolkits, liaise with the Home Office to ascertain mother’s legal status, make contact with Baby T’s health visitor and, if any trafficking concerns emerged, these were to be heard at an Early Intervention Threshold meeting. (Weekly threshold meetings decide whether escalation of cases to statutory services is required). On the same date mother and Baby T attended the Ilford Medical Centre. Baby T was examined and there were no concerns. 4.44 On 17th February 2017 the Early Intervention family support worker made a home visit to mother, during which Baby T was seen. A CAF was completed which included an action plan which was agreed with mother. It is not known if an interpreter was used. The plan included booking an appointment with a GP practice, registering with a dentist, contacting the Salvation Army to obtain new clothes and essential baby items, attending a children’s centre with the baby where mother would also be able to access English for Speakers of Other Languages (ESOL) classes, obtain emotional support by attending a social group and/or seeing a counsellor, reviewing her expenditure by completing a financial assessment and seeking clarity in respect of legal status. Mother would be supported to complete the action plan with the assistance of the family support worker using an interpreter. 4.45 On 20th February 2017 the family support worker contacted NELFT (NELFT was previously the North East London NHS Foundation Trust but when the Trust expanded beyond North East London it was decided that the organisation would be 18 referred to only as NELFT) to advise that mother and Baby T had moved to Ilford from Croydon. NELFT was advised that mother spoke no English and that her spoken language was Vietnamese. A community nursery nurse carried out an opportunistic home visit the following day. No interpreter had been booked and so the nurse spoke to her with the assistance of another tenant who was able to interpret. The tenant shared her telephone details with the community nursery nurse and agreed to be the point of contact with mother. Mother and Baby T were allocated to a health visitor in order to complete a ‘transfer in’ with the assistance of a Vietnamese interpreter. 4.46 On 24th February 2017 the Children’s Centre family support worker visited mother and Baby T for the first time and helped them register with a local dentist, accompanied them to the Children’s Centre and explained what support would be available to her and the child at the centre. 4.47 On 8th March 2017 the health visitor made the ‘transfer-in’ contact with mother. A Vietnamese interpreter had been booked for this home visit but Language Shop, an agency used by NELFT to book interpreters, had advised that no interpreter was available the day before the home visit. The tenant interpreted once more. Mother reported that Baby T was her ‘first child’. No concerns were reported and the health visitor decided that mother and Baby T would receive the ‘universal’ health visiting service. 4.48 On 21st March 2017 the Early Intervention family support worker reported that mother had not attended any sessions at the Children’s Centre with Baby T after being shown the facility and signposted to relevant sessions. It was decided that the Children’s Centre family support worker would accompany mother to sessions and would help to facilitate mother attending ESOL classes. The Children’s Centre family support worker visited mother and Baby T on 4th April 2017 to encourage her to attend sessions at the Centre, providing a new timetable of activities and a food voucher. 4.49 On 5th April 2017 mother and Baby T attended a clinic for a follow up weight review. Mother was late for the appointment and so the booked Vietnamese interpreter had left prior to her arrival. This appointment is not part of the health visiting ‘universal’ offer but the health visitor had arranged it to gather further information given the previous interactions without an interpreter. The appointment continued without the interpreter and mother disclosed unspecified emotional wellbeing difficulties which resulted in the health visitor referring her to the improving access to psychological therapies (IAPT) service. IAPT is a primary care psychological therapies service, providing evidence-based treatments for people with depression and anxiety disorders with no comorbidity and complexity. 19 4.50 On 12th April 2017 the health visitors IAPT referral for mother was received and a face to face triage meeting was arranged and an interpreter booked. A half hour triage appointment is offered in order to identify the main problem and consider whether IAPT can help, to assess risk and to identify if it is safe to treat the patient within the service or if it is required a step up to secondary care. 4.51 On 27th April 2017 mother and Baby T visited the Children’s Centre. She was very distressed as the debit card on which her asylum support allowance was loaded had been ‘swallowed up’ by the ATM. Mother said that she could not understand the information displayed on the ATM screen and must have pressed the wrong button. Both the Children’s Centre family support worker and the Early Intervention family support worker were present along with an interpreter. The interpreter made telephone calls to arrange for a replacement debit card to be sent to mother within 3-5 days. Mother was also provided with a food voucher but the Ilford food bank was not open again until Saturday 29th April 2017 (this was two days away). A Children’s Centre manager agreed that money from the Centre’s ‘tea and coffee jar’ could be used to but mother some food to tide her over until the food bank re-opened. The health visitor was present and she checked Baby T and said she was a little concerned about the child’s weight as she was gaining weight only slowly. She made a further appointment to see mother and Baby T. Because mother had been so distressed, it was decided to postpone the first team around the child (TAC) meeting which had been arranged to take place later the same day. The TAC involves relevant agencies working with the child and family to address unmet needs. Whilst at the Children’s Centre mother asked to be linked into counselling as she said she was starting to have nightmares. The health visitor advised colleagues that she had referred mother to IAPT. 4.52 On 16th May 2017 the IAPT triage assessment was completed to ascertain mother’s current mental health difficulties and suitability for treatment by primary care. A risk assessment and crisis plan was completed. The risk assessment identified ‘risk to self’ as mother was said to frequently have thoughts that life was ‘not worth living’. Mother was said to have no plans or intentions of suicide or self-harm. An IAPT professional discussion took place the following day at which it was decided that mother met the criteria for Post-Traumatic Stress Disorder (PTSD) and she was allocated as a priority due to her clinical presentation and the fact that she had a six month old baby. She was allocated to the IAPT Step 3 (one to one cognitive behavioural therapy (CBT)) waiting list. The then target for clients to be allocated a therapist for CBT was 16 weeks. 4.53 Also on 16th May 2017 the rescheduled TAC meeting took place. Mother, Baby T and an interpreter were present. During the meeting it was agreed by all 20 attendees that the Early Intervention and Family Support Service (EI & FSS) would close their involvement with the case and hand over to the Children’s Centre family support worker, who was in attendance, to carry out the outstanding actions from the CAF. The outstanding actions were supporting engagement with ESOL, supporting attendance at a social group, completion of a financial assessment (although it had been noted that, as an asylum seeker, mother was in receipt of £70 per week) and contact with Home Office and mother’s solicitor. Mother’s IAPT referral was noted to be outstanding although it actually took place on the same date. Two Neglect Toolkits had been completed, neither of which indicated any concerns. 4.54 The Children’s Centre family support worker continued to support mother and Baby T for a time and on 5th June 2017 provided mother with a letter to take to the Salvation Army ‘baby bank’ which consists of a collection of good quality second hand baby clothes and equipment available free of charge to help with the costs of having a baby. 4.55 On 25th June 2017 mother took Baby T to Queen’s Hospital (part of the Barking, Havering and Redbridge University Hospitals Trust (BHRUT)) ED by private transport. Mother was accompanied by a friend who acted as an interpreter. The identity and gender of the friend were not recorded. Baby T’s symptoms were described by mother as vomiting for one day after feeds, high temperature, abdominal pain and reduced appetite. After being examined by a paediatric consultant, Baby T was diagnosed with viral gastroenteritis, prescribed medication and later discharged home. The child protection information sharing system was checked and no alerts were found in respect of baby T. No safeguarding concerns were identified as a result of completion of the ED safeguarding screening tool. Discharge information included verbal advice and a gastroenteritis information leaflet (in English). A routine discharge letter was sent to Baby T’s GP practice. 4.56 On the same date (presumably prior to attending Queen’s Hospital ED), mother took Baby T to the Barking Community Hospital walk-in centre (managed by NELFT) with vomiting. The latter location is around 5 miles from Queen’s Hospital. Mother left the walk-in centre before being seen by the streaming nurse and advanced nurse practitioner. A paediatric information sharing form was sent to Baby T’s health visiting team which was recorded as received and allocated to mother’s health visitor on 4th July 2017. These forms are sent by post and then placed for an allocations meeting before being allocated to the appropriate health visitor for any action required. There was no recorded follow up and no upload of the document onto the EPR (Electronic Patient Record). 21 4.57 On 5th July 2017 a Children’s Centre family support worker wrote to the Early Intervention family support worker to advise that they had closed mother and baby T’s file. By this time the Children’s Centre family support worker who had previously been supporting mother and Baby T had left the service. Mother’s contact with the Children’s Centre thereafter was limited to one visit, on 19th July 2017, to attend a support session. 4.58 On 12th July 2017 mother took Baby T to Ilford Medical Centre as the child had been ill with a fever since the previous day. After examining the child, nasal drops were prescribed. Two small blanching spots (disappear when pressed) were noted on the baby’s abdomen. As this was an unplanned GP appointment, no interpreter had been booked and the GP attempted to use google translate. Patients who require an interpreter are asked to bring a friend to interpret if they make an emergency, as opposed to a planned, appointment. 4.59 On 14th July 2017 mother telephoned IAPT to ask about the waiting time for therapy. A message was passed to the IAPT service manager but mother received no response to her query. As previously stated the then target time for allocation to a CBT therapist was 16 weeks and 9 weeks had elapsed since mother’s triage appointment. 4.60 On 17th July 2017 mother took Baby T to the Ilford Medical Centre. The baby had been coughing frequently. With the assistance of an interpreter the GP discussed symptoms of viral illness and asked mother to keep a diary of the baby’s symptoms for two weeks and return to the GP with it. Mother enquired about the BCG vaccine for Baby T. She had previously been given a helpline number to ring but had been unable to use this without an interpreter. The GP contacted the health visitor who advised that Baby T was in a BCG backlog. Mother went on to disclose difficulty in sleeping and experiencing nightmares in which someone was chasing her. She said she had been prescribed medication by a GP in Cardiff which had helped her to sleep but had caused drowsiness, headaches, nausea and dizziness so she had stopped taking them. She also said she had had postnatal depression. She said she had seen IAPT eight weeks earlier for an initial assessment but had had no contact since then (paragraph 4.51). She said she wanted to die, adding that she had been having thoughts of wanting to step into the traffic. She said she lacked support from relatives or friends. She said she hadn’t heard from the Home Office for a year and she didn’t feel her lawyer was actively seeking an update on her claim for asylum because of difficulties in obtaining legal aid. The GP referred mother to the Redbridge Access, Assessment & Brief Intervention Team (RAABIT). (RAABIT is a first point of entry for mental health services for adults aged 18-65 in Redbridge and provides an initial mental health assessment and referral or signposting to other organisations or services. If appropriate the service can offer medical review and/or 22 brief mental health intervention for up to one year. This may include key-working or psych educational groups, support worker input and liaison with other services such as secondary psychology). During the conversation the GP documented that mother had a social worker ‘who came once but never came back again’. On this basis the GP made an incorrect assumption that mother and Baby T were already known to children’s social care and, as a result, decided not to refer mother and Baby T to children’s services. 4.61 RAABIT was telephoned by the GP on the same date. The GP stated that mother had a history of post-natal depression, difficulties sleeping and suicidal ideation. Baby T was recorded to be a ‘protective factor’. Mother was awaiting treatment from IAPT. The GP had recorded that mother had a social worker ‘when the baby was born’ but there was uncertainty over whether there was continuing social worker involvement. The referral was processed as urgent and an assessment arranged within 48 hours. A Vietnamese interpreter was booked and a female interpreter was requested. The GP was to send over the completed referral form. 4.62 On 19th July 2017 mother was assessed by RAABIT with the assistance of a male interpreter. She presented with low mood, feelings of hopelessness and poor appetite. Her cognition appeared intact. It was documented that the impression gained was that mother was suffering from post-natal depression, although she also disclosed trauma arising from rape and imprisonment in Vietnam. She expressed suicidal thoughts but denied any attempt to act on these or harm her baby. She discussed her ongoing immigration issues and said that her future aim was to get these issues ‘sorted out’ so that she could work in order to provide for herself and her baby. 4.63 The outcome of the assessment was that mother was accepted by RAABIT, a care plan was agreed and her risk was assessed as ‘low’. A psychology referral (refugee pathway) - which is a clinical service offering evidence-based, trauma-focused psychological therapy to people experiencing PTSD due to their experiences prior to seeking asylum - was made on 31st July 2017, an appointment was arranged for her with the Refugee and Migrant Forum East London (RAMFEL) so that she could discuss immigration issues and a referral was made to Imagine, which provided a day opportunities service for mental health clients. Mother was to be prescribed Mirtazapine with the dosage increased from 15mg to 30mg after one week. Mirtazapine is an antidepressant medicine. A medical review, with interpreter, was booked for 5th September 2017. 4.64 On 25th July 2017 the Early Intervention case in respect of Baby T was formally closed by a senior family support worker on the basis that all actions had been completed, when in fact they had not (paragraph 4.52). It was recorded in the case 23 notes that mother was currently no recourse to public funds (NRTPF) and had a case worker at the Home Office. However, it was recorded that the case would remain open in children’s centres with a named worker supporting mother and Baby T. (By this time the Children’s Centre had closed mother and baby T’s file – paragraph 4.57). 4.65 On 31st July 2017 IAPT contacted mother by telephone to arrange the CBT appointment. Mother was unable to understand the call and requested a text be sent to her. An initial appointment was arranged for 7th August 2017, an interpreter booked and an appointment letter sent. 4.66 On 4th August 2017 a RAABIT key worker accompanied mother to her solicitors as she intended to request a change in solicitor. No further role was identified for the RAABIT key worker and so mother was discharged from RAABIT key working, whilst remaining open for the forthcoming RAABIT medical review. 4.67 The 7th August 2017 IAPT appointment with mother did not go ahead as Language Shop advised that there were no interpreters available and mother did not attend. When mother was contacted by telephone, she appeared to be unaware of the appointment. It was decided to confirm a Vietnamese interpreter before attempting to arrange future appointments. Language Shop later advised that they had ‘fewer interpreters, especially in this part of London’. 4.68 On the same date mother took Baby T to Ilford medical centre. An interpreter was present. Mother was concerned that the baby had a dry cough and an intermittently blocked nose. The baby was examined and found to be well. Reassurance was provided to mother. Mother disclosed that she had yet to collect the prescription of Mirtazapine (paragraph 4.60) and was advised to do so. She was also advised of possible side-effects. She reported that her sleep pattern remained poor but she had no suicidal ideation. It was planned to review her again in two to three weeks. 4.69 On 17th August 2017 Baby T was seen with mother by a health visitor for a 9-12 months health review at a Children’s Centre. No interpreter was present and Language Line was not used. No concerns were noted. Mother reported that Baby T had had a cough and cold for about four weeks. She said medication had been prescribed by her GP with little effect. She was advised to take the child back to see the GP. Mother was also advised to access ESOL classes as she spoke limited English. 4.70 On 21st August 2017 the initial CBT appointment with mother took place. Mother had asked for a female interpreter but this had not been possible to arrange. 24 The telephone interpreting service was used instead but difficulties were experienced in hearing the interpreter and sustaining the call. Mother’s history was obtained, during which she became tearful. She said she had arrived in the UK in October 2015, had later ‘met someone’ and became pregnant. The father had left her prior to the birth of Baby T. She said he continued to call her ‘once in a while’ but as she didn’t have the father’s telephone number, she was unable to contact him. Mother went on to say that she had started to experience anxiety symptoms, nightmares and a ‘sense of suffocation’. She added that during the day she was distracted from her thoughts because she was busy with the baby, but at night, or when alone, she felt very anxious. The IAPT high intensity therapist felt mother was very isolated as she spoke no English and appeared to be suffering from trauma-like symptoms. Mother said she had thought about hurting herself but could not do this as she had to take care of her child. She said she was at risk if she was sent back to Vietnam. 4.71 On 25th August 2017 mother’s scheduled medical review was postponed from 5th September (paragraph 4.60) until 10th October 2017 as a result of an NELFT policy change which resulted in clinic appointments being reassigned. This policy change arose from a requirement to extend the duration of appointments to facilitate the use of a specific risk assessment by psychiatrists. 4.72 On 4th September 2017 the Language Shop advised IAPT that they remained unable to provide a female Vietnamese interpreter and the IAPT high intensity therapist tried to contact mother by telephone using a telephone interpreter to ask if she was willing to work with a male interpreter. However, no contact could be made. The IATP plan was to discharge mother from the service if she was unwilling to work with a male interpreter. A female interpreter had been found but she was only available for telephone interpreting which was not considered appropriate as the interpreter would not necessarily be in a confidential location and remote interpreting is not considered conducive to therapeutic work. 4.73 The following day the IAPT high intensity therapist was able to contact mother by phone using the telephone interpreter. It was explained to mother that there was only a male interpreter available who had been used for the 19th July assessment (paragraph 4.59). Mother said she did not wish to work with the male interpreter as she felt he did not like her. It was explained to mother that because another interpreter could not be found, she would be discharged from the IAPT service. Mother was said to understand and accept this. A discharge letter was sent to mother and her GP the following day. (As stated in paragraph 4.63, mother had also been referred to the refugee psychology service. She attended an assessment appointment with this service after the death of Baby T. IAPT is a primary care psychological service whilst the refugee psychology service is a secondary care 25 psychological service. Patients cannot be open to both primary and secondary care psychological services concurrently). 4.74 During September 2017 mother began working illegally in a nail bar as a nail technician. She began leaving Baby T with a babysitter - Female C - at Address 7 in the London Borough of Barking and Dagenham from around 9.15/9.30am until 7pm on three or four days each week. Female C had begun advertising her services as a babysitter on an online Vietnamese community page that same month and mother was her first client. Mother and Female C had not known each other prior to this time. Mother paid Female C £30 per day to care for Baby T. 4.75 On 5th October 2017 Female C collected Baby T from mother at a bus stop near Address 7 which was the usual arrangement. This was the eleventh time Baby T had been left with the carer. On the previous day (4th October 2017) Baby T had been unwell and a challenge for Female C to look after. It is understood that the child had needed to be held ‘all the time’. On 5th October 2017 Baby T was described by Female C as being ‘out of sorts’, not properly taking her food and twice vomited her food up after her arrival at Address 7. Shortly before noon the London Ambulance Service (LAS) was called to a report of Baby T being unwell whilst being looked after by Female C at address 7. Baby T appeared to be very unwell and to have experienced seizures. Female C was unable to provide any information relating to the identity of Baby T or mother. Baby T was transported to BHRUT Queen’s Hospital ED, Romford and the LAS made a referral to Redbridge MASH after contact had been made with mother who arrived at Queen’s Hospital shortly after the LAS. 4.76 Queens Hospital ED also made a referral to the Redbridge MASH in which Baby T was described as being ‘very poorly’ and was later found to have a significant right sided subdural bleed with mid line shift. The referral expressed concern that Baby T, mother and possibly Female C may have been trafficked as two apparently Vietnamese males were with mother at hospital and initially declined to say who they were or what their relationship to mother and Female C was. One of the two men later said that he was the partner of Female C and the other male said that he had transported mother (who he said he did not know) to hospital after seeing her in distress. 4.77 Whilst MASH checks were being carried out in respect of Baby T, it was noticed that there was another child (child 2) living at the same address (address 6 in Ilford) with a similar date of birth. Information held on the Redbridge Early Help system included the following: On 14th September 2017, child 2’s mother had a problem with her asylum supported accommodation in that two weeks ago the shared kitchen ceiling 26 collapsed due to a leak and has still has not been fixed. Pieces of plaster were still falling off. The only friends that child 2’s mother had were the women living in the same accommodation. On 18th September 2017, child 2’s mother said that the hole in the kitchen ceiling had still not been fixed and pieces from the ceiling had fallen on her head. The Clearsprings housing manager had advised her that someone would be calling round to repair the ceiling within the week but this hadn't happened. The family support worker agreed to call the housing manager to obtain an update on when the ceiling would be repaired. On 29th September 2017, child 2’s mother said that scaffolding had been fitted but the repair had not been completed. She was advised to contact the housing manager for an update. 4.78 The outcome of the referrals from LAS and Queen’s Hospital in respect of baby T was that her case was allocated to the Child Protection and Assessment Team for a Child and Family Assessment (CAFA) to be completed, and for a strategy discussion with the police to take place as the injury to Baby T was considered unexplained. 4.79 Baby T was later transferred to GOSH where she died later on 5th October 2017 aged almost eleven months. 4.80 On 6th October 2017 the police contacted the Home Office to request a status check in respect of mother and advise that Baby T had died. The Home Office appeared to have had no contact with mother or Baby T since her dispersal to Ilford on 18th January 2017. The babysitter - Female C - and her child 4.81 Female C is also a Vietnamese national and entered the UK as a tourist on a visitor visa on 23rd August 2013. She stayed for around a month before returning to Vietnam. During her initial stay in the UK, Female C reported that she reconnected with a friend from her childhood in Vietnam who had been living in London for a time. Female C decided to travel back to the UK on the same visitor visa in November 2013 and remained in the UK after the visa expired on 16th February 2014. She began worked illegally in a nail bar in December 2013. 4.82 Female C reported that she met her child’s father during the summer of 2014. The father is also of Vietnamese heritage but was brought up in Hong Kong and is understood to be a British citizen. Female C reported seeing her child’s father for a 27 time but didn’t regard him as her boyfriend as he ‘never showed commitment to her’. She discovered that she was pregnant in February 2015 but when she told the father he suggested she obtain an abortion as he was unable to commit to bringing up a child. Their relationship ended around this time. Female C has reported that she never considered getting an abortion and decided to bring the child up on her own, adding that she began working longer hours to save money for the arrival of the baby. 4.83 Female C’s first recorded contact with agencies was a visit to Homerton University Hospital Accident and Emergency (A&E) in Hackney on 18th March 2015 when she would have been approximately seven weeks pregnant. Due to what Homerton Hospital has described as an ‘IT anomaly’, no information about the reason for her attendance or the treatment she received is available. 4.84 On 27th April 2015 a GP practice referred Female C to Homerton Hospital for antenatal care. It has not been possible to access the referral so no details of the information ascertained by the GP, including whether there were any safeguarding concerns, are available. Female C was offered an initial midwifery antenatal appointment for 8th May 2015 but she rearranged this for 22nd May. 4.85 On 22nd May 2015 Female C attended her antenatal booking appointment. She was considered to be a ‘late booker’, in that her first midwifery contact was at 16 weeks gestation. No explanation for late booking was documented. She was noted to be twenty three years of age, ‘not fluent’ in English, unemployed and ‘unsupported’. She was noted to be living with friends. No partner details were provided although his nationality was recorded as Vietnamese. The midwife documented that an interpreter would be required for subsequent appointments. It is not known whether Female C was referred to a Public Health midwife who could have provided specialist antenatal care. 4.86 Female C gave birth to her child at Homerton Hospital on 29th October 2015 by spontaneous delivery. The baby was documented to be well with no problems identified. The following day Female C and her child were discharged to an ‘out of area’ maternity team as Female C was not resident in Hackney. 4.87 Female C applied to the Home Office for leave to remain in the UK on the basis of her right to family/private life on 7th March 2016. At that time she said she had been supported by a friend who had provided food and accommodation since 30th October 2015. At the time of her application for leave to remain she was living at address 8, which she said was the family home of her employer at the nail bar. 28 4.88 Female C later started a catering business from her home and began advertising on social media as a babysitter at address 7 in Barking and Dagenham in September 2017. She, her partner (who is a Vietnamese national who overstayed a student visa) and her child had moved to that address on 16th September 2017 where they occupied a room in a shared house. As previously stated, Baby T became seriously ill whilst being looked after by Female C at Address 7 the following month 5.0 Mother’s Views 5.1 Mother contributed to this review through an interpreter. As the conversation took place prior to the conclusion of criminal proceedings, mother was requested not to discuss any contact she may have had with the baby sitter - female C - including the events which led up to the death of Baby T. 5.2 Mother expressed her appreciation for the support she received in the London Borough of Hackney. When she initially approached services in Hackney she described herself as being in a ‘very difficult situation’. She had nowhere to live and didn’t know where to go. She said that everyone she came into contact with there, including the GP, the midwife and the ‘nurse’ tried to help her. She said that she was referred to the ‘mother and children support team’ which helped her to contact the Home Office. It is assumed that the ‘mother and children support team’ is either the Hackney First Access Screening Team (FAST) social worker who advised mother to contact the National Asylum Support Service helpline (paragraph 4.6) or the Hackney Multi-Agency Team (MAT) which supported her with her asylum seekers application (paragraph 4.8). Quite understandably, mother had only a vague grasp of the title and roles of many services she came into contact with. 5.3 Mother went on to describe her move to emergency overnight accommodation at address 2 and her initial accommodation at address 3 in Croydon. She recalled staying in the latter address for around two months during which Baby T was born. She said that the support she received from the health visitor in Croydon was ‘very good’ and that she ‘helped her a lot’. It seems certain that she was referring to the Croydon Parent Infant Partnership (PIP) key worker with whom she had substantial contact whilst living in Croydon rather than the health visitor with whom her contact was quite limited. 5.4 She said that she was moved to Cardiff when Baby T was about one month old. She said she shared a room with others whilst in Cardiff but said that she felt ‘very lonely’ because ‘nobody supported her’. She said that whilst she was staying in Cardiff, she rang the ‘health visitor’ in Croydon (presumed to be the Croydon PIP key 29 worker) to ask her to help her. She said that the ‘health visitor’ tried to help her, but ‘nobody came to support her’ whilst she was in Cardiff. 5.5 Mother said that the reason for her move to Cardiff had been explained to her. She was told that the accommodation in Croydon was not suitable for a mother and baby and that it would be good for her and the baby in Cardiff. She was reassured that she would be staying in Cardiff for only a short period of time. 5.6 After her arrival in Redbridge, mother said that a health visitor offered her support but due to the language barrier, she was unable to understand mother and therefore was not in a position to do anything to help her. Mother’s account is consistent with the limited engagement the Redbridge health visitor achieved as a result of the unavailability of an interpreter (paragraph 4.47) and subsequently the booked interpreter leaving prior to mother’s late arrival for an appointment (paragraph 4.49). 5.7 Mother went on to describe how another Redbridge ‘health visitor’ supported her for a time before stopping visiting her without explaining why. It is assumed she is referring to the Early Intervention family support worker who provided her with support between March and May 2017. The Early Intervention support appeared to come to a fairly abrupt end with several tasks outstanding (paragraphs 4.53 and 4.62) and mother clearly picked up on this. 5.8 Mother described how she subsequently sought support from the ‘Job Centre’ where she says she was provided with food bank vouchers ‘a few times’ as well as baby clothes and toys. Job Centres are not commissioned to provide services to people who have no recourse to public funds including asylum seekers. They do provide support to refugees whose claim for asylum have been granted and, as a result, are able to obtain a National Insurance card, seek employment and claim mainstream benefits. Mother was asked if she was referring to a Children’s Centre rather than a Job Centre but she was adamant that it was the latter. It is possible that mother may be referring to Troubled Families employment advisors who are Job Centre employees who work in partnership with the local authority and others to address the needs of families referred to the Troubled Families team for support. These employment advisors are based in Children’s Centres and it is possible that mother may have spoken to them when visiting the Children’s Centre. 5.9 Mother went on to say that the Job Centre stopped supporting her after a time and told her that they had closed her case. Again, it seems likely that mother is referring to the Children’s Centre rather than the Job Centre. After support from the Early Intervention and Family Support service ceased, the plan was for mother and 30 Baby T’s case to remain open in the Children’s Centre but the latter quickly closed her case also (paragraph 4.57). 5.10 When mother was recounting her experiences of the ‘health visitor’ and the ‘Job Centre’ ceasing supporting her, it was clear that she had been both worried and confused at this turn of events; worried at how she would cope without their support and confused because she said she had not been told why the support had ended and her case closed. She said that the ending of support had put her in a ‘difficult situation’ although she seemed unprepared to enlarge on, or further describe, this ‘difficult situation’ and the lead reviewer decided not to probe this further because of her grief at the death of her child and her continuing mental health issues. 5.11 Mother was critical of Ilford Medical Centre where she and Baby T were registered. She said that she took Baby T to see the GP quite often and saw many different GPs. She said that the GPs were often unable to help her and Baby T because of the absence of interpreters. However, she said that one female GP had been ‘very kind’ to her and had referred her to mental health services (paragraph 4.58). 5.12 When asked about her experiences of the mental health services in Redbridge to which she had been referred by the GP, mother said that they were ‘very good, very helpful’. Mother did not appear to wish to enlarge further. It was clear that she was very satisfied with the support she was currently receiving from a support worker who is also a Vietnamese interpreter. 5.13 Returning to her experiences at Ilford Medical Centre, she was critical of the attitude of reception staff towards her. On one occasion there was no interpreter available and so mother telephoned a friend who was a Vietnamese national who could speak English. However, mother said that the reception staff laughed at her and refused to talk to her friend on the telephone. There was no mention of Baby T being with her on this occasion. Ilford Medical Centre has responded to mother’s criticisms by saying that it would be out of character for administration staff to laugh at any patient as they are trained in how to deal with patients who cannot speak English. They are also trained to deal with vulnerable patients professionally and sensitively. 5.14 Mother recounted another visit to the same GP practice. She said Baby T was ill and once again she was unable to communicate with reception staff. She said she then began waiting in the GP practice, her baby was ill and she couldn’t explain what the problem was to the reception staff. She said that after a time she began to cry and people around her noticed her distress and that she was unable to speak 31 English and ‘raised their voices’. She said that this led to a doctor calling her into a room and arranging an interpreter. It is unclear from the chronology of contact between Ilford Medical Centre and mother and Baby T when this incident may have occurred. Ilford Medical Centre has responded to mother’s criticisms by saying that all practice staff undergo mandatory training to enable them to be alert to any signs of a distressed patient in the waiting area. Additionally it is their policy for practice staff to inform the duty doctor if an unwell patient is brought into the surgery, in order that the patient can be triaged and treated accordingly. 5.15 She expressed satisfaction with the accommodation in Redbridge in which she and Baby T were placed. She said that there were four mothers and their children sharing there, adding that one of the other asylum seeker mothers was also Vietnamese which she seemed to value. She added that the other Vietnamese asylum seeker had been supported by the same support worker as her and that her case had also been closed abruptly. When asked about the state of repair of the property, mother said that the ceiling of the kitchen was ‘broken a little bit’ but that this had been fixed. 5.16 When asked about interpreting services generally, mother said that they were very good in Hackney and Croydon. She said that whenever anyone came to see her they always had an interpreter with them (Interpreters were often, but not always, available to practitioners in Hackney and Croydon when communicating with mother). She said that whilst living in Cardiff, she received no support so was unable to comment on the quality of interpreters there. Mother described the availability of interpreters in Redbridge as ‘not good’. 5.17 When asked about the support she received from Migrant Help, mother said that she was so happy and thankful for the support they gave her and Baby T. She said that when she went to them she had nowhere to live and no documents to allow her to live in the UK. She said that Migrant Help were ‘very ready’ to help her. 5.18 She said that when Baby T died she didn’t know how to make funeral arrangements. She said she returned to the ‘Job Centre’ but they reiterated that they had closed her case and said that they couldn’t do anything to support her. She said that after Baby T died she was visited once or twice by the ‘health visitor’ who asked her if she needed any support but then she ‘disappeared’ and didn’t contact her anymore. 5.19 When asked to reflect on the support she had received as a pregnant asylum seeker and as an asylum seeker with a young child and suggest any improvements which could be considered, mother said she felt very grateful for the support she had received. She was particularly appreciative of the support she had received 32 when she was pregnant and when Baby T was first born. She said that the practitioners she had come into contact with had been kind and helpful. She mentioned only one thing which she felt could be improved which was what she described as the ‘disappearance’ of support in Redbridge. She said that when she arrived in Redbridge, she and Baby T received support for a time but then it had ended without notice or explanation. 6.0 Learning Themes 6.1 In this section the learning themes emerging from this review will be explored which will also enable the specific terms of reference questions set out in Section 2 of this report to be addressed. Decisions made by the Home Office (and services commissioned or funded by the Home Office) in response to Mother’s claim for asylum and later application for asylum support 6.2 At the time mother initiated her asylum claim, the Home Office considered her circumstances to be relatively stable in that she was living in a private flat in Hackney with the father of the unborn Baby T. It was established that the father was a UK citizen and was said to be supporting mother financially. Mother was provided with written advice on how to apply for financial support whilst her asylum claim was decided upon by the Home Office, but she made no claim for financial support at that time. The Home Office did not believe that she had been, or was being exploited in any way. 6.3 When mother’s circumstances changed after the father of Baby T left her and withdrew financial support, the Home Office promptly approved emergency accommodation and subsequently longer term asylum financial and accommodation support. However, the Home Office later lost sight of mother and Baby T. They wrote to her on 7th December 2016 to advise that they had been unable to make a decision on her asylum claim within six months of her original claim and intended to review her case in three months (paragraph 4.26). This review did not take place and so the Home Office exercised no further oversight of mother and Baby T’s case until notified of the death of Baby T in October 2017. The Home Office has advised this SCR that during this period they were experiencing resource issues as a result of high turnover of decision making staff and, at national level, the asylum directorate was struggling with the increasing age and volume of what are described as non-straightforward cases. 33 6.4 Therefore during the period from December 2016 to October 2017 the Home Office was not in a position to assure themselves that they were complying with Section 55 of the Borders, Citizenship and Immigration Act 2009, which requires them to carry out their existing functions in a way that takes into account the need to safeguard and promote the welfare of children in the UK. It is accepted that once mother and Baby T had moved from initial accommodation to longer term asylum support (accommodation and financial) in Redbridge in January 2017, their circumstances had stabilised to an extent and they were receiving support from Clearsprings and could access support from Migrant Help. However, mother remained vulnerable due to her social isolation, lack of English, limited resources, risk of exploitation and the loss she experienced in Vietnam in terms of the death of her husband and the loss of contact with her older children. Baby T’s vulnerability was directly linked to that of her mother who had demonstrated that she would need support and guidance in parenting the child. The Home Office Healthcare Needs and Pregnancy Dispersal Policy (4) further describes the potential vulnerability of mothers and young babies in terms that are very similar to mother and Baby T’s potential vulnerability (paragraph 6.15) and research on asylum seekers in the UK (paragraph 6.62) further emphasises potential vulnerabilities. If Home Office case workers making decisions about cases such as mother and Baby T are considered to contribute to safeguarding and promoting the welfare of the children of asylum seekers in the UK, then they did not do so for the majority of Baby T’s short life. 6.5 Nor were they in a position to contribute to the Home Office Adults at Risk Safeguarding Strategy in respect of mother during the same period. The Home Office established an Asylum Safeguarding Hub in autumn 2016 to implement the Adults at Risk strategy by engaging with the NHS, social services and police to promote intervention and support for customers in respect of safeguarding, trafficking and modern slavery. Had Home Office case workers become aware of the deterioration in mother’s mental health, they could have referred her to the aforementioned Asylum Safeguarding Hub to consider the necessary response including a referral to another agency such as health or social care (5). Additionally, the deterioration in mother’s mental health had the potential to expose Baby T to harm which may have merited a child safeguarding referral by the Home Office. 6.6 Turning to the decision to disperse mother and Baby T to Cardiff, clearly they needed to move from their initial accommodation in address 3 to accommodation in which longer term asylum accommodation and support could be provided. The justification for the move to Cardiff was that there is a limited supply of accommodation within London and South East England and that it was a temporary dispersal until suitable accommodation could be sourced nearer to London. However, dispersal to accommodation in the London Borough of Hillingdon had initially been planned for the same day that mother and Baby T were dispersed to 34 Cardiff and called off because it was one day prior to the six weeks following birth during which Home Office policy states a move should not take place. It is not known why Hillingdon was rejected whilst Cardiff was chosen, although the Clearsprings Group, which is one of three companies which each hold two of the six regional contracts for providing asylum seeker accommodation in the UK, has the contracts for London and South East England and Wales and South West England. 6.7 Home Office Healthcare Needs and Pregnancy Dispersal Policy states that, on dispersal, they aim to assist in ensuring the ‘effective handover of care’ but the policy goes on to stress the ‘critical role’ of the applicant (mother) in helping to ensure continuity of their care during dispersal, by divulging healthcare needs to the Home Office ‘as well as providing dispersal information to treating clinicians/midwives’ (6). Mother, supported by Migrant Help, notified the agencies which were supporting her in Croydon of her impending dispersal to Cardiff but the process by which agencies in one area share information with agencies in another area to which vulnerable people are moving is not without risk. In mother’s case Croydon Early Help promptly made referrals to Cardiff but Croydon health visiting service did not appear to make any referral, despite providing a ‘Universal Plus’ service to mother and Baby T, and eventually only provided information to their counterparts in Cardiff after mother had moved on from Cardiff to Redbridge. Migrant Help referred mother to their equivalent agency in Cardiff five days before she left Cardiff although this review has been advised that Migrant Help personnel are based within the accommodation to which mother was ‘dispersed’ in Cardiff and would therefore have been readily available to provide support to mother and Baby T. 6.8 It is not possible to reach any conclusion other than the dispersal of mother and Baby T to Cardiff exposed them to risk. Although mother was able to access services in Cardiff, she was moved again during her short stay in the city which was completely inappropriate. ‘Dispersal’ to Cardiff terminated the post-natal support network on which mother and Baby T had come to rely in Croydon and increased her vulnerability. It was unrealistic to expect her Croydon support network to be quickly recreated in Cardiff, particularly as effective support is founded on clarity in respect of needs and positive human relationships, both of which take time to develop. Mother said that she felt lonely and unsupported during her stay in Cardiff. Additionally, the dispersal to Cardiff took place just prior to the Christmas/New Year holiday period during which many services operate at diminished levels including public transport. Given that the plan was for the dispersal to Cardiff to be a temporary move prior to a return to accommodation nearer London, it is unclear why consideration was not given to leaving mother and Baby T in their initial accommodation in Croydon until the move to longer term asylum support in, or 35 near, London could be achieved, particularly as the accommodation in Cardiff was also initial accommodation. 6.9 The House of Commons Home Affairs Committee noted that ‘Initial accommodation is not suitable or intended for long term use. However, the reality is that asylum seekers are housed in initial accommodation for far longer than the target of nineteen days’ (7). Mother stayed in initial accommodation at address 3 from 8th October 2016 until 19th December 2016 (Baby T was with mother in the accommodation from her birth on 7th November 2016) which is a total of 72 days. The Home Affairs Committee has also advised that ‘there should be as little disturbance as possible to the routine of pregnant women and new mothers, particularly in terms of their relationship with health professionals but if this means a stay in initial accommodation is prolonged then that accommodation must provide the appropriate support’ (8). The key factor in mother greatly exceeding the 19 day target was her pregnancy and postnatal care. Given that the target had already been exceeded to such an extent, the decision to move mother and Baby T to Cardiff rather than allowing them to remain in initial accommodation in Croydon for a further month appears even less justifiable. 6.10 Concerns arose about the condition of the asylum accommodation mother and Baby T shared with other asylum seeking mothers and children in Ilford (paragraph 4.75). These concerns were not linked to mother and Baby T until shortly after the child’s death. A hole in the kitchen ceiling of the property had developed during September 2017 which did not appear to have been promptly addressed by Clearsprings as the provider. 6.11 Reports from the National Audit Office, the Home Affairs Committee and the Independent Chief Inspector of Borders and Immigration have raised concerns about the standard of asylum accommodation, the arrangements for inspection and the arrangements for recording and responding to complaints from tenants. The Home Affairs Committee has observed that the number of complaints about accommodation issues varies enormously between asylum accommodation providers. Private contractors - G4S, Serco and Clearsprings - each held two of the six UK asylum accommodation provider contracts. In 2015 G4S received 42,783 complaints, Serco received 127 and Clearsprings just 25. The Home Affairs Committee took the view that the low level of complaints recorded by Serco and Clearsprings were not a true reflection of the number of complaints made by asylum seekers. 6.12 Clearsprings have advised this SCR that the accommodation in which mother and Baby T were placed in Ilford was provided by Clearsprings via a sub-contracted agent. The agent had a contractual agreement with Clearsprings to carry out periodic inspections of the property, and to rectify any defects found during such 36 inspections. Clearsprings also carried out monthly audits of sub-contracted properties. During 2018 the Asylum Accommodation and Support Services Contracts (AASC) were open to tender. During the tender and bidding period, Clearsprings state that they reviewed their sub-contractor contracts and made the operational decision to bring all property inspections and defect rectification logging in-house. Clearsprings add that whilst they continue to obtain properties from various sources, all property inspections, defect logging, and maintenance is managed directly within the Clearsprings Repairs and Maintenance Team. Any defects logged will be categorised and allocated to the appropriate tradesperson and will be completed within agreed timescales, thereby providing for more efficient management of all Asylum properties across the portfolio. All defects that are landlord responsibility (wear and tear) are sent to the sub-contractors and monitored by Clearsprings. 6.13 Clearsprings go on to add that Migrant Help has been awarded the contract to provide an Advice, Issue Reporting and Eligibility Service (AIRE) to all asylum seekers in the UK which they say provides for a greater level of transparency in the reporting of issues in all asylum properties, and an enhanced process for all service users to report any issues that affect their journey through the asylum process. 6.14 Mother accessed the support of Migrant Help on several occasions. They assisted her to obtain emergency accommodation, longer term asylum accommodation and financial assistance, the maternity payment and with transport to appointments. Migrant Help’s involvement with mother diminished following her transfer to Redbridge as it was assumed that she was less likely to need their support once her long term asylum support was in place. The effectiveness of the interface between Home Office asylum seeker support services and ‘mainstream’ health and social care services 6.15 Mother was four months pregnant with Baby T at the time she made her asylum claim. The Home Office Healthcare Needs and Pregnancy Dispersal Policy makes clear that pregnant asylum seeking women may be affected not only by complex social factors within the UK (lack of knowledge of the health system; problems with interpretation), but also by poor health and other medical concerns arising as a result of pre-arrival issues, such as a poor overall health status, underlying and possibly unrecognised medical conditions, possible female genital mutilation (FGM) issues, psychological and medical effects of flight from war torn countries, fears about immigration and languages difficulties (9). The policy also recognises that maternal stress in pregnancy has a detrimental effect on subsequent childhood development (10). 6.16 Mother spoke no English, was likely to be unfamiliar with the manner in which services were accessed in the UK, appeared to be wholly dependent on the father of Child T and may have experienced trauma as a result of what she disclosed about 37 her previous life in Vietnam. As mother was vulnerable, then it followed that her unborn baby could also be vulnerable. However, no signposting to services or referral appears to have been considered by the Home Office at the time mother initiated her asylum claim. Whilst it is accepted that mother was being supported by the father of Baby T at the time she made her asylum claim, the possibility that these arrangements may prove to be fragile could have been considered. 6.17 In his 2018 inspection of the Home Office’s approach to the identification and safeguarding of vulnerable adults, the Chief Inspector of Borders and Immigration stated that where a particular vulnerability is identified or suspected during initial asylum screening, the interviewer should refer the case to the Asylum Safeguarding Hub to consider the necessary response, including a possible referral to other agencies. The particular vulnerabilities referred to by the Chief Inspector include pregnancy (11). 6.18 When mother’s claim for emergency asylum support was approved and she was placed in initial asylum support accommodation in Croydon, the Home Office, via the asylum accommodation provider ClearSprings, liaised with relevant agencies in the local area in which mother was placed. ClearSprings prompt referral of mother to local agencies helped mitigate the risks associated with moving mother, whose estimated delivery date was under a month away, from Hackney to Croydon. 6.19 The decision to disperse mother and Baby T to Cardiff exposed them to the risk that postnatal care and other support would be disrupted. As stated in paragraph 6.6, Home Office policy states that, on dispersal, they aim to assist in ensuring the ‘effective handover of care.’ Migrant Help supported mother to prepare for the move to Cardiff but the onus was primarily placed on mother and the ‘mainstream’ agencies supporting her to do all they could to ensure the ‘effective handover of care’ although it is accepted that mother and Baby T were able to access support from Clearsprings and Migrant Help in her asylum accommodation in Cardiff. 6.20 The Home Office has advised this review that dispersals can be halted at the request of an applicant with the backing of a midwife or medical professional should it be required due to ‘complications/needs of mother and baby’. Additionally, the manager of the Rainbow Health Centre in Croydon can withhold dispersal of clients if there is a ‘high need’ such as fleeing domestic violence or there is a complex medical need for child or adult. The manager did not feel that mother and Baby T met the ‘high need’ criteria. However, there is no indication that other agencies involved in supporting mother and Baby T in Croydon at that time were aware that they had the option of requesting the halting of their dispersal to Cardiff. 38 6.21 Information sharing in support of mother and Baby T’s transfer from Cardiff to Redbridge was also problematic. Clearsprings, as the provider of her longer term asylum support accommodation in Ilford, did not refer mother and Baby T to any local services when she arrived in Redbridge on 18th January 2017. The Home Office Healthcare Needs and Pregnancy Dispersal Policy states the provider of dispersal accommodation is contractually obliged to take a supported person to a GP within 5 working days of their arrival at the dispersal address if the person has a pre-existing condition or is in need of an urgent GP appointment. (11B) The policy states that children under nine months are covered by this arrangement. Mother appears to have had no contact with local agencies until 2nd February 2017 when she went to Ilford Medical Centre with Baby T. In their contribution to this review Clearsprings have advised that they would have signposted mother and Baby T to local services such as ‘health’. (Clearsprings appear to have been more proactive in referring mother to local services when she moved into initial asylum accommodation in Croydon). Clearsprings also state that they were unaware of the concerns which arose about mother’s mental health whilst she and Baby T were living in Ilford and were unware of the support being provided by the Redbridge Early Intervention and Family Support Service and subsequently the Children’s Centre. Mother’s consent would have been required for agencies providing support to her and Baby T to share information with Clearsprings but there is no indication that engaging with Clearsprings as mother’s asylum accommodation and support provider was considered. This was a missed opportunity. Clearsprings have further advised this review that had agencies shared any concerns about mother and Baby T with them, the Clearsprings safeguarding manager could have become involved. 6.22 The asylum accommodation occupied by mother and Baby T in Ilford is a large eight bedroom property and the other rooms were also occupied by mothers and babies. The London Borough of Redbridge has no involvement with the property and it is not usual practice for the National Asylum Support Service (NASS) to advise the Borough’s Housing Service if they place a family in Redbridge. It is understood that the Housing Service will usually only hear about a family living in a local property when they approach Redbridge to advise that NASS is about to evict them. 6.23 The Home Affairs Committee concluded that the ‘poor condition of a significant minority’ of asylum support properties led them to conclude that the current compliance regime (inspections primarily by the Home Office and the provider’s housing inspectors) was not fit for purpose’. The Home Affairs Committee went on to recommend that the inspection duties carried out by the Home Office should be transferred to local authorities although this was subsequently rejected by the Home Office. 39 6.24 Concern has been expressed that asylum seeking mothers and children are living together in properties such as address 6 and that services may to a large extent be unaware of their presence in the Borough. In mother’s case she and Baby T had been in contact with a range of local services in Redbridge although by the time of Baby T’s death they were in contact only with primary health services. Whilst bringing together a number of vulnerable mothers and children under one roof may bring some benefits, such as mutual support, and in mother’s case informal interpreting from another Vietnamese asylum seeker, there is the potential for some risks to increase, including the risk of exploitation by others. 6.25 In their contribution to this review, Homerton Hospital recommend that practitioners providing support to asylum seekers should receive bespoke training on the nuances and complexities of the asylum system. Whilst existing safeguarding training highlights the vulnerabilities of asylum seekers it may need to be enhanced so that practitioners can better support vulnerable people such as mother and Baby T. The support provided to mother and Baby T by mainstream health and social care agencies 6.26 There is no indication that mother had contact with any agencies during the period following her stated arrival in the UK (27th October 2015) and her contact with the Home Office to claim asylum over seven months later (7th June 2016). 6.27 Once mother presented to a Hackney GP on or around 4th July 2016 she was referred to midwifery services although little detail was obtained about her circumstances by the GP practice. Homerton public health midwifery provided effective support once mother’s vulnerabilities had been ascertained. Health visiting in Hackney became aware of mother after the public health midwife referred her to the children’s centre multi-agency team (MAT) meeting which the health visitor attended. It would have been good practice for there to have been a discussion of mother’s case between the midwife and health visitor and possibly a joint assessment. Homerton Hospital has advised this SCR that the health visiting service was carrying an increased number of vacancies and undergoing a restructure at the time of mother’s involvement with midwifery services. Additionally, the pathway from midwifery to health visiting for notification of vulnerable pregnant women was less clear then than it is reported to be now. 6.28 When mother moved to Croydon she received Early Help support although there was a significant delay in making the first contact with her (from 10th to 31st October 2016). The work with mother and Baby T was of a practical nature, ensuring the family was accessing health services, midwifery, health visiting and legal support through Migrant Help. Whilst the support was provided over a short 40 period of time, it was intensive with very regular visits which often included interpreters. However, because of the anticipated length of time mother and Baby T were placed in Croydon, work did not progress beyond ensuring that the practicalities were in place and so there was limited opportunity to support mother through nurturing or therapeutic support. Nor was the keyworker able to complete an early help assessment although she was able to use assessment tools to begin to explore the needs and strengths of the family and mother’s hopes and dreams for her baby. However, mother actually stayed in Croydon from 8th October until 19th December 2016 which may have been sufficient time for an early help assessment to have been carried out. 6.29 There is no indication that any discussion about mother took place between the specialised midwife and specialist health visitor for homeless families in Croydon during the antenatal period. The health visitor was unable to fully complete the new birth visit within accepted timescales due to the wrong interpreter being booked and the further visit expected for a family being provided with a ‘universal plus’ service did not take place. Croydon health services have advised this SCR that there was a shortage of health visitors at the clinic where the specialist health visitor for homeless families was based which may have resulted in the specialist health visitor covering both ‘universal’ and ‘universal plus’ families at that time. This may also have been a factor in the delay in providing health visitor records to Cardiff. Croydon Health Services have advised this review that their health visitor staffing levels have continued to fluctuate with each health visitor carrying caseloads of over 600 children. 6.30 In Cardiff mother was able to access GP services and the Croydon’s PIP keyworker’s prompt referral to Cardiff MASH ensured that her and Baby T’s vulnerabilities were brought to the attention of a health visitor. Mother and Baby T received a ‘universal’ level of health visitor service whilst in Cardiff which was not informed by their health visitor records from Croydon as these did not arrive until they had left for Redbridge. 6.31 Mother and later Baby T’s periods of residence in Hackney (three months and four days after first accessing services there), Croydon (two months and ten days) and Cardiff (one month which included the Christmas/New Year holiday period) were very brief and made it difficult for mother to make connections, achieve even a limited degree of independence and resulted in work having to be started all over again each time she and the child were moved. The brevity of the stays also put pressure on agencies to work quite rapidly with the family whilst limiting the depth and intensity of the work it was possible to accomplish. 41 6.32 The transfer to longer term asylum accommodation and support in Redbridge provided agencies with the opportunity to work with mother and Baby T over a longer period. However, the Early Intervention and Family Support Service was only involved with mother and Baby T from February until May 2017 despite several tasks identified from the initial CAF remaining incomplete and concerns about mother’s mental health having arisen by the stage their case was closed. The plan was for mother and Baby T’s case to remain open to the Children’s Centre but, inexplicably, their case was closed by the Children’s Centre on 5th July 2017 (paragraph 4.57), a decision which coincided with the departure of the Children’s Centre family support worker who had been supporting mother and Baby T. Although mother and Baby T were able to continue to access sessions at the Children’s Centre, what mother described in her contribution to this SCR as the ‘disappearance’ of her support (paragraph 5.19), appeared to affect her adversely. 6.33 It is understood that Early Intervention and Family Support were going through changes to structure and staffing at the time they closed mother and Baby T’s case. This SCR has been advised that the Early Intervention and Family Support Service now benefits from a stable and experienced management team and that there is now a Triage team which accepts cases requiring short pieces of targeted support. This has resulted in caseloads for individual family support workers dropping from thirty families to an average of twenty. 6.34 Mother and Baby T were provided with a ‘universal’ health visiting service in Redbridge. Arguably the family should have received a ‘universal plus’ service as they did in Croydon. An important factor in deciding which level of service was appropriate was the initial transfer-in visit by the health visitor during which interpreting was provided by one of mother’s fellow tenants. The lack of an interpreter may have contributed to a lack of pertinent information ascertained from mother who may have been reluctant to share sensitive information with the other tenant. There may also have been a lack of professional curiosity by the practitioner. 6.35 However, there was an opportunity to review the level of support being provided to mother and Baby T at a subsequent appointment (paragraph 4.49) when mother’s disclosures about her emotional wellbeing led to the health visitor making a referral to IAPT. Lack of professional curiosity was again in evidence when there was no health visitor follow up to the paediatric information sharing form after mother left Barking Community Hospital walk-in centre without Baby T being seen (paragraph 4.55). The health visitor conducted the 9-12 month review of Baby T without an interpreter or the use of Language Line (paragraph 4.67) which could have prevented the review being completed as fully as possible including discussion of pertinent issues such as mother’s emotional wellbeing following the health visitor’s earlier IAPT referral. 42 6.36 The IAPT triage assessment of mother in May 2017 determined that mother met the criteria for PTSD and she was considered to be a priority due to her clinical presentation and the fact that she was caring for a six month old baby. Mother was seen within the 16 week target for priority clients to be allocated a CBT therapist, although when, after waiting 9 weeks, she rang IAPT to ask about the waiting time, she received no reply. The 16 weeks target for priority clients has now been set at four weeks. However, practitioners who attended the learning event organised to inform and validate this SCR, questioned whether NELFT was resourced to deliver this revised target. 6.37 Whilst waiting for her CBT appointment from IAPT, mother was referred to RAABIT by her GP. On this occasion she was diagnosed with post-natal depression and was prescribed an antidepressant. The referring GP gained the impression that mother was being supported by a social worker which was never clarified by either the GP or RAABIT and appears to have persuaded the GP that a referral to children’s social care was unnecessary. This was a missed opportunity for a referral to have been made to the MASH. 6.38 Mother was rapidly discharged from RAABIT key working although the key worker appeared to have quite a limited remit which was to ensure medication was started in accordance with the instructions of the psychiatrist and to refer mother onto other services. The key worker is a non-medical practitioner allocated to a service user requiring support for a limited time period and aims to support the service user to try and prevent a crisis situation developing. 6.39 Mother was later discharged from IAPT services after just one session with the CBT therapist during which a fairly full history was obtained despite the use of the telephone interpreting service which made sustaining the interaction with mother problematic. Mother had objected to a male Vietnamese interpreter used earlier and efforts to source a female interpreter had been unsuccessful. Mother’s reasons for objecting to the male interpreter, beyond saying that she felt he did not like her, could have been further explored. The Director of the Vietnamese Mental Health Service, which is based in the London Borough of Southwark, has contributed to this review. The service provides mental health support to people from Vietnam (including asylum seekers and refugees) who are living in the UK. He observed that Vietnamese women would be reluctant to accept a male interpreter to discuss personal or intimate medical issues. NELFT did not discuss mother’s case with her health visitor, who had made the IAPT referral, prior to discharging mother although her GP was notified. 43 The impact of the frequent moves of mother and Baby T from one local authority area to another 6.40 Mother moved from the London Borough of Hackney (where she had first claimed asylum) to Croydon (where she was placed in initial asylum support accommodation) and from Croydon to Cardiff before being placed in longer term asylum supported accommodation in the London Borough of Redbridge. Communication between services in Hackney and Croydon was very effective. Mother left Hackney on Friday 7th October 2016 and on the next working day (Monday 10th October 2016) the Hackney public health midwife contacted the safeguarding maternity team at Croydon University Hospital to handover the care of mother and her unborn baby. Two days later, contact took place between a Hackney health visitor and her counterpart in Croydon to advise of mother’s transfer. On the same date a family support worker from Hackney referred mother to Croydon Early Help service. It is unclear whether mother’s GP records transferred from Hackney to the Croydon GP practice. 6.41 When mother and Baby T were dispersed from Croydon to Cardiff, mother’s Croydon PIP key worker promptly contacted Cardiff Social Care to inform them that mother and Baby T had moved to their area and the following day completed a multi-agency referral form to enable the family to continue receiving support. There is no indication that mother and Baby T’s medical records were transferred from Croydon to the Cardiff GP practice she accessed whilst there. It seems unlikely that mother and child registered with a GP practice in Cardiff. Croydon Health Services did not transfer health visitor records to Cardiff until after mother and Baby T had moved on to Redbridge. 6.42 Mother and Baby T were permanently dispersed from Cardiff to the London Borough of Redbridge on 18th January 2017 but did not access any local services for over two weeks until mother presented at Ilford Medical Centre with Baby T on 2nd February 2017. Ilford Medical Centre was informed by mother that she and Baby T had previously been registered with the Rainbow Health Centre in Croydon and both sets of medical records were transferred to Ilford quite promptly. 6.43 Ilford Medical Centre did not refer mother or Baby T to any agency on initial registration. A GP from the Medical Centre has advised this review that a GP could have referred mother and Baby T to the health visitor or mother could have self-referred. A GP referral was less likely given the very limited information obtained from mother at the time she registered herself and Baby T at the Medical Centre. The medical records for mother and child arrived at Ilford Medical Centre on 9th and 2nd March 2017 respectively and so there was an opportunity to review the records and consider referrals at that stage but this was not done. 44 6.44 Mother telephoned her Croydon PIP key worker on 6th February 2017 to tell her that she had returned to London, although she mistakenly thought she had been sent to the London Borough of Barking and Dagenham. After establishing that mother was in Redbridge, the Croydon PIP key worker completed an Early Intervention Panel referral in respect of mother and Baby T. This led to the involvement of a family support worker who notified the health visitor of the arrival of mother and Baby T. 6.45 Mother and Baby T’s dispersal to Cardiff not only increased their vulnerability whilst staying in that city but it also adversely affected information sharing with Redbridge. Mother found herself having to start again in Redbridge as she had not been in Cardiff long enough for any service there to ‘take ownership’ of her case and assume responsibility for contacting services in Redbridge. It was fortunate for mother that she had retained the contact details of the Croydon PIP key worker, who promptly referred her to the Redbridge Early Intervention and Family Support Service. Use of interpreting services in supporting mother and Baby T 6.46 NHS England set out principles for high quality interpreting and translation services in Primary Care Services (12) which have wider applicability. The principles are as follows: Patients should be able to access primary care services in a way that ensures their language and communication requirements do not prevent them receiving the same quality of healthcare as others. Staff working in primary care provider services should be aware of how to book interpreters across all languages, including sign language, and book them when required. Patients requiring an interpreter should not be disadvantaged in terms of the timeliness of their access. Patients should expect a personalised approach to their language and communication requirements recognising that ‘one size does not fit all’. High ethical standards, a duty of confidentiality and safeguarding responsibilities are mandatory in primary care and this duty extends to interpreters Patients and clinicians should be able to express their views about the quality of the interpreting service they have received, in their first of preferred language and formats (written, spoken, signed etc) 45 Documents which help professionals provide effective health care or that support patients to manage their own health should be available in appropriate formats when needed The interpreting service should be systematically monitored as part of commissioning and contract management procedures and users should be engaged to support quality assurance and continuous improvement and to ensure it remains high quality and relevant to local needs. 6.47 There were several occasions when agencies struggled to achieve these standards when working with mother. 6.48 On the two occasions on which the Home Office had face to face contact with mother a qualified Vietnamese interpreter was provided. The initial accommodation in which mother was placed in Croydon had access to Vietnamese interpreters. Migrant Help also used interpreters to communicate with mother. 6.49 The Croydon Early Help PIP keyworker initially attempted to use Google Translate to communicate with mother. When it became clear that this was not effective, it was decided that an interpreter would be booked for subsequent meetings. Of the nine further meetings with mother, interpreters were available for five of them. 6.50 The Redbridge Early Intervention family support worker was able to obtain the services of an interpreter when she met with mother and Baby T at the Children’s Centre on 27th April 2017 and when she held the TAC meeting on 16th May 2017. Otherwise the involvement of interpreters is unknown. 6.51 There were several occasions when mother’s interpreting needs were not, or not fully, addressed leading to less than satisfactory outcomes including her initial registration with Ilford Medical Centre which led to little information being obtained from her. This may have been a factor in the absence of any referrals of mother and Baby T to local services by the GP practice. Additionally, the absence of interpreting services appears to have been a factor in preventing the Redbridge health visitor in gaining a fuller understanding of mother and Baby T’s needs and which influenced the decision to offer only a ‘universal’ health visiting service. 6.52 There were several occasions when mother’s interpreting needs were not, or not fully, addressed leading to delayed appointments (paragraphs 4.17) or instances when the purpose of the meeting could not be achieved (paragraph 4.42). On one occasion a Mandarin interpreter was booked by mistake which meant that the Croydon health visitor was unable to complete a new birth visit (paragraph 4.21). 6.53 There were several occasions when a Vietnamese interpreter had been booked but the agency contracted to provide the interpreter was unable to do so 46 (paragraphs 4.47, 4.65 and 4.68), often at very short notice. The provider suggested that there was a shortage of Vietnamese interpreters in this part of London. One meeting arranged between mother, NELFT and the lead reviewer to enable mother to contribute to this review was cancelled at very short notice through interpreter unavailability. 6.54 On another occasion the Vietnamese interpreter may not have had adequate skills, although this does not appear to have been picked up on by the Croydon health visitor using the interpreter to communicate with mother (paragraph 4.24). Mother was recorded as saying that she wasn’t isolated and had a stable family environment which seem unlikely to have been her actual responses. 6.55 On occasions practitioners made use of the services of a friend of mother’s who is believed to have been a fellow Vietnamese asylum seeker who could speak English. The friend proved an effective point of contact to make and confirm appointments with mother but on at least one occasion was used for a wider interpreting role which may not have been entirely appropriate due to the friend’s lack of training and the potential risk that she may have added, omitted or edited information. However, Ilford Medical Centre’s policy is to advise patients who need an interpreter and are making an emergency, as opposed to a planned appointment, to bring a friend to interpret for them. 6.56 Mother was discharged from the IAPT service because the agency which supplied interpreters to NELFT were unable to source a female interpreter as requested by mother. Mother’s rejection of the male interpreter provided during an earlier contact with IAPT created a dilemma for the service. It would have been helpful to explore her reasons for objecting to the male interpreter as it seems likely that there were cultural factors involved (paragraph 6.39). However, no discussion took place with mother or with any of the other services involved with mother to try and find a solution. 6.57 Various practitioners signposted mother to ESOL (English for Speakers of another Language) but there is no indication that mother accessed this service. It would have been helpful to work with mother to overcome any barriers to accessing the classes such as the cost of public transport and the availability of creche facilities. The Learning and Work Institute mapped ESOL provision across Greater London in May 2017 (13) and found that reductions in Adult Education funding had seen participation in ESOL learning fall between 2010 and 2016 although many providers reported high levels of demand. The mapping exercise found that ESOL classes in Redbridge were over-subscribed with evidence of particular demand for provision at lower levels of understanding of English. 47 The effectiveness of single and multi-agency responses to safeguarding concerns in respect of mother and Baby T 6.58 The short periods during which mother was known to services in Hackney, Croydon and Cardiff limited the completion of detailed assessments. As a result, a reasonably full picture of mother’s vulnerabilities was only obtained over time. Potential indications of trafficking will be considered later in this report as will the lack of information obtained about father and the circumstances in which he appeared to abandon mother. 6.59 The fullest information about mother’s past life in Vietnam was obtained by her then solicitor in December 2016 and shared with her Croydon PIP key worker (paragraphs 4.26 to 4.28). This indicated that mother may have experienced considerable trauma as a result of the arrest of her husband and herself and their treatment whilst in detention which apparently led to the death of her husband. Mother may also have experienced separation and loss arising from leaving her two older children and her parents in Vietnam. The IAPT triage assessment of mother in May 2017 found that she met the criteria for PTSD (paragraph 4.65). She was offered CBT but only one session took place – in August 2017 – before she was discharged from the service. She was also prescribed an antidepressant. 6.60 Mother also disclosed a previous history of postnatal depression to her Croydon health visitor (paragraph 4.24) which she was reported to have self-managed. She said she was experiencing postnatal depression following the birth of Baby T when she saw the Ilford Medical Centre GP in July 2017 (paragraph 4.58) which appeared to be confirmed by the subsequent RAABIT assessment (paragraph 4.60). 6.61 During the July 2017 conversation with her GP, mother said she wanted to die, adding that she had been having thoughts of wanting to step into the traffic. When assessed by the RAABIT practitioner two days later she presented with low mood and a sense of hopelessness. She expressed suicidal thoughts but denied any intent to act on these or harm her child. When she met the CBT therapist in August 2017 (paragraph 4.68) mother disclosed anxiety symptoms, nightmares and a ‘sense of suffocation’. She said she had thought about hurting herself but could not do this as she had to take care of her child. 6.62 Social isolation also appeared to be a key factor in mother’s presentation. She told the Redbridge GP that she lacked support from relatives or friends and the IAPT high intensity therapist felt mother was very isolated as she spoke no English. Mother’s lack of connectedness to the world in which she then lived including having nowhere she could visit to practice her religion. Social isolation, dependence and 48 boredom have frequently been found to be present in the UK asylum seeker experience, together with high rates of self-harm and risk of suicide (14). 6.63 The impact on mother’s parenting of Baby T of her mental health issues and the effects of her life as an asylum seeker did not appear to be fully considered by agencies in contact with her. At the time of the GP referral to RAABIT, the child was perceived to be a ‘protective factor’ in respect of mother’s mental health. Previous SCRs have found that whenever practitioners perceive children as ‘protective factors’ in respect of parental mental health, the unintended outcome is invariably to increase risks for the children who in this case was a six month old baby (15). Whilst there is no evidence that mother’s mental health issues affected her parenting of Baby T, perceiving the child to be a ‘protective factor’ may have been a factor in the absence of a referral to children’s social care at the time her GP referred her to mental health services in July 2017. 6.64 It is important to note that most parents or carers who experience mental ill health will not abuse or neglect their children. However, mental health problems are frequently present in cases of child abuse or neglect. An analysis of 175 serious case reviews from 2011-14 found that 53% of cases featured parental mental health problems (16). Additionally, the risks to children are greater when parental mental health problems exist alongside problems such as unemployment, financial hardship, poor housing, discrimination and a lack of social support (17). Together, these problems can make it very hard for parents to provide their children with safe and loving care (18). In mother’s case her mental health problems were accompanied by unemployment, financial hardship, some evidence of housing which was in an unsatisfactory state of repair and social isolation. 6.65 As previously stated there was a missed opportunity for either mother’s GP or NELFT to make a referral to children’s social care when mother’s mental health appeared to further deteriorate in July 2017 (paragraphs 4.60 and 4.61). Additionally Redbridge Early Intervention and Family Support and the Children’s Centre closed mother and Baby T’s case at a time when they were aware that mother had been referred to IAPT, but they were unaware of the outcome of IAPT referral. 6.66 Concerns about mother’s parenting had arisen from time to time including co-sleeping, leaving her baby on the edge of the bed and leaving the baby with a male resident of address 3 who was unknown to her. Such concerns as did arise were not linked to mother’s mental health issues. Mother’s co-sleeping with Baby T was attributed to Vietnamese culture and advice was provided to her. However, the Redbridge Early Intervention family support worker completed two Neglect Toolkits, neither of which indicated any concerns. Additionally, mother was assiduous in seeking medical assistance when Baby T became ill. 49 6.67 Services in contact with mother and Baby T were consistent in perceiving the child’s level of need to be at Level 2 (‘Children with Additional Need’) in that she needed additional support to ensure her health and development needs were met (19). This additional support is referred to as ‘early help’ or ‘early intervention’ and can often consist of family support and children’s centre support as received by mother and Baby T in Croydon and Redbridge. Baby T’s needs were never assessed as reaching Level 3 (‘Children with Complex Multiple Needs’) which may have led to the drawing up a ‘child in need plan’. Arguably the multiple challenges facing asylum seeking mothers and their infant children could propel them from Level 2 to Level 3. In Baby T’s case, her mother’s deteriorating and ultimately untreated mental health issues should have led to a reconsideration of the decisions taken by Redbridge Early Intervention and Family Support and the Children’s Centre to close her case. Had referrals been made to children’s social care by mother’s GP or NELFT when her mental health deteriorated in July 2017, or by NELFT when mother was discharged from their IAPT service in September 2017, it seems likely that the decision to close Baby T’s case would have been reconsidered and support at Level 2 resumed. 6.68 ‘Contextual safeguarding’ is an approach to safeguarding children and young people which recognises and responds to more than individual and familial risks (20). The concept has generally been applied to adolescents because as they get older they spend increasing amounts of time outside the family home and experience greater influence from their peer group for example. It may be that the ‘contextual safeguarding’ concept could be usefully applied to the children of asylum seekers such as Baby T because of a range of factors which can impact upon their safety and wellbeing. Arguably poverty drove mother to work illegally which necessitated leaving Baby T in the care of an unregistered childminder also working in the illicit economy in which the framework of standards, inspection and scrutiny do not apply. 6.69 The fragility of Baby T’s existence is illustrated by the events described in paragraph 4.51. As an asylum seeker mother could not open a UK bank account. However, mother’s weekly allowance was loaded onto a debit card which was ‘swallowed up’ by an ATM after she inadvertently pressed the wrong buttons whilst attempting to obtain cash for food. Mother, with Baby T, went to the Children’s Centre in a ‘distraught’ state. She is recorded as saying ‘tired’, ‘headache’ and ‘I hungry’. There she received very good support. An interpreter arranged for a replacement debit card to be sent to her within 3-5 days, which is a very long time to be without any money to buy food. An appropriate offer of food bank vouchers did not help her as the Ilford food bank was closed on that day and the next. Eventually the Children’s Centre family support worker was authorised by a manager 50 to take money from their ‘tea and coffee’ jar to purchase vegetables, meat and fish to tide her and Baby T over until the food bank opened two days later. 6.70 The social model of disability, which recognises the role of disabling environments as contributory factors, recognises poverty as a risk factor for mental illness (21). The level of asylum support (currently £37.75 per week for each person in the household plus an additional £5 per week for a baby under one year of age) compared to mainstream welfare benefits is intended to reflect the fact that asylum seekers in accommodation do not have to pay for utilities. However, lack of resources often leads to an inability to plan for the future, living each day as it comes, dependency on others and experiencing hunger (22) as this case discloses. Mother eventually decided to take the risk of working illegally in order to increase her income, as did the babysitter – female C. 6.71 Mother’s decision to leave Baby T with the babysitter Female C whilst she began working as a nail technician appears to have been motivated by the desire to improve her financial circumstances but obviously carried risk. The babysitting service provided by Female C was unregulated and mother had no prior knowledge of her. Mother was her first customer so it was not possible to obtain any testimonials from other parents who had used the service. It is assumed that mother took comfort from the fact that Female C was Vietnamese - and would therefore provide a culturally acceptable service – and was also the mother of a young child herself. The ‘lived experience’ of Baby T 6.72 Baby T was eleven months old when she died. The child lived with mother in initial asylum accommodation at address 3 for the first six weeks of her life. This is not accommodation which is intended for very young children so the environment is unlikely to have been particularly child-friendly. 6.73 She was ‘dispersed’ with her mother to Cardiff for a month during which there was a further change of address. Mother has said she felt alone and unsupported in Cardiff. The frequent moves in the first months of Baby T’s life militated against tranquillity and stability. Baby T’s father played no part in her life. 6.74 Baby T had a more stable existence once she and mother moved to Redbridge in January 2017. The accommodation was shared with other mothers and babies so Baby T may have enjoyed the company of other infant children. 6.75 Mother became mentally unwell from April 2017 but she was able to prioritise the needs of Baby T over those of her own and promptly sought medical care for the 51 child whenever she was ill. It is unclear what effect mother’s post-traumatic stress disorder and postnatal depression had upon Baby T. There is an absence of observations about the attachment between mother and Baby T in the records shared with this review. The barriers of language and culture may have been factors in this as may the relatively short periods during which agencies engaged with mother and Baby T. The Redbridge Children’s Centre which provided support to mother and Baby T for a time recently shared records with this review which provide some insight into the development of Baby T and her attachment to her mother. Baby T was described as a happy and contented child who was alert and attentive. She regularly smiled when she was given attention. She was clean and well dressed. Mother very responsive to her daughter’s needs, calming her when she cried, placing her on her lap when she awoke and animatedly reading stories to her. 6.76 Mother had limited funds for food and clothing and the health visitor expressed concern at one stage that Baby T was not gaining weight as quickly as might have been expected (paragraph 4.51). 6.77 During September 2017 mother began leaving Baby T in the care of the babysitter Female C whilst she worked long hours in a nail bar. It was during the eleventh day on which she had been left in the care of Female C that Baby T sustained the traumatic injury which caused her death. The quality of care provided to Baby T by the female C prior to the incident is not known. Female C was caring for her own child so there should have been an opportunity for Baby T to interact with another young child. However, Female C appeared to have become accustomed to living ‘under the radar’ and so Baby T seems unlikely to have been taken to relevant groups in the community whilst Female C was caring for her. Female C may also have been distracted by the demands of the catering business she also ran from the home in which she cared for Baby T. Indications of trafficking or exploitation concerns and agency responses 6.78 When mother telephoned the Home Office to initiate her claim for asylum on 7th June 2016, she was asked if she had been subject to exploitation on the way to, or in, the UK and whether the agent who facilitated her journey to the UK had forced her to do anything she did not want to. She answered in the negative. 6.79 During her screening interview the following day, mother was asked ‘in your country of origin, on the way to the UK or within the UK, have you ever been subject to exploitation? For example, being forced into prostitution, forced labour, or do you have reason to believe you were going to be exploited?’ Again, mother answered in the negative. 52 6.80 However, in an asylum interview conducted after the death of Baby T, mother said that when she arrived in the UK she was taken to a family by the person she travelled with and helped them tidying the house, cooking, taking care of children and after a period of time befriended the father of Baby T and he arranged accommodation for her. This response raised some potential trafficking concerns and so follow up questions could have been asked to clarify if mother had been exploited or if she had simply being helpful to the family who had taken her in. An evidence and policy review conducted by the University of Birmingham entitled Poverty among refugees and asylum seekers in the UK found that destitute women were sometimes subject to sexual exploitation in exchange for resources such as housing or food (23). 6.81 When mother was seen by the specialised midwife at the Rainbow Health Centre in Croydon (paragraph 4.13) there is no documentation to indicate that the midwife explored mother’s whereabouts from the stated date of entry into the UK and no reference to her demeanour given that the victims of modern slavery can appear withdrawn whilst providing vague information about their personal, social or medical history. The Rainbow Health Centre did not use a specific template to assess for modern slavery in 2016 although the review has been advised that this has since been rectified. The short periods mother was known to services in Hackney, Croydon and Cardiff limited the completion of detailed assessments as stated earlier. It also limited the opportunity to explore less obvious vulnerabilities such as trafficking or exploitation. There was also a lack of inquisitiveness about trafficking and exploitation by practitioners on other occasions, including the period when Redbridge Early Intervention Service was working with mother and made no contact with either the Home Office or her solicitor, which were actions which went unaddressed. Nor did the Early Intervention Service assist mother with a planned financial assessment other than noting she was then in receipt of £70 weekly in the form of Asylum support. 6.82 Concerns about exploitation arose at the time of the fatal injury to Baby T. Queens Hospital included these concerns in their referral to Redbridge MASH (paragraph 4.74). Two apparently Vietnamese males were with mother at the hospital and initially declined to say who they were or what was their relationship to mother and Female C. One of the two men later identified himself as the partner of Female C and the other male said that he had transported mother (who he said he did not know) to hospital after seeing her in distress. 6.83 In his contribution to this review the Director of Vietnamese Mental Health Services said that Vietnamese nationals who had been helped to flee the country often incurred a debt as a result which could be as high as twenty thousand pounds depending on the route taken. It is not known whether mother was in debt to 53 anyone involved in helping her to travel from Vietnam to the UK, although she disclosed that her parents had paid bribes to secure her release from prison. A 2019 research study into the causes, dynamics and vulnerabilities to human trafficking in Albania, Vietnam and Nigeria (24) – countries which have consistently been amongst the top countries of origin for potential trafficked persons referred to the National Referral Mechanism – found the amounts being requested to pay for journeys to the UK were often unlikely to be paid upfront. Whilst small deposits might be made upfront or at different stages in the journey, the extortionate amounts being demanded for the journeys were accepted as debts. This meant individuals were debt bonded and highly vulnerable to being coerced into forced labour upon arrival. In mother’s case it seems likely that any debt would be deducted from her earnings in the UK. ‘Hidden Males’ 6.84 There was insufficient professional curiosity about Baby T’s father’s details, questioning of father’s role, or of anyone else who may care for Baby T, which would have informed both clinical and safeguarding risk. 6.85 The issue of ‘hidden males’ in families is a recurrent theme in SCRs conducted when children die or suffer significant harm (25). These SCRs have frequently found that practitioners rely too much on mothers to tell them about men involved in their children’s lives. If mothers are putting their own needs first, they may not be honest about the risk these men pose to their children. Another ‘hidden male’ finding is that practitioners do not always talk enough to other people involved in a child’s life, such as the mother’s estranged partner(s), siblings, extended family and friends. This can result in practitioners missing crucial information and failing to spot inconsistencies in the mother’s account. Baby T’s father appeared to completely disengage from his relationship with mother prior to the birth of the child but there was generally a lack of professional curiosity about him particularly as he seemed to be a presence in mother’s life as late as August 2017 when mother disclosed to the IAPT therapist that father continued to call her ‘once in a while’ but as she didn’t have his telephone number, she was unable to contact him (paragraph 4.70). Managerial oversight/Supervision 6.86 There were a number of instances where there appears to have been a lack of managerial oversight or supervision. 6.87 The Home Office decision to decline mother’s application for maternity grant was incorrect. Given that mother was being supported under the Immigration and Asylum Act 1999 at the time of her application and that the application was made 54 within eight weeks of mother’s estimated delivery date, there were no grounds to refuse it. The application was refused by a junior member of staff at a time when mother was considered to be destitute. The only way the matter appeared capable of remedy was for mother to be supported by Migrant Help to make an appeal which was successful. The question arises as to whether it would have been preferable for there to have been some checking of the decision to refuse which would have prevented the stress and uncertainty likely to have been experienced by mother in having her application refused which necessitated an appeal. The Home Office has advised this review that the member of staff who mistakenly turned down mother’s maternity grant application has received managerial advice and that training in this area has improved. 6.88 In Croydon there is limited evidence of supervision oversight on mother’s file, which is being addressed as a whole service priority in line with their children’s improvement plan. However, from discussion with the PIP keyworker, she sought and was offered supervision support after visits to mother, but these were not recorded. 6.89 Croydon Health Services have advised this SCR that there was a shortage of safeguarding supervisors during period October to December 2016 and so there may not have been a robust system in place to provide three monthly safeguarding supervision to health visitors (who were themselves under pressure) and records for this period are not available. Recording of supervision was revised in 2018 and is now considered to be more robust. 6.90 NELFT has advised this review that there is no record of the Redbridge health visitor taking the case of mother and Baby T to any form of supervision for discussion, which would have been good practice given the known vulnerabilities of mother and the involvement of the Early Intervention family support worker and the health visitor’s involvement in the TAC process. 6.91 There was a delay of over two months in a senior family support worker closing mother and Baby T’s case, and adding management comments, due to workloads in the service at the time. This case closure did not prompt any query about the outcome of mother’s IAPT referral. Information Sharing 6.92 The routine sharing of information between BHRUT and universal services within NELFT for routine ED attendances did not occur from April 2016 until September 2017. At that time BHRUT became concerned about the amount of data being shared between BHRUT and NELFT with no apparent information governance 55 arrangements in place and so this was ceased pending a review. It is understood that at that stage NELFT were unable to provide BHRUT with an information sharing agreement that had been duly signed off by both organisations. 6.93 Prior to April 2016 the process at BHRUT Queen’s and King George Hospitals was for a report to be generated daily from Symphony (Emergency Department System) which showed details of children living in Havering, Barking & Dagenham and Redbridge and included the triage notes and previous attendances for all children who presented the previous day. This also included clinical and demographic information. This information was sent to NELFT who provided this information to their health visitors and the school nursing service in respect of children under five years. This sharing of information was ceased from April 2016 although BHRUT has advised this SCR that any safeguarding concern would be raised ‘in the normal way’ to children’s social care, independently of this process. However, information sharing about ED attendances of children, whilst not justifying a safeguarding referral, may contribute vital information towards building a fuller picture of developing safeguarding concerns. 6.94 In respect of mother and Baby T the health visitor does not appear to have been made aware of their 25th June 2017 attendance at Queen’s Hospital ED. However, when Baby T was admitted to Queen’s Hospital ED on the date of her death, the ED safeguarding advisor completed an ED community health visitor and school nurse notification form notifying the health visitor of the attendance. The babysitter - Female C and her child 6.95 Female C appears to have largely avoided contact with services until she became pregnant. Her GP referred her to Homerton Hospital for antenatal care. There was a lack of professional curiosity in respect of the reasons for her late booking and there appears to have been no referral to the specialist public health midwife despite the fact that Female C met the criteria for this to have been considered. 6.96 Her child was delivered in Homerton Hospital and the baby was documented to be well with no problems identified. No details of post-natal support have been provided to the review. 6.97 Female C had no recourse to public funds (NRTPF) and made no approach to the London Borough of Barking and Dagenham NRTPF team for any assistance. Overall, her contact with services appears to have been limited. She did not register her child with a GP until May 2016. Although Female C’s interaction with agencies was limited, her pregnancy and the birth of her child increased her contact with 56 services quite substantially for a time. During this period there appeared to be limited exploration of what the implications of Female C’s NRTPF status could be for her and her new born child, including the risk of accommodation instability, destitution and exploitation. NRTPF means that an individual has no entitlement to welfare benefits, social housing, no ability to hold a driving licence, open a bank account, go to college or university or gain employment. A previous Serious Case Review which was commissioned following the deaths of a woman and her two year old child who had been refused leave to remain in the UK and then ‘over-stayed’, found that the ordinary safety-net represented by relatives, friends, neighbours, nursery school etc. may be entirely absent for a family …..seeking to avoid attention.. (26). There is no indication that Female C was referred to the local NRTPF team or that referrals to any local specialist voluntary organisations were considered. 6.98 Female C applied for leave to remain in the UK on 7th March 2016. Her child was four months old at this time. She told the Home Office that she was being supported by a friend who provided food and accommodation. Her application was submitted in paper form. There was no face to face or telephone contact with the Home Office at that time. The Home Office have advised the SCR that, at the time of Baby T’s death nineteen months after she made her application, checks were continuing in respect of Female C’s application for leave to remain in the UK and that further information had been requested of her, which she had not provided. As with mother and Baby T, the length of time it can take for applications to be processed means that there is a possibility that the circumstances of a vulnerable mother and child can deteriorate during the intervening time. 6.99 The Home Office did not consider it necessary to make contact with health or social care agencies in respect of Female C or her child because no vulnerability concerns were evident from the paper application submitted. Female C was never accommodated by the Home Office and any address changes she made following her arrival in the UK were assumed to have been of her own volition. 6.100 Female C initially worked illegally in a nail bar prior to the birth of her child and later started a catering business from her home and began advertising on social media as a baby sitter at address 7 in Barking and Dagenham in September 2017. She had only recently begun acting as an unregistered childminder a short time before Baby T died following a traumatic injury whilst in her care. No agency became aware of the babysitting service she was providing until Baby T’s injury. 6.101 This review has not been advised of any risk that Female C might present to children had previously been observed by any practitioner in contact with her or her child. However, Female C did not engage with mainstream services until the onset of 57 her pregnancy and the details of her contact with GP services, midwifery and health visiting provided to this review is brief. 6.102 Female C was noted to have limited English and it understood that interpreters were booked for antenatal appointments although the limited information shared with this review means that it is not possible to confirm this. Good Practice The quality of care offered to mother and the unborn Baby T once referred to Hackney maternity services was good. There was evidence of good and effective interagency working between maternity and children’s social care family support services, and timely referral and handover of care between maternity units and family support services from Hackney to Croydon. Mother, though destitute, appeared very reluctant to leave the support she was receiving in Hackney, particularly that which was being provided to her by the public health midwife, which suggests that she valued the support she was receiving. The Home Office made a prompt decision to provide support to mother when she became destitute and implemented the decision very quickly to ensure that she was provided with emergency accommodation the same night. The hotel receptionist at address 3 – a Migrant Help employee was a key part of the support offered and was in regular contact with the keyworker, including informing her of the birth of the baby. Croydon sent mother for early obstetric assessment which is in line with local recommendations particularly for women that are recent migrants to the UK to allow for additional obstetric/medical assessment. This appears to go beyond NICE guidelines (27). The Croydon PIP keyworker not only provided valuable support to mother and Baby T whilst they were living in Croydon but made a prompt referral to services in Cardiff when mother and Baby T were ‘dispersed’ there. When subsequently contacted by mother after she arrived in Redbridge, she again promptly referred mother to Early Help services. The response of the Early Intervention and Children’s Centre family support workers to mother’s distress when she was without money, food and without access to the local foodbank was both resourceful, caring and kind. 58 There was evidence of effective use of the BHRUT A & E Safeguarding Children Trigger Checklist and checks of the Child Protection Information Sharing (CP-IS) in respect of both attendances and evidence of staff considering potential safeguarding concerns. 7.0 Findings and recommendations Home Office initial response to mother’s asylum claim 7.1 When mother initiated her asylum claim in June 2016 she disclosed she was four months pregnant with Baby T. She, and therefore the unborn baby, were vulnerable for multiple reasons such as lack of understanding of the English language, lack of knowledge of the UK health system and mother may have been suffering psychological issues arising from the circumstances surrounding her departure from Vietnam. Although the father of the child was supporting her financially, mother was completely dependent upon this support. At around four months gestation, mother was already late for obtaining antenatal support. 7.2 In the event mother presented to a GP practice within a relatively short period of time (early July), was referred to midwifery and was able thereafter to access specialised antenatal care. However, it would have contributed to mother and the unborn baby’s health and welfare if the Home Office had referred her to local primary health services at the time she first initiated her asylum claim. As stated in paragraph 6.18, mother should have been referred to the Home Office’s Asylum Safeguarding Hub, which may have led to a referral to local primary health services. It is recommended that BHR Safeguarding Partners request the Home Office take proactive steps to ensure that pregnant asylum seekers and asylum seekers with young children are referred to local primary care services at the point of first contact. Recommendation 1 That the Home Office take proactive steps to ensure that pregnant asylum seekers and asylum seekers with young children are referred to local primary care services at the point of first contact. Lack of Home Office oversight of mother’s case 7.3 The Home Office exercised no oversight of mother’s asylum claim from 26th January 2017 until they were notified of the death of Baby T in October of that year. 59 This impacted upon their ability to assure themselves that they were complying with Section 55 of the Borders, Citizenship and Immigration Act 2009, which requires them to carry out their existing functions in a way that takes into account the need to safeguard and promote the welfare of children in the UK (paragraph 6.4). Although mother and Baby T had been ‘dispersed’ to longer term asylum support accommodation at address 6 in Ilford earlier in January 2017, the vulnerabilities of an asylum seeker mother with an infant child are numerous and well documented in Home Office guidance. The Home Office has advised this review that they were experiencing heavy demand and high turnover of relevant staff (paragraph 6.4) at that time. 7.4 The Home Office has advised this review that they have implemented clearer guidance for reviewing cases which would prevent the drift in oversight of mother’s case after further review of her case was deferred for three months after the birth of Baby T (paragraph 4.26). The BHR Safeguarding Partners may wish to seek assurance from the Home Office that the new guidance has had the desired effect in preventing the drift in oversight of cases involving very young children. Recommendation 2 That the Home Office provide assurance that new guidance has had the desired effect in preventing the absence of oversight in cases such as that of mother and Baby T. Home Office decision to ‘disperse’ mother and Baby T to Cardiff 7.5 The decision to ‘disperse’ mother and Baby T from Croydon to Cardiff when the child was 5 weeks and 6 days old interrupted the care and support being provided to mother and child and increased the risks to which they were exposed. NICE guidelines entitled Postnatal care up to 8 weeks after birth (28) identify the essential core (routine) care which every woman and her baby should receive in the first 6-8 weeks after birth. It is therefore welcome that, in their contribution to this review, the Home Office has acknowledged that the current six week policy should be extended to eight weeks or on receipt of sign off by the clinician of postnatal checks in order to facilitate the continuity of postnatal care to its conclusion. 7.6 However, in this case the ‘dispersal’ was intended to be temporary and so it proved to be when mother and Baby T were moved back to London after a month in Cardiff. Whilst it is acknowledged that there is considerable pressure on asylum support accommodation in London and the South East of England, to ‘disperse’ mother and Baby T to Cardiff appears to have been an unreasonable decision compounded by a further accommodation move in Cardiff. The practitioner learning 60 event arranged to inform and validate this SCR strongly endorsed the view that the primary Home Office focus appeared to be on processing mother as an asylum seeker and that the needs of Baby T received less attention. This has emerged as a central theme of this SCR. It is recommended that the BHR Safeguarding Partners supports the Home Office recommendation that asylum seeking mothers and their baby are never moved before the child is eight weeks old or the relevant clinician confirms that essential core postnatal care has been completed, whichever is the longer. It is also recommended that the BHR Safeguarding Partners request the Home Office rule out the temporary ‘dispersals’ of asylum seeking mothers and very young children. Recommendation 3 That the BHR Safeguarding Partners write to the Home Office in support of their recommendation that asylum seeking mothers and their baby are never moved before the child is eight weeks old or the relevant clinician confirms that essential core postnatal care has been completed, whichever is the longer. Recommendation 4 That the Home Office should consider ruling out the temporary ‘dispersals’ of asylum seeking mothers and very young children. Requests to halt ‘dispersals’ 7.7 This review has been advised that practitioners are empowered to request the ‘dispersal’ of an asylum seeking mother and baby due to ‘complications/needs of mother and baby’. It seems unlikely that mainstream agencies involved in supporting mother and Baby T in Croydon would have been aware that they could request the halting of their dispersal to Cardiff. 7.8 Whilst existing safeguarding training highlights the vulnerabilities of asylum seekers it needs to be enhanced so that practitioners can better support vulnerable people such as mother and Baby T. There are more supported asylum seekers relative to population in Redbridge than any other London Borough, with the exception of Barking and Dagenham (29). Practitioners providing support to asylum seekers would benefit from receiving bespoke training on the nuances and complexities of the asylum system. Raising awareness that practitioners can challenge dispersal decisions and the grounds on which they may do so should be included in any enhanced training provided. It is therefore recommended that the BHR Safeguarding Partners consider the provision of enhanced training on the 61 complexities of the asylum system to practitioners involved in providing support to asylum seekers and their children. On the basis of this SCR, there is a need for this type of training across a number of London Boroughs and in other areas in which asylum seekers are placed. Recommendation 5 That the BHR Safeguarding Partners considers the provision of enhanced training on the complexities of the asylum system to practitioners involved in providing support to asylum seekers and their children. Recommendation 6 That the BHR Safeguarding Partners share this SCR report with the London Safeguarding Board so that the provision of enhanced training on the complexities of the asylum system to practitioners involved in providing support to asylum seekers and their children can be considered by other London Boroughs. Role of asylum accommodation provider in making referrals to local services 7.9 Mother’s asylum accommodation provider, Clearsprings Ready Homes was very proactive in promptly referring mother to local services when she was provided with initial asylum support accommodation in Croydon. However, when mother and Baby T were moved to longer term asylum support accommodation in Redbridge, there is no indication that Clearsprings referred or supported mother to access local services. There was a delay of over two weeks before she and Baby T registered with a GP and it took the intervention of mother’s former PIP keyworker in Croydon to refer her for Early Help. As stated in paragraph 6.22, this delay was in breach of the accommodation provider’s contractual obligations. 7.10 It is possible that the contrast between the help mother was provided with by Clearsprings in Croydon and Redbridge is related to the fact that the former accommodation is initial asylum accommodation in which Migrant Help staff are located whilst the latter was longer term accommodation in which mother, who was now in receipt of asylum financial support for food and clothing etc. was expected to manage her affairs more independently. However, mother clearly needed support to access local services and it does not seem unreasonable to expect her specialist accommodation provider to assist her. Helping her access services as quickly as possible would have helped her to become more independent. 7.11 It is recommended that the BHR Safeguarding Partners requests the Home Office to ensure they have robust mechanisms in place to ensure that providers of asylum support accommodation fulfil their contractual obligations to ensure pregnant 62 asylum seekers and asylum seekers with young children access primary care without delay, accompanying them where this is stipulated in the contract. Recommendation 7 That the Home Office ensure they have robust mechanisms in place to ensure that providers of asylum support accommodation fulfil their contractual obligations to ensure pregnant asylum seekers and asylum seekers with young children access primary care without delay, accompanying them where this is stipulated in the contract. 7.12 In their contribution to this review Clearsprings have observed that no agency supporting mother and Baby T in Redbridge shared any concerns with them as their asylum accommodation provider. This would have required the consent of mother but no agency appears to have considered the potential benefits of sharing information with Clearsprings via their sub-contracted accommodation provider. It is therefore recommended that this issue is addressed when the learning from this case is disseminated to practitioners. Practitioners who attended the learning event which informed and validated this SCR felt that the Home Office could encourage appropriate information sharing by publicising information about their safeguarding role and arrangements and how local health and social care practitioners can best engage with Home Office safeguarding services. Recommendation 8 It is therefore recommended that when the BHR Safeguarding Partners disseminate the learning from this case to practitioners the potential benefits of sharing information with asylum accommodation providers is highlighted. Recommendation 9 That the Home Office publicise information about their safeguarding role and arrangements and how local health and social care practitioners can best engage with those Home Office safeguarding services. Registration of asylum seekers with GP practices 7.12 The GP practices in Hackney and Redbridge were not successful in obtaining comprehensive information from mother about her health needs (and those of Baby T in respect of Redbridge). This may well be linked to the lack of use of interpreters. In Redbridge, the Ilford Medical Centre gave mother the new patient questionnaire in English to take away and she later returned it after obtaining help to complete it from a fellow Vietnamese national who had some English. When Female C visited a 63 UK GP for the first time after becoming pregnant, the information obtained from her appeared to be quite limited. 7.13 Given the importance of the role of the general practitioner as a provider of primary care and as a key gateway through which specialist health services are accessed, it is vital that as comprehensive a picture of the health needs of pregnant asylum seekers and asylum seekers with infant children are ascertained. In Redbridge the GP practice was able to obtain mother and Baby T’s medical records from their Croydon GP within a reasonable amount of time but the lack of information initially gathered from mother prevented a prompt referral to the health visitor. 7.14 It is recommended that Redbridge Clinical Commissioning Group ensure that all GP practices within the Borough are made aware of the importance of obtaining comprehensive information from pregnant asylum seekers and asylum seekers with infant children on registration so that all health needs can be addressed. It is also recommended that the BHR Safeguarding Partners request NHS England to emphasise the importance of obtaining comprehensive information from pregnant asylum seekers and asylum seekers with infant children to all GP practices in England. Recommendation 10 That Redbridge Clinical Commissioning Group make all GP practices within the Borough aware of the importance of obtaining comprehensive information from pregnant asylum seekers and asylum seekers with infant children on registration so that all health needs can be addressed without delay. Recommendation 11 That the BHR Safeguarding Partners requests NHS England to emphasise the importance of obtaining comprehensive information from pregnant asylum seekers and asylum seekers with infant children to all GP practices in England. Effectiveness of support provided to mother and Baby T 7.15 Mother received excellent support from the specialist public health midwife in Hackney, indicating that people in specialist dedicated roles can make a real difference. The Parent Infant Partnership key worker in Croydon also provided very effective support to mother and Baby T, in Croydon and in helping them access services in Cardiff and Redbridge. 64 7.16 However, agencies often struggled to engage effectively with mother and Baby T because they had limited time in which to build a relationship and conduct assessments. This was particularly the case in Croydon and Cardiff although the delay in dispersing mother and Baby T from their initial accommodation in Croydon probably provided early intervention services with the necessary time to carry out more in-depth work including an assessment. Health visiting services did not engage fully effectively with mother and Baby T in any of the three London Boroughs in which mother resided although mother and Baby T were correctly recognised to require the ‘Universal Plus’ service in Croydon although this level of service was not delivered. Once mother and Baby T arrived in longer term asylum supported accommodation in Redbridge, agencies had the opportunity to provide more than a ‘stop-gap’ service but both the Early Help and Family Support service and the Children’s Centre closed mother and Baby T’s case prematurely. In respect of the former service there were several actions outstanding and the outcome of mother’s referral to IAPT was unknown. In respect of the latter service it had been agreed that they would keep mother and Baby T’s case open but they did this for only a brief period. The premature closure of her case caused mother a degree of anxiety at a time when she was experiencing mental health issues. 7.17 Many of the services which mother and Baby T came into contact with in Redbridge often worked in isolation from one another. The exception to this was the TAC process which brought Early Intervention and Family Support, the health visitor and the Children’s Centre together, although as stated above, the outcome of this partnership working was not effective. Effective communication took place when mother’s GP referred her to RAABIT although neither service clarified whether or not mother and Baby T were in contact with a social worker and an opportunity to refer them to the Multi-Agency Safeguarding Hub (MASH) was lost. The discharge of mother from the IAPT service without her mental health needs being met should have generated a conversation with her health visitor at the very least. 7.18 It is recommended that this SCR report is shared with the Safeguarding Children Partners in the London Boroughs of Hackney and Croydon and in Cardiff so that they can consider the report and advise of any needs for improvements in practice which they identify, and the action they propose to take. Recommendation 12 That the BHR Safeguarding Partners share this SCR report with the Safeguarding Children Partners in the London Boroughs of Hackney and Croydon and in Cardiff so that they can consider the report and advise of any needs for improvements in practice which they identify, and the action they propose to take. 65 7.19 It is also recommended that Redbridge Early Intervention and Family Support (now the Family Together Service) should review its arrangements for case closure, to ensure that cases are not closed without confirmation that all planned actions have been carried out and wherever possible planned outcomes have been achieved. Recommendation 13 That Redbridge Family Together Service reviews its arrangements for case closure, to ensure that cases are not closed without confirmation that all planned actions have been carried out and wherever possible planned outcomes have been achieved. Impact of mother’s mental health on Baby T 7.20 When mother began presenting with mental health issues including post-traumatic stress disorder, postnatal depression and suicidal ideation, the impact of these issues on her parenting capacity went largely unconsidered by practitioners. Both Redbridge Early Intervention and Family Support and the Children’s Centre without ascertaining the outcome of mother’s referral to IAPT. The only inter-agency communication about mother’s mental health were the referrals by the health visitor to IAPT and by the GP to RAABIT. The only multi-agency discussion about the potential impact of mother’s mental health on her parenting took place between the GP and RAABIT when Baby T was inappropriately seen as a ‘protective factor’ in respect of mother’s mental health. As previously stated a referral to children’s social care was considered but ruled out on the erroneous and unverified belief that mother and Baby T were already being supported by a social worker. 7.21 Research indicates a number of key issues for practitioners to take into account when assessing the risks that parental mental health could present to any child within the household including (30) the paramount importance of focusing on the child; that assessment should be informed by the parent or carer's background, medical history and current circumstances with attention paid to other risk factors alongside mental ill health such as financial hardship; always taking threats of suicide seriously; and assessment should be a shared task between children’s social workers and adult mental health practitioners. 7.22 It is recommended that the BHR Safeguarding Partners seek assurance over the level of practitioner awareness of the issues to be considered when parents present with mental health issues. Dissemination of the learning from this SCR may provide an opportunity for a range of disciplines, including adult mental health 66 practitioners to reflect on the potential impact of parental mental health on their children. Recommendation 14 When disseminating the learning from this SCR, that the BHR Safeguarding Partners ensure that the key issues for practitioners to take into account when assessing the risks that parental mental health could present to any child within the household are prominently included. Access to interpreter services 7.23 Whilst many agencies which came into contact with mother made effective use of interpreter services to engage with her and better understand her needs, there were several occasions when mother’s needs were not fully understood or her access to services was delayed or limited as a result of lack of use, or access to, interpreter services. Any barriers to communication with mother had the potential to increase her vulnerability and as she was the mother of Baby T, put the child at risk as well. 7.24 It is recommended that the BHR Safeguarding Partners (which covers the local authority areas of Barking and Dagenham, Havering and Redbridge across which a single set of multi-agency safeguarding arrangements are being introduced) develop and implement as a matter of priority a strategy for improving the availability of appropriate interpreting services across the three local authority areas. Recommendation 15 That the BHR Safeguarding Partners develop and implement as a matter of priority a strategy for improving the availability of effective interpreting services across the London Boroughs of Barking and Dagenham, Havering and Redbridge. 7.25 The court which convicted Female C of the manslaughter of Baby T found that she shook the child hard and probably also threw her. Shaken baby syndrome or abusive head trauma (AHT) is the leading cause of death and long term disability for babies who are harmed (31). Research suggests a demonstrable relationship between the normal period of peak crying in babies and the incidence of babies subject to AHT. There is a higher level of cases of AHT in the first month of life, a peak at 6 weeks of age and a decline in cases during the third to fifth month of a baby’s life. Baby T was eleven months old at the time of her death although it is known that she had been unwell on the day before her death and that the babysitter had found caring for her quite challenging on that occasion. Excessive crying in babies can be difficult to manage for parents and carers and they need to be 67 advised on how to manage episodes of prolonged crying. It is not known whether the babysitter had been provided with advice on how to handle excessive crying by any of the practitioners she came into contact with when her own child was born. In Redbridge advice on how to manage crying and sleepless babies is available online and a Google translate facility on the website allows the information to be accessed in Vietnamese. This translate facility does not appear to be available in the Boroughs of Barking and Dagenham and Havering. 7.26 The BHR Safeguarding Partners may wish to seek assurance that advice to parents on caring for crying and sleepless babies is accessible in all community languages. Recommendation 16 That the BHR Safeguarding Partners seek assurance that advice to parents on caring for crying and sleepless babies is accessible in all community languages. Asylum Seeker Accommodation in Redbridge 7.27 Following the death of Baby T concerns arose about potential unmet needs and risks faced by asylum seekers, particularly pregnant asylum seekers or asylum seekers with children who are placed in the London Borough of Redbridge without local services being necessarily aware of their presence. Particular concern has been expressed about the potential vulnerability of numbers of vulnerable asylum seekers placed together in multiple occupancy properties such as the address in which mother and Baby T were living at the time of the child’s death. 7.28 The BHR Safeguarding Partners may wish to consult with Redbridge Housing and other partners about how the learning from this review can inform approaches to address the risks associated with the placing of asylum seekers with dependent children in the Borough. Recommendation 17 That the BHR Safeguarding Partners consult with local housing providers about how the learning from this review can inform approaches to address the risks associated with the placing of asylum seekers with dependent children in the Borough. Practitioner awareness of modern slavery 7.29 In general, there was a lack of curiosity about mother’s whereabouts from the time she entered the UK until she claimed asylum, the dynamics of the relationship 68 with Baby T’s father who supported her financially for a time before abandoning her and the likelihood that mother and/or her family had incurred a debt for her flight to the UK which put her at risk of financial exploitation. 7.30 When the learning from this SCR is disseminated to practitioners this may present an opportunity to remind practitioners about indications of modern slavery and the expected response. It is therefore recommended that when the BHR Safeguarding Partners disseminate the learning from this SCR, the opportunity is taken to remind practitioners about policy and practice in respect of modern slavery. Recommendation 18 That the BHR Safeguarding Partners widely disseminate the learning from this SCR and take that opportunity to remind practitioners about policy and practice in respect of modern slavery. 7.31 When this SCR report was presented to the final meeting of Redbridge Local Safeguarding Children Board, the Board decided to make the following additional recommendation: Recommendation 19 That the Government should introduce legislation which would require the Home Office to inform a local authority of the details of any child placed or dispersed to their area with an asylum seeker parent or parents. 69 8. References (1) Retrieved from https://www.mellowparenting.org (2) Retrieved from https://www.england.nhs.uk/wp-content/uploads/2014/03/hv-serv-spec.pdf (3) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/695864/Vietnam_-_Ethnic_and_Religious_groups_-_CPIN_v2.0_ex.pdf (4) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/496911/new_Healthcare_Needs_and_Pregnancy_Dispersal_Policy_EXTERNAL_v3_0.pdf (5) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/769849/ICIBI_inspection_of_the_Home_Office_safegaurding_of_Vulnerable_Adults_Feb-May_2018.pdf (6) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/496911/new_Healthcare_Needs_and_Pregnancy_Dispersal_Policy_EXTERNAL_v3_0.pdf (7) Retrieved from https://publications.parliament.uk/pa/cm201617/cmselect/cmhaff/637/637.pdf (8) ibid (9) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/496911/new_Healthcare_Needs_and_Pregnancy_Dispersal_Policy_EXTERNAL_v3_0.pdf (10) ibid 70 (11) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/769849/ICIBI_inspection_of_the_Home_Office_safegaurding_of_Vulnerable_Adults_Feb-May_2018.pdf (12) Retrieved from https://www.england.nhs.uk/wp-content/uploads/2018/09/guidance-for-commissioners-interpreting-and-translation-services-in-primary-care.pdf (13) Retrieved from https://www.london.gov.uk/sites/default/files/gla_esol_mapping.pdf (14) Retrieved from https://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/iris/2014/working-paper-series/IRiS-WP-1-2014.pdf (15) Retrieved from F58F-42AD-B89A 96A4A692DF77&searchterm=maternal%20mental%20health&Fields=%40&Media=%23&Bool=AND&SearchPrecision=20&SortOrder=Y1&Offset=10&Direction=%2E&Dispfmt=F&Dispfmt_b=B27&Dispfmt_f=F13&DataSetName=LIVEDATA (16) Retrieved from https://www.nspcc.org.uk/preventing-abuse/child-protection-system/parental-mental-health/ (17) ibid (18) ibid (19) Retrieved from http://www.redbridgelscb.org.uk/wp-content/uploads/2015/09/Redbridge-LSCB-Multi-Agency-Thresholds-Document-September-2018-Final.pdf (20) Retrieved from https://contextualsafeguarding.org.uk/about/what-is-contextual-safeguarding (21) Retrieved from https://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/iris/2014/working-paper-series/IRiS-WP-1-2014.pdf (22) ibid 71 (23) ibid (24) Retrieved from https://www.antislaverycommissioner.co.uk/media/1277/between-two-fires-understanding-vulnerabilities-and-the-support-needs-of-people-from-albania-viet-nam-and-nigeria-who-have-experienced-human-trafficking-into-the-uk.pdf (25) Retrieved from https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ (26) Retrieved from https://www.mscb.org.uk/mscb/downloads/file/163/2018-serious-case-review---ellie-overview-report (27) Retrieved from pregnancy-and-complex-social-factors-service-provision-pregnant-women-who-are-recent-migrants-asylum-seekers-or-refugees-or-have-difficulty-reading-or-speaking-english-service-provision.pdf (28) Retrieved from https://www.nice.org.uk/guidance/cg37/resources/postnatal-care-up-to-8-weeks-after-birth-pdf-975391596997 (29) Retrieved from https://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN01403#fullreport (30) Retrieved from https://www.nspcc.org.uk/preventing-abuse/child-protection-system/parental-mental-health/ (31) Abusive head trauma: mechanisms, triggers and the case for prevention – presentation by Dr S. Smith March 2017. 72 Appendix A SCR Process and Panel Membership An SCR Panel of senior managers from partner agencies was established to oversee the SCR which was chaired by the independent chair of Redbridge LSCB. The membership of the panel was as follows: Independent Chair (Chair) Redbridge LSCB Court Progression Manager London Borough of Barking and Dagenham Operational Director, Children & Families London Borough of Redbridge Director, Integrated Care NELFT Designated Doctor for Child Death NELFT/Redbridge CCG Specialist Crime Review Group (SCRG) Representatives Metropolitan Police Service (MPS) Principal Social Care Lawyer Legal Services, London Borough of Redbridge Contract & Compliance Manager – COMPASS UK Visas & Immigration, Home Office Designated Nurse Safeguarding Children and LAC NHS Redbridge Clinical Commissioning Group (CCG) Business Manager (Secretariat) Redbridge LSCB David Mellor Independent Lead Reviewer It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports including chronologies and agency reports which described and analysed relevant contacts with Baby T, his mother, Female C and her child were completed by the following agencies: HM Government Home Office LB Redbridge Early Intervention and Family Support Service (EI&FSS) 73 NHS Redbridge Clinical Commissioning Group NELFT NHS Foundation Trust Barking, Havering and Redbridge University Hospitals Trust (BHRUT) LB Barking and Dagenham Metropolitan Police Service (MPS) London Ambulance Service (LAS) Croydon Health Services Croydon Early Help Homerton University Hospital The provider of mother and Baby T’s accommodation, Clearsprings Ready Homes contributed to the review by commenting on a late draft of the SCR report. Migrant Help contributed through a telephone conversation with the independent reviewer. The Director of the Vietnamese Mental Health Services also contributed valuable insights to this review via a meeting with the lead reviewer. Mother contributed to this review through a conversation with the lead reviewer with the assistance of an interpreter. NELFT were providing support to mother at that time and the lead reviewer is grateful to her NELFT social workers for their assistance. It is planned for a summary of this SCR report to be translated into Vietnamese and shared with mother in due course. A practitioner learning event was held to inform and validate the learning emerging from the SCR. This was an extremely well attended event to which colleagues travelled from Cardiff and the London Boroughs in which mother and Baby T lived. The lead reviewer developed a draft report. With the assistance of the SCR Panel, the report was further developed into a final version and presented to Redbridge Local Safeguarding Children Board on 15th October 2019. |
NC52758 | Death of 4-month-old-baby after being found unresponsive in bed with its mother. Learning includes: reinforcing messages about potential risks to a child's safety of alcohol use by parents, even where there is no dependency; adequately managing every stage of the social care response from screening to the allocation of support; allowing for disclosure of domestic abuse by female perpetrators at routine domestic abuse screenings of pregnant women and new mothers; ensuring multi-agency co-ordination takes place as soon as the need for early help is identified and before a threshold for social care involvement is met; and keeping the lived experience of the child central to practitioners' work. Recommendations to the safeguarding partners include: learning from the National Review into SUDI in families where children are considered at risk of significant harm should be fully implemented in their area; changes introduced to the referral process should be monitored to ensure all cases are being appropriately screened; relevant partner agencies should review their internal systems and guidance around making and following up referrals including providing feedback to all referrers in a timely way; screening questions used for domestic abuse should be reviewed and if necessary reframed to avoid any unconscious bias; action should be taken to ensure that all practitioners are confident to explore situations involving domestic abuse, including establishing who is using abusive behaviours and who is the victim; and communication around the potential risks to a child's safety of alcohol use by parents should be reviewed and strengthened.
| Title: Local child safeguarding practice review: Baby JS. LSCB: Solihull Safeguarding Children Partnership Author: Zoë Cookson Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review: Baby JS Independent Lead Reviewer: Dr Zoë Cookson May 2023 Contents 1. Introduction and Background page 2 2. Methodology and Process page 2 3. Analysis and Identification of Learning page 3 4. Considering the Risk Factors page 4 5. The Front Door page 7 6. Exploring issues of domestic abuse page 11 7. Co-ordinating a multi-agency early help approach page 15 8. The Voice and Lived Experience of the Child page 18 9. Conclusion and Recommendations page 19 2 1. Introduction and Background 1.1 Purpose of this Review This purpose of a child safeguarding practice review is to explore how practice can be improved to prevent, or reduce the risk of, a repeat of similar incidents. Reviews seek to understand both what happened and whether this reflects systematic issues in either policy or practice that could be addressed to better safeguard children. A review is not designed to hold individuals or organisations to account.1 1.2 Context Baby JS (aged four months) was found unresponsive in bed with mother, an ambulance was called and paramedics administered CPR. Baby JS was subsequently pronounced dead in the hospital Emergency Department. The cause of death has been recorded as unascertained by the Home Office Pathologist. Father and mother had recently been through an acrimonious separation that took place shortly after baby JS’s birth. At the time of baby’s death, father had moved out and mother was the primary care giver. Mother was also the primary care giver of JS’s older siblings – aged six and two. 2. Methodology and Process 2.1 A systems-based approach, consistent with Working Together to Safeguard Children 2018, was adopted for this review. Efforts have been made throughout to understand how actions and events were perceived at the time and to avoid hindsight bias. 2.2 An independent Lead Reviewer (Dr Zoë Cookson) was appointed to manage the review process, chair all relevant meetings, facilitate the Practitioner Learning Event and author the final report. She was supported by a Review Team made up of local safeguarding professionals from key agencies. 2.3 The following Key Lines of Enquiry were developed as part of the Rapid Review and refined by the Review Team: • The impact of the processes followed at the front door in terms of screening (including timeliness), effective information sharing and decision making. • The effectiveness of the Early Help Assessment and subsequent plans to ensure a co-ordinated multi-agency response to the family’s individual needs. • The potential for unconscious bias around female perpetrators of domestic abuse and how this affects actions and decision making. • The impact of alcohol use on parenting capacity when no evidence of drug or alcohol dependency. • The extent to which the cumulative risks from alcohol use, mental health needs and domestic abuse, when present in combination, impacted on outcomes in this case. • Whether indicators of neglect were appropriately logged and reported and whether the voice of the child was always considered. • The extent to which domestic abuse, including coercion and control, affected parenting capability in this case. 1 There are other processes for this purpose including employment law, disciplinary procedures, professional regulation and – in exceptional cases – criminal proceedings. 3 2.4 The Review Team agreed the focus of the review should be the date of mother’s engagement with services around her pregnancy to the date of baby JS’s death. It was agreed that information prior to these dates would be considered where relevant. In practice, however, no concerns came to the attention of agencies until the month of JS’s birth so the focus of this review has been on a narrower time period – from the month of baby JS’s birth to the date of JS’s tragic death. The review does not go beyond the date of baby’s death. 2.5 The review drew on the initial scoping information submitted by agencies to the Rapid Review alongside individual agency analysis of learning related to the agreed Key Lines of Enquiry, and a multi-agency chronology of events. 2.6 A reflective Practitioner Learning Event was held with frontline practitioners. This sought to obtain first-hand experience from those working with the family, and to also understand the context that practitioners were working within. 2.7 Both mother and father were invited to contribute to the review and asked whether they wished their parents to be invited to participate. Mother initially replied to say that she would like to be involved and would like to be interviewed as a family group with the maternal grandparents. It was noted that the timing of this involvement would depend on the police investigation. Mother and the maternal grandparents were contacted in February 2023 to set a date to meet the Lead Reviewer and they requested that the interview be delayed until April 2023. Despite several attempts, the Lead Reviewer was not able to make contact with mother or the maternal grandparents in April 2023 and an interview did not, therefore, take place. Father was interviewed via Microsoft Teams in May 2023. 3. Analysis and Identification of Learning 3.1 Introduction The cause of baby JS’s death has been recorded as unascertained by the Home Office Pathologist. However, the potential risk factors that may have impacted on baby’s death – and on adherence to safe sleep advice – were examined as part of this review. Unfortunately, there is insufficient evidence to make a judgement regarding the existence or impact of many of these risk factors, largely because the knowledge agencies had of the family in this case was limited during the time period being examined. This review has, however, identified important wider learning about safeguarding practice in Solihull that has the potential to improve the safeguarding of other children in the area. The detailed examination of this case identified learning about the processes followed at the children’s social care front door at the time of the referral. While the incident that led to baby JS’s death did not relate to domestic abuse, this case identifies learning around how agencies view, and respond to, domestic abuse. Similarly, while the detailed examination of the case found the family’s needs were inappropriately filtered as early help and should have followed a safeguarding route, the case does highlight learning about how agencies work together to support families 4 requiring early help. In particular, it reveals a tendency to rely on children’s social care to co-ordinate multi-agency early help work. 4. Considering the Risk Factors 4.1 National Research In July 2020, the national Child Safeguarding Practice Review Panel (the Panel) published a review into sudden unexpected death in infancy (SUDI) in families where the children are considered to be at risk of significant harm.2 The report noted that infants dying suddenly and unexpectedly represented one of the largest groups of cases notified to the Panel. Almost all of the tragic incidents involved parents co-sleeping in unsafe sleep environments with infants, often when the parents had consumed alcohol or drugs. In addition, there were wider safeguarding concerns – often involving cumulative neglect, domestic violence, parental mental health concerns and substance misuse. These predisposing risks were often combined with out-of-routine incidents or ‘situational risks’, where unexpected changes in family circumstances meant an infant was placed in an unsafe sleep environment.3 4.2 Predisposing risk factors in this case Several professionals were aware that mother had mental health problems, largely because mother shared this information with them. Mother was receiving support from the perinatal mental health service and their observations found mother to be meeting the needs of her children. Domestic abuse was a feature of the parent’s relationship. However, this was not explored by professionals at the time and the extent and nature is unknown (see section 6 of this report). There was insufficient evidence to make a judgement regarding the presence of other predisposing risk factors in this case (see section 4.2.1 – 4.2.3 below). 4.2.1 Alcohol Use Alcohol use, even if there is no dependency, can have a negative impact on parenting capacity. When under the influence of alcohol, parents may make decisions they would not usually make and there is a risk that these decisions can place children in danger. Where an adult is struggling, agencies should discuss the strategies they are using to cope including the use of alcohol and other substances. Mother was asked about alcohol use as part of routine enquiries by multiple agencies.4 This did not identify any concerns about the use or alcohol or any other substances 2 The Child Safeguarding Practice Review Panel, Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm (July 2020). 3 These ‘situational risks’ include moving to different accommodation; a family party; the arrival of a new partner; the baby being unwell; alcohol or drug use on the night in question. 4 Lifestyle issues, including alcohol, were explored during mother’s antenatal assessment by the midwife and no concerns were identified. Alcohol and substance misuse was included in the screening process undertaken by children’s social care following the safeguarding referral, and also in her 5 and there were no indicators of alcohol use in any of mother’s interactions with professionals.5 Mother is, however, known to have consumed alcohol on the night before JS’s death. The family support worker reported that, in a parental conflict session a few days before baby JS’s death, father mentioned concerns about mother going out drinking with friends while she was responsible for the children. However, the family support worker reported that his concerns appeared to be around who mother was leaving the children with rather than concerns about mother’s alcohol consumption. In light of events, the family support worker reflected that she could’ve gone back and explored the mention of alcohol in more detail but at the time she felt the focus of father’s concerns were on mother’s friendship group. Indeed, she explained that one of the outcomes of the session was an agreement regarding which individuals both parents were happy for the children to be around. In his interview with the Lead Reviewer, father strongly disputed this account of the issues he raised at the parental conflict session. He reported raising serious concerns regarding mother’s alcohol consumption. These concerns were based on his knowledge of people taking bottles of alcohol into the house and mother’s past behaviour when drinking alcohol. Father reported also raising concerns about the people who mother was mixing with, particularly as some were known to be involved in drug use. Father feels his concerns about the safety of the children in this environment were not taken seriously. Indeed, as with the issue of domestic abuse (see section 6), he feels that there was a gender bias in favour of mother. 4.2.2 Cumulative Harm No investigations were made around cumulative harm by any agency. The combined presence of key risk factors was not identified by any professional and there was no multi-agency working to share information. As outlined above, alcohol use was not considered an issue for mother by professionals. There was also no exploration of drug use. At the Learning Event, one agency shared that they were aware mother had taken drugs in her past but that had been before any of her children were born and they had no concerns. Mother’s mental health needs were known to some agencies working with mother but others were unaware: neither the midwifery service nor the primary school attended by the oldest sibling6 knew of any mental health difficulties. Several of the professionals working with family were unaware that domestic abuse may be a feature of the parents’ relationship. Indeed, as noted in section 6.4, the nature of domestic abuse within the family was not explored or understood by professionals and, therefore, remains largely unknown. assessment by the perinatal mental health service mother. Mother stated that she used to be a social drinker before having children but did not drink now. In the health visiting screening at both the New Birth and six to eight week contact, mother reported that she was not drinking alcohol. 5 There was a historical alcohol related police incident (just over 3 years before baby JS’s birth). There was, however, no information at that time to suggest that alcohol was an issue for either parent beyond overindulgence at a party. 6 When he met with them the month before baby JS’s death, father informed the school that mother is bipolar but this was not verified by any formal information and is not correct. 6 This limited exploration of risk factors at the time makes it impossible to determine retrospectively the impact of cumulative risks. 4.2.3 Neglect Responses to this review from all agencies who were engaged with the family stated that no indicators of neglect were identified within the household.7 The only concern noted was by the health visitor during the six-week review. The health visitor noted the floor was cluttered and dirty crockery was within easy reach of children. This had the potential to result in a physical injury to JS’s two-year old sibling and create a trip hazard for parents whilst carrying baby. Home safety advice was given, additional visits were offered and mother reported she had support from the perinatal mental health team. The home environment had improved by the next visit and the health visitor recorded that both baby JS and two-year old sibling appeared well cared for and were dressed in clean appropriate clothes. Father did raise concerns about JS’s oldest sibling with her school, expressing a concern that she hadn’t been given breakfast on one occasion and on another noting her hair had been matted. School staff responded that they had no concerns.8 JS’s oldest sibling was closely monitored by school staff and they saw no evidence of neglect either prior to or during the review period. 4.3 Safe Sleeping Health visiting standards state that a safe sleep assessment should be completed at the New Birth and six-to-eight-week visits. This should include an observation of the baby’s sleeping area. A safe sleep assessment is clearly documented in baby JS’s health records and is extensive. The health visitor documented that the family was adhering to safe sleep advice, had been advised not to co-sleep and parents had been signposted to the Lullaby Trust for further information. Sudden Infant Death Syndrome (SIDS) was also discussed. Baby JS’s sleeping environment was observed and recorded to be in a Moses Basket. This is consistent with the National Panel’s review of sudden unexpected deaths in infancy which found that in all cases safe sleep advice, including information leaflets, had been given to parents and documented, frequently on more than one occasion. However, the Panel found that this advice is not always clearly received or acted on by some of the families most at risk.9 To engage effectively with these families, the national review concluded that local areas need to move beyond a framework that sees SUDI risk reduction in isolation from other risks and as solely the responsibility of a narrow range of health professionals. The review recommended that practitioners in all agencies who are working with families with children at risk need to develop a clear evidence-informed 7 This included the midwifery service, the family support worker from children’s social care, the perinatal mental health service, the school of the oldest sibling, and the police officers who attended the home address and conducted enquires in response to the serious incident. 8 As noted elsewhere in this report, the school had been offering this oldest sibling support around her relationships with other children for some time. 9 Mother did not participate in this case review and it is not possible to determine why safe sleeping advice was not followed on the night of baby JS’s death. 7 understanding of parental decision-making in relation to the sleep environment and how this might be changed. In light of this, the Panel encouraged local safeguarding partners to adopt a ‘prevent and protect’ practice model. As a matter of good practice, safeguarding partners in Solihull should ensure that this model has been reviewed and action taken to implement this, as appropriate, across the area. 4.4 Good Practice The health visitor appropriately challenged the home conditions at the six-week review and provided advice on home safety. These issues were addressed by mother. While no concerns were identified with screening processes, following JS’s death Solihull Integrated Addictions Service were invited to provide refresher training to the health visiting team in Solihull on alcohol screening to support best practice with families. Learning While the cause of baby JS’s death has been recorded as unascertained by the Home Office Pathologist, the circumstances would suggest that alcohol consumption may have played a part. No agency identified alcohol use as an issue for mother. The case identifies the importance of reinforcing messages around the potential risks to a child’s safety of alcohol use by parents, even where there is no dependency. The Solihull Safeguarding Children Partnership recognised this during the Rapid Review of baby JS’s death and developed a one-page briefing. This is accessible on the internet at this link. The briefing was circulated to all strategic leads across the Partnership with a request that they take action to embed the learning within their organisation’s operating processes. The Safeguarding Children Partnership are monitoring and collating feedback to ensure this action is completed. 5. The Front Door 5.1 Referral Mother was in receipt of universal services until referred to the perinatal mental health team in December 2021, and then to children’s social care in January 2022. Mother phoned the duty number for the perinatal mental health team on 4th January 2022 reporting that, during an argument, she had “slapped / clipped” father while he was holding their two-year-old. She was distressed and expressed concern about how close she had come to hitting her son. Mother reported she had also phoned children’s social care for support. The perinatal mental health service called to verify this with social care. Mother did not appear to be known to social care so the perinatal mental health team called mother back and obtained consent to make a referral. The referral was then made. 8 5.2 Social care screening 5.2.1 The screening process followed A children’s social care manager identified that the screening should be completed by a Level 4 social worker within the MASH (multi-agency safeguarding hub). Although received on 5th January, this screening was not undertaken until 13th January. The social worker spoke to the perinatal mental health service, although there are conflicting accounts of whether this was as part of the formal screening or in a call to ascertain mother’s phone number. The perinatal mental health service provided a summary of their recent assessment of mother. The social worker phoned both mother and father. Mother reported that father had never been physically violent towards her, but she had been physical towards him. Father disclosed physical abuse from mother over a number of years. Father stated he had no concerns about the needs and safety of the children. A DASH Risk Assessment was completed on mother on 13th January but not on father. No information from other agencies was requested. The social worker undertaking the enquiries made a recommendation to step the family down to early help and this was approved by an early help manager who was not social work qualified. No further action was taken until 27th January when mother was informed by letter that a family support worker would be allocated. 5.2.2 Analysis of the screening On reviewing the screening process that was followed, managers within children’s social care identified significant concerns. The screening itself was inadequate as phoning parents and the referrer does not enrich information sufficiently to allow a threshold decision to be made. Lateral checks should have been completed and the absence of these resulted in missed opportunities for information about the family to be brought together (see section 7.3.2). The focus was on the parents rather than the children. Despite this focus on the parents, the emotional aspect of domestic abuse and coercive control was not recognised in the screening process. The situational impact of a new baby, depression, isolation, domestic abuse and admittedly struggling to cope with three young children was not considered in enough detail and the risks that can emerge from this were not identified. There appears to have been a presumption that early help would be the outcome of the screening conversations. Consent for an early help assessment was obtained from mother in the screening conversation before the phone call to father had been made. Consent for an early help assessment was also sought from father at the start of the phone call, before he was asked any questions about the family’s circumstances and situation. Father disclosed physical abuse during the subsequent conversation but this did not lead to a revision of the recommendation to continue to early help. 9 The decision was not quality assured by a social work qualified team manager, allowing the case to leave the MASH and move to support at level 3. There was a delay before the decision was shared with mother. The agency who made the referral was not informed of the outcome of their referral and, despite participating in screening conversations, father was also not informed of the outcome. Social care managers examining this screening process agree that this should have been assessed and managed as a Level 4 safeguarding case and it was not appropriate to transfer this to early help. 5.2.3 Action that has been taken to address the issues in MASH screening This case is illustrative of a wider problem with MASH screening at that time and action has been taken to address the concerns identified. Social workers are now allocated to all children referred to the MASH and these social workers are responsible for leading all enquiries. At least two core checks with agencies are required for all enquiries in addition to conversations with the referrer, parents and – if appropriate – the child(ren). This ensures adequate information is gathered for enquiries to be meaningful and for a threshold decision to be reached. A qualified social work manager quality assures and signs off all cases before they leave the MASH into any other service. Feedback to the referrer and those participating in the screening is expected. The referral form has been revised. This includes the removal of the requirement for the referring organisation to specify the ‘level’ of the case. At the Learning Event for this review, practitioners particularly welcomed the removal of the previous choice between family support and social worker assessment as they do not feel equipped to make these judgements. 5.3 Timeliness of response There was timely screening and response from the perinatal mental health service. They received the referral on 16th December and completed their screening on the following day, making a formal appointment for home visit on 31st January 22 and providing contact details should mother need immediate support. The perinatal mental health service were also responsive when mother contacted them in distress on 4th January. They provided telephone support, initiated the safeguarding referral and brought forward the first home visit with mother from 31st to 11th January. In contrast, there were significant delays in taking action on the safeguarding referral to children’s social care with a two and half month gap between the referral and support being provided. The referral was received on the 5th January, screening conversations were held on 13th January, and mother was informed of the decision to allocate a family support worker on 27th January. Social care have confirmed that screenings should be completed within one or two days of receipt of the referral. There was a further delay allocating a family support worker due to capacity pressures but mother was given contact details for the team in case of urgent change. Children’s 10 social care were aware that a worker from the perinatal mental health team would be visiting and supporting the family whilst they waited for a family support worker. However, this worker from the perinatal mental health team was not informed of any social care decision making or plans. A family support worker was allocated on 17th February but, due to an oversight and annual leave, the case was not picked up by the family support worker until 7th March. The family support worker phoned mother on the 8th March, visited her on the 9th March and initiated contact with other agencies on 15th March. The family support worker commenced work on the early help assessment. Changes have since been made to how the “unallocated” list of those waiting for early help family support is managed. Both the referral and the child and family’s circumstances are now reviewed by a duty team manager who contacts those professionals who are already involved with the child or family. Support is then allocated on the basis of the level of need. Children’s social care are also in the process of recruiting additional staff to enable them to better manage this waiting list. This includes two extra social workers, one qualified social work manager and three additional family support workers. 5.4 Good Practice The perinatal mental health service demonstrated good practice by verifying mother’s assertion that she had already contacted children’s social care following the incident on 4th January. As mother did not appear to be known to social care, it was good practice that the perinatal mental health service obtained consent and made the referral. Learning This case demonstrates significant weaknesses in the social care response. The initial screening was inadequate and there appears to have been a presumption that it would result in a transfer to early help. The screening did not draw on information from other agencies and did not consider the changes in potential risk revealed through screening conversations. For example, father’s disclosure of a history of physical abuse by mother. Given the presenting issues, the referral should have been assessed and managed as a Level 4 safeguarding case and should have resulted in a Strategy discussion. This would have been an opportunity to explore whether the three children were at risk due to domestic abuse (see section 6 below). There were also significant delays at every stage of the process, from screening to the allocation of support, as well as noticeable gaps in the feedback on the outcome of the referral. Having recognised these weaknesses, it is important to note that changes have been made to the way that MASH screenings operate in Solihull. These should address the issues highlighted in this review. Changes have been made to how the ‘unallocated list’ is managed for those waiting for family support. Early Help services more broadly are also currently being redeveloped with additional funding to ensure a comprehensive service is in place in Solihull which is able to meet demand. 11 6. Exploring issues of domestic abuse 6.1 Definition of domestic abuse The Domestic Abuse Act 2021 defines domestic abuse as behaviour between two people aged 16 or over who are personally connected to each other that involves any of the following: physical or sexual abuse; violent or threatening behaviour; controlling or coercive behaviour; economic abuse10; psychological, emotional or other abuse. It does not matter whether the behaviour consists of a single incident or is a pattern of behaviour. The Domestic Abuse Act 2021 also states that children are victims of domestic abuse that is perpetrated against their parent or carer. 6.2 Evidence of domestic abuse 6.2.1 Screenings for domestic abuse University Hospitals Birmingham NHS Foundation Trust, who deliver midwifery services, have a policy that domestic abuse screening should be completed at least three times during the antenatal period. Mother was asked five time and no concerns were identified. Covid-19 restrictions were in place during the period that mother engaged with midwifery services and she was, therefore, seen without father. This meant that the midwifery service had no contact with father. This would, however, have provided mother with an opportunity to disclose domestic abuse if she was the victim. South Warwickshire University NHS Foundation Trust, who deliver the health visiting service, also have comprehensive policies around domestic abuse screenings. A routine enquiry was made at the new birth visit and mother denied any domestic abuse. When asked the routine enquiry at the six week visit, mother disclosed that she had hit father in the face during an argument. In response to this, the health visitor discussed the negative impact on children of witnessing physical abuse with mother. The health visitor also followed up and verified mother’s assertion that a referral had already been made to children’s social care. 6.2.2 Incidents of domestic abuse In the relatively short timescale covered by this review, there were two key incidents that shaped both the actions and perceptions of professionals. Both relate to domestic abuse. In the first (the incident that led to the social care referral), mother was the perpetrator of physical violence while, in the second incident just over two months later, father was accused of coercive and controlling behaviour. Agency responses to these incidents reveal unconscious bias about female perpetrators of domestic abuse and also demonstrates a failure to fully explore the nature of the relationship between the parents. It is worth noting that there was one other incident indicating potential domestic abuse that fell outside of the formal review period. In October 2018, father reported an assault 10 This is any behaviour that has a substantial adverse effect on the victim’s ability to acquire, use or maintain money or other property, or obtain goods or services. 12 by mother to the Police following a night out drinking. He retracted this the following day. 6.3 Unconscious bias around female perpetrators of domestic abuse There is evidence of unconscious bias around female perpetrators of domestic violence. At the Learning Event, practitioners noted that routine domestic abuse screenings of pregnant women and new mothers are focused on mother as the potential victim and suggested that questions could be reframed to avoid this unconscious bias. For example, in this case, the health visitor recalled asking mother a question along the lines of ‘has there been any domestic abuse in your relationship?’ (framed this way because she was aware a toddler was in room) and this led mother to disclose the January incident where she had been the perpetrator. The initial social care screening was in response to the referral report of mother’s “slap / clip” to father. As part of this screening mother admitted to being physical towards father in the past. Father also disclosed physical violence by mother to him over a number of years. Despite this, the DASH assessment looking at the risks associated with domestic abuse was completed on mother not father. No follow up action was taken in response to father’s disclosure of domestic abuse, even though this abuse was substantiated by mother during the screening conversation. Father was not offered any support and he reported feeling “like I don’t matter” and “no-one cared what I said.” Father was the victim of domestic abuse and consideration should have been given to the risk towards him from mother’s behaviour. Instead, the recommendation from the screening was the allocation of a family support worker to support mother with no reference being made to father. It is possible that this unconscious bias around female perpetrators of domestic abuse may have influenced how the risks to baby JS and JS’s siblings were perceived. The two-year old sibling could have been injured by mother should her “slap” to father have struck the child instead. However, the referral did not prompt a Strategy discussion to consider whether the three children were at risk due to domestic abuse. It is possible that this was because father was not seen as a victim of domestic abuse (despite clear disclosures by both father and mother during the screening conversations). Other agencies have also reflected that they did not fully explore mother’s actions as a perpetrator of domestic abuse. The perinatal mental health service, for example, reflected that there was an over reliance on self-reporting by mother and an acceptance of her word that she hadn’t perpetrated any further domestic abuse. Had multi-agency conversations been held, it would have been possible to triangulate this and additional information – such as the 2018 incident recorded in Police files – may have led to more exploration of mother’s role as a perpetrator. Instead, mother’s future engagement with the perinatal mental health service was focused on the stresses she reported father was placing on her and support was provided to mother to help her deal with this. 13 6.4 Failure to explore the nature of the relationship between parents Mother described coercive behaviour by father towards her. From these descriptions, and their interactions with mother, several practitioners had a strong perception that father was controlling towards mother. This, however, remains an unverified perception: the focus of most professionals was on mother and they had no engagement with father. The exceptions to this were the family support worker and the school of the oldest sibling. The family support worker was aware of the incident in January in which mother hit father but described this as being a one-off event as a result of ongoing parental conflict rather than domestic abuse. Both parents described heated arguments which included a lot of screaming and shouting. In contrast to other practitioners, the family support worker did not have the impression that father was controlling or using coercive behaviours. Mother told the family support worker that father was a good father and mother said she wanted him to be more involved with the children and to see them more. Similarly, in his conversations with the family support worker, father said that he thought mother was a good mother. Both parents agreed to attend a parental conflict session with the family support worker. This was held on 30th March and the family support worker felt this meeting was very positive.11 The family support worker reported that mother and father both expressed their concerns openly and agreed actions moving forward. Indeed, when she left, the family support worker felt mother and father were both calm and described how they both chose to stay behind to have a coffee together. In recognition of mother’s mental health difficulties, the family support worker checked that mother knew how to access support from the perinatal mental health service and confirmed that a visit from the service was scheduled. The only other agency who had any engagement with father was the primary school of the oldest sibling. School staff saw father on a regular basis but they were unaware of any potential issues related to domestic abuse (as either a victim or potential perpetrator). Had the school known, they may have taken action to ensure that other agencies were aware of the support they were offering to this sibling. The primary school had been providing specialist Play Therapy support to the oldest sibling with her relationships in school since her Reception Year. Social care also have a record of a call from the oldest sibling’s childminder in 2019 reporting concerns about her behaviour and making false allegations that someone had hit her. It is possible that this unusual behaviour could be a result of this child witnessing domestic abuse within the family. However, her behaviour could equally be due to other factors. The absence of multi-agency working (see section 7 below) means these issues weren’t explored during the period that professionals engaged with the family. The true dynamics of the parents’ relationship and the potential effects on their children, therefore, remained unknown at the time of baby JS’s death. 11 Father had a different view of this meeting: this is covered in section 4.2.1 14 6.5 Impact of domestic abuse While there are domestic abuse indicators, these do not appear to have directly influenced the tragic events of baby JS’s death. Key professionals were aware of mother’s physical assault of father in January 2022 but remained confident of her ability to safely parent her three children. Similarly, professionals who believed mother to be subjected to controlling behaviour from father did not feel this negatively affected her parenting capability. At the Learning Event, and in reflective feedback, practitioners described how they had observed good bonding between mother and her children as well as responsive and safe caring. However, witnessing domestic abuse within the family is likely to have had a detrimental impact on the children’s emotional wellbeing. The extent of any domestic abuse was not explored at the time and is, therefore, unknown. 6.6 Good Practice Routine enquiries around domestic abuse were completed by both the midwifery and health visiting service. This prompted mother to disclose to the health visitor in January 2022 that she had hit father. The health visitor demonstrated good practice by verifying the referral with children’s social care when mother stated that she had self-referred to social care. While there was no multi-agency working to examine issues of domestic abuse, there are examples of good practice on a single agency level. For example, the health visitor discussed the negative impact of children witnessing physical abuse. Following the parental conflict session, the family support worker checked that mother knew how to access support from the perinatal mental health service and confirmed that a visit from the service was scheduled. Learning While the incident that led to baby JS’s death was not related to domestic abuse, this case does identify learning around this issue that has the potential to improve the safeguarding of other children in the Solihull area. Routine domestic abuse screenings of pregnant women and new mothers need to allow for disclosure of domestic abuse by female perpetrators. It is, therefore, important that screenings do not focus exclusively on mother as the potential victim. Agencies who undertake these screenings should review the questions used and, if necessary, reframe questions to avoid this unconscious bias. Guidance should be included to encourage the father’s voice to be considered as part of routine screenings, wherever practical. Fathers who are victims of domestic abuse should be considered in the same way as mothers in regard to support and intervention. There is a need to ensure that all professionals explore and identify the dynamics of situations involving domestic abuse. This includes establishing who is using abusive behaviours and who is the victim. It also requires a recognition that a victim of domestic abuse could also be a perpetrator. Risks to children need to be thoroughly understood in all referrals related to domestic abuse and consideration must be given to the direct harm of domestic abuse on children. 15 7. Co-ordinating a multi-agency early help response 7.1 Early Help The analysis in section 5 of this report explains that the needs of this family were inappropriately filtered as early help and should have followed a formal safeguarding route to allow the exploration of potential domestic abuse and the impact on the three children. This does not, however, prevent this case from being used to identify learning about how agencies in Solihull work together to support families requiring early help. The circumstances of this family’s experience in the relatively short review period suggests a tendency for agencies to work in isolation, a lack of inter-agency information sharing, and a reliance on children’s social care to co-ordinate early help work. 7.2 Definition of Early Help The Early Help Guidance (2019) issued by Solihull Local Safeguarding Children Partnership defines early help as: “the support that is delivered to any child at Level 1 to Level 3 of Solihull’s Threshold guidance. It includes universal interventions that are offered to an entire population to prevent problems developing and targeted support to particular children and families with additional needs. The purpose of Early Help is to support the well-being of children and families by tackling emerging needs at the earliest opportunity and prevent them from getting worse. This means working with children and families to engage and include them as equal partners and to support them to access additional services that can promote positive outcomes.” Solihull’s Early Help Procedure also makes it clear that: “any universal or specialist service can offer early help, including community and voluntary sector organisations” and this support should be offered: “as soon as an unmet need is identified for a child / young person”. 7.2.1 Reliance on children’s social care to lead early help Several agencies have reflected there was a missed opportunity to offer early help support to the family in December 2021 before the safeguarding incident in January 2022. There was also a lack of multi-agency co-ordination immediately after the incident. At the Learning Event for this review, professionals from a range of agencies reflected that multi-agency meetings in Solihull are too often reliant on social care organising them. There was a consensus that multi-agency co-ordination needs to take place as soon as the need for joint working is identified and this should not wait until a threshold for social care involvement is met. Work did not commence on an early help assessment until the family support worker from children’s social care picked up the case two and a half months after the January 16 incident. The scheduled completion date for the early help assessment was 25th April 2022. At the time of baby JS’s death, therefore, no multi-agency meeting had been held, the circumstances and needs of the family had not been explored, and no plan had been drawn up for a multi-agency response. The lack of co-ordination meant that agencies continued to work in separate organisational silos. Indeed, mother had multiple visits and phone calls from agencies – often on the same day. Multi-agency meetings would have helped triangulate information and could have helped return some of the focus to the lived experience of the children rather than centring upon the difficulties in the parents’ relationship. 7.3 Information Sharing Despite several agencies being aware (from either December 2021 or January 2022) that the family may require additional support and that multiple agencies were involved, there was no formal sharing of information. 7.3.1 Over reliance on mother sharing information Instead, there was a reliance on mother sharing information with professionals. For example, the perinatal mental health team knew about the 2018 incident involving the police as mother disclosed this to them. The health visitor knew about the involvement of the perinatal mental health service and the incident in which mother “slapped” father because mother shared this information. 7.3.2 Absence of information sharing at the time of the referral Children’s social care did not make any lateral checks in response to the referral. Indeed, they appear to have obtained information on the assessment undertaken by the perinatal mental health team largely by accident when they telephoned the service because they hadn’t been able to contact mother. No other agency sought formal information from others. This absence of information sharing around the time of the referral led to a missed opportunity for developing a shared understanding of the family’s needs. For example, it would have given the police an opportunity to share their information about the incident in October 2018 when father claimed that mother had assaulted him. (Due to an oversight, this had not been shared at the time, possibly because no child was present.) There was also a missed opportunity at this time to ensure that all relevant agencies were aware the family had additional needs. The school of the oldest sibling knew that the parents had separated but had no knowledge of any concerns until a meeting with father on 2nd March. School then received an alert from the police on 15th March (prompted by mother’s complaint about father), which was the same day the family support worker telephoned them. Although they maintained usual levels of vigilance as they would for all children, they were not aware of the potential need to provide additional support between January and March. 7.3.3 No shared understanding of outcome of the referral Children’s social care did not share their decision to allocate a family support worker and undertake an early help assessment with any other agency. 17 Those agencies who were aware of the referral did not proactively follow up the outcome of the referral when they did not hear from children’s social care. Nor did they seek to initiate conversations with other agencies about the family. 7.3.4 Father’s views Father was a victim of domestic abuse and this was not acted on (see section 6.3). Father reported feeling dismissed when he shared concerns about neglect of the oldest sibling with school and was advised to report these concerns to the MASH himself as the school had not identified any signs of neglect. Father’s concerns about mother’s alcohol use (see section 4.2.1) were not followed up. 7.3.5 Formal notification and sharing of information between agencies The perinatal mental health team showed good practice sharing information on their work with the GP Practice and in their referral to children’s social care but they did not communicate directly with the health visiting service. The importance of effective communication and joint working between the perinatal mental health service and heath visitors was recognised by the Rapid Review of this child’s death. To improve the support to new mothers with significant mental health needs, practice has been reviewed and new guidance has been agreed. Perinatal mental health teams now update health visitors following appointments with clinicians by copying them into GP letters. Care co-ordinators also now contact health visitors when they are allocated to ensure information is shared and communication pathways are set up. There was a suggestion, in the written feedback to the Practitioner Learning Event, that improvements could be made to how community midwives assess mental health at discharge, ensuring key events are handed over to health visitors. 7.3.6 The need to share information at an early stage The family support worker did contact other agencies in order to begin to gather information shortly after she picked up the case. Unfortunately, delays meant that this was two and a half months after the referral and only two weeks before JS’s tragic death. Bringing together information at an earlier stage would have allowed practitioners to be more professionally curious and explore need within the family and issues such as potential domestic abuse. For example: • Mother as a potential perpetrator of domestic violence was unknown to some practitioners working with mother. • Since Reception, and during Year 1, school had been offering specialist Play Therapy to oldest sibling to support her with her relationships in school. If other concerns were known about potential domestic abuse, it may have led to further exploration of what was happening within the family. • School staff were seeing mother, father or his new partner daily (often twice a day) and felt that, had they known more, they may have been more alert to watching for potential concerns and may have been able to offer support. • Multi-agency discussion and co-ordination would have ensured more focus on the lived experience of the children in the family rather than the focus on the parents’ relationship. 18 In the written feedback at the Learning Event for this review, several practitioners reflected it would have been useful to share information and develop a multi-agency chronology as part of partnership working. 7.4 Good Practice The perinatal mental health team showed good practice sharing information on their work with the GP Practice. Learning Multi-agency co-ordination needs to take place as soon as the need for early help is identified and this should not wait until a threshold for social care involvement is met. In line with Solihull’s Early Help guidance and procedures, all agencies need to be proactive in responding to identified need and should obtain consent from the family to share information with other agencies. Where formal referrals are either made or known, agencies need to be similarly proactive in following up the outcome of these. The referral should not be viewed as an end itself. Agencies need to ensure processes are in place to make appropriate notifications about their work and to work with key partners. As noted in section 7.3.5 above, perinatal mental health teams now update health visitors following appointments with clinicians by copying them into GP letters. Care co-ordinators also now contact health visitors when they are allocated to ensure information is shared and communication pathways are set up. 8. Voice and Lived Experience of the Child 8.1 Voice and Lived Experience of the Child Children, especially babies and infants, are usually seen in the care of their parents and it can be challenging to ascertain their wishes and feelings. Whilst supporting parents to provide appropriate parenting is important, it is crucial that the risks to children, their needs, wishes, feelings and their lived experiences are also examined. Records of several agencies report positive observations of baby JS. The health visitor recorded good interactions between mother and baby, while the midwifery service reported that JS was gaining weight, was being breast fed and appeared to be well cared for. The perinatal mental health service noted that mother at times reported feeling overwhelmed but observations showed her to be meeting the needs of her children and interacting positively with them. However, the service has reflected that the focus on supporting mother with her mental health and the conflict within her relationship with father meant that the lived experience of the children was not always proactively considered. A large part of the work by the family support worker was also focused on the parents’ relationship but time was spent considering the children’s needs. In the short time the family support worker engaged with the family, the children were seen three times in their home environment. The family support worker took proactive action to secure funding for the middle sibling to attend nursery, made a referral for an Autism consultation for this child and contacted the health visitor about his two-year-old check. 19 The family support worker also provided advice on behaviour management and healthy sleep regarding this middle child and on feeding for baby JS. At the family support worker’s request, direct work was undertaken with JS’s oldest sibling by the school Designated Safeguarding Lead in the form of the ‘three houses’ tool. (The family support worker felt the oldest sibling would respond better to an adult she knew well). GP files record mother reporting that JS’s middle sibling, aged two, was suffering from night terrors. Accounts of the period when these had been a problem and their frequency changed between the telephone consultation with the GP in mid-March and the face-to-face consultation one week later. This inconsistency does not appear to have been explored at the time. There is also no evidence of questions being asked about any other changes within the family that may have impacted on the child. 8.2 Good Practice In the short time the family support worker engaged with the family, she proactively arranged support for the children. For example, securing funding for a nursery placement and Autism assessment for the middle sibling and initiating direct work in the form of the ‘three houses’ tool with the oldest child. Learning This case demonstrates how easy it is for the voice of the child to be overshadowed by the needs of parents. More could be done to ensure that the lived experience of the child remains central to practitioners’ work. 9. Conclusion and Recommendations This review has identified significant learning around screening at the social care front door as well as issues around the timeliness of the response. While the incident that led to baby JS’s death was not related to domestic abuse, this case also identifies learning around domestic abuse that has the potential to improve the safeguarding of other children in the Solihull area. Similarly, while the family was inappropriately filtered as early help, the examination of the response to this case illustrates where improvements could be made to multi-agency working around early help in Solihull. Finally, this review draws on the learning from the National Panel’s review into sudden unexpected death in infancy and highlights the importance of ensuring that the recommendations from that review have been acted upon. The learning points at the end of each section of this report have been used to inform the recommendations below. It is anticipated that these will be used by the Solihull Safeguarding Children Partnership to create detailed SMART action plans capable of delivering real change. 9.1 Recommendation 1: Acting on the learning from the National Review into SUDI in families where children are considered at risk of significant harm Safeguarding partners should review the learning from all national reviews and ensure it is fully implemented in their area. Almost three years on from the publication of the National Panel’s review into SUDI where children are considered at risk of significant 20 harm, it would be timely for the Solihull Safeguarding Children Partnership to request evidence and assurance from all relevant partners that appropriate action has been taken. An action plan should be developed if this identifies any concerns. 9.2 Recommendation 2: Assurance of the impact of changes to the front door Changes have been made to the way referrals are managed in Solihull’s MASH (multi-agency safeguarding hub). These should address the issues identified in the screening of this case. However, given the significance of the issues, it is crucial that ongoing monitoring takes place beyond initial assurance checks. Evidence of this monitoring, and of the impact of the overall changes to the social care front door, should be provided by Solihull MASH to the Safeguarding Children Partnership to provide assurance that the changes introduced are making a real difference and all cases are now being appropriately screened. 9.3 Recommendation 3: Responding to and following up referrals This case demonstrated weaknesses in the feedback when a referral is made to children’s social care and also in the follow up of referrals by other agencies. It is, therefore, recommended that: • Assurance is provided by the Solihull MASH to the Safeguarding Children Partnership that practitioners in the MASH are providing feedback to all referrers in a timely way. This feedback should include any key actions for the referring agency as well as the formal outcome of the referral. • Relevant partner agencies review their internal systems and guidance around making and following up referrals. All agencies should commit to ensuring that frontline practitioners are aware of their responsibility to proactively chase the outcome of a referral if they have not been informed. Guidance must be clear that referrals cannot be seen as an outcome in their own right. 9.4 Recommendation 4: Screenings for domestic abuse Routine domestic abuse screenings of pregnant women and new mothers need to allow for disclosure of domestic abuse by female perpetrators. Agencies who undertake these screenings should review the screening questions they use and, if necessary, reframe questions to avoid any unconscious bias. Guidance should be included to encourage the father’s voice to be considered as part of routine screenings, wherever practical. Relevant agencies should provide assurance to the Solihull Safeguarding Children Partnership that a review has been completed, with evidence of any learning and changes that may be necessary. 9.5 Recommendation 5: Recognising and responding to domestic abuse The Domestic Abuse Partnership Board and Safeguarding Children Partnership should work together to co-ordinate an audit of the understanding of domestic abuse amongst relevant staff in Solihull and take action to ensure that all practitioners: • are able to recognise domestic abuse; • know how to respond to incidents of domestic abuse; • are confident to explore situations involving domestic abuse, including establishing who is using abusive behaviours and who is the victim; 21 • have an understanding of coercive and controlling behaviour; • are mindful of the importance of avoiding unconscious bias, including around female perpetrators; • fully understand the impact of domestic abuse on children, including the fact that children are victims of domestic abuse perpetrated against their parents or carers. In doing this, it is recommended that local tools developed to support practitioners to recognise and respond to domestic abuse are pro-actively promoted to all relevant practitioners. For example, Solihull Local Safeguarding Children Partnership have recently produced guidance on parental conflict which includes a series of question to support staff to identify and distinguish between parental conflict and domestic abuse. 9.6 Recommendation 6: Multi-agency co-ordination of early help Multi-agency co-ordination needs to take place as soon as the need for early help is identified and should be delivered by existing professionals using a collaborative approach rather than waiting until a threshold for social care involvement is met. All agencies should review their service operating procedures to ensure: • all practitioners understand the need to follow the Early Help procedures to ensure a co-ordinated approach to working with the family; • robust information sharing takes place before a case progresses to statutory services. 9.7 Recommendation 7: Raising awareness of the risks of alcohol and drug use by parents This case identifies the importance of reinforcing messages around the potential risks to a child’s safety of alcohol use by parents, even where there is no dependency. Solihull Safeguarding Children Partnership have already taken action to raise awareness amongst professionals of the risks to a child’s safety of alcohol use by parents. The Partnership is collating feedback in order to monitor how agencies are promoting these messages to staff. More could, however, be done to share this message directly with families. Solihull Safeguarding Children Partnership should review how they communicate the risks associated with alcohol and drugs use with parents and carers and how this could be strengthened. Birmingham have been doing this through their ‘Who’s in Charge?’ campaign (see box below) and Solihull may wish to consider adopting this or something similar. Birmingham’s ‘Who’s in Charge?’ campaign In the four year period ending in March 2020, 35 babies in the West Midlands region died while sharing beds or sofas with adults who had consumed more than two units of alcohol or used illegal drugs. In response to this, the Birmingham Community Healthcare NHS Trust and Birmingham Safeguarding Children Partnership launched the ‘Who’s in Charge’ campaign in November 2020. 22 The campaign uses a series of short hard-hitting films, urging parents, and those with responsibility for children, to be aware of the risks and potentially dangerous consequences of drinking alcohol while caring for children and to always know ‘Who’s in Charge?’ The videos depict some of the most worrying trends identified locally and nationally, particularly baby deaths connected with sleeping on a sofa or co-sleeping in a bed with an adult who is under the influence of alcohol. |
NC043779 | Death of a 4-month-old child in June 2009, from injuries resulting in irreversible brain damage. The partner of Child V's maternal aunt was found guilty of manslaughter and sentenced to six years imprisonment. A child protection investigation in respect of Child V's cousin was instigated following Child V's admission to hospital. Child V was known only to universal services with the exception of professional involvement following a minor head injury, sustained whilst in mother's care. Partner of V's aunt was misusing steroids and was known to have previously sought medical care for injuries suggestive of aggressive behaviour. Issues identified include: all injuries to non-mobile children should be regarded as highly suggestive of non-accidental injury; awareness of parental misuse of steroids as a potential risk factor for children should be improved; and referral following suspected abuse should include details of any other children who are in contact with the suspected perpetrator. Makes recommendations for: Oxfordshire Local Safeguarding Children Board, health and police services.
| - 1 - Executive Summary SERIOUS CASE REVIEW IN RESPECT OF A CHILD V Chris Few November 2011 - 2 - INTRODUCTION The Local Safeguarding Children Board Regulations, 2006, require Local Safeguarding Children Boards to undertake reviews of serious cases. In August 2009, when this Serious Case Review commenced, the applicable guidance on conducting such reviews was at Chapter 8 of Working Together to Safeguard Children 2006. This has subsequently been revised by Working Together to Safeguard Children 2010. The provisions of the more recent guidance are not however retrospective and this Review has been completed in accordance with the 2006 document. A Local Safeguarding Children Board should always undertake a Serious Case Review when a child dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in the child’s death. This is irrespective of whether Local Authority children’s social care is, or has been, involved with the child or family. The purpose of a Serious Case Review is to: Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children Identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result; and As a consequence, improve inter-agency working and better safeguard and promote the welfare of children. Serious Case Reviews are not inquiries into how a child died or who is culpable. That is a matter for the Coroners and criminal courts, respectively, to determine as appropriate. Summary of Circumstances Leading to the Review V was an only child and in June 2009, when 4 months old, was taken to the family GP in a collapsed state. The child was initially taken to the local hospital Emergency Department where a severe brain injury was diagnosed, then transferred to the paediatric intensive care unit in Oxford. It was identified that V’s brain injury was irreversible and that further medical intervention would be of no benefit. Treatment was withdrawn in consultation with V’s family and the child died shortly after. A criminal investigation in relation to the death of V has been conducted by Thames Valley Police. The partner of V’s maternal aunt was found guilty on 20 July 2011 of Manslaughter and was sentenced to 6 years imprisonment. The Serious Case Review sub-group of Oxfordshire Safeguarding Children Board (OSCB) considered the circumstances of V’s death and recommended that a Serious Case Review be conducted. That recommendation was endorsed by the Independent Chair of the Board on 3 August 2009. Terms of Reference Draft Terms of Reference were agreed by the Oxfordshire Safeguarding Children Board Serious Case Review sub-group. The final Terms of Reference identified that the Review, whilst commissioned by the Oxfordshire Safeguarding Children Board, would be reported not only to that Board but also the Reading Safeguarding Board because the original Hospital where V was treated was in the Reading area although the matter was at all times an Oxfordshire case. - 3 - Key features in the case, for consideration in the Review, were: Agencies should consider whether relevant information about any of the adults was known by agencies during the ante-natal period and whether it was considered adequately and whether appropriate action was taken and if not why not Were there any previous incidents which raised child protection concerns about V's care and were they responded to appropriately by agencies, specifically an earlier incident which necessitated attendance at the local Emergency Department Agencies should review records relating to the parents of V’s cousin, which is relevant to subsequent decision making in the care of the child and identify any risk factors known relating to that child and if so, was the information appropriately shared Whether race, religion, language and cultural needs were met during intervention with the family by all agencies to include learning disabilities and or any mental health issues Police and Children’s Social Care to review their initial response during the first 48 hours post incident. To analyse any actions in relation to how agencies worked together to safeguard V and cousin during this time. Serious Case Review Panel The Serious Case Review Panel was chaired by Andrea Hickman, Independent Chair of the Oxfordshire Safeguarding Children Board. Chris Few, an independent consultant, was appointed to write the Overview Report at the outset of the Serious Case Review. He had conducted an agency management review for Education Services as part of a previous Serious Case Review in Oxfordshire but otherwise has no personal or professional connection with any agency in the county. Other members of the Serious Case Review Panel were: Lead Solicitor Oxfordshire County Council Superintendent Thames Valley Police Designated Nurse Oxfordshire Primary Care Trust Deputy Director Corporate Affairs Royal Berkshire NHS Foundation Trust Designated Doctor Oxfordshire Primary Care Trust Lead Officer Safeguarding Oxfordshire County Council Business Manager Oxfordshire Safeguarding Children Board Review Process It was recognised at the first panel meeting that the Serious Case Review would not be able to be completed until after the conclusion of the Police investigation. All extensions to the timescale for the Review were agreed by the Panel, in consultation with the Government Office South East (GOSE). The Serious Case Review Overview Report was presented to, and accepted by, the Oxfordshire Safeguarding Children Board on 13 October 2011. - 4 - The Overview Report and this Executive Summary have been copied to the Chair of the Reading Safeguarding Children Board with an offer to formally present it at a meeting of that Board. Action was taken during the Serious Case Review process to ensure that identified learning was implemented at the earliest opportunity. Contributions to the Review Individual Management Reviews (IMRs) were received from: Thames Valley Police Oxford Radcliffe Hospitals NHS Trust Community Health Oxfordshire Royal Berkshire NHS Foundation Trust Oxfordshire County Council – Children’s Social Care. These were supplemented by: consulting relevant research reports access to policy and guidance documents copies of documents and records from meetings and communications correspondence with individuals and agencies to confirm and clarify information. Family Engagement Family members were informed that this Serious Case Review was taking place. Following the conclusion of the criminal investigation they were invited to contribute to Serious Case Review but did not do so. It is intended that the findings of the Review will be shared with family members prior to publication of the Executive Summary. SUMMARY OF EVENTS SURROUNDING THE DEATH OF V The child’s mother brought V to the family GP surgery in a collapsed state. V had suffered a head injury, was critically ill and in respiratory arrest. V was transferred to a local Emergency Department. Owing to the seriousness of V’s condition, the child was transferred to the Paediatric Intensive Care Unit (PICU) at Oxford. At the PICU it was identified that V’s injuries had resulted in irreversible brain damage. This was discussed by medical staff with family members and it was agreed to withdraw further treatment. V was christened and died shortly afterwards in mother’s arms. From the outset it was suspected that the injuries sustained by V were not accidental. It was reported that V had been in the care of one or more adults within the family during the hours preceding admission to hospital. Referrals were made to Oxfordshire Children’s Social Care in relation to both V and to V’s cousin (the child of V’s maternal aunt and her partner). These were reported to the Police. As a result of these referrals a criminal investigation in respect of the injuries to V and a child protection investigation in respect of V’s cousin were instigated. Cultural and diversity issues The children and adults in this Serious Case Review are all white British and from English speaking families. - 5 - The family of V were identified as being members of the Church of England by both hospitals involved and account taken of their faith in arranging for V to be christened before he died. No other diversity issues were identified during agencies’ contact with the family. LEARNING FROM THE REVIEW This Review is perhaps unusual in that the greatest learning relates to events after the incident that led to it being commissioned. This learning is no less important for that. Lessons learned from practice prior to V’s death Prior to the incident, professional involvement with V and family was mainly in relation to universal health service provision. In April 2009 V sustained a minor head injury whilst in the care of mother. As the fatal injuries to V were inflicted by the partner of V’s maternal aunt, it is highly unlikely that any response to V’s injury in April 2009 could have led to his death being either predicted or prevented. This judgement is however made with the benefit of hindsight and there should have been more of an investigation into the circumstances of how the injuries occurred in a non-mobile child. Therefore, all injuries to non-mobile infants should be regarded as highly suggestive of non accidental injury unless there is an adequate explanation. The plausibility and consistency of any explanation with an injury needs to be carefully considered. The partner of V’s maternal aunt (convicted of causing V’s death) was misusing steroids and had previously sought medical attention for injuries that suggested aggressive behaviour. This was known to his GP and hospital staff. . However no professional could reasonably be expected to have identified that this might pose a risk to V. Awareness of parental misuse of steroids as a potential risk factor for children should be improved. Lessons learned from practice after V’s death There were deficits in the processes by which the injuries to V were referred to Children’s Social Care and then to the Police. The principle Police focus was in relation to the criminal investigation to the detriment of clearly establishing V’s cousins whereabouts and safety. Action taken to safeguard this child did not happen until over 24 hours after V’s admission to hospital and in one instance, potentially placed the child at risk. Fortunately V’s cousin was not harmed during this period. When abuse or neglect is suspected, the referral of this to Children’s Social Care and the Police should include details of any other children who are in contact with a suspected perpetrator and this must result in action to assess and respond to the safeguarding needs of those children. The Police did not respond to persistent requests for information as to the whereabouts of Vs cousin from Children’s Social Care. This should have been escalated more robustly by Social Care. As a consequence there was a lack of joint working on this issue.in first two days after the injury to V were characterised by poor communication; a lack of joint working; a focus by the Police as an organisation and by individual staff members on the criminal - 6 - investigation to the detriment of their safeguarding responsibilities; and a failure within Children’s Social Care to fully adhere to, and ensure compliance by other agencies with, child protection procedures. Escalation procedures were engaged by Children’s Social Care but should have been pursued more robustly. All Police staff should understand that they have a responsibility for safeguarding children, which is as important as their responsibility to detect crime. They should know about, and comply with, the national and local policies, procedures and guidance on how they should exercise that responsibility. Children’s Social Care must insist on compliance with, national and local policies, procedures and statutory guidance on safeguarding children; persistently using established escalation procedures to secure this compliance where necessary. Areas of Good Practice Following the injury in June 2009 the response of health agencies to the medical needs of V was appropriate and gave V an optimum chance of surviving the injuries. Sadly they were too severe for these efforts to be successful. The health service response to the emotional and spiritual needs of V’s family was also appropriate and effective. The initial referral by the Emergency Duty Team Co-Ordinator to the Police Enquiry Centre was of a high standard, both in terms of an accurate summary of events and clarity of the issues. CONCLUSION It is the conclusion of this Serious Case Review that the death of V could not reasonably have been either predicted or prevented by any professional. The contributing Individual Management Reviews also identified specific areas in which organisational and individual practice could have better contributed to safeguarding children and made recommendations to have these addressed. These are outlined at Appendix A. RECOMMENDATIONS The implementation of recommendations from both the Individual Management Reports and the Serious Case Review are the subject of current action plans developed by the Oxfordshire Safeguarding Children Board. All agencies have internal systems for monitoring implementation of the actions, progress is also reported to that Board via the Quality Assurance and Audit subgroup. 1. That the Oxfordshire Safeguarding Children Board and Reading Safeguarding Children Board ensure that their procedures in relation to the recognition of physical abuse are sufficient to ensure that that any traumatic injury to a child who is not independently mobile is considered as highly suggestive of non accidental injury unless there is an adequate explanation, the plausibility and consistency with the injury of which has been confirmed by experienced medical opinion. 2. That the Oxfordshire Safeguarding Children Board and Reading Safeguarding Children Board ensure that the significance of injuries to children who are not - 7 - independently mobile is highlighted in their multi-agency training provision and the training provided by their partner agencies. 3. That the Oxfordshire Safeguarding Children Board ensures that reference to non-prescription steroid use is included in its multi-agency training provision and the training provided by its partner agencies in relation to parental substance misuse. 4. That the Oxfordshire Safeguarding Children Board and Reading Safeguarding Children Board ensure that their child protection procedures and all referral documentation used by their partner agencies require and prompt the inclusion of details regarding other children within the household or in contact with the alleged perpetrator of child abuse. 5. That Thames Valley Police ensure that all of its staff understand and accept their responsibility for safeguarding children and are aware of the procedures and guidance within which they should exercise that responsibility. 6. That the Oxfordshire Safeguarding Children Board require Oxfordshire County Council Children’s Social Care and Thames Valley Police to provide reports on how they will ensure compliance by their organisation and staff members with national policies, statutory guidance and local procedures in relation to joint working and information sharing to protect children. Reading LSCB have indicated that they accept all recommendations and have implemented all required actions. In addition to the recommended action, the Overview Report Author brought recognition of parental steroid use as a concern for children to the attention of the National Safeguarding Delivery Unit for consideration of including it in the revised version of Working Together to Safeguard Children, (2010). This Review has been submitted to Ofsted and evaluated by them as Good. - 8 - Appendix A Agency Management Report Recommendations Community Health Oxfordshire & Oxfordshire Primary Care Trust 1. Guidance for follow up of A&E attendances to be developed for Universal Children’s Services including the recommendation that a contact should be made to discuss safety issues with parents/carers when a child presents with an accidental injury under the age of one year old. 2. The significance of A&E attendances as a possible risk factor for children and young people to be captured in Community Health Oxfordshire’s safeguarding children and young people training and group supervision sessions. 3. Content and style training to be included in future documentation training. Review of Health Visitor documentation in the GP electronic records to be included in the safeguarding reviews undertaken by the Safeguarding Team. 4. The induction process for skill mix staff to formally include the use of the Staff Nurse Handbook and the process to be audited across Universal Children’s Services to ensure consistency across teams. This should include ensuring protected time is in place for supervision of community staff nurses and nursery nurses. 5. Routine enquiries to be asked of mothers regarding domestic abuse to be included in the Healthy Child Program for implementation across Universal Children’s Services. Community Health Oxfordshire’s domestic abused strategy and guidelines to be adopted across Universal Children’s Services once ratified by Clinical Standards. 6. Information regarding reducing the risk of “Shaken baby” and the vulnerabilities of babies to be given by universal children’s staff to all families as part of the primary birth contact. Royal Berkshire NHS Foundation Trust 1. Include consideration of the developmental stage of babies and children in child protection training for A&E and paediatric staff concerning indicators of physical abuse. 2. Review the system used to inform Health Visitors about the attendance of children at the A&E department, particularly infants under 1 year of age. 3. Consider the inclusion of the use of non-prescription steroids in child protection training concerning the impact on the care of children when parents/carers misuse substances. 4. Ensure that all staff working with adults are aware of the high risk factors that are associated with significant risk to children particularly substance abuse, domestic violence and mental illness. 5. Review and modify the RBNHSFT child protection referral form to prompt consideration of all children who may be at risk not only those in the immediate household. - 9 - Oxford Radcliffe Hospitals NHS Trust 1. Staff should explicitly identify who is present and who they communicate with, using names not just family role. Explicit documentation of family members and their behaviours assists in developing a more comprehensive and holistic record enhancing individualised care and provides greater understanding of the social situation. 2. Documentation in cases of probable non-accidental injury should also include a comprehensive record of all actions being taken to assess and safeguard all members of the extended family who may be considered at risk. Oxfordshire County Council Children’s Social Care 1. Children’s Social Care and Police should be required by the Safeguarding Board to affirm that they will in future adhere to and comply with national standards for responding to child welfare concerns and OSCB procedures and will swiftly escalate any incident of non-compliance by another agency. 2. A written out of hours agreement or protocol should be drawn up between Police, Social Care and Health which creates a clear expectation that feedback on agreed actions will take place and is specific about how, when; and by and with whom. 3. SCB should make a formal request to Children’s Social Care to ensure that recording includes (a) the identities of staff undertaking all actions; and (b) decisions with reasons. Thames Valley Police 1. Named officers within this review should be advised where their actions were viewed to fall short of what was expected and training provided to address this if required. 2. Control Room procedure should be reviewed to ensure that when a single report is received detailing two separate serious incidents that both are dealt with expeditiously and appropriately. It will also enable clearer lines of communication with partner agencies. 3. Force Senior Detectives should be reminded of the need for the on call Detective Inspector to attend and take initial charge of the investigation unless there is a good reason for non attendance. They should be sure that all officers involved, including the CAIU DC, understand what their role is and what their objectives are in that role. 4. Officers involved in this case to be advised that CEDAR entries should be created in a timely manner, accurately kept and detailed to show actions taken until Major Crime have taken ownership of the case. 5. Where there are concerns about the welfare of a child, Social Care should be requested to attend addresses with police unless a risk assessment indicates this would not be safe. This would assist officers in establishing the suitability of carers for a child. 6. Training for the CID officers involved on the importance and procedure of safeguarding children. 7. Senior detectives involved to review guidance to ensure they are clear when there is a requirement to attend and the roles of specialist staff being deployed. - 10 - 8. When there is a serious incident involving a child/ children, where the Major Crime Unit are involved it is essential that there is a named Single Point of Contact within the Police and Social Care in order that communication is maintained. This link is vital to prevent a breakdown in information sharing at a critical stage. |
NC52311 | Removal of a newborn infant girl from her family under an emergency protection order, and subsequent placement in foster care. Learning includes: the local safeguarding partnership considers providing training and development for professionals working with parents and carers who may seek to manipulate and deceive; the local safeguarding partnership and partner agencies consider the requirement for a succinct process which details how to raise an alert across health services, including the need for as much information as possible about an individual. Recommends that: the safeguarding partnership reviews the existing unborn baby protocol, including guidance on the management of demographic information, the importance of discharge planning meetings, the use of toxicology results, and the risks of decision making without them, and the escalation of professional concerns between agencies; and a review of how embedded the protocol is within practice.
| Title: Multi-agency review of ‘Hattie’. LSCB: Hampshire Safeguarding Children Partnership Author: Kim Jones and Kieran Lyons Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 HAMPSHIRE SAFEGUARDING CHILDREN PARTNERSHIP Multi-Agency Review of ‘Hattie’ Chronological overview of Hattie’s case In December 2017 Hattie’s mother had a telephone consultation with her GP. She stated that she thought she was 16 weeks pregnant and requested a termination. She described her life as chaotic and that she had addiction problems. The GP gave her the information to self-refer (this is usual practice) for a termination of pregnancy. In February 2018, a referral was made into Hampshire Multi-Agency Safeguarding Hub (MASH) by the British Pregnancy Advisory Service (BPAS) raising concerns about the challenges they had encountered with Hattie’s mother. She had not attended or had cancelled a number of termination appointments (five in total). They also reported that Hattie’s mother disclosed that she was addicted to Dihydrocodeine (a semi-synthetic opioid analgesic prescribed for pain) but was receiving support from her GP to stop taking it. At the same time, Hattie’s father was one of two males stopped in a car which was found to contain numerous wraps of a class A drug and a large quantity of cash. He was subsequently convicted of possessing heroin and crack cocaine and fined. It is worthy of note that Hampshire Constabulary have almost 300 recorded involvements with Hattie’s mother and father dating from 1991 to 2018. In March 2018, Children’s Services made telephone contact with Hattie’s mother who stated that she did want a termination of pregnancy and would book urgently. Hattie’s mother was considered to be 23 + weeks gestation and at the cut off point for a termination. The case was allocated for a S17 (Child in Need) Children and Family Assessment. Announced and unannounced home visits were attempted by Children’s Services, to no avail. Hattie’s mother attended the Emergency Department around this time, with abdominal pain. She was accompanied by her sister, who refused to continue to care for her. She was described as pregnant, living in a squalid flat, using crack cocaine and had taken an overdose of paracetamol. She was discharged from the Emergency Department, with a referral to Adult Social Care reportedly being made. In April 2018, the case was progressed to a S47 Child Protection investigation due to a lack of engagement and continued risk taking behaviour and Unborn Hattie was made subject to a Child Protection Plan in May 2018. It was noted that Hattie’s mother had older children who were removed from her care in a different local authority. The Child Protection Plan was sent to Police and Midwifery Services. Midwifery in turn notified the Health Visiting Service. Information was shared across Hampshire and Southampton midwifery services in case the mother made contact with them, a national alert was also requested as part of the Child Protection Plan. The mother did not engage with any maternity service throughout the duration of her pregnancy. 2 In May 2018, Hattie’s father failed to appear at the Magistrates Court for the offence of recklessly endangering an aircraft arising from an incident in November 2017. Hattie was born in July 2018 in a hospital outside of Hampshire’s geographical boundaries – she was estimated to be 36 weeks gestation. Her mother, who arrived in labour, provided false personal details. She reported to be 40 years old and living with a travelling community in Belfast and she stated that it was her 2nd pregnancy. She stated that she had not received any antenatal care in either pregnancy; the care she had received was from a ‘lay person’ within the travelling community and that she was currently living in a car. The false details which were provided did not correlate or match to anyone on the NHS Spine. The hospital commenced the ‘Concealed Pregnancy Pathway’, which includes undertaking urine toxicology, referring to Children’s Services (in this case the Children’s Services where she presented to (not Hampshire)) and arranging a discharge planning meeting. Neonatal withdrawal symptoms were observed including jittery movement and unsettled behaviour. The midwives had some concerns about maternal drug use; however the mother denied drug misuse. The local Children’s Services Department based on information provided did not think that the threshold for social care intervention had been met. Therefore, a discharge planning meeting was not held. Instead they indicated that they would follow up with the family at the address mother had provided – which was false. Two days after discharge the toxicology report confirmed Hattie had traces of heroin, cocaine and morphine in her system. A strategy meeting was held and she was reported missing to the Police on the same day. Coincidently, Children’s Services and Hampshire Police were completing an unannounced joint visit to the suspected property of mother and father at the time mother and Hattie were reported missing. Hattie was found on the same day, at her maternal aunt’s house and was made subject to Police Protection and taken to hospital for examination. An Emergency Order was subsequently granted and Hattie was placed in foster care following discharge from hospital on the same day. Learning from the case 1. Antenatal Care The initial referral into Children’s Services by BPAS was considered to be good practice. BPAS as a charity work with the NHS to provide women with a safe service when they have decided to have a termination of pregnancy. To access this service, a woman must present her NHS number to them. In this case, that allowed them to make a referral to Children’s Services, with the correct demographical details when concerns regarding non-engagement and substance misuse arose. 3 Aside from initial contact with the BPAS service, Hattie’s mother did not engage with any health professional throughout the duration of her pregnancy. It was also difficult to ascertain who held ultimate responsibility for her care, as there seemed to be, at times, different providers taking the lead. This was compounded by Hattie’s parents moving across geographical boundaries, which led to a lack of clarity in terms of residence. There was an opportunity in March 2018 when Hattie’s mother presented to the Emergency Department, at approximately 5 months pregnant with abdominal pain, for her to be assessed by a midwife. From what was ascertained at the learning event, a referral was made to Adult Services, not Children’s Services and she was accompanied by her sister (ultimately whose care Hattie would later be found in). On this occasion she did not use false details, however, it is likely that she informed professionals that she intended to have a termination of pregnancy. It was considered at the learning event, if the repeated declaration regarding her planning to have a termination was a distraction tactic, intended at this stage to deceive professionals. There was also a discussion about the need for professionals to ensure they remain curious and pause to reflect on all of the information known and that not known to properly evaluate risk. Learning Point: Hampshire Safeguarding Children Partnership is to consider providing training and development for professionals working with parents and carers who may seek to manipulate and deceive. This should include the phenomenon first described by Reder & Duncan (1999) as ‘closure’, ‘flight’ and ‘disguised compliance’. 2. Child Protection Planning Within Hampshire there was evidence of an appropriate escalation of concern in response to mother’s failure to engage with services and given the issue with her contact details and addresses, indication that she may be actively evading Children’s Services and other professionals. When progress was unable to be made with the Child and Family Assessment, an investigation under s47 Children Act (Child Protection) was triggered leading to an Initial Child Protection Conference, all without engagement from the parents. A robust plan was developed and shared across partner organisations, and there was evidence that the plan was included within partner organisations records (Police, GP, HV & Midwifery). One element of the plan however, which appeared to have lacked sufficient rigour was in relation to the ‘national alert’. It was unclear how the national alert had been issued, and it was Children’s Services understanding that this was completed by health professionals. There was no evidence that a national alert had been shared regarding Hattie’s mothers non-engagement with professionals and concern for Hattie. Indeed the hospital where Hattie was born stated that they had not been in receipt on an alert in respect of the mother. On reviewing NHS England’s policy in relation to alerts, it is clear that the national team no longer issue national alerts and that it is the responsibility of local statutory agencies to collaborate with the Designated Professionals in the local area, to agree how to use existing networks to safeguarding the child/individual. 4 Learning Point: West Hampshire CCG in collaboration with Hampshire Safeguarding Children Partnership and partners are to consider the requirement for a succinct process which details how to raise an alert across health services. This should include the need for as much information as possible about the individual, such as NHS Numbers, due date and photographs (where possible) to ensure that they can be utilised by receiving organisations. Consideration will also need to be given to how widely the alert is to be distributed around the county, region and/or country. 3. Delivery and post-natal care At the point of admission, there was a deliberate action taken by Hattie’s parents to deceive and lie to professionals. The details of her name, date of birth and social circumstances were all fabricated. Despite not being able to identify a NHS Number the hospital did allocate a hospital number so that her care could progress (e.g. blood tests could be completed). This lack of a NHS number, should have served as an indicator or red flag in terms of what the midwifery service were being told by the mother. Without access to the correct demographical details, systems such as Child Protection – Information Sharing (CP-IS) would not have highlighted to professionals that Unborn Hattie was subject to a CPP. Hattie’s mother did inform the hospital that she had not been in receipt of any antenatal care and this led to the initiation of the ‘Concealed Pregnancy Pathway’. This pathway indicates that a referral should be made to Children’s Services and that a discharge planning meeting should take place. This internal hospital process is corroborated by the local areas LSCP Procedures which highlight that a ‘Multi-agency meeting should be held prior to discharge to assess risk and agree plan’. Despite a referral being made to Children’s Services and known risk factors being present (no antenatal care, living in a car, suspected drug use, demographic details not corresponding with the NHS Spine), a discharge planning meeting did not happen as the local Children’s Services Department decided that the threshold for social care intervention had not been met. This decision was not challenged or escalated by the midwifery service, despite a clear process for escalation being in place for all professionals. Another area which is part of the pathway is in relation to urine toxicology. In Hattie’s case, the urine toxicology was not collected until 24 hours post-delivery and not processed as urgent. This resulted in her being discharged with her mother, prior to the results being available, which in retrospect, if they had been available could have potentially changed the decision to allow discharge. Action Point: Hampshire Safeguarding Children Partnership should review the existing Unborn Baby Protocol to ensure that they reflect the learning from this case; including guidance on the management of demographic information, the importance of discharge planning meetings, the use of 5 toxicology results and the risks of decision making without them and the escalation of professional concerns between agencies. Once reviewed and if necessary, updated, the Partnership should seek to explore how embedded the Protocol is within practice. 4. Conclusion Hattie’s case was challenging for all professionals involved, primarily due to the laws around unborn babies, and the fact that professionals can only intervene when the baby is born. In this case, Hattie’s parents did not willingly engage with professionals and falsified details when they had engaged with services out of necessity. There are some learning points from the case which may help to ensure that professionals are more alert to features from this case, namely the importance of alerts, corroborating demographic details and escalating concerns when professionals step away from due process. Ultimately, Hattie was located quickly and did not suffer harm as a result of being in her parents care and she is now safe in the care of the local authority. Learning event completed on: 21/05/2019 Discussed at LIG on: 11/07/2019 Report completed by: Kim Jones, Designated Nurse for Safeguarding Children – West & North Hampshire CCGs Kieran Lyons, Service Development Lead - Hampshire County Council 27/08/2019 This report has been shared with the Local Safeguarding Children Partnership of the geographical area where the hospital and Children’s Services Departments are based. This has allowed them to contribute to the report and to adopt relevant learning points within their own learning and improvement programme. |
NC048163 | Child sexual exploitation of three girls by a young adult female who was involved in sexual activity with them and additionally recruited them in abusive sexual behaviours by a number of older adult males between January 2013 and August 2015. All girls had complex needs and missing from home episodes. Hannah had a history of self-harm, alcohol and substance misuse and may have been involved in grooming other young people herself. She was on the Child Sexual Exploitation (CSE) list and was a Child in Need. Samantha was added to CSE list following her mother's concern about her relationship with a 26 year old man, which resulted in a police referral to children's social care. Lauren was looked after by her grandparents from 2011 who struggled to manage her behaviour. The police were involved following a violent incident by her grandfather and a Section 47 enquiry began. She was in foster care for short periods and a Care Order was discussed. The alleged perpetrator was relatively young and had been a vulnerable child; in tandem with Hannah on occasions, she was part of a wider network of predominantly male operatives. Issues identified include: the difficulty in identifying the alleged perpetrator as a risk to children; the need for services to work with parents to strengthen parental confidence as perpetrators set out to deliberately drive a wedge between child and family; importance of early intervention in responding to sexual exploitation; the need to understand children as victims without choice or informed consent. Uses narrative stories for each of the children as the basis for identifying emergent themes and the Review Panel worked collaboratively to identify critical pathways, points of learning and to focus on thematic issues. Makes recommendations to introduce a process for responding to vulnerable children/young people which incorporates child sexual exploitation, in particular identifying and minimising risk from a non-familial source, build on factors that increase resilience, facilitate a multi-agency team around the child and facilitate partnership with key people in the life of the young person. Also recommends the LSCB is regularly kept abreast of information relating to sexual exploitation and missing from home incidents. Please note that this report was written in September 2016 but was published in April 2017.
| Serious Case Review No: 2017/C6379 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Serious Case Review SEPTEMBER 2016 Considering Child Sexual Exploitation Contents Page no. 1. Introduction 1 2. Membership and Conduct of the Serious Case Review Panel 2 3. Methodology and Family Involvement 2 4. The National and Local Context 5 5. Key Lines of Enquiry 10 6. Analysis 11 7. Learning Outcomes 34 8. Agency Reflections and Service Improvements 36 9. Recommendations 41 10. Glossary of Terms 42 1 1. Introduction 1.1. This Serious Case Review has been commissioned by the Local Safeguarding Children Board (LSCB) and examines the approach taken regarding Child Sexual Exploitation, between January 2013 and August 2015, by agencies represented on the LSCB. The Review uses the experiences of three (female) children known, for the purposes of this report, as Hannah, Lauren and Samantha, to inform the analysis and findings and to draw conclusions and recommendations for both improving practice and ensuring more successful outcomes for children and young people. 1.2. A less common feature of this review is that the alleged perpetrator was a young adult female, who had herself experienced a disruptive childhood. There was intelligence and information to suggest that she had been involved in sexual activity with Hannah, Lauren and Samantha and had additionally recruited them for involvement in abusive sexual behaviours by a number of older adult males. During the Review the alleged perpetrator had been subject to ongoing Police enquiries and has now been charged with a number of offences. 1.3. In this regard and given the context, the alleged perpetrator’s actions, both in respect of recruitment and actual abusive behaviours, have to be located in a much broader context of power, coercion and control which ultimately originate with a number of male perpetrators. 1.4. The Review is thematic rather than individual to each child and whilst drawing on the experiences of all three children and where possible, their parents, carers and family members, it both explores and analyses information in relation to a number of distinct, but interconnected key lines of enquiry. 1.5. The Overview Report is not constituted as three separate reviews, however a substantial amount of information regarding all three children is considered. The narrative experiences of the children are blended, both to inform the thematic analysis but also to provide some understanding from the children’s perspective regarding their experiences. 1.6. The Review references the national initiatives and reporting and considers the extent to which these have influenced local developments, as part of the drive to both understand and respond to Child Sexual Exploitation (CSE) in the LSCB Area. 1.7. The commissioning of this Review, whilst not a mandatory requirement under statutory guidance, is evidence of a willingness to achieve a deeper understanding regarding the issue of sexual exploitation across the LSCB area and to develop and improve local responses for children and young people. 2 2. Membership and Conduct of the Serious Case Review Panel 2.1 The LSCB appointed two independent Reviewers to facilitate the Review. Neither Reviewer has had any professional contact with any of the agencies involved and both have previous experience in undertaking Serious Case Reviews. In order to oversee the conduct of the Review and co-ordinate the involvement of agencies, a Panel was formulated which comprised of the following senior staff: Associate Director of Nursing, Mental Health Trust Senior Inclusion Manager, Education Safeguarding Officer, Education Principal Inclusion Manager, Services to Schools Senior Manager, Clinical Commissioning Group Service Manager for Review and Inspection, Local Authority Independent Single Agency Author, Local Authority Head of Nursing-Safeguarding, NHS Foundation Trust Detective Chief Inspector, Police Clinical Manager, Sexual Health Services Team Manager, Drug and Alcohol Support Services Managing Director, Local Therapeutic Services Assistant Director Children’s Services, Barnardo’s 2.3 The panel met on seven occasions and developed the key lines of enquiry for the review and co-ordinated all agency contributions. There was an authentic desire to use this Review to learn from and enhance local multi-agency working in order to develop practice and responses to children at risk of CSE. 3. Methodology and Family Involvement 3.1 Working Together 2013, the version applicable during the start of the Review, requires that Serious Case Reviews are conducted in such a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; Is transparent about the way that data is collected and analysed, and Makes use of relevant research and case evidence to inform the findings. 3 3.2 All agencies completed individual chronologies and analyses of agency involvement detailing what was known regarding the three children. The agency reports addressed the following questions: What is your analysis of your agency involvement with the subject child during this period? Were any assessments undertaken? Were services delivered appropriately according to organisational/statutory guidance? Were there any indicators of concerns for the child and how were these responded to? To specifically include indicators of emotional vulnerability and child sexual exploitation. Are there any factors that should be taken into account that impacted upon organisation/team/individual practice ? How satisfied is your agency that judgements in respect of safeguarding and promoting the welfare of children were sound and supported by firm evidence? Was risk to children sufficiently identified and acted upon? Are you satisfied by the management oversight? Did workers have access to reflective supervision? Was information shared across agencies at appropriate points? If not, what do you think may have prevented this from happening? Is there any organisational learning that you can identify for your agency from the information available to you? In respect of sexual exploitation: Does the agency/service consider itself to have sufficient knowledge and skills to identify and respond to CSE? Are there any gaps in knowledge that need addressing? The reports were completed thoroughly; they were analytical and demonstrated a robust and reflective approach to judgements of practice. 3.3 The timescale for the Review was determined as 1st January 2013 to the 3rd August 2015. It was agreed that this would provide scope to include historical events which were relevant, allowing for a greater understanding regarding more recent interventions and decision making. 3.4 The timelines and agency analyses were condensed into three narrative stories for each of the children and these were presented to the Panel Meeting in December 2015. These narrative stories provided the basis for identifying the emergent themes which the Review Panel believed were key. 4 In this respect the Review Panel worked collaboratively to identify critical pathways, points of learning and to focus on thematic issues. 3.5 A multi-agency practitioner meeting took place with practitioners and first line managers to consider the emerging themes and their relevance to wider and current practice. 3.6 The views of the children and their parents and carers were also sought. Ongoing investigations and a period of change limited the ability of the Review Team to explore perspectives of Lauren at an early stage. Shortly after the review was presented to the Board Lauren expressed a desire to contribute to the Review and a meeting was arranged with the Board Business Manager and Reviewer. Lauren was an extremely articulate young person, she spoke candidly of her need for nurture, acceptance and belonging and how initially this is what she truly believed the alleged perpetrator was offering her. Lauren explained that she would deliberately deceive professionals when she perceived them as threat to developing this relationship, but that she liked most of the professionals who worked with her. Lauren believed that protection should have been implemented whilst she lived with her mother and that greater controls should have been achieved for her during her adolescent years. Significantly, Lauren described that she enjoyed the controls imposed by her current carer, and how she will ask to push a boundary simply because hearing the word no makes her feel cared for. Lauren urged professionals to think beyond the obvious, to consider the role of adults in the children’s lives and how they may be connected. Lauren singled out the local mental health service as one which provided consistency and emotional support, and also stated that the two significant social workers had shown her care and concern. 3.7 The Mother of Hannah was spoken with and provided useful insights regarding the experiences of both herself and her daughter; however Hannah was clear that she did not want to contribute to the Review. Attempts were also made to contact Samantha and her family, however no response was received from Samantha and family members were unable to contribute because of other commitments. 3.8 The majority of the source information for this Review has come from the agencies’ own internal reports, contributions and analysis. Accounts of any deficits in performance have come from the agencies themselves and reflected an honesty, willingness and open minded approach to learning. This culture of transparency has enabled the Panel to have genuinely challenging discussions about how local systems can be adapted to better meet the needs of children at risk or exposed to child sexual exploitation. 3.9 The review reflected on a process of developing awareness and consequent improvement of services that have emerged in the LSCB area over the past 3 years in relation to Child Sexual Exploitation. 5 4. The National and Local Context 4.1 Child Sexual Exploitation is now recognised as a crime against a child that has far reaching consequences for the child’s life, the family and Society as a whole. The Children’s Society publication “Old Enough to Know Better” (November 2015) outlined that until relatively recently children were being exploited and then criminalised for their involvement in commercial exploitation. Only in 2015 was the law changed, which means that it is no longer possible to prosecute a child under the age of 18 for involvement in their own sexual exploitation. The language of ‘child prostitution’ has also been renamed as what it really is: Child Sexual Exploitation. Given that this Review is in relation to Child Sexual Exploitation, the working definition as described by government and adopted by the Review is as follows: Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability.” (National Working Group for Sexually Exploited Children and Young People and Working Together to Safeguard Children, 2015). 4.2 The following national, enquiries, research and inspection have all been published during the time frame for this Review: The See Me, Hear Me Framework, published in January 2014 was an inquiry into Child Sexual Exploitation in Gangs and Groups published by the Office of the Children’s Commissioner. The Jay Report, an Independent Inquiry in to Child Sexual Exploitation in Rotherham 1997-2013, by Professor Alexis Jay, which identified a range of factors at both managerial and practitioner Level, which created the conditions within which long standing and large scale sexual abuse of children in the community took place. OfSTED Thematic Inspection: The Sexual Exploitation of Children: “It Couldn’t Happen Here, Could it?” published in November 2014 identified 6 a number of findings from Practice which impacted upon successful outcomes for young people at risk of CSE. Real Voices, an Independent Report by MP Ann Coffey, examining responses to sexual exploitation in Greater Manchester in 2014 and drawing on events in Rochdale, emphasised the need to listen carefully and seriously to children and young people. Threat Assessment of Child Sexual Exploitation and Abuse: the Child Exploitation and Online Protection Centre (CEOP), published July 2013, which highlights that approximately 5% of UK children suffer contact sexual abuse at some point in childhood. Between 2011/12 and 2013/14, 90% of all Local Authorities have seen rises in Police recorded child sex offences with Police Forces nationally identifying a 40% increase in the recording of Child Sexual Exploitation Offences. 4.3 The Review recognised that these national initiatives had influenced much policy formulation, service delivery and practice in the LSCB area. 4.4 The LSCB area has a less urban and smaller minority ethnic demographic from many other areas where Child Sexual Exploitation has been linked to gang culture and particular issues regarding ethnicity. The recognition of Child Sexual Exploitation in the area has been a developing and emergent process and agencies have demonstrated a real desire to both comprehend and respond to, in a more effective way, an issue which has become more of a reality for the area, particularly over the past three years. 4.5 The commissioning of this Serious Case Review, whilst not mandatory in respect of national guidance, has also evidenced a strong multi-agency commitment to recognising and responding to the issue more effectively. This is further evidenced in local reporting and the number of local initiatives which have reflected this development as awareness of the extent and nature of the problem has grown. It was also evident from discussions with Panel members and practitioners that within the time of the review, particularly during its early stages, less was known about Child Sexual Exploitation. 4.6 Responses to Child Sexual Exploitation have also taken place within a changing landscape regarding the reorganisation and reshaping of Children’s Services. The introduction of the single assessment, the implementation of the revised version of Working Together (2015), the response to the publication of the Munro Report and changes to the commissioning of School Nursing services, which has impacted on recruitment and retention, have all been significant issues. 4.7 A recent Elected Member Briefing Paper in respect of Child Sexual Exploitation has identified key issues for the area such as: 7 Increased awareness of Child Sexual Exploitation and the consequent demand for services and impact on agencies. The need to ensure that robust early intervention and preventative services are in place. The need for effective information sharing between partner agencies and the Voluntary Sector and effective cross referencing of information and softer intelligence. The need for the effective disruption of offending behaviours. The need for ongoing awareness raising regarding Child Sexual Exploitation, particularly in Education settings and with parents, carers and families. 4.8 In order to respond to these issues the following services are available in the area: Barnardo’s Services, including both local and national initiatives. Independent Sexual Violence Advocate Service (ISVA), working with children and young people who have experienced sexual violence. Awareness raising with licensing and night workers in respect of protecting children from Child Sexual Exploitation. Missing from Home: allows early identification of risk and ensures a consistent approach to Return Interviews and referrals to support services where appropriate. Youth Workers: includes the delivery of Risk Taking Roadshows to all secondary schools across the LSCB area and the delivery of tailored Child Sexual Exploitation group work and individual one-to-one work with young people. 4.9 The LSCB leads the governance arrangements for Child Sexual Exploitation Services within the area and in collaboration with other LSCBs has performance management systems and reporting arrangements in place. 4.10 The Sub Regional Strategic CSE Group provides strategic direction across the wider sub regional area for agencies working with children and young people who may be at risk of, or vulnerable to exploitation. The Strategic Group also provides a forum for sharing good practice and intelligence across the sub regional Local Safeguarding Children Board Sub Groups and is chaired by a Police Superintendent. The Sub Regional Group has also taken the lead to deliver a preventative initiative, which aims to raise awareness and offer advice to small businesses such as taxi firms, hotels and fast food outlets, regarding the prevalence of Child Sexual Exploitation. The group has also taken the lead to deliver a major publicity campaign which provides information for children, families and professionals regarding signs and symptoms, advice and guidance. 4.11 The LSCB, CSE Sub Group, aims to strengthen the identification of young people who are vulnerable, exploited, missing or trafficked and to ensure 8 robust and effective safeguarding processes are in place in the area. The Group holds responsibility for the Strategy and Work Plan and oversees the CSE Practitioners Group. The Work Plan of the Group reinforces the four priorities of the Sub Regional Strategic CSE Group which mirror the themes of the See Me Hear Me Framework; Preventing, identification of those most at risk and ensure focussed early intervention. Protecting, to offer support and the provision of services to young people who are at risk of sexual exploitation. Prosecuting, to proactively identify perpetrators of Child Sexual Exploitation and to disrupt offending behaviour. Publicising, the promotion of awareness of Child Sexual Exploitation through schools, agencies, families and communities. 4.12 The CSE Practitioners Group works collaboratively to safeguard children and young people by sharing intelligence, interrogating data relating to possible perpetrators and locations of concern and examining new referrals and historical information. 4.13 The LSCB undertakes quarterly audits of randomly selected Child Sexual Exploitation cases, the findings of which are reported to the LSCB and are used to inform service improvement and delivery. 4.14 The following training and awareness raising programmes have also been delivered in LSCB area: Child Sexual Exploitation Drop in Sessions, which are available to Elected Members, Officers and partner organisations, including voluntary, statutory and community groups and which can be accessed through the LSCB Training Programme; Safeguarding Children from Sexual Exploitation, a one day training session available to Elected Members, Officers and partner organisations, including voluntary, statutory and community groups through the LSCB; Chelsea’s Choice, an awareness raising theatre production, commissioned by the LSCB for all secondary schools, which has currently reached a significant number of pupils, practitioners and parents; E-Learning Accredited Awareness Raising Programme, which reflects current research, government guidance and best practice; A Safeguarding Conference, facilitated by the LSCB which included contributions from Barnardo’s, Chelsea’s Choice and young people from the area. 4.15 A review of these developments clearly indicates a purposeful multi-agency recognition that Child Sexual Exploitation does exist within the sub regional area and that young people, both male and female are being groomed by a number of perpetrators. It is also unlikely however, that available intelligence 9 and data reflects the full scale of the issues as sexual exploitation and trafficking, in particular, are offences which involve silent victims, who may not have identified themselves as a victim of exploitation. Children may be deterred from reporting due to fear, intimidation, manipulation, control, embarrassment, self blame or mistrust of professional agencies. In the LSCB area there has also been a rise in Child Sexual Exploitation cases, in line with the national average noted above, with victims being predominantly female and white European. Offenders are predominantly male and the highest number of victims are aged between 14 and 15 years closely followed by those aged 16 or 17 years . 4.16 The local Police force has established a specialist unit specifically for gathering and managing Child Sexual Exploitation intelligence. Progress with regard to investigations is also shared at a strategic level with Directors of Children’s Services, Chairs of LSCBs and Senior Officers. 4.17 There is therefore, a set of robust initiatives, responses and developments which reflect a commitment from Statutory and Voluntary agencies to respond to Child Sexual Exploitation, raise awareness, improve outcomes for children and young people via robust safeguarding arrangements and to enable the effective prosecution of offenders. This was clearly reflected in both the commitment of the Serious Case Review Panel and the openness, honesty and commitment to learning by Practitioners and Managers who participated in the Practitioners Event and Briefing. In this respect the culture demonstrated by the representative agencies was positive, open to challenge, learning and reflective. 5. Key Lines of Enquiry 5.1 Whilst an initial Terms of Reference and scope regarding the Review were agreed at the Panel Meeting of the 19th October 2015, these were developed and amended into Key Lines of Enquiry. The Initial Terms of Reference were in respect of; The experience of the young people involved and whether agencies maintained a focus on the young person. A consideration of the actions of the agencies and individuals in relation to who knew what when and was this knowledge understood in relation to sexual exploitation. What factors militated against the early recognition of the risk of sexual exploitation. Whether procedures were correct and were applied consistently. Interagency information sharing. Supervision and support arrangements for staff. Training of staff in understanding and recognising sexual exploitation. 10 5.2 The Key Lines of Enquiry which were identified by the Review Panel as being of critical importance, followed the production of the children’s narrative stories and developed the original Terms of Reference into what the Panel believed were the critical factors which required exploration and analysis. These were in respect of: Thresholds: what factors influenced decision making regarding interventions, what tools and models were used to inform decision making and how effectively were safeguarding procedures utilised? Joint Working: how effective were relationships between the Police and Children’s Social Care and how effective were the relationships between the CSE Strategic Groups and Operational Practice? Multi agency working: how effective were responses to Missing from Home episodes, how effective was the multi agency planning process, how well understood were common language and processes and how effective was professional challenge? Vulnerability Factors: what were the specific vulnerability factors for Hanna, Lauren and Samantha and how effectively were these factors considered in any assessment, planning and interventions for these children? Also, how common were these vulnerability factors for all three children? Role of Parents and Carers: what were the specific issues for practitioners in respect of working with the parents and carers of the three children? How were the children assessed in the context of these relationships? Were parents and carers assessed as protective or harmful and what were the common features for these three children regarding their family backgrounds? The Child’s Voice: how were the voices of children heard and how did this influence any decision making and interventions? Understanding Child Sexual Exploitation: namely when or how was Child Sexual Exploitation identified and what were the implications for practitioners regarding skills, knowledge or resources? 6. Analysis All agencies provided comprehensive timelines, chronologies and analyses regarding involvement for all three children. These contributions, in addition to contributions made by practitioners and managers, provided the sources for the analysis in respect of the key lines of enquiry. This was assisted by contributions from Panel Members as well as the Independent Reviewers. 6.1 Thresholds of Intervention 6.1.1 The LSCB area have established robust safeguarding procedures, underpinned by a Child Concern Model. This approach enables practitioners to locate interventions in a consistent, targeted and systemic manner. 11 Contributions from Panel members and practitioners indicated a general consensus that Safeguarding processes often work well, particularly for younger children. For older children and teenagers such as Hannah, Lauren and Samantha there were perceived deficits regarding the appropriateness of child protection systems which may have precluded their application when responding to those young people who are at risk of sexual exploitation. Review participants recognised that Child Protection systems are more often used for younger children or when risk is perceived to originate from parents or care givers, rather than from an external source in the community. 6.1.2 For Hannah, there were specific concerns which included ongoing associations with the alleged perpetrator, a number of missing from home episodes and a previous history of self harm, alcohol and substance misuse. There was also resistance from both parents to agency intervention and support, including assertions from Hannah’s father that her relationship with the alleged perpetrator was a positive one. This hindered engagement with the family and created difficulties in assessing risk of harm to Hannah. 6.1.3 There was also emerging intelligence that Hannah may also have been involved in grooming other young people, warranting consideration at the CSE meetings. Additionally, there was a significant volume of concerning photographic data which was recovered by Police, describing sexual relationships between Hannah and at least two males over twenty years of age. Hannah had described to her Social Worker intimidation by the alleged perpetrator and her associates and there was Police Intelligence to suggest that Hannah was associating with at least 2 males, about whom significant safeguarding concerns had been expressed. 6.1.4 This information and intelligence emerged over time during the Review period and interventions whilst provided initially on an Early Help basis then continued on a Child in Need basis. A first referral was made to Children’s Social Care by school in April 2014, regarding Hannah’s relationship with the alleged perpetrator and significant drug and alcohol misuse. The outcome of the referral concluded that outreach support would be provided. Hannah’s father at this point had also been described as rejecting of support, refusing any interventions and had attempted to minimise the risks to Hannah. Later that month, Hannah was admitted to hospital following a paracetamol overdose, which Hannah described as a suicide attempt and self harm lacerations. In June 2014, because of concerns raised by Police and the NSPCC regarding Hannah’s associations, Hannah was added to the CSE list. This included children considered at the CSE Practitioners group and the process was considering the circumstances of up to 60 children at any one time. 6.1.5 In August 2014, Hannah was found by Police in the early hours of the morning with the alleged perpetrator and a male about whom there were serious concerns regarding the exploitation of children. Following this it was 12 agreed that a Common Assessment Framework (CAF) would be completed on Hannah’s return to school. This response did not comply with the threshold criteria and reflected a much lower response than was necessary. By October 2014 there was evidence of interagency challenge when concerns were expressed by the Police regarding the level of social work intervention. Police intelligence suggested that Hannah had been attending an address where drug and alcohol use was taking place and where the alleged perpetrator was attending, along with older adults. It was agreed that a Social Care Assessment would be completed and Hannah’s Social Worker was directed to complete an assessment. 6.1.6 The Chair of the CSE Practitioners meeting also raised a concern that responses to Hannah should be treated as a Child Protection/Safeguarding issue, not as a Child in Need intervention. The Chair requested an immediate Strategy Meeting as she believed that Hannah was being sexually exploited and that Hannah’s parents were not engaging with the Social Worker. This incidence provides evidence of oversight and challenge but, given the subsequent actions, no effective feedback loop, as no assessment was completed for four months which again concluded a need for Child In Need services. A new, specifically chosen Social Worker was appointed to impress upon Hannah’s parents that there was reliable information to suggest that Hannah was being exploited. In November 2014 a significant volume of photographic material was recovered from Hannah’s phone and she reported to her Social Worker that she was in a relationship with a male who posed a risk to children. Hannah’s parents were again described at this time as hostile and intimidating to receiving this information. The conclusion of the assessment resulted in a referral to local Barnardo’s services, and whilst this was an appropriate referral, Hannah remained defined as a Child In Need throughout the Review period. 6.1.7 For Samantha, her involvement with Children’s Social Care prior to 2014 was limited to the provision of equipment and signposting to other services. It is well documented that Samantha’s mother found her behaviour to be challenging and difficult to manage. In March and June 2014 there were Missing From Home (MFH) episodes and concerns reported by Samantha’s mother, that Samantha was in a sexual relationship with a 26 year old man and that Samantha was at the address of the alleged perpetrator. In June 2014, on the date of the 2nd MFH episode, it was indicated that Samantha had been assaulted by her Grandmother and again later the same evening by a member of the public. On this occasion Samantha was reported as heavily intoxicated and in the presence of a 26 year old male, about whom there were significant safeguarding concerns. Whilst the first missing incident was not shared by the Police, later in June the Police did make a referral to Children’s Social Care which stated that Samantha had been in a sexual relationship with an older male and was associating with the alleged perpetrator. The outcome of that referral was that the Early Help Service would continue to support Samantha, with no indication that a further 13 assessment was necessary. This would suggest that the key indicators of CSE such as association with older males and missing from home were not sufficiently understood as risk factors at that time. In October 2014, Samantha was added to the CSE list for consideration at the Practitioners Group. 6.1.8 Using a locally agreed referral tool, the Police made a further referral to Children’s Social Care in April 2015, this was recorded as a contact when it should have been treated as a referral and the Police were informed that Early Help had been offered to Samantha. The Police had also provided additional information that multiple males had been contacting Samantha via Facebook, in relation to sex and drug use. At this point the Assistant Director for Children’s Social Care, following concerns expressed by the Police, requested that this be progressed to a referral and an appropriate Assessment. This again indicated appropriate challenge by the police. The subsequent assessment led to a referral to local Barnardo’s services in July 2015 which did result in significant attempts to engage her by the allocated worker, although Samantha was inconsistent in her responses and engagement. 6.1.9 For Lauren the interventions follow a different pathway. Lauren had been living with her grandparents since 2011 and they were struggling to manage her behaviours. Grandmother was concerned that Lauren had been missing on at least one occasion and that she had been uploading photographs of herself kissing boys on social media sites. In February 2013 Police were called to the Grandparents home, as it had been reported that Lauren had been refusing to comply with boundaries and was being restrained on the floor. Lauren disclosed that her Grandfather had head butted her and a Section 47 Enquiry commenced. Lauren was accommodated but returned to her Grandparents home after 11 days in foster care, at which time the Police Investigation was incomplete and her grandfather had not been spoken to regarding the incident. 6.1.10 Within a short space of time, the situation deteriorated to the point that a tent had been erected in the garden for Lauren to sleep in. This resulted in Lauren being accommodated in July 2013 for a second time and she returned back to her Grandparents care in November 2013, at Grandmother’s request and following Lauren’s wishes. It was clear that the Children’s Social Care Team had reservations, but felt powerless to direct any other option. This decision for Lauren to return home was not however underpinned by an assessment of the risks and there was no risk management process put in place. There were continued reports of Lauren being missing from home, at one point for four times during one week and a further allegation that her Grandfather had head butted her. Whilst the relationship between Lauren and her Grandfather had been acknowledged as a volatile one, with reports of Lauren attacking both her siblings and her Grandparents, interventions remained on a Child in Need basis. 14 6.1.11 In May 2014, Lauren was accommodated for a third time following a further Section 47 Enquiry and this time the application of the Public Law Outline (PLO) was considered. The Section 47 Enquiry also concluded that Lauren should remain in Foster Care. Information provided to the review indicated that an application for a Care Order was discussed with Lauren by the Independent Reviewing Officer, but that Lauren was adamant that she did not want this to happen. Further discussions took place but ultimately a decision was made not to initiate care proceedings. 6.1.12 There are a number of issues which flow from the narrative stories of the three children. Firstly, that that application of thresholds did not sufficiently identify risk of CSE and consequently utilised Child in Need or Common Assessment Framework (CAF) Protocols without consideration of child protection procedures associated with higher levels of risk. Secondly, for all the children there were points which clearly evidenced increased risk of significant harm but which did not result in a review of how thresholds were being applied. In attempting to understand why more formal safeguarding systems had not been applied, a number of themes emerge. Practitioners and managers raised the issue that child protection procedures and Conference are seen as a forum where risk is presented solely from within the structure of the family rather than from the community. This may have been a factor which precluded the application of child protection processes, as the major source of risk for all three children was their association with the alleged perpetrator and a number of older males. The application of the Child Protection Plan also carries with it the inference that any safeguards that parents or carers may be providing are inadequate, leading to an overall assessment of continuing risk of significant harm, where parents and carers are a significant risk factor. 6.1.13 Practitioners also described some of the difficulties in applying a protective system where there are ambivalent, resistant or challenging behaviours exhibited by the young people. Throughout the process Hannah consistently denied any sexual involvement with the adults who posed a risk of harm, whilst Lauren indicated that she did not want to be subject to Care Proceedings, stating that there were too many people in her life and that she did not want any further involvement. The perceived effectiveness of safeguarding systems for hard to engage young people was therefore a consideration. For Samantha, there were misplaced assumptions regarding her capacity to consent based on her chronological, rather than her functioning age, alongside a poor understanding of an ability to exercise choice in an abusive situation, which then influenced decision making. 6.1.14 There may also have been a reticence to use what has traditionally been seem as a more adversarial system, in the desire to achieve a greater level of engagement with family. The resistant and sometimes hostile stance of Hannah’s parents in particular demonstrate this, as practitioners clearly 15 wanted to engage more positively with Hannah’s parents to enhance her protection. For Lauren, violence had become part of the family dynamics, with Lauren herself often being violent towards her Grandparents and siblings and it was difficult for practitioners to differentiate between victim and perpetrator, particularly with regards to the violent episodes in the home. There was however, sufficient evidence to indicate that the actions of Lauren’s carers were both emotionally and physically harmful to her. If the practitioners had been more minded with regard to sexual exploitation, they may have given greater consideration to the damaging effects of this behaviour on Lauren’s self-esteem and how this could have increased her vulnerability to exploitation. For Hannah, the resistant and minimising stance of her parents was clearly a concerning enough risk factor. 6.1.15 Whilst practitioner perspectives regarding the appropriateness of child protection systems have been noted, there were issues for all three children, regarding some level of risk posed by their parents and carers. Whilst Lauren’s experience was different, in that she was accommodated several times, there was evidence that at least one Section 47 enquiry remained incomplete and that Lauren moved back to her Grandparents a number of times without a good enough assessment of risk or a risk management plan. For Lauren there were two broad levels of intervention, Accommodation as a Looked After Child, or interventions on an Early Help or Child in Need basis. Whilst an application for Care Proceedings for Lauren was considered and recommended by the Social Worker, this was not progressed and a number of practitioners described this as a missed opportunity. 6.1.16 Whilst it may be that the Board does need to consider more innovative ways of identifying and managing risk and vulnerability for older children and young people, particularly in the area of Child Sexual Exploitation, there was sufficient information to suggest that Safeguarding Procedures may have been a more appropriate response in all these cases. Practitioners and Managers described the use and value of an agreed diagnostic tool which assisted decisions regarding where interventions are to be located, yet analysis indicated that this was not used either consistently or appropriately in all the cases. It was difficult to get a sense of transition from Early Help via Common Assessment Processes to Child in Need and then Child Protection levels as events unfolded. 6.1.17 In terms of the unusual circumstances regarding the gender of the alleged perpetrator, the following issues emerged. The alleged perpetrator was a relatively young female who had herself been a vulnerable child. This may have hampered the ability to recognise that essentially what was taking place was the sexual abuse of children by an adult. Powerful normative societal values perceive women as nurturers and sexual abuse as a feature connected to male dominance and power. Although statistically sexual offenders are in the vast majority male, there are many examples of women who operate as sexual abusers alone and within a partnership. In the context of Child Sexual 16 Exploitation, the recruitment of other young people by a peer is also a common feature. This will have been compounded by the age of the alleged perpetrator. Assessing circumstances whereby a young person is considered a victim as well as perpetrator is a particularly challenging aspect of sexual abuse. The alleged perpetrator, in tandem with Hannah on occasion, was part of a wider network of predominantly male operatives, whom this review has not considered and as one practitioner stated ‘we have been looking [criminally] at the wrong people. Finding: Assessing risk of sexual exploitation must be embedded into early help services. Thresholds need to be applied at a level consistent with risk. Social work assessments need to be applied in a timely manner. Looked After Children care planning needs to focus on security and permanence. 6.2 Joint Working 6.2.1 The Review acknowledged both the commitment to joint working evidenced by Panel Members and also the clear protocols which are in place governing joint working in the area. However, analysis of information presented to the review indicated a variable picture, with evidence of good practice, challenge and timely interventions but with some evidence of weaker responses. 6.2.2 Consideration of the responses to Missing from Home episodes presents variable, but often less than satisfactory responses. In Hannah’s case, her parents did not always report her missing. Hannah’s mother informed the review that they wanted to address the issue themselves and evidence suggests that there was a level of parental resistance and hostility, particularly regarding Police involvement. This clearly limited the ability of agencies to respond to events as they were unfolding. In some instances there was a delay in information sharing, which hindered the effectiveness and agility of responses and concerns were expressed by Police regarding delay and the quality of joint working during the investigative process regarding Hannah. 6.2.3 On occasions when Missing from Home incidents were responded to by the Police, there is evidence to suggest that information was not always shared with Children’s Social Care. In Samantha’s case there were two Missing from Home episodes, one which took place in March and the second in June 2014. No referral specifically followed either incident. The incident in June ended when Samantha was found by Police Officers with a much older male who was supplying her with alcohol. This episode was not subject to any Police 17 investigation and no referral information was communicated to Children’s Social Care regarding this incident. Information was also conveyed by Samantha’s mother to Police Officers at the time, regarding her daughter’s complex needs, developmental functioning and her vulnerability to sexual exploitation. The Police analysis acknowledges that whilst Samantha was located and advice provided, no offences were recorded and the alleged assault by her grandmother was not mentioned and not crimed. This is also the case with regard to an allegation, made at the same time by Samantha’s mother that her daughter was in a relationship with a 26 year old male. In addition, no checks were undertaken regarding Samantha’s Aunt, with whom she then went to stay until the volatile situation that the Police were responding to had calmed down. The subsequent referral was recorded as a contact only, and it was noted that, as Samantha was shortly due to move out of the area to be with her mother, the risk was diminished. 6.2.4 Information from Lauren in June 2014 suggested that she had witnessed sexual activity between Samantha and an older male, although it was not until October 2014 that Samantha was referred to the CSE Practitioners Group. In February 2015 at 3am, Samantha contacted the Police requesting assistance as she was concerned and frightened regarding the actions and behaviour of a male who was intoxicated and behaving aggressively. Police attended, although it is recorded that Samantha was with another female who took Samantha to another address. No details were recorded of who the other female was, who Samantha was left with and whether this was either suitable or appropriate. There was also no referral attached to the event which suggested again that information was not shared with Children’s Social Care. The absence of referrals beyond the Police appeared to relate to officers not contextualising or understanding what might have been taking place due to a lack of knowledge regarding the signs and symptoms of exploitation and the specific risks faced by the child, even though she had already been considered at the CSE meeting. 6.2.5 The issue of Hannah’s parents non-reporting of missing episodes has already been described and this in itself was a significant risk factor which should have been clearly identified as a safeguarding concern within the family. However, Hannah disclosed that on occasion she had been picked up, sometimes as late as at 4am by the Police, without any other agency being made aware that she was missing. 6.2.6 There are a number of examples of good practice with the Social Worker for Hannah responding to police information in a timely way and attempting to engage her parents. Recording for Hannah was detailed and thorough. 6.2.7 Lauren had no missing episodes recorded until January 2014 when there were at least 6 episodes recorded during the month. Recording for Lauren is patchy by Children’s Social Care, which makes it difficult to understand some of the responses. In June 2014 the school expressed concern about Lauren 18 being missing, although it was subsequently recorded during a meeting at school a few days later, that there were no safeguarding concerns for Lauren. There were however, instances of good practice and clear evidence of more appropriate responses regarding missing episodes for Lauren whilst she was in Foster Care. Thee responses were robust and appropriate, indicating that Looked After Children processes were in place and joint working between Police and Children’s Social Care was better supported. 6.2.8 There were some practical considerations which impacted on the effectiveness of joint working, such as a lack of notice being given regarding key meetings, which hindered the ability of key officers to attend. This was evident in exchanges between the Police and Children’s Social Care (CSC) regarding Hannah in September 2014, where Police information indicated that they understood there was no social work activity and insufficient contact between the Police and CSC regarding safeguarding Hannah. However records indicate that a Social Work service was being provided at this time along with support offered by a local Drug and Alcohol service for Young People regarding Hannah’s alcohol use. 6.2.9 The analysis of joint working indicates a varied picture, with some instances of positive and timely practice and other indications that key information was not always communicated, particularly between Police and Children’s Social Care. Information also suggests that there were examples of misunderstandings, such as the assumption made by Police that there had been no Social Work involvement for Hannah during the summer of 2014, when a number of services were being provided. When some referrals were made by Police to Children’s Social Care, such as in the case of Samantha, they were not always responded to in a robust manner. For Police Officers who may have been relatively inexperienced, or who lacked a knowledge base regarding the dynamics and complexities of Sexual exploitation, this raised the importance of training, development and access to guidance and information which impacted on the quality of response. Practitioners also described uncertainty about what information could be shared, particularly with parents, and which information could be legitimately shared with professionals, all of which impacted on a shared understanding of the children and risks they were facing. Information from the Practitioner Event suggested that Police Officers responding to missing episodes were not always sufficiently knowledgeable about signs and symptoms of sexual exploitation and that intelligence systems did not always reflect children about whom there were specific concerns. Whilst the lack of an application of a more appropriate safeguarding system will have undoubtedly contributed to this issue, a more systemic approach to the recording and administration of information about specific children may have improved the ability of officers to identify and share indicators regarding ongoing risk. 19 Finding: Quality of information is significant, particularly when sharing across agencies. Uniformed police officers need to have sufficient knowledge of sexual exploitation to deploy safeguarding responses. Missing from home is a key indicator and needs a consistent and coherent multi-agency response. 6.3 Multi Agency Working 6.3.1 The Review acknowledged the willingness of multi-agency partners to work together in the area and this was evidenced during the Review by the agencies represented. The Independent Reviewers observed a culture that was constructively challenging and open to learning, with agencies demonstrating a strong commitment to both understand the nature of what had been taking place and to develop local solutions and responses. There is a strong foundation for multi-agency working which is supported by comprehensive policies and procedures. 6.3.1 There were a considerable number of agencies involved with the three children, particularly for Hannah and Lauren, to the point where Lauren believed she was overwhelmed with services and consequently expressed frustration at having to repeat her story to so many professionals. Whilst these local agencies were providing valuable therapeutic and support services, the absence of a more focussed planning process was noticeable and this was an issue raised by the mother of Hannah during the Review. This absence of a structured approach to multi-agency planning and review also contributed to some practitioners feeling like they were working in the dark. Whilst this was due in part to the developing and emerging awareness of the nature of sexual exploitation, practitioners described a lack of clarity and explicitness regarding the issue which would have been assisted by a better defined and sharper focus on multi-agency planning and review. There were however, some good examples of effective informal communications between practitioners and this may have compensated for the overarching weaknesses. 6.3.2 The perceived weaknesses in the child protection system, to respond effectively to high levels of risk and vulnerability outside of the family, influenced and impacted on the quality of multi-agency working. It is also true however, that whilst Child in Need and Early Help models were utilised, because they were perceived as being far more co-operative and consensual, there remained an absence of a multi-agency infrastructure regarding children’s plans, meeting and reviews. Consequently, all of the interventions for the children, particularly Samantha and Hannah, were not structured around an individual child’s plan. Practitioners and managers described how 20 Child In Need and Early Help arrangements are not always perceived as statutory in the way accepted for child protection processes, which has a limiting effect on activity and attendance at meetings, which can often be resource led and therefore inconsistent. Whilst Lauren’s views regarding the need for Care Proceedings have been noted, there is a question as whether this was allowed to override what was in her best interests. Although Lauren’s home life was chaotic, leading to regular family breakdown, no firmer or more decisive action was taken and Lauren needed to be subject to a more rigorous risk management approach. These findings are consistent with the Ofsted Thematic inspection published in November 2014 which identified the following similar themes: That Local authorities and police are not always following formal child protection procedures with children and young people at risk of child sexual exploitation. Screening and assessment tools, where they exist, are not well or consistently used in some local authorities to identify or protect children and young people from sexual exploitation. Plans of how local authorities and their partners are going to support individual children and young people at risk of, or who have been sexually exploited, are not robust. Local authorities are not keeping plans for Children in Need under robust review. This leaves some children in a very vulnerable position without an independent review of their changing circumstances and needs. Management oversight of cases is inconsistent and is not strong enough to ensure that cases are always being properly progressed or monitored in line with the plan. 6.3.3 The infrastructure regarding the arrangements of the CSE meetings has been described under the section on Local Context, yet analysis of how these systems operated indicated a number of issues. Firstly, decisions and information were shared at a strategic level but there was a concern from practitioners that this was not sufficiently cascaded down to operational activity or case management. Secondly, feedback from Practitioners suggested that because the Police did not issue information for a number of weeks, other professionals were not always aware of the salient issues at a point when they could take action. Consequently practitioners described some uncertainty and ambivalence regarding what they were responding to, and how timelines impacted upon their options. A striking message which emerged during the Practitioner Event was the description of sexual exploitation in these cases as a ‘Guarded Secret’. This will have undoubtedly influenced and contributed towards a limitation in recognising what is essentially sexual abuse of children and will have contributed to a lack of clarity regarding decision making. Thirdly, and connected to this point, the relationship between the Strategic and Practitioner CSE Groups was not always clear and information flow was not efficient, timely or agile. Recommendations from CSE meetings were not always actioned and there 21 was no feedback to ensure this occurred. The Jay Report (2014) emphasised the absence of risk assessment and risk management as part of an environment that left risks badly managed. 6.3.4 Comprehensive information was supplied by the schools, certainly in Hannah’s case regarding concerns about her relationship with the alleged perpetrator. The concern about how and where softer information and intelligence could be shared without the knowledge of family meant that in many instances, agencies did not have common knowledge. This was compounded by the use of Child in Need or Early Help multi-agency approaches where service provision and interventions are based around parental/young person consent regarding information sharing and communications. The use of the Child Protection Conference, with a facility for confidential intelligence sharing and discussion may have assisted with this, particularly in respect of concerns regarding the children’s associations and networks. 6.3.5 The issue of capacity and resources does merit some consideration. A common theme emerging from the Practitioner Event was that working with children and young people at risk of sexual exploitation is both time and resource intensive, in terms of recognition and response, building trust and relationships and multi-agency working. A number of practitioners raised the issue of capacity in this respect and also suggested that whilst interventions for much younger children are extremely robust in the LSCB area, there is a need to remain equally focussed on the vulnerability of teenagers. This is a message supported by the Children’s Society publication, Old Enough to Know Better which illustrates the particular vulnerabilities of 16 and 17 years olds to sexual exploitation, and in particular how the law offers less protection to a child of this age. This includes the fact that a child at 16 is of a legal age to consent without any clear definition of consent and is often seen as no longer a child despite the provisions of the Children Act 1989. The child is unprotected through the disruption of offenders by means of Child Abduction Warning Notices, which only apply to children under 16. 6.3.6 Practitioners reported a culture that supported challenge, and this is evidenced specifically through this Review. In the case of Samantha, intervention by the Assistant Director for Social Care following an alert from the Police did lead to an assessment being completed in place of the already existing CAF. However, in the case of Hannah, concerns reported by the CSE chair did not generate a more robust safeguarding response. In this sense therefore, the evidence from the Review regarding the effectiveness of professional challenge is mixed. There are examples of leadership challenge but this was weaker in follow up. Officers suggested that a more practitioner inclusive multi-agency approach to audit could offer a way forward in enabling a greater understanding of where weaknesses occur in multi-agency working, as well an opportunity to undertake reflective practice in a multi-agency context. 22 6.3.7 Practitioners received professional supervision, but the sole focus remained a single agency approach, which is open to the charge of being narrow in focus, particularly when responding to some of the complexities regarding sexual exploitation. In this respect it was felt that the development of a model of professional thinking time would be welcomed, in the context of facilitated, purposeful, professional only meetings. In evaluating whether a culture of curiosity was embedded within agencies, the evidence again suggested a mixed picture. It was clear that the foster carer caring for Lauren was both tenacious and determined in attempting to establish whether Lauren was having contact with the alleged perpetrator. This resulted in the foster carer following her to school on a number of occasions and reporting her concerns to the Fostering Agency which in turn were shared with the Local Authority. Both Hannah’s parents and Lauren described the involvement of one particular member of school staff who communicated well with the children, their carers and agencies on a regular basis and whom Lauren reported as being only one of two individuals that she could trust. 6.3.8 By contrast, when Samantha attended the Urgent Care Centre in February 2014, reporting that she had been kicked in the arm, there are no enquiries with regard to what had happened. Whilst there were additional concerns in relation to her complex needs, challenging behaviours, sensory impairments and deteriorating family dynamics, there were no referrals to Children’s Social Care from key agencies who had been involved with her in the early stages of the Review. At a multi agency meeting in March 2014 it is recorded that the medical specialist had planned to contact agencies in the area local to where Samantha was living with her mother, yet there is no indication in any records that this took place. Similarly, when Samantha moved area for a short time to be with her mother, the minutes of the CSE meeting (December 2014) recommended that the Police must share information with local Policing in the area Samantha had move to. However, Samantha is not mentioned in the minutes of the CSE Meeting in February 2015 and no indication is given that this recommendation had been actioned. When Samantha moved back to the LSCB area and was seen by the Education Psychology Service it was then concluded that Samantha’s particular combination of difficulties would make her very susceptible to exploitation. 6.3.9 Hannah had considerable contact with CAMHS in 2013 in relation to concerns regarding low self esteem, deliberate self harming, relationship difficulties, familial mental health issues, challenging behaviours, learning difficulties and an inability to engage with services. Whilst these signs and symptoms in themselves are not necessarily an indication of or susceptibility to sexual exploitation, they do point to significant vulnerability. In early March 2014 a referral was made to Children’s Social Care regarding Hannah’s relationship with the alleged perpetrator and alcohol and possible cocaine use, in late March, Hannah attended hospital following an overdose where it was noted that she had lacerations to her arm and there were concerns noted regarding 23 her low mood, lack of friends, parental resistance and a lack of school support. Hannah was admitted to hospital approximately 3 weeks later, following a missing episode and an episode of self harm using a pencil sharpener blade. She was 14 at this time, and no enquiries or communications took place with Children’s Social Care, regarding her vulnerabilities. 6.3.10 Practitioners had raised the issue of lack of knowledge, uncertainty regarding when sexual exploitation needed to be considered and stereotypical assumptions regarding gender roles in Child Sexual Exploitation as being a hindrance in recognising exploitation. The Rule of Optimism (Dingwall, Eekelaar and Murray 1983) was also recognised as a possible rationale for understanding how professionals process and rationalise certain indicators and events, limiting the ability to identify safeguarding concerns. The consistent use of Early Help or Child in Need Systems will have reinforced this pattern of thinking. Recognising the significance of inhibitors is critical in developing a more effective culture of curiosity or respectful uncertainty. Conformational bias, the tendency to see what already supports rather than what challenges our views is a dangerous pitfall for professionals, and one which needs skill, critical thinking and a reflective and challenging working environment to mitigate against. Finding: There is a strong commitment and desire to work together and a culture of willingness, transparency and challenge. Multi-agency structures across all the continuum of need are necessary to underpin communication and safer outcomes. Children’s Plans need to be underpinned by accurate assessment of risk and need. 6.4 Vulnerability Factors: 6.4.1 In examining the particular vulnerability factors for the three children a number of common themes emerge. There were social histories which include the absence of parental figures, particularly mothers. This was the case for both Lauren, who had not had contact with her mother for a number of years and Samantha whose mother was living a significant distance away during the period of Review. This also extended to fathers, so that whilst Hannah’s mother was present, her father was reported to work for significant periods of time away from the family home. Lauren, who was living with her grandparents, had not any contact with her birth father for a number of years and there are no records of Samantha’s birth father. 6.4.2 Histories of abuse and family dysfunction were evident. This was particularly the case for Lauren who had experienced physical violence including 24 exposure to domestic violence at home, her mother and mother’s partner’s substance addiction and prolonged experience of caring for her younger siblings. The CAMHS summary of January 2013 records, a girl who has been abandoned by her mother who is a current heroin user, who has a history of family breakdown, hostile or rejecting relationships, being bullied at school by other children, communication difficulties, tells lies and displays anger and aggression. These circumstances also appear to be replicated, at least in part, in the family setting of her Grandparent’s home. For Samantha, there was involvement by additional agencies as far back as 2006 regarding support around boundaries, challenging behaviours, the provision of aids and adaptations and a referral to CAMHS, which followed concerns regarding sexual activity with 2 boys when she was 8 years old. Samantha had a sensory impairment and learning difficulties, a diagnosis of Attention Deficit Hyperactive Disorder (ADHD) and functioned well below her developmental age. These elements were insufficiently considered in relation to her susceptibility to sexual exploitation. For Hannah there were concerns regarding low self-esteem, self-harm, relationship difficulties, the prevalence of mental health issues within the family, challenging behaviours and low mood. 6.4.3 For all the children, the interventions would have been better progressed through comprehensive and robust assessments of risk. These early indicators of vulnerability should have influenced to a greater extent the decision making around thresholds of interventions, in accordance with the LSCB threshold document. Lauren was consistently reminded by her Grandparents that she was worthless and they often conveyed messages that suggested to her that she was evil and unwanted. The incident whereby a tent was put up in the garden for Lauren to sleep in is almost beyond comprehension and will have conveyed a profoundly negative and corrosive message regarding her self worth, self esteem and intrinsic value. In this respect the significance of low warmth/high criticism environments with regard to the assessment of vulnerability and risk, as referenced in Messages from Research (1995), is particularly applicable. 6.4.4 A related issue for all three children was their regular use of social media sites which was influencing their responses and behaviours and whilst this is a more complex issue to analyse, for these children it provided a form of communication and networking that increased, rather than minimised their vulnerability. The only evidence of any attempt to manage this was by the foster carer for Lauren, who attempted to limit the use of the internet and i-pad and provided appropriate parental/adult oversight. The need for e-safety knowledge is a significant one for parents, carers and practitioners, as in general terms, adults are often less knowledgeable than children about the changing pace of technology. 6.4.5 For all the children there were also indications that drug and alcohol dependency, risk taking behaviours, episodes of missing from home, issues of 25 abandonment and loss, dependencies on the alleged perpetrator and associations with a number of males who posed a risk, were also all prevalent. As all the children at some point, displayed some significantly challenging and ambivalent behaviours, the Review considered how much this influenced an assessment of vulnerability, rather than an assessment of the children as being challenging or difficult. This was raised by practitioners as possibly lessening an assessment of vulnerability and awareness of abusive contexts, increasing the assumption that children and young people are therefore self determining or making active choices. Whilst the Review did not find any evidence of concerning practice in this regard, there was an acknowledgement that challenging behaviours can often be conceptualised as a problem for or within the child, rather than a symptom of vulnerability. 6.4.6 There was certainly recognition at the Practitioner Event, that the characteristics described will have increased susceptibility to sexual exploitation and that the inconsistent use of screening tools and the lateness regarding social work assessments, particularly for Hannah and Samantha will have prevented an early and more holistic analysis of vulnerability. This will have impacted on both awareness and recognition of risk. The vulnerability and risk factors described above were consistently acknowledged by practitioners as concerning, providing evidence that collective and organisational thinking had developed beyond the Review Period. Whilst it was also acknowledged that some of these features in themselves do not definitively predict the presence of, or susceptibility to sexual exploitation, there was certainly some recognition that the prevalence of such a number of these factors increased vulnerability significantly. To this end, there is a need to ensure that Early Help organisations have a firm understanding of sexual exploitation with comprehensive guidelines and for social work assessments to be analytical rather than descriptive. Finding: Attachment and loss are highly significant vulnerability factors. Complex needs such as disability, mental health, drugs and alcohol need to be considered as part of assessment and risk assessment. Long standing family dysfunction compounds the potential for successful interventions. 6.5 Role of Parents and Carers 6.5.1 Policy, Procedures and Practice in the LSCB area are strongly orientated towards developing meaningful and outcome focussed partnerships with parents, family members and carers. This is evidenced by the use of the holistic approach in the area and the various tools which aim to capture the views, wishes and feelings of parents and carers at all stages of interventions. 26 6.5.2 An analysis of the role of parents and carers in these three cases indicated several common themes, some of which have been described earlier. For Lauren, who had not had contact with her mother for a number of years and about whom there was some evidence of idealised thinking by the child, the relationship was characterised by ambivalence, broken promises regarding contact and a consistent awareness of her mother’s inability to break free from significant drug dependency. A dysfunctional dynamic was also present in the relationship between Lauren’s mother and her Grandparents with evidence to suggest that Lauren’s mother exacerbated some of the difficulties that Lauren was experiencing with her Grandparents. In March 2013, Lauren’s mother had not fulfilled a promised commitment to have contact with Lauren; this was highly distressing for Lauren, particularly as her mother requested an assessment as a carer when she was accommodated. Whilst this was appropriately not progressed, it will have created confusion and ambivalence for Lauren. Again, as before these messages will have had a corrosive impact on Lauren’s emotional well being, in addition to the negative behaviours of her Grandparents which have been described above and which indicate poor attachment and greater vulnerability. Of particular concern were events in September 2013, where Lauren’s birth father, with whom she had not been having contact, resumed a relationship with her and contact between Lauren and her birth father began to take place. This broke down quickly and will have undoubtedly created additional rejection and distress for Lauren, increasing her emotional fragility and vulnerability, particularly in respect of her need for acceptance and belonging. 6.5.3 For Hannah, the role of parents differed markedly. There was evidence of an ambivalent relationship between Hannah and her mother. There are a number of occasions where Hannah’s father is noted as being rejecting of support, requesting that agencies leave Hannah alone and that Social Work involvement would be professional overload. There are also occasions when Hannah’s mother indicated that she was displeased with the service and there was a belief by professionals that the parents were obstructing access to their daughter. For much of this time interventions were provided for Hannah on an Early Help and Common Assessment Framework (CAF) basis, and even up to November 2014 there are indications that the CAF had still not been completed. As described earlier, the chair of the CSE Practitioners Group raised concerns regarding the lack of a Child Protection focus and concerns were also expressed in October 2014 that the parents were minimising concerns. The lack of co-operation, and potential for collusion from Hannah’s parents was not sufficiently assessed as a risk factor which increased Hannah’s vulnerabilities and susceptibility to further exploitation. 6.5.4 Hannah’s mother stated to the Review that whilst Hannah was sneaking out at night, both parents had wanted to protect her without agency involvement. When asked about the hostile stance that both parents had taken with agencies, particularly the Police, Hannah’s mother reported that on one occasion the Police had raided and searched the house, had 27 threatened to “drag” Hannah down the stairs and accused her father of being a “poor” father. Hannah’s mother also reported that whilst Hannah was unwell in bed, officers had arrived in a number of vehicles, had demanded her phone and also took items that the Police did not have authorisation to take, such as an i-pad, as the warrant was only in respect of the phone. In this respect Hannah’s mother reported that the manner and demeanour of officers was intimidating and threatening. This suggested that even at this late stage, the gravity of the concerns regarding the images or data that Hannah may have been in possession of, was not fully appreciated or understood by her parents. 6.5.5 For Samantha, there were significant issues regarding her Grandmother that were not adequately assessed. The incident in June 2014 where the alleged perpetrator reported to Samantha’s mother over the telephone, that her Grandmother had physically assaulted Samantha, was never addressed. Neither was the connection between Samantha’s mother and the alleged perpetrator sufficiently explored. Similarly, the apparently volatile relationship between Samantha and her Grandmother was not sufficiently explored or addressed in any assessment, which is particularly pertinent given Samantha’s complex needs. Interventions progressed on an Early Help basis until May 2015 when the Assistant Director for Children’s Social Care instructed that a Children and Families Assessment was to be undertaken. 6.5.6 There is a significant amount of information to suggest that parental factors were not sufficiently addressed as part of an assessment of risk or vulnerability. For Samantha and Hannah, the resultant assessments were undertaken at a late stage and only after direction from senior management in Children’s Social Care and challenge by the Police. The absence of a risk management approach indicated that issues of risk due to parental or carer behaviours were not taken seriously enough. 6.5.7 A further question for the Review was in relation to how Parents were assessed, in terms of either partnership or risk. Given that professionals expressed a concern regarding a lack of information, there is no doubt this was also mirrored with the parents/carers. A publication by PACE (Parents against Child Sexual Exploitation) in 2014 states that ‘families are often traumatised twice over – firstly by the horror of witnessing their child suffer, and the impact of that on themselves and their family, and secondly, by the way they can be treated by agencies who seek to safeguard the affected child. All too often, parents are side-lined and either ignored as ‘forgotten safe guarders’ or deemed ‘failed carers’. In many situations, a strong approach to parental partnership can be a determining factor in promoting resilience and building self-esteem for children affected by sexual exploitation. The extent to which parental partnership is achievable however will be determined by a number of factors: 28 Whether there is a concern that the sexual exploitation is being facilitated by the child’s parent. Whether there is concern that the sexual exploitation is facilitated by the child’s parent failing to protect. Whether there are other related or non- related concerns present. These questions need to be assessed within any assessment of sexual exploitation. This is in addition to responding to the reaction of parents/carers, in respect of being able to emotionally cope with the presence of sexual exploitation, to determine how well they are able to meet the immediate needs of their child. 6.5.8 The discussion and considerations about how to best structure work with parents and carers in relation to sexual exploitation is considered in the recommendations. Finding: Assessing parental potential for partnership is an important component of a Child and Family assessment. Parents and carers should be engaged as safeguarding partners as far as is possible. Practitioners are not confident that existing multi-agency processes fit well with responding to sexual exploitation. 6.6 The Child’s Voice 6.6.1 The Review acknowledged that there are a number of policy, procedural and practice initiatives in the LSCB area which assist professionals to capture the views, wishes and feelings of children and young people. This indicated a strong commitment across the multi-agency partnership to the importance of the voice of the child. Child Protection Conferences and Looked after Children’s processes routinely use tools to establish the child’s wishes and feelings. The involvement of young people in recruitment and selection is further evidence of a commitment to the voices of children and young people. There is also a quarterly audit on Children and Young People’s Views which is part of the Local Safeguarding Board Performance Management Framework. Case recording systems in Children’s Social Care consistently prompt practitioners to record children’s contributions via comment boxes. Review participants did point to the importance of a coherent analysis of this data and recognised that a critical element was how this information is used to shape and deliver services. 6.6.2 The children considered during this Review remind us that children’s voices come in many guises. There was significant evidence to suggest high levels of distress, anxiety and aggression, even at an early stage. For Hannah this 29 manifested itself in deliberate self harming, low mood, anxiety, poor self esteem and challenging behaviours. There were also instances of suicidal ideation and relationship difficulties which were impacting on her ability to function appropriately at a number of levels. Poor relationships with her parents and reports of anxiety and panic were also evident. Whilst Hannah had initially denied any sexual activity with either the alleged perpetrator or the associated males about whom there had been concerns, there was some evidence of risk taking behaviours which could have been explored in more detail from the child’s perspective. Whilst many of these behaviours could be viewed as a form of communication, there was little evidence to suggest that they were framed as such and used to inform assessment and planning. Indeed as described earlier, social work assessment was considerably late, which suggests that these features were not addressed as early as they could have been. 6.6.3 Whilst there were concerns regarding Samantha’s relationship with the alleged perpetrator, Samantha did not disclose any verbal information to suggest that this might be the case. However given Samantha’s complex learning needs it would have been important to have had a more critical approach to communication and reaching an understanding of her world. For Lauren who became Looked After, there were also similar indicators of distress and anxiety, particularly regarding the relationship with her family members. Lauren was posting pictures of herself on the internet, along with personal contact information, conveying powerful messages connected to approval, acceptance and worth. There are also instances where Lauren was reported to be taking her clothes from her Grandparents never to be seen again or returned in a poor state. Again, whilst these instances relate to behavioural rather than verbal responses, they do indicate the presence of powerful and complex emotions and thoughts which did not receive the attention, analysis and exploration that may have informed the assessment and planning process. 6.6.4 In June 2014 witnesses disclosed that Lauren had been engaging in sexual activity with the alleged perpetrator, although this was denied by Lauren at the time. It was also recorded that due to the volume of work the investigation was not formally handed to the Senior Investigating Police Officer until the end of September 2014. In October 2014, Lauren provided a full and frank account of grooming and sexual abuse and in March 2015, she disclosed to the Barnardo’s Worker that she had been locked in a room by the alleged perpetrator and that an older man had then arrived and raped her. This information was reported to the Police and Children’s Social Care. It was not until February 2015 that Lauren disclosed to her therapeutic practitioner the extent of her feelings about herself, her feelings about her mother, her experiences of being sexually exploited and her experience of significant abuse and neglect when she was younger and living with her mother and siblings. These disclosures are both profoundly distressing to read and highly informative regarding Lauren’s vulnerability and history. 30 Lauren also described her feelings of shame associated with the town and disclosed information to suggest that both the alleged perpetrator and Hannah were both recruiters in a wider ring of sexual exploitation who facilitated meetings with various older men. Lauren reported that it was the alleged perpetrator who made her feel wanted at a time in her life when no one enabled her to feel valued or important. Lauren also described her fear of the alleged perpetrator being angry if she said no to the men who had abused her which indicated her exploitation and powerlessness but also control and domination by the alleged perpetrator. This is a view which was echoed by the mother of Hannah, when describing the relationship that her daughter had with the alleged perpetrator. 6.6.5 The work which was undertaken with Lauren by a local therapeutic service was one of the most insightful, informative and thoughtful episodes recorded during the Review period and illustrated both the critical importance of listening carefully to the child’s narrative and also the time and resource intense nature of this therapeutic work. It was a theme that was articulated several times by practitioners and indicated the crucial importance of time, acceptance, relationship building, trust (and therefore organisational capacity) when working with children and young people who are at risk of sexual exploitation. 6.6.6 For all these children there were issues relating to attachment and loss and the importance of associations and peer groups with regard to belonging. There were also issues relating to how non-verbal communications, in the form of behavioural or emotional responses, could be understood and articulated. This analysis was lacking in assessment and when assessments did take place there appeared to be a lack of attention given to the children themselves and the world seen through their eyes. One of the points raised by practitioners was the importance of understanding why young people gravitated towards certain hotpots in the local area. 6.6.7 There was some evidence to suggest that, at times, the behavioural issues were seen as the problem and this raised a question of how agencies both conceptualise and respond to children who exhibit some challenging behaviours in the context of sexual exploitation concerns. For Samantha, the most striking feature regarding fixed thinking around behaviours was in respect of an assertion that, because Samantha was 17 years old, the situation was considered ‘difficult’ and she was ‘not breaking the law’. This failed to take into account her complex needs, learning difficulties, developmental functioning and therefore her vulnerability. This statement also rested on an assumption, at least in part, that Samantha had the capacity and cognitive understanding to be making an informed choice about the abuse she was experiencing, mistakenly locating it in a framework of consent. It failed to take into account issues of power and vulnerability and therefore her susceptibility to exploitation. Whilst this illustrates some of the complexities regarding informed consent, it also raises a question of how 31 best to protect older, but still very vulnerable young people, particularly when legal provisions such as the Child Abduction Order, served on the alleged perpetrator in respect of Lauren, only apply for children up to 16 years of age. 6.6.8 The Children’s Commissioner publication Protecting Children from Harm: A Critical Assessment of Child Sexual Abuse in the Family Network in England and Priorities for Action (November 2015) notes that there is an over-reliance on children disclosing abuse to statutory services and that refocusing is required so that professionals are attuned to changes in the behaviour of children and their emotional responses, ultimately enabling them to talk about their experiences. Finding: Non-verbal communications are as significant as verbal communications. Consistency of professionals is significant regarding the child’s ability to engage. Disclosure should not be considered as a defining criteria for assessment of sexual abuse/ exploitation. Access to therapeutic services is critical. 6.7 Understanding Child Sexual Exploitation 6.7.1 As indicated, awareness and understanding of Child Sexual Exploitation has been an emergent and developing issue in the LSCB area, which has been shaped by national responses and a strong multi agency commitment to identify and respond to the problem locally. The Review also acknowledged that this has taken place within a rapidly changing public service landscape which has had significant implications regarding organisational capacity and the allocation of resources. The Review acknowledged that responding to Child Sexual Exploitation and working with young people is both time and resource intensive. It is dependent upon the ability of professionals and practitioners to form meaningful, safe and trusting relationships with young people over time, enabling them to disclose, share and confide in the individuals who are working with them. 6.7.2 Understanding this form of abuse is also dependent upon professionals having access to comprehensive information which forms the multi-agency policy framework. This particularly relates to information and procedures regarding signs and symptoms and how to seek advice and consultation if professionals are concerned. Responding at the earliest opportunity is key to redirecting the critical pathway for a child. For Hannah there were observations made by the school in March 2014 regarding both threatening and intimidating behaviour by the alleged perpetrator towards pupils, regarding the interactions and relationships with Hannah. This was early 32 evidence of a possible controlling relationship followed by concerns expressed by the Police that Hannah and the alleged perpetrator were observed being intimate together, with the alleged perpetrator describing Hannah as her girlfriend. This resulted in a detailed referral to Children’s Social Care. The concerns in respect of Hannah’s vulnerability, self harm and her relationship with the alleged perpetrator are acknowledged by Children’s Social Care, however, it is agreed that only outreach work will be provided with no case manager. Over the next 2 months there are continuing reports of Hannah self harming, misusing alcohol and being missing from home which did not result in a review of the suitability of the response. 6.7.3 During May 2014 the Police reported to Children’s Social Care that Hannah had been associating with a male who had conditions not to be in the presence of under 16s. Whilst Hannah was interviewed as part of ongoing Police enquiries and further concerns were reported by the Police regarding Hannah’s associations, interventions continue to be provided under Early Help. In September 2014, it is reported in the CSE minutes that Hannah is grooming and being groomed. In this case, there was clearly recognition of exploitation as early as March 2014, however it was the robustness of the responses that were weak and this is evident in the concerns raised by the Chair of the CSE Meeting and the Police regarding the appropriateness of interventions to Hannah. 6.7.4 For Samantha, the first indication that she may have been sexually exploited was also in March 2014, at the point where she was first reported as missing from home. Her Grandmother provided information that she was drinking with a 25 year old male and expressed concerns regarding her vulnerability. In June 2014, Samantha was reported missing from home for a second time and her Mother reported that Samantha was having sex with a 26 year old man and being pressured to do so. Police information also confirmed that Samantha and an older male were in a sexual relationship and that they had both been found intoxicated. Police intelligence indicated that Samantha had been frequenting the alleged perpetrators flat and was found to be there. There is however no explicit recorded recognition by agencies that Samantha may have been sexually exploited. Further concerns were reported regarding Samantha associating with the alleged perpetrator and other older males yet interventions continue on an Early Help basis. It is only in October 2014 when Samantha was referred to the CSE Practitioners Meeting that there was an indication that ‘she may have been subject to sexual exploitation’. As described earlier, a Children and Family Assessment was not undertaken until May 2015. 6.7.5 There is also no evidence which suggests the consistent use of any screening tools, other than the referral tool completed by the Police in April 2015, which resulted in the Assistant Director for Children’s Social Care directing that the contact should be progressed to a referral and a subsequent assessment regarding Samantha. An earlier and more consistent approach 33 regarding the use of screening tools, in all of the above cases, may have helped to crystallise thinking and form a sharper response at an earlier stage. 6.7.6 For Lauren there were some indications as early as January 2013, yet no concerns were reported or recorded regarding possible sexual exploitation until a referral was made to Barnardo’s in July 2013 although the rationale for this was not recorded. It is not until May 2014 that concerns were reported to Children’s Social Care by the Police, in respect of Lauren being in a sexual relationship with the alleged perpetrator and it was at this point that a CSE referral was completed. In the same month, and as a result of discussions at the CSE Practitioners Group, concerns are discussed regarding Lauren’s associations with the alleged perpetrator and the controlling and coercive nature of the relationship. As with Samantha and Hannah, the first recorded indication of the possible sexual exploitation of Lauren was in May 2014, despite the earlier presence of some sexual exploitation indicators. The recording in respect of Lauren was patchy and incomplete in places. Similarly, there is no evidence of the use of screening tools at an early stage which may have provided for a more informed response. 6.7.7 The recognition and response raises some common issues. The consistent use of screening tools, combined with a methodical use of the LSCB threshold document as a diagnostic tool to locate appropriate interventions should have assisted a more appropriate set of responses. Screening tools regarding Child Sexual Exploitation were not utilised at an early stage, particularly in respect of CAMHS and Sexual Health Services. Although there was some recognition that Child Sexual Exploitation was a possibility, it was not explicitly recorded and there appeared to be some hesitance around recognition. This does resonate with a consistent theme raised by practitioners that there was a guarded secret surrounding this issue. This may well be linked to confidence for practitioners in respect of recognition and response and the significance of information, training and education was therefore acknowledged as a vital factor. In addition the introduction of a multi-agency model of professional thinking time and practitioner led audits will assist to develop a stronger culture of curiosity, respectful uncertainty and confidence. 6.7.8 The raising of awareness at an Early Help Stage is fundamental to earlier and more effective recognition and response. Access to consultation for practitioners was also acknowledged as critical, as not all of the signs and symptoms will necessarily indicate that sexual exploitation is occurring. Yet for all these children there were significant early indicators of vulnerability which were evident. In addition, the importance of early holistic assessment based on the Assessment Framework, particularly in respect of understanding the child’s needs, parental capacity and environmental factors, will be vital in any diagnosis or analysis of risk and vulnerability. This may well have also provided for earlier referrals to the CSE processes. 34 6.7.9 The relationships between the Strategic and Practitioner CSE processes did not always result in sharing of information effectively. Practitioners described not having enough clarity and information and that whilst there was awareness that cases were discussed at CSE meetings, there were concerns expressed that a minimum of information was reaching the operational and practice level which detracted from more effective responses. Finding Practitioners have developed awareness of sexual exploitation during and beyond this period of review and this continues. The CSE process needs to be familiar to practitioners. Professionals need time to think together to better respond to sexual exploitation. 7. Learning Outcomes 7.1 Agencies across the area have a clearly outlined multi agency strategy to respond to Child Sexual Exploitation. The Strategy, illustrated in the CSE Work Plan broadly adopts that recommended by the See Me Hear Me Framework and outlines four key priorities: Prosecute: Disrupting, arresting and prosecuting CSE offenders Prevent: Raising awareness of CSE among young people, parents, carers and potential perpetrators Protect: Safeguarding young people and supporting professionals and providing strong leadership, effective systems and working with partners to tackle CSE Publicise: To reflect that the community has an important part to play in responding to child sexual exploitation 7.2 In respect of prevention, a central feature of this Review was the identification of the alleged perpetrator as a risk to children. This common thread was identified by the Police and placed into the CSE planning process to respond to the needs of the children. Although recognition of each child as a child at risk could have occurred sooner, it is important to remember that this was established through a pattern of information from police intelligence that was emerging over a period of time and was not as linear as it would appear in hindsight. There was a sense of discomfort throughout the Review, that the alleged perpetrator was herself a victim of sexual exploitation as a child and that her activity was easier to target than the older males referenced at the head of an abusive structure. 35 7.3 This Review highlights the challenge of raising awareness and the significant scope that the task covers in terms of professionals, family, young people themselves and the community. Ensuring an appropriate level of awareness for even one agency such as the Police requires a constant rolling programme reaching out to all personnel working in the community. 7.4 This Review has identified some areas of weakness in relation to the protect agenda, which are reflected in the recommendations made to the Board. There is the will and desire to improve on practice and to develop multi-agency systems in a way that best supports the risks faced by children. 7.5 While there are areas of practice that can be strengthened to better support multi-agency systems around children, perhaps the most significant issues to be addressed is how to achieve an infrastructure that recognises the limitations of the Child Protection Process for children at risk from non-familial sources, and establish a protocol that sets out a framework for responding to and managing the risks posed by the situation and actions of young people who are vulnerable to abuse or exploitation. There are several examples of such models; commonly they feature multi-agency planning, objective and challenging review, and a lead Professional. Whatever model is used, it is critical that assessments are comprehensive, analytical and culminate in robust assessments of risk, as without this, plans are likely to be misguided. The practitioners were keen to explore a model that better reflected the position of parents and carers of children. It is important to be ever mindful that a calculated approach by perpetrators of child sexual exploitation sets out to strip parents of their ability to fulfil their parental responsibility and that perpetrators will set out to deliberately drive a wedge between the child and their family that causes trust between parents and child to break down with the ultimate goal of estrangement. Conversely, some parents may themselves be groomed and this was an issue raised during the review. It is vital therefore that services work with parents in a way that recognises the impact on the whole family dynamics and seeks to strengthen parental confidence. 7.6 This Review provides a reminder for all professionals of how easy it is to lose sight of the child’s day to day life and how the world presents from their perspective. There remains a need to re-enforce through training understanding children as victims without choice or informed consent and to ensure that all aspects of culture reflect this value, particularly language, attitudes and decision making. This need would also be assisted through the introduction of a model of addressing risk which recognises that children are victims without victimising their future, by enabling children to take greater control of their lives within a framework of nurture and support. 7.7 A key message through every element of enquiry is that working with children at risk of sexual exploitation is very time consuming, as well as requiring a great deal of tenacity by the practitioner. The time consuming 36 nature of the work can be a significant potential barrier to achieving success for children. Practitioners spoke about the time it takes to build up a relationship of trust with children and how the competing demands for time can make this difficult. Given high demand on services, managers often feel under pressure to maintain very tight criteria and can close cases precipitously. The role of first line management is entirely significant to practitioners feeling supported in working in such a difficult area of work, and essentially being prepared to continue in the face of rejection by the child. The multi-agency culture must reflect that a child is a child as defined under the Children Act, and that what is often described as the wilderness years between 16 and 18 does not become a determining factor in considering vulnerability. Lauren commented on how a secure and safe placement came late for her and that she needed to feel at a much earlier point that professionals were willing to exert a greater degree of control. 7.8 For children consistency of workers is extremely important, and in responding to sexual exploitation, the process of case allocation should be mindful of this. Working with children at risk requires extremely skilful direct work, and the Review provided an example of this. There is a relatively good range of services for direct work and allocations were timely on each occasion. The contribution from Lauren emphasised both of these points. 7.9 As in all aspects of working with families in need, the importance of early intervention is entirely significant to later successful outcomes, and this is particularly true of children at risk of sexual exploitation. Early intervention services that educate, build up self-esteem and develop resilient characteristics in children and families are the most effective way to pre-empt and reduce risk. 8. Agency Reflections and Service Improvement 8.1 There has been significant reflection evidenced by all the agencies represented on the Panel during the review. Panel members have engaged positively with the process and there is a collective view that systems are now stronger and leaner, with many changes being driven by national guidance, inspection and enquiry. 8.2 The Review acknowledged the importance for all organisations, but particularly those such as Early Help, Sexual Health Services, CAMHS and the Police to have access to, and consistently use a coherent framework to enable an early and more effective recognition and response. Positively, agencies are responding to concerns regarding sexual abuse with the numbers of children subject to Child Protection Plans in respect of Sexual Abuse at 8% of the total numbers of children subject to plans. This is slightly greater than the national average. 37 8.3 In terms of the multi agency reflection and improvements, the development of the CSE Warning signs and Vulnerabilities Checklist and its distribution to all organisations is a significant element of the CSE Work Plan. This is evidence of a greater strategic and more standardised approach to the issue of early recognition and response and will assist agencies to more consistently respond to early indicators of risk. 8.4 An initiative which has been implemented for all young people under 18 is the Spotting the Signs framework for providers of Sexual Health Services. This was recognised as being especially helpful, particularly given the particularly sensitive nature of the information shared with sexual health services. 8.5 In respect of multi-agency reflection and improvement, the importance of capturing all relevant information from young people who have been missing from home or care was identified as being of critical importance. A quarterly multi-agency audit of missing/return interviews has already been implemented, in tandem with a Service Improvement clinic, chaired by the Assistant Director for Children’s Social Care. Revised missing from home protocols have been introduced, so that all children who are reported as missing from home or care now routinely have a return interview. There have been improvements in the collection, quality and analysis of the data set. This has been implemented by the Strategic CSE and improvement has been evidenced by systematic audit. These improved performance management arrangements regarding the quality assurance of these interviews, with regular audit and feedback into practice will also enhance the effectiveness of ensuring successful prosecutions. 8.6 The Review recognised the importance of community awareness and engagement particularly in terms of understanding the factors, signs and symptoms that are evident when children and young people are at risk of sexual exploitation. The Review acknowledged the importance of comprehensive information, in the form of a media communication strategy, including warning signs and vulnerabilities, particularly for schools but also for small businesses, hotels, bed and breakfast accommodation, taxi firms and fast food outlets. 8.7 An issue recognised by the review was the importance of training, development and awareness raising initiatives, some of which have been identified earlier. Engagement with the variety of agencies that come into contact with children and young people is of critical value and the importance of this has already been raised in National Reports. The Review has both acknowledged this issue and taken significant steps to ensure that training and awareness-raising sessions, including the role and function of the CSE arrangements, are available to all practitioners, first line managers, schools, Heads of Service and Elected Members. These have been described earlier as part of the LSCB CSE Strategy and Work plan. These are; 38 Child Sexual Exploitation Drop in Sessions, which are now available to all Elected Members, Officers and partner organisations, including voluntary, statutory and community groups and which can be accessed through the LSCB Training Programme. Safeguarding Children from Sexual Exploitation, a one day training session available to all Elected Members, Officers and partner organisations, including voluntary, statutory and community groups through the LSCB. Chelsea’s Choice, an awareness raising theatre production, commissioned by the LSCB for all secondary schools, which has currently reached several thousand pupils and which has been re- commissioned. E-Learning Accredited Awareness Raising Programme, which reflects current research, government guidance and best practice. A Safeguarding Conference, facilitated by the LSCB which included contributions from Barnardo’s, Chelsea’s Choice and young people from the area. The LSCB has also initiated work with PACE (Parents against Sexual Exploitation) to develop an on-line information package for schools and has also developed stronger links to Faith and Community Groups. 8.8 Barnardo’s have embedded in their strategic planning the requirement that practitioners capture as much relevant information as early as possible, from case histories and chronologies. There has been further reinforcement of the importance of regular and timely communication with key professionals and the high value of professional challenge regarding the best interest decisions of children. Practitioners and Managers are continuing to ensure that multi agency meetings take place in accordance with local procedures and managers and practitioners continue to attend mandatory safeguarding training. Barnardo’s also continue to deliver LSCB and single agency training and issues regarding responding to disguised compliance are being actively addressed. Managers are continuing to provide oversight and sign off to ensure case recording meets organisational standards. Reflection time and monthly clinical group supervision is also being provided to ensure critical analysis and models of best practice are being developed which incorporate the voices of children. 8.9 A specialist resource provided by Barnardo’s, in the form of a dedicated Child Exploitation Worker for children aged 5-16 years will be critical in ensuring that access to resources is timely and efficient. A dedicated Barnardo’s practitioner is located within the Social Work Team to provide a more integrated response. 8.10 For the Police Service, there has been recognition that the most appropriately trained officers must be deployed at the earliest opportunity to capture all relevant information and evidence. The development of the dedicated Police team is intended to improve operational and strategic effectiveness. The force has recognised the importance of dedicated 39 resources in his area and this will assist the consistent and regular review of cases where CSE is an issue. The Police have also developed ‘hotspot information’ regarding people and areas, to enable effective identification of perpetrator behaviour and areas of risk, with the Police holding a hotspot list which is regularly subject to review. Alerts are created if there are more than 2 repeat incidents. 8.11 The raising of awareness, particularly for Police Officers and night time economy workers, including Hotels and Bed and Breakfast accommodation, which forms part of the CSE Work Plan, are also critical moves forward. 8.12 For Looked After Children’s and Safeguarding Health Services monthly bulletins are now circulated to GP Practices across the area to highlight key issues regarding CSE. Information has been distributed to safeguarding leads regarding CSE and the Clinical Commissioning Group (CCG) are providing updates for the governing body regarding actions and learning. Any learning and development is being incorporated into training. 8.13 The NHS Foundation Trust have utilised the Department of Health, Helping School Nurses to tackle Child Sexual Exploitation (2015) and Learning Lessons from Serious Case Reviews (Brandon et al 2012) as part of training to recognise vulnerabilities at an earlier stage. 8.14 School Nursing Services have identified and used “Helping School Nurses to Tackle Child Sexual Exploitation” (DOH 2015) as a tool for identifying good practice and areas for development. Electronic Information systems have also been developed and improved to facilitate earlier and more effective identification of risk and this is being quality assured on a consistent basis. Staff are also being provided with training to improve the culture of curiosity, professional confidence and assertiveness and familiarity with signs and symptoms. 8.15 It was also acknowledged that there were effective single agency models of effective and reflective supervision in operation, enabling a much higher degree of critical thinking. However, review members reflected on the usefulness of developing multi-agency supervision, peer challenge, and audit, utilising frameworks such as the Tony Morrison model of supervision which has already been adopted by the NHS Foundation Trust. 8.16 For schools the importance of developing lines of effective communication and information sharing, particularly in respect of mid term transfers, has been acknowledged and that early help, interventions and referrals must be in accordance with local protocols such as the LSCB threshold document. There has been the introduction of weekly inclusion meetings with key professionals and the importance of challenge has been recognised and reinforced. Training is being provided which reflects developments in responding to CSE. 40 8.17 For Children’s Social Care there has been recognition that liaison between the CSE and the key Social Worker requires improvement. Consequently the administrative process regarding CSE has been improved particularly in respect of attendance and minute distribution. The CSE Practitioners Group is now more rigorously tracking actions from meetings. CSE processes are now incorporated into induction processes and supervision must evidence outcomes of CSE meetings where appropriate. The Barnardo’s worker located within the Social Work Team is now provided with access to relevant information systems to assist more effective communications and responses and there is now the provision of the “management tab” on the electronic case file system which will assist information sharing and sight of management decisions for practitioners. If three referrals regarding any child are made within a year, a consultation must take place with the Team Manager and a written rationale provided for any decisions made. In addition, there is now a revised risk assessment tool for CSE which was introduced in 2015 8.18 As noted in 9.5, Children who go missing are now tracked more rigorously and consistently and information is passed to relevant practitioners in a more timely way. A co-ordinator ensures that individual children have an interview, unless it is declined, and children who go missing on 3 or more occasions within a 4 week period are automatically discussed at the CSE Practitioners Group. This includes arrangements with neighbouring authorities in respect of children who are placed out of the area. 8.19 There has been acknowledgment that vulnerable children and young people need to form trusting, meaningful, sustainable and safe relationships with people who can help and support them. This, by its very nature is both time and resource intensive; therefore organisational capacity and a relevant skills and knowledge base for officers are absolutely essential. Again there has been a consistent recognition of this during the Review with a dedicated resource for Child Sexual Exploitation being provided in both Social Care and the Police. 8.20 This Review has recognised the importance of communicating that Safeguarding Children is everybody’s Responsibility. Consequently, the Sub Regional CSE Strategic Group has also taken the lead to deliver a preventative initiative, which aims to raise awareness and offer advice to small businesses such as taxi firms, hotels and fast food outlets, regarding the prevalence of Child Sexual Exploitation. The group has also taken the lead to deliver a major publicity campaign, , which provides information for children, families and professionals regarding signs and symptoms, advice and guidance. In this respect there has been a strong acknowledgement that community engagement and awareness are as vital as professional engagement and awareness. This initiative has been extended by Licensing in the LSCB area to work with taxi drivers. 41 9. Recommendations 1. That the LSCB explores the feasibility of introducing a process for responding to vulnerable children/young people which incorporates child sexual exploitation and: Identifies and minimises risk from a non-familial source; Builds on factors that increase resilience; Facilitates a multi-agency team around the child; Facilitates partnership with key people in the life of the young person. 2. Taking into account of outcome of recommendation 1, the LSCB to be satisfied that information available through the CSE strategy systemically feeds into the operational approach and response to children in need. 3. That the LSCB requests training needs analysis from partner agencies that explores the ability of professionals and agencies to identify and respond to indicators of child sexual abuse and exploitation from early help through to targeted services. 4. That the LSCB seeks assurance that each child currently identified at risk of sexual exploitation from information available through the CSE strategy has an assessment of their needs and that actions are taken accordingly. 5. That the LSCB promotes the use of purposeful professionals only meetings/thinking time to support multi-agency reflection, support and challenges in case where risk is not reducing. 6. That the LSCB is presented with key data and information at a regular frequency relating to sexual exploitation and missing from home and that this is used to monitor activity and influence resources. 7. That LSCB continue to champion the developments to address child sexual exploitation and seek data through a range of sources to evidence the impact. 42 10. Glossary of Terms ADHD Attention Deficit Hyperactive Disorder CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CAO Child Abduction Order CCG Clinical Commissioning Group CSC Children’s Social Care CSE Child Sexual Exploitation JSNA Joint Strategic Needs Assessment LA Local Authority LSCB Local Safeguarding Children Board MFH Missing From Home NSPCC National Society for the Prevention of Cruelty to Children OfSTED Office for Standards in Education PLO Public Law Outline S47 Section 47 Enquiry (Section 47 Children Act 1989) SIO Senior Investigating Officer |
NC52422 | Death of a child in a road traffic collision in 2020. Adam was believed to have been at risk of criminal exploitation at the time of his death. Learning includes: always follow safeguarding procedures to assess and manage the risk of harm to a child in parallel with any criminal investigation; practitioners should professionally challenge and escalate any decisions that they do not agree with; ensure the risks and the impact of non-engagement to the child have been assessed before closing a case and consider escalating the concerns if those risks are still prevalent. Recommendations include: practitioners need to be able to distinguish between factual information and hearsay evidence that needs to be utilised to inform a risk assessment; consider adverse childhood experiences (ACEs) and trauma informed practice as a strategic priority together with the need to provide training on the impact of ACEs on children, including where there has been a history of criminality; adopt the Child Safeguarding Practice Review Panel's recommendation that all safeguarding partnerships have an understanding of the nature and scale of the problem of child criminal exploitation, and are able to identify children engaged with and at risk from criminal exploitation; strategic partners to agree and implement a contextual safeguarding response that will engage and empower members of the community.
| Serious Case Review No: 2022/C9476 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. August 2021 Page 1 of 11 Adam Local Child Safeguarding Practice Review August 2021 Page 2 of 11 1. Background and Introduction to the review 1.1 Background This child safeguarding practice review was commissioned by a Local Safeguarding Children Partnership (LSCP) in November 2020 following a Rapid Review of Adam’s case. Adam died tragically in a road traffic collision. Adam was believed to have been at risk of criminal exploitation at the time of his tragic death. He was suspected of being involved in criminal activity but this had not resulted in any formal outcome or charge and was being investigated. Adam and his family received support from a number of services including Children’s Social Care and the Complex Safeguarding Team and there were concerns about how partners worked together to identify and provide timely support in response to the risks of child criminal exploitation. 1.2 Methodology A case discussion tool, developed by Salford Safeguarding Children Partnership was used by a Practice Review Panel to review the effectiveness of multiagency work which had been undertaken with Adam and his family. This required the gathering of a multiagency chronology of events from agencies and the identification of key lines of enquiry by the Panel for further analysis. The following themes have been identified: • Gathering, analysing and sharing of information • Delayed Service Offer • Poor Engagement • Child Criminal Exploitation and Contextual Safeguarding 1.3 Practitioner Involvement A learning event was held with practitioners and team managers that had direct involvement in the case. The views of practitioners gained from the respective multi agency chronologies and the Practitioner event have been included within the report and analysed by the Practice Review Panel. 1.4 Family Involvement At the time of writing this report several attempts had been made by the Local Children’s Safeguarding Partnership to contact Adam’s family, inviting their involvement with the Practice Review. To date the family have not responded to these requests and so we have been unable to include their views and experiences in the practice review. August 2021 Page 3 of 11 2. Key Findings Through multi-agency examination of events in Adam’s life the Review Panel found four practice and system themes. These are briefly summarised below and examined in further detail in section 5 of the report. 2.1 Gathering, analysing and sharing of information Adam appeared to be viewed by agencies as a criminal rather than as a child who may have been demonstrating learnt behaviour and who was vulnerable to criminal exploitation. As a result agencies had not considered his increasing involvement in criminal activity as a safeguarding matter. As a result the multi-agency approach was used to gather information about him which could be used primarily to assist with criminal investigation. 2.2 Delayed Service Offer A referral was made to the Complex Safeguarding Team at the point when there was clear evidence that Adam was actually involved in criminal activity. This was despite potential indicators of criminal exploitation having been identified some months earlier by agencies. The perceptions of some level of risk which some indicators of child criminal exploitation may or may not have had to Adam’s safety was not consistent between multi agency partners. This meant that there was a delay in making referral to the Complex Safeguarding Team. Child Criminal Exploitation was not being perceived to require the same urgency of risk as that of intra familial child abuse. Exploitation was not necessarily being perceived to be a safeguarding issue. 2.3 Poor Engagement The Practice Review panel identified that there was limited engagement of Adam and his family with services. This should have led to a re-assessment of the level of safeguarding risk including the likely impact on Adam’s daily lived experience; significantly in the context of living in a family where adult care givers had criminal convictions. Because Adam was being viewed as a “perpetrator of crime” the need for him to be protected from harm appeared to have been missed with agencies being slow to make due assessment and intervention. 2.4 Child Criminal Exploitation and Contextual Safeguarding The risk to children and young people of the impact of criminal exploitation is ongoing and has been widely identified nationally. The Practice Review Panel identified that practitioners do not necessarily perceive exploitation of children, through various routes, as being synonymous with accepted definitions of child abuse. Children are viewed as being part of the problem rather than demonstrating learnt behaviours from the context in which they live their lives. August 2021 Page 4 of 11 Practitioners in this case had identified the early indications of child criminal exploitation. However, unlike CSE indicators these are not a widely known and therefore not embedded in practice. Practice does not reflect the magnitude of the push pull factors in relation to Child Criminal Exploitation or that they warrant a safeguarding referral and intervention. 3. Strengths in Practice Adam had attended school with roughly 90% attendance in years 7-10. Only in year 11, and with the closing of schools to many pupils due to Covid-19, did Adam’s attendance drop to 47%. As a ‘vulnerable child’, due to Adam’s Child in Need status, efforts were made to get Adam to attend school as normal. His school made good attempts to support Adam and they also tried to transition Adam into further education. Social Workers in particular were persistent in the efforts to engage with Adam and his family. In addition they did consult with a Clinical Psychologist about alternative forms of engagement. Assessments were completed and it was noted that the social worker was able to capture Adam’s wishes and feelings as part of the Child and Family Assessment. The multi-disciplinary Complex Safeguarding Team has brought the working arrangements of Children’s Social Care, Police, and Health colleagues closer together. Those partner agencies had already begun to map out community issues and local associates. 4. Learning Points 4.1 Learning Points for Practitioners • Always follow safeguarding procedures to assess and manage the risk of harm to a child in parallel with any criminal investigation. • Utilise the Early Help Assessment and Team Around the School approach at the earliest opportunity when responding to signs of criminal exploitation. • Remember to professionally challenge and escalate any decisions that you do not agree with and; • Refer to the District Safeguarding Procedures for guidance on a wide range of safeguarding issues including child criminal exploitation and resolving professional disagreement and escalation. 4.2 Learning Points for Managers • Support your staff to escalate concerns when there is professional disagreement. • Promote and check your staffs awareness and compliance with the District Safeguarding Procedures. August 2021 Page 5 of 11 • Ensure the risks and the impact of non-engagement to the child have been assessed before closing a case and consider escalating the concerns if those risks are still prevalent. 4.3 Key Messages for the Safeguarding System • LSCP should be assured that partner agencies utilise the Early Help Assessment and Team Around the School approach at the earliest opportunity when responding to signs of exploitation. • LSCP to seek assurance that the ‘Understanding Exploitation’ training course provides guidance on how services should respond to the early signs of exploitation and promotes the complex safeguarding offer. • LSCP to host a Practitioner Forum on the topic ‘developing trusted relationships’ so that professionals can share good practice and develop alternative ways to engage families. • Strategic partnerships should undertake a strategic need assessment so they have an understanding the nature and scale of the problem and are able to identify children engaged with and at risk from criminal exploitation. • Strategic partners (LSCP and Community Safety Partnership) to agree and implement a contextual safeguarding response that will engage and empower members of the community. 5. Analysis & Findings with Key Recommendations The Review has found four system and practice areas that are significant in Adam’s story and these are analysed in greater detail with key recommendations for the partnership in this next section. This Review has found some similar themes to the National Panel’s Report into child criminal exploitation ‘It was hard to escape’ and these specific points are referenced below. 5.1 Gathering, Sharing and Analysing Intelligence Information collated as part of the review showed that professionals had a lot of information about Adam and his family. Although this might not have been sufficient to secure a conviction in relation to criminal activity the level of risk to Adam was enough to warrant an earlier statutory child protection intervention. School were contacted by Police in 2019 regarding an investigation into vehicle theft but were advised at that point not to inform Adam or his parents so as not to prejudice the police investigation as per their standard practice. The school then became aware, through 3rd party information, of a snapchat post which indicated that Adam was driving a car. The school contacted Adams Mother about the information that they had received who stated that it was Adams Uncle driving the car. According to school records they shared that information August 2021 Page 6 of 11 with the Police, sought advice from the Multi-Agency Safeguarding Hub and subsequently made a safeguarding referral that was then rejected due to a ‘lack of consent’. Partner agencies did not adopt a child 1st, offender 2nd approach and therefore did not see Adam as a vulnerable child that needed safeguarding. There was also no further referral to Youth Justice Services. The Panel agreed that the Police position could have been challenged rather than accepted and that partner agencies should have other means to discuss their concerns when some of the information couldn’t be shared with the family. For example an early help platform such as the Team around the School approach would have enabled those discussions to take place and for information to be shared with partner agencies. In addition effective triaging must take place within the MASH regardless of whether or not information can be shared with the family. Recommendation 1 LSCP should be assured that safeguarding partners effectively invoke safeguarding procedures even when some information cannot be shared with the family due to a criminal investigation. It was the schools understanding that their safeguarding referral would be kept on record in case any further concerns were raised. However, Children’s Social Care have no record of that referral on their system. The review panel agreed that this could have led to a strategy meeting or professionals meeting. The effectiveness of the strategy meeting process and its alignment to ‘Working Together to Safeguard Children’ (2018) has already been identified and actioned in another Local Child Safeguarding Practice Review. There is evidence of multi-agency sharing of information within the child and family assessment, of multi-agency representation and information sharing at a strategy meeting in 2020, and at subsequent child in need meetings. However, Children’s Social Care noted in their analysis that there is conflicting information about whether a S47 enquiry was agreed or not. Following the strategy meeting a form is completed 'record of outcome of s47' where Child in Need (CIN) is determined as the threshold. It’s unclear whether this was a single agency or joint agency decision and there is a lack of clarity regarding the actions that were agreed as part of the CIN plan. In addition Children’s Social Care have acknowledged that Child in Need meetings were not held in line with procedures. CIN meetings should be held a minimum of every 3 months and locally best practice would state 6 weekly. The recording of the strategy meetings and compliance with the frequency of CIN meetings have been identified as areas of learning for Children’s Social Care. Recommendation 2 LSCP seeks assurance from statutory partners that they are working in accordance with Working Together to Safeguard Children 2018. Practitioners didn’t feel that they could record and share information because it was based on hearsay rather than evidence. There was a lack of information sharing between partner agencies and evidence of those partners adopting a silo mentality rather than working together to identify and respond to risk at the earliest opportunity. Intelligence was not recorded as a safeguarding or vulnerability concern and there is no evidence that a referral to the Complex Safeguarding Team was considered at that point. August 2021 Page 7 of 11 Recommendation 3 Practitioners needs to be able to distinguish between factual information and hearsay evidence that needs to be utilised to inform a risk assessment. 5.2 Delayed Service Offer Professionals compartmentalised Adam’s circumstances as criminal behaviour which had to be investigated by the Police as oppose to showing more curiosity regarding the family history and lived experience. A referral was only made to the Complex Safeguarding Team when there was clear evidence that Adam was involved in criminality and yet some of the indicators of potential Child Criminal Exploitation (CCE) had been known about several months prior. The response from partners to indicators of CCE and to the families criminal history were not the same, or provided as early, as they might have been for other types of intra-familial abuse where they would act to safeguard children when they have reasonable cause to suspect that abuse or neglect. In particular there was no early help offer. The Child Safeguarding Practice Review Panel found in their review into criminal exploitation that “Effective practice is not widely known about or used. Even when local areas and practitioners know the children at risk of being drawn into criminal exploitation, many are not confident about what they can do to help them. There are a number of different approaches being taken across the country but little reliable evidence of what works, and no central point where effective evidence is evaluated and disseminated.” (The Child Safeguarding Practice Review Panel, 2020). While evidence of what works in relation to child criminal exploitation specifically might be a gap practitioners should not forget what we know to work in relation to the wider safeguarding system most notably parenting support and family safeguarding (Evidence Store - What Works for Children's Social Care (whatworks-csc.org.uk). In relation to this case there was no Early Help Assessment, referral to the Early Help Access Point or Team Around the School meeting which might have led to earlier family support. Despite the view that Adam was an ‘offender’ there was also no referral to the Youth Justice Service for preventative services. Recommendation 4 LSCP should be assured that partner agencies utilise the Early Help Assessment and Team Around the School approach at the earliest opportunity when responding to signs of exploitation. National research based on many types of exploitation of children has identified that factors within the family, especially early childhood experiences, may have some influence on the susceptibility of young people to have increased risk of both intra and extra familial exploitation in later childhood. Multi-agency risk assessments of both intra and extra familial exploitation should incorporate the child’s earlier life experiences and assessment as to how these may impact on the child’s present level of safeguarding risk. August 2021 Page 8 of 11 Recommendation 5 LSCP consider ACES and trauma informed practice as a strategic priority together with the need to provide training on the impact of ACES on children, including where there has been a history of criminality. Recommendation 6 LSCP to seek assurance that the District ‘Understanding Exploitation’ training course provides guidance on how services should respond to the early signs of exploitation and promotes the complex safeguarding offer. 5.3 Poor Engagement Adam was referred to the Youth Justice Service, Substance Misuse Service (CGL) and then later to Children’s Social Care and Complex Safeguarding. All of those referrals were appropriate but based on limited information that restricted the remit of those services and led to a limited service offer, largely due to an inability to engage with the family. The case was allocated as Child in Need so the family still had to be engaged with their consent. This combined with the referral to the Complex Safeguarding Team might have been successful but partners’ efforts to engage the family were ineffective. The Child and Family assessment was completed and the complex safeguarding assessment appropriately identified Adam as medium risk of CCE. While the family refused to work with the Complex Safeguarding Social Worker they did agree to continue work with the social worker that was coordinating the child in need support. This suggests that the parents were influencing the level of service intervention and not the professionals. The limited engagement should have led services to re-assess the level of risk and the likely impact of that limited engagement on Adams daily lived experience. If the known risks associated with CCE had been linked with the potential impact of the families criminal history then child protection thresholds could have been applied sooner. The lack of engagement from Adam and his parents with the Complex Safeguarding Team could have been viewed alongside a history of poor parental engagement with other services and escalated the concerns from practitioners which could have warranted consideration at an initial child protection conference. Professionals at the Practitioner Learning event recognised the need to engage with the parents, in order to engage Adam. This was despite concerns that his parents could potentially be encouraging, or even implicit in, Adams criminal behaviour. Engaging the family would have opened up a dialogue about those concerns, the potential risks and how to manage them. The Panel concluded that one of those partner agencies needed to establish a ‘trusted relationship’ not only with Adam but also his parents to improve their engagement. The national Child Safeguarding Practice Review Panel identified trusted relationships as being essential to effective communication and risk management. Whilst there was some evidence of practitioner’s persistence and considered alternative forms of engagement it was apparent the family were referred too soon to other services when practitioners experienced difficulty in engaging the family, which impacted the ability of developing trusted relationships. August 2021 Page 9 of 11 Recommendation 7 LSCP to host a Practitioner Forum on the topic ‘developing trusted relationships’ so that professionals can share good practice and develop alternative ways to engage families. Professionals from the Practitioner Learning Event believed that there was ‘disguised compliance’ from parents that kept them at arms-length. This meant that no direct or meaningful intervention was ever delivered to Adam. The panel debated whether this was disguised compliance or just non-compliance and considered whether practitioners lack confidence in challenging families and escalating concerns. There is guidance for practitioners on ‘Dealing with Persistent Non-Engagement with Services by Uncooperative Families’ which advises that persistent non-engagement with a service should trigger a review and impact assessment in respect of any children within a family. Recommendation 8 LSCP, via the Learning and Improvement Group, should raise awareness of the District Safeguarding Procedures. It was the view of the Panel that ending an intervention that wasn’t achieving positive outcomes while the risks are still prevalent minimises the perceived risk by the family and gives the impression that those services are not required. This impacted on the ability of the next service to provide credible support or intervention. Recommendation 9 LSCP should be assured that a decision to close a case to one service (due to persistent non-engagement or dis-engagement) is informed by a child focused multi-agency risk assessment and agreed upon by those services that are involved in working with the family. 5.4 Child Criminal Exploitation and Contextual Safeguarding There is concern that safeguarding partners are not adequately equipped to protect those at risk of harm from child criminal exploitation. While successfully engaging with the family might have helped to reduce some of the risks to Adam there were also extra familial risks to Adam that were identified by practitioners involved in the case. Adam was suspected of dealing Cannabis in the local community, he was suspected of driving illegally and he was linked to known associates who were involved in criminal activity. Professionals at the Practitioner Learning Event recognised that many young people in the local area will experience push factors such as poverty, neglect or abuse, lack of opportunities or positive activities as well as pull factors; such as the glamorisation, status and financial gain; toward criminal associates and activity. Those push and pull factors could cause other young people to become involved in crime and anti-social behaviour. Due to the lack of early identification of indicators we do not know or understand the scale of the problem or what our profile is. The Panel were concerned that some of those young people living in ‘at risk’ communities could be disguised by ward level data where neighbouring areas are more affluent or less isolated. August 2021 Page 10 of 11 Recommendation 10 LSCP adopt the following recommendation; The Child Safeguarding Practice Review Panel recommend that all safeguarding partnerships have an understanding the nature and scale of the problem and are able to identify children engaged with and at risk from criminal exploitation. There are extra-familiar factors that safeguarding partners and community safety partners need to work together on to address. LSCP, via the Complex Safeguarding Strategic Group, has already undertaken further consultation with partner agencies from Adams local community and liaised with the relevant local councillors. Issues such as service withdrawal and increased community isolation over the past 10 years have been raised at a Neighbourhood Learning Circle, a multi-agency forum to identify and discuss place based concerns. As a result the risk of other young people being exploited, within this particular community and more generally across the Local Authority area, has been identified and raised with the statutory safeguarding partners, education, and with the Operations and Neighbourhoods Service which encompasses the Community Safety Partnership and Youth Services. A multi-agency group of senior leaders will be convened to agree a strategic response to those place based issues. The Panel recognised the impact that Adams death had on the community and the need to consider community relationships with this work. Recommendation 11 Strategic partners (LSCP and Community Safety Partnership) to agree and implement a contextual safeguarding response that will engage and empower members of the community. August 2021 Page 11 of 11 References “It was Hard to Escape”: The Child Safeguarding Practice Review Panel Report 2020 DfE: HMO: London. The Child Safeguarding Practice Review Panel - It was hard to escape - report (researchinpractice.org.uk) Wroe, L. (2019) ‘Contextual Safeguarding and ‘County Lines’’, The International Centre, Contextual Safeguarding Network. Contextual-Safeguarding-and-County-Lines-Briefing_-Wroe-Oct-2019-FINAL.pdf (csnetwork.org.uk) Evidence Store (May 2021) What Works for Children’s Social Care. Evidence Store - What Works for Children's Social Care (whatworks-csc.org.uk) Dealing with Persistent Non-Engagement with Services by Uncooperative Families (proceduresonline.com) |
NC52323 | Death of a child in hospital in July 2015. Child D was reliant on others to meet his care and support needs due to a range of conditions and disabilities. Learning is embedded in the recommendations. Recommendations for the local safeguarding children board include: ensure that the children with disabilities service has a robust process in place to ensure that any decision to close the case of a child or young person with complex needs as a child in need is sound; commission a review of the effectiveness of safeguarding practice within the children with disabilities service; ensure that partner agencies have robust systems in place to ensure that decisions to cease service provision as a result of service user non-engagement are not taken without fully considering any safeguarding implications; make use of the learning emerging from this case to develop a shared understanding of neglect in cases where the child or young person has complex health and social care needs; review the protocol for resolving professional disagreements, and ensure it is widely shared and used; examine the process by which children and young people with complex needs transition from children's to adult health and social care services; ensure that advocacy is offered at regular intervals to parents of children and young people with complex needs where appropriate; ensure that the parents of children and young people with complex needs are offered carer's assessments where appropriate; make appropriate use of interpreters when one parent has no or insufficient understanding of English. Please note that this report was written in 2017 but was published in 2022.
| Title: Serious case review, Child D. LSCB: Blackburn with Darwen Local Safeguarding Children Board Author: David Mellor Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review, Child D March 2017 2 Contents Page number Introduction 3 Terms of Reference 4 Glossary 5-7 Synopsis – Summary of contact with Child D 8-29 and significant events Analysis 30-53 Findings and Recommendations 54-59 Appendix A 60-61 Process by which SCR conducted 3 1.0 Introduction 1.1 Child D was diagnosed as having microcephaly and very severe developmental delay at an early age. Child D had profound and multiple learning difficulties, epilepsy, very limited movement, was partly gastrostomy fed from 2008 and nil by mouth from October 2014 and was only able to communicate primarily through facial expressions. Child D was reliant on others to meet his care and support needs. 1.2 Following the death of Child D in hospital in July 2015 Blackburn with Darwen Local Safeguarding Children Board (LSCB) decided to commission a serious case review (SCR) on the grounds that during the months prior to Child D’s death there had been concerns over alleged parental neglect which a range of partner agencies had been working together with Child D’s parents to address. During this period Child D’s health had been in sharp decline which had created a very challenging decision making environment for all agencies involved and from which it was anticipated much valuable learning could be obtained. 1.3 The LSCB decided to adopt a “systems approach” to conducting the SCR. The process by which the SCR was conducted is shown in more detail in Appendix A. 1.4 The LSCB appointed David Mellor as the lead reviewer and independent chair of the review group established to oversee the SCR. The membership of the review group is also shown in Appendix A. David Mellor is a retired chief police officer, a former independent chair of several safeguarding boards and has conducted a number of previous SCRs. 4 2.0 Terms of Reference 2.1 The terms of reference for this SCR were articulated quite broadly to avoid inadvertently excluding significant practice events which could emerge during the Review Group’s work and the conversations with practitioners and family. 2.2 As an initial guide, the BwD LSCB SCR Consideration Panel identified the following areas for the Review Group and the Independent Reviewer to include in their discussions and analysis of the case: 1. Were there any opportunities for preventative work and escalation, single or multi-agency that were missed for Child D; 2. What was the quality of information sharing and working together across all agencies; 3. What was the extent of parental non-engagement, the reasons for this, the way agencies responded to this and the impact this had on Child D; 4. What outcomes, for Child D and family, were services trying to achieve; what systems and processes (single and multi-agency) did agencies have to achieve the outcomes and what can be learned to improve these; and 5. Were the diversity needs of Child D and family met by services. Timeframe 2.3 The SCR Consideration Panel decided to request agencies which had had relevant contact with Child D to provide detailed chronologies for the period from 1st January 2013 until Child D’s death in July 2015. 5 3.0 Glossary Aspirate – is to breath in a foreign object (sucking food into the airway). A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. The Common Assessment Framework (CAF) is a process for gathering and recording information about a child in respect of whom practitioners have concerns in which the needs of the child and how those needs can be met are identified. Continuing Healthcare (CHC) – NHS continuing healthcare, also known as NHS continuing care or "fully funded NHS care", is free care for outside of hospital that is arranged and funded by the NHS. There is specific guidance in relation to continuing health care for those under the age of 18. This National Framework for Children and Young People’s Continuing Care sets out an equitable, transparent and timely process for assessing, deciding and agreeing bespoke continuing care packages for young people whose needs in this area cannot be met by existing universal and specialist services. Court of Protection –The Court of Protection makes decisions on financial or welfare matters for people who lack mental capacity. The Court is responsible for: • deciding whether someone has the mental capacity to make a particular decision for themselves • appointing deputies to make ongoing decisions for people who lack mental capacity • giving people permission to make one-off decisions on behalf of someone else who lacks mental capacity • handling urgent or emergency applications where a decision must be made on behalf of someone else without delay • making decisions about a lasting power of attorney or enduring power of attorney and considering any objections to their registration • considering applications to make statutory wills or gifts • making decisions about when someone can be deprived of their liberty under the Mental Capacity Act CwD – Children with Disabilities Do Not Attempt resuscitation (DNAR) – A DNAR form is a document issued and signed by a doctor, which tells the medical team not to attempt cardiopulmonary resuscitation (CPR) – which is an emergency treatment used to restart a person’s heart and breathing. The DNAR form is not a legally binding document. The reason that a DNAR form exists is because without one a healthcare team would always attempt CPR. 6 Deprivation of Liberty Safeguards (DoLS) - The DoLS were introduced in 2009 and protect the rights of people aged 18 or above who lack the ability to make certain decisions for themselves and make sure that their freedom is not inappropriately restricted. No one can be deprived of their liberty unless it is done in accordance with a legal procedure. The DoLS is the legal procedure to be followed when it is necessary for a resident or patient who lacks capacity to consent to their care and treatment to be deprived of their liberty in order to keep them safe from harm. The DoLS can only be used if the person will be deprived of their liberty in a care home or hospital. In other settings, and for children aged 16 and above the Court of Protection may authorise a deprivation of liberty. Dysphagia – the medical term for difficulty in swallowing. Gastrostomy – is a surgical opening through the abdomen into the stomach. A feeding device is inserted through this opening which allows the person to be fed directly into their stomach, bypassing their mouth and throat. There are many reasons why someone might benefit from a gastrostomy, including difficulty in swallowing which increases the chance that they will aspirate (breathe in food). Independent Mental Capacity Advocate (IMCA) - The purpose of the Independent Mental Capacity Advocacy Service is to help particularly vulnerable people who lack the capacity to make important decisions about serious medical treatment and changes of accommodation, and who have no family or friends that it would be appropriate to consult about those decisions. The role of the Independent Mental Capacity Advocate (IMCA) is to work with and support people who lack capacity, and represent their views to those who are working out their best interests. Lactic Acidosis – is when lactic acid builds up in the bloodstream faster than it can be removed. Lactic acid is produced when oxygen levels in the body drop. Lower Layer Super Output Areas
Lower Layer SOAs have an average of roughly 1,500 residents and 650 households. Measures of proximity (to give a reasonably compact shape) and social homogeneity (to encourage areas of similar social background) are also included. SOAs give an improved basis for comparison across the country because the units are more similar in size of population than, for example, electoral wards. They are also intended to be stable, enabling the improved comparison and monitoring of policy over time. Mental Capacity Act: The Act is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 or over. Microcephaly – is a condition where a baby’s head is much smaller than expected. Microcephaly can occur because a baby’s brain has not developed properly during pregnancy or has stopped growing after birth, which results in a smaller head size. Babies with microcephaly can have a range of other problems such as seizures, developmental delay, intellectual disability, problems with movement and balance, 7 feeding problems such as difficulty swallowing, hearing loss and vision problems. It is a lifelong condition. Nil by Mouth (NBM) – The patient is not allowed to have any form of food, drink or medications by mouth. PEG – (Percutaneous Endoscopic Gastrostomy) is a type of gastrostomy device which consists of a flexible polyurethane tube held in place by a disc inside the stomach. An external triangle fixator sits on the skin of the abdomen and keeps the tube securely in position. SaLT – Speech and Language Therapist Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. Special Educational Needs (SEN) - children have special educational needs if they have a learning difficulty which calls for special educational provision to be made for them. The fundamental principles which apply to SEN are that a child with special educational needs should have their needs met, that these needs will normally be met in mainstream schools or settings, the views of the child should be sought and taken into account, parents have a vital role to play in supporting their child’s education and children with special educational needs should be offered full access to a broad, balanced and relevant education, including an appropriate curriculum for the foundation stage and the National Curriculum. Thickened liquids – or “custard thick” liquids are often used in the management of dysphagia to improve bolus (chewed food at the moment of swallowing) control and to help prevent aspiration. 8 4.0 Summary of contact with Child D and significant events (From the birth of Child D, until the end of 2012). 4.1 Child D was a British citizen of Asian descent. In 1998 Child D’s mother brought Child D into a health visitor clinic for the first time. Child D had already missed a number of appointments for immunisations. The health visitor was very concerned about development and presentation as Child D was unable to control head movements and had poor muscle tone. Child D’s mother disclosed her child had been experiencing small seizures for over a month. Child D was subsequently diagnosed as having microcephaly and very severe developmental delay. 4.2 Difficulty was encountered in encouraging Child D’s mother to bring her child to subsequent appointments for a computerised tomography (CT) scan and in encouraging her to engage with the “full package of care” which had been put in place for Child D by mid-1998. 4.3 In 2001 a statement of special educational needs (SEN) was issued in respect of Child D whilst attending a special school. During the early school years Child D’s attendance was described as “poor”, which also had a knock-on effect on attendance at paediatrician appointments which were arranged to take place at school. A pattern of non-attendance at appointments with other services such as dietician and opthalmics was also noted. 4.4 GP records show that from at least 2004, Child D’s mother had insulin dependent diabetes, hyperthyroidism and depression. Child D’s father was in good health except for gastritis, for which he had been prescribed medication since 2009. 4.5 In 2006 a gastrostomy was recommended for Child D to address feeding and nutrition issues but the parents were opposed to this procedure. However, a referral for the gastrostomy was made in 2007 owing to concerns over Child D’s decreasing weight. When Child D’s parents did not attend gastrostomy related appointments, a CAF (early help child and family assessment) was initiated which led to a referral to Children’s Social Care in 2008. A core assessment was completed which identified Child D as a Child in Need (CiN) because of concerns about a failure to thrive and the absence of agreement from parents to a medically advised gastrostomy. Parental neglect was also highlighted as an issue at this time. The CiN plan included supporting the parents to engage with the gastrostomy process and offering respite care at a local authority service, a setting which offered short breaks for children and young people with disabilities. 4.6 The gastrostomy was performed in late 2008. In addition to gastrostomy feeding, Child D continued to eat orally as well. Subsequently, feeding difficulties were noted and there were recurring gastrostomy infections. Despite the gastrostomy, concerns over Child D’s weight persisted. In 2009 weight was recorded as 18.2kg - which is significantly below 0.4 centile - which at that time was thought to be due to poor food intake and missing out feeds overnight. 9 4.7 In early 2011 Child D had nine teeth extractions under anaesthetic “through lack of attendance at orthodontist”. Late that year Child D’s allocated respite placement was suspended as Child D had not attended at since the summer of that year. 4.8 The police attended Child D’s home address four times between 2008 and 2012 in response to concerns about domestic violence. On one occasion, Child D’s mother reported that her husband had assaulted her. All of the other incidents involved conflict between Child D’s mother and Child D’s eldest sibling who had played some part in Child D’s care for a number of years. 4.9 Children’s Social Care now reflect that a strategy meeting should have been considered in respect of Child D in 2009 and 2011 in response to concerns from a number of professionals. A range of agencies noted what they describe as a prolific history of Child D’s parents failing to attend appointments, not seeking timely medical assessment and refusing or failing to engage with numerous offers of extra help. 4.10 Child D’s mother became pregnant with her fifth child in 2012. (Significant Practice Episode 1 – the events leading to the closure of Child D’s case as a Child in Need in June 2014.) 4.11 During 2013 concerns began to arise over whether the home feeds for Child D were being fully utilised by parents. In late February 2013 the home feeding company supplying specialist feed packs for Child D telephoned the hospital paediatric dietician to say that they had made no delivery that month as Child D’s parents had advised that they were “overstocked”. (Usual supply at that time was 84 packs a month or 3 x 500mls packs per day.) On that occasion the hospital paediatric dietician contacted Child D’s mother in order to check feed stock levels and was advised by the mother that there was 61 days of feed currently at home (184 x 500ml packs). Although there is no record of any explanation of why the stocks were so high being sought or recorded, the hospital paediatric dietician has advised this review that Child D’s mother advised that her child was not tolerating the level of feed required as a result of being unwell. The hospital paediatric dietician considered this explanation to be acceptable as children with complex needs may go through phases where all feeds are not used up. 4.12 In June 2013 Child D’s mother gave birth to her fifth child. During July 2013 Child D’s mother contacted the Out of Hours GP service to say that she was worried about recurrence of her depression and “emotional breakdown”. It was noted that the antidepressants she had previously taken had been stopped because of her pregnancy. She was advised to book an appointment with her GP but there is no record of her doing so. 4.13 On a home visit by the hospital paediatric dietician in August 2013, a stock check with Child D’s mother disclosed 100 x 500ml packs of home feed. Although no record was made of any explanation provided, the hospital paediatric dietician has advised this review that Child D’s mother again said that her child was not tolerating 10 feed because of being unwell. Child D’s mother said she was feeding Child D with 3 x 500ml packs per day. Child D’s mother disclosed that she was feeding Child D with a pureed diet which she described as “mash, fish and beans and toast with butter dipped in tea.” Child D’s mother was advised by the hospital paediatric dietician to continue on this plan. Although it is difficult to puree toast, the dietician has advised this review that it is acceptable to soften it with liquid and then mash it with fingertips to a mushy consistency – which Child D’s mother was advised to do. 4.14 During August 2013 Child D’s case was transferred from social worker 1 to Child Support Officer (CSO) 1 within the Children with Disability (CwD) Hub. The summary of Child D’s case prepared at that point made reference to respite care being in place, transition to adult services to commence at age 17 and that Child D’s Child in Need (CiN) status was to continue. 4.15 During a home visit by community occupational therapists in August 2013, Child D’s mother said she was experiencing difficulty in changing nappies as she couldn’t open Child D’s legs. This suggested some tightness in Child D’s hips which could have justified a letter to the paediatric consultant to consider whether some form of medication or surgery was necessary to reduce the apparent hip adduction (movement of the leg inwards towards the body). However, no contact with the paediatric consultant was made at this point. 4.16 During October 2013 Child D was examined by a locum consultant paediatrician at school who noted some resistance when abducting the left hip. (moving away from the midline of the body) The locum consultant paediatrician was also made aware by Child D’s mother that Child D cried when having nappies changed and that she (mother) felt that Child D was experiencing pain in the left leg. As a result, X-rays of Child D’s hips were arranged. 4.17 Later in October 2013 CSO 1 carried out a CiN visit to Child D’s home. Child D was seen and “no concerns” were noted. When the case was discussed in a supervision meeting in early November 2013, it was decided that CiN home visits would take place every three months as opposed to the previous regime of monthly visits (the October 2013 home visit was the first monthly CiN home visit achieved since June 2013). 4.18 In late November 2013 the hip X-ray for Child D was cancelled as Child D had not been brought to the appointment. It appears that Child D’s mother may have been confused about the need for a prior letter to arrange the X-ray when in fact it had been expected by professionals that she would promptly take Child D to hospital for this purpose. When this apparent confusion was finally recognised – in early December 2013 – Child D’s mother was advised by a school nurse to take her child to hospital that day. Child D and mother attended the hospital A&E the same day where an X-ray was undertaken. Child D was diagnosed with a chronic dysplastic left hip (meaning that there was a general looseness or instability in the hip which meant a proneness to dislocation or partial dislocation) and partial dislocation. Child D was discharged home with analgesia (medication which acts to relieve pain). 11 4.19 To rule out any infection to the left hip, blood tests were arranged for the following day but Child D’s mother did not bring her child to hospital, saying she was unwell. 4.20 In December 2013 a school nurse at Special School 2 sent an email to Children’s Social Care to notify them that Child D’s mother had delayed taking her child to hospital for X-ray in connection with the hip problems (see Paragraph 4.18 above) and had also missed the last bi-annual X-ray in October 2013. The following day CSO 1 telephoned Child D’s mother who was recorded as telling the CSO that Child D had “very free hips” which tended to dislocate. No further action appears to have been taken by the Children with Disabilities Hub in respect of this matter. 4.21 Later in December 2013, it was decided that Child D’s hip did not require a surgical intervention at that time but that the position would be reviewed by an Orthopaedic Surgeon in three months (this follow-up appointment was arranged for March 2014 but Child D was not brought to the appointment). 4.22 In late January 2014 a CiN review meeting for Child D took place but mother did not attend. Nor did she attend the rearranged CiN review meeting in March 2014. 4.23 In early February 2014 the company providing the specialist feeds contacted the hospital paediatric dietician to advise that they had been unable to make contact with Child D’s parents, adding that they had made no delivery of feeds since November 2013. The hospital paediatric dietician arranged a meeting with Child D’s mother which was to take place the following day. However, Child D’s mother did not attend and it appears that there was no further follow up. 4.24 In early April 2014 Children with Disabilities Hub sent a letter to Child D’s mother inviting her to a CiN review for Child D which had been rearranged for late April 2014 after the cancellation of the previous two CiN review meetings through non-attendance. The letter also advised that the respite care service would be withdrawn if she did not attend the CiN review meeting. 4.25 During April 2014 and May 2014 the specialist school nurse contacted the hospital paediatric dietician to say that Child D was unwell and only tolerating two feeds of 250ml in school. On both occasions the hospital paediatric dietician attempted to contact Child D’s mother by telephone and left her a message. 4.26 The thrice rearranged CIN review meeting scheduled for late April 2014 was cancelled after Child D’s mother again did not attend. A home visit by CSO 1 obtained no reply. As a result, a further letter was sent to Child D’s mother suspending the respite care service. CSO 1 and the team manager from the Children with Disabilities Hub decided to attend Child D’s annual educational SEN review which was scheduled to take place at his school in early May 2014. However, Child D’s mother did not attend this educational review, necessitating its rearrangement. 12 4.27 In early May 2014 CSO 1 met with their team manager to discuss Child D’s case which it was decided was “to be prepared for closure” on the grounds that the respite care offered under Section 17 of the Children Act 1989 was a voluntary offer of support which Child D’s parents were not obliged to accept. CSO 1 was to carry out a further CiN visit and liaise with “health” and Child D’s school to ensure that there were no safeguarding concerns. Liaison with Child D’s school did take place but if liaison with relevant health services took place at this time, it went unrecorded. 4.28 The CiN home visit referred to in the previous paragraph was accomplished in mid-May 2014 during which Child D’s mother expressed her dissatisfaction with the respite care service on the grounds of staff continuity and poor communication. Child D’s mother was also advised to rearrange the annual educational review she had missed with Child D’s school. 4.29 Later in May 2014 the specialist feed company again contacted the hospital paediatric dietician to advise that Child D’s mother had declined deliveries for May and June 2014. 4.30 Also in late May 2014 Special School 2 emailed the Children with Disabilities Hub team manager to raise a number of concerns in respect of Child D including missing school, missing respite, missing CiN reviews, missing educational reviews and refusal of feeds and equipment for feeds by Child D’s mother. The school recorded that these concerns “begin to paint a picture that I am not comfortable with”. The school also enquired about a “joint review” meeting which they implied that the Children with Disabilities team had committed to arranging following Child D’s mother’s non-attendance at successive CiN reviews. In reply the Children with Disabilities Hub team manager advised that respite had ceased at Child D’s mother’s request and suggested a joint SEN review should be arranged. 4.31 In early June 2014 CSO 1 carried out an unannounced home visit in which they saw Child D and spoke with mother who explained that she had a backlog of feed supplies because Child D had missed feeds through being unwell. She said she had reduced feeds when her child was unwell and was gradually building them up again. 4.32 The next day Child D was weighed in school. Child D’s weight was recorded as 37.6kg (5 stones 13lb). It was noted that a loss of 2.3kg (5lb) in weight had taken place since October 2013. No action appears to have been taken in respect of this weight loss. The following month a further loss of 1kg (2.2lb) was noted when Child D was again weighed at school. Again no action appears to have been taken despite this significant weight loss in a little over a month. By this time Child D was almost aged 17 and body weight had noticeably dropped away from the expected pattern possibly indicating evidence of a “failure to thrive”. 4.33 The rearranged annual SEN review for Child D took place at Special School 2 in mid-June 2014. The meeting was attended by Child D’s mother, senior management from the school, CSO 1 and Child D’s teaching assistant. Child D’s Physiotherapist and Occupational Therapist were invited but did not attend. No other health 13 professionals were invited. Child D’s mother reiterated the explanation given to CSO 1 in early June 2014, that Child D had missed feeds through being unwell. It was noted that Child D’s attendance at school had declined during the school year (56% compared to 77% in the previous year) as a result of ill health. CSO 1 advised that because Child D would no longer be accessing respite at the respite care service, the case would be closed to the Children with Disabilities Hub. Special School 2 state that they raised concerns about this although these are not recorded in the record of the SEN review. 4.34 Child D’s transition plan – which was intended to ensure transition from children’s to adult’s services is managed as effectively as possible – had been a standing item for consideration at the annual SEN reviews since being initiated in year 9 of school. Despite the decision of the Children with Disabilities Hub to close the case, the transition plan was not amended in any way. As a result, Child D’s transition plan continued to state that transfer to adult social care would take place at 18 years of age. The transition plan also continued to state that Child D’s social worker was social worker 1 despite the case having transferred to CSO 1 ten months previously. 4.35 At the end of June 2014 the decision to close Child D’s case to the Children with Disabilities Hub was confirmed. There were considered to be “no compromised parenting issues” and “no recent concerns expressed by other agencies”. (Significant Practice Episode 2 – more regular instances of Child D not tolerating feeds and lack of engagement from parents between September 2014 and January 2015) 4.36 In late July 2014 the hospital paediatric dietician carried out a home visit to Child D, whose mother said Child D was having 2 x 500ml feeds a day via pump plus pureed food (also described as a soft mashed diet). The hospital paediatric dietician advised to continue on an oral diet and to try and re-introduce the third 500ml feed which had been discontinued after a chest infection. The hospital paediatric dietician decided to review the situation in one month. 4.37 In mid-September 2014 Child D began vomiting at school just before home time. Child D was collected from school by mother who requested an appointment with the community consultant paediatrician at the school as Child D had not been seen by them “for a long time”. No appointment was made in response to Child D’s mother’s request. 4.38 At the end of September 2014 Child D was admitted to the hospital emergency department from school after vomiting copiously after being tube fed by a health care assistant whilst lying on a plinth – a method of feeding which appeared to contravene medical advice. (This was Child D’s first day back at school after an absence of two weeks). After Child D’s arrival in the emergency department, Child D’s mother told Special School 2 Deputy Head that she was only feeding Child D a small amount (100mls per hour) and had been feeding curries, soups and toast softened by dipping in tea. 14 4.39 Child D was subsequently admitted to hospital and diagnosed with aspiration pneumonia. (Aspiration pneumonia is a consequence of both vomiting and inhaling fluid into the lungs or of problems with the swallow reflex causing fluid to go into lungs). This can be a life threatening incident. Child D remained in hospital for 12 days on an adult respiratory ward. 4.40 The circumstances described in paragraph 4.38 were investigated by the health trust that employed the health care assistant following a complaint from the school that the event was managed inappropriately by the health care assistant. The investigation found that the special school nurse (also employed by the health trust) had advised the health care assistant to follow a feeding procedure which involved Child D being fed in a position which was contrary to usual procedure. The action subsequently taken when Child D began vomiting and potentially aspirating was overseen by a nurse from another provision/team in the health trust who was covering the substantive post holder and who was unfamiliar with Child D and the equipment. As a result, a new procedure for managing emergency health situations in school was introduced which included a process to assist care delivery when nurses needed to cover duties due to lack of staffing resources. 4.41 At the beginning of October 2014 a Do Not Attempt Resuscitation order (DNAR) was discussed with Child D’s mother who expressed agreement with this course of action which was then implemented. The DNAR order did not preclude full medical intervention in relation to Child D’s acute illness. 4.42 Also in early October 2014 an initial swallow assessment was carried out by a hospital Speech and Language Therapist (SaLT) locum. As Child D was on an adult ward, the SaLT was an adults SaLT. The hospital consultant had decided that Child D should be nil by mouth (NBM) and nil by PEG. The hospital adult SaLT locum recommended this advice should be followed until further information was obtained from the community paediatric SaLT who had been involved with the patient previously. The hospital adult SaLT locum later recommended that it would be in the patient’s best interests to be assessed in the community, rather than in hospital, for consistency of input given the long-term feeding difficulties and recurrent chest infections which had resulted in multiple readmissions. 4.43 PEG feeding recommenced a few days later. After repeated attempts to contact the community paediatric SaLT service, the adult SaLT locum at the hospital exchanged emails with community paediatric SaLT 1 to query whether Child D’s mother was feeding Child D “additional oral intake” which could have contributed to his condition. The latter confirmed that the most recent recommendations were for well mashed food and custard-thick fluids but that Child D had been discharged from their service in December 2013. 4.44 In October 2014 Child D was discharged home from hospital after requiring “full support” to meet all of needs whilst in hospital, specifically maintaining hygiene and dressing; pressure relief; mobility, positioning, moving and handling; management of continence; nutrition; management of the chest to prevent 15 aspirational pneumonia; management and prevention of epileptic seizures; management of any acute episodes of illness; extra support when becoming agitated and restless; anticipation and management of pain; and social and emotional needs (which were difficult to address in an acute ward). It was also noted that there were times when Child D would be deemed medically fit for discharge home, only to have a further acute episode which would necessitate remaining in hospital for further treatment. Child D remained NBM. It was the responsibility of the ward to explain NBM to Child D’s mother when Child D was discharged from hospital. There is no documentation to confirm that this explanation was provided and that understanding of the explanation was tested. 4.45 Later in October 2014 Child D was referred to community paediatric SaLT 1 by an hospital adult SaLT, requesting that Child D’s tolerance of additional oral intake be reviewed. The level of risk/urgency of the referral was assessed by the community paediatric SaLT and deemed to be “routine/low risk of choking/aspiration”. Contributing to this assessment of risk/urgency was the view that as Child D was NBM, and would not be at risk from oral intake. 4.46 In late October 2014 community paediatric SaLT 1 and the community clinical lead in dysphagia carried out a home visit to Child D, but were unable to fully complete their assessment as Child D was sleeping throughout the visit. Child D’s mother said she was gradually increasing gastrostomy feeds. She added that prior to admission, she had been feeding Child D small amounts of pureed food and fluids. She said that she was aware that thickened fluids were advised and given in school at this time but she did not feel that Child D required this as Child D tolerated what she gave him and showed no signs of distress or aspiration. Child D’s mother did not appear to be challenged on the non-thickened fluids she was giving her child. She was advised to continue NBM and community paediatric SaLT 1 said that a full feeding assessment would take place in school when Child D’s condition improved. It was documented that the plan for Child D might be to remain NBM long term if the risks of aspiration were considered to be high. 4.47 In late November 2014 a special needs school nurse contacted the hospital paediatric dietician querying Child D’s feed regimen given that NBM had been advised in hospital. The hospital paediatric dietician contacted Child D’s mother who said that Child D was on 2 x 500ml feeds plus a pureed diet. The hospital paediatric dietician made no contact with the community paediatric SaLT team to confirm any swallow recommendations and sent a feeding plan to Child D’s school. 4.48 On the same day Special School 2 emailed Children with Disabilities Hub team leader to express concern that Child D was not attending school and difficulties were being experienced in contacting mother. In response the team leader said that Child D was no longer an open case to the Hub and suggested that the school contact the Education Welfare Officer. 4.49 By early December 2014 Child D’s Health Care Plan (HCP) had been outstanding for six months. The HCP had been sent to Child D’s parents by the special school nurse to complete on several occasions. The lack of a current HCP 16 would be a risk to the safety of care delivery for Child D in school as needs/medications may have changed from the previous year’s HCP. 4.50 In early December 2014 a Special School 2 Teaching Assistant carried out a home visit to Child D who had an abscess under the arm for which antibiotics were being provided. Child D’s mother was noted to be feeding orally. As a result, Special School 2 notified community paediatric SaLT 1 who said she would contact Child D’s mother to advise her to stop this practice immediately. She made repeated attempts to contact Child D’s mother who did not respond to messages left. 4.51 In early January 2015 community paediatric SaLT 1 decided to discuss Child D’s case with a senior colleague after further unsuccessful attempts to contact Child D who remained off school after the holidays. A few days later a discussion took place between the community paediatric SALT and the dysphagia clinical lead but the action agreed upon was merely to send an “opt in” letter to Child D’s parents requiring them to contact SaLT if they wanted an appointment. Discharge from the service would be the outcome if they chose not to “opt in” within three weeks. The letter was copied to special needs school nurse at Special School 2 who did not make an entry in the child health records for Child D or take any action. (Significant Practice Episode 3 – the initial hospital concerns about unmet needs and plan for CAF from January to March 2015) 4.52 In late January 2015 Child D was admitted to the hospital from home by ambulance after the GP had been called to the family home as Child D had been unwell for two days. Child D was stabilised for one day in the Critical Care Unit, where respiratory support was provided, before transfer to a ward. Child D was diagnosed with acute renal failure with lactic acidosis. 4.53 Child D was in the care of a hospital adult dietician who calculated nutritional requirements based upon an estimated weight. Child D was started on 1000 ml of adult feed per day via PEG which was initially tolerated before aspirating on food towards the end of January 2015. At the beginning of February Child D re-started feeding but remained NBM. The hospital adult dietician recorded that Child D was “usually on pureed / soft diet alongside feed”. Information was provided by community paediatric SaLT that Child D’s family had confirmed that pureed diet / oral intake was “only in very small amounts”. A hospital swallow test was requested. 4.54 The following day a hospital SaLT began an initial assessment/information gathering exercise prior to conducting the swallow test and was advised by nursing staff on the ward that Child D’s mother said that she gave small amounts of mashed diet. Past SaLT reports were requested from paediatric community SaLT 1 who provided a report dated October 2014 which stated that a swallow assessment had not been possible following Child D’s return home from hospital due to drowsiness and that they had recommended that Child D remain NBM with PEG feed until a formal SaLT assessment could take place. It was stated that this assessment had not taken place because attempts to contact Child D’s mother had proved unsuccessful. 17 Community paediatric SaLT 1 said they had been advised by Special School 2 that Child D’s Mother was giving him oral tastes against SaLT advice. 4.55 The next day – when Child D was due to be discharged home – the hospital SaLT analysed the information collected in respect of Child D and questioned whether discharge home was safe. Two hospital SaLT colleagues then carried out a swallow assessment of Child D which revealed oral hypersensitivity, no bolus manipulation and no swallow triggered which meant that the risk of aspiration was high. As a result, they confirmed Child D’s NBM status. The hospital SaLTs liaised with the hospital complex case manager who was unaware of any “social issues” in respect of Child D and advised them to discuss the issues with the ward manager and to arrange a meeting to resolve the issues they highlighted. 4.56 Specifically, the concerns of the hospital SaLTs were as follows: • Child D had been NBM since discharge from hospital in October 2014 • The community SaLT had been unable to assess Child D in October 2014 as Child D was drowsy and advised mother to continue with NBM • Child D was slow to recover and there had been weight loss • It was reported that Child D’s mother had decided that Child D was not to attend school until health had improved • It was reported that Child D’s school was having difficulties contacting the family • The school report that Child D was having ‘oral tastes’ against SaLT advice. 4.57 Whilst the ward manager felt that these safeguarding issues should have been raised in the community, they agreed to raise the concerns with the adult safeguarding team at the hospital who then passed the matter onto the hospital safeguarding children team. 4.58 The hospital SaLTs then made contact with community paediatric SaLT 1. The latter agreed to review the swallow test in the community once Child D was discharged from hospital and agreed to notify “safeguarding” prior to discharging Child D from their caseload if the previous difficulties in contacting the family were repeated. 4.59 The hospital safeguarding children team made contact with Children’s Social Care and established that Child D’s case had been closed the previous year and that no CAF was currently open for Child D. A plan emerged to commence a CAF upon discharge from hospital. 4.60 An initial safeguarding meeting was arranged for mid-February 2015 which was to take place at the hospital. Community paediatric SaLT 1 sent apologies and provided the meeting with a report. However, the report consisted of a letter sent to Child D’s GP following the home visit in October 2014. This letter included Child D’s mother’s acceptance of not following medical advice prior to the hospital admission at that time and included failed contacts since then. However, the crucial information that Child D’s mother had re-introduced oral feeding and the 18 professional opinion of the consequence of these actions was not included in the information sharing. 4.61 At the safeguarding meeting a senior manager from Special School 2 agreed to lead on completion of the CAF, whilst stressing the importance of input from health professionals. Child D’s mother attended and consented to the CAF process but expressed her opposition to the involvement of Children’s Social Care. The justification agreed for initiating the CAF was that Child D’s mother had been feeding her child orally against medical advice. Child D’s mother stated that she did not understand that NBM meant nothing at all, not even water. 4.62 Child D was discharged from the hospital in late February 2015 after 34 days. At this point an explanation was provided to mother that Child D needed to be kept as NBM because of the risk of aspiration. 4.63 Various professionals were unable to make any contact with Child D’s mother in the week or so following Child D’s discharge from hospital. However, a hospital community paediatric liaison nurse managed to visit the family home at the end of February 2015 with a nurse from the specialist feed company, in order to assess pressure areas and potential ulcer sites and to provide information to the family, check the gastrostomy site and check the feeding regime. They found Child D in bed with a vest and nappy on. The bed had a plastic cover on the quilt and pillow. Child D appeared alert and calm. However, they were concerned that Child D may be spending prolonged periods in bed which could lead to pressure areas developing and by the fact that the bed had plastic covers and Child D was not dressed. They also noted that Child D was very thin. These concerns were discussed with Child D’s mother who explained that Child D was being changed at the time of the visit and was always present at family mealtimes, sitting at the table in a specialist chair. 4.64 By the beginning of March 2015 completion of the CAF appeared to have been delegated to a special needs school nurse. The justification for this delegation was that Child D was not attending school and that most of the concerns about Child D were considered to be health related. The specialist school nurse felt that they were not the most appropriate professional to complete the CAF having had little contact with Child D. It was subsequently decided that the hospital community paediatric liaison nurse would complete the CAF during a home visit to Child D which took place a few days later. 4.65 Later in March 2015 community paediatric SaLT 1 wrote to Child D’s parents advising them that, as SaLT had been unable to contact them to assess Child D’s eating, drinking and swallowing, the parents should contact the service so that an assessment could be arranged. They were warned that if no contact was made within two weeks then Child D would be discharged. This appeared to undermine the agreement community paediatric SaLT 1 had made not to discharge Child D from their caseload in the event of difficulties in making contact without alerting safeguarding services first. 19 4.66 Later in March 2015 the CAF was submitted to Children’s Social Care. Although the CAF related to all the children living in the family home, only information regarding Child D was actually included. A family support manager subsequently read the CAF, identified that it was incomplete and returned it to the lead professional to rectify the situation and resubmit. 4.67 In later March 2015 a Team Around the Family (TAF) meeting took place at Special School 2. Child D’s mother attended although she arrived 45 minutes late. The concerns which had led to the meeting were summarised as follows: • Child D’s mother had not been engaging with community SaLT, physiotherapist, dieticians or school and had not attended appointments with the consultant community paediatrician • Child D had attended school only five times since September 2014. (In the previous year there had been 55% attendance) • Child D had experienced “dramatic” weight loss. Lack of engagement with the paediatric dietician meant that the feeding regime could not be updated • Only the community liaison nurse and a physiotherapist had managed to gain access to Child D’s home when Child D was reported to have been in bed wearing just a vest and nappy with no duvet/ covers. The amount of interaction between Child D and family had been questioned. A number of actions were agreed: • Phased return to school from late March 2015 (Mondays and Thursdays), then full time after Easter • Community paediatric SaLT to assess swallowing at home and if mother did not engage then Child D would be removed from their caseload • Child D to be seen with mother at school by physiotherapist and dietician on in March 2015 and to be weighed in school • Child D to be seen by community consultant paediatrician in clinic in May/June 2015 • Community paediatric nurse to undertake fortnightly home visits to check for skin problems and pressure sores. Additionally, the professionals in attendance agreed that the case needed escalating to Children’s Social Care and a referral was made by the hospital safeguarding practitioner. 4.68 At the TAF meeting the hospital paediatric dietician calculated feeds/nutrition for Child D based on a body weight of 40kg which appears to have been a substantial over-estimate as in early April 2015 Child D’s weight was recorded in hospital to be 27.6kg. Therefore, the resultant feed volume, speed and type of formula may well have been incorrect. (Significant Practice Episode 4 - care planning, protection and discharge processes from March 2015 until Child D’s condition was diagnosed as requiring palliative care at the end of May 2015) 20 4.69 Child D returned to Special School 2 in late March 2015 after a lengthy period of absence but later the same day was admitted to the hospital from school after vomiting during the lunch break. It is possible that the incorrect feed volume and speed arising from the over-estimate of Child D’s weight referred to in paragraph 4.68 above may have contributed to this situation. Child D suffered two large seizures whilst in the emergency room where medical staff expressed concern about the dehydrated and malnourished state of Child D. 4.70 The same day Children’s Social Care arranged a strategy discussion for Child D which was attended by a range of partner agencies. Additionally, welfare checks were made in respect of Child D’s younger siblings generating concerns about their attendance at school. The outcome of the strategy meeting was to progress to enquiry under Section 47 of the Children Act and Child D’s case was allocated to Children’s social worker 2. Another Children’s social worker visited Child D in hospital later that day. There they spoke to Child D’s mother and medical staff. At this point nursing staff expressed concern about “poor interaction” between Child D’s mother and her child. 4.71 A further strategy meeting took place at the end of March 2015. A number of key agencies were not represented and provided no reports. Child D’s three younger siblings were included in the discussions. It was noted that Child D’s father had been abroad since February 2015 and was not due to return until May. Child D’s mother was reported to have paid two brief visits to her child since admission to hospital. Given Child D’s age, it was decided that the case would be worked jointly with Adult Social Care, to whom a referral was made the same day. (The case was allocated to Adults social worker 1 at the beginning of April 2015.) It was also noted that children aged between 16-18 years fell within the scope of the Mental Capacity Act 2005 and an application to the Court of Protection could be made. Further information was to be requested from the community paediatrician as to Child D’s health and condition. 4.72 The following day a hospital safeguarding practitioner expressed concern about the risk of infection to Child D if kept in hospital for too long. 4.73 Later in April 2105 Child D was seen by community paediatric SaLT 1 on the hospital ward where NBM, nil by PEG and to receive intravenous fluids only was decided. The community paediatric SaLT 1 noted Child D to be agitated and not in an appropriate position for a feeding assessment. The practitioner confirmed that Child D should remain NBM and discharged from the community paediatric SaLT service (as Child D was no longer to be fed orally long term there was no requirement for swallowing assessments to be undertaken as Child D was no longer deemed at risk of aspiration due to oral intake) subject to referral back if health improved and he returned to school. Child D was not seen by any hospital SaLT at this time or thereafter. 4.74 The same day an Initial Child Protection Conference (ICPC) took place in respect of Child D and three younger siblings, although the emphasis was on Child 21 D. Child D mother was challenged over her history of non-engagement with services after she said that she always made herself available for social work visits and meetings and that missed appointments were the result of her poor memory. Although the community consultant paediatrician was unable to say whether Child D’s recurrent chest infections and pneumonia were due to the severe difficulties and health condition or parental neglect they agreed that Child D’s mother’s attendance at appointments had always been poor and that she needed support to meet Child D’s needs. Child D’s recent abscesses on the arm, ribs and groin were discussed. Occupational therapist 1 stated that there had been no history of pressure damage which indicated good positional care previously. It was unanimously agreed that a Child Protection Plan was required for Child D under the category of neglect. A joint assessment (children and adults services) of Child D’s needs and parent’s ability to meet those needs was to be undertaken. A schedule of expectations would be drawn up to be signed by Child D’s parents. A Core Group was to be established which would meet in late April 2015. (No Child Protection Plan was required for his siblings although they were considered to be CiN.) 4.75 During early April 2015 a DNAR was put in place for Child D. In accordance with hospital policy, two consultants assessed and agreed this. The family were stated to be in agreement although it appears that only Child D’s mother was consulted (with father abroad). Child D was deemed to lack capacity to consent. 4.76 By mid-April 2015 Child D was considered well enough to be discharged home and health advice was that prolonging a spell in hospital risked a hospital acquired infection. A discharge planning meeting was due to take place shortly. Discharge home without a support plan in place was of concern to both Adult and Children’s Social Care. However, no medical evidence had been provided to specifically attribute any of Child D’s health problems to neglect. It was decided that a determination was required as to whether Child D had capacity and understanding to make decisions relevant to the care that was provided, and to this end there was further consideration of an application to the Court of Protection. 4.77 Children’s Social Care’s legal advisor also questioned whether the DNAR in place in respect of Child D had been agreed by his father who remained abroad. 4.78 Two days after being considered fit for discharge, plan to discharge Child D were delayed following aspiration and a further chest infection. However, the meeting arranged to plan discharge went ahead as all professionals were in attendance. A number of actions were agreed including that Child D was to attend school daily unless poorly in which case mother was to have Child D checked by the family GP or through open access at the hospital and the school was to follow up with health services; if Child D was not at school and there was no contact with mother then Social Services would be contacted; a package of support in the mornings was discussed with Child D’s mother who agreed to this after initial reluctance; and Child D’s mother was to fully engage with professionals. It was noted that the community consultant paediatrician had said that Child D’s life expectancy was less than one year and that health was expected to worsen. 22 4.79 Later in April 2015 Children’s Social Care challenged the DNAR on the basis that it had been signed by the mother alone and sought clarification in respect of the mental capacity assessment of Child D. 4.80 The same day a Care Planning meeting took place which was chaired by the Service Leader, Children’s Social Care which was attended by the children’s and adults social work and legal teams. The meeting confirmed the requirement for a joint assessment by children’s and adults social care and health to identify Child D’s needs and whether parents could meet those needs with support. It was stated that if Child D’s health needs could not be met at home, then an application to the Court of Protection would need to be considered – perhaps on an emergency basis. A carer’s assessment was to be offered to Child D’s mother as was advocacy. Contact was to be made with the Head of Service for Children’s Services who would consider a referral to the LSCB for a Serious Case Review as agencies were not considered to have taken appropriate action to raise safeguarding issues. An Independent Mental Capacity Advocate (IMCA) referral was to be made in respect of Child D. It was considered difficult to establish whether Child D’s mother’s neglect had caused or contributed to Child D’s health deterioration “as medical professionals cannot/will not state that deteriorating health is linked to neglect”. 4.81 The first Core Group meeting to discuss Child D was also held in late April 2015 when it was noted that Child D remained unfit for discharge. It was said that the plan remained for a package of care to be provided at home to ensure needs were fully met. The next core group meeting was scheduled for late May 2015. 4.82 In late April 2015 a meeting took place at the hospital at which the schedule of expectations referred to earlier was to be discussed with Child D’s mother. (She may have been unwell – see Paragraph 4.85) She did not attend and it was noted that several agencies had had difficulty in contacting her by telephone. Nor had she provided incontinence pads for Child D which the hospital had requested urgently. (Special School 2 arranged to provide these instead.) She was also noted to have made just one visit to Child D that week. The schedule of expectations of Child D’s parents was discussed and it was agreed that it would include commissioned social care support for one hour each morning and a further two hours on Saturdays and Sundays, alternate weekly visits by Children and Adult social workers, parental engagement with the full range of multi-disciplinary services Child D required, attendance at school unless unwell and attendance at six monthly dental check-ups. 4.83 However, at the same meeting, Children’s social worker 2 and Adult social worker 1 expressed doubt over whether Child D could safely return home as a result of lack of parental engagement with services and the risks arising from the frequent difficulties in contacting Child D’s mother. At this point Palliative Care Placement 1 was considered to be a promising placement as it was “set up for deteriorating health” and Child D would have 1:1 support, including throughout the night. (Palliative Care Placement 1 offered services for people with a wide spectrum of needs including learning disabilities, complex health needs, physical disabilities and acquired brain injuries, enabling them to live independently and safely in their own 23 tenancy. The service was said to comprise self-contained apartments with a staff presence on site 24 hours a day.) 4.84 On the same day the Continuing Health Care (CHC) checklist was due to be completed in respect of Child D to inform the care package ultimately provided. 4.85 The following day Child D’s mother was admitted to the hospital via emergency ambulance with diabetic ketoacidosis, which is caused by a severe lack of insulin. She self-discharged the next day. 4.86 Also in late April 2015 an Adult Social Care solicitor recommended an urgent application to the Court of Protection in respect of Adult D. Application forms were then prepared in anticipation of instructions to issue proceedings. 4.87 By early May 2015 Child D’s hospital consultant was said to be anxious to progress hospital discharge. Discussions took place around transfer to a ward in hospital 2 but the respite care service was also under consideration as a short term placement, although it was said not to be open every day. Child D’s mother was said to be agreeable to a short term placement. 4.88 The IMCA referral in respect of Child D was made in early May 2015 and two days later IMCA advised that they are unable to allocate an IMCA straight away, suggesting that a best interest’s decision should be made and that they would provide a post-decision report. Sourcing alternative IMCA provision was considered. 4.89 In early May 2015 Adults social worker 1 was advised by a hospital ward sister that it appeared that Child D was coming to the end of life, due in particular to the risk of aspiration. 4.90 In mid May 2015 Child D’s mental capacity was assessed in respect of residence and care. The outcome was that Child D lacked capacity. On the same date a carer’s assessment was carried out in respect of Child D’s mother which resulted in a referral to the carer’s service. 4.91 In mid May 2015 discussions took place between Adult’s and Children’s Services regarding the funding of the proposed care package for Child D once discharged from hospital. The contribution of health towards the package remained to be assessed. The Service Manager Adult Social Care expressed reluctance to fund the package without a commitment from health given the extent of medical needs experienced by Child D. The potential for Children’s Services to fund the package/placement was also discussed. It was noted that there were three potential routes to secure joint funding with health which were: • Children’s Commissioning Panel • Complex Cases Panel • Continuing Health Care Panel. 4.92 Adult social worker 1 sought advice from the hospital complex case team over whether Child D’s complex health needs could be assessed using the adult 24 Continuing Health Care route as Child D would reach 18th birthday in two months. They were advised that this would not be possible until the child was 18. 4.93 In mid May 2015 a best interests meeting was held for Child D at Special School 2. Child D was apparently medically fit for discharge and had ceased aspirating since posture had been well managed. The majority view of professionals was that Child D should not be discharged home without a substantial package of care being in place. It was decided to discharge Child D to Palliative Care Placement 1 as an interim arrangement to provide the space for Child D’s mother to demonstrate full engagement with relevant agencies. Child D’s parents were not in agreement with this course of action and stated that they would seek independent legal advice. It was recognised that the placement could not commence until Palliative Care Placement 1 staff had received the relevant training in order to meet Child D’s care needs, but that this would be expedited. The point that a prolonged stay in hospital would not be in Child D’s best interests was reiterated. 4.94 Also in May 2015 the hospital complex needs nursing service received a referral from Children’s Social Care for a Health Needs Assessment (HNA) to be completed in respect of Child D. (Health Needs Assessments are reports submitted to health commissioners to determine long term funding to ensure complex needs are met appropriately.) 4.95 Also in mid May 2015 a care planning meeting was held in respect of Child D. The outcomes were consistent with the best interests meeting held the previous day. Additionally, it was decided that an urgent application (welfare element) to the Court of Protection would be made to enable an appointed person to make health and welfare decisions in respect of Child D. It was also agreed that pending decisions over funding should not delay Child D’s placement. Reference was also made to expediting the HNA referred to in paragraph 4.94 above. 4.96 Later in May 2015 Children’s social worker 2 met with Child D’s parents. An interpreter was present. The social worker advised that the Council intended to go to Court of Protection to enable Child D to be accommodated permanently at Palliative Care Placement 1, but with promotion and facilitation of family contact and home visits. (This appears to be an unexplained departure from the stance taken at the Best Interests meeting earlier in May 2015 (Paragraph 4.93)) The parents confirmed that they had sought legal advice. They added that they would agree to a short term but not a permanent placement. They also said that they would accept a 24 hour care package within their home but would not accept the involvement of social care in any such home care arrangements. 4.97 Also in late May 2015 a further discharge planning meeting took place and a possible discharge date of early June was discussed. 4.98 In late May 2015 a further Core Group Meeting was held at Special School 2. At this meeting Child D’s mother apparently pleaded for a “second chance”, adding that she was concerned about the impact on Child D of not being cared for at home. The community consultant paediatrician questioned whether there would be 25 sufficient stimulation for Child D at Palliative Care Placement 1 and wished to further explore whether a care package could be put in place at Child D’s home. Children’s social worker 2 advised that there would need to be evidence of significant improvements in Child D’s mother’s engagement before a return home would be considered. 4.99 The same day Child D’s final SEN review meeting took place at Special School 2. The school, children’s social care, special needs school nurse and Palliative Care Placement 1 were represented. Reports were received from physiotherapy and occupational therapy. A placement at Palliative Care Placement 1 was confirmed as the plan for Child D which was said to necessitate a Court of Protection application. A school return date was discussed as was the need for dietician advice on Child D’s feeding regime. No report or contribution was received from the consultant paediatrician or dietician. 4.100 Also in late May 2015 the community complex needs nursing service completed the HNA in respect of Child D which concluded that he did not meet the criteria for a package of health care. 4.101 The same day hospital professionals came to the conclusion that Child D’s health had deteriorated to the point where he now needed end of life palliative care. As a result, the proposed placement at Palliative Care Placement 1 was no longer considered appropriate as that placement lacked registered nurse support. (Significant Practice Episode 5 – care planning and protection processes once palliative care was determined at the end of May until Child D’s death in July 2015) 4.102 In late May 2015 the Council decided to place the Court of Protection application on hold whilst the local authority reconsidered its position in the light of the deterioration in Child D’s health. 4.103 Children’s Social Care challenged the HNA referred to in Paragraph 4.99 above, specifically questioning the weight given to the information gathered from Child D’s parents. 4.104 A best interests meeting scheduled for early June 2015 was cancelled as both consultants overseeing Child D’s care were due to meet with parents in the week to discuss transitioning to palliative care. Apparently they also intended to discuss discharging Child D to Palliative Care Placement 2 with parents. 4.105 In early June 2015 the community consultant paediatrician and the acute medical consultant met with Child D’s parents who were advised that their child’s lifespan had considerably shortened and that 24 hour nursing care was required in whatever placement. Child D’s parents were keen for Child D to return home to die 26 with 24 hour nursing care provided. The consultants expressed themselves in support of this option and requested the local authority consider Child D’s changing needs sympathetically adding that trying to separate Child D from family in these circumstances would be counterproductive. They added that there was a need to look at how to provide the 24 hour nursing care as soon as possible. 4.106 The Council reconsidered its position. Notwithstanding their continued reservations about a home placement for Child D, they concluded that, if it was confirmed that appropriate nursing/palliative care could be arranged at home and that the parents indicated that they were engaged in this plan, then Child D should return home. 4.107 On the same date, Adult social worker 1 contacted IMCA again and was advised that an IMCA had still not been allocated and that timescales for allocation could not be provided. 4.108 Three days after the consultants met with parents, the community complex needs nursing service suggested that a new HNA may be appropriate as Child D might now have more dependant health needs following the deterioration in condition. 4.109 Five days after the consultants met with parents a health and social care planning meeting took place at Special School 2. The meeting was chaired by the Service Lead, Children’s Social Care. The community consultant paediatrician confirmed Child D’s condition was terminal and stated a view that it would be “cruel” to place Child D anywhere other than home with 24 hour nursing care. Parental engagement in hospital had improved with one parent staying overnight with Child D who was noted to be responding very positively to his father who had returned from his trip abroad. Children’s and Adult’s Social Care remained concerned at Child D’s mother’s previous lack of engagement with professionals. It was thought that the parents would engage with health services but would be resistant to engaging with social care in any home care package. The potential for a placement at Palliative Care Placement 2 was discussed but it appeared that Child D did not meet the placement’s criteria but that the “hospice at home” service which the placement offered could be an option. It was agreed that greater clarity about Child D’s current health needs was required in order to determine the package of care required and it was noted that this would be informed by a repeat of the HNA by the hospital complex needs nursing service. The meeting also considered what Child D would want. Sources of funding were discussed and the fact that Child D would not turn 18 for several weeks was seen as a potential barrier to Adult Social Care funding prior to that point. A further planning meeting was arranged to take place in seven days. 4.110 On the same date the Council refined their position to confirm agreement to a home placement for Child D subject to an appropriate package of support to ensure health and safeguarding needs were met and subject to the mother and father accepting the care package and entering into a written agreement, breach of which would result in court proceedings. Some form of contingency plan was also to be considered. 27 4.111 Six days after the consultants met with parents, discussions between health and social care appeared to achieve a reverse in the previously held view that the continuing health care (CHC) funding route would not be available for Child D until the child attained the age of 18. Adult social worker 1 highlighted Care Act guidance and requested planning for transition as a matter of urgency due to Child D’s increased health needs and the medical team’s view that a package of nursing support was needed. It was also noted that the Department of Health National framework for CHC and NHS funded care stated that adult health services need to be involved in assessments and care planning for young people transitioning to adult services to be in place to pick up on needs when the young person reaches 18. 4.112 Seven days after the consultants met with parents, the second health needs assessment was completed and submitted to the Clinical Commissioning Group (CCG) Commissioning Support Unit (CSU) requesting a nursing care package for 10 hours overnight every night. The case was transferred to the CHC lead within the CCG CSU and was to be dealt with urgently. 4.113 Twelve days after the consultants met with parents, there were discussions between the CHC lead within the CCG CSU and the hospital discharge co-ordinator. The latter appeared to understand that the plan was to discharge Child D to the Palliative Care Placement 2, 18-25 unit in the first instance. As an NHS commissioned service, it was stated that a placement at Palliative Care Placement 2 would not incur further costs. The potential for a later discharge home from Palliative Care Placement 2 was also discussed. It was suggested that Palliative Care Placement 2 could help determine how Child D’s needs could be met within the family home environment. Any subsequent discharge home would necessitate a CHC assessment. The Palliative Care Placement 2 “plan” was shared with social care services. 4.114 However, later the same day the hospital safeguarding lead clarified health’s position, stating that they continued to pursue a 24 hour home care package and that Palliative Care Placement 2 was not being progressed as an option. 4.115 Two weeks after the consultants met with parents, the CHC nurse assessor telephoned a private provider, which advised that they could accommodate the care package requested. A cost of £5124 per week was quoted although training would be required to meet Child D’s complex health needs, a risk management plan would be required and clarification of parental involvement required. These costings were to be considered by the CCG on the next working day. 4.116 On the next working day the CHC lead within the CCG CSU advised that further information would be required to support the application for funding of Child D’s care package including detail of the support the district nurse could provide, awareness and support of Child D’s GP, provision of registered nurse oversight to manage risks, greater clarity over why the parents could not provide any support, training of staff involved, whether a DoLS was in place and detail of alternative placement options considered. The CHC lead also advised that the cost of the 28 proposed care package was far above comparative care packages, adding that costs would be reduced if the family could fulfil the role of second carer. 4.117 Also on the same day the Carer’s Service made an unsuccessful attempt to contact Child D’s mother by phone to check whether she wished to continue with counselling as she had missed two appointments. 4.118 Two days after the CHC Lead’s additional queries it emerged that a factor in the CHC’s lead’s lack of clarity over why Child D’s parents could not play a role in the home care package was a reluctance amongst health professionals to share information about the safeguarding concerns in respect of Child D. Children’s social worker 2 advised the hospital discharge co-ordinator that the safeguarding concerns were well known to a range of health professionals. During the conversation, the former advised the latter that the district nurse service would be able to provide four visits per day as part of the home care package but would not be able to provide registered nurse oversight 24/7. 4.119 Eight days after it was originally discussed as a placement option, the CCG CSU confirmed that Palliative Care Placement 2’s at home service was not an option for Child D as they did not accept referrals after the patient’s 16th birthday and the service they offered would be one visit a week plus access to an on call advice service. On the same date it was also confirmed that Child D would require suction on a regular basis by a trained carer. The timing of Child D’s needs for suction were unpredictable. Suction was not a service the parents had previously required when caring for Child D at home. 4.120 Three weeks after the consultants had met with parents, Children’s Social Care expressed concern over the delay in decision making in respect of Child D’s placement in a letter to the hospital Head of Governance. Child D’s parents also expressed their frustration and advised the social workers involved that they were keen to get their child home. 4.121 Three days after this professional escalation, Child D suffered a significant deterioration in health. The prognosis was noted to be very poor. Child D was transferred ward for a trial of non-invasive ventilation. Nursing staff were unable to contact the family on repeated occasions to explain what was happening to their child. 4.122 The next day CCG CSU staff appear to have been advised to cease work on the funding application for Child D’s case because of the very poor prognosis. 4.123 Four days after the significant deterioration Child D died with parents being present. 4.124 The following morning Children’s social worker 2 telephoned Child D’s mother to ask her if she intended to attend the review child protection conference scheduled for that day. Child D’s mother advised her that her child had died the previous evening, a fact that the social worker was unaware of. The Council subsequently 29 expressed their concern to the hospital that they had not received a timely notification of Child D’s death despite a child protection plan being in place which put Children’s social worker 2 in a difficult position. The telephone conversation with the social worker would also have been very upsetting for Child D’s mother. 30 5.0 Analysis of the case General 5.1 This was an extremely challenging case because it involved a young person with complex health needs who was on the verge of reaching adulthood at the point at which concerns about parental neglect led to statutory safeguarding intervention. Decision making in the case was complicated by Child D’s deteriorating health. Child D remained in hospital for the last few months of his life whilst attempts to discharge were frustrated by frequent relapses in health and difficulties in reaching professional agreement over where to discharge to. And as the prognosis for Child D became increasingly bleak and required palliative care, there were profound disagreements between those professionals who felt the priority was to allow Child D to return home to die and those who felt that Child D could not be sent home until appropriate 24/7 care had been put in place. 5.2 The last few months of Child D’s life must have been a deeply upsetting period for Child D’s family and Blackburn with Darwen LSCB expresses sincere condolences to them. Learning Themes: Did Child D experience neglect? If so how effectively did agencies respond to indications of neglect? (The following sections (Paragraphs 5.3 – 5.65 and Paragraphs 5.82 – 5.113) are intended to address Terms of Reference question 1 “Were there any opportunities for preventative work and escalation, single or multi-agency that were missed for Child D?” and Terms of Reference question 2 “What was the quality of information sharing and working together across all agencies?”) 5.3 This is a case in which there were profound disagreements between professionals. The key issue on which professionals disagreed was over whether Child D was neglected. 5.4 Neglect is defined in Working Together as “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger;
• ensure adequate supervision (including the use of inadequate care-givers); or
• ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs”. 31 Neglect: access to appropriate medical care or treatment 5.5 Neglect in terms of ensuring access to appropriate medical care or treatment was apparent from the start of Child D’s life. Mother disclosed that her child had been experiencing small seizures for over a month before she took her child to the health visitor clinic in 1998 several months after birth. (Paragraph 4.1) 5.6 In February 2011 Child D had nine teeth extractions under anaesthetic “through lack of attendance at orthodontist”. (Paragraph 4.7) 5.7 When Child D was referred for X-ray in October 2013 to ascertain whether the left hip had been dislocated, mother did not take her child to hospital for the X-ray until early December 2013 (Paragraph 4.16 and 4.18) although she claimed not to have appreciated that she could take her child directly for X-ray without waiting for formal referral. Neglect: protecting a child from physical and emotional harm or danger 5.8 Neglect in terms of protecting a child from physical (and emotional) harm or danger also appeared to be present in this case. In late November 2014 Child D’s mother told the dietician that Child D was on 2 x 500ml feeds plus a pureed diet in contravention of medical advice that Child D should be NBM, (Paragraph 4.47) putting Child D at risk of aspiration pneumonia which would constitute a “serious impairment of Child D’s health”. 5.9 In December 2014 Special School 2 Teaching Assistant 1 carried out a home visit to Child D and observed that mother was feeding orally in contravention of NBM advice. (paragraph 4.50) 5.10 In early February 2015 a locum acute inpatient SaLT made a safeguarding referral in respect of Child D on the basis of information provided that Child D was having “oral tastes” against SaLT advice resulting in a high risk of aspiration. (Paragraph 4.56) 5.11 Whilst it is unclear if NBM was fully explained to Child D’s mother at the point at which Child D was discharged from hospital in early October 2014 (Paragraph 4.44), there is no doubt that NBM was fully explained to her by community paediatric SaLT during a home visit in late October 2014. (Paragraph 4.46) Neglect: concerns over Child D’s weight 5.12 Child D’s weight loss and lack of weight gain were a recurring theme and could have given rise to concerns that Child D was failing to thrive. Paragraphs 4.6, 4.11, 4.13, 4.32, 4.56 relate to this concern, which raised questions over whether “adequate food” was being provided. 5.13 Coupled with this concern was the not infrequent evidence of under-utilisation of home feeds. (Paragraph 4.11, 4.13, 4.23 and 4.30) 32 5.14 However, this is a complex issue. Child D’s paediatric dietician advised the review that she accepted the validity of Child D’s mother’s explanation – that because of Child D’s ill health Child D had been unable to tolerate feeds - for the under-utilisation of feeds. The dietician added that had Child D been a less medically complex child, this would have been an issue which would have been looked into further. The dietician advised that the build-up of unused feed supplies seen in this case was not common but was more likely to be present in cases where the child has complex needs. 5.15 However, contact between the paediatric dietician and Child D was limited for a number of reasons which meant that Child D’s weight was monitored much less frequently than should have been the case. A patient’s weight is a key factor in determining whether feed volume should be increased, decreased or changed. 5.16 Special School 2 commented that Child D had not been seen by the paediatric dietician for so long that they were not sure what to feed and how much. They were following the most recent prescription given by the dietician which may no longer have been accurate. The school added that their expectation was that the special needs school nurse would work closely with the dietician in an effort to try and overcome this problem. However, evidence of effective collaboration between the special needs school nurse and dietetic services in this case is not abundant. 5.17 The importance of regular weighing of Child D was illustrated at the TAF meeting in late March 2015 when the paediatric dietician calculated feeds/nutrition for Child D based on a body weight of 40kg which appears to have been a substantial over-estimate. During 2013 Child D’s body weight was recorded as close to 40kg but in 2014 body weight had declined to between 36.6 and 37.6kg. By the time of the TAF meeting body weight had probably declined still further because at the beginning of April 2015 (less than two weeks after the TAF meeting) body weight was recorded in hospital to be only 27.6kg. Therefore, the resultant feed volume, speed and type of formula were incorrect. (Paragraph 4.68) This may have been a factor in the serious aspiration incident when Child D next attended school in late March 2015. (Paragraph 4.69) 5.18 Indeed four out of five school attendances in 2014-15 Child D experienced vomiting and two of these resulted in hospital attendances. During the same period there was only one admission to hospital from home. 5.19 The community consultant paediatrician, who has known Child D since early childhood advised the review that Child D has always been a difficult feeder with different feeding regimes used to manage low weight gain or weight loss, including the gastrostomy which took place in 2008. (He added that parents of children with similar conditions to Child D require a considerable amount of persuasion when more invasive methods of feeding are introduced, as PEG feeding impacts considerably on the normal family dynamics of feeding and socialising. He said he had considerable sympathy with the parent’s initial reluctance to have the gastrostomy procedure and their reluctance is not an uncommon response.) He did not believe that Child D’s 33 weight loss was evidence of parental neglect because the medical condition meant that Child D was likely to lose weight and find difficulty in gaining weight. 5.20 However, the argument that inability to tolerate feed due to complex health needs was the key factor in weight loss and the build-up of unused feeds is capable of challenge on two grounds. Firstly, concerns over the build-up of feeds were initially raised in February 2013. At this time Child D’s health appeared to be relatively stable and attendance at school had increased from 66% in 2011-12 to 77% in 2012-13. The relatively strong attendance suggests that it should have been possible for Child D to have been weighed and seen by a dietician regularly. 5.21 Additionally, it was noted that Child D’s body weight began to increase whilst in hospital where feed formula, volume and speed of delivery were adjusted by the acute dietician in consultation with the acute paediatrician, where nursing care was constant and Child D was fed appropriately when infections allowed. However, it is accepted that hospital is a controlled environment where all health specialisms are on hand whereas care of complex needs in a community setting requires a much higher degree of co-ordination. 5.22 What is of concern is that so little proactive action was taken by a wide range of professionals to gain a shared understanding of the issue in order to determine whether or what action should be taken which might have included escalation or possibly a medical review. Neglect: care provided by Child D’s parents 5.23 Professionals observations of the care provided to Child D by family generated mixed views about whether neglect was present or not. In late February 2015 a community paediatric liaison nurse carried out a joint visit with the feeds company nurse and expressed concerns about Child D spending prolonged periods in bed which could lead to pressure areas developing and the fact that the bed had plastic covers and Child D was not dressed. When questioned about this, Child D’s mother said that she was in the process of changing her child and was always present at family mealtimes, sitting at the table in a specialist chair. (Paragraph 4.63) 5.24 At the TAF meeting in late March 2015 it was noted that limited access to Child D’s home by professionals had prevented a fully evidence based view of the care provided. 5.25 In late March 2015 nursing staff expressed concern about “poor interaction” between Child D’s mother and her child when she visited in hospital. (Paragraph 4.70) They also expressed concern about the frequency of her visits. (Paragraph 4.71) 5.26 However, BwD CSO 1 advised the review that Child D appeared to be well cared for on the relatively limited number of occasions on which they managed to gain access to the home and appeared to be part of the family. Other professionals such as the dietician also spoke positively about the quality of care provided by Child 34 D’s mother and elder sibling. And when Child D’s recent abscesses on arm, ribs and groin were discussed at the ICPC in early April 2015, Occupational Therapist 1 stated that there had been no history of pressure damage indicating good prior positional care. Neglect: missed appointments 5.27 Neglect may also have been a factor in the frequency with which appointments were missed - many of them vital. This was a pattern which also appeared to begin early in Child D’s life. 5.28 Within the first few months of Child D’s life, Child D had already missed a number of appointments for immunisations. (Paragraph 4.1) 5.29 During early school years Child D’s attendance was described as “poor”, which also had a knock-on effect on attendance at paediatrician appointments which were arranged to take place at school. A pattern of non-attendance at appointments with other services such as dietician and ophthalmics was noted also. (paragraph 4.3) 5.30 A range of agencies including community nurses, consultant paediatrician, dental surgeon, dietician and paediatric surgery recorded a substantial number of appointments to which Child D was not brought. 5.31 When Child D left hip was X-rayed in early December 2013, in order to rule out any infection to the hip, blood tests were arranged for the following day but Child D’s mother did not bring her child to hospital, stating that she was unwell. (Paragraph 4.19) 5.32 And when it was decided that Child D’s hip did not require a surgical intervention at that time but that the position would be reviewed by an Orthapaedic surgeon in three months time, Child D was not brought to the follow-up appointment in March 2014. (Paragraph 4.21) 5.33 Child D’s community consultant paediatrician advised the review that the frequency of missed appointments was not a cause for concern as Child D’s condition was relatively stable. However, Child D’s condition became much less stable from 2014 by which time the pattern of regularly missed appointments had become entrenched and undermined the confidence of several agencies in the genuineness of parental engagement when safeguarding concerns emerged. Neglect: attempts to encourage Child D’s mother to engage: 5.34 Substantial difficulty was encountered in encouraging Child D’s mother to engage with services. This was evident from early in Child D’s life. Challenges were noted in encouraging her to engage with the “full package of care” which had been 35 put in place for Child D in 1998. (paragraph 4.2) Child D’s mother’s refusal or failure to engage with numerous offers of extra help is noted in Paragraph 4.9. 5.35 In conversation with this review, Child D’s mother’s GP said that in her culture, “people look after their own as much as possible for as long as possible”. He added that this stance “strongly prevented them from accepting services and letting go”. 5.36 In her contribution to this SCR, Child D’s mother’s distrust of “social services” was very apparent, although this appeared largely to have originated in events which took place in the last months of her child’s life. She appeared to have developed a positive relationship with Children’s social worker 1 who linked very effectively with Special School 2 to support Child D’s mother in getting her child to school more regularly. 5.37 An important consequence of lack of parental engagement and frequently missed appointments was that Child D was not seen by professionals as frequently as should have been and the opportunity for concerns to be noticed, recorded and for evidence of those concerns to accumulate was greatly diminished. Neglect: difficulties in contacting Child D’s mother 5.38 Care for Child D was compromised by difficulties in contacting Child D’s mother - often at critical times: 5.39 When Child D’s mother was noted to be feeding orally in December 2014, Special School 2 notified community paediatric SaLT 1 who said she would contact Child D’s mother to advise her to stop this practice immediately. However, the latter professional made repeated attempts to contact Child D’s mother who did not respond to messages left. (Paragraph 4.50) 5.40 When Child D was discharged from the hospital in late February 2015, various professionals were unable to make any contact with Child D’s mother in the week or so following her child’s discharge from hospital at a time when there were concerns over whether she would comply with the NBM guidance. (Paragraph 4.63) 5.41 In late April 2015 it is noted that several agencies had difficulty in contacting Child D’s mother by telephone. Nor had she provided incontinence pads for Child D which the hospital had requested urgently. (Paragraph 4.82) Neglect: the vital role of Special School 2 5.42 Special School 2 played a vital part in ensuring Child D’s care needs were met as it was the place where Child D accessed health care from a range of services such as physiotherapy, dietician, SaLT and school nurse. It was also a place where appointments with other professionals such as the community consultant 36 paediatrician could take place for the convenience of Child D’s family. The school was also a place of safety and a place of scrutiny where any concerns might become apparent and could be shared by professionals. 5.43 However, the ability of Special School 2 to fulfil all of these important functions was compromised by deteriorating attendance. Child D’s school attendance was stable during the school years 2008-9 to 2013-14, fluctuating between a low of 53% and a high of 77%. However, from September 2014 Child D only attended school five times. Given that Child D had been de-registered as a CiN three months earlier, Child D became much less visible to agencies from the summer of 2014. 5.44 As school attendance plummeted, one wonders whether Special School 2 could have been more proactive in raising concerns? Educational Welfare tend to be deployed differently in special schools as absences are more likely to be as a result of complex health needs and therefore considered to be “authorised”. This was the case with Child D. Education Welfare are able to take action where non-attendance is unauthorised or unexplained but only a small number of Child D’s absences fell into these categories. The Head of Special School 2 takes the view that more proactive engagement of Education Welfare would have made little difference as they would likely have faced similar difficulties in engaging with Child D’s parents. He adds that in any event Special School 2 no longer benefitted from a dedicated Education Welfare Officer due to budget cuts. However, Children with Disabilities Hub expectation was that Education Welfare could have taken a more active role once Child D’s status as a CiN ended. This expectation appears to have been founded on a misunderstanding of Education Welfare’s role in respect of post 16 pupils such as Child D which is limited by the absence of sanctions for pupils of that age who are absent from school. Neglect – need for a shared understanding of neglect where the child’s needs are complex 5.45 The profound disagreement between professionals over whether Child D experienced neglect is a very concerning feature of this case which must be addressed. Child D and other children and young people with complex needs are an extremely vulnerable group and they are entitled to expect professionals to adopt a common approach to understanding neglect. In the absence of a common approach, the risk of neglect continuing unaddressed increases. 5.46 On the definition of neglect set out in Working Together parental neglect appears to have been made out in respect of Child D in terms of failure to access medical care, failure to protect from physical harm, regularly missing appointments, lack of parental engagement including difficulty in making contact with parents. There are mixed views about the quality of care provided by parents and the extent to which there was a failure to thrive. 5.47 However, caring for a child with complex needs is very challenging indeed and as a result the emphasis of professionals is inevitably, and rightly, on supporting families to provide the level of care the child needs. In these circumstances a great 37 deal is expected of the parents including understanding their child’s medical condition, knowing when to seek medical assistance, understanding the role that a range of professionals can play in supporting and assisting them, advocating for their child’s needs when necessary etc. In these circumstances it is more challenging for professionals to determine when, and to what extent neglect may be present. For example, absence from school may be much more prevalent, build-up of feeds may relate to inability to tolerate them, reluctance to access support may arise from genuine parental concern that no-one understands their child’s needs as well as they do, and so on. 5.48 When concerns over parental neglect led to statutory intervention in this case the disagreement between social care and health appeared to narrow down to a binary choice over whether Child D’s ill health, including potentially life threatening instances of aspiration, was caused or contributed to by parental neglect or was to be expected as a result of deteriorating health. This review suggests that determining whether neglect is present requires a much more nuanced approach. This case may be a valuable case study to assist in developing a shared understanding of neglect in cases where the child or young person has complex health needs. Neglect – practices of key services not conducive to effective safeguarding practice (i) Community Paediatric Speech and Language Therapy (SaLT) service 5.49 Safeguarding children practice within the community health trust’s community paediatric SaLT service has been found to be less than robust by this review. 5.50 When reinforcing hospital advice that Child D should continue to be NBM in October 2014, Child D’s mother gave them the impression of being a knowledgable and competent carer who fully understood these instructions. When they were advised in December 2014 by Special School 2 that Child D’s mother was giving tastes of foods, and they were unable to contact her, the positive impression of Child D’s mother from the October home visit meant that the report from school did not cause concern. As a result, they did not consider a referral to safeguarding services within their health trust. (At this point the community health trust SaLTs had no knowledge of previous safeguarding concerns in respect of Child D) 5.51 In early February 2015 the community SaLT did not attend an important safeguarding meeting in respect of Child D and omitted crucial information from the report provided to that meeting. (Paragraph 4.60) 5.52 The community SaLT service appeared to depart from their undertaking not to discharge Child D from their caseload without first contacting safeguarding on one occasion. (Paragraphs 4.58 and 4.65) Additionally the community SaLT service appeared to adopt a rigid approach to discharging individuals from their caseload following non-engagement. In discharging service users there appeared to be no consideration of the wider picture nor any assessment of any risks involved in 38 discharge from service. The community SaLT advised this review that they had misunderstood the need to keep Child D’s case open as a request from mother, whereas the request came from the hospital’s inpatient SaLT team. 5.53 In their contribution to this review, community SaLT 1 said that they were unaware of any concerns in respect of Child D’s case prior to January 2015. They suggested that record keeping was incomplete at that time and that key colleagues in the special needs school nurse service did not have access to the information system on which information about Child D would have been recorded. 5.54 A further observation about the community health trust’s SaLT service is that arrangements for collaboration between themselves and the hospital trust’s SaLT service appeared far from seamless. (ii) Special Needs School Nurse Service (SNSN) 5.55 The role of the community health trust’s Special Needs School Nurse team (which also includes Health Care Assistants) at Special School 2 includes (in brackets how the role differs to other special schools LCFT provide school nurse services to): • Medication dispensing and feed dispensing (undertaken by Teaching Assistants in other special schools with support and training provided by the nurses) • Dealing with any TAF, CiN, CP or LAC issues for the pupils at the school; contributing to education reviews (SEN) for pupils • Responding to any ill health issues for children when in the school which can range from dealing with scratches to serious ill health issues that may require hospital referral (in other special schools, scratches, bumps or bruises are dealt with by Teaching Assistants) • Parent/Carer consultations as part of Health Care Plans. 5.56 The aim in providing special needs nurse services to special schools is that they lead on case planning and early help/safeguarding tasks whilst teaching assistants dispense medication and organise feeds. There has been discussion on bringing school nurse practice at Special School 2 into line with other special schools for a considerable time between the Head Teacher and senior community health trust managers, but with no successful conclusion. Special School 2 takes the view that the needs of their pupils are more complex than other special schools. 5.57 Special Needs School Nurses contributed to this review and offered the view that as all medical issues are dealt with by their team, relatively “minor” medical issues impact upon the time they have available to undertake early help, CiN or Child Protection work. As a trained nurse is required to be on site during the school day, the nurse’s capacity to attend multi-agency meetings is reduced unless there is cover. 5.58 The nurses suggested that the following organisational issues impacted on their ability to exercise effective oversight of Child D’s case: 39 • record keeping in the school was not in line with community health trust’s policy with records for different medical and feeding needs kept in separate files (e.g. PEG feed file, epilepsy file etc.) and no overall record kept in the child’s file • weights and measurements were not always recorded in the community health trust files, and if recorded were then not always recorded on a centile chart • the scales within the school were rarely reliable to give an accurate weight • inconsistent practice in recording DNAs/FTAs for clinics or attendance issues as significant events • Child D’s file had not been case load weighted so that any concerns would not be immediately evident on viewing a file. It was suggested that the community health trust weighting tool may not be entirely applicable for Special School pupils as the majority of children could be CiN and so all, or most, files may have priority flags as a result • Case files for Special School 2 pupils are paper based which can create problems when new pupils begin at the school as their existing records are likely to be electronic which the nurses may be unable to readily access. The nurses say they are then over- reliant on parents completing HCPs in order to become aware of medical needs • One nurse said that when they began working at Special School 2 there had been no handover of the 150 cases. All files pupils are bulky and so reviewing each of them had not been possible. Reviews of files tended to happen only when incidents occurred. As a result, Child D was not on nurse’s radar until February 2015 • As a result of firewall issues (health and school) the nurse’s access to electronic care records and other community health trust intranet resources is limited within the school. Apparently it has not been possible to find a technical solution to this issue. 5.59 It is clear that the special school nurse service within Special School 2 did not exercise effective oversight of Child D’s case. Numerous issues with swallowing between January and June 2014 did not generate any contact with the community SaLT service. Concerns which could have merited a safeguarding referral such as the delay in seeking medical attention to Child D’s dislocated hip in 2013 do not appear to have been dealt with effectively. The absence of an up to date HCP from Child D’s parents went unaddressed for far too long. 5.60 The organisational issues set out in Paragraph 5.58 are not consistent with effective safeguarding practice. Special School 2 acknowledges that the relationship 40 between the leadership of the community health trust and the school has been challenging, but they do not accept that this is an acceptable reason for ineffective safeguarding practice. (iii) Acute Health Trust Paediatric Dietetics Service 5.61 Child D’s dietician worked 15 hours per week in a number of clinics across East Lancashire. She held one clinic each month in Special School 2. Her caseloads meant that she was unable to fully complete tasks from clinic. The practice was for the practitioner alone to manage their cases without input from the wider team and no management oversight which impacted on ability to liaise with partners, update records and follow up missed appointments. 5.62 As stated earlier, the scales in Special School 2 did not always work and a lack of administrative support to assist in liaising with special needs school nurses for clinic arrangements meant weight and height measurements were not regularly undertaken. As stated earlier, weight and length measurements were crucial to calculation of Child D’s feeds. 5.63 Contact with Child D was adversely affected by lack of attendance at clinics as absences from school increased. The process for monitoring missed appointments was not robust resulting in children who missed appointments not always being identified. Neither was the process of re-booking missed appointments sufficiently robust for children who constantly missed appointments like Child D. 5.64 A consequence of these issues was that the risks in Child D’s case were perceived to be lower than they probably were and, as a result, professionals were not in a position to verify or challenge the accounts given them by Child D’s mother. There was an absence of links between the dietician and community SaLT. The reasons for this are unclear, as in complex needs cases there is an expectation that the school nurse, dietician and SaLT would undertake joint work. 5.65 As Child D began to be admitted to hospital more frequently, management of the case moved between the hospital and community dieticians which adversely affected oversight of his case, although in the latter stages of Child D’s life, sharing of information was good. The support needs of Child D’s mother (In this Section of the report (Paragraphs 5.66 – 5.81) Terms of Reference question 3 “What was the extent of parental non-engagement, the reasons for this, the way agencies responded to this and the impact this had on Child D?” will be addressed) 5.66 Child D’s mother had insulin dependent diabetes, hyperthyroidism and experienced depression. (Paragraph 4.4) There is some evidence that she had difficulty in satisfactorily managing her conditions. (Paragraph 4.85) Caring for a child with such complex needs as Child D must have put an immense strain on parents and immediate family. Mother appears to have been very much the primary 41 carer although Child D’s elder sibling seems to have played a role in care until she left the family home. As Child D’s father was unable to speak english, his wife was the exclusive contact with agencies. However, it seems clear that his return from abroad in late May 2015 coincided with much greater parental presence at the hospital where Child D was noted to have a very positive connection with father. 5.67 Child D’s mother became pregnant with her fifth child in 2012 and gave birth in 2013. Shortly after the birth she contacted the Out of Hours GP service to say that she was worried about recurrence of her depression and “emotional breakdown”. It was noted that the antidepressants she had previously taken had been stopped because of her pregnancy. (Paragraph 4.12) There may, or may not, be any connection between the arrival of a fifth child in June 2013, at a time when she was less able to rely upon her grown up eldest daughter for support and the significant decline in Child D’s attendance at school noted in 2013 -14 school year. 5.68 However, her first referral to the Carer’s Service did not take place until May 2015. (Paragraph 4.90) It is unknown whether this was considered, or offered, prior to this date. In any event she struggled to sustain engagement with the Carer’s Service (Paragraph 4.116), although by this time Child D was terminally ill. 5.69 Child D’s mother speaks english fluently and presented to this review as a capable and confident person. Her claims that missed appointments were the result of her poor memory (Paragraph 4.84) and that she simply didn’t understand the meaning of NBM and was confused about the arrangements for taking Child D for X-Ray for a potential dislocated hip were not wholly convincing. 5.70 However, as the safeguarding concerns about Child D escalated in the last few months of Child D’s life, large number of professionals became involved and as she was exposed to a range of legal and commissioning processes, she must have found this overwhelming at a time when she and her family were having to come to terms with the increasingly bleak prognosis for Child D. Child D’s parents were rightly advised to obtain independent legal advice. 5.71 However, Child D’s parents should have been offered advocacy support at this time. Several professionals have advised this review that they themselves did not fully understand the issues being discussed in the meetings during Significant Practice Episodes 4 and 5. Others commented on the burden placed upon Child D’s mother during this period, with a senior manager from Children’s social care commenting that Child D’s mother must “have been completely confused by it all after having raised her child until age 17 then people telling her that her child couldn’t go home”. The community consultant paediatrician reflected that the hospital should have been more of an advocate for the family. 5.72 Overall professionals failed to achieve an appropriate balance between support and challenge in their relationship with Child D’s mother. Looking over the period covered by this SCR, Child D’s mother was insufficiently challenged by professionals particularly in respect of her increasing failure to engage with services. Over time, professionals appeared to become desensitised to this lack of engagement and 42 appeared to largely accept it. Yet when safeguarding concerns began to escalate from March 2015 the approach of professionals became much more challenging to her. The dietician felt that professionals “went in all guns blazing” and spoke quite offensively to Child D’s mother. The schedule of expectations drawn up by social care in April 2015 was a legitimate approach but the chances of Child D’s parents complying with it seemed remote given the absence of any relationship of trust to underpin it. In hindsight, the loss of the trusting relationship between Child D’s mother and Children’s social worker 1 when the Children with Disabilities service was reorganised in 2013 appears to have been significant. 5.73 The relationship between Child D’s mother and professionals may have been affected by issues of race, culture and religion. Several professionals made reference to the strong emphasis in families of Asian heritage to “look after their own”. It is unclear to what extent this was a factor in this case. Certainly Child D’s mother spoke of her child as “her baby” and expressed doubt about the ability of services to provide Child D with the same level of love and care that she provided. It has also been suggested that agencies may have made assumptions about Child D’s family wishing to “look after their own”, which may have sub consciously affected their decision making at times. (This paragraph addresses Terms of Reference question 5 “Were the diversity needs of Child D and his family met by services?”) Views of Child D’s parents 5.74 Child D’s parents met with the independent reviewer and the LSCB safeguarding development manager in order to contribute their views to this review. Child D’s father was born abroad and speaks little english. Child D’s mother was born in the UK and is english speaking. The religious identity of the family is Muslim. The family live in social housing in a ward, which falls within the bottom 10% of the most deprived areas in England. Three out of the four Lower Layer Super Output Areas in the ward fall in the bottom 1% whilst one falls within the bottom 20%. An interpreter was present to enable Child D’s father to fully participate. Through her parents, Child D’s elder sibling was also invited to participate in the review, given her involvement in caring for her sibling. It is understood that she decided against participating. 5.75 Overall, Child D’s parents said that they understood Child D’s needs better than anyone. Child D’s mother believed that the care she, her husband and elder daughter had provided to Child D at home had resulted in Child D being relatively free from hospital care for the first 15 years of life. Child D’s mother was critical of the care her child received whilst receiving respite care between 2012 to 2014. 5.76 Once feeding difficulties and infections became more prevalent, Child D’s parents felt that problems with either swallowing or infection were treated differently by professionals. If problems arose at school, then the matter was “swept under the carpet” in their view. If the problems arose at home and necessitated hospital care, then they were accused of neglecting their child. 43 5.77 When she agreed to participate in the CAF, Child D’s mother said she was under the impression that she would receive additional support, but instead it escalated to social care trying to take Child D into care. 5.78 Child D’s mother’s overwhelming feeling was of being judged, of services looking down on her and using quite historic information to justify Child D being taken into care. 5.79 The parents felt that in “allowing” their child to die in hospital, services achieved what they wanted by not sending their child home to die. They felt that this did not benefit their child in any way. 5.80 Child D’s parents strongly felt that agency nurses could have been used by the hospital to provide the necessary nursing care at home which would have allowed Child D to be discharged home to die. Engagement of Children’s Services 5.81 Children’s Services became involved with Child D from 2006 when concerns arose over failure to thrive and parents’ unwillingness to agree to gastrostomy despite concerns over weight loss. This ultimately led to a CAF and the identification of Child D as a child in need (CiN) (Paragraph 4.5) 5.82 A child in need is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. 5.83 In August 2013 Child D was transferred from the case load of Children’s social worker 1 to CSO 1 who was a member of the newly formed children with disability hub which at that time consisted of six CSOs managed by a team leader who was a qualified social worker. At that point Child D’s parents were accessing respite care from the respite care service. 5.84 CSO 1 experienced considerable difficulty in gaining access to Child D’s home for monthly CiN visits or engaging mother in CiN reviews which had to be repeatedly rearranged. However, after Child D’s mother advised CSO 1 that she no longer wished to avail herself of the respite care service, Child D’s case was closed as a CiN, subject to CSO 1 liaising with health and Special School 2 to ensure there were no safeguarding concerns. 5.85 The rationale for this decision was that the respite care offered under Section 17 of the Children Act 1989 was a voluntary offer of support which Child D’s parents were not obliged to accept. Whilst CSO 1 was aware of some of Special School 2’s concerns and had experienced difficulties in contacting Child D’s family and accessing the family home, she found Child D’s mother to be open and honest. CSO 1 felt that mother was meeting Child D’s needs and had a right to decline services. 44 5.86 It is a questionable how thoroughly the liaison with health services was carried out. The chronologies submitted by health agencies as part of this SCR do not record any liaison. When they contributed to this review CSO 1 said that they were aware of the school attendance issues but only became aware of the concerns over unused home feed subsequent to the decision to close Child D’s case. 5.87 At the point at which the decision to close Child D’s case to the children with disabilities hub was confirmed at the end of June 2014, it was documented that there were considered to be “no compromised parenting issues” and “no recent concerns expressed by other agencies”. (Paragraph 4.35) The latter point was incorrect as Special School 2 had expressed their reservations about the decision. (Paragraph 4.34) 5.88 The Children with Disabilities Hub team manager has advised the review that there is often a conflict of opinion between Children’s social care and Special School 2 about whether a case should remain open. It is unclear how thoroughly, and in what forum the concerns of the school were explored? A senior manager from the school advised the review that they were unaware of procedures for resolving professional differences set out in the Pan-Lancashire LSCB policy and procedures. 5.89 The decision to close Child D’s case as a CiN was questionable and the timing appeared unwise for the following reasons: Disabled children are more vulnerable to abuse (DfE Safeguarding Children with Disabilities (2009) because: • Many disabled children are at an increased likelihood of being socially isolated with fewer outside contacts than non-disabled children • Their dependency on parents and carers for practical assistance in daily living, including intimate personal care, increases their risk of exposure to abusive behaviour • They have an impaired capacity to resist or avoid abuse • They may have speech, language and communication needs which may make it difficult to tell others what is happening • They often do not have access to someone they can trust to disclose that they have been abused • They are especially vulnerable to bullying and intimidation • Looked after disabled children are not only vulnerable to the same factors that exist for all children living away from home, but are particularly susceptible to possible abuse because of their additional dependency on residential and hospital staff for day to day physical care needs. 5.90 All but the last bullet point applied to Child D whose disabilities were very substantial. Child D’s speech, language and communication needs were such that the primary means of communication was by facial gestures. And given the withdrawal of respite and the difficulties with Child D’s school attendance, the risk of social isolation appears to have been high. CSO 1 said they considered this issue but were convinced by Child D’s mother’s assertion that she regarded Child D as her baby and that no-one else could care for Child D as well as she did. 45 5.91 At the point of case closure, safeguarding concerns were beginning to accumulate. These concerns were articulated by Special School 2 in their email to the Children with Disabilities Hub team manager in May 2014 in which they highlighted concerns in respect of Child D including missing school, missing respite, missing CIN reviews, missing educational reviews and refusal of feeds and equipment for feeds by Child D’s mother. A senior manager at the school concluded that these concerns “begin to paint a picture that I am not comfortable with”. (Paragraph 4.30) 5.92 And closing Child D’s case when Child D was less than a few weeks away from a seventeenth birthday precluded arrangements being made for transitions to adult social care services which had been an integral part of the forward planning for Child D when the case was handed over by Children’s social worker 1 in August 2013. Had Child D remained a CiN for a further 27 days the social care transition process would have formally begun. 5.93 The Children with Disabilities Hub team manager has contributed to this review and advised that the decision to close Child D’s case was relatively unusual. The team manager felt that the concerns about Child D that the Hub were aware of at the time the case was closed were not unusual in complex needs cases. She accepted that because of poor recording and inadequate information sharing, a full picture of the concerns relating to Child D was not obtained prior to case closure. 5.94 One wonders whether the formation of a predominantly CSO, as opposed to social worker led, children with disabilities services may have contributed to the less than satisfactory decision to close Child D’s case. Engaging effectively with Child D’s mother to ensure that Child D’s care needs were met had become quite a challenging assignment by 2013. (In the interaction with CSO 1, Child D’s mother appeared to get her needs met at the expense of Child D’s.) And drawing out the safeguarding concerns in this complex case required a degree of skill and experience which CSOs might not be expected to possess. It certainly may have been advisable for a social worker to have accompanied the CSO on the home visit to Child D which preceded case closure. 5.95 Additionally, it is noticeable that the children with disabilities service played a much less prominent role during the increasingly challenging decision making which took place during Significant Practice Episodes 3, 4 and 5, when one would have expected their expertise to be of particular importance. Representation at key strategy, care planning, best interests and discharge planning meetings was intermittent and it is unclear to what extent Children with Disabilities Hub contributed to assessments and plans. Whilst senior management from the Hub were involved in discussions over funding and Court of Protection issues they do not appear to have been involved in subsequent decision making over discharge home when Child D move to palliative care. 46 Transition from Children’s to Adults Services 5.96 At the point when concerns that Child D was being neglected led to child protection measures in March 2015, Child D was over 17 and a half years of age. Child D’s close proximity to adulthood generated a range of issues including whether Child D should be cared for on a child or adult hospital ward, whether continuing health needs should be assessed as a child or an adult, from which budgets funding for health and social care should come from and whether deprivation of liberty safeguards applied to him for example. 5.97 The difficulties professionals encountered in approaching and attempting to resolve these issues raised questions about the effectiveness of arrangements which had been put in place for managing Child D’s transition from children’s to adult health and social care services. 5.98 Child D’s transition plan was in place from year 9 (age 12) at Special School 2 and was revisited at each annual SEN review thereafter. However, there appears to have been little overall change in the plan between year 9 and year 13 when Child D’s final SEN review took place. For example, the transition plan included transfer from children’s to adult social care with Children’s social worker 1 allocated responsibility for this. But the plan was not updated to reflect the reallocation of Child D’s case from Children’s social worker 1 to CSO 1 in 2013, nor was it updated when Child D’s case was closed to Children’s Social care as a CiN in 2014. 5.99 Child D’s transition plan addressed only current health needs and there appeared to be no plan for potential transfer from the hospital trust’s Paediatrics team to their Community Adult Learning Disability team for example. There was no paediatrician or school nurse involvement (it is not known if they were invited) in the SEN reviews and contributors appeared to dip in and out over the six year period. Only one report was received from the dietician (in year 10) who never attended. There was no Children’s social worker involvement until year 11 and verbal updates only thereafter. An Adult’s social worker was invited in year 10 but not thereafter. The respite service sent reports in 2 out of the 3 years they were involved. The only constant was Special School 2 and Child D’s parents – with the latter attending all but one of the SEN reviews. 5.100 Overall the impression gained is that the SEN review process was primarily an administrative task rather than a meaningful planning process in which the plan was revised over time to reflect identified and emerging needs and risks. 5.101 As previously stated the closure of Child D’s case as a CiN precluded the transfer of the case to adult social care services. This process would have begun had the case still been open to Children’s Social Care when Child D reached 17. In the event the case was closed a few weeks prior to Child D’s 17th birthday. 5.102 The guidance on transition arrangements at that time was set out in a Department of Health Good Practice Guide entitled Transition: Moving on well (2008) which stated that transition should be seen as a process and not an event 47 and that preparation should begin early. The guidance recognised that children are surviving longer into adulthood with conditions that they would once have died from. The health transition plan was envisaged to be much broader than medical diagnosis. It was envisaged that the most relevant health professional would help the young person navigate their way around the health and social care system. (In Child D’s case there was no involvement of health professionals in his transition plan.) The guidance highlighted the risk of parental disengagement arising from poorly managed transition. Health practitioners who contributed to this SCR appeared unaware of this DoH guidance and were unable to identify any local health guidance on transition. 5.103 A CQC review of the transition of children with complex health needs to adult services entitled From the Pond into the Sea (2014) found that the transition process was variable and that the above DoH guidance had not always been implemented. In particular, the review found that 80% of cases they examined did not have a transition plan that included their health needs, there was no lead professional in 50% of cases, the burden of co-ordinating transition often fell upon parents and assessments to allocate funding were often completed by professionals with no prior connection with the family. (In Child D’s case his health needs as a child and then as an adult were assessed during significant practice episodes 4 and 5 by health professionals who had no prior knowledge of his case.) 5.104 During the final months of Child D’s life major reforms of transition began. The Children and Families Act 2014 came into force in September 2014. This act envisages a system from birth to 25 years including a single Education, Health and Care plan to improve co-operation between all services involved in transition. The Act also emphasises SEND (Special Educational Needs and Disability) in which preparing for adulthood is a key element. And in April 2015 the Care Act 2014 was implemented which placed a new duty on local authorities to carry out a Child’s Needs Assessment if there are likely to be care and support needs post 18. These reforms are reflected in Children’s Services revised transitions guidance which has been shared with this review. This new transitions guidance may need to be revisited in the light of this SCR. For example, the guidance advises parents of young people who are unable to make their own decisions to talk to their social worker for advice on mental capacity. In this case Child D had no social worker from 2013 and his case was closed to children’s social care from 2014. 5.105 There was effective joint working between children’s social care and adult social care, and their legal teams, in Child D’s case once safeguarding concerns arose in 2015. However, when interviewed, practitioners, managers and legal advisors involved observed that they had had to negotiate a steep learning curve in terms of understanding each other’s processes and added that it would have been useful to have been able to call upon a specialist in transition. 5.106 Joint working between adult and children’s practitioners within health services was also apparent. A similar learning curve was also remarked upon by several health interviewees. However, there appeared to be a less flexible approach to transition which is evidenced by an initial insistence on Child D’s health needs 48 being assessed as a child. Crucial time was lost in planning for Child D’s needs in pursuing a child’s health needs assessment which ultimately proved a less suitable vehicle than the adult continuing healthcare route. Professional disagreement between Social Care, Health and Education 5.107 Tensions arose between social care services and health services in determining how best to meet the increasingly complex care needs of Child D and ensure his safety. For example, whilst social care saw the hospital as a place of safety, health professionals pointed out the increasing risks of hospital infection for Child D as discharge from hospital was delayed to ensure safeguarding concerns were addressed in any post-discharge arrangements. 5.108 Social care became frustrated with paediatrician difficulty in providing a clear answer to the question of whether parental neglect may have caused or contributed to Child D’s deteriorating health. This was a difficult question to provide an unequivocal answer to. An apparently less difficult question which social care felt they had equal difficulty in obtaining a clear answer to was whether the deterioration in Child D’s health, such as weight loss and more frequent aspiration, might be expected or anticipated consequences of his complex health needs. (In interview the acute health trust consultant said that weight loss would have been expected during a period of infection, for example) 5.109 This challenging case understandably generated some emotional responses. Health professionals expressed the view that social care were being cruel in resisting Child D’s return home once it became clear that health had deteriorated to the point at which palliative care only was required. 5.110 The Council were so concerned about the pace of the assessment of the 24 hour care package required by Child D that they wrote to the Head of Governance at the acute health trust. They also considered making a formal complaint when the same health trust failed to notify them of the death of Child D. 5.111 One wonders how strong the personal relationships were between senior managers in social care and senior clinicians and commissioners, if it was necessary to write to the Head of Governance rather than picking up the phone or arranging a short notice meeting or teleconference. One also wonders whether use might have been made of the many statutory and non-statutory partnership fora on which health and social care colleagues attended? 5.112 Additionally, other disagreements went unresolved. As stated earlier Special School 2’s concern over the closure of Child D’s case by children with disabilities team in June 2014 did not appear to be satisfactorily addressed. In interview, a senior manager from the school indicated a sense of powerlessness when they found themselves in disagreement with Adult and Children’s Social Care during meetings to plan Child D’s care as Child D’s health deteriorated in the final months of life. She asked “what recourse did you have if you disagreed with anything in this case?” adding that they were “not aware of LSCB escalation procedures”. 49 Decision making during Significant Practice Episodes 4 and 5 (In the following sections (Paragraphs 5.114 – 5.133) Terms of Reference question 4 “What outcomes, for Child D and his family, were services trying to achieve; what systems and processes (single and multi-agency) did agencies have to achieve the outcomes and what can be learned to improve these?” will be addressed.) 5.113 Decision making was very challenging as Child D’s health deteriorated. The complex plan for Child D’s discharge, which had been painstakingly constructed through consultation with a very wide array of professional disciplines, had to be largely abandoned once it became clear that Child D required palliative care. Then an almost completely new plan was required against unknown, but probably quite short, timescales. Perhaps inevitably, concerns about processes tended to dominate discussions. It is unclear whether the focus on processes might have obscured the desired outcomes at times. 5.114 The possibility was ever-present that Child D could die in hospital before the completion of plans which were being urgently made to die at home where Child D needed to receive care uncompromised by parental neglect. Involvement in such a difficult decision making process appeared to have exacted quite an emotional toll on several of the professionals interviewed for this SCR. 5.115 With the benefit of hindsight, some options which were ultimately found not to be viable remained “on the table” for longer than was helpful. For example, the health needs assessment for children proved an unsatisfactory vehicle for achieving a 24 hour care package for Child D. This was because a key focus of the assessment was to provide a reasonable level of care to support the parents and not to take over from them. Had this been understood by social care from the outset, this may have led to earlier active consideration of the adult health assessment route, although it is appreciated that health initially ruled this adult health needs assessment route out. 5.116 Additionally, one wonders if Palliative Care Placement 2 was ever a viable option for palliative care for Child D? Apparently Palliative Care Placement 2 wouldn’t be prepared to admit a patient under 16 without parental consent which may not have been forthcoming, probably necessitating the submission of the application to the Court of Protection. And Palliative Care Placement 2’s hospice at home service was discovered, at a very late stage in the process, to be some distance from the level of care Child D required if Child D was discharged home. 5.117 Again with the benefit of hindsight, one wonders whether the palliative care plan of 24 hour care at home for Child D was actually achievable? The clinical advice was that 24 hour care would be required because “airways would need to be cleared by suction and for administration of medicines”. (The acute health trust consultant in interview for this review) When the detail of the health package began to be examined by the CCG, it became clear that this package of care was going to be very challenging to achieve and even more challenging to achieve quickly. 50 5.118 Was it actually viable for Child D to be cared for anywhere but an inpatient setting, given how poorly Child D was and the fact that needs were more complex than parents had become accustomed to meeting in earlier years. The acute health trust consultant said in interview that “it was clear that he was probably never going to be discharged”. 5.19 One final observation about decision making in this extremely complex case; this case had many of the features of an emergency in that decisions were being made against very tight deadlines, there were implications for a human life, there were legal and professional dilemmas to resolve etc. It might have been prudent to adopt approaches to decision making which are used in emergency or critical incident management such as forming a multi-agency “gold” group which brought together key partners from health (clinical), health (commissioning), adult social care, children’s social care, education, legal and others with a suitably qualified person in the role of chair. Leadership 5.120 Within the Council the role of senior managers in taking legal advice and arriving at a considered position was apparent throughout Significant Practice Episodes 4 and 5. Key decisions were escalated appropriately. 5.121 It was more difficult to discern where leadership was being exercised within the health economy where decision making appeared quite dispersed. Clinicians appeared to decide the level of overall care required, complex case specialists assessed detailed health needs and then the commissioners considered how to resource the care package which emerged. It appeared to be a logical process into which urgency could be injected through fast track processes, but it was not easy to discern the impact of senior management oversight. Certainly social care found it quite challenging to engage with such a dispersed decision making process and in interviews for this review suggested that it would have been useful if health had been able to identify a single point of contact (SPOC). Deprivation of Liberty Safeguards (DoLS) 5.122 Because of safeguarding concerns, the discharge of Child D from hospital was delayed on several occasions between February and July 2015 despite the fact that Child D was considered fit to be discharged. This raised concerns that the deprivation of his liberty may need to be authorised. As Child D was over 16 and under 18, any DoLS authorisation would have needed to be actioned by the Court of Protection and on the advice of the Adult social care solicitor an application to the Court was prepared but eventually abandoned at the point at which it was decided that Child D needed palliative care only. 5.123 It is worthy of note that the hospital DoLS advisor took the view that no authorisation was required as Child D’s parents were fully involved in discharge planning discussions, did not object to hospitalisation, were not restricted in visiting their child and made no attempt to remove their child from hospital. However, it 51 seems unlikely that Child D’s parents fully understood DoLs, they did not initially access legal advice and did not have the support of an advocate. Inappropriate discharge from services 5.124 There were occasions when agencies withdrew services or discharged Child D from their service without fully considering the implications of so doing. In this case there was a risk that a perverse incentive was thus offered to Child D’s mother to further disengage from services which did not appear to be considered. 5.125 For example, CiN visits were reduced from monthly to three monthly despite the inability of CSO 1 to achieve even monthly visits. This seemed to be “rewarding” Child D’s mother for not engaging with the Children with Disabilities service. 5.126 The community SaLT appeared to have a rigid policy of removing Child D from their caseload if they were unable to make contact with mother. They even appeared to discharge Child D from their caseload after providing an undertaking not to do so without first contacting safeguarding on one occasion. Appropriateness of decision to complete a CAF 5.127 Was a CAF referral an appropriate response to the concerns articulated by the hospital acute SaLT in respect of Child D? A referral to children’s social care appeared inevitable as there was concern that medical advice was not being following which was putting Child D’s life at risk. The referral was delayed from early February 2015 until late March 2015 whilst the CAF process ran its course. A consequence of this delay was that measures to safeguard Child D were put in place quite suddenly which increased the urgency with which decisions needed to be made. Child D’s death in hospital 5.128 Was it in Child D’s best interests to remain in hospital until death? The hospital health trust states that Child D’s needs were assessed, monitored, managed and met whilst in hospital receiving 24 hour care from a multi-disciplinary team of staff. They add that although that as the hospital was not able to discharge Child D home to die, Child D was cared for with dignity and respect to enable a peaceful death. Child D’s family were present and staff were able to support them as well as Child D. 5.129 Had it been possible to discharge Child D it is clear that Child D would require 24 hour care to a higher level than parents had previously managed to provide at home. As stated earlier, this was due to the necessity of clearing airways with suction to prevent aspiration. There was also the potential for respiratory arrests, seizures and infections. Had Child D died at home there is a possibility that there could have been further child protection enquiries. 52 5.130 The acute consultant and community consultant paediatrician question whether Child D ever got to the stage where Child D could be safely discharged from hospital during the palliative care period prior to death. 5.131 Child D died on an adult ward with limited stimulation. The acute consultant said that Child D was admitted to an adult ward due to the fact that Child D was approaching 18 years of age and that management on an adult ward would aid future transition to adult services. 5.132 It is not known if there is any shortage of non-hospital based palliative care for young people with very complex needs. This case suggests this may be the case given the difficulty found in finding a hospital discharge option other than home with 24 hour care. DNAR 5.133 Child D’s father did not appear to be consulted in respect of the two DNAR decisions taken in respect of Child D. The absence of consultation with the father in respect of the second DNAR decision was challenged by social care. The hospital chronology indicated that decision making in respect of these DNAR decisions was in line with expected practice in that one parent was consulted who would then would be expected to advise the other. This does not appear to be an entirely satisfactory basis on which to proceed given the potential for two parents to have a difference of opinion on an issue of this significance. Independent Mental Capacity Advocate availability 5.134 An IMCA referral in respect of Child D was made in early May 2015 and two days later IMCA advised that they are unable to allocate an IMCA straight away. By early June 2015 the IMCA had still not been allocated and timescales for allocation could not be provided. This review has received no information about the pressures the IMCA service may have been under, but this does not appear to be a satisfactory state of affairs. The IMCA could have had an integral role to play had the Court of Protection application been pursued. 53 6.0 Findings and Recommendations Closure of Complex Needs CiN cases 6.1 This review has been advised that the closure of Child D’s case as a Child in Need shortly before the 17th birthday was a relatively unusual decision in a case in which the child had such complex health needs. The process by which Child D’s case was closed was far from robust. Case closure took place without full consideration of safeguarding concerns and the timing of the decision, just prior to transition to adult services would have formally begun, was unwise. It is understood that as a result of reflecting on this case, the Children with Disabilities service would now only close a case as a CiN after completing a single assessment which should enable any risk of significant harm to be considered. Recommendation 1: That Blackburn with Darwen Local Safeguarding Children Board obtains assurance that the Children with Disabilities service has a robust process in place to ensure that any decision to close the case of a child or young person with complex needs as a Child in Need is sound. Safeguarding Review of Children with Disabilities Service 6.2 Children’s Service moved to a Child Support Officer (CSO) led Children with Disabilities service in 2013. This review suggests that this significant change may have diminished the effectiveness of safeguarding practice within the Children with Disabilities service. The review raises questions about the extent to which Children with Disabilities CSO’s receive the training, support and supervision necessary to address the safeguarding challenges that cases involving children with complex needs can generate. Considerable onus is placed on the Children with Disabilities team manager as the team’s only qualified social worker to sign off all assessments and chair all half yearly reviews of cases amongst other functions. Additionally, the Children with Disabilities service appear to have played a less than prominent role in contributing to decision making during significant practice episodes 4 and 5. Recommendation 2 That BwD LSCB commissions a review of the effectiveness of safeguarding practice within the Children with Disabilities service. Discharge from Services 6.3 Ceasing service provision because of service user non-engagement appears to be a standard, relatively automatic decision for some agencies which has the potential to undermine safeguarding children arrangements. In the case of the Community Paediatric SaLT service the presence of safeguarding concerns appeared to have no discernable impact on the process by which service provision ended. And Child D’s mother’s decision to decline respite care from the respite service appears 54 to have been the key factor in Children with Disabilities service’s decision to close Child D’s case as a CiN in June 2014. Recommendation 3 That BwD LSCB seeks assurance from partner agencies that they have robust systems in place to ensure that decisions to cease service provision as a result of service user non-engagement are not taken without fully considering any safeguarding implications. Shared Understanding of Neglect 6.4 When concerns over parental neglect led to statutory intervention in this case the disagreement between social care and health appeared to narrow down to a binary choice over whether Child D’s ill health, including potentially life threatening instances of aspiration, was caused or contributed to by parental neglect or was to be expected as a result of deteriorating health. This review suggests that determining whether neglect is present in cases involving children and young people with complex needs requires a much more nuanced approach. However, it is vital that there is a shared understanding of what constitutes neglect, otherwise joint working will be undermined, children may be exposed to the risk of significant harm for longer and conflict between agencies is likely to result. This case may be a valuable case study to assist in developing a shared understanding of neglect in cases where the child or young person has complex health needs. Recommendation 4 That BwD LSCB makes use of the learning emerging from this case to assist in developing a shared understanding of neglect in cases where the child or young person has complex health and social care needs. Streamlining Statutory Processes 6.5 Complying with statutory child protection processes generated a substantial number of multi-agency meetings during significant practice episodes 4 and 5. It may have been possible to streamline or otherwise adjust the process in a case such as this where decisions needed to be taken with urgency. It may have been prudent to adopt approaches to decision making which are used in emergency or critical incident management such as forming a multi-agency “gold” group which brought together key partners from health (clinical), health (commissioning), adult social care, children’s social care, education, legal and others with a suitably qualified person in the role of chair. Recommendation 5 That BwD LSCB consider whether it would be appropriate to set out in broad terms, processes which could be followed or considered where a complex case required urgent multi-agency decisions to be made. 55 Health Services and Decision Making Authority 6.6 This case discloses that there was difficulty in establishing where authority resided within health services and commissioning involvement when critical decisions needed to be agreed by partner agencies in respect of Child D. It is suggested that the identification of a Health Single Point of Contact (SPOC), and knowledge of the safeguarding, decision making and crisis escalation processes would have been of assistance in this case. Recommendation 6 That BwD LSCB invites the CCG and local NHS providers to consider how to provide clarity to partner agencies over where authority for decision making resides within the health sector when critical multi-agency decisions need to be made and report back to the Board on their findings. Resolving Professional Disagreements 6.7 This was a case in which professional disagreement was a prominent aspect. This was particularly apparent at the point at which Child D’s case was closed as a CiN; in discussions between social care, health and education practitioners and managers over whether parental neglect had contributed to Child D’s deteriorating health; and in deciding whether, and in what circumstances, Child D could be discharged home to die. However, the Protocol for the Resolution of Professional Disagreement Between Agencies Working with Children in Blackburn with Darwen was never invoked nor apparently even considered. The Special School 2 senior manager advised this review that they were unaware of the protocol and this may have been the case for other practitioners also. 6.8 The protocol may be in need of improvement in any case as it is predicated on escalation to increasingly senior levels. The protocol makes no mention of tried and trusted means of resolving conflict such as the involvement of a third or independent party to mediate for example. Recommendation 7 That BwD LSCB reviews its protocol for resolving professional disagreements, ensures it is widely shared and promotes its use. Transition from Children’s Services to Adult Services 6.9 Considerable changes have been implemented, or are in the process of being implemented to the process by which young people with complex needs transition from children’s services to adult social care and health services. The case of Child D largely preceded these changes but discloses a number of deficiencies in the transition process which may still be present in the redesigned process. 56 Recommendation 8 That BwD LSCB and BwD Safeguarding Adults Board (SAB) establish a joint task and finish group to examine the process by which children and young with complex needs transition from children’s to adult health and social care services in the light of the learning from this SCR. “Language barriers” 6.10 The conversations with practitioners highlighted the overall professional competence and commitment of colleagues within a wide range of disciplines. What the conversations also disclosed was that the majority of practitioners who specialise in children’s health and social care often lacked even a basic knowledge of adult health and social care law, policy and procedure - and vice versa. This led to considerable difficulties in a case in which Child D was a child on the cusp of adulthood. Practitioners were striving to work effectively with colleagues who often spoke a “different language”. It would seem sensible to invest in ensuring there are at least some practitioners who “speak more than one language”. This could be done by identifying those practitioners who may have experience in both children’s and adult services, arranging periodic job shadowing and running joint training for example. Recommendation 9 That BwD LSCB and SAB obtain assurance that partner agencies ensure that identified individuals receive the training and support necessary for them to operate effectively across the children’s and adult health and social care fields. Professional engagement with Child D’s parents 6.11 This case discloses substantial challenges in engaging with the parents of Child D. It would be of value for practitioners and managers to reflect on the learning which emerges from these parental engagement challenges and consider whether professional expectations of Child D’s parents were pitched at an appropriate level and whether there is scope to flex the way in which practitioners work with parents and families of children with complex needs. 6.12 There is broad agreement that Child D’s parents must have found the series of meetings which took place during significant practice episodes 3, 4 and 5 bewildering. Given the strong emphasis on working with families and helping them to build upon their strengths, it would surely have been appropriate to have ensured Child D’s parents had access to advocacy, to enable them to play a more informed part in decision making about their child. 57 Recommendation 10 That BwD LSCB ensures that the learning arising from this SCR is widely disseminated and in particular practitioners and managers are asked to reflect on how best to engage with and support families of children with complex needs. Recommendation 11 That BwD LSCB obtains assurance that advocacy is offered at regular intervals to parents of children and young people with complex needs where appropriate. Carer’s Assessments 6.13 Child D’s parents do not appear to have been formally offered a carer’s assessment until April 2015. It would therefore be prudent for BwD LSCB to seek assurance that the parents of children and young people with complex needs are offered carer’s assessments when appropriate. Recommendation 12 That BwD LSCB obtain assurance that the parents of children and young people with complex needs are offered carer’s assessments where appropriate. Use of interpreters 6.14 Partner agencies involved in providing support to Child D had much less engagement with father than with mother. A contributing factor may have been the fact that the father did not speak english. However, an interpreter was not always provided for him. Partner agencies appeared to take the view that if one parent spoke english, he or she could generally interpret for their spouse. This appears to be a pragmatic approach which may suffice generally but there were many occasions in this case in which the parents were involved in making critical decisions in which informed consent and engagement necessitated the use of an interpreter. Recommendation 13 That BwD LSCB obtains assurance from partner agencies that they make appropriate use of interpreters when one parent has no english or insufficient understanding of english to be able comprehend what is taking place. Education Welfare role 6.15 Education Welfare did not engage in Child D’s case despite substantial absences from school because the majority of those absences were adjudged to be authorised. The assumption that Child D’s absences were largely related to complex needs appeared to have been open to challenge had they examined absence 58 alongside other concerns such as parental engagement with services and access to home address for example. Recommendation 14 That BwD LSCB requests Education Welfare to review their policy and practice in respect of the monitoring of school absence of pupils under the age of 16 who have complex needs. Safeguarding Practices within Individual Agencies 6.16 Several key agencies did not operate in a manner which contributed to effective safeguarding practice. For example, there are many examples of inadequate recording of information, deficits in timely information sharing and in partnership working generally. Some basic but vitally important issues were not grasped such as ensuring scales actually worked for example. 6.17 A drawback in the systems approach adopted for this SCR is that whilst there has been a helpful focus on practitioner views on what needs to change as a result of the learning emerging from this review, there has been no obligation on contributing agencies to advise the review of any action plans they have, or are in the process of implementing as a result of learning from this review. Recommendation 15 All agencies involved in this SCR should be asked to advise BwD LSCB of actions and learnings they have taken as a result of this review and the outcomes they anticipate achieving. BwD LSCB may wish to seek assurance that single agency action plans have been implemented and outcomes achieved. 59 Appendix A The process by which this SCR was conducted After BwD LSCB decided to commission a SCR there was an initial meeting between the lead reviewer, the LSCB safeguarding development manager and Child D’s mother to explain the SCR process and to invite her, her husband and Child D’s elder sibling to contribute to the review. A review group of senior managers from partner agencies was established to oversee the SCR which was chaired by the lead reviewer. The membership of the review group is as follows: David Mellor, Independent Lead Reviewer Safeguarding Development Manager, BwD LSCB Principal Solicitor, the Council Service Leader, Children’s Services Social Work, BwD Borough Council Service Leader, Children’s Services Education, BwD Borough Council Service Leader, Adult Services, BwD Borough Council Head Teacher, Special School 2 Review Officer, Police Designated Doctor, Clinical Commissioning Group & Community Paediatrics Designated Nurse, Clinical Commissioning Group Named Nurse, Hospitals Trust Named Nurse, Community Health Trust Independent Advisor to Review Group, Carer’s Service. Chronologies which described and analysed relevant contacts with Child D and family were completed by the following agencies: • Legal Services – including both children and adult solicitor involvement • Children’s Services & Education – including early help, social care, children with disabilities, Independent Review Officer (IRO), Disability Respite Service, education welfare and special educational needs services • Adult Social Care • Special School 2 • Police • Acute Hospital Trust – including A&E, Medical Assessment Units, paediatrics, physiotherapy, midwifery, diabetes, dietician, speech & language therapy, occupational therapy, orthodontics, surgical teams, genetics, continence, safeguarding, DoLs and complaints services • Community Health Trust – including occupational therapy, physiotherapy, school nurse, speech and language therapy (SaLT) and complex packages of care services • CCG & NHS England – including GP and Clinical Commissioning Unit services 60 The review group analysed the chronologies and identified five significant practice episodes. Conversations then took place with practitioners from participating agencies who had had significant contact with Child D and family. The lead reviewer and the LSCB safeguarding development manager met with Child D’s parents, and with the assistance of an interpreter recorded their contribution to the review. The lead reviewer then further analysed the chronologies, the records of the practitioner conversations and Child D’s parents’ contribution in order to prepare an initial draft report which was shared with practitioners at a learning event where practitioners were invited to comment on the accuracy, completeness and balance of the report. The lead reviewer further developed the report to reflect the comments from practitioners before sharing a late draft with review group members whose comments were taken account in preparing a final report. It had been intended to share the final draft of the report with Child D’s parents but efforts to arrange a meeting with them to facilitate this have been unsuccessful on a number of occasions. |
NC52230 | Review commissioned in April 2017 following five convictions for sexual offences of adults who had previously worked at St Paul's School London. Allegations had also been made against 32 ex-staff members and there had been recent involvement from the police, local authority, health professionals and Local Safeguarding Children Board (LSCB) with the school. Alleged offences had taken place from early 1960s onwards with many relating to the 1970s and 1980s. Sixteen of the alleged perpetrators were deceased. Fifty-nine ex-pupils were seen by the lead reviewers. Attendance at the school ranged from pupils who started in 1953 through to those who left in 2015. Six of the 59 ex-pupils seen were victims of perpetrators who stood trial. Ethnicity and nationality not stated. Findings include: accepting responsibility for past abuse must be a foundation for moving forward and developing an effective safeguarding culture; schools face difficulties in balancing a response to allegations of abuse that takes account of employment law, education legislation and good safeguarding practice; there are gaps in the national safeguarding system in relation to the recruitment and regulation of teachers, the Disclosure and Barring Service and the way in which information is shared across national organisations. Recommendations include: Charity Commission should make explicit their expectations regarding best practice at times of crisis and specifically that protecting the reputation of the charity includes openness and honesty about any poor practice; Home Office should establish a system of advocacy and support for complainants in child sexual abuse cases both pre- and post-trial to ensure consistency between areas.
| Official Richmond Safeguarding Children Board Everybody’s Business: Keeping Children Safe in School A Serious Case Review into Events at St Paul’s School Report Author Jane Wonnacott MSc MPhil CQSW AASW Review Chair Edi Carmi BSc (Hons) CQSW Dip in Management 13th January 2020 FINAL 13.1.20 Page 2 of 112 Official Contents FINAL 13.1.20 Page 3 of 112 Official BACKGROUND AND CONTEXT INTRODUCTION This serious case review was commissioned in April 2017 by Richmond Safeguarding Children Board following five convictions for sexual offences of adults who had previously worked at St Paul’s School London. At the time of this decision the Richmond Safeguarding Children Board was also aware that there had been allegations made against 32 ex members of staff and there had been recent involvement by the police, local authority, health professionals and the Safeguarding Children Board with the school. The events leading up to the decision to carry out a serious case review and the rationale for the review are explained in more detail in sections three and four of this report but from the start it was clear that this was a complex set of circumstances that had evolved over time. Although the school had been subject to external inspections, conducted internal reviews including commissioning reviews by independent consultants and worked hard to put in place systems and processes to keep children safe, it was the unanimous view of the serious case review subgroup at Richmond that a wide holistic statutory review of the conduct of agencies involved in allegations of abuse from 1960 onwards would be in the public interest. Although the impetus for the review had been allegations and convictions relating to sexual abuse, the final terms of reference acknowledged that one type of abuse rarely exists in isolation and the review also explores how pupils can be safeguarded from physical and emotional harm. The aim of this review is to identify lessons relevant for safeguarding children today, but the starting point has deliberately been to seek to understand the experience of ex-pupils and survivors of abuse at St Paul’s who are now adult men. We have wanted to keep their experience as pupils at the heart of the review. Although systems, procedures and guidance may have changed, the fundamental dynamics of abuse have not. We may now be better at recognising physical and emotional harm and understand much more about the modus operandi of sexual offenders: but abuse may still happen and in particular, adults with a sexual interest in children will continue to find ways to offend, with often devastating consequences for those they have harmed. Understanding the relationships and culture within an institution at the time when the abuse happened allows us to reflect on current cultures and safeguarding practices through this lens and develop a deeper awareness of what may prevent abuse reoccurring in the future. In exploring the experiences of ex-pupils, the report does refer to allegations, complaints and concerns about ex-teachers at the school. The purpose of this review is not to judge whether these allegations were true but to consider what lessons can be learned about safeguarding practice from the way in which they were dealt with. Specifically, where an allegation did not result in any criminal conviction it is not the intention of the report author to imply that this allegation was factually true, since this is not the purpose of this review. FINAL 13.1.20 Page 4 of 112 Official This is a report aimed at improving the safety and wellbeing of children and the review panel have debated the extent to which it should include exploration of the way in which adults have been treated by the school, safeguarding and criminal justice systems. The final report does include comment on these matters for two reasons. Firstly, the way people who have been abused as children are treated when they disclose abuse is an important indicator of the culture that drives our response to children and secondly, protecting children in the future will be affected by the extent to which adults are able to talk about their experiences and potentially bring perpetrators to justice. Although much of the learning may appear to focus on professional and organisational processes, we should not forget that the testimonies of ex-pupils show the potentially devastating, lasting impact of all forms of abuse; with responses ranging from supressing memories of events, through to difficulties with adult relationships and mental health problems including suicide. During the review we have spoken to 59 ex-pupils who have shared their perspective of what happened at the school and the impact on them as children and adults. We have also heard about their experience of the school and other agencies when the abuse became public knowledge. We are immensely grateful to this group of people for sharing information which was often painful to recall. They have given us an invaluable insight into changing school cultures, the behaviour of perpetrators and alleged perpetrators, how it felt for them to be a pupil at the school and, for some how it felt to be abused by a member of staff. Some of the experiences we heard about will be specific to pupils at selective independent schools, although many will also apply to children in all schools and can contribute to our understanding of how we can work together to safeguard children in schools today. This review has taken place over an extended period due to the amount of information that needed to be processed and the breadth of issues that emerged. It has also been vital to consult properly with significant people with an interest in the review before the final report was agreed and published and to take legal advice as to what information could be included in the final report. It is important to emphasise that the process of the review has generated learning that has been acted upon without waiting for publication and this is explored in relevant sections of this report. There has been ongoing dialogue with the senior management team at St Paul’s who have been open to reflecting on where the school can build on the improvements that have already taken place, and have kept the review up to date with new information about their experience of working with the national safeguarding system. This has revealed gaps that affect all schools and has been commented on within this report. This report The purpose of a serious case review and publication of the ensuing report is to contribute to professional learning and improvement through understanding what happened, why it happened and what this means for future practice. This is an unusual serious case review due to its depth and breadth and this report attempts to do justice to the wide-ranging information gained from many individuals whilst remaining focused on learning lessons FINAL 13.1.20 Page 5 of 112 Official that are relevant for practice today. The report is derived from a vast amount of written and verbal information and difficult judgements have had to be made about the level of detail that is included. Inevitably some people will feel that it does not do justice to their experiences whilst others may feel the level of non-recent detail is unnecessary if the aim is to focus on future learning. The final content of the report is the responsibility of the report author and the review chair (the lead reviewers) taking account of legal advice. The report is set out in the following sections: Background and context 1 Introduction to the review and explanation of report structure 2 St Paul’s School: history and governance 3 The background events that led to the review 4 The way the review was conducted Summary 5 Summary of main findings What happened 6 What do we know about the abuse that took place at St Paul’s Understanding why and what can we learn? 7 Analysis of why the abuse was not recognised at the time 8 Analysis of the way the school responded to specific allegations of abuse 9 Overview of the school’s actions to improve safeguarding practice 10 Analysis of the way in which the wider safeguarding system responded when there were specific allegations of abuse 11 Understanding the impact of relationships across the safeguarding system on safeguarding practice 12 Analysis of the role of health professionals in safeguarding children in the school 13 Analysis of the role of regulatory activity in protecting children 14 What can be learned about day to day safe practice in St Paul’s 15 Findings and Recommendations - overall analysis of learning and recommendations for system improvement. FINAL 13.1.20 Page 6 of 112 Official Case studies In order to explore practice issues in detail and to make sure that the evidence base for the findings is clear, the report author compiled detailed case studies for discussion with the review panel outlining events that took place in relation to convicted perpetrators of abuse and others where allegations had been made. The case studies were informed by chronologies from the organisations involved as well as by information gathered from ex-pupils. The specific cases were selected to illustrate various time periods and themes that are explored in the main body of the report. The accuracy of the information within the case studies was checked by panel members. Following legal advice given to the lead reviewers, it was agreed the detail contained within each individual case study should not be set out as appendices to this report. Some of the information referred to events or alleged events that had not been proven in a court of law and, although some material is in the public domain via press reports, it was agreed that it would not be proportionate and fair to include this in a format which would increase the likelihood of individuals being identified. The above has resulted in an inability to comment on the detail of specific cases although steps have been taken to include sufficient detail to ensure that learning has not been lost. Ex-pupils may feel that their information has not been valued but this is definitely not the case and the information about specific perpetrators and alleged perpetrators remained important in informing the analysis set out in this report. Ten cases involving four of the six convicted perpetrators and six alleged perpetrators1 were analysed in detail by the panel and the table below sets out the timeframe that they relate to and the main issues that emerged from the analysis. 1970’s- 1980’s Cases illustrate: • grooming behaviour, “hiding in plain sight” and failure to recognise and respond within the school community; • the interface between school and church; • alcohol use in school and staff/pupil boundaries; • grooming behaviours and responding to rumours, concerns and evidence of inappropriate behaviour particularly where the teacher is popular and charismatic; • managing allegations in school including recording. 1980’s Cases illustrate issues relating to: • recognising the meaning of a pupil’s behaviour and changes in academic performance; • the conduct of police investigations and supporting alleged victims post trial. 1990’s A case from this period illustrates the importance of tight recruitment processes for freelance staff, school’s receiving accurate references, use of alcohol in school, recognising concerning behaviour and a positive response when a previous conviction comes to light. 1 Alleged perpetrators include those who had been investigated and found not guilty, investigated and no further action was taken and those where there have been allegations that were not substantiated at all. FINAL 13.1.20 Page 7 of 112 Official 2000’s Cases illustrate: • use of alcohol and boundaries between staff and pupils and managing communications with the school community post-conviction; • the importance of a code of conduct within school; • managing allegations within Children’s Social Care and across local authority boundaries; • managing allegations in school and decisions to suspend; • challenges of working with voluntary residential organisations and faith groups; • the positive role of the disclosure and barring service; • recognising emotional abuse and the impact of abuse on pupils; • the proper use of HR processes; • challenges in managing communications where a member of staff is suspended; • the need for effective communication between schools and the teaching regulator; • decision making by the teaching regulator; • positive work with voluntary residential activity organisations; • the importance of a positive relationship between the school and LADO; • managing allegations within the local authority; • thresholds for police enquiries; • giving and receiving employment references. Terminology This report aims to minimise the use of acronyms in order to increase accessibility for a wide range of readers. One acronym that has been used is the LADO who has responsibility for oversight of allegations of abuse in organisations and is referred to in national guidance as the Designated Officer. Although national guidance no longer refers to this role as “the LADO” it is still the term generally used by organisations working with children. In line with the London Child Protection Procedures, it is used in this report in order to distinguish between safeguarding leads in health and education who can also be referred to as ‘designated’ leads. Pupils who have attended St Paul’s are known as Old Paulines. This report has chosen to refer to “ex-pupils”. This is not in any way meant to disrespect the traditions associated with the school but is aimed at making the report accessible to a wider audience. This report has been anonymised and no pupil, ex-pupil, staff member or other related practitioners have been referred to by name. This also applies to perpetrators and alleged perpetrators of abuse, even though names have appeared on websites and the national press. This decision was taken to comply with the law in relation to those who have not been charged with any offence, to protect the confidentiality of any individuals associated with convicted or alleged perpetrators of abuse and also to help in remaining focused on issues rather than personalities. FINAL 13.1.20 Page 8 of 112 Official Children’s Services is the generic term used in the report to refer to the organisation in Richmond that provides all services to children and, where this specifically refers to social work services, this is referred to as Children’s Social Care. Within Richmond all of these services are delivered on behalf of the local authority by Achieving for Children, a Social Enterprise Company set up on 1st April 2014. Senior staff at the school During the period covered by the review there have been five Head Teachers of Colet Court (now St Paul’s Juniors), and seven High Masters of St Paul’s School who have overall responsibility for the management of the whole school. Where relevant, these senior staff are referred to in the report as follows. High Master Junior School Head Teacher HM1 1960-61 HT1 1964-71 HM2 1962-72 HT2 1972-98 HM3 1973-85 HT3 1999-06 HM4 1986-91 HT4 2007-16 HM5 1992-03 HT5 2016-present HM6 2004-11 HM7 2011-present ST PAUL’S SCHOOL: HISTORY AND GOVERNANCE St Paul’s School is an independent day and boarding school in West London for boys aged between seven and 18. Boys up to the age of 13 are educated at St Paul’s Juniors (previously known as Colet Court), which has shared the same site as the senior school since 1968. Although both a boarding and a day school, the number of pupils boarding are now very small; with 35 boarding pupils in the senior school in the 2018/19 academic year. St Paul’s was founded by John Colet Dean of St Paul’s Cathedral in 1509 when it was usual for school governance to be entrusted to the church, but Colet believed that “he yet found the least corruption” in married laymen and chose The Mercers Company (“Mercers”) to run the school. The Mercers are a livery company, founded in the City of London in the fourteenth century and today use their income from property to fund philanthropic activities. They currently have an association with 16 schools, colleges and academies. The Mercers support the schools through their young people and education programme in a variety of ways including funding, building projects, funding research into effective mental health support for children in schools and supporting governing bodies; with a common feature that the school runs itself. FINAL 13.1.20 Page 9 of 112 Official The relationship between St Paul’s and The Mercers has always been close and this relationship and associated governance arrangements have evolved over time. These arrangements are highly relevant to the governance of safeguarding and system of redress to survivors of abuse which is explored later in this report. Most of the abuse at St Paul’s that is discussed in this report took place prior to 2007 when governance arrangements changed. Prior to 2007, the two St Paul’s Schools were part of the St Paul’s School Foundation, a registered charity of which the Mercers’ Company was the sole trustee. As trustee the Mercers’ Company appointed the majority of the governors who were ‘managing trustees’ of their respective school with full responsibility for its administration and management. As the school was not a separate, incorporated legal entity, all contracts and commitments were entered into by the governors as individuals and so they were personally liable for the school’s operation, to the extent not covered by the assets of the school and the Foundation. By 2007, it was clear that it was no longer prudent or feasible for the two schools to be structured as part of an unincorporated charity or for individual trustees to be liable for the school’s activities. In line with many others in the sector The Mercers decided to make St Paul’s School and St Paul’s Girls School independent charities in their own right. The Mercers maintained an element of oversight through their right to appoint up to 14 out of 16 governors, a veto over the acquisition and disposal of property and the admission of girls. The chair of the governing body must be a Mercer. It has been clear from talking to ex-pupils that there has been a degree of confusion as to The Mercers’ role and the extent to which they are currently involved in the day to day running of the school and responsible for current safeguarding culture and practice. This extends beyond ex-pupils as until very recently (2018) The Mercers Company was named on the Department of Education website as the proprietor of the school whereas this is not the case. Most ex-pupils who spoke to this review also ascribed The Mercers with a proprietorial role. EVENTS LEADING UP TO THE SERIOUS CASE REVIEW Allegations of Abuse In 2014, articles in the press, primarily in The Times newspaper, reported on a culture of abuse that had been prevalent at public schools across the UK. The first article2 named 130 private schools; St Paul’s was not on this list. However, as a result of the publicity, former pupils from St Paul’s contacted the Times journalist and there were subsequently a series of articles specifically focused on St Paul’s. Allegations were made relating to staff, both living and deceased, and former pupils were either put in contact with the Metropolitan Police by the journalist or made contact directly themselves. As a result, the Metropolitan Police became aware of allegations made by former pupils in respect of 30 St Paul’s teachers who were no longer working at the school. These alleged 2 Norfolk, A (2014) 130 private schools in child abuse scandal - Attacks on hundreds of boys at elite establishments. Scandal at 130 schools. Times, The (London, England) - January 20, 2014. FINAL 13.1.20 Page 10 of 112 Official offences had taken place from the early 1960’s onwards with many relating to the 1970’s and 1980’s. Sixteen of the alleged perpetrators were by then deceased. In the case of the deceased, no further action was taken. In 2013 another alleged perpetrator was brought to the attention of the police by the school following suspicious images being found on a school’s computer. Another allegation was investigated following concerns raised by pupils in the boarding house. The Metropolitan Police had set up a special inquiry to investigate the allegations of non-recent abuse under the operational title Operation Winthorpe and as a result of this operation and a previous investigation by the local police team five former teachers from St Paul’s School were convicted of sex offences involving children. In addition, one teacher stood trial but was found not guilty and another case was withdrawn just prior to trial and a not guilty verdict was recorded. Not all offences involved pupils at St Paul’s School and one perpetrator was found to have had several convictions after leaving St Paul’s School; before the allegations about abuse at the school were made. The perpetrators and convictions are set out in Appendix 4 of this report. As the abuse allegations emerged, two parallel processes developed. Firstly, the school came to the attention of the regulatory authorities. The Department for Education commissioned an emergency inspection by the Independent Schools Inspectorate and the Charity Commission instigated a Statutory (s46) inquiry. Secondly, the Governors commissioned a series of reviews primarily aimed at making sure that the school was compliant with current legislation and guidance and that current pupils were being adequately safeguarded. An additional review was commissioned by the school and carried out by a QC3. This investigated a specific allegation made by parents of an ex-pupil that complaints in 2005 about one of the convicted perpetrators were not investigated properly by the school. Their son had taken his own life aged 21 having described feeling bad ad worthless since suffering emotional abuse at the school. The findings of this review were also reported in the press.4 The implications and impact of these inspections and reviews are explored further within this report and a timeline is set out in Appendix 9. Alongside the reviews and regulatory activity there was an increase in involvement with the school by the Local Authority Designated Officer5 (LADO) and the Local Safeguarding Children Board (LSCB). The Richmond Safeguarding Children Board wished to ensure that the school was now complying with its statutory duty in relation to safeguarding children and promoting their welfare and that any lessons that had been learned by the school were understood by the Board and available to other similar schools in their area. This was not always experienced as supportive by the school. The relationship between Safeguarding Children Boards and independent schools has been noted in another 3 A senior barrister 4 Norfolk, A. (1015) St Paul’s ignored concerns about ‘unstable’ teacher. The Times 15th October 2015. 5 The Local Authority Designated Officer is a qualified social worker who has responsibility for oversight and management of allegations against people who work with children. FINAL 13.1.20 Page 11 of 112 Official serious case review6 as an area for development and it became clear that further work needed to be done to develop a productive working relationship in this case. It was in April 2017, after the conclusion of the last of a group of trials involving ex-staff from the school that the decision was made by the Safeguarding Children Board to commission this review. The final trial involved a perpetrator who had abused boys at the school in the 1970’s and had received an 18 years prison sentence for serious sexual offences. At that time, the criteria for instigating a serious case review were that abuse or neglect of a child was known or suspected and either a child had died or been seriously harmed and there was cause for concern as to the way in which the authority, their Board partners or other relevant persons had worked together to safeguard the child.7 The purpose of the review is to contribute to learning and improvement through reviewing what happened, why it happened and what needs to be in place to prevent a reoccurrence in the future. The Richmond serious case review sub group reviewed all the information known about the abuse that had taken place at St Paul’s School and agreed that there was both evidence of serious harm and concern that all the relevant people and organisations had not worked effectively together to safeguard children at St Paul’s over many years. The concerns about interagency working extended through to the more recent period after the abuse had come to light. The subgroup unanimously agreed to recommend to the Chair of the Safeguarding Children Board that a serious case review should be commissioned. This review is taking place within a national context of increasing awareness of the nature and impact of sexual abuse experienced within institutions in the United Kingdom over many decades. These institutions include schools, children’s homes, hospitals, the Catholic Church and the Church of England. As a result of this awareness, in March 2015, the Home Office set up the Independent Inquiry into Child Sexual Abuse (IICSA) as a statutory inquiry to consider the growing evidence of institutional failures to protect children from child sexual abuse, and to make recommendations to ensure the best possible protection for children in future. The events at St Paul’s School that have triggered this review therefore need to be understood as part of a national culture that existed over many years which failed to keep children safe. It is hoped that the findings of this review will contribute to the growing knowledge and evidence base about the experience of children, its impact over time and the best way of responding when abuse comes to light. Before the start of the serious case review the school had self-referred to IICSA and Richmond Safeguarding Children Board also notified IICSA of their intention to carry out the review. IICSA agreed that the serious case review should go ahead and that the final report should be submitted to the national inquiry. All survivors of abuse at St Paul’s who had contact with this review were offered details of the IICSA truth project should they wish to share their detailed testimonies. 6 Hammersmith & Fulham, Kensington and Chelsea and Westminster LSCB (2016) Serious Case Review: Southbank International School. https://www.rbkc.gov.uk/pdf/Southbank%20SCR%20REPORT%2012%201%2016.pdf 7 HM Government (2015) Working Together to Safeguard Children Page 75. FINAL 13.1.20 Page 12 of 112 Official THE REVIEW PROCESS Background and terms of reference In line with expected procedures at the time8 the Chair of Richmond Safeguarding Children Board appointed lead reviewers who are independent of the Local Safeguarding Children Board and partner agencies. Both lead reviewers worked together throughout the review process with Edi Carmi taking prime responsibility for chairing the review and Jane Wonnacott for writing the final report. Both reviewers have extensive experience of carrying out serious case reviews including those focused on abuse within schools and other institutional settings. Full details of the reviewers’ experience is set out in Appendix 1. The lead reviewers worked with a panel which included representatives of agencies who, either had specific expertise, or whose agencies had been involved with the school in relation to abuse allegations. The members of this panel are set out in Appendix 2. Care was taken to try to ensure, as far as possible, that no panel member had direct personal involvement with the issues under consideration. This did prove challenging, particularly as a focus of attention was the relationship between the Local Safeguarding Children Board (LSCB) and the school, and members of the LSCB including Designated health professionals were involved with the school during the period under review. The LSCB and the panel were keen to involve St Paul’s in the panel process in order to make sure that technical aspects relating to the day to day running of the school were correctly understood, both now and in the past. It was eventually agreed that the best possible option would be for the professional advisor to the LSCB9 and Designated health professionals10 to stand down from the panel and for the school’s representative to be a member of the governing body who is not part of the senior leadership team or specifically responsible for safeguarding. The panel are very grateful for the help and input of the governor and the school team who have been instrumental in providing a large amount of factual background information. The lead reviewers received representation from an abuse survivor who felt strongly that survivors should also be represented on the panel. The lead reviewers had some sympathy with this request but, after discussion, the decision of the Chair of the Safeguarding Board was this was not appropriate as to find one person representing all views would be impossible. The lead reviewers had already planned for all those who contributed to the review, including ex-pupils, to be offered the opportunity to see a draft of the report before it was finalised and comment on the facts, findings and recommendations. It was agreed that this would be the mechanism whereby survivors’ views could be represented in the final report. 8 HM Government (2015) Working Together to safeguard Children Page 78 9 The professional advisor is usually a core member of serious case review panels in Richmond and has responsibility of quality assuring the overall process. They had prior involvement with St Paul’s and therefore it was not appropriate for them to be part of the panel in this case. 10 The term designated doctor or nurse denotes professionals employed by Clinical Commissioning Groups to provide strategic advice and guidance on safeguarding children to the health community and multi-agency partnerships. In this case they had carried out a health assurance visit to St Paul’s. FINAL 13.1.20 Page 13 of 112 Official The first task of the panel was to agree the terms of reference for the review and these are attached at Appendix 3. After careful consideration by the panel and chair of the Safeguarding Children Board, the timeframe for the review was agreed as 1960 through to the end of April 2017. This is an extremely long time period, but it was felt necessary in order to understand the experience of those who had been abused at the school, why abuse had happened and to make sure that any lessons relevant for today’s practice have been learnt by both the school and the multi-agency system. Although some ex-pupils were known to have been abused and were party to the criminal proceedings, the review team wished to give all ex-pupils who could have been affected in any way by physical, emotional or sexual abuse at the school, and may not have been heard in court, an opportunity to contribute to the review. The review has therefore aimed to explore both the factors contributing to the non -recent abuse of pupils that led to a conviction in court, situations where there was no conviction, but allegations had been made and situations where pupils at the time had concerns but did not make an allegation. It has also been important to understand the experience of ex-pupils who have views about the factors that contributed to an unsafe culture and the ongoing impact of abuse on survivors right up until the present day. Some allegations were not investigated by the police due to the death of the alleged perpetrator; others did not reach court for a variety of reasons and in one case a trial resulted in a not guilty verdict by a jury. Responses to allegations of abuse and issues relating to the effectiveness of multi-agency working are a feature throughout the whole timeframe of the review and it has been important to understand the positive aspects of modern practice as well as any areas for learning that remain within the system. During the review, in July 2018, a teacher who had worked at St Paul’s for 16 years was prosecuted, pleaded guilty and convicted of arranging to meet a child to commission a sex offence and inciting a child to commit a sexual act. No pupils at St Paul’s are known or suspected to have been abused at any time by this member of staff. Details of the police operation11 and the school’s response are included in the review as it provided an illustration of the way such issues are dealt with today. This has shown full compliance by the school with expected procedures and good communication and cooperation by the school with other agencies. The case has also highlighted remaining gaps in the national safeguarding system. The conduct of the review The first stage of the review involved gathering paper information in the form of chronologies and other relevant documents. This was not straightforward due to the number of known and alleged perpetrators and known and alleged victims. The first task involved the Metropolitan Police compiling a list of all allegations, convictions and associated victims and for agencies to review information held on their files. Where information was held in relation to specific individuals, permission was sought by the relevant agency for this to be released to the review. 11 This was carried out by Thames Valley Police as the teacher lived in their area. FINAL 13.1.20 Page 14 of 112 Official There was a delay to this stage of the review, partly because of the large quantity of information to be accessed and checked by the different agencies involved and also because St Paul’s School rightly needed to consider their position in releasing the data that they held. The school queried whether they could release information to Richmond Local Safeguarding Children Board as the Board is not registered as a data controller. They also took legal advice and contacted the Office of the Information Commissioner. The LSCB had not encountered such a challenge previously when undertaking complex reviews and discussed the reasons for the delay with the Department for Education. It became clear that there was no specific guidance as to whether an LSCB should register as a data controller or the process for sharing sensitive data for the purposes of a serious case review where the LSCB had not registered. This issue took some weeks to resolve before the school were able to release their individual chronologies. This demonstrates difficulties inherent in sharing sensitive personal data between agencies and the importance of a shared understanding of the legal underpinning for any such sharing. Negotiations at this stage became polarised and adversarial and indicative of the breakdown of trust between the school and LSCB. The causes of this breakdown of trust are explored later in this report and these highlight the importance of relationships when working in a challenging and complex environment. The following organisations submitted chronologies and other associated documentation: ➢ Achieving for Children – LADO service; ➢ Department for Education; ➢ Independent Schools Inspectorate; ➢ Richmond Safeguarding Children Board; ➢ St Paul’s School; ➢ Teaching Regulation Agency (previously NCTL); ➢ The Metropolitan Police; ➢ The Charity Commission. As well as reviewing relevant documentation, the panel considered the best approach to addressing the terms of reference. These included developing an understanding of practice, culture and relationships over time; both within the school and across the multi-agency network. In order to achieve this, it was agreed that key people from all the organisations who had submitted chronologies should be seen plus specific individuals who were considered to have important information to contribute to the review. This included independent experts who had been commissioned by the school to review the school’s practices and responses. The list of professionals who contributed to the review is set out in Appendix 6. National guidance at the time of this review stipulated that a review seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight 12 In order to understand the experience of children at the school during the time period covered by the review it was agreed that the starting point for the review should be offering survivors and all ex-pupils from the school an opportunity to contribute. A letter was sent via the school system offering this opportunity and by the end 12 HM Government (2015) Working Together to Safeguard Children Page 74 FINAL 13.1.20 Page 15 of 112 Official of the review period 59 ex-pupils were seen by the lead reviewers. Attendance at the school ranged from pupils who started in 1953 through to those who left in 2015. Six of the 59 ex-pupils seen were victims of perpetrators who stood trial. The names of those seen were not disclosed to the wider panel. All discussions were written up and letters sent to the person concerned summarising the discussion and asking for any errors to be corrected. The details of these discussions have informed the findings of his report. Where any new allegations were made during this process the lead reviewers asked the permission of the ex-pupil before putting them in contact with the Metropolitan Police. In any situation where the ex-pupil did not wish to speak to the police but where there were allegations against a person who could continue to pose a risk to children the name of the alleged perpetrator was passed to the police. The second group of people who were approached to contribute to the review in order to understand the viewpoint of those involved were current and past staff members and the method for contacting them was agreed with the school. The school explained that they do not hold contact details for all staff who taught at the school during the timeframe for this review but identified 15 ex staff for whom they did have contact details and wrote to them asking whether they were agreeable for their details to be passed to the serious case review. 10 agreed and their details were forwarded to the LSCB. One member of staff specifically did not agree and another four did not respond. Caution should be exercised in viewing this group of participants as representative of the views of all ex staff as they represent those whose contact details were known and agreed to talk to the review. lt is also of note that reviewers have been informed by one past member of staff (who was also a parent) that although their details were known by the school, they were not contacted to contribute to the review in the first instance, but did so later. The school also wrote to current staff who had worked at the school during the 1970’s and 80’s and asked whether their details could be forwarded to the serious case review. All five staff gave their permission and their details were passed to the LSCB. All other staff were made aware of the serious case review and that they could contact the LSCB directly. The employment details of school staff spoken to for the review are listed in Appendix 7. Three staff members spoken to were female, the other seven were male. Of these 10 staff: ➢ Two staff were ex-pupils; ➢ Four staff had sent their children to the school. Limitations and constraints The terms of reference for this review deliberately specified a long time period and covered the wide range of issues that impinge upon the protection of children in a school environment. This is a strength of this review but also a limitation as choices had to be made about information that could be gathered in the time available. The aim was to be proportionate and focus on new information or information that was likely to lead to the most learning. FINAL 13.1.20 Page 16 of 112 Official The review panel considered whether to offer current and past parents an opportunity to speak to the review. One of the previous reviews commissioned by the school (the Badman review) had included parental perspectives and the decision was taken that it would be proportionate to use this information to inform this review rather than conducting a separate parental consultation. The school informed all current parents that the serious case review was taking place and where a parent chose to contact the review, the team were happy to speak to them. One parent gave information to the review coordinator but did not wish to speak to the reviewers, four other parents did ask to speak to the review, and another gave information after a chance encounter in another setting. Additionally, some of the ex-pupils that we spoke to either were previous parents or currently had children at the school. We acknowledge that a large sample of parental perspectives is a gap in this specific review process. The possible learning from hearing from convicted perpetrators was also considered. The review panel considered carefully whether to offer this group a chance to contribute but the review panel concluded that on balance the extra time and cost involved could not be justified in relation to any learning that may result. Analysis of information and production of the report All information was collated into a detailed working document which contained case studies which had been written following careful consideration of all the agency information and the discussions with ex-pupils. Each draft of this document was checked for accuracy by panel members and was used to develop the final analysis and findings of this report. The intention was always to share a final draft of the report with all contributors in order that they could check that their own information had been fairly represented and also contribute further to the final analysis and recommendations. Before this stage of the process: ➢ A draft of the report was shared with the Metropolitan Police. This was because there were ongoing police inquiries involving ex-staff from the school. This was to make sure that they were aware of the material gathered during this review, assess the relevance of any material and meet their legal obligations regarding Disclosure13. The police team confirmed that they were happy for the draft report to be shared with contributors; ➢ Advice was sought from a QC regarding the contents of the report. The analysis was further developed through sharing a draft with those who had contributed and wished to read the report. Contributors were asked to check for factual accuracy and to comment on the findings and recommendations. All comments were carefully considered, and a judgement made by the author as the amendments that were needed. A final draft was then approved by the panel. 13 Disclosure is providing the defence with copies or access to all material that is capable of undermining the prosecution case and/or assisting the defence. FINAL 13.1.20 Page 17 of 112 Official SUMMARY OF MAIN FINDINGS SUMMARY Introduction This review has considered allegations of abuse at St Paul’s School over five decades with a view to understanding what happened, why it happened and what this means for current safeguarding practice both at St Paul’s and other schools. Safeguarding children cannot be the responsibility of one organisation and this review has therefore focused not only on events at the school but also on the multi-agency system which is designed to protect children from harm. As a result, the findings and recommendations are relevant for St Paul’s, other schools and the safeguarding system as a whole. The review’s national findings will be drawn to the attention of the relevant national agencies and the Child Safeguarding Practice Review Panel. The findings and recommendations focus on: ➢ Accepting responsibility in order to effect cultural change; ➢ Developing positive relationships and partnerships as a prerequisite for effective safeguarding practice; ➢ Working with safeguarding in a school environment – balancing various legal requirements; ➢ Developing and refining national systems and guidance; ➢ Managing complex investigations – the need for strategic oversight; ➢ Refining practice systems and processes within the school. All review recommendations are set out in section 16 of this report. Background Within St Paul’s, many of the ex-pupils who approached the Serious Case Review described a culture over many years where abuse of all forms was endemic within the school. One ex-pupil has vividly described boys being inhibited from speaking out by an overwhelming culture of power, complicity and coercion. Boys at Colet Court (the junior school) were particularly vociferous in describing to this review a culture where physical violence by staff and between pupils was prevalent and the dominant culture was one of accepting both physical and sexual violence as a “rite of passage”. Allegations or concerns about abuse were not responded to adequately by the school. The evidence presented to this review indicates that this was particularly prevalent between the 1960’s and 1990’s. The approach was adult rather than child focused, with maintaining the reputation of the organisation and the needs of the alleged perpetrators being prioritised over any consideration of the impact that their behaviour had on pupils. There are examples of concerns about staff behaviour either not being recognised as presenting a risk to pupils or being responded to by moving the member of staff on without recourse to the proper HR procedures or discussion with statutory agencies. One member FINAL 13.1.20 Page 18 of 112 Official of staff who was moved from a role within the boarding house was convicted several years after retirement of possessing indecent images. Some staff who had concerns were reluctant to think ill of this colleague who was apparently held in high regard by pupils and parents and they also worried about raising concerns without concrete proof. On another occasion records show that there was an apparently deliberate destruction by the (then) High Master of diaries detailing inappropriate behaviour which included spanking of pupils by a teacher. As a result of their destruction, these diaries were not available to a later police investigation of allegations made against this member of staff. The position of St Paul’s as a high achieving, fee paying, competitive entry school inhibited some pupils from speaking out about concerns due to being acutely aware of their parent’s pride that they were at the school and in some cases the financial sacrifices that they were making. Evidence shows that the response of the school began to change in the twenty-first century and from 2013 onwards St Paul’s has focused on fulfilling and exceeding statutory requirements in relation to safeguarding practice and developing policies with the welfare of pupils at their heart. The school carried out internal reviews and commissioned six reviews of various aspects of safeguarding practice by external consultants and a QC. These have contributed to the ongoing improvements to the safeguarding system within the school which have included an overhaul of systems, policies and procedures, including the appointment of a safeguarding coordinator, and a focus on achieving cultural change. There has also been a greatly increased involvement by the governing body in the scrutiny of safeguarding practice. It was within this context that this serious case review has taken place. Lessons for safeguarding - what did the review find? A major challenge for the school has been to demonstrate unequivocally that it accepts responsibility for past abuse, both in relation to victims of convicted perpetrators and those situations where the perpetrator has died or there has been no conviction. In 2014 the school was unprepared for the impact of publicity surrounding allegations of the history of abuse within the school, the scrutiny by external agencies and did not have sound relationships with the local authority and LSCB to help them through the process. They were perceived by some ex-pupils as slow to apologise to the whole school community and appeared defensive both to external agencies and in early communications to past and present pupils. Although a great deal of attention was being given to policies and procedures there was less evidence to those outside the school that these were underpinned by cultural change. An apology issued to the whole school community after the conclusion of the criminal trials focused on those affected by the actions of the convicted perpetrators. Some ex-pupils affected by physical and/or sexual abuse where the alleged perpetrator was not a convicted member of staff felt that the school were not interested in them. The lack of a wider apology in 2014 was as a result of discussions with the Metropolitan Police who asked the school to pass any allegations directly onto them without engaging with the complainant. It was also the clear understanding of the school that the police had FINAL 13.1.20 Page 19 of 112 Official asked them not to reach out to past pupils until police enquiries had been completed. This understanding guided the school’s responses to previous pupils until the trials of former staff were completed in February 2017 when it asked the police for permission to reach out through the independent Barnardo’s review. During the process of this review there has been willingness on the part of the school to engage in dialogue and accept professional challenge, demonstrating positive progress in developing an open culture where effective safeguarding practice can flourish. An area for further development is to consider how survivors of abuse might work positively with the school in order to use their expertise to further improve safeguarding practice. The multi-agency safeguarding system has not been clear enough in its communication with the school and given a steer as to what could be communicated by the school to the whole school community. Communication would have been improved had the multi-agency strategic management of complex investigations been more effective and this may have helped to an approach to supporting all ex-pupils affected by abuse at the school. The review has confirmed the importance of trusting relationships between schools and safeguarding partners whose role is to both provide support and challenge practice. Attention needs to be paid to these relationships as preparation for a possible future crisis. The review has acknowledged the tensions facing schools when fulfilling their responsibilities as employers, educational establishments and safeguarding professionals. Balancing these requirements is not easy and there is a danger that in protecting the rights of the employee, pupils will believe that any discussion about abuse is not possible. Ensuring that the safety of pupils is the paramount concern needs to be clearly enshrined in all legislation and guidance relevant to schools and emphasised in communications with staff and pupils. The national context for safeguarding in education is now vastly different to that during the 1970’s and 1980’s when the majority of abuse at St Paul’s took place. However national systems need to continue to evolve and this review has identified some gaps in the current national safeguarding system that need to be addressed. Specifically: ➢ The way in which employment references should be followed up when they are vague, insufficient or raise concerns needs clarifying; ➢ A code of practice for out of school settings cooperation with investigations needs to be published; ➢ The system for referring alleged perpetrators who are found not guilty in court to the Teaching Regulation Agency is not consistent and this need clarifying; ➢ The system should be reviewed to make sure that there is no delay in prohibiting convicted perpetrators from teaching where appropriate; ➢ A protocol should clarify information sharing arrangements between the Charity Commission and Department for Education. Specific areas of practice that need to be addressed at a national level are: ➢ Promoting safeguarding supervision in schools; ➢ Clarifying the role of school GPs; ➢ Standards of expected practice in relation to school alcohol polices; FINAL 13.1.20 Page 20 of 112 Official ➢ Independent investigation (outside the governing body) of complaints investigations that cannot be resolved by the senior leadership team. The review found specific areas of safeguarding practice within the school that could be improved in order to further improve safeguarding practice, although these are not statutory requirements. ➢ Parents need to feel confident that if they raise any concerns about a teacher this will not reflect badly on their son. Although this is not the intended message given by the school there should be a heightened sensitivity to the worries that parents may have as to how they will be thought of in such circumstances; ➢ The review recommends that the current expectation that tutors are invited to a pupil’s home for a meal is stopped. Even with safeguards this gives the wrong impression regarding boundaries between staff and pupils; ➢ Good practice in the anonymous reporting of concerns in the junior school should be replicated in the senior school; ➢ The recording of counselling sessions within the junior school needs review in order to make sure that they are sufficiently detailed and contemporaneous to support effective safeguarding practice. Conclusion This review has brought into stark relief the complexities surrounding keeping children safe in school. Whilst many of the experiences of ex-pupils explored within this review could be described as “non-recent” and expected responses today would be very different, there are lessons for safeguarding that transcend time and place and raise important questions for our current safeguarding practices. A minority of recommendations are specific to St Paul’s School and even these may have relevance in other school settings. The majority of recommendations are aimed at firmly establishing a culture where the safety and wellbeing of pupils is paramount and in helping schools to put this into practice in a context where academic success may be perceived as the top priority in state maintained and independent schools alike. The recommendations recognise the importance of a sound legislative, strategic and procedural framework, but most importantly the crucial role played by sound relationships across safeguarding partnerships. These relationships need to be based on trust, clear respectful communication and a willingness to challenge, reflect and learn together. FINAL 13.1.20 Page 21 of 112 Official WHAT HAPPENED ABUSE AT ST PAUL’S: WHAT DO WE KNOW? The Facts Sexual abuse allegations were made to the Metropolitan Police against 32 staff who previously worked at St Paul’s School from the 1960’s through to 2017.14 16 of these staff are now deceased. There were over 80 individual complaints against these staff, mostly by ex-pupils from St Paul’s School. In compiling this information and reviewing the timeline, the number and range of allegations of all forms of abuse became clear to the review panel. As a result of these allegations: ➢ Five former staff were convicted of sexual offences15; ➢ One former staff member stood trial and was found not guilty; ➢ One case was withdrawn at court and a not guilty verdict recorded. This was due to no evidence being offered since a key complainant was too ill to continue with the criminal justice process. Of the alleged perpetrators who are deceased, one was still alive when the first allegation was made against him in 2001 and at that time was a member of the clergy. There was no further action taken by the police in relation to this and there are no records of this allegation held by Lambeth Palace. A second allegation was made by two ex-pupils against a former school chaplain before his death in 2000. This was investigated by the police, but no further action was taken as the alleged perpetrator denied any wrongdoing and the ex-pupils did not wish to take this further with the police. It is important to re-iterate the point made in the introduction that where this report refers to allegations, complaints or concerns about ex-teachers at the school, the purpose of this review is not to judge whether these allegations were true, but to consider what lessons should be learned in respect of safeguarding from the manner in which they were dealt with. Specifically, where an allegation did not result in any criminal conviction, it is not the intention of the author of this report to imply that the allegation was factually true, since this is not the purpose of the review. The wider picture The information given to this review by ex-pupils and former staff, as well as that contained within various press reports and other documents, gives a picture of the abuse, alleged abuse and the context within which abuse took place over four decades. St Paul’s is unlikely to be different from many other institutions of its time. We should not judge response of the school in the past by today’s standards, but equally we should not forget 14 See Appendix 5 for a timeline of dates the alleged perpetrators and perpetrators were employed at the school. 15 For details of these offences please see Appendix 4 FINAL 13.1.20 Page 22 of 112 Official that for some ex-pupils, the abuse that took place affected their school life and has continued to haunt them through adulthood. No institution can claim to prevent all abuse, but we are now acutely aware that being sensitive to the signs of abuse and acting quickly should these occur are the cornerstones of good practice. In addition, understanding and accepting the past helps institutions to ingrain the best safeguarding practice within their culture. The best organisations will be open about past mistakes and will be sensitive to the needs of those who were or may have been abused. This is discussed further in section 8 using our knowledge so far about the depth and breadth of abuse at the school over time. The 1960’s This covers the period when the school was situated in Victorian buildings in Hammersmith prior to moving to the new site in Barnes in 1968. This has some significance in terms of the impact of environment on opportunities to abuse16 with descriptions of boys being made to swim naked in the swimming pool in Hammersmith which had no windows. One pupil also describes being caned in a master’s study high up in the Hammersmith building reached by its own staircase well out of sight of other staff or pupils. This was far less likely in the new Barnes building which was more open and functional and designed to be less intimidating for the boys. The accounts of life at both Colet Court and St Paul’s during this period contained a substantial element of physical violence including use of corporal punishment which was not banned in UK state schools until 1986 and in independent schools until 1998. (St Paul’s School banned its use in 1982 before legally required to do so.) Although one ex-pupil who contributed to this review described the school as a civilised place with no cruelty, the culture was described by others as “brutal”, “a hard knocks bullying culture” and “sadistic” with physical punishment being used at times where boys were struggling academically. More than one ex-pupil talked about boys in Colet Court being hit for giving the wrong answers in class. The culture as described to us was one where parents did not complain, were deferential to the authority of the teacher and were likely to take the school’s side and see the boy as being at fault. Comments were made to this review by ex-pupils about keeping a “stiff upper lip” and emotion being seen as a weakness. Sexual abuse appears to have been known and tolerated by staff and at times the violence also had a sexual element such as removing the pupil’s trousers for a private caning. Other teachers were described as voyeurs, with pupils warning each other about who to avoid, for example when taking a shower. A parent has told the review that her son has said that it was sport to comment and joke about teachers who were rumoured to be homosexual. Parents who were more engaged in what happened in school may have been a protective factor with one pupil describing his belief that the interest of his parents 16 Identifying “target” locations where abuse is more likely is now becoming part of risk reduction strategies. See discussion of situational prevention: Kaufmen et al (2012) in Erooga M (ed). Creating Safer Organisations. Chichester: Wiley-Blackwell. FINAL 13.1.20 Page 23 of 112 Official in what was happening in school kept abusive teachers at bay. The 1970’s and early 1980’s The timeline in Appendix 5 of this report shows the periods of employment of relevant members of staff who were either subsequently convicted or alleged to have committed abuse against pupils. The majority were employed during this period of time. Descriptions by ex-pupils show a clearer differentiation between Colet Court and St Paul’s Senior School and bullying was described as part of the culture “particularly at Colet Court”; although a number of teachers from both schools were named as being particularly violent. One ex-pupil described teachers as having “licence to terrorise”. Other descriptions included teachers hitting pupils across the head, banging boys’ heads on the desk and beating a boy so badly that he had to be hospitalised. One ex-pupil felt positively about all aspects of the school during this period and it is notable that he also described parents who were very supportive and would always follow up any issues with school staff. A parent has told this review that in their opinion this was not always possible as in their opinion the school appeared to actively discourage parental involvement. Where parents were not involved, boys seem to have been more easily targeted by abusive teachers. Generally, those handing out the extreme physical punishments were not those who were believed to have had a sexual interest in boys although there are exceptions where physical and sexual violence went hand in hand. The pattern seems to be that boys were at most risk of sexual abuse from those teachers who cultivated an image of the “good guy” in contrast to those staff who were more hierarchical and disciplinarian in their approach. One convicted perpetrator was described as being perceived at the time as “cool” and would often socialise with the rowing team in the pub. There are several examples of grooming behaviours during this period, including taking an interest in specific pupils and getting to know their families. One ex-pupil described perceiving one of the members of staff who abused him and was later convicted, as a ‘friend’ who was kindly and supportive. The pupil played squash with him during evenings and weekends and was flattered by his attention. The abuse only stopped when a lodger living with the family recognised what was happening and told the perpetrator he knew “what he was up to”. During this period there are examples of blurred boundaries with teachers buying pupils alcohol, and others inviting boys to their homes. Ex-pupils described one teacher (also a school chaplain who is now deceased) as opening the door to boys in his dressing gown and one ex-pupil has alleged that he was sexually abused by this member of staff. This staff member was known to have a problem with alcohol, and this became depicted as a cartoon in the school magazine. Ex-pupils and past staff have told the review of rumours about a female teacher during this period. These rumours related to sexually provocative behaviour, meeting boys in pubs and clubs and inviting boys home. FINAL 13.1.20 Page 24 of 112 Official The issue of boundaries between staff and families today is discussed further in section 14 but comments from staff indicate that, in the past, teachers believed that it was the responsibility of the parents to monitor any contact. Two comments illustrating this view were: I knew pupils stayed overnight with [alleged perpetrator] but I feel the parents were to blame. [An alleged perpetrator] was known to have parties in his house for boys in his class and they were told to go in football strip – we thought the parents knew. One ex-pupil who was abused over an 18-month period described eloquently the phase before the abuse began saying; “once you have been groomed, when the individual strikes it is too late to get away either physically or emotionally”. These teachers were often known to have favourites and one of the convicted perpetrators made no attempt to hide this and was known to take boys for drives in his car. According to several ex-pupils the current favourite of the moment was clear for all to see and on one occasion was even joked about in a public forum. Comments would be made by other pupils and one survivor spoke of feeling anxious, trapped and ostracised by his own peer group for being “teacher’s pet”. Other ex-pupils who were not close to the group surrounding this teacher told the review that they did not notice anything at all, possibly reflecting the size of the school and the separation between peer groups with different interests. One teacher who was frequently mentioned by those ex-pupils at the school during this period was convicted in 2014 for possessing indecent images of children, having retired from the school over ten years earlier. It is also notable that a retired senior staff member provided a character witness statement for the defence at the trial of this ex staff member and there were very mixed descriptions from ex-pupils, many of whom commented on his popularity and inspirational teaching style, whilst some also noting that it was “common knowledge” that he had an interest in young boys. One ex-pupil told the review that he had heard that this teacher kept a list of boys he fancied, and another pupil described being told by a friend that this teacher had touched him inappropriately in his room at night. There were also several comments made to this review by ex-pupils about this member of staff having favourite pupils for sherry in his study on Sundays and sitting with his arm around pupils. Due to his popularity there was a reluctance to make any formal complaints and one ex-pupil commented to the reviewers “challenging [the member of staff] would have been like calling your dad a paedophile”. Ex-pupils also spoke of a protective culture amongst the staff and a fear that if you spoke out it would be held against you. Another comment from a parent went further, saying that speaking out was impossible if you wanted to remain at the school. A number of ex-pupils told the review about the ‘common knowledge’ even amongst pupils who had already left the school, that in the early 1980’s a member of staff had videos in his study depicting ‘child pornography’. Those who had been involved in finding these videos wanted the review to know that they had seen the videos and they depicted torture, were very upsetting to look at and their presence in the member of staff’s study was brought to the attention of school staff. Piecing together the series of events from the ex-pupil and staff interviews it seems most likely that although the content may have FINAL 13.1.20 Page 25 of 112 Official contained child abuse images the videos became referred to as ‘pornographic’ and the detail of what they contained may not have been relayed to the High Master at the time. (The member of staff who was first told about the images is deceased and this cannot be checked). Another ex-pupil who saw the videos describes not reporting them because he was aware that the member of staff concerned could lose his job. Nothing was recorded in the staff file and the matter was dealt with informally by removing the member of staff from any role in the boarding house. The implications of this episode are discussed further in section seven of this report. Another theme through this period was the pressure associated with being a pupil in a high achieving school. One ex-pupil described Colet Court as like a “piranha tank” where no one wanted to be seen to be the weakest. Boys who were struggling academically or were not good at sport appear to have had a particularly difficult time. From the perspective of pupils at that time the culture was the complete antithesis of a healthy supportive educational environment. This serves as a reminder for any school of the need to avoid a culture which promotes a focus on achievement at all costs. The review has also heard from one ex-pupil of sexual and physical abuse by peers during this period. Messages about who could be spoken to were not clear and this, accompanied by the shame and stigma associated with the abuse, meant that this was not an issue that was spoken about or reported to any adult at that time. The late 1980’s and 1990’s Descriptions of violent behaviour by staff, and also bullying between pupils, continued through this period; with one description of a pupil in the senior school being led into drug taking by prefects and being physically assaulted in public by his peers. Another description was given of a teacher dragging a pupil around the classroom and throwing him out of the door and another dangling boys out of windows by their ankles. Ex-pupils have told this review that these were not isolated incidents and such behaviour was known about within the staff group although seems not all staff were aware with a member of staff at the time telling the review that they cannot recall these or similar incidents. Many of the incidents described to the review took place at Colet Court with two ex-pupils separately described the culture there as “like Lord of the Flies”. Ex-pupils told this review of a continuation of blurred boundaries for some pupils in the senior school particularly in relation to staff drinking alcohol with pupils. One ex-pupil described a positive culture in one of the senior boarding houses where junior boys would talk to senior boys about concerns. The reviewers were told about a teacher’s diary being found by a cleaner and shown to pupils. This contained descriptions of him spanking boys and inappropriate comments such as “nice boxer shorts”. It was positive that this was relayed by junior pupils to a senior boy who passed it onto the house master, but events thereafter were concerning as the member of staff resigned. This is discussed further in paragraphs 8.34-8.37. The problems for institutions such as St Paul’s operating within a national context of poor standards of practice in relation to staff recruitment can be seen in the appointment of a FINAL 13.1.20 Page 26 of 112 Official part time PE Assistant in 1990, employed through his own company. He was later convicted of indecent assault against a pupil at St Paul’s and received six years and eight-month custodial sentence. He had submitted a CV, and his staff file shows that this was after a chance encounter and conversation with the then Head of PE. His CV did not give a full employment history but showed that he had extensive experience as a sports coach in various organisations and in 1978 had been awarded the Queen’s Silver Jubilee medal for sport. Another CV on file (apparently a later version) stated that his contract with one of the armed forces had expired and he was awarded a full pension. He was interviewed by the Head of PE and offered work on a freelance basis at the school. This interview was followed up with a meeting with the High Master. He gave four referees (from the armed forces, a London Borough, and two public schools). Two were taken up and both (including the one from the armed forces) were very positive. It was later during police investigations that it became apparent that this member of staff had been convicted of gross indecency against a 15-year-old boy in 1979 and was fined £100. At the time of this conviction, he was serving with one of the armed forces and a submission to this review from the school notes he had been required to leave as a result of this matter. 2000 onwards Descriptions of Colet Court during this period did not contain accounts of the extreme harsh regime of earlier years but the review was told that parents routinely said that “you survive Colet Court to get to St Paul’s” The recognition of the negative impact of emotional abuse on young people has not always been widely recognised and it was during this period that the events explored in the Laidlaw Review took place17. This concluded that on balance a member of staff emotionally abused and humiliated one pupil at Colet Court between 2003 and 2005. This pupil experienced mental ill health as an adult and took his own life whilst at university. The member of staff’s colleagues at the time have described him as having favourite pupils, a known crush on a former Colet Court pupil, and also to be prone to extreme rages. One staff member who had a son at the school recalls that his son did not want to go into the scholarship class with this teacher as he was known to be a bully and have favourites. The Laidlaw Review found that when the parents of the pupil made complaints in 2005 and 2006 the school failed to investigate properly, and the Head of Colet Court and the High Master were too easily deceived by the member of staff’s popularity with many pupils and parents. The review concluded that neither of the 2005 or the 2006 complaints were followed up, as they ought to have been, with the effect that nothing was done in the years to protect other children that [the member of staff] might have picked on. In relation to sexual abuse the information given to the review indicates that pupils and parents were becoming more willing to speak out about abuse and the school were becoming aware of their responsibilities to deal with allegations of sexual and physical 17 This review had been commissioned by the school in 2015 following a complaint by parents that their earlier complaints about a member of staff had not been investigated properly by the school. See Appendix 10 for further details. FINAL 13.1.20 Page 27 of 112 Official abuse but did not always manage this well. The challenges of changing culture within organisations such as St Paul’s is explored further in section seven of this report. At least one teacher during this time was referred to by pupils as a “paedo” although this mainly remained at the level of gossip and jokes between the boys rather than being reported to parents or the school. One parent has however told the review that a member of staff, later convicted for possessing indecent images, called her in for a meeting to express concern that her son had called him “a paedo”. This parent feels that this was an example of the member of staff “hiding in plain sight”. The parent’s immediate reaction in the meeting was to support the teacher in reprimanding her son and she has since reflected on the fear that parents have about their son getting into trouble. Many parents have fought hard to get their son into the school and will be reluctant to complain about anything. This is explored further in section seven below. From 2000 to date there have been four allegations of sexual abuse relating to staff who were working at St Paul’s. The circumstances surrounding the allegations shows a changing environment, both in terms of how the allegations came to light and the response of the school. One allegation was made by pupils, another by a parent and another as a result of standard IT surveillance within the school. The fourth was as a result of external police activity. Although there are indications of many positive developments in the way these were handled the cases also illustrate the challenges associated with changing practice. In 2013, pupils alleged that a teacher gave boys alcohol and touched pupils inappropriately. It was positive that these pupils had felt able to talk to a senior member of staff about these allegations. The senior staff member attempted to triangulate the information by offering other pupils the opportunity for pupils to speak with him to disclose additional concerns before he made a referral to the LADO. Expected practice at that time (2013)1819 would have been for there to have been an earlier discussion with the local authority20 before investigating within the school. When the police and LADO considered the case, they decided not to investigate further. Although internal disciplinary action was taken this was understandably not evident to the whole school community, although pupils who had raised the allegations were made aware of the action taken by the school. Although the school were complying with the reporting restrictions of the Education Act, and explained this to pupils, this was not fully understood with one ex-pupil expressing concern to the reviewers that this episode was “brushed under the carpet” and that the boys received a strong message that it was not to be discussed. The review was also told that other boys in the school heard discussing the episode were threatened with detention, although this is disputed by the school. It is important to acknowledge that this was how the response of the school was perceived by pupils at that time and this could have been interpreted as a message that concerns about abuse should not be discussed. From the school’s perspective they were working within the legal framework which sets out their 18 As in 'Safeguarding children and safer recruitment in education' (December 2006). 19 HM Government (2010) Working Together to Safeguard Children Page 359. Paragraph 14. 20 The school have assured the review that practice today would be different and the LADO would be informed immediately. FINAL 13.1.20 Page 28 of 112 Official responsibilities to both staff and pupils and the episode illustrates the complexities of managing allegations within school and is explored further in section ten of this report. Also in 2013, a parent complained to the headmaster of Colet Court about inappropriate boundaries by one member of staff towards her son. It was alleged that this member of staff had become too close to their family, was overly tactile with her son and had been seen rubbing her son’s thigh. He was not responding to requests to “back off”. This resulted in more proactive action by the school than had been the case in previous decades and the head teacher appropriately told the High Master and the matter was referred to Richmond LADO. Further inquiries with school staff revealed that there had been rumours about this member of staff as far back as the 1990’s. The end result was that the police took no further action and at a disciplinary hearing the member of staff’s actions were found to constitute serious professional misconduct and he was given a final written warning. He retired soon after. Another allegation was made in 2013, this time as a result of the school ICT officer informing the Designated Safeguarding Lead of Colet Court that during routine checking of file sharing areas, a large file containing legal images of boys had been found in a member of staff’s area. Further investigation found that activity had involved attempts to access sites with links to pictures of young boys. The next day (a Thursday), further investigation of activity in previous months, showed evidence of browsing and downloading images of young boys, some were straightforward portrait images and others in suggestive poses, plus Facebook activity. The head and deputy head of Colet Court informed the High Master and the same day sought advice from an experienced trainer who advised referral to the LADO. The High Master approved this course of action, but this did not happen immediately, and the member of staff’s internet activity was monitored over the weekend. The school chronology acknowledges that this was not the right decision: instead the Police/LADO should have been informed immediately and this is clear in the school’s current procedures. The LADO was informed on Monday morning and referred to the local police child abuse investigation team. The initial agreement with the LADO was that the member of staff could remain in school with a risk assessment in place so that he would not be alerted to suspicions. He was arrested the next day with bail conditions that he should not attend school or be left alone with anyone under 16 years. The school instigated disciplinary proceeding, the Disclosure and Barring Service were informed, and the member of staff concerned resigned within the month. A note was placed on his file stating that any future reference request will include a statement that he resigned while facing a disciplinary hearing for gross misconduct and include the details of any future criminal proceedings and/or referrals to regulatory agencies. On this occasion there was a clearer message from the school about the circumstances. Staff were briefed that the member of staff had resigned after it had been found that he had downloaded “inappropriate written material” and a letter was sent to parents to this effect and the next day pupils in his form were told and asked not to spread rumours but to talk to the deputy head if concerned. The review has been asked by a parent to consider whether the phrase “inappropriate written material” is a truthful description of the activities FINAL 13.1.20 Page 29 of 112 Official that included accessing images of young boys. This is a fair point, but the communications would have been influenced by a concern not to jeopardise criminal investigations. This is further evidence of the issues explored in Finding Two and the need for support to schools in managing communications in these circumstances. In 2018 a teacher who had been teaching at St Paul’s for seventeen years was arrested in the Thames Valley Police area having been tracked by the police having sexualised online communication with a 13-year-old girl. Further details of this case are discussed in section eight as although it demonstrates a prompt and appropriate response by the school once they became aware of the member of staff’s identity, and effective liaison with the LADO, there are also lessons to consider in the use of language in written communication. Other lessons primarily relate to the role of social media platforms, communication between police officers and the school and the effectiveness of the Disclosure and Barring System and the regulation of the teaching profession. UNDERSTANDING WHY AND WHAT CAN WE LEARN? WHY WAS ABUSE NOT RECOGNISED? This section of the report primarily focuses on general themes relating to the overall culture of the school and how this has in the past supported a system where the sexual, physical and emotional abuse of pupils was not recognised. The section explores the challenges associated with changing a whole school culture that also have relevance today. Section seven of this report which explores the school’s response to specific allegations is also relevant to consideration of why abusive behaviour was not recognised as such and sheds light onto the immediate response to allegations and the way in which these may or may not immediately be considered to fall within the realms of child abuse. A question of culture? The abuse of children cannot be prevented by policies and procedures alone but requires a culture that has at its heart a real desire to put the safety of children centre stage, zero tolerance of any form of abuse and an understanding that abuse can be present in any institution at any time. The culture of an organisation, in the absence of explicitly values based leadership, develops from a myriad of individual and collective attitudes, values and actions that develop over time. This is often referred to as “the way things are done around here” (Deal & Kennedy, 2000). The appointment of High Master 7 in 2011 came at a time when “the way things were done” in too many child care organisations in the UK was to privilege the needs of adults and the organisation over the needs of children. Similarly, at St Paul’s School information given to this review gives a picture of a culture over previous decades where the safety of children was not at the heart of the organisation. Too often, the possibility of abuse was FINAL 13.1.20 Page 30 of 112 Official not acknowledged and, when it was, there was a response which appears to have been focused on maintaining the reputation of the organisation and the needs of staff rather than the needs of pupils and. On at least three occasions in the 1970’s and 1980’s staff resigned or retired after allegations had been made, or their behaviour had been commented on by pupils, parents or colleagues. On one occasion evidence in the form of a diary detailing punishments was destroyed and information given to the Department for Education and Science that evidence of beatings would be mentioned in future references was not followed through. Although knowledge about the prevalence of sexual abuse had been available for many years, this discussion had primarily remained within the professional community. By 2012, the revelations about Jimmy Savile made the sexual abuse of children part of the national conversation, along with a recognition of the part that organisational culture can play in allowing abusers to hide in plain sight. Within this context, and faced with allegations of abuse within the school, High Master 7 took steps to change the safeguarding culture at St Paul’s to one where the safety of pupils at the school was paramount. The specific steps that were taken to improve safeguarding practice are set out in section nine of this report. Established cultures cannot be changed overnight, and a picture has emerged of an organisation with a real desire to change and develop excellence in safeguarding but also an organisation with deep rooted beliefs and behaviours which have from time to time, during the period of change, hindered the most effective safeguarding practice. The development of sound practice and, alongside this, deep cultural change, has been a challenge to both the current leadership and the surrounding multi agency partnership. The associated lessons for all parties are explored throughout this report. From the perspective of those ex-pupils who spoke to this review, it should have been obvious to those in authority from the 1960’s to the 1990’s that some teachers were either physically, emotionally or sexually abusing boys. As one ex-pupil alleged to this review: There was an underlying sense that this was a system where male teachers were involved with boys and this was almost a rite of passage that boys had to navigate their way through. It was something boys had to deal with and it was almost Darwinian in that the weak and frail were preyed upon the most. Behaviours such as being asked by some teachers to do PE in the nude, knowledge that teachers kept journals about their behaviour (including instances of ‘spanking’) and boys being sodomised in the toilets were a cultural ‘given’. However, there is a stark mismatch between pupil’s assumptions that abuse was “common knowledge” and the perceptions and actions of staff within the school at that time. The reasons for this will vary between individuals and time periods: Whatever the reason, many ex-pupils feel that they were let down by school staff and a system that failed to act to protect them and they wish to understand why this occurred. This understanding is also important in providing a context for checking the effectiveness of current arrangements within St Paul’s and in the wider education system. FINAL 13.1.20 Page 31 of 112 Official Assumptions and abuse as “normal” behaviour The early period covered by this review (1960’s -70’s) coincided with a time when physical violence in the form of corporal punishment was still legal and the harsh regime described by many ex-pupils would have been prevalent across many similar schools. Staff who had been brought up through the same system may not have been likely to question the validity of this approach. A similar dynamic may have been the case in respect of sexual abuse in the 1960’s with it being regarded as almost inevitable. Lack of action to prevent it would have been compounded by a lack of any clear procedures or guidance as to what to do with any concerns. This explanation does not in any way mitigate the extreme distress caused to the ex-pupils that we spoke to who experienced physical and sexual abuse. It does serve as a reminder of the importance of putting pupils at the heart of the safeguarding system and for institutions to constantly reflect on the degree to which cultural norms and assumptions may be driving harmful behaviours. Assumptions also came into play in relation to staff believing that parents knew and were happy about close relationships with specific staff and pupils. Assuming that parents were happy for their son to spend time with teachers beyond school-based activities, other staff members ignored the danger associated with lax boundaries and failed to question or challenge the apparently very close relationships that developed. There is some evidence that the gender of the staff member may have influenced assumptions about “normal behaviour” and this had an impact on both recognition and response. Both ex-pupils and staff described the behaviour of a female member of staff as “sexually provocative” and spoke about her lack of boundaries, inappropriate conversations and socialising with pupils in pubs and clubs. Serious concerns about her behaviour with at least two pupils were raised during discussions for this review and on one occasion it seems that senior staff knew of the possible sexual abuse of a pupil. Information suggests that although this happened during a period when any complaint about a staff member was not treated seriously enough, the gender of the teacher compounded the problem, with little sympathy for the alleged victim who was either seen as being complicit in events or the cause of the problem. The dynamics of the staff group Although there is no suggestion that staff deliberately failed to report suspected abuse, staff discussions for this review do reveal a reluctance to think badly of a colleague and friend. Many staff had been at St Paul’s for a long time (although this situation has now changed), a few had also been pupils at the school and there was a strong sense of loyalty to colleagues which detracted from a child centred approach. This was specifically an issue where there was no clear “evidence” of abuse and the staff member was concerned about making an allegation that could have a negative impact on a colleague’s career. Where staff did have concerns, they tended to think about the individual as emotionally troubled rather than dangerous and one ex staff member told this review they lacked the confidence to act. Some staff have now reflected on situations where, with the FINAL 13.1.20 Page 32 of 112 Official benefit of hindsight, they now wish that they had spoken to someone about worrying behaviours and would have welcomed clearer direction at the time. The member of staff, who was convicted for the possession and distribution of indecent images of children some years after he left the school is an example of a situation where the popularity and charisma of the member of staff meant that concerning behaviours were not challenged or even noticed by other staff members. Ex-pupils wanted the review to know that this member of staff had considerable contact with the school after retirement. They described him showing prospective parents around the school and being active in the former pupil’s association although the school have no records of this being the case. He has also been described by ex-pupils as living “in plain sight” for years and being “untouchable”. The extreme difficulties that many staff members had in coming to terms with this particular member of staff’s conviction and the disquiet expressed by some that he is now no longer able to attend functions at the school is testimony to the difficulty in admitting the possibility that the charming, empathic colleague might also abuse children. The phrase “thinking the unthinkable” is often used when training staff to recognise abuse. However, in any institution, this will not achieve the desired aim unless there is also a recognition that thoughts are influenced by emotions and staff need space to explore and express conflicting emotions that are influencing their responses and arrive at decisions about any action that should be taken. Safeguarding supervision is one place where this can occur and is embedded in the day to day practice of professions including health and social care but is less well developed in schools. Although the Early Years Foundation stage requires supervision to be in place for staff in nurseries and reception classes21 there is no similar expectation for teachers of older children where issues will be no less complex. There are logistical challenges in implementing supervision within a school environment22 but the evidence from this case would suggest that this is an important area for practice development. St Paul’s have been proactive in moving beyond statutory requirements by putting in place safeguarding supervision for all pastoral and safeguarding leads and a formal evaluation of impact would be a positive contribution to national learning. Ex-staff members described a dynamic, particularly in the senior school, where the impact of a large busy staff team was that people tended to be close to only a small group of like-minded colleagues. A narrow focus on their own role and function and cliques within the staffroom resulted in worrying behaviours by others not being noticed by many in the staff team. In addition, the possibility of abuse, particularly sexual abuse, appears not to have been on the radar of many in the staff group from the 1960’s through to 2000 and if they were concerned, they lacked confidence to do anything about it. One staff member commented to the review that one of the boys who was weak academically may have been exploited by a staff member: “I was half conscious that something was going on, but I lacked the grip to do something”. Subsequently a different ex-pupil made allegations of sexual abuse against this member of staff although this did not lead to a conviction. 21 Department for Education (2017) Statutory Framework for the Early Years Foundation Stage Page 21 22 See chapter 6 in Sturt, P and Rowe, J (2018) Using Supervision in Schools. Brighton: Pavilion FINAL 13.1.20 Page 33 of 112 Official The review is aware of one instance in the early 1980’s where a member of staff brought the behaviour of one of the convicted perpetrators to the attention of the High Master following a “joke” in the school magazine about his close relationship with a pupil. This did not result in any action by the High Master. The reason for inaction is not clear and despite several attempts by the review team it has not been possible to make contact with the master who made the complaint and was the one ex-teacher who provided evidence for the prosecution in court. This lack of awareness amongst staff at that time was compounded by a lack of training, few policies and procedures and no clear message that abuse “could happen here”. Since the advent of the first national safeguarding guidance for schools in 200623 training and safeguarding policies have been formalised. When the current High Master was appointed in 2011, he immediately began a process of reviewing and improving policies and procedures; for example, consolidating and improving a school-wide staff code of conduct. Although changes in culture and practice will take longer to embed than a change in procedures, discussions with current and recent staff for this review highlight that there is now a general acknowledgement that the school has become more child orientated and staff now know when, how and to whom to report concerns. Many staff spoke of the relentless focus on safeguarding through training and procedures but one staff member made the observation that an overemphasis on procedures could give a false sense of security and another referred to a feeling that some systems such as neutral reporting felt like “back covering”. One ex-pupil and parent who still has strong links with the school felt strongly that the pendulum had swung too far, and procedures were inhibiting the use of common sense. Staff who have been at the school as it has grappled with managing abuse allegations will now be hyper aware of the expectations placed upon them. The challenge will be to ensure a relentless focus on the safety of pupils remains embedded in the culture of the school as the leadership turns over and new staff join the organisation. Academic excellence Historically, St Paul’s reputation as a centre of academic excellence appears to have contributed to a culture where both parents and boys were reluctant to complain. From discussions with more than one current or recent parents this may still be a pertinent issue that needs further consideration. The way in which complaints processes may either encourage or discourage complaints is considered further in paragraphs 7.26-7.32 below. Some ex-pupils told the review that they were acutely aware of their parent’s pride that they had gained a place at St Paul’s and, in some instances, they knew parents were making considerable financial sacrifices to send them there. Within this context some pupils spoke of not feeling able to admit that their experience may be less than perfect. The review was told by recent past parents that the school is felt to be a powerful institution and where the parents group heard rumours about teachers at the school these would not be brought to the attention of the senior leadership team as they would not wish to be seen to be causing trouble that may reflect badly on their son. This is particularly 23 Department for Education (2006) Safeguarding Children and Safer Recruitment in Education. FINAL 13.1.20 Page 34 of 112 Official pertinent when the school is responsible for university references. Parents who did complain about the behaviour of one of the convicted perpetrators told the review that they were ostracised by other parents for criticising a popular teacher. In the past, deterioration in schoolwork was not explored as a form of communication or distress. Negative school reports for some pupils abused by convicted perpetrators clearly show uncharacteristic behaviours including deterioration in the quality of their work. These were then seen as the pupil’s problem. There was no evidence of any attempt to understand the causes of such changed behaviour or attainment and for the pupils the distress of the abuse was compounded by negative feedback about their academic performance. The associated emotions were hard to handle in such a competitive environment and, in some instances, have had a long-term negative impact on their mental health. St Paul’s have taken steps to improve the wellbeing of pupils. The previous focus on academic excellence and competition at the expense of pupil care in Colet Court has been mitigated by the removal of the requirement (which commenced in 1976) to pass an examination to obtain a place in the senior school. This exam no longer exists, and boys at the junior school are automatically given a place at the senior school unless this is clearly not the right educational pathway for them. However, although such steps are important, St Paul’s exists within a national culture where academic success has been the benchmark by which schools and individuals are judged with the attendant risk that this will influence the actions of staff, parents and pupils. Complaints and allegations In the early stages of following up a concern it can be difficult to identify when a complaint about the behaviour of a member of staff is in fact an allegation of abuse. This will depend upon evidence, thresholds and professional judgement, and these difficulties were evident when members of staff were accused of giving alcohol to boys and violating boundaries. As discussed elsewhere in this report in paragraphs 8.43-8.46, one such incident was reported to the LADO, but then the LADO, the school and the police had different points of view as to whether this was potential abuse that required external investigation or a complaint that could be handled internally. Since then revised guidance local training for designated safeguarding leads have made the thresholds and expectations much clearer. Professional judgements are not infallible, but what is crucial is that complaints are taken seriously and investigated properly in order to make sure that it becomes clear when behaviour crosses the boundaries into abuse. The Laidlaw review clearly identified when failures in responses to complaints meant that opportunities to identify abusive behaviour were not taken: It ought to have been clear to both [x and x] that the complaints were likely to have substance to them. A proper investigation would not only have revealed them to be true but that there was further evidence of inappropriate behaviour by [the staff member]. FINAL 13.1.20 Page 35 of 112 Official The heightened sense of awareness necessary to identify abusive behaviour was displayed by neither of the heads….24 The report into safeguarding practice commissioned by the school in 2017 (the Barnardo’s report) found that the school had developed good systems whereby concerns about the behaviour of a member of staff could be reported. There remained some challenges in making sure that complaints from individuals outside school, such as parents, were always treated in the appropriate way. The authors of the Barnardo’s report told this review of one example where they found that a parent had expressed concern about the behaviour of a member of staff “in the light of historic abuse”, this was not immediately treated as a possible safeguarding concern and was thought to be as a result of boys spreading rumours. Once this was brought to the attention of the High Master appropriate action was immediately taken. The Barnardo’s report acknowledged that the issue of whether concerns about the behaviour constituted a complaint or allegation is a difficult one for all schools and organisations and commented: Matters relating to concerns regarding adults’ behaviour towards children was consistently well managed and properly dealt with within the school. However, there was some evidence that staff and managers may need some support with considering how best to manage and properly deal with concerns regarding staff conduct or behaviour, which may be inappropriate and does not constitute an immediate safeguarding risk to children, but which may present risks to children if it is repeated and not addressed. It is recommended that senior managers may find benefit in accessing a workshop on the interface between safe working practice and the management of allegations against staff, as this can be a particularly complex area for all schools. The focus should be on improving understanding of how leaders might best manage concerns regarding the behaviour or conduct of staff, allegations against staff and general safeguarding matters respectively. (4.6.2) This serous case review would concur with Barnardo’s regarding the need to make sure that complaints from outside school, including those from parents are always treated appropriately. Although only a small number of parents have directly contributed to this review, they give a consistent message about the courage that is needed to complain and the fear that any complaint may have a negative effect on the treatment of their son. It is therefore incumbent upon the school to understand this and treat all complaints with the same degree of fairness and respect. The complaints procedure at St Paul’s is fully compliant with statutory requirements and similar to other schools. It involves three stages: informal resolution, a formal investigation - usually by the High Master - and finally an opportunity for the complainant to put their case to a panel, two of whom are governors and one who is independent of the school. If it is not resolved at this stage the procedures state that the school can close down the complaint and the complainant can contact the Department for Education School Complaint Unit. At no stage is there a requirement that there will be an individual independent investigation of the complaint by someone external to the school prior to consideration by the panel. 24 Laidlaw Report Paragraph 11 FINAL 13.1.20 Page 36 of 112 Official Given the feelings expressed by parents about the perceived power of the school, a procedure which has no external element until the third stage, which involves putting their case to a panel, may feel intimidating and is unlikely to redress any power imbalance. A more balanced approach within statutory guidance would be similar to many Local Authority Children’s Services procedures which include independent investigation reports before any panel or final adjudication. This is relevant to safeguarding since some complaints about the behaviour of staff may indicate possible abusive behaviours, for example where the complaint refers to favouritism, bullying or similar behaviours that may have a negative impact on emotional wellbeing. An analysis of the history of abuse at St Paul’s and other similar organisations makes clear that there are risks associated with managing such concerns about staff behaviour within the school system without a strong parental voice and adequate independent scrutiny. THE RESPONSE OF THE SCHOOL TO ALLEGATIONS OF ABUSE As well as managing specific current cases there is the broader issue of how a school responds to evidence that pupils have been abused in the past. For those who have in any way been affected by abuse, the issue of who is ultimately taking responsibility for past abuse is of crucial importance. This section of the report will start with exploring this issue of responsibility and the school’s response to survivors of abuse before moving on to considering practice where specific allegations have been made. In relation to specific allegations the response of the school falls into three main categories ➢ The immediate response when an allegation is made; ➢ Managing the allegation within the whole school community; ➢ Responses following criminal investigations. The final part of this section will reflect on the way in which the school has focused on learning lessons from past mistakes in order to improve contemporary responses to allegations of abuse. Past abuse: the issue of responsibility Although the focus of this serious case review is on lessons for current safeguarding practice, the way in which a school responds to non-recent abuse allegations is a litmus test for current safety as the safest institutions are those who are willing to admit mistakes and continue to be alert to the possibility that abuse could have happened, or could happen in the future. In addition, the response to those who were previously abused at the school is an important marker of the extent to which an institution has internalised and demonstrated a real understanding of child abuse and continuing its impact for the victim/survivor. The overriding impression is that St Paul’s were totally unprepared for what faced them in 2014. FINAL 13.1.20 Page 37 of 112 Official As a registered charity the school did not notify the Charity Commission of the arrest of members of staff in 2013 and 2014. These should have been reported as a serious incident and the school now accepts that they should have done so. Correspondence from the (then) Chair of governors in a personal e-mail to the (then) Chair of the Charity Commission describes surprise that the Commission were going to open a statutory inquiry into the school’s current safeguarding practices, questioned the evidentiary premises underpinning the decision to initiate an inquiry and stressed the need for the Charity Commission and the school to combine their efforts to protect the reputation of the charity. The school went on to challenge the way the inquiry was carried out and the impression given was of an institution that did not welcome external scrutiny. The challenges associated with accepting responsibility whilst protecting the reputation of the charity are explored further in Finding One. For an institution that is used to being one of the best in the country, it appears to the lead reviewers that it has been a challenge for the school to comprehend the scale of humility—and its manifest expression—needed to admit mistakes and manage the emotional aftermath. Although letters to the school community and communications with ex-pupils from 2014 -17 show a determination to be open about the allegations and assure current parents that the school was safe, the content and tone of the communications was perceived by some ex-pupils as aimed at minimising reputational damage and not wanting to accept responsibility and publicly acknowledge the severity of past abuse. The tone of some confidential correspondence from the school to safeguarding partners was also interpreted as defensive and contributed to the concern of the LSCB chair that the school could not listen to advice and guidance when this was offered to them. This is explored in more detail in section 11 of this report. One example frequently referred to during discussions with ex-pupils was a letter sent by the High Master in 2014 following police investigations into an ex-teacher which resulted in the conviction of an ex-staff member25 for the possession of child abuse images. This letter that was sent out to all ex-pupils following the conviction is an example of a communication that was well intentioned but angered many ex-pupils who knew of rumours and allegations whilst he was at the school. The tone of the letter was understood by many as another example of the school failing to accept responsibility and wishing to distance the school from the conviction of a perpetrator of abuse. They continue to feel that it failed to acknowledge the seriousness of his offences or the possibility that he may have abused pupils at the school. The letter stated that the conviction related to events that took place long after the staff member’s retirement from St Paul’s, that he had always been held in high regard by colleagues and pupils, that there was no record of complaints whilst he was at the school and the school had not been contacted by the police during their investigation. The letter expressed surprise and shock at the conviction and stated that the member of staff would no longer be able to enter school premises without clearance from the Disclosure and Barring Service barred list. 25 This conviction was for the possession and distribution of images and did not relate to the abuse of pupils from St Paul’s School. FINAL 13.1.20 Page 38 of 112 Official The High Master had not been informed of the rumours about this staff member by any longstanding member of staff and there was nothing in his staff file to suggest that there had been any concerns; (the issue of allegations about “pornographic videos “ found in his study is explained in paragraph 6.20 above). The letter was written in good faith, it drew the attention of all current parents and pupils to the conviction and sought to provide reassurance that current pupils would be protected, but with the benefit of hindsight the High Master recognises that it conveyed the wrong and unintended impression to those ex-pupils who had concerns about the staff member’s previous behaviour when he was teaching at the school. Ex-pupils have told the review that the impression given was that the school wished to distance itself from the conviction of an ex-member of staff who had taught at the school for 37 years and had remained in contact with some staff at the school. That notwithstanding, ultimate responsibility for the lack of sensitivity in response must lie with previous senior staff at the school who failed to record adequately previous allegations about this member of staff’s possession of “pornographic videos” and make adequate inquiries about this at the time. Linked to the acceptance of responsibility is the issue of how a school apologises to those who may have been affected by non-recent abuse. From the school’s perspective, from 2014 onwards they were having to juggle several often-competing demands and this review acknowledges that there was a lack of consistent advice and support from statutory agencies to help them through this process. This is discussed further in Finding Two, Three and Five of this report. The role of the governing body is important, and evidence points to governors having to come to terms with the severity of what had happened, their role as trustees of the charity and responsibility to the current school community. The review has heard that in communications with individual survivors and statutory organisations some members of the governing body were perceived to be unduly defensive and gave the impression that minimising reputational damage was their priority. The reviewers have not seen any evidence that this was the intention of the governing body or senior leadership as a whole but it does indicate the shift in culture and the unconscious bias that needs to be addressed in order to move towards an organisation that will readily accept responsibility for past mistakes. The learning for the governors of St Paul’s and other schools is that careful honest thought must be given as to the motivation behind each communication and the extent to which it keeps the wellbeing of current pupils and survivors at its heart. Use of language has been an important issue and it is here that learning lessons from survivors of abuse could be of assistance. For example, one survivor explained that comments which refer to the number of ex-pupils who had a positive experience at the school are insensitive because they might imply that the needs of survivors are of less importance than the experience of the majority. Once the extent of the non-recent abuse came to light, the school have told this review that they were first and foremost focusing on supporting police inquiries and making sure that any perpetrators were brought to justice. They told the review that they had been instructed by the Metropolitan Police in 2014 not to contact any ex-pupils directly and they FINAL 13.1.20 Page 39 of 112 Official passed any allegations of non-recent abuse directly to the police. They were not aware of the detail of police inquiries including the names of the alleged victims. The school aimed to keep the school community and ex-pupils informed and signposted them to the NSPCC national helpline should they need support. The letters sent from 2014 onwards to parents are also clearly aimed at allaying any concerns of current pupils and parents and assure them that systems were being reviewed and pupils were safe at the school. A letter sent to the whole school community by the Chair of Governors in February 2017 after the conclusion of the criminal trials contained an apology and stated “we wish to apologise to you and all those in our community who have felt the impact of these cases”. Lead reviewers have been told by some ex-pupils who had alleged abuse by those who had not been convicted this gave the impression that they had been abandoned by the school. In a submission to this review the school comments that the reason the school did not apologise generically for all past abuse in 2017 was that an institution that apologises generically for past abuse that it still only dimly understands, is making an empty PR gesture. A genuine apology of real contrition, and a sincere acceptance of responsibility can only follow from detailed knowledge of what had happened. The school argues that their plan to commission a wide-ranging review by Barnardo’s and the acceptance of the Barnardo’s proposal which included listening to the voice of victims/survivors and considering unsubstantiated allegations would have given them a sound base from which to apologise and accept responsibility. Following the decision to undertake this serious case review the school agreed to postpone the start of the Barnardo’s review and amend the terms of reference to avoid duplication across the reviews. The plan had been for the Barnardo’s reviewers to work with the serious case review in carrying out any interviews but the timing and logistics of this proved impossible. The school have told this review that they were concerned that this delay and change of plan would confuse ex-pupils and be interpreted as the school shirking their responsibility. These concerns were expressed in correspondence to the LSCB chair and lead reviewers between May and July 2017. There are lessons to learn in respect of how to apologise in a manner most likely to be welcomed by victims as genuine. Although the school cite the reason for a more generic apology being a lack of specific knowledge about what had happened, one approach could have been to write a letter and ask the police team to pass this on to any ex-pupils who had made allegations. There had also, by February 2017, been enough information within previous press reports to indicate that there were likely to be more ex-pupils who would describe themselves as victims of non-recent abuse than had been involved in the trials and more alleged perpetrators. In the light of this it would not have been unreasonable for the apology in February 2017 to acknowledge that there may be ex-pupils who were not involved in the trials who may have been affected by non-recent abuse at the school and to apologise to them if that was the case. The High Master was open to discussion with the lead reviewers about the continued need for an apology and a letter was sent to all ex-pupils in September 2018 and a further letter in February 2019. The review has been informed that not all ex-pupils or parents who were FINAL 13.1.20 Page 40 of 112 Official known to have been affected recall receiving these letters although both letters were published on the website. The first letter apologised unreservedly for the inappropriate and abusive behaviours of some teachers and gave an open invitation to a meeting with the High Master. The tone of this letter was perceived by a small group of ex pupils as somewhat defensive although the school have informed the review that 89% of those who responded to the school were very positive about its contents. A number of pupils contacted the school and met the High Master and following these discussions, a further letter was sent in February 2019 giving a more personal reflection by the High Master on what had happened and showed a willingness to engage with confronting what had happened and learning from past mistakes. In summary, it is the opinion of the lead reviewers that St Paul’s gave the impression to ex-pupils and some partner organisations that they were reluctant to accept responsibility for non-recent abuse of pupils at the school. They were perceived as being slow to apologise and this was distressing for many ex-pupils who had suffered abuse. This review accepts that this was not the intention of the school and the reality was that this was an un-precedented situation for them to manage, for which they were not prepared. For any school in this situation, planning alongside key safeguarding partners must be key and, in this case, there was insufficient support and constructive challenge and dialogue between the school and the local safeguarding system. Strategic planning needs to consider the needs of all ex-pupils and families from the outset of any investigation and identify sources of support and when and how the school can issue apologies. This is discussed further in Finding Three. The School’s response to survivors The issues in this section relate specifically to adult survivors of abuse rather than child safeguarding. These issues have been included as they formed part of the evidence given to the review by ex-pupils and from the perspective of some survivors are an indication as to the school’s depth of understanding of child abuse including the potential impact of abuse on individuals. This is a legitimate point of view. The issue of redress is a sensitive area and survivors who spoke to the review had strong opinions about the way it had been handled and the message this gave about the school’s capacity to accept responsibility. As identified by submissions to IICSA26 : ……there is no “one size fits all”. There are a variety of outcomes that victims/survivors seek from the civil claims process. These include: acknowledgment of the abuse having taken place; acknowledgement of the harm done; justice; compensation; access to counselling and therapeutic support; an apology; an independent and impartial investigation; truth and accountability; punishment of the abuser; an admission of institutional failure; a commitment to learning lessons; changes to prevent recurrence; vindication; closure; and a “day in court”. 26https://www.iicsa.org.uk/key-documents/916/view/inquiryseminarupdatereport-accountabilityandreparations.pdf FINAL 13.1.20 Page 41 of 112 Official The evidence suggests that the High Master of St Paul’s approached the task of responding to survivors from a position of compassion and a wish to do the right thing, and to take a flexible approach which circumvented some of the challenges presented by governance and insurance arrangements. However, some survivors did not experience the approach taken as a positive one and, although the review has been told that The Mercers have always been willing to consider requests for redress from any former pupil, the communication from the school did not make this clear. Those ex-pupils where abuse had not been proven in a criminal court told the review they were unaware of this. There are now ex-pupils whose alleged abuser has not been convicted whose claims are being considered. The system that was devised was complicated by the change in governance in 2007 and an ongoing discussion with insurers about liability and liability in the absence of insurance. This was not always clearly conveyed to survivors resulting in misunderstanding about liability and the approach to handling claims. The abuse carried out by convicted perpetrators took place before 2007 when there was no separate legal entity in place and all contracts and commitments by the school were entered into by governors as individuals. The majority of governors were Mercers and The Mercers Company was corporate trustee of the St Paul’s School Foundation, which after the 2007 restructure retained ownership of school land and their investments. The Charity Commission had in fact warned the school it could not make compensation payments to victims in relation to actions before the school itself existed as a legal entity i.e. pre 2007. The Governors did though apply for special dispensation to use its own money to provide ongoing support to victims and the school and The Mercers worked together to deal with redress for pre 2007 abuse. It became clear to the school that the two insurers that had covered the school prior to 2007 were likely to take a more protracted approach to victim’s claims, and the school have told the review that they asked The Mercers to put insurance on one side and deal immediately with redress themselves. The Mercers and the school collaborated on agreeing the best approach and a lawyer was then instructed by The Mercers to assist the school in setting up a scheme of redress and to have this ready as soon as the criminal trials had finished. Following negotiations all survivors settled. The school report that for the majority of survivors their engagement with this scheme has been positive and none have had to resort to litigation. In contrast more than one survivor has told this review that they did not feel positive about the process and described it as distressing. It is beyond the scope of this review to comment on the pros and cons of specific redress schemes for survivors of abuse as this is a complex area with competing viewpoints and experiences but the feelings of some survivors about the process in this case need to be heard and understood. What is clear from discussions that have taken place during this review is that there are immense challenges in developing such schemes and the likelihood is that not all will feel that it in any way compensates them for the abuse they have experienced. FINAL 13.1.20 Page 42 of 112 Official In the opinion of the reviewers, whilst a great deal of attention has been paid by the school to developing a system of redress for those who were abused by convicted perpetrators it is less apparent that there was a plan for reaching out to those whose abuser or alleged abuser is dead or not convicted of a crime or where an affected pupil may be deceased. Two civil claims were made against St Paul’s in 2014 alleging abuse by members of staff who are now deceased. These claims were passed to insurers and were repudiated on the basis that the alleged abusers were dead, the school had investigated as far as they were able and found no records to support or disprove the claims and the passage of time meant that the school’s ability to investigate and defend the claim had been compromised and no further contact had been received from either claimant. This approach has left some ex-pupils and parents feeling that the school does not care about their experiences and is reluctant to take any responsibility for the harm they may have suffered. The school strongly rebuts these criticisms and insists that it has made every effort to address the needs and concerns of each survivor on an individual basis. As explored elsewhere in this report, from the school’s perspective they did not know who had alleged abuse and did not feel able to reach out more widely whilst police investigations were still taking place, having understood from the police that no further contact was appropriate at that time; (see paragraph 8.14 above). A lesson for the future is that a strategic approach which plans for a response to both proven and alleged survivors needs to be in place. Managing specific allegations in 1970’s and 1980’s There can be no doubt that the response to allegations in the 1970’s and 1980’s fell well short of the standards that would be expected today and it is likely that St Paul’s School was not very different from some other similar institutions in the way that concerns about individual staff were dealt with without the involvement of outside agencies. That notwithstanding, there are clear examples of situations where the response was poor even by the standards of the time. A focus on preserving the reputation of the organisation and an approach which privileged the needs of adults over the wellbeing of children meant that abuse was not reported and this failure to act in the best interest of pupils left children at St Paul’s and elsewhere at risk from sexual offenders. This is clear from the examples below. Ex-pupils have told the review about the alleged inappropriate behaviour of an assistant chaplain in the 1970’s and 80’s and school records confirm that it was known that he invited sixth form pupils to his flat and one parent had complained about this. An ex-pupil has told this review that he believes that the senior chaplain was aware of this inappropriate behaviour as the ex-pupil’s father phoned the senior chaplain on one occasion and asked him whether he would like his son to be going around to the flat and he replied that he would not. This pupil alleges that on one occasion he woke up in the member of staff’s bed after becoming drunk the previous evening. The assistant chaplain was suspended in1985 due to concerns about teaching quality and alcohol use (not for inviting pupils to his flat). Following in-patient hospital treatment and confirmation from a doctor that he was fit to work he returned to teaching under clear conditions regarding punctuality, teaching quality and abstinence from alcohol. When concerns about his FINAL 13.1.20 Page 43 of 112 Official drinking became more serious, he was dismissed. Following an appeal, the Governors decided on a negotiated resolution and he took early retirement with an ex gratia payment in lieu of notice. No formal action was taken about concerns regarding his behaviour with pupils other than where it impacted in their academic performance. The lead reviewers checked whether the Church of England had any record relating to this chaplain and none could be found. The review has also heard from ex-pupils that in the late 1980’s cleaners found a diary in a master’s room where he detailed spanking boys. There was also a video with unpleasant (but legal) pornography and both items were passed on to pupils. A senior pupil at the time has told the review that he was shown the diary which detailed punishments with notes such as “nice boxer shorts”. He described telling the house master and after doing so he does not remember seeing the member of staff again. He “disappeared”, and the message was that the school had moved on from this incident. Some other ex-pupils recall being told to keep quiet about what had happened and describe the school as putting a lot of time and effort into finding out which pupil had sold the story to a national newspaper. The official message from the school to the pupils was that the member of staff had resigned for family and personal reasons and his staff file indicates that colleagues were informed he had resigned with immediate effect after he had “beaten” some boys in the school. When the Department for Education and Science contacted the school about a report of the above incident in the press, the school informed them that if the member of staff had not resigned then he would have faced disciplinary action in connection with a video of corporal punishment and a punishment diary. The Department for Education and Science asked for further information in order that they could consider the member of staff’s suitability to teach. The further information supplied included that no evidence of indecency had been found by the school and the Department for Education and Science was assured that events would be mentioned to any future employer. The school also commented that “the problem is compounded in that certain parents supported the beating” and “they asked their sons to be transferred to him as tutor knowing he beat boys”. Even though the school had banned corporal punishment before these events took place the culture was still one that minimised the impact of physical abuse and did not prioritise the safety of pupils. Within a year the school supplied a written reference in support of the member of staff’s application for a non-teaching job which did not adhere to the assurance given to the Department of Education and Science. This reference stated that he was a very successful school master and exceedingly conscientious and “I can recommend him in every way in that he has a good mind is very ambitious and a fine organiser”. High Master 4 confirmed to the member of staff that a reference had been submitted, that the diary had been destroyed and advised him not to worry and to let him know if there was anything else he could help him with. Destroying the diary shows an extremely serious lack of judgement on the part of the High Master and is further evidence of a culture which failed to put the safety and welfare of children first. This member of staff was an alleged perpetrator whose court case in 2016 resulted in a not guilty verdict due to lack of evidence. Although it cannot be said with FINAL 13.1.20 Page 44 of 112 Official certainty that the presence of the diary in his school file would have changed this verdict it is possible that it would have assisted the police inquiries. Also, in the 1980’s, a member of staff now convicted of abusing pupils left suddenly after a pupil’s mother went to the High Master concerned about her son’s wellbeing. This pupil had been a “favourite” of the staff member and was ostracised by his own peer group for being so. There are no concerns recorded in the member of staff’s file staff although anecdotal information from ex-pupils and an ex member of staff’s police statement provide evidence that there were suspicions about him. A joke about his relationship with one pupil appeared in a public forum and an ex member of staff has now told the police that he was going to bring this to the attention of the High Master but, on his way to do so, saw an undermaster and commented to him that either the boy that wrote the joke should be expelled or “one of us [meaning the member of staff] should be in prison”. The undermaster said that he would take it up with the High Master and it was eight weeks later that the member of staff left the school. One of his victims told this review that after he left the school, he saw another current member of staff (later convicted of possessing indecent images) in a social situation and confided in him about his abuse by the perpetrator concerned. There is no evidence that this resulted in any further action. The expectation would have been that this information would have been relayed to the High Master who should have informed the local authority and the police. A failure to act decisively and appropriately where there were suspicions of sexual abuse not only left pupils at risk of harm but also damaged their emotional and academic development. The issue of ascribing deteriorating academic performance as the pupil’s problem rather than considering the reasons behind it has been discussed elsewhere. In another example the unprecedented step was taken of moving a pupil up to the senior school a year early, away from his peer group. The ex-pupil understands that this occurred once other parents complained about him sharing accounts of what had happened between him and a member of staff with his peers. This pupil also alleges that the school were aware of the member of staff’s inappropriate behaviour with pupils and this was corroborated by ex-staff members who spoke to this review. However, there is no evidence that concerns were relayed to senior managers at the time. The move was re framed as an “opportunity” to go into the upper school but from the ex-pupil’s perspective this was the cause of profound emotional problems for him. Although these examples of failure to act to protect children may have reflected a wider cultural problem at the time which failed to put children first, this does not negate the extreme suffering experienced by pupils at the school. Even where abuse was brought to the attention of those in authority, they did not inform the statutory agencies and children were left at risk of abuse from people who should have been protecting them. This not only failed pupil’s at St Paul’s but also put children in the wider community or at other schools at risk. FINAL 13.1.20 Page 45 of 112 Official Managing specific allegations – more recent practice More recently, under the leadership of the current High Master and Designated Safeguarding Lead there has been a marked improvement in responses to allegations although this has taken time to develop. When pupils complained about inappropriate behaviour and use of alcohol by a master, there was a willingness to listen to pupils and take allegations seriously. There was initially a lack of judgement by the school in investigating internally by conducting interviews with the pupils before contacting the local authority or police and the school have acknowledged that this was not best practice at that time. Following referral, the police decided to take no further action, although there was a further investigation a year later. This again did not lead to any criminal prosecution. The broad outline of subsequent events can be traced via meeting minutes but discussions with the LADO and further commentary from the school reveals differing points of view as to the quality of practice and judgements made by both parties. Indeed, these differing points of view are clear from the minutes of the second management of allegations meeting which were challenged by the school and clearly set out areas of dispute. From the LADO’s perspective his concern was that the school were defining the member of staff’s behaviour as improper rather than abusive and were placing too much emphasis on the fact that the member of staff had expressed contrition and had cooperated with the safety plan. Following a review of all the information in his possession he advised that the member of staff should be suspended, and that he would be making a referral to the Disclosure and Barring Service. The school provided the Disclosure and Barring Service with all relevant information, including the details of the disciplinary procedures and outcomes which by that stage had been concluded and after consideration the decision made was that it was not appropriate to bar the member of staff. The school did not understand why the LADO appeared to change his mind about the advice he gave, and that they felt referral to the Disclosure and Barring Service should have followed the completion of all investigations and disciplinary procedures to make sure that teacher concerned had the chance to state their case and the Disclosure and Barring Service could make the decision on all the information available. Although there was nothing to prevent the LADO making his own referral to the Disclosure and Barring Service, this was unusual practice and driven by a concern about the school’s original response to the allegations and an appropriate concern that the threshold for understanding behaviour as abusive (rather than improper) was too high. The LADO also felt the police threshold at that time was too high and that the fact the police did not take any action should not prevent safeguarding activity taking place. There is further discussion about the relationship between the school and the LADO in section nine of this report. A later “lessons learned” meeting with the new head of the LADO service noted that it was unusual for a referral to be sent to DBS without an investigation being undertaken by FINAL 13.1.20 Page 46 of 112 Official Police and/or Children Services but that the LADO can refer when the legal duty is not met and where there are safeguarding concerns. At the time the statutory guidance was not sufficiently clear regarding timings of referrals to the Disclosure and Barring Service in such cases. The most recent statutory guidance27 has now clarified that a referral should only happen after the completion of all investigations and disciplinary procedures. This case was then referred to the teaching regulator (NCTL) but the case did not progress to a panel hearing and no further action was deemed necessary. Around the same time another member of staff (who was later convicted of possessing indecent images) was referred to the local authority when images of boys were found on his computer. The school’s chronology identifies that legal images of boys were found on a Wednesday during a routine check of the computers in Colet Court; further investigation found that activity had been taking place with attempts to access sites with links to pictures of young boys. The Headmaster of Colet Court was informed. The next day (Thursday) further activity was found on the computer of the member of staff concerned which included downloading images of boys posing in sexually suggestive ways. The High Master was informed. The designated safeguarding lead at Colet Court consulted with an experienced freelance child protection trainer who advised referral to the LADO. The decision taken within school was to monitor internet activity of the member of staff over the weekend. According to information given to the review by the school, new evidence came to light over the weekend and the LADO was informed on the Monday morning. It is the view of the lead reviewers that the school could have been swifter in informing the LADO of the images that had been found and should have contacted the LADO rather than a child protection trainer. Even though the images found on the Wednesday were legal they were unusual, and as outlined above, it was clear by Thursday that the member of staff was being proactive in attempting to access sexually suggestive images of young boys. There had been previous complaints about this member of staff, and this should also have influenced decision making at this point. The school dispute this analysis and argue that it was only over the weekend that explicitly erotic material was accessed and that at the time the guidance to schools regarding expected speed of reporting was not specific. There is agreement between all parties that had these events happened within today’s context there would have been a prompt discussion with the LADO. Both these instances appear to reflect differing views as to what constitutes risky or abusive behaviour and highlights the need to move to a broader understanding of what these involve. Two of the convictions of staff were for the possession of indecent images and various communications, but most notably that from the (then) Chair of Governors questioning the Charity Commission’s inquiry report, take issue with these convictions being referred to as child abuse. Even though no pupil at the school may have been harmed the possession of such images should have been understood as falling within the definition of child abuse and involving abuse of other children. 27 New guidance Keeping Children Safe in Education (2019) is now explicit that referrals to the Disclosure and Barring Service should be made “after the resignation, removal or redeployment of the individual”. FINAL 13.1.20 Page 47 of 112 Official Managing specific allegations within the school provides many challenges, most particularly at the interface of good safeguarding practice and employment law. Ex-pupils told this review that they believed even more recent allegations in 2013 had been “hushed up” when the reality is that is that the school had reported three issues to the LADO and the police that year, and all three were investigated. However, teachers in such circumstances possess rights under both employment and criminal law, which have to be observed and prevent any school from sharing details with third parties. This can create the impression to third parties, even those within a school, that issues are not being followed up when in fact they are. Section 141F of the Education Act 2002, inserted under section 13 of the Education Act 2011, introduced an anonymity clause for teachers who are subject of an allegation. It is an offence for anyone to put information regarding an allegation by a pupil against a current teacher into the public domain, where this is likely to lead to the public identifying the teacher, prior to any charge or subsequent court appearance or before the Teaching Regulation Agency publishes information about an investigation. This means that schools face challenges in encouraging a culture of openness whilst at the same time protecting the confidentiality of the accused in an institution where rumours are likely to be rife. It is unhelpful if the message is somehow conveyed to pupils that the school wishes to shut discussion down as this is at odds with good safeguarding practice which would always want to encourage open dialogue about any concerns relating to inappropriate or abusive behaviour. The most recent conviction of a member of staff in 2018 does provide evidence of an organisation that is learning from past mistakes and has a deeper understanding of how to manage the aftermath for both past and current pupils and their parents. This example is set out in some detail as it refers to recent practice and serves to highlight good practice as well as some the challenges involved, including the use of language, and the need for clarity about communication processes amongst all agencies. It also indicates that the current system in place to prohibit offenders from teaching may not be working efficiently. This member of staff had been a science teacher at St Paul’s for seventeen years when, in February 2018 he was arrested in the Thames Valley Police area having been tracked by the police having sexualised online communication with someone he believed to be a13-year-old girl. He had been tracked and known to be both a teacher and a father from November 2017, but his true identity could not be revealed by the social media platform as their policy is only to do so if there is a risk to life. Regulation of social media platforms is being debated at a national level and this example serves to remind those considering this issue of the way in which perpetrators can hide behind the anonymity that they provide. Having made arrangements to meet with the “girl” he was detained by the police and immediately wrote to St Paul’s telling them of the arrest under the Sexual Offences Act and offering his resignation, citing a “nervous breakdown” leading to him making “ill-judged decisions”. The initial contact from Thames Valley Police to the school was unfortunate as the police communications manager contacted a junior member of the marketing department at St Paul’s giving information regarding the arrest. This member of the marketing department FINAL 13.1.20 Page 48 of 112 Official was unaware of, and wholly unprepared for, the situation. Police officers should be reminded that they should only speak to the Designated Safeguarding Lead or Head regarding an allegation/concern/suspicion/arrest of a teacher. There immediately followed good communication between the school, LADO and the police and the school informed the Disclosure and Barring Service immediately they were aware of the arrest. Expected procedures were followed which resulted in the school holding a disciplinary hearing and recording that the member of staff would have been dismissed had he not already resigned. There was discussion during this process about what point the Teaching Regulation Agency should be informed and advice from the LADO was that this should not happen until point of charge. The school then put them on immediate notice of the case pending further information and kept them regularly updated. Statutory guidance28 advises that this should be considered at the point an allegation is substantiated or at the point of dismissal but is not unequivocal in setting out expectations as it is with a referral to the Disclosure and Barring Service, where there is a legal duty to inform them when a school thinks that an individual has engaged in conduct that has harmed (or is likely to harm) a child. There is further discussion of when to involve the Teaching Regulation Agency in paragraphs 13.19-13.23. Letters were sent to staff and parents (agreed by the LADO) explaining that the member of staff would not be returning to school after half term due to “mental ill health” and being involved in an investigation that “has nothing to do with the school or his work here”. The aim of the school was to give parents, pupils and the wider school community as much information as was possible within the confines of the law. The teacher had rights to anonymity under law, yet the school had to explain his sudden departure in a manner that was not misleading while providing reassurance against possible suspicions that the issue related to an allegation involving pupils at the school. The school worked closely with the LADO and the police to agree the contents of the letter. On the one hand, including the phrase that the issue had nothing to do with his work in school is technically correct, but is hard to square with a sexual offence and can give the impression of a school wanting to distance itself from the issue. On the other hand, without an explicit assurance that the issues were unrelated to conduct within St Paul’s then the letter would have given rise to parents and members of the community worrying about the possibility that the staff member was suspected of abusing pupils at the school. The member of staff was charged on 22nd June 2018 with arranging to meet a child for the commission of a sexual offence and inciting a child to commit a sexual act (aged 13). His first appearance at court was set for 24th July 2018. Throughout this time, the school and LADO were advised by the police officer in charge of the case that Thames Valley police would not be making any statement until the day of the first court appearance on 24th July 2018. This continued to be confirmed as the approach at a strategy meeting on 12th July and the school arranged its own communications to the school community based on this assurance. Then, on 18th July, the school was advised directly by Thames Valley Police Communications Department that their press release would go out the next day. The school queried this and were told by the police officer in 28 DfE (2018) Keeping Children Safe in Education Paragraph 234 FINAL 13.1.20 Page 49 of 112 Official charge of the case that he had not been aware of the police’s obligation to supply a press release so press could attend court if they wished. The police press office did agree to delay the release by 24 hours but from the school’s perspective this still gave them only limited time to finalise their own communications to ensure the school community was advised prior to the police press release. The school submission to this review notes that the member of staff appears to have been told by the police that the timing of their press release was forced by the school’s decision to write to their community (when the opposite was true). When the police did issue the press release this erroneously referred to the date of charge as 19th July (rather than 22nd June). At this point the school were able to write and advise all current and past pupils about the member of staff’s pending court appearance and one letter was drafted to current parents and another to past pupils. Again, this shows the difficulties in drafting communication that is sensitive to everyone’s needs. More than one survivor of previous abuse at the school took issue with the reference in the letter that was sent to current parents which stated that the member of staff had informed the school that he was obtaining professional support for mental ill health which had led him to act out of character and to his subsequent arrest. The intention behind the communication was positive as the school wished to be open and proactive in communicating with their community. However, with hindsight this was not a good choice of words, as to survivors of abuse, or to other members of the community, this phrase is interpreted as diminishing or excusing his actions. This captures the difficulties faced by schools when communicating on such matters as different sections of the community have different expectations and needs for information. Many current pupils, staff and parents sought some explanation from the member of staff for his actions: the school prohibited him from writing to his students and their parents but included this explanation instead. Communicating to the different needs of different sections of the community on matters of sexual abuse is almost impossible for schools to balance. Survivors of abuse could be a useful resource for schools in helping them to understand the impact of abuse over time and how this should underpin current communication strategies. Following the conviction of this member of staff, although the school had informed both the Disclosure and Barring Service and the Teaching Regulation Agency, his name did not appear on the barred list for seven months after he pleaded guilty and at this point he had not been prohibited from teaching by the Teaching Regulation Agency. This is discussed further in section Thirteen of this report. IMPROVING PRACTICE - THE SCHOOL’S RESPONSE Once it became clear in 2014 that past safeguarding practice at the school had failed pupils, the governors and senior management team undertook an extensive review of current processes and procedures. A timeline of these reviews integrated with other external inspections is set out in Appendix 9 and details of those reviews commissioned specifically by the school and their response in Appendix 10. The internally commissioned reviews covered all aspects of safeguarding practice including health provision and show FINAL 13.1.20 Page 50 of 112 Official that the school took what had happened seriously and have resulted in a range of improvements; some of which were designed to make sure that the school was totally compliant with statutory guidance and others derived from a wish to move beyond compliance to excellence in safeguarding practice. The evidence seen by the lead reviewers shows the enormous amount of energy and resources that were committed by the school to this process. This section of the report cannot explain and comment on all the practice developments that have been made but concentrates on those areas where developments address the issues that have been identified through information gathered for this review. In 2013 a review of boarding policies and practices was conducted, and a number of changes were implemented. Some of these changes reflect specific issues relating to the boarding environment with the need to make sure that there was sufficient oversight by staff outside the boarding house. There were changes to the location of staff accommodation, boarding house staff were to no longer act as pastoral tutors to pupils, increased staffing to increase mutual and increased oversight from senior managers and governors. Although not driven by all the information that is now available from ex-pupils via this serious case review, the changes in 2013 respond to the concerns of ex-pupils who had been boarders in the 1970s and 1980s who told the review of blurred boundaries between staff and pupils and the problem of the location of staff accommodation within the house. Other responses included an updated code of conduct (which is clearly linked to principles and values which put the safety of children first) and an alcohol policy as well as increased staff training. The focus on expected staff standards of practice within the code of conduct is important as this should give all staff the confidence to challenge colleagues whose behaviour is outside the code. This previous lack of confidence to challenge colleagues has been commented on elsewhere in this report. In 2014 the school commissioned an unannounced independent safeguarding review by a leading firm of solicitors with expertise in compliance in independent schools. This found the school to be compliant but recommended changes in the formatting of the single central register, amendments to staff information posters and job descriptions. These changes were immediately implemented. The single central register has been seen by the lead reviewers and is now an extremely comprehensive document which covers all aspects of pre-appointment checking. Also in 2014, the school commissioned Graham Badman to carry out a comprehensive independent review of the safeguarding policies, procedures and culture of the school, and to make recommendations to enable the school to develop and improve practice. The report published in 2015 noted that the school was fully compliant with statutory requirements and made recommendations for the Governing Body to enable the school to move beyond compliance to excellence. The report noted mistrust underpinning the relationship between the school and local authority, mainly due to disagreements with previous LADOs and recommended that four specific concerns from the local authority should be reviewed by the governing body. These were subsequently addressed in the school’s action plan. During the review the LSCB chair met with the school and the review FINAL 13.1.20 Page 51 of 112 Official team and was noted to be helpful in offering support and suggestions, asking for a meeting to review progress in due course. The report by Graham Badman is available from the school 29 and further details of significant actions and recommendations can be found in Appendix 10 of this report. It was as a result of the Badman review that a safeguarding coordinator was appointed, working across both junior and senior schools and the quality of safeguarding audits by the governing body was improved. These now provide effective scrutiny and the governing body is now appropriately involved in overseeing the quality of safeguarding practice within the school. It was also following the Badman review that changes were made to the operation of the Christian Union within the school. This is significant in relation to this serious case review as the Christian Union was mentioned by several ex-pupils, with some seeing it a force for good whereas others were concerned about the degree of oversight provided, particularly on residential activities. One past parent told the review that she was aware that her son was uncomfortable in the Christian Union in the 1990’s but although he mentioned this to his tutor, those running the union were popular so a complaint would seem to be disloyal. Both residential and non-residential activities were run by ex-pupils operating through a registered charity, called the “Pauline Meetings”, the school was not directly involved in the administration and running of the organisation and the charity operated within its own safeguarding procedures. It is not clear how transparent this arrangement was to pupils and parents who may have expected that the school were responsible for safety standards. In 2014, the school revisited the historic arrangements and determined that it would be clearer, safer and better for the school to take over the safeguarding and organisational functions of all of the activities of the Christian Union, to ensure absolute transparency of arrangements and quality assurance of safeguarding procedures. All activities were brought under the school’s educational visits policy and procedures, and are led by staff employed by the school, supported by the ex- pupil volunteers. This arrangement means that the school has oversight of all activities and is responsible for the standards of safeguarding practice. Lines of accountability for both parents and pupils are therefore much clearer. In order to respond to concerns that staff had not always felt able to speak about any worries they may have about the behaviour of a colleague and to give staff an opportunity to inform the safeguarding lead about any actions they may have taken that could be misinterpreted, a process of neutral reporting has been introduced. The school policy notes that the purpose of neutral reporting is to protect both pupils and the staff working with them and allows a system for a simple record to be kept in case events are later referred to or any patterns emerge. It is important that this is a neutral act with no detriment or stigma associated with making the report. Discussions with staff members confirmed that the possibility of neutral reporting is well embedded in the minds of staff although the examples given of where this had been used related to notifying about their own behaviour rather than others: for example, finding themselves alone with a pupil after 29 https://www.stpaulsschool.org.uk/safeguarding-pupil-welfare FINAL 13.1.20 Page 52 of 112 Official a drama rehearsal. This innovative system which may be of interest to other schools would benefit from a formal evaluation in order that learning about the benefits and areas for improvement in this the system could be disseminated more widely. The other important area that was highlighted from consideration of past abuse incidents was the need to have in place a culture and systems which supported pupils to report any concerns about the behaviour of others. A review of safeguarding practice at the school carried out by Barnardo’s in 2017 sets out a range of methods whereby the school had developed a culture of listening to pupils. It noted: the pupils consulted stated that they feel well supported and appreciated the many talks given to them about keeping safe. They clearly knew who to talk to or what to do if they felt unsafe and named a range of people they could talk to or methods through which they could report concerns e.g. Heads of Year, Form Tutor, welfare boxes. One case study examined for this serious case review noted that in 2013 there was evidence that pupils were more open about reporting abuse to the Designated Safeguarding Lead and it is also of interest that they did so after attending a level 1 safeguarding session. Training pupils to understand what safeguarding means would seem in this instance to have had a positive effect. There is a difference between the junior and senior school in respect of the way they can report concerns about staff or pupil behaviours. In the junior school pupils have access to an online platform called Toottoot which enables them to report any concerns anonymously. Reported concerns usually go direct to the pupils’ head of year who will investigate the matter. This system relies on the head of year reporting any concerns that might relate to inappropriate staff conduct to the head teacher who would be in a position to identify serious concerns of patterns of behaviour that need attention. In the senior school ‘Anything to Say’ (A2S) is a group of pupils devoted to listening to what other pupils have to say about any matter relating to life at school or outside it and answering any questions pupils might have. Emails received by the service are immediately passed to A2S anonymously and responded to within one day. Only the member of staff in charge will be able to see the sender's e-mail address and submissions remain completely confidential, except where the member of staff in charge thinks that there is considerable, immediate risk to the sender or those around him. In that case, the member of staff in charge may intervene to ensure the safety of the sender and those around him, following the safeguarding and child protection procedures of the school. This system does not have the features of an anonymous reporting system that would enable senior managers to see and respond to patterns of complaints and this is discussed further in Finding Six. A further investigation commissioned by the school in December 2014 was carried out by Jonathan Laidlaw QC (the Laidlaw report)30. This focused on the way that the school had handled complaints parents had made about the treatment of their son in 2005–07 and again in 2011 and 2013. Their son had taken his own life as a young adult and from the perspective of the parents concerned, the Laidlaw report was only commissioned after considerable pressure from themselves supported by another parent and ex-pupil. The school confirm that representations were made, but the governors concluded 30 Further details of investigation are set out in Appendix 10 of this report. FINAL 13.1.20 Page 53 of 112 Official separately that this parental complaint from the mid-2000s must be independently reviewed once police clearance had been received. Following consideration of the details of the Laidlaw report, the senior management team decided to adjust the content of the compulsory safeguarding training for all staff to place special emphasis on spotting and reporting possible signs of inappropriate or odd behaviour that might lead to or indicate possible physical, emotional or sexual abuse, and how to report any such concerns. With the agreement of the family an annual lecture series on mental health was inaugurated in the name of their son and there has been an increased emphasis on promoting positive mental health within the school. The report by Barnardo’s into the effectiveness of safeguarding practice commented that the mental health and wellbeing of pupils is high on the school’s agenda. THE RESPONSE OF THE WIDER SAFEGUARDING SYSTEM TO ABUSE ALLEGATIONS The Local Authority The LADO plays a key role where allegations have been made about a member of staff within a school. The national requirement for local authorities to appoint a designated officer (LADO) to manage allegations against adults who work with children was first set out in statutory guidance in 200631 reiterated in 201032 and further developed in guidance issued in 201333. At the point of first contact with St Paul’s in 2013, Richmond Children’s Services did not have a dedicated LADO role or team and the officer concerned also had responsibility for chairing child protection conferences. It was within this context that St Paul’s experienced the LADO as tardy in producing minutes of meetings and highlighted the need for an adequately resourced LADO service. This is now in place. Also, in 2013, there was no expectation within Richmond that children’s social workers would routinely attend allegations management meetings. This meant that consideration of whether there should be child protection enquiries under section 4734 planning for any such enquiries or support that might be provided by social workers for pupils could not take place at that meeting. Again, this is now routine practice. The details of the disagreement in 2013-14 between the school and the LADO as to whether a referral should be made to the Disclosure and Barring Service is set out in paragraphs 8.42-8.48 of this report. The sequence of events contributed to a deterioration in the relationship between the LADO and St Paul’s. The school experienced late arrival of meeting minutes and when they did arrive felt them to be inaccurate; these issues were 31 HM Government (2006) Working Together to Safeguard Children Page 152 32 HM Government (2010) Working Together to Safeguard Children Page 200 33 HM Government (2013) Working Together to Safeguard Children Page 48 34 Section 47 Children Act 1989 requires the Local Authority to undertake enquiries when they have reasonable cause to suspect that a child (who lives or is found in their area) is suffering or is likely to suffer significant harm. FINAL 13.1.20 Page 54 of 112 Official raised by the school with the LADO’s manager. The LADO has told the review that he checked the minutes with the police officers concerned and they were satisfied that they were accurate. Whilst it is not possible to comment on the accuracy of minutes it is clear that the administration of meetings was poor, and this seems to be a result of a LADO service which was structurally unfit for purpose at that time35. The Department of Education were informed in 2013 of concerns about the school’s practice by Ofsted who had been contacted by the LADO who, at the request of the Department for Education shared two sets of strategy meeting minutes. This triggered the emergency inspection in 2014. The school was informed of the referral to the Department for Education but have told this review they were not informed of the reasons or the procedures being followed, and the LADO “declined to explain the process” or to engage in any discussion about it. From the perspective of the school this caused the relationship between the LADO and the school to deteriorate. The lead reviewers have spoken to the LADO believe that he did explain the process however it is clear that full transparency in such situations should always be expected practice.” The issue of when a LADO should refer to the Teaching Regulation Agency (which is now responsible for the regulation of teachers) is discussed in Section Thirteen of this report. Police investigations Children will be best protected in the future where the criminal justice system works fairly and efficiently to bring perpetrators to justice. In this case police investigations meant that six perpetrators have now been convicted. Most of the people who had contact with the police and contributed to this review spoke very positively of their experience. Those who made allegations felt that they were always listened to and the police acted professionally. However, there are a number of specific issues that have come to light that need to be considered as areas where practice may be improved both in relation to specific police practice and the wider criminal justice system. In 2013, the LADO felt that the local police child abuse investigation team was operating a high threshold, and this had led to no further action at that time in the case of one allegation. A subsequent review of the case in 2014 acknowledged this and a police investigation initiated. It is possible that pupils who made the original allegation would have been more forthcoming had they been interviewed at the time rather than some months later. One ex-pupil raised the issue of an investigation in 2001 where an alleged perpetrator was also a member of the clergy. He felt that there was a delay in the investigation due to liaison between the police and church authorities and the church may not have responded appropriately to the potential risks. Although the ex-pupil clearly recalls being told that Lambeth Palace had been contacted, there is nothing in the police records about this and the Church of England National Safeguarding Team have confirmed to the review that there are no records of this incident have been found in Church of England files. This begs 35 From 2014 there was a restructuring of the LADO service in order to address these problems. FINAL 13.1.20 Page 55 of 112 Official the question of whether the police did liaise with the church and if they did, whether this was properly considered and recorded. Similarly, there is no record in the church of the member of staff (referred to in paragraph 8.33) who was a member of the clergy leaving his position at the school as a result of alcohol misuse. One of the cases that reached the stage of criminal court, was recorded as not guilty due to the poor mental health of one of the complainants. This meant that he could not give evidence. Since abuse survivors may well have emotional or mental health difficulties it is important that our system does all it can to support them in giving evidence and although is particularly relevant to adult survivors, it is also important in keeping children safe from perpetrators of abuse. Currently there are schemes to support children, but adults in this position are signposted by the police via a leaflet to voluntary organisations where there may not be specialist help or services may be stretched. A more consistent service needs to be in place if justice is to be achieved. Although police investigations generally stop when a verdict is reached at court, the management of a not guilty verdict requires sensitivity particularly towards the complainant. The Crown Prosecution Service had authorised a charge against one such teacher. The fact that a charge had been brought meant that the decision had been made that there was sufficient evidence for a realistic prospect of conviction and that prosecution was in the public interest. Following the not guilty verdict by a jury the complainant who lives out of the UK was informed by a telephone call from a police officer and the words he recalls hearing were “you were not believed”. Although these words are likely to have been part of a longer explanation, and, from the police and Crown Prosecution Service perspective, they had felt there was sufficient evidence to present to a court, these words have stayed with the complainant and caused considerable distress. In this case the distance involved made a more personal approach difficult, but it serves as a reminder that thought needs to be given as to how our system can adequately provide support to complainant pre and post-verdict, whether the verdict is guilty or not. In this case there have been some specific lessons for the police as a result of some criticisms made by the judge. These were not a formal complaint but resulted in an internal investigation by the Metropolitan Police. One issue raised by the judge was whether an officer introducing themselves as from the “paedophile unit” was appropriate. Although the name of this unit has now changed this was the official name at that time and it is the view of the senior officer who undertook the internal police investigation that the officer was not wrong to use this terminology as it is hard to see how an officer can introduce themselves by anything other than the organisational name of their team. Another concern within this trial was the way in which intimate photographs had been taken and whether it had been necessary for the alleged perpetrator to have been detained by the police overnight. The internal investigation found that these were areas where police practice could have been improved. The allegation in this case was made by one pupil and relates to two incidents one when he was at Colet Court and another particularly serious incident which was alleged to have taken place at the member of staff’s home when he was in the senior school. The alleged victim told the review he told friends about the first incident and following complaints from FINAL 13.1.20 Page 56 of 112 Official other parents about his sexually precocious behaviour, he was moved up into the senior school a year early without taking the common entrance exam. Staff have told this review that this would have been unheard of at the time, but confirmation that this happened has now been found within the alleged victim’s school records. A report within the record comments that this pupil was ‘kicked upstairs’ from Colet Court six months ahead of his time in an unprecedented way because he had outgrown local rules. The pupil explained to us that he told police on more than one occasion the causal link between being sexually abused and being moved up a year, but when the police prepared his witness statement the only recorded reason was as his academic ability. There is nothing in the school record to suggest that academic ability was the reason. Police statements are written by the investigating police officer using the verbal information given by the complainant and in this case, the significance of the information about moving up a year early seems to have been missed. It has not been possible to speak to the officer concerned to understand the police view and whether it was considered relevant evidence in the case. One issue in relation to the police approach is the challenge faced by police in achieving a balanced approach in complex investigations. In 2014 when the investigation took place, the guidance to police officers was that first and foremost they should believe the complainant. This approach, may have been behind some of the concerns of the judge about the investigation but the information gathered from this serious case review (outlined above) would point to a complex picture where some evidence supporting the complainant’s account was not given sufficient weight and other aspects of the police investigation such as the manner in which the alleged perpetrator was treated following arrest (for example the procedures that should have been followed when taking intimate photos) were not of a sufficiently high standard. The guidance to police regarding their approach to complainants in sexual abuse cases is now different, with an expectation that investigators will take an approach which respects the complainant’s information and is also open to all possible explanations. Achieving this requires effective support and supervision of those in the front line who will be subject to conflicting and emotional responses and need the opportunity to reflect on day to day practice. Current supervisory documentation provides a valuable checklist for the supervisors of child abuse investigations, but it does not include any reference to the need for emotional support, exploring unconscious biases and the emotional responses that may have an impact on officers and their decision making. The involvement of out of school settings One issue that has emerged from consideration of the case studies is the link between several of these staff to other activities outside school, such as holiday clubs and other voluntary residential activities. Some staff against whom allegations had been made, worked outside school for such organisations and it is concerning that in 2013 when the LADO contacted a faith based residential holiday organisation where an alleged perpetrator worked he felt that they were “not interested” in hearing about the allegations of grooming activity that had been investigated by the police. On another occasion notes from meetings record there was an appropriate response from an Educational Cruise Company when they were informed of allegations against a member of staff. FINAL 13.1.20 Page 57 of 112 Official It is to be hoped that action following the Government consultation on a code of practice for safeguarding children in out of school settings36 may address some of the weaknesses in this aspect of safeguarding practice. The link between these settings and the LADO needs to be strengthened with an expectation of information sharing and participation in any inquiries involving staff and volunteers. Managing Complex Investigations Complex abuse is described in the current London Child Protection Procedures37 as: …abuse involving one or more abusers and a number of related or non-related abused children and may take place in any setting. The adults concerned may be acting in concert to abuse children, sometimes acting in isolation or may be using an institutional framework or position of authority such as a teacher, coach, faith group leader or be in a celebrity position to access and recruit children for abuse. …The complexity is heightened where, as in historical cases, the alleged victims are no longer living in the setting where the incidents occurred or where the alleged perpetrators are also no longer linked to the setting or employment role. These will all need to be taken into consideration when working with a child or adult victim. …..Where the Strategy Discussion confirms that the investigation will relate to complex and organised abuse, it will appoint a multi-agency Strategic Management Group ….The Strategic Management Group should be chaired by a senior manager from children’s social care38. Using the above definition, the investigations into allegations of abuse at St Paul’s fell into this category. It should be noted that it is only since February 2014 that Children’s Social Care is expected to chair strategic management group meetings and before that date the procedures stated that the meeting should be chaired by the police (or rarely by local authority Children’s Social Care). Consequently, at the point that the need for a strategic management group was being considered the expectation that Children’s Social Care would take the lead and chair the meeting was relatively new. In December 2014, following discussions with partner agencies, the Professional Advisor to the LSCB raised the need for a strategic approach via e-mails to the Senior Investigating Officer in Operation Winthorpe. The senior investigating officer agreed to chair the meetings; terms of reference were prepared by the professional advisor to the Local Safeguarding Children Board and are set out in Appendix 8 of this report. One meeting took place in early 2015 with an agreement that the group would meet every two-three months until the end of the last trial. 36 Department for Education (2018) Out of School Settings a voluntary safeguarding code of practice. Government Consultation 37 http://www.londoncp.co.uk/chapters/organised_complex.html 38 It should be noted that in 2014 when the abuse first came to light procedures allowed for the meeting to chaired either by the police or Children’s Social Care. FINAL 13.1.20 Page 58 of 112 Official Meetings did take place although continuity and regularity were hampered by changes in senior police personnel and it is unclear how far the group fulfilled all the requirements of the terms of reference. For example, although the terms of reference required identification and liaison with relevant LSCBs and their local agencies, there is no evidence of this happening in respect of the management of an investigation where the arrest took place outside the Metropolitan Police area. Minutes have been obtained from the LADO meetings in the area where the previous member of staff was working and was arrested which contain worrying information. At the first meeting the Richmond LADO had sent apologies and the investigating police officer gave information about the member of staff’s behaviour at the time of arrest and during interview. This described a member of staff who would be totally unsuitable to work with young people. These minutes also contain information from the police statement that when this member of staff was working at St Paul’s in the 1980’s other pupils from St Paul’s would visit the member of staff’s house for counselling and that the school encouraged 1:1 time socialising with pupils outside and within their homes. The second meeting took place at the point that the CPS had decided to charge the member of staff with two offences of gross indecency and three indecent assaults over two incidents. The member of staff remained suspended and their post had been made redundant. At the meeting it was acknowledged that this could lead to them slipping though the net as regards to the Disclosure and Barring Service but. health problems were noted and the unlikelihood that they would be seeking employment elsewhere. Information from the LADO in the area where the teacher resided is clear that there would have been no consideration of referring to NCTL (who were at that time responsible for teaching regulation) unless found guilty. This does not seem to have been a joint decision with the Richmond LADO which would have been appropriate given that the alleged offences were against an ex St Paul’s pupil. This case should have prompted a planned approach to communication between the police investigating team and the Richmond LADO and clarity regarding roles and responsibilities for informing other agencies such as those responsible for teaching regulation. It would also have been appropriate for the Richmond LADO to explore with the school the implications of pupil’s visiting staff homes and determine whether this could still be current practice. This might have been more likely had Children’s Social Care been chairing the meetings. Issues relating to teaching regulation are discussed further in paragraphs 13.19-23 of this report. Part of the problem in developing a strategic approach to management seems to lay in the split between non-recent allegations of abuse at the school being investigated by the Police via Operation Winthorpe, and those current investigations into staff who were still working at the school. The later investigations were led by the local police Child Abuse Investigation Team. Where the member of staff was still employed by the school, the local LADO (and therefore Children’s Social Care) were aware, but they would not have known of the totality of police activity relating to non-recent incidents at the school. The school were certainly not fully aware of all the police investigative activity. The result of this lack of effective strategic management meant that there was no coordinated approach to working with the school on a communication strategy. One of the FINAL 13.1.20 Page 59 of 112 Official tasks of the strategic management group set out in the London Child Protection Procedures is to…. ensure that appropriate resources are available to meet the needs of the children and families or adult survivors, including any specific health issues arising from the abuse. Working with the school to develop an approach which provided information and support to those who had made allegations as well as the whole school community might have prevented some of the disquiet amongst the group of ex-pupils who had been affected. What seems to have happened is that the development of the police structure for managing complex investigations had not been sufficiently well aligned with safeguarding procedures. The Police system for the management of complex operations involves a clearly defined structure led by Gold, Silver and Bronze Commanders. Gold groups were first introduced in 2000 and Gold commanders will lead a group focused on overall strategy. Silver commanders will coordinate tactical activities and Bronze commanders control resources and actions at incident level. What is less clear is how this dovetailed with an overall multi -agency approach to the child abuse investigations that were linked to St Paul’s School. There was little apparent planning for the involvement of social work advice and expertise which could have focused on ensuring the needs of families and adult survivors was met. There is a current need for procedures to provide clarity about the interface of the police command structures via Gold, Silver and Bronze groups and the multi-agency strategic management of complex safeguarding inquiries. Gold groups are mentioned within the London Child Protection Procedures (8.2.5) but their role vis a vis the multi-agency network remains unclear. Children’s Social Care are now expected to chair strategic management meetings for complex abuse inquiries which does clarify the importance of an approach that encapsulates maintaining the integrity of criminal investigations alongside the needs of the wider community. This should now be taken further with an integrated approach which is understood by all. ST PAUL’S, THE LSCB AND RELATIONSHIPS WITH OTHER STATUTORY BODIES. The LSCB When the terms of reference for this review were being agreed, the Local Safeguarding Children Board (LSCB) chair suggested that the role of LSCB should form part of the review as although in her view there was a negative atmosphere she wanted to clarify what had happened to bring about such a difficult relationship. St Paul’s were also keen that the review should examine the relationship between the school and the Local Safeguarding Children Board (LSCB). The picture that has emerged is a complex one influenced by several factors which are expanded upon below: ➢ A confusion of roles and responsibilities, with the school expecting more support from the LSCB than was within the LSCB’s remit; ➢ A different perspective between the school and the LSCB regarding the quality of the relationship between them from 2013 onwards: the depth of concerns within the school were not apparent to the chair of the LSCB; FINAL 13.1.20 Page 60 of 112 Official ➢ Clash of cultures and diametrically opposed communication styles; ➢ Relationships within the LSCB. Confusion of roles and responsibilities – support to schools From the school’s perspective, by early 2017 trust in the LSCB had been eroded by a series of events which they believed illustrated an unjust and deficit focused approach to work with the school. Also, from the time of the first allegations of non-recent abuse in 2014, the school had expected a more supportive approach from the LSCB and felt that this had not been forthcoming. They cited the support that Southbank International School had received39 following the abuse of their pupils by a member of staff and felt that they had not received this level of help. The situation at Southbank School40 was very different to St Paul’s as in that case there was a current joint police investigation and social care s.47 enquiry, not just a single agency police investigation. Consequently, a team of social workers worked alongside police colleagues and as a result there was considerable involvement by the LADO and education safeguarding lead for the local authority. At St Paul’s, there were two current investigations in 2013 managed by the local police Child Abuse Investigation Teams alongside Operation Winthorpe which was a police investigation focusing on non-recent abuse by staff who were no longer working at the school. It must be stressed that it was not the role of the LSCB to provide operational support to the school, this role should have sat with children’s services. Had there been strategic oversight of the investigations (see section ten of this report), support via the local authority could have been planned and more effectively met the school’s needs. The issue of general support and safeguarding advice to schools is not specific to this case and it has highlighted the need for local safeguarding support for schools to be readily available beyond the statutory LADO requirements and for these arrangements promoted across the education sector. Some local authorities have retained a senior officer with the role of safeguarding lead for education who provides a free service to both independent and maintained schools, and in other areas financial restraints have meant that this role no longer exists. Arrangements within Richmond and Kingston (delivered by Achieving for Children) do not include a free service to independent schools but independent schools in the area are able to buy advice from an online safeguarding advisor and since September 2016 a social work qualified education safeguarding advisor or an online safeguarding advisor. This service was not widely advertised but is now promoted through the regular designated safeguarding lead networks for independent schools. St Paul’s only became aware of and used the service of the online advisor after safeguarding issues emerged in 2014. In addition, in 2016, the LSCB appointed a 14hour per week term time education coordinator to provide free liaison with maintained and independent schools. 39 Hammersmith & Fulham, Kensington and Chelsea and Westminster LSCB (2016) Serious Case Review: Southbank International School. https://www.rbkc.gov.uk/pdf/Southbank%20SCR%20REPORT%2012%201%2016.pdf 40 The author and chair of this review were also author and chair of the Southbank review: any information set out in this report regarding Southbank School is already in the public domain. FINAL 13.1.20 Page 61 of 112 Official Relationships over time – differing perspectives From the perspective of the LSCB, they had tried to forge a close and supportive working relationship with the school and believed that they had done so, with the designated safeguarding lead from the school becoming a member of the LSCB representing independent schools and being asked to chair the independent school’s forum set up by the LSCB. The school’s submission to the review is less positive with a view that there had been an historic failure to provide support to independent schools in the Borough and a belief that there had been insufficient support following Operation Winthorpe. The Board chair was unaware of these issues at the time and there is no indication that they were raised directly with her. Communication and collaboration The LSCB’s prime role was to work with the school in scrutinising and ensuring good safeguarding practice. The LSCB needed to be assured that the school had learnt lessons from their knowledge of past abuse and that the current safeguarding culture and systems were meeting the needs of pupils. As a part of this process the serious case review sub-group asked the professional advisor to the LSCB to compile a report outlining what was known about both non-recent abuse and current allegations so as to assist them in making any recommendations about next steps including whether the threshold was met for a serious case review. In a spirit of collaboration, the plan was for this to be a shared joint report with the school. This was a reasonable course of action, but the school have told the review that communication with the school from the professional advisor at this point was not clear in respect of the purpose of the report. The LSCB chair has a different recollection and believes that the purpose of the report was discussed with the school. When a draft of the advisor’s report was shared with the school they were concerned about several inaccuracies and although discussions took place to try and agree a final draft, the school became increasingly unhappy about the unwillingness of the author to recognise their concerns and make all the changes asked for. From the perspective of the LSCB reasonable amendments were made but it became clear that an agreement could not be reached and in order to reduce conflict with the school the professional advisor and LSCB chair agreed that no report would be presented to the sub-group and the school would be asked to make their own presentation; which they did. The unintended consequence of this attempted collaborative approach was a breakdown in the relationship between the LSCB and the school. Both parties contributed to this breakdown. Communications from the LSCB at times lacked clarity and were not always prompt but answering correspondence which was usually several pages long about matters that the Board chair believed had been resolved in face to face meetings was a time-consuming process. The LSCB in Richmond was judged by Ofsted to be good in December 201741 , the chair was very experienced and found this a challenging and unusual situation to manage. 41 Ofsted (December 2017) Review of the effectiveness of the Local Safeguarding Children Board FINAL 13.1.20 Page 62 of 112 Official Correspondence between the school and the LSCB in 2013 and again 2017 is another example of a negative communication pattern. The school raised concerns about the policies on the LSCBs website being out of date. Whilst the tone of communications could be considered as wanting to apportion blame the lack of prompt response from the LSCB to the school was also not helpful. In both instances the lack of constructive dialogue, with each party showing little understanding of the other’s point of view is an indication of the deep-rooted distrust between them. The style of communication between the school and partners is unusual in a multi-agency safeguarding environment. It comes across as combative and more appropriate to intellectual debate than an attempt to understand the others’ point of view and reach a mutually satisfactory agreement. Although this may not be the school’s intention, it serves to highlight the importance of relationships where open honest dialogue and constructive challenge can take place. The overarching picture is of a clash of cultures and expectations between the school and specific staff in the LSCB and some misunderstandings about the various roles and responsibilities of the LSCB, the LADO and Children’s Social Care. The significant breakdown in the relationship between the LSCB and the school became apparent to the LSCB from the autumn of 2016 onwards when they began to review information in order to determine whether a serious case review should take place. The school agrees that the relationship broke down in the autumn of 2016, but attributes this to the LSCB’s lack of transparency about the process it was following and their concern about factual inaccuracies in the LSCB’s initial draft report. Relationships within the LSCB The management of the quality assurance of the health arrangements is an example of where any tensions within the safeguarding partnership can result in lack of effectiveness in challenging external organisations and holding them to account. The LSCB and Health partners did not manage the quality assurance of health arrangements at the school well (discussed in paragraphs 12.14-12.21 below) and some of the difficulties stemmed from, and, resulted in lack of confidence in the professional advisor by health professionals. The full detail of these concerns is not relevant to this review report, but it is of concern that the Designated Doctor has told the review that concerns were raised about the professional advisor’s conduct with senior leaders in the local authority and the Chair of the LSCB but this was not resolved to the satisfaction of the Designated Doctor. This lack of constructive dialogue and communication between partners resulted in a poor response to the school undermined a focus on scrutinising and challenging safeguarding practice. Developing more effective communication and trust must be a priority in the newly developing safeguarding partnerships. Other Statutory Bodies Although the new High Master in 2011 had begun a process of improving safeguarding arrangements and making sure that they were in line with modern practice, managing the specific allegations in 2013 was the first time that these procedures had been tested. The FINAL 13.1.20 Page 63 of 112 Official overriding impression at this stage is of a situation where a school was not used to external scrutiny and there were no pre-existing relationships that allowed both parties to navigate their way through differing perspectives on what action should be taken. From the outside St Paul’s is perceived as a powerful institution, used to being in charge and in fact some of the ex-pupils who contributed to this review spoke of still being frightened by the power of the school. There are important general lessons here for working together across the independent and public sectors. There may be a perception by independent schools that statutory bodies have a prejudice against them, and by statutory bodies that independent schools are powerful and bastions of privilege. The potential for these biases needs to be acknowledged and time taken to develop and build positive working relationships before a crisis develops. Where relationships break down the means of resolving this needs to be clear rather than positions becoming polarised and a loss of focus on what really matters; good effective safeguarding practice. As the extent of non-recent abuse became public, St Paul’s describe feeling “under siege”, managing an inquiry by the Charity Commission, and an emergency inspection by the Independent Schools Inspectorate and interest from the national press. Communications from the school to statutory bodies during this period came across as defensive and adversarial. For example, the Chair of Governors sent a strong letter to the Charity Commission querying whether the threshold for a statutory s46 inquiry had been reached (although the school now accept that it had) and then queried the scope and process of the inquiry itself. The school argued that the Commission’s initial letter was unclear about whether this was an investigation into the historic abuse concerns or current arrangements and was unclear about the scope of the inquiry. The school also entered into extensive dialogue with the Department for Education regarding the definition of a “serious failing” which was the phrase the Department had used in their letter to the school dated 7th April 2014. The school asked the Department to define what constituted a serious failing and to confirm if internal threshold or guidance existed for the Department for Education on this point. The school remain concerned that there is no published criteria and this issue is discussed further in paragraph 13.16 of this report. From a consideration of the information submitted to the review from all relevant agencies, it is easy to see why the impression was of an organisation focused on managing their reputation rather than engaging in a dialogue focused on learning. The school strongly refute this assertion and argue that the Charity Commission and Department for Education were challenged privately and out of the public eye. In their view the grounds for challenge were entirely legitimate but they do now accept that the timing and tone were wrong. It is the issue of tone and quality of communications within a multi-agency environment that is a point of learning for all involved with more consideration given as to how communications will be perceived and understood by those to whom they are directed. THE HEALTH SYSTEM AND SAFEGUARDING IN SCHOOLS Health practitioners are key members of the safeguarding system and where a school has boarding facilities the role of members of the health team are particularly significant. In the case of St Paul’s, this team consists of a matron in the boarding house, school nurses, a FINAL 13.1.20 Page 64 of 112 Official GP and school counsellors. Not all provision is full time with the GP working 5 hours per week and the school counselling service providing 3.5 hours per week at the junior school and up to 17 sessions per week (of 35 mins) at the senior school. The national context for this team is that individuals are accountable to their own professional bodies. Alongside this the local Clinical Commissioning Group commissions the health safeguarding team which consists of a Designated Doctor, a Designated Nurse and a Named GP: only the Designated Nurse works full time in this role. These designated safeguarding professionals have a responsibility for effective clinical, professional and strategic leadership for child safeguarding within the health economy and this includes assisting and facilitating the development of quality assurance systems. Statutory guidance42 also makes it clear that this applies to private healthcare and independent providers of health. The review has heard that during 2015-17 the health safeguarding team in Richmond was experiencing some challenges, primarily relating to confusion around role, responsibilities and lines of accountability and there were difficulties in relationships between team members which resulted in poor communication and planning of responses. This became particularly relevant in relation to a safeguarding assurance visit to the school in September 2016 which is discussed further in paragraphs 12.15-12.21 below. School nursing In 2016 the school carried out a comprehensive review of the service with the intention of strengthening the provision, particularly in respect of the school nursing service. This included the creation of a new Head Nurse to ensure proper accountability and line management, and adherence to new safeguarding policies. The review and changes in working conditions resulted in the loss of several experienced school nurses who had been at the school many years. Their views about the way in which the changes were managed by the current senior leadership team is described below but in addition they have helped this review to understand previous safeguarding cultures in the school described elsewhere in this report. It is the view of nurses that the changes to the service following the review were not handled well. They felt that their experience was not valued, and that the culture within the senior leadership team was defensive, intimidating and policy driven. This perspective is disputed by the school although the communication style described by the school nurses is similar to that described by some of the other contributors to this review (see paragraphs 11.7-11.11). The school’s perspective is that proper procedures were followed, and all four nurses were offered employment within the new structure, which they declined. The focus is now on building a team in line with the expectations of a modern school nursing service. There is every reason to believe that this team will provide a positive contribution to the overall safeguarding environment within the school. 42 Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff: Intercollegiate Document (2019) Page 84 FINAL 13.1.20 Page 65 of 112 Official GP Provision GP provision at the school is provided by a practitioner whose own GP practice is in a neighbouring Borough. All boarders are registered with the school’s GP and provision of a service to those pupils is the priority. In practice, because there are a small number of boarders whose medical needs tend to be limited, most of the GPs time is taken up with other pupils’ needs, particularly responding to sports injuries. They also provide consultation to staff if time permits. The role of the GP in the safeguarding system within the school is constrained by the hours available and the complexity of working in a school where many day pupils come from outside the Borough and even boarders are likely to be also registered with a GP elsewhere. There are additional issues relating to provision of safeguarding advice from the local partnership. GPs would normally seek safeguarding advice from the Named GP in their local area and in this case, it is unclear whether the GP would seek this from the Richmond Named GP or from the area where their own practice resides. It is apparent that the Richmond Named GP had no professional relationship with the GP at the school believing that this was the remit of the named GP in the neighbouring Borough. This was not the understanding of colleagues in Richmond LSCB. The situation was further complicated as the quality assurance role of the Clinical Commissioning Group did not extend to scrutiny of GP provision for boarders at the school. When the GP at St Paul’s sees a day pupil there is no automatic notification to the pupil’s home GP. This is a gap in the system and if any drugs are prescribed, this is not line with General Medical Council guidance43. This gap in communication also prevents the child’s registered GP building a comprehensive picture of their medical history. Similarly, the school’s GP may not be notified of other outside medical consultations by boarders and this was of concern to the school in the case of medication (methylphenidate) prescribed to a boarder by a private paediatrician for the symptoms of ADHD. This paediatrician has reflected on their prescribing practice and the risks associated in assuming that the parent or guardian accompanying the child will automatically inform the school and ensure safe storage of medication. Where a child is seen privately by a paediatrician the referral may not come from the registered GP (unlike for NHS patients) and this raises a broader issue concerning the degree to which patients seen privately may be disadvantaged in the safeguarding system. It has also been brought to the attention of the review that there are no national guidelines from the Royal College of GPs regarding the expectations of the GP role in schools. The Counselling Service Prior to the 1980’s, when much of the abuse discussed in this report took place, there was no counselling service at the school. The school counselling service started in the 1980’s but did not feature in our discussions with ex-pupils as a place where they could go to 43 https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/sharing-information-with-colleagues FINAL 13.1.20 Page 66 of 112 Official discuss their concerns about the interactions between staff and pupils. In fact several were unaware of the service and comments were made by ex-pupils (one of whom is a recent parent) that “boys do not want to go to someone inside the school” and, “a counsellor employed by the school would be seen as part of the establishment” One of the counsellors currently working in the senior school, has been in post since 1998 and has managed only one allegation against staff. Although the service plays an important role in promoting the mental wellbeing of the pupils, the evidence would suggest that it plays a marginal role in providing a place where pupil’s discuss concerns about inappropriate or abusive behaviour by staff. This is not a criticism of the service but an issue that needs to be understood by those with responsibility for the overall safeguarding strategy within the school. Today, the school provides a counselling service for boys in both the junior and senior schools. In the senior school there are two part time counsellors offering 17 appointment slots a week and one part time counsellor in the junior school offering six-seven sessions. All are professionally registered Practitioner Psychologists. In the senior school this is a confidential service and pupils are informed that if confidentiality needs to be broken this would normally be discussed with them, but they may not be informed if doing so prevents a serious act of harm from being carried out. Contemporaneous handwritten notes are kept of each session, are kept securely in the counsellor’s office and form part of the medical record. The review team were interested to be informed by the counsellor for the junior school that they do not keep notes although the school are adamant that notes are kept and they comply with professional requirements. Further clarification was sought which explained that no handwritten notes are kept or stored on the premises but instead a brief electronic report is sent via the school email to the head of year after the initial assessment and, if applicable, at the end of treatment. This report is minimal with a brief outline of the presenting problem and a treatment plan. This report is stored on the pupil’s welfare notes. This practice would fulfil the requirements of the professional standards for psychologists44 which simply require that the practitioner should keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines; although how far such a record is comprehensive could be debated. The review has been told that this is different from the system in the senior school because of the maturity levels of pupils and different levels of confidentiality; the junior system involved referrals with parental knowledge, but this is not the case with all referrals in the senior school. What is less clear is how effective this system is in documenting the detail of issues that either individually or cumulatively may indicate a safeguarding concern. Quality Assurance There is a danger that non-maintained schools may sit outside the day to day systems that are there to develop and monitor the health provision for children in school. In the case of St Paul’s there is no evidence of any interaction between the school and the local health safeguarding system until after the abuse investigations from 2013 onwards. 44 https://www.hcpc-uk.org/standards/standards-of-proficiency/practitioner-psychologists/ FINAL 13.1.20 Page 67 of 112 Official A health assurance visit to the school on 30th September 2016 illustrates the misunderstandings that can occur when interaction occurs at a point of crisis rather than being the norm. It also serves to confirm the importance of healthy working relationships between members of the safeguarding partnership and the negative impact on the partnership’s ability to hold organisations to account where such relationships are not in place. The Designated Nurse had carried out a number of these audits, but it was the first time the Designated Doctor at the time, had done so as it was not usually their role. The Named GP at the time had asked to join the audit team, but it was considered that the audit did not require three safeguarding professionals to visit the school. With hindsight, the presence of the Named GP could have focused their attention on the role of the GP at the school. As a result of the audit the Named GP was asked to make contact with the school but did not do so and passed this task to the neighbouring Borough. From the perspective of the school they had thought that a visit from the Designated Doctor and Nurse in September 2016 was to follow up on the issues around concerns arising from methylphenidate prescribing by a private paediatrician. These concerns had been notified to the LSCB. In fact, there seem to be conflicting opinions as to the purpose of the visit. Three different opinions have been presented to the review and even now there is still no clear explanation as to who commissioned the audit. The three opinions are: ➢ The visit was at the request of the LSCB as part of general information gathering to inform a report on the school to be presented to the serious case review subgroup; ➢ The visit was part of a usual pattern of health safeguarding assurance visits to schools in the Borough; ➢ It was primarily to follow up and discuss prescribing practice following the concerns about methylphenidate prescriptions but, as would be usual practice, the Designated professionals took the opportunity whilst at the school to discuss various aspects of safeguarding practice, write up discussions and present them in the form of an action plan. In fact, the visit should have sat under the auspices of the Clinical Commissioning Group and, whilst the findings of the audit could be made available to the LSCB, the Designated Doctor and Nurse were not there as officers of the LSCB as was believed by the school. Nothing in communications either between the LSCB and the Designated professionals or the Designated professionals and the school made this purpose clear. The visit is described by all parties as difficult and following the visit, the school were surprised to receive a formal action plan and were unhappy about some of its content and then even more unhappy in delays in receiving any response to their e-mails from the Designated Doctor and Nurse. From the perspective of the health professionals they did not reply as the LSCB asked them not to. This is a further indication of confusion of roles and responsibilities surrounding the audit as it would have been best practice for health practitioners to own their action plan and reply to the school. The school notified the LSCB that they were considering a formal complaint to the CCG although they decided not to do so in the interest of maintaining a good working FINAL 13.1.20 Page 68 of 112 Official relationship with the LSCB. At this point the factors underlying the problems were, lack of clarity about the purpose of the audit, absence of clear communication from the health professionals, lack of any previous working relationship between Designated professionals and the school and a deteriorating relationship between the school and the LSCB regarding the production of a report for the serious case review sub group (see paragraph 11.7 of this report). From the perspective of the LSCB, the reaction of the school to the health audit was highly unusual and contributed to the view of the LSCB that this was a school who were defensive and unwilling to engage with statutory agencies. This experience highlights the need for safeguarding partnerships to direct and foster the development of relationships between relevant individuals and agencies in order to prevent avoidable relationship breakdown which will have a detrimental effect on learning and practice improvement. SAFEGUARDING CHILDREN THROUGH REGULATORY ACTIVITY As an independent school St Paul’s is now subject to statutory inspections designed to provide assurance that the required education and welfare standards are met. As a charity it is also subject to regulation by the Charity Commission, and the Teaching Regulation Agency has responsibility for the regulation of qualified teachers at the school. Much has changed since most of the known abuse at St Paul’s took place, although there are legitimate questions to ask as to how the regulatory requirements enable inspectorates and regulators to identify practices which leave children at risk, including how a school deals with allegations. Inspections, the Charity Commission and Department for Education The interaction between St Paul’s and the Charity Commission has been commented on in paragraph 8.6 above. From the perspective of the school, in 2014 they were subject to both the statutory inquiry carried out by the Charity Commission alongside an emergency inspection by the Independent Schools Inspectorate and at the time this contributed to a feeling of being “under siege”. They have questioned whether this process could have been rationalised. Under the circumstances, the need for scrutiny from two organisations was necessary as each have a different function. The Charity Commission is established by law as the regulator and registrar for charities in England and Wales and their regulatory role focuses on the charity trustees and their conduct. The Charities Act 2011 gives the Commission a statutory function to investigate concerns identified in the administration and running of a charity and in serious cases of abuse the Commission may investigate and open an inquiry. The inquiry looks at a wide range of evidence with the aim of resolving any problems and preventing further abuse. This a different focus from inspections by the Independent Schools Inspectorate who are responsible for inspections of St Paul’s School and both were necessary in this case. FINAL 13.1.20 Page 69 of 112 Official The Independent Schools Inspectorate (ISI), a not for profit organisation that is approved by the Secretary of State for Education to carry out inspections of independent schools in membership of the Associations which form the Independent Schools Council. The statutory purpose of inspections is to report to the Department for Education on the extent to which schools are meeting the Independent Schools Standards Regulations (2014). The first set of these dedicated standards was created in 2003 and were therefore not in existence for much of the time period covered by this review. Prior to 2003 Independent Schools were inspected by HM Inspectorate of Schools under the Education (Schools) Act 1992 and prior to that by the Secretary of State under the Education Act 1944. Boarding provision was inspected by various inspectorates until the Independent Schools Inspectorate assumed responsibility in 2012. Inspections take place approximately every three years and can only be a snapshot of a school’s performance at a point in time taking account of information known, and evidence gathered as part of the inspection. The Department for Education as regulator of schools, acts as a central point for gathering information for onwards transmission to other relevant bodies such as local authorities and inspectorates. ISI, however, does also receive information directly from parents, members of the public and from other agencies and any information received directly by ISI is promptly passed to the Department for Education. Historically, inspectors were heavily reliant on intelligence from the Department for Education and on the school itself disclosing any serious incidents which had occurred or come to light since the previous inspection. Practice has now developed, and ISI also contact LADOs prior to each inspection and an on-line search is completed. Where information has been received from any source, and if appropriate, ISI contacts individual agencies in order to ensure that inspectors are briefed as fully as possible in advance of the inspection. The school is also required to respond specifically to the following question: ‘Please indicate any cases where a member of staff or other person connected with the school is subject to investigation, has resigned, or has been dismissed or disciplined because of questionable conduct with children. In each case, briefly mention any referral made Disclosure and Barring Service (DBS) or the Teaching Regulation Agency (TRA) (or their predecessor bodies) since the previous ISI inspection:’ Part 6 of the Independent Schools Standards Regulations requires the proprietor to ensure that: ‘any information reasonably requested in connection with an inspection under section 109 of the 2008 Act which is required for the purposes of the inspection is provided to the body conducting the inspection and that body is given access to the school’s admission and attendance registers;’. Where it is found that a school has failed to provide such information, this standard would not be met and regulatory action could be taken by the Department for Education. Colet Court and St Paul’s School passed all independent inspections up until the emergency inspection in 2014 and there is no evidence that either school failed to inform the Independent Schools Inspectorate of any relevant information when inspections took place. In February 2014, there was an unannounced emergency inspection requested by the Department for Education following concerns raised with them by the Richmond LADO FINAL 13.1.20 Page 70 of 112 Official about the school’s handling of two allegations. Prior to the inspection being commissioned, the inspectorate had no knowledge of the allegation relating to a member of staff who had been found with inappropriate (albeit legal) images on their school computer and had been subject of a police investigation. In October 2013, they had heard about the LADO’s concerns regarding his difference of opinion with the school regarding the needs for referral to the Disclosure and Barring Service (as outlined in paragraphs 8.41-64 of this report). On receipt of this information from the LADO, the Independent Schools Inspectorate referred the concerns on to the Department for Education. The school remain concerned that although they knew that the LADO had contacted the Department for Education they had not been told of the reasons for the referral or the procedures being followed. The emergency inspection was commissioned at the end of November 2013 and took place three weeks after the start of the Spring term. This allowed for the right team to be assembled and that there was time to gather pre-inspection information and prepare thoroughly. The focus of this inspection was specifically on safeguarding, whereas the routine inspections carried out previously including the one which occurred a year earlier in March 2013 looked at all applicable standards. In contrast with earlier inspections, the team carrying out the 2014 inspection also had the benefit of contextual information from the Department for Education regarding two recent allegations which enabled them to shape the inspection accordingly. This single focus on safeguarding and the time available enabled the questioning, evidence gathering and analysis to be more focused than for the 2013 inspection. At the emergency inspection, St Paul’s and Colet Court failed the following Education (Independent School Standards) (England) Regulations 2010 (“ISSR”) standards and The National Minimum Standards for Boarding Schools January 2013 (“NMS”): ➢ ISSR 7 (safeguarding arrangements); ➢ ISSR 8 & MNS 11 (safeguarding arrangements for boarding schools); ➢ ISSR 19 (suitability of staff); ➢ ISSR 22 (central register of appointments – now known as the single central register); ➢ NMS 14.1 (safer recruitment). The advice note sent to the Department for Education clarified that ISSR 7 and NMS 11 were not met because the school’s child protection policy did not have regard to guidance issues by the Department for Education and ISSR 8 is automatically not met where there is a failure to meet any of the National Minimum Standards. Specifically, at that time: ➢ the process for reporting concerns was unclear; ➢ the policy contradicted itself in relation to the handling of allegations; ➢ reporting lines were unclear; ➢ the referral process was undermined by various “caveats and thresholds”; ➢ there was a lack of clarity around staff training and the role of the designated safeguarding person; ➢ there was a lack of clarity around working with the LADO and LSCB; FINAL 13.1.20 Page 71 of 112 Official ➢ weaknesses in the implementation of the policy were identified: incomplete safeguarding training records; insufficient proprietorial oversight; uncertainty among staff as to safeguarding lines of communication. The Department for Education determined that the inspection had identified “serious failings” and required the school to submit an action plan. There then followed a challenge from the school as to the definition used to determine that the failings were “serious”. From the school’s perspective, the shortcomings mainly related to record keeping and were minor, technical breaches rather than material breaches affecting the safety of pupils. The school have told the review that they remain concerned that the original inspection report did not specify the number or exact nature of shortcomings, so it was not possible for materiality to be assessed from the contents of the report and it is their view that the breaches were technical. The independent reviewers do not accept that this was the case since the advice note giving the details of the issues of concern (see 13.12 above) was sent to the school on 7th April 2014. The Department for Education have told this review that they did not accept the school’s argument that the failings should not be defined as serious and wished to move the situation on. A minister from the Department for Education therefore contacted the Mercers to ask for their assistance in resolving matters. From the Mercers’ perspective the purpose of any such meeting was to explain that they had little jurisdiction and the governors were responsible for any response. A final action plan was eventually agreed and approved by the Department for Education and the school passed the follow up monitoring inspection in October 2014. This episode raises three issues. One is the issue of ‘materiality’ in inspection judgements. The notion of materiality, derived from the Human Rights Act, has now been introduced into inspection guidance. This permits inspectors to take a holistic view of all the inspection evidence, and to base their judgements on whether a standard has been met in all material respects. This in effect screens out the possibility that a school will fail an inspection on technicalities. However, this would not have changed the judgement in 2014 as the review has been informed that if such failings were identified in a school today, they would be considered to be material and the school would be judged to not meet the applicable standards. The second linked issue relates to whether there is a need for objective criteria to define what is deemed to be a serious failing. This remains an issue for the school who argue that criteria should be published by the Department for Education. Having discussed this matter with the Department for Education and the Independent Schools Inspectorate this review does not make a recommendation that criteria are needed. The clear expectation of the inspection standards45 is that children will be safe and well educated if all standards are met. In effect these standards are the criteria and if there are material failings (see 13.15 above) then these are serious. The use of the word “serious” by the Department for Education has no real impact beyond the reputation of the school and does not affect the safety and wellbeing of children. 45 Currently these are set out in The Education (Independent School Standards) Regulations 2014. FINAL 13.1.20 Page 72 of 112 Official The third issue relates to the continuing need for clarity about the role of The Mercers in the governance of the school. There is no reason to believe that lack of clarity is intentional, but arrangements are complicated and a challenge to understand for anyone outside the system. It is of concern that the governance structure was unclear to the Department for Education and therefore the Independent Schools Inspectorate whose inspectors rely on the registration information published by the Department for Education. Regulatory activity is an important element of the safeguarding system and to be efficient and effective there needs to be a greater degree of clarity about where ultimate responsibility for good practice sits in any organisation. During this review it became clear that the school, LADO and Charity Commission and knew of an incident in 2018 when a member of staff had been arrested but the inspectorate were not aware of this. Although technically the Independent Schools Inspectorate did not need to be informed until the next inspection, the view of the ISI (and serious case review panel) was that it would be best practice for information sharing to take place as soon as a serious incident comes to light. ISI have raised this issue with the Charity Commission and the Department for Education and the formal information sharing protocol is being reviewed to clarify the information flow between the Charity Commission and the Department for Education when they become aware of a serious incident. Teaching Regulation Agency and Disclosure and Barring Service The Teaching Regulation Agency (TRA) has responsibility for the regulation of the teaching profession, including misconduct hearings and the maintenance of the database of qualified teachers. Prior to April 2018 this function was carried out by the National College of Teaching and Leadership (NCTL). Guidance is clear that employers have a statutory duty to consider referral of cases involving serious professional misconduct to the Teaching Regulation Agency. Where a teacher’s employer has dismissed the teacher for misconduct or would have dismissed them had they not resigned first, they must consider whether to refer the case to TRA.46 The standard of proof used by the TRA in deciding whether to issue a Prohibition Order is “balance of probabilities” rather than “beyond reasonable doubt “ the standard in criminal proceedings. The prime motive of the ex-pupil who made an allegation against the teacher who worked at St Paul’s in the 1980’s and was eventually found not guilty was to prevent future work with young people, but because of the verdict no referral was made by the area in which the teacher worked to the regulator (then NCTL). There is a potential gap in the system here with no one organisation or professional seeing it as their responsibility to notify TRA of such a circumstance, although the TRA told this review they would expect to be notified. The reason for notification is that the standard of proof for the TRA is “balance of probabilities” rather than “beyond reasonable doubt” as used in criminal proceedings, and there is a need to assess the information in this light. The experience of the TRA is that in some areas the police do notify, but the Metropolitan Police do not understand this to be 46 https://www.gov.uk/guidance/teacher-misconduct-referring-a-case#referrals-by-employers FINAL 13.1.20 Page 73 of 112 Official within their remit. The Department for Education told the review that the LADO could undertake such a notification, but the LADO involved in the area where the member of staff was living did not understand this to be their role where there had been a not guilty verdict. The expectations of LADOs and Police in these circumstances needs to be clarified in statutory guidance in order to make sure the proper assessments are made and the potential for future harm to pupils is reduced. St Paul’s have drawn the attention of the review to a gap in regulatory provision when a member of staff is convicted. In two cases there has been a delay of several months in the member of staff being placed on the barred list following conviction. In relation to the most recent conviction in 2018 an e-mail to the school from the Teaching Regulation Agency informed them that the TRA’s case will therefore be placed into abeyance whilst this matter is being considered by the DBS. When this point was raised by the school with the Disclosure and Barring Service, they were informed that although this specific case could not be discussed, all correct processes had been followed. If that is the case, there is the possibility that within a delay of several months when the teachers name is neither barred by the DBS nor prohibited from teaching, they could find paid or unpaid work with children. At the very least a system needs to be in place that enables a swift prohibition of a teacher when convicted of an offence against children. The TRA confirmed to the school that if the disclosure and barring service put a teacher on the children’s barred list then this automatically bars them from working with children for the time they are on the list. This means that the TRA does not carry out a hearing and the teacher is not named on the TRA prohibited teacher list, because the DBS barring decision effectively bans them from teaching children during that period. The TRA confirmed that in such cases the automatic teaching ban is therefore only for the length of time the teacher is on the DBS barred list. The TRA do not look at the case further so do not assess whether in the TRA’s view the teacher should be banned from teaching children for longer. DAY TO DAY SAFE PRACTICE St Paul’s provided the review with a large amount of information setting out their present policies and procedures aimed at complying with national standards and moving beyond these to setting a high standard of safeguarding practice. Much work has been done and other inspections and reviews have complimented the school on their rigorous approach to ensuring that they have a robust safeguarding framework in place, as is expected within UK schools. Progress has been commented on in section nine of this report and as in all organisations there will be areas for further learning and improvement. The main focus of this section of the report is on lessons for day to day ‘safe’ practice emerging from knowledge of past abuse at the school. These lessons are relevant for all schools and in some cases other organisations who provide activities for children and young people. FINAL 13.1.20 Page 74 of 112 Official Recruitment There has been a great deal of focus in recent years on improving practice in recruiting staff to roles where they are working with vulnerable groups. Guidance for schools47 sets out in detail expectations regarding all aspects of staff recruitment and from the evidence seen by this review St Paul’s is now fully compliant. Before the advent of national safeguarding guidance, recruitment practices at St Paul’s and other institutions were loose and judged by today’s standard unsound. There are examples within the case studies that informed this review of: ➢ St Paul’s receiving references that did not disclose a candidate’s previous conviction for a sexual offence against children (see paragraph 6.27); ➢ St Paul’s allowing an alleged perpetrator to resign and then giving a positive character positive reference; albeit for a job not working with children (see paragraph 8.36). St Paul’s did give a reference in 2016 to another school (agreed with the LADO) noting that a member of staff had supplied pupils with alcohol in an inappropriate context and another allegation had been investigated and found to be unsubstantiated. They were surprised that no contact was received from the other school for further information. This was not in line with expected practice at St Paul’s as since September 2016, St Paul’s has always obtained verbal verification of all references, even though this is not a statutory requirement. Schools, like any employer, are under no legal obligation to provide any reference and employers commonly only confirm that the person worked for them and supply relevant dates. However, receiving schools are obliged to ‘have regard to’ statutory guidance which states that references should always be obtained, they should be scrutinised and should ensure that all specific questions have been answered satisfactorily. Any past disciplinary action or allegations that are disclosed should be considered carefully. Here, the school appointing the member of staff above clearly did not feel that they needed clarification, although St Paul’s were surprised not to receive a phone call given the contents of the reference. In these circumstances the outgoing school could refer their concerns to the relevant inspectorate or the Department for Education. While there is no statutory requirement to report such matters to the inspectorate, St Paul’s were encouraged to do so following discussion of this case at the serious case review panel, and the school informed the Independent Schools Inspectorate. In order to prevent any room for doubt this review is recommending that all schools should obtain verbal references, alongside written references from the previous employer following the decision to appoint a member of staff. This is discussed further in Finding Four. One case that caused concern amongst many ex-pupils related to the appointment of a teacher to replace a member of staff who had been arrested in 2013 for the possession of indecent images. The teacher appointed had been a previous pupil and member of staff at St Paul’s and had been subject to an allegation of inappropriate conduct (not relating to children) which had received press attention whilst working at another independent school. 47 Department for Education (2018) Keeping Children safe in Education. Pages: 29-50 FINAL 13.1.20 Page 75 of 112 Official One important issue here which is beyond the scope of this review is whether this school should have notified the body regulating teachers at that time since this was behaviour that could bring the profession into disrepute. In appointing this member of staff, St Paul’s carried out all the required employment checks and because neither reference was from his last employment, the head teacher at Colet Court (who was aware of the alleged inappropriate behaviour with an adult) spoke to the previous school and received confirmation that there were no questions about the teacher’s suitability to work with children and later put this in writing. The High Master was aware of this decision. The school’s submission to this review notes that: The issue is whether appointing someone against whom there had been an unsubstantiated allegation of a legal indiscretion six years earlier was appropriate or not. In September 2013 this was judged acceptable. Although St Paul’s did not breach any statutory guidelines in making this appointment, this situation reveals the limitations of an understanding of safeguarding which focuses solely on procedural compliance. It is a failure to act in the spirit of the guidance and to use safeguarding initiative on behalf of other children. The appointment of a teacher where there were public allegations regarding an indiscretion (with an adult), to replace a teacher who had been accused of possessing sexual images of children was extremely poor judgement. Firstly, trust that boundaries will be maintained is an all-important aspect of safeguarding and this teacher had been accused of boundary violation and breach of trust. Secondly, in 2013 it was extremely important to give boys at the school the message that, in the light of the recent arrest of a member of staff the ultimate focus was on keeping them safe and that the staff group could be completely trusted to maintain appropriate boundaries at all times. The allegations about this teacher were common knowledge amongst many pupils and parents and his appointment gave completely the wrong message about the school’s attitude to safeguarding. It is however important to note that the school did take action to remove this teacher in 2014 and risked legal action under employment law in asking him to move on. For some ex-pupils, the above episode illustrates the power of the “old boy network” and past allegiances outweighing all else, with the teacher concerned having been both a pupil and a former teacher at the school. The school refute this and have told the review that this appointment in fact came about because the teacher’s subject was is a highly specialist and scarce subject, these are bright boys and getting a [specialist teacher in this subject] at short notice is very difficult. There is no evidence that the teacher concerned represented a threat to children, but for some ex-pupils it is indicative of a culture which does not recognise the risks associated with staff teams built on past and current informal networks and fits with the culture that they experienced during their time at the school where the pursuit of academic excellence has overridden all else. The review accepts that the aim of the current senior management team is to put the mental wellbeing of pupils first and there is evidence of innovative thinking and practices associated with this focus. However, the imperative to meet high academic standards whilst focusing on the safety and wellbeing of pupils is a current issue for all schools (not confined to the independent sector) and this example is illustrative of the complexities of this process. FINAL 13.1.20 Page 76 of 112 Official Although the current High Master has been focused on modernising the school and recruiting and developing a staff team with a much wider range of background experiences then previously, there is no room for complacency. Where a staff group is recruited from a pool of staff who have all been through a similar educational system, it will take time for well-established cultures to change and for unhealthy attitudes and beliefs to be challenged. The governing body will need to be committed to ensuring the current positive approach to ensuring compliance with recruitment standards achieves diversity and a culture where any entrenched attitudes and values are challenged. Listening to pupils Listening to children is a cornerstone of good safeguarding practice yet it is an aspect which can become a trite phrase rather than a phrase with real meaning. The education system is by its very nature based on a power imbalance between child and teacher, and there is ample evidence that, in the past, former teachers at St Paul’s used this to their advantage while working at the school. Pupils who were abused, for a variety of reasons set out elsewhere in this report, did not speak out about what was happening or have been ignored. In recent years, the school have focused on developing a culture where pupils can express any concerns. The internal safeguarding review completed by Barnardos in 2018 commented that: Pupils have numerous ways to report any concerns they may have and the school has tried to create a culture of ‘let’s talk’ about issues. When pupils start at the school they are given a Prep/Homework diary which contains details of who to go to if they are worried or concerned. Young people have been involved in creating some video clips to help other children around emotional health and wellbeing. Pupil surveys take place annually across both schools and the Governing Body receives and scrutinises these, taking forward any actions agreed to be necessary. Pupils are buddied up with older boys for support and there are comments/concern boxes available for pupils to use anonymously. Teachers and upper 8th boys respond to anonymous email queries through the ‘Anything to Say’ mailbox and Tutor groups are also used to encourage discussion among pupils about worries or concerns. There is evidence that when a pupil raises concerns that these are acted upon appropriately…. The pupils consulted stated that they feel well supported and appreciated the many talks given to them about keeping safe. They clearly knew who to talk to or what to do if they felt unsafe and named a range of people they could talk to or methods through which they could report concerns e.g. Heads of Year, Form Tutor, welfare boxes. The review understands that the mailbox system is currently for the junior school pupils only and a similar anonymous reporting system could usefully be developed for senior school pupils. It is interesting that the concerns raised by pupils about AP8’s behaviour in 2013 followed child protection awareness training being given to all prefects and it was one of these FINAL 13.1.20 Page 77 of 112 Official prefects that made the allegation. Empowering young people through knowledge about what behaviour they should expect from those in positions of authority may be an area for further development through the PHSE curriculum. Relationships with parents: the tutorial system and safeguarding practice Along with other schools in both the maintained and non-maintained sectors the degree to which St Paul’s School has encouraged parental involvement in their son’s education has evolved over time. Pupils educated at the school in the 1960’s and early 1970’s typically spoke about a distance between school and home with parents handing their sons over to the school and having little involvement in their education. If any boys criticised the sometimes harsh or physical punishments the usual parental response was to assume the boy was in the wrong. This would have been in line with a general hierarchical culture within education at the time where the teacher’s authority would not be questioned. The message whatever happens at school stays at school would have facilitated a splitting between school and home (particularly for boarders) which would have made it unlikely that parents became aware of abuse by teachers. The challenges which parents experience in complaining about any aspects of their son’s life in school have been explored elsewhere in this report. St Paul’s has a well-developed tutorial system which encourages a close relationship between individual boys, tutors and their parents. This tutorial system allocates each senior school pupil to a tutorial group which meets daily and consists of boys from a cross section of all year groups. The boy usually remains with this tutor and the tutorial group for the duration of his time at the school and care is taken in matching boys with tutors. Where the relationship is not working well changes can be made. The role of the tutor is to provide mentorship and support with the pupil’s academic and pastoral progress and as part of this to maintain a close working relationship with the boy’s parents. It is traditional for parents to invite the boys tutor to the family home for a meal, and staff told the review that this provides the tutor with the opportunity to understand the boy’s home environment and make them more approachable to the family. The school website notes that: the rapport that a boy and his family develop with his tutor lasts throughout his time at St Paul’s School and often beyond. Staff spoken to for this review were very positive about the system and a recent school pupil survey found that 87% of pupils surveyed agreed with the statement that they could talk to their tutor about things that were worrying them or if they needed advice. Of the remaining 13%, 5% said they would not talk to their tutor with remaining 8% saying they had no view or did not know. In addition to the positive aspects of the system there are risks associated with the system which need to be acknowledged and steps taken to mitigate them, preserving the many positive aspects. In the past, relationships developed between several perpetrators or alleged perpetrators and families that crossed the boundaries from what would be expected in a professional relationship including staying with families in the home. In this way families were groomed FINAL 13.1.20 Page 78 of 112 Official alongside the young person and for boys who were being abused their abuser followed them from school into their home. Such risks may also be present in other situations such a close-knit community where friendships form across teacher /parent boundaries. The school have thought about issues that were raised by the trial of one of the perpetrators in 2017 and have begun to pilot a co-tutor system which involves more than one tutor working with a tutorial group. This should reduce the likelihood of exclusive or “special” relationships forming which could be exploited by the member of staff. Many of the 59 ex-pupils spoken to for this review, most of whom had not been abused, questioned why a part of the approach involves tutors being invited to family homes. One parent has also told the review that this can feel uncomfortable, pupils dislike it and the role of tutor could be developed without this expectation. Another ex-pupil believes that the fact that his parents did not invite his tutor home was held against him. There seems to be no good reason why this practice needs to continue. Informal relationships may already exist or develop as they do in any community and in that case will need to be disclosed to the school via the neutral reporting system (see para 9.10). This gives a message that care needs to be taken where boundaries become fluid rather than encouraging formalising the arrangements via the current system. Alcohol in school Not all pupils remember that alcohol use by pupils was tolerated at the school, but the chronologies and accounts of pupils are clear that alcohol played a part in much of the abuse that took place. It is clear that in the past there was a high level of tolerance where staff were known to have an alcohol problem, and this is sometimes described as a source of amusement to the boys. Other ex-pupils have spoken of staff going to the pub at lunchtime and returning inebriated. Allegations about the use of alcohol by staff were as recent as 2013 and there are examples within the cases analysed for this review which illustrate the dangers associated with the fraternisation and blurred boundaries that can result. In relation to pupils, the modern school has a policy which allows for alcohol to be served (but not sold) to boys aged 16-18 with parental permission at society/club dinners and on school trips (in line with legislation of the host country). This is likely not to be dissimilar from other schools in both state and independent sector. An initial trawl of local authority procedures in relation to staff use of alcohol only found one (Surrey) where there is a zero-tolerance approach to staff and alcohol and the St Paul’s code of conduct does allow for staff to drink alcohol within the boundaries of the code. There is emerging scientific evidence about the impact of alcohol on children and the current advice from the chief medical officer is that no child should drink alcohol under the age of 15 and between age 15-17 this should always be in a supervised environment. The guidance goes on to say that: Parents and young people should be aware that drinking, even at age 15 or older, can be hazardous to health and that not drinking is the healthiest option for young people. FINAL 13.1.20 Page 79 of 112 Official Although the policy at St Paul’s is in line with the law and the guidance, there is the additional issue of the part that alcohol plays in blurring boundaries and increasing vulnerability. This was a factor in the abuse of children at the school and the view has been expressed strongly by one victim (where alcohol was a factor in his non-recent abuse) that alcohol should not be allowed at all. In addition, the review was informed that one of the reasons that the Teaching Regulation Agency dropped the case against one teacher from St Paul’s was that the school had a policy that permitted use of alcohol at meals and this would be used by his defence. Alcohol use is embedded within English culture and there is an argument that young people should be taught to use alcohol sensibly. It is arguable whether this should take place within an education environment. Taking account of these factors and the increasing medical evidence, schools may wish to consider banning the use of alcohol by pupils and staff on school premises (as they would tobacco) and extending this ban for school events off site, for example residential visits. At a national level, given the strong message from the Department of Health, the Department of Education should review all the evidence and give a clear steer to schools as to the expected standards of practice. FINDINGS & RECOMMENDATIONS Finding 1: Accepting responsibility for past abuse must be a foundation for moving forward and developing an effective safeguarding culture. St Paul’s School is a registered charity and the governors of the school are the charities trustees. Trustees must act in the best interests of their charity48 and report any serious incident that may harm its reputation. Acting in the best interest of the charity and a focus on reputation runs the risk that trustees will seek to minimise public exposure of abuse allegations rather than understanding that the reputation of organisations will be enhanced by admitting mistakes and accepting responsibility. It is through openness and honesty about what went wrong that safeguarding will be improved in the future. This link between promoting the reputation of the charity through reflecting on mistakes and engaging willingly with investigations and inquiries could be enhanced in the Charity Commissions guidance for trustees. There are many and varied views as to what “taking responsibility” for what happened in the past means and how best to do it. For some people who have been affected by the abuse, an apology and compensation are enough, for others, resignations of some senior managers or governors is a demonstration that responsibility for the past has been accepted. For others the most important aspect of accepting responsibility is to ensure safeguarding practice within the school is as strong as possible and to put right what went wrong in the past. Conversations with survivors of abuse at St Pauls have identified that 48 https://www.gov.uk/government/publications/the-essential-trustee-what-you-need-to-know-cc3/the-essential-trustee-what-you-need-to-know-what-you-need-to-do#s6 FINAL 13.1.20 Page 80 of 112 Official an important aspect is a clear statement from the school that they accept responsibility for the past abuse of pupils. This review has found that, within this context of competing views, finding the right approach has been a challenge for St Paul’s School. The intention of the current senior management team and governing body has been to do the right thing through being open and transparent with the school community and apologising to those affected at the end of the criminal trials. It is the opinion of the independent reviewers is that the school has not always been sufficiently sensitive in their use of language (verbal and written) and have at times inadvertently given the impression that the needs and feelings of survivors and other affected ex-pupils are not important. The review has found no evidence that the current senior management team or governing body have attempted to cover up what happened in the past, but it has found that they have not issued a clear statement that accepts responsibility for the abuse experience by past pupils although they thought they had done so. They were also slow to offer a general apology to all pupils who had made allegations of abuse at the school. The first information about the extent of allegations of non-recent abuse was in 2014 yet the apology that included all past pupils was not sent until September 2018. The apology in the Old Pauline Magazine on 2017 focused on those affected by the criminal trails and was not sufficiently clear that it was directed at any pupils who had been affected by abuse at the school at any time. This has been an area of discussion and learning through the review period and the High Master has now sent two letters to the school community which were intended to explicitly express sorrow and regret at what has happened and clearly apologise to those who have been affected. There are several factors contributing to the delay in issuing a general apology and this has been explored in paragraphs 8.18-8.21 above. Significantly, this was a new situation for the school for which they were not prepared, and they relied on guidance from statutory agencies. The police informed the school that they could not contact ex-pupils and the school would not have details of individuals who had made allegations. Although the school were making plans as to how to respond, planning an appropriate response was also hindered by a breakdown in trust between St Paul’s School and the multi-agency partnership and gaps in the overall strategic planning for this complex inquiry. This is explored further in Finding Three. The review has found evidence that a culture existed in the past where abuse was not identified and dealt with properly. Although some of the responses by past senior leaders were not dissimilar from those in other organisations49, this does not excuse behaviour which fell short of expected standards and the knowledge that was available within the professional community at the time.50 Finding the best way to accept responsibility and move on to embed cultural change within St Paul’s and other schools who have a similar experience the school could be greatly 49 See for example reports in respect of Jimmy Saville and evidence submitted to the independent Inquiry into Child Sexual abuse in respect of the Church of England. 50 For example, in 1993 the report into abuse at Castle Hill School had been published, exploring the dynamics of sexual abuse in a residential school and called for more stringent checks for school staff. FINAL 13.1.20 Page 81 of 112 Official helped by using the expertise of ex-pupils and survivors of abuse where they are willing to do so. Using their experiences to frame current practice and responses is a positive way to helping the current community to engage with the pain of past experiences, learn from them and move beyond the danger of a simple compliance with procedures to a real understanding of reason for practice change. The school and the LSCB chair jointly agreed that they should begin this process by having a staff member attend every day of the trials and they used this information to review practice. They also intended to contact ex-pupils through the internal review carried out by Barnardo’s but this did not happen in order not to duplicate the work of this serious case review. Now all statutory processes are complete, engaging positively with ex-pupils as part of the process of embedding and maintaining cultural change will be an important aspect of future practice. Recommendation 1a St Paul’s School should issue a clear unambiguous statement that they accept full responsibility for the past abuse experienced by pupils at the school. Recommendation 1b The Department for Education should support all schools where there have been non-recent abuse allegations to engage with survivors of abuse in order to use their experience to reflect on their response to non-recent abuse and consider learning for the future. Recommendation 1c St Paul’s School should engage directly with survivors of abuse at Board level and consider co-opting a survivor of abuse to the Board of Governors. Recommendation 1d The Charity Commission should make explicit their expectations regarding best practice at times of crisis and specifically that protecting the reputation of the charity includes openness and honesty about any poor practice. Recommendation 1e The Department for Education should require schools (state maintained and independent) to have a communication strategy in place for situations where there have been allegations of abuse against a member of staff. This strategy should draw in advice and support from statutory agencies and take account of current Statutory guidance regarding confidentiality and also take full account of learning from survivors of abuse in such situations. Finding 2: Schools face difficulties in balancing a response to allegations of abuse that takes account of employment law, education legislation and good safeguarding practice. This can result in an unintended message to pupils that concerns about abuse should be kept secret. This review has found that school’s response to allegations of abuse involves balancing the requirements of employment law, education legislation and best safeguarding practice. Best safeguarding practice, based on positive relationships with children, involves FINAL 13.1.20 Page 82 of 112 Official developing an open, honest culture where the possibility of abuse is always on the table and there can be a swift response to preventing staff who may pose a risk from having contact with children. Pupils and staff need to feel able to explore worries about the behaviour of colleagues, and there needs to be a system whereby accumulating concerns can be shared. This needs to take place within a legislative context which promotes fairness in the treatment of staff against whom allegations are made, protecting their right to anonymity whilst investigations take place and preserving their employment rights. This complex system was not always understood by everyone involved and most worryingly it can be interpreted by pupils as an imperative to keep quiet and not talk about the possibility that abuse could take place within the school. Schools may also receive apparently conflicting advice from lawyers specialising in specific aspects of the law and safeguarding professionals. At the very least, the inherent tensions within the system need to be more clearly spelt out in safeguarding guidance and this translated into information given to the school community. One positive move forward suggested to the review team would be for the Education Act to develop the same approach as the Children Act to establishing a paramountcy principle regarding the safety and welfare of pupils. The school has queried what would happen in the case of malicious/unfounded allegations but it the view of the review panel and lead reviewers that where any allegation occurs the starting point should be pupil safety and welfare. Recommendation 2a The Department for Education should ensure that national guidance to schools on safeguarding practice is clear about best practice in managing the tension between employment law, education legislation and safeguarding practice. Schools should ensure that the whole school community understand its impact on managing allegations and that it should not have a negative impact on pupil’s coming forward to express concerns about the behaviour of a member of staff by making the needs of the child their paramount concern. Recommendation 2b The Department for Education should consider embedding the principle that the child’s welfare is paramount into education legislation in order to assist schools in making decisions when there appear to be competing alternatives. Finding 3: Safeguarding partnerships must make the quality of relationships within and between individuals and agencies a top priority in order to provide a high support/high challenge environment which will promote effective safeguarding practice. In relation to the non-recent abuse at St Paul’s School there was no evident relationship between the school and the statutory agencies prior to 2013. As a result, when there were FINAL 13.1.20 Page 83 of 112 Official issues of concern the school did not consult with outside bodies and managed situations where there were any concerns about staff behaviour internally. This would not have been different to many other similar institutions at the time. The lack of any historical relationship meant that in 2013 when the school did have cause to liaise with the LADO there was no foundation on which to build, and when each challenged the other his escalated quickly into unhelpful defensiveness. There were problems on both sides, with the school not following expected practice in 201351 52 by interviewing pupils who had made an allegation before referring to the LADO and the LADO service not always communicating effectively with the school. For example, there was no dedicated minute taker resulting in late minutes and although the LADO told the school that they were referring concerns about the school to the Department for Education they did not provide full written details of the rationale for this action. The situation in both respects has now changed as there is now evidence that the school always promptly refer to the LADO and the LADO service in Richmond is now organised to provide an efficient service. The lead reviewers have discussed the sequence of events in 2013 with both the LADO and the school and reviewed written information from both parties. As a result, they have formed the view that the school had good reason to question aspects of the LADO service but equally the LADOs advice to the school was appropriately focused on making sure that all relevant steps were taken to ensure the safety of the pupils. Of concern is the way in which the relationship between the school and the LADO so quickly deteriorated. Rather than attempting to understand each other’s point of view and resolve professional differences the debate became polarised and defensive on both sides. This tendency for the senior leaders at the school to become defensive when challenged was an issue raised by a range of individuals and organisations who contributed to this review. This is explored elsewhere in this report: (see for example 11.8 and 12.4) This lack of trust between the school and the local authority in 2013 did not provide a good foundation when, following the abuse allegations in 2014, the LSCB aimed to work with the school to understand what lessons had been learned and the effectiveness of the current safeguarding arrangements at the school. From the perspective of the school, the LADO and the LSCB were one entity and concerns about the LADOs advice in 2013 affected their perceptions of the Board’s role from 2014 onwards. Scrutinising learning and current practice was an appropriate role for the Board but an additional complicating factor was that relationships and communication within the LSCB and its constituent agencies was causing misunderstandings, and this prevented a coherent and planned approach to working with St Paul’s. There was a similar deterioration in relationships as had been experienced in 2013 with legitimate concerns from the school about the accuracy of a report prepared by the professional advisor for the serious case review subgroup. This report had been requested by the group in order to facilitate decision making as to whether a serious case review 51 As in 'Safeguarding children and safer recruitment in education' (December 2006). 52 HM Government (2010) Working Together to Safeguard Children Page 359. Paragraph 14. FINAL 13.1.20 Page 84 of 112 Official should take place. Relationships should not have deteriorated in the way that they did, and it is the view of the lead reviewers that the LSCB did not always address all the concerns of the school speedily through clear communication and this was frustrating for the school. In addition, the school did not always appreciate that they were (and are) perceived be a powerful institution and can be unaware of the impact of their own communication style on those who are used to a less combative approach to challenge. These problems in relationships developed in the absence of a positive relationship with local authority children’s services which could have provided support to the school alongside the challenge from the LADO and LSCB and helped the school in the development of their safeguarding practices. Support by the local authority’s education safeguarding team to schools outside the local authorities control varies from local authority to local authority with some providing a totally free service and other’s working with service level agreements and charging structures. There is no national requirement and it is down to individual schools to understand the local provision and access this accordingly. This case demonstrates the importance of good relationships with the local authority and consistent support to all schools who are dealing with complex safeguarding matters. This should not be confused with the very specific role that the LADO fulfils in providing oversight of allegations of abuse in organisations. Reviewing all of the above, a key finding of this review is that relationships matter. Multi-agency partnerships need to be fully functioning with strong, positive relationships between members if they are to effectively challenge each other and external institutions. Recommendation 3a National safeguarding guidance should be clear that the foundation of safeguarding partnerships is the golden thread of relationships between agencies and this must be the lens through which safeguarding is planned and executed. Recommendation 3b There should be a national requirement for local authorities to provide a system of quality assured local safeguarding advice and support for all schools which is beyond the LADO role. All schools should be expected as part of the inspection process to demonstrate that they are aware of local resources and that they are sourcing appropriate advice and support service. Finding 4: There remain gaps in the national safeguarding system in relation to the recruitment and regulation of teachers, the Disclosure and Barring Service and the way in which information is shared across national organisations. Whilst policies and procedures cannot on their own keep children safe, they provide an important framework for practice. The review has found that although the recruitment system is much improved, employment law dictates that unsubstantiated concerns about a teacher’s behaviour within the school should not be included within a reference. It is up to FINAL 13.1.20 Page 85 of 112 Official the receiving school to decide whether any information within the reference should be followed up verbally or in writing. It is common in other organisations with responsibilities for children to always follow up a reference, usually with a telephone conversation, when the decision had been made to offer a position and this is part of established safe recruitment training. St Paul’s have included this non-statutory requirement as part of their safer recruitment procedures and extending this as a requirement for all schools is a subject of a recommendation from this review. It was of concern that during one investigation into allegations made by a pupil that the member of staff concerned worked as a volunteer in a residential activity organisation and this organisation did not wish to engage in dialogue with the LADO. It is also of interest that more than one teacher against whom allegations were made worked in outside school activity settings. This highlights the importance of the government’s current work on developing a code of conduct for such organisations. Another area of concern was the finding that the Teaching Regulation Agency had not received any notification in respect of the teacher where there had been a not guilty verdict. Notification should have been made by the LADO and/or school in the area where the arrest took place either at the point of arrest or when a verdict was reached. From the Teaching Regulation Agency perspective in some areas the role of notifying them following a not guilty verdict falls to the police although this is not the case in the Metropolitan Police area, The standard of proof for the Teaching Regulation Agency is (balance of probabilities” rather than “ beyond reasonable doubt”) and there should have been a thorough investigation as to whether this teacher should have been prohibited from teaching. One further gap in the system that St Paul’s helpfully brought to the attention of the review is the time that it can take to prohibit a teacher from teaching following being found guilty of child abuse offences. In two cases this took several months to place them on both the barred list via the Disclosure and Barring Service and the prohibited list by the Teaching Regulation Agency. This potentially allows the person concerned to work with children in the meantime and the system needs to be streamlined to speed up the process. It became clear during this review that the Independent School’s Inspectorate was not aware of the investigations regarding a recent perpetrator although the Charity Commission had automatically been informed as this was a serious incident. Further discussions between the Independent Schools Inspectorate, the Department for Education and the Charity Commission highlighted the need for an information sharing protocol between the three agencies in order to make sure that all relevant information can consistently be collated and taken account of. Recommendation 4a The Department for Education should strengthen the safer recruitment guidance to ensure a fair and consistent process is in place in all schools for the verification of references which satisfies first the need to protect children and then the requirements of employment law. FINAL 13.1.20 Page 86 of 112 Official Recommendation 4b The proposals by the Department for Education for a code of practice for out of school settings should become expected practice and include the need to cooperate fully with the LADO when a member of staff has been identified elsewhere as possibly posing a risk to children Recommendation 4c The Department for Education in collaboration with other state departments should clarify who has responsibility for notifying the Teaching Regulation Agency when there is a not guilty verdict in a trial involving a teacher. Recommendation 4d The Department for Education should lead an immediate review of the system to eradicate the time lag between an offender’s conviction and appearance on the Disclosure and Barring Scheme barring list, in order to remove the possibility that an offender could obtain voluntary work with children. In addition, the Teaching Regulation Agency must be notified of a conviction immediately so that an interim prohibition order can be issued, which would flag concerns to all prospective employers within the education system. Recommendation 4e The Charity Commission and Department for Education should consolidate their current discussions regarding information sharing and developed a protocol to guide action in the future. Finding 5: The procedures in London for police and the multi-agency partnership do not provide sufficient clarity as a foundation for managing complex investigations in these circumstances. This review has found that police investigations generally worked well and these investigations resulted in six convictions of former staff from St Paul’s School. In one case there are some areas where the individual investigation could have been improved and this has been subject of an internal review by the police. From consideration of this case the issue of support and supervision of officers with responsibility for investigations became apparent. Investigating child abuse may be stressful and all professionals need to manage a range of feelings and emotions and consider how these may be affecting their practice. Traditionally investigating police officers have a great deal of autonomy and there is minimal time for the type of reflection and supervision that is common in other professions. This should be an area for practice improvement. Although most survivors were positive about the criminal process, albeit acknowledging that it was very stressful, the review has found that where there is a not guilty verdict there is room for a more coherent support plan. Further discussion about support for complainants has revealed a gap in provision. Although some forces have resources to appoint a specially trained officer to keep regular contact with complainants this is not the case within the Metropolitan Police and complainants are signposted to other services such as victim support. For complainants without strong family support this may not be FINAL 13.1.20 Page 87 of 112 Official enough, particularly in situations where they may not have wished to tell family and friends about their complaint. This is of significance for child safeguarding as children are likely to be best protected where they are consistently well supported regardless of age and the recommendation from this review is that there should be a national system of advocacy and support for complainants- both children and adults. The review has also found that there is a need for greater clarity in the multi-agency management of complex inquiries and that communication between partner agencies and the school does not always work well. This is particularly so where there are inquiries into non recent abuse alongside those focusing on current allegations. The split in the system for investigation within the police means that there is an even greater need for an overarching system of communication between all concerned in order to support the school in managing the multi-layered inquiries and communicate appropriately with the school community. The system of Gold Silver and Bronze group within the police are designed to manage the investigation of complex criminal inquiries and there is a lack of clarity about how these should dovetail with complex inquiries involving safeguarding children where Children’s Social Care are required to take the lead through chairing the strategic management meeting. The most recent conviction of a member of staff who, in 2018 pleaded guilty to arranging to meet a child to commission a sexual offence and inciting a child to commit a sexual act had highlighted the need for absolute clarity and good communication between police and schools regarding when names will be released to the press in order that the school can plan an appropriate communication strategy. This did not work well in the case of P6 with inaccurate information being given to the school. This case has also confirmed that social media platforms could do more to assist police in their inquiries when there is strong evidence that a user of the platform is grooming another and also has current access to children and young people. Recommendation 5a The Home Office should establish a system of advocacy and support for complainants (children and adults) in child sexual abuse cases both pre and post-trial in order to ensure consistency between areas. Recommendation 5b The Metropolitan Police should establish a system for the supervision and support of officers carrying out child abuse investigations in order to quality assure the investigation process and provide the emotional support required to minimise the likelihood of any bias within the investigation process itself. Recommendation 5c The Department for Education and Home Office should review guidance and practice relating to complex abuse investigations in order to make sure that: FINAL 13.1.20 Page 88 of 112 Official ➢ Where there are current police inquiries relating to an institution alongside specified operations focusing on non-recent abuse one strategic management group has oversight of the whole picture and can plan to meet the needs of survivors, current children and the organisation as a whole; ➢ There is clarity about the link between police command structures via Gold, Silver and Bronze groups and the multi-agency management of complex inquiries. Recommendation 5d Home Office guidance should clarify the process of informing interested parties when names of alleged or convicted perpetrators are released to the public and press statements made. All police officers should be aware of the policy and be able to advise others with accurate information. Recommendation 5e The Department for Digital Culture Media and Sport should require social media platforms to release information to the police where they have reason to suspect that a suspect has continuing access to children during an investigation into child abuse. Finding 6: This review has found a number of areas where practice could develop further, some areas are specific to St Paul’s and others have wider applicability. St Paul’s School has responded to the allegations of non-recent abuse with a tenacious approach to reviewing internal systems and improving practice and the current High Master estimates he has spent around 20% of his entire working hours on safeguarding issues since 2014. The school has had its safeguarding provision and procedures reviewed on nine occasions since 2014 and has told the review that has confidence that its current systems and processes are amongst the best in the country.’ Many significant practice improvements have been made but as in any system there will always be more to do. This review has set out a summary of the main areas where St Paul’s have responded to internal reviews and national developments by improving their safeguarding systems. The Badman review in 2015 made recommendations for school governors which have resulted in a governing body focused on monitoring evaluating and improving safeguarding practice. The review by Barnardos in 2017 commented that the annual internal audit carried out by the lead governor for safeguarding exceeds expectations and is evidence of the school’s commitment to ongoing learning, to raising awareness of its safeguarding responsibilities and to ensuring accountability from those working directly with children through to the governors. The High Master and members of the senior management team have also made safeguarding a priority and have provided this review with much evidence of the intensive work that has been done by the school, particularly in relation to the mental health of FINAL 13.1.20 Page 89 of 112 Official pupils, staff recruitment and the monitoring of safeguarding practice by the school’s safeguarding team and safeguarding committee. Developing safeguarding practice is a process of continuous learning for all involved and additional learning has continued with the school as this review has progressed. The following recommendations have developed from discussions with the school and serious case review panel, some of which have applicability beyond St Paul’s. The following recommendations link to specific aspects of practice discussed in this report and for further detail please see the relevant paragraph. Recommendation 6a (paragraphs 14.25-14.32) At a national level, given the strong message from the Department of Health, The Department of Education should work with the Department of Health to review the evidence in respect of the impact of alcohol on young people and links with child abuse and give a strong steer to schools as to the expected standards of practice for staff and pupils in day and boarding environments. Recommendation 6b (paragraph 12.8) The role of GPs within school should be clarified through the development of guidance by the Royal Collage of General Practitioners Recommendation 6c (paragraph 7.16) The Department for Education should require schools to develop a system of safeguarding supervision for staff which provides an opportunity for reflection on any concerns about the safety of pupils. Recommendation 6d (paragraphs 7.29) St Paul’s School should review communication with its parents in order to strengthen the message that parents are welcome at the school and any concerns or complaints about the wellbeing of their son in school are welcome and will be treated sensitively. Recommendation 6e (paragraphs 7.29-30) The Department for Education should revise national complaints guidance for schools to ensure that complaints that cannot be resolved informally (stage 1) or by formal internal investigation (stage 2) should always include an independent investigation at the next stage prior to any panel hearing. Recommendation 6f (paragraphs 14.19-14.24) St Paul’s School should stop promoting any expectation that parents invite tutors to the family home for a social visit. Any visits to the home should be formalised and recorded. Recommendation 6g (paragraphs 9.13 and 14.15) St Paul’s School should review their process for anonymous reporting of pupils concerns in the senior school and make sure that it replicates the good practice in the junior school. Recommendation 6h (paragraph 12.13) St Paul’s School should require the counselling service in the junior school to keep contemporaneous notes in line with expectations in the senior school. FINAL 13.1.20 Page 90 of 112 Official Recommendation 6i (paragraph 14.20) St Paul’s School should understand any barriers that might be in place preventing pupils from talking openly to their tutors and take steps to overcome them. Implementing Learning and Monitoring Change: Recommendation for the Local Safeguarding Partnership. Recommendation 7 The serious case review panel are aware that what has been recommended may be seen as challenging for both St Paul’s School and the Departments of State. Moreover, there is no mechanism for local partnerships to hold Departments of State to account. A panel member has knowledge of the Independent Jersey Care Inquiry and the powerful motivator for change of the recommended review by the same panel two years after publication. For that reason, and given the complexity of our findings, we recommend that a similar short review of progress in about two years would be advisable in this case to consider the progress of the recommendations locally and nationally. The partnership board should consider how best this should be undertaken. FINAL 13.1.20 Page 91 of 112 Official SUMMARY OF RECOMMENDATIONS Recommendation 1a St Paul’s School should issue a clear unambiguous statement that they accept full responsibility for the past abuse experienced by pupils at the school. Recommendation 1b St Paul’s School should continue to engage with survivors of abuse at the school in order to use their experience to reflect on their response to non-recent abuse and consider learning for the future. Recommendation 1c St Paul’s School should engage directly with survivors of abuse at Board level and consider co-opting a survivor of abuse to the Board of Governors. Recommendation 1d The Charity Commission should make explicit their expectations regarding best practice at times of crisis and specifically that protecting the reputation of the charity includes openness and honesty about any poor practice. Recommendation 1e The Department for Education should require schools (state maintained and independent) to have a communication strategy in place for situations where there have been allegations of abuse against a member of staff. This strategy should draw in advice and support from statutory agencies and take account of current Statutory guidance regarding confidentiality and also take full account of learning from survivors of abuse in such situations. Recommendation 2a The Department for Education should ensure that national guidance to schools on safeguarding practice is clear about best practice in managing the tension between employment law, education legislation and safeguarding practice. Schools should ensure that the whole school community understand its impact on managing allegations and that it should not have a negative impact on pupil’s coming forward to express concerns about the behaviour of a member of staff by making the needs of the child their paramount concern. Recommendation 2b The Department for Education should consider embedding the principle that the child’s welfare is paramount into education legislation in order to assist schools in making decisions when there appear to be competing alternatives. Recommendation 3a National safeguarding guidance should be clear that the foundation of safeguarding partnerships is the golden thread of relationships between agencies and this must be the lens through which safeguarding is planned and executed. FINAL 13.1.20 Page 92 of 112 Official Recommendation 3b There should be a national requirement for local authorities to provide a system of quality assured local safeguarding advice and support for all schools which is beyond the LADO role. All schools should be expected as part of the inspection process to demonstrate that they are aware of local resources and that they are sourcing an appropriate advice and support service. Recommendation 4a The Department for Education should strengthen the safer recruitment guidance to ensure a fair and consistent process is in place in all schools for the verification of references which satisfies first the need to protect children and then the requirements of employment law. Recommendation 4b The proposals by the Department for Education for a code of practice for out of school settings should become expected practice and include the need to cooperate fully with the LADO when a member of staff has been identified elsewhere as possibly posing a risk to children. Recommendation 4c The Department for Education in collaboration with other State departments should clarify who has responsibility for notifying the Teaching Regulation Agency when there is a not guilty verdict in a trial involving a teacher. Recommendation 4d The Departing for Education should lead a review of the system for prohibiting teachers from teaching following being found guilty of a child abuse offence, in order to make sure that there is no delay. This should include the TRA investigating and making their own decision regarding length of prohibition from teaching to assess whether it should be for a longer period that the person is on the barred list. Recommendation 4e The Charity Commission and Department for Education should consolidate their current discussions regarding information sharing and developed a protocol to guide action in the future. Recommendation 5a The Home Office should establish a system of advocacy and support for complainants (children and adults) in child sexual abuse cases both pre and post-trial in order to ensure consistency between areas. Recommendation 5b The Metropolitan Police should establish a system for the supervision and support of officers carrying out child abuse investigations in order to quality assure the investigation process and provide the emotional support required to minimise the likelihood of any bias within the investigation process itself. FINAL 13.1.20 Page 93 of 112 Official Recommendation 5c The Department for Education and Home Office should review guidance and practice relating to complex abuse investigations in order to make sure that: ➢ Where there are current police inquiries relating to an institution alongside specified operations focusing on non-recent abuse one strategic management group has oversight of the whole picture and can plan to meet the needs of survivors, current children and the organisation as a whole; ➢ There is clarity about the link between police command structures via Gold, Silver and Bronze groups and the multi-agency management of complex inquiries. Recommendation 5d Home Office guidance should clarify the process of informing interested parties when names of alleged or convicted perpetrators are released to the public and press statements made. All police officers should be aware of the policy and be able to advise others with accurate information. Recommendation 5e The Department for Digital Culture Media and Sport should require social media platforms to release information to the police where they have reason to suspect that a suspect has continuing access to children during an investigation into child abuse. Recommendation 6a At a national level, given the strong message from the Department of Health, The Department of Education should work with the Department of Health to review the evidence in respect of the impact of alcohol on young people and links with child abuse and give a strong steer to schools as to the expected standards of practice for staff and pupils in day and boarding environments. Recommendation 6b The role of GPs within school should be clarified through the development of guidance by the Royal Collage of General Practitioners Recommendation 6c The Department for Education should require schools to develop a system of safeguarding supervision for staff which provides an opportunity for reflection on any concerns about the safety of pupils. Recommendation 6d St Paul’s School should review communication with its parents in order to strengthen the message that parents are welcome at the school and any concerns or complaints about the wellbeing of their son in school are welcome and will be treated sensitively. Recommendation 6e The Department for Education should revise national complaints guidance for schools to ensure that complaints that cannot be resolved informally (stage 1) or by formal internal investigation (stage 2) should always include an independent investigation at the next stage prior to any panel hearing. FINAL 13.1.20 Page 94 of 112 Official Recommendation 6f St Paul’s School should stop promoting any expectation that parents invite tutors to the family home for a social visit. Any visits to the home should be formalised and recorded. Recommendation 6g St Paul’s School should review their process for anonymous reporting of pupils concerns in the senior school and make sure that it replicates the good practice in the junior school. Recommendation 6h St Paul’s School should require the counselling service in the junior school to keep contemporaneous notes in line with expectations in the senior school. Recommendation 6i St Paul’s School should understand any barriers that might be in place preventing pupil’s from talking openly to their tutors and take steps to overcome them. Recommendation 7 The serious case review panel are aware that what has been recommended may be seen as challenging for both St Paul’s School and the Departments of State. Moreover, there is no mechanism for local partnerships to hold Departments of State to account. A panel member has knowledge of the Independent Jersey Care Inquiry and the powerful motivator for change of the recommended review by the same panel two years after publication. For that reason, and given the complexity of our findings, we recommend that a similar short review of progress in about two years would be advisable in this case to consider the progress of the recommendations locally and nationally. The partnership board should consider how best this should be undertaken. FINAL 13.1.20 Page 95 of 112 Official APPENDIX 1: DETAILS OF LEAD REVIEWERS Edi Carmi (review chair) Edi Carmi, qualified as a social worker in 1978 and after a career as a practitioner and manager in both statutory and voluntary sectors, has worked independently for 19 years. During that time she has focused primarily on the safeguarding of children, undertaking serious case reviews as well as writing policy and procedure. She was the lead author of the first pan London child protection procedures, as well as the procedures throughout the South East. Since 2009 she has been working with the Social Care Institute for Excellence (SCIE) in the development and implementation of the Learning Together methodology for learning from practice and more recently leading the national audit of diocesan safeguarding for the Church of England and author of the 3 published overview reports. She has considerable experience on learning from reviews where there are multiple victims, involving both non recent and recent abuse; this has included reviews into cases of child sexual exploitation, child on child abuse, the early deaths of 13 care leavers in Somerset and the abuse of children within adopted families. She has a particular interest in institutional abuse and was the author of a report for the Diocese of Chichester, subsequently known and published in 2014 as the 'Carmi' report, into the abuse of choristers. She was also a joint lead reviewer, with Jane Wonnacott, on the serious case review into Southbank International School London. Jane Wonnacott (report author) Jane qualified as a social worker in 1979 and has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on child protection practice. She has significant experience in the field of safeguarding at a local and national level. Since 1994 Jane has completed in excess of 150 serious case reviews, many of national significance. She has a particular interest in safeguarding practice within organisations and was the lead reviewer for two reviews into abuse in nurseries and the serious case review into Southbank International School London. She has contributed to the literature exploring effective safeguarding education settings. Jane is a member of the national Child Safeguarding Practice Review Panel pool of reviewers. As Director of In-Trac Training and Consultancy, Jane has been instrumental in developing a wide range of safeguarding training and oversaw In-Trac’s contribution to the development of the “Achieving Permanence” training materials for the Department of Education. She has a long-standing interest in supervision and developed a national supervision training programme for social workers with the late Tony Morrison. She has recently worked with colleagues to apply this model in school settings. FINAL 13.1.20 Page 96 of 112 Official APPENDIX 2: PANEL MEMBERS ➢ Associate Director School Standards and Performance, Achieving for Children; ➢ Deputy Head of Investigations Team, Charity Commission; ➢ Detective Sergeant, Specialist Crime Review Group, Metropolitan Police Service; ➢ Deputy Chair of Governors, St Paul’s School; ➢ Director of Children’s Social Care, Achieving for Children; ➢ Designated Doctor for Safeguarding Children, Wandsworth Clinical Commissioning Group; ➢ Consultant Psychiatrist, CAMHS; ➢ Chief Inspector, Independent Schools Inspectorate; ➢ Head of Law, Social Care and Education, South London Legal Partnership. FINAL 13.1.20 Page 97 of 112 Official APPENDIX 3: TERMS OF REFERENCE Decision to hold the Review This Learning and Improvement Case Review has been instigated by Richmond LSCB (Local Safeguarding Children Board) under the auspices of Working Together 2015. The LSCB Chair, decided on 26.04.17 that a Serious Case Review should be held in respect of St Paul’s School, Barnes following concerns about multi-agency working in situations of non-recent child abuse from 1960-2013. St Paul’s School includes both the Senior and Junior Schools (formerly known as Colet Court). Notification to the Department for Education was made on 09.05.17, to IICSA (Independent Inquiry into Child Sexual Abuse) on 09.05.17 and to the National SCR Panel on 04.05.17. It was deemed that the case review was necessary because it is now known that at times during the period in question: • Children have been harmed and there are concerns how the organisations or professionals worked together to safeguard the children; • Children are known to have been subjected to particularly serious sexual abuse in the period 1974 - 1992; • Another child is known to have suffered emotional abuse from September 2003 - June 2005 • Agencies had a significant history of involvement with the School since 2013. (Working Together 2015) Methodology: This review will use a methodology for the serious case review, which focuses on learning about the safeguarding systems in the period under review within the school and the multi-agency environment. This aims to learn how to improve the ways professionals in all agencies can better safeguard children within SPS and other children's educational establishments. The review will have two lead reviewers. Edi Carmi will be the independent Chair: she is an experienced SCR review report writer and Chair. The other reviewer will be Jane Wonnacott, an independent experienced reviewer, who will be the prime author of the report. Both have a social care background of expertise. The Serious Case Review will be overseen by a Panel, which will support the work of the lead reviewers, agree the review process, help facilitate the co-operation of their own agency and agree the final report. The lead reviewers will determine the exact nature of the evidence required and how this should be collated. This determination will include information from the: ➢ Metropolitan Police; ➢ London Borough of Richmond Children’s and Adult Services; ➢ Richmond LSCB; FINAL 13.1.20 Page 98 of 112 Official ➢ St Paul’s School, including the School Health Team and School Counsellor; ➢ Any relevant evidence from health services including GPs - Wandsworth and Richmond CCGs (Clinical Commissioning Groups) and community health services, including mental health services as required; ➢ National College of Teaching and Learning (NCTL); ➢ Independent Schools’ Inspectorate (ISI); ➢ Charity Commission. In line with national guidance which expects that professionals, families and survivors should be fully involved in serious case reviews, the review panel will determine what opportunities to offer staff, pupils and former pupils (including survivors), parents and professionals to contribute to the review directly. This will include consideration of how the review learns about cultural change and how best to communicate the findings of the review. Key issues and questions this case raises: The purpose of this Serious Case Review is to establish understanding of the multi -agency management of allegations of abuse in SPS and to identify learning for multi-agency working with independent schools and other relevant educational establishments. The review has been timed to begin after the trials for Met Police Operation Winthorpe ended in February 2017 and when information was released into the public domain. The reviewers will consider in respect of all agencies involved: ➢ What happened at St Paul’s School? This relates the what is known about the abuse children suffered in the period under review, and what opportunities were there to investigate possible abuse of pupils, including the events already identified through the police investigation; ➢ Professional responses: Who did what and the underlying reasons that led to individuals and organisations acting as they did?; ➢ What improvements have been made and how they have been sustained? ➢ What further improvements need to be made? Lines of enquiry So as to build on learning from the Southbank International School Serious Case Review (January 2016), published by Hammersmith & Fulham, Kensington and Chelsea and Westminster LSCB the SCR Review Panel have highlighted the following lines of enquiry: ➢ How to effect changes in an institution to improve the safeguarding of children; ➢ How can we develop national learning around the interface between independent schools and the multi-agency safeguarding systems; ➢ What can we learn about the involvement of the whole integrated school network in keeping children safe, including school nursing, school counsellor and school GP? ➢ How do internal school health systems relate to the wider multi-agency safeguarding systems? FINAL 13.1.20 Page 99 of 112 Official Time period of review Enquiries and chronologies will cover the period from 1960 to 19.04.17. This latter date marks the point when it was recommended by the SCR sub-group of the LSCB to initiate a serious case review. The decision to cover this extended period is to be able to look at both historical, non-recent and current practice, so as to cover: ➢ The periods when perpetrators and alleged perpetrators were working at the schools; ➢ The period when the more recent perpetrator worked at the school and also the concerns highlighted in the Laidlaw review; ➢ Current practice (it is usual and expected in serious case reviews to contrast and compare current safeguarding practice / culture to that existing when the abuse occurred). Panel members Senior managers from involved agencies constitute the SCR Panel: ➢ Edi Carmi – Lead Reviewer: Independent Chair; ➢ Jane Wonnacott – Lead Reviewer: author of report; ➢ Governor, St Paul’s School; ➢ Director of Children’s Services Children’s Social Care (Achieving for Children); ➢ Named Nurse SWLStG (South West London and St George’s); ➢ Associate Director for School Standards and Performance, Education Services, AfC; ➢ LSCB legal adviser; ➢ Designated Doctor, Wandsworth CCG; ➢ Metropolitan Police Review Team; ➢ Chief Inspector Independent Schools’ Inspectorate; ➢ Deputy Head of Investigations Team, Charity Commission. The LSCB manages and provides administration for the review process. Information from agencies Each agency will be asked to provide information to the SCR as follows: Preliminary information: In order to facilitate what information is required and where this can be obtained we are firstly asking the police to provide the names of each ex member of staff from SPS who has been convicted or suspected of abusing children. This includes suspected abuse of children who were not pupils at the school. Also for the police to provide all pupils or ex-pupils of SPS known or suspected to be a victim of abuse from any ex members of staff at SPS . There is no information of this nature in relation to current members of staff, but should this emerge the SCR needs to be notified. Agencies (see section 2) are asked to identify what sources of information may provide relevant information about each person on the police list. Consideration needs to be given to where there FINAL 13.1.20 Page 100 of 112 Official may be concerns reported e.g. the individual child and adult files and records of complaints, concerns and disciplinary investigations. Agency Chronology Each agency is required to provide a chronology of the information on files about any concerns or complaints in relation to the welfare of children linked to the behaviour of staff named on the police list, and the professional responses that resulted. To accomplish this the files of the ex-teachers on the police list are to be accessed, along with the files of those ex-pupils who are mentioned in the police list. The latter should include checking for relevant information on all the child's files, including any GP, School Nursing and School Counsellor records. It is important in include the rationale at the time for decisions made and actions taken or not taken. The time period to be covered is 1960-19.04.17 For SPS and SPJ, we are requesting, in addition to the information on named individuals, a review of the following records for any allegations (and responses) that indicate concerns that a member of staff has behaved in a way that has harmed a child, or may have harmed a child, possibly committed a criminal offence against a child or behaved towards a child in a way that indicates he or she could pose a risk of harm to children: • the Welfare/Safeguarding Concern files, • the SPS/SPJ Formal Complaints files, • SPS/SPJ Informal Concerns files, • Bullying files. Relevant information relating to individuals should be provided without disclosing the individual’s name (using a code instead e.g. child A, teacher X). The purpose of this information is to assist an understanding of safeguarding culture over time. If the name of a pupil and/or member of staff comes up repeatedly or is the subject of serious concerns, the relevant individual's files should be checked for more detail of the management of the concerns / complaints. Other agencies are asked (at least initially) to collect information relating to the individuals identified by the police (children and convicted or suspected perpetrators). Additionally, please include all contacts with the school itself around safeguarding. Should SPS and police identify further individuals of interest (either as victims or suspected perpetrators), the SCR Panel may ask for further information. All agencies should use the chronology template provided by the LSCB, as the individual agency chronologies will be merged so as to provide a single multi-agency chronology. Agency report No management reviews are requested as part of this SCR. Instead, each agency is asked to provide a very brief comment on practice of their agency over the years, and thoughts in relation to the issues and lines of enquiry listed in sections 3 and 4 of these terms of reference. Additionally, each agency is asked to identify any staff who should participate in the review by way of an individual or group meeting. FINAL 13.1.20 Page 101 of 112 Official Involvement of staff The review will consider the collated chronology and develop its learning through individual practitioner and group interviews. The group sessions will be particularly helpful to consider cultural change. Involvement of victims /survivors, pupils and families Victims / survivors and/or their families will be offered opportunities for individual meetings with the lead reviewer and another panel member. Research evidence Appropriate research will also be used to inform the review. Review report The Review report will identify how the learning will be acted upon by agencies and within which timescales, in order to improve safeguarding practice in the borough, other local authority areas involved. It is also anticipated that the review will provide learning for independent institutions in general and possibly for other children's educational establishments. Parallel reviews SPS have commissioned Barnardo's to undertake an independent review of safeguarding culture within the school. This will be provided to the SCR. It is not intended that Barnardo's approach any victims/survivors for interview and Barnardo's will collaborate with the SCR lead reviewers, including a planning meeting, to ensure in so far as possible that no-one is subject to repeated meetings (unless that is their wish). There is a current Met Police Sapphire investigation taking place involving an ex- teacher from St Paul’s School. No current or past pupil from SPS is involved in this investigation. This and any subsequent investigations will be reported into the SCR Panel by the Met Police representative, DS Rendell, but will not be taken into the scope of the review. There has been a Police senior management review into one of the recent investigations, which led to Court acquittal. A timeline is found at Appendix 1. Management of SCR Elisabeth Major, LSCB Professional Adviser will be the link person for the review and will coordinate this review with Sarah Bennett, LSCB Coordinator. These terms of reference have been agreed by the LSCB Chair, Deborah Lightfoot on 5th July 2017, following discussion at the first panel on 29th June and the SCR Subgroup on 5th July 2017. The terms of reference should not be changed by any independent agency or by the overview writer. Where changes or amendments are required as a result of emerging issues, this should be agreed by the SCR Review Panel and by the LSCB Chair. FINAL 13.1.20 Page 102 of 112 Official APPENDIX 4: CONVICTED PERPETRATORS Perpetrator Date of Conviction Offences and Sentence Period of Employment at St Paul’s School P1 1979 July 2016 Convicted of gross indecency against a 15-year-old boy. He was fined £100. At the time of this conviction, P1 was serving with the Royal Navy and was required to leave. Convicted of indecently assaulting a pupil at St Paul’s School in 1992. He received a six years and 8 months custodial sentence. 1990-92 1990-1992 P4 April 1987 May 1991 August 2001 May 2010 November 2011 September 2016 Convicted of gross indecency with a child and fined £350. Convicted of gross indecency with a child and fined £100 and bound over for 12 months. Convicted of four counts of indecent assault and sentenced to four years imprisonment and required to register on the Sex Offenders Register for life. He was released from custody in March 2004. Convicted of Making Indecent images of Children. He received a two-year Conditional Discharge and was made subject of a Sexual Offences Prevention Order for life. Convicted of breaching his notification requirements and sentenced to an 18-month Community Order and a Supervision Requirement. A travel ban was imposed, preventing him from travelling outside of the UK until November 2016. Convicted of non-recent indecent assault on a St Paul’s pupil and possession of indecent images of children and sentenced to 14years and 9 months imprisonment. 1973-75 P5 February 2014 Convicted of possession, making and distribution of indecent images of children and sentenced to two years imprisonment suspended for two years, Supervision Order. Sex Offenders Notice for ten years. 1965-2003 P2 June 2015 13 offences of possession of indecent images of children. He was sentenced to three years imprisonment suspended for 24 months, 2-year supervision order, sex offenders notice for 7 years, Sexual harm prevention order for 7 years and disqualified from working with children. 1992-2013 P3 February 2017 Sentenced to 18 years imprisonment for 24 counts of non-recent indecent assault and 1 count of gross indecency. 1972-81 Final 13.1.20 Page 103 of 112 Official APPENDIX 5: TIMELINE OF PERPETRATORS AND ALLEGED PERPETRATORS EMPLOYMENT AP44 started in 2000 but end date unknown Perpetrator AP7 start date unknown but employment ended in 1975 Alleged Perpetrator AP41 (Deceased) employment dates unknown FINAL 13.1.20 Page 104 of 112 APPENDIX 6: PROFESSIONAL DISCUSSIONS FOR SERIOUS CASE REVIEW Charity Commission: Head of Schools and Education, regulatory compliance Head of Investigations and Enforcement Senior Investigator Department for Education: Team Leader Deputy Director for Independent Education Division Feltham CAIT: Detective Constable Detective Superintendent Independent Schools Inspectorate: Chief Inspector Duty Team member Legal, Regulatory and Policy team Duty Team member LADOs: Current LADOs and former LADO LSCB: Professional Adviser LSCB Chair Health: Designated Doctor for Safeguarding Children Designated Nurse Private Consultant Paediatrician Insurance Company: UK Legacy Technical Manager Mercers Company: Clerk to the Mercers Principal Staff Officer Legal Representative Met Police: Sergeant, Met Police Review Team Detective Constable, Operation Winthorpe Retired DI (was SIO), Operation Winthorpe Detective Superintendent School Counsellors: Dr, SPS counsellor Dr, SPS juniors counsellor School Health: Chief Operating Officer School doctor Head Nurse SPS Nurse St Paul's Juniors Nurse, Former School Nurse SPS Former School Nurse SPS Former School Nurse Colet Court Former School Nurse Colet Court School Leadership and safeguarding professionals: High Master, (x 2 meetings) Safeguarding Governor Chair of Governors Deputy Chair of Governors FINAL 13.1.20 Page 105 of 112 Human Resources Director Designated Safeguarding Lead (x 2 meetings) Safeguarding Coordinator TRA (Formerly NCTL): Team Leader Head of Operations Head of Teacher Misconduct Unit Report Authors of Commissioned Reports: Jonathan Laidlaw QC Co-authors “the Badman report” Barnardo's Report authors: FINAL 13.1.20 Page 106 of 112 APPENDIX 7: STAFF DISCUSSIONS FOR SERIOUS CASE REVIEW Ex Staff Dates at School Senior or Junior? 1. 1966-97 Senior 2. 1978-2007 Both 3. 1991-1999 Both 4. 1968-2002 Junior 5. 1976-2016 Senior 6. 1981-2009 Senior 7. 1965-2001 Senior 8. 1974-2006 Both 9. 1970-2004 Both 10. 1967-2002 Senior Current staff 1. 1986-present Junior 2. 1983 -present Senior 3. 1978-present Senior FINAL 13.1.20 Page 107 of 112 APPENDIX 8: TERMS OF REFERENCE FOR STRATEGIC MANAGEMENT GROUP Strategic Management Group An investigation of organised and complex abuse, as these Operations constitute, is carried out under the auspices of the LSCB. Recognising the strategic complexity of these operations, Richmond LSCB has requested the formation of a Strategic Management Group (SMG) to coordinate and oversee these Operations and report to the LSCB. This follows LSCB Procedure Organised and Complex Abuse Investigations [enclosed] and builds on Working Together 2013, the London Child Protection Procedures 2014. The SMG will remain in existence at least until the Court or CPS has made a decision regarding the alleged perpetrators. The SMG ensures a coordinated response to concerns of complex and organised abuse. It acts as a steering group to ensure: • Identification and liaison with relevant LSCBs and their local agencies; • An information sharing protocol; • The scale of the investigation, and staff required; • The tasks of the joint investigative group and its interface with the SMG, via a named coordinator; • Development of a risk management protocol; • Agreement regarding the management of potential compensation for victims; • Sufficient support, safety and debriefing of staff involved in the investigation; • Preparation of [vulnerable] witnesses for criminal proceedings; • Secure records management; • Briefing of key senior leaders, including the LSCB Chairs and a media strategy; • The welfare of children and vulnerable adults involved; • The timely commitment of resources to the investigation; • Involvement of independent / third sector agencies; • The quality, progress and integrity of the investigation; • The appropriate timing of the termination of the investigation; • A debrief meeting with the joint investigation group to identify lessons learnt; • Regular reports in writing to the LSCB SCR Subgroup; • The recommendation to the LSCB regarding a review of the case. The SMG must agree a schedule of dates for future meetings. FINAL 13.1.20 Page 108 of 112 APPENDIX 9: OVERVIEW OF INTERNAL AND EXTERNAL REVIEWS AND INSPECTIONS OF ST PAUL’S SCHOOL ISI Inspection October 2001 ISI Inspection November 2007 ISI Inspection March 2013 ISI Emergency Inspection February 2014 Independent Compliance Inspections (VWV) April 2014 Badman Review Commissioned June 2014 Charity Commission Statutory Inquiry opened June 2014 Laidlaw Review commenced January 2015 Independent Compliance Inspections (VWV) August 2014 ISI Progress Monitoring Visit October 2014 Badman Review findings published March 2015 Laidlaw Review findings published July 2015 Charity Commission statutory inquiry findings published August 2015 Independent Boarding Review October 2015 Independent review of in-house provision of routine medical services January 2016 ISI Inspection – Boarding & Compliance March 2016 ISI Inspection – Educational Quality and Compliance March 2017 Barnardos review completed December 2017 FINAL 13.1.20 Page 109 of 112 APPENDIX 10: SUMMARY OF INTERNAL REVIEWS AND THE SCHOOL’S RESPONSE. Internal Case Review In 2013 following a serious incident a review of boarding [policies and practices led to a number of changes. The changes were effected immediately and included: ➢ A reduced workload of the House Master and increased boarding staff team to ensure mutual supervision; ➢ Changes to accommodation of staff to further reduce risk; ➢ Boarding House staff no longer act as pastoral tutors to boarders – providing boarders with a pastoral tutor who is not a member of the house staff helps to ensure any concerns can be raised away from the house; ➢ Level 2 and 3 Child Protection training, as appropriate for all staff; ➢ Updated Staff Code of Conduct and Alcohol Policy; ➢ Increased oversight of the boarding house by Senior Managers and Governors; ➢ Increased induction training for staff regarding safeguarding and Staff Code of Conduct. Independent Compliance Review In 2014, the Governing Body responded to the publication of news stories about historic abuse allegations, and the introduction of KCSIE53 in April 2014, by commissioning an unannounced independent safeguarding review by a leading firm of solicitors with expertise in compliance in independent schools. This found that the school was compliant with statutory requirements and suggested several improvements which were immediately implemented. These included changes in the formatting of the single central register, amendments to staff information posters and job descriptions. The Badman Review In June 2014 the Governing Body commissioned Graham Badman, who had no previous contact with the school, to carry out a comprehensive independent review of the safeguarding policies, procedures and culture of the school, and to make recommendations to enable the school to develop and improve practice, in order to move beyond basic standards of compliance. The Badman Review confirmed that the school was “fully compliant with statutory requirements and regulations pertaining to child protection.” Its recommendations were therefore designed to enable the school to move from compliance to becoming a centre of excellent practice and focused on strengthening the role of the Governing Body. As a result of the recommendations of the review an action plan 53 Department for Education: Keeping Children safe in Education FINAL 13.1.20 Page 110 of 112 was implemented in 2015 and 2016 and was monitored frequently by the Governing Body. Significant actions were: ➢ changing the name of the preparatory school to St Paul’s Juniors to create a single school identity; creating a single admissions office with unified marketing and communication; and a review and alignment of school policy, management and staffing and curriculum; ➢ The development of an annual Governor safeguarding review; ➢ The creation and appointment to the new role of a Safeguarding Coordinator who is Deputy Designated Safeguarding Lead at both schools, providing a link across the schools and ensuring consistent standards of practice. The Safeguarding Coordinator also reports to the weekly pastoral management meeting at the senior school, the weekly safeguarding management meeting at the junior school and provides supervision meetings for the school nurses, undermasters and boarding housemaster. This role also undertakes training of staff on safeguarding issues; and is available to all staff to discuss any safeguarding issue; ➢ The establishment of a new Governors’ Safeguarding Committee with a specific remit to bring together the governance and oversight of safeguarding policy and practice across the whole school. The Laidlaw Review In January 2015 the school commissioned Laidlaw QC to investigate a complaint by parents about the way that the school had handled complaints they had made about the treatment of their son in 2005 – 07 and again in 2011 and 2013. The request from the parents for the investigation had been prompted by the arrest of a member of staff at Colet Court for the possession of indecent images of children. Although the Laidlaw report was commissioned by the school, a full copy was given to the parents who were happy for this to be given to this serious case review and have spoken openly to the reviewers knowing that the final serious case review report will be a public document. In addition, the contents of the Laidlaw report were shared by the parents with a journalist and reported in detail in The Times newspaper54. The Laidlaw review found that the investigations by a previous head teacher at Colet Court and a previous High Master at St Paul’s School were not in accordance with regulations. Laidlaw did not make any recommendations for improvement to the school, on the grounds that he was ‘quite certain’ that the complaint would have been treated differently in 2015. His basis for this judgement was the evidence of confidential and anonymous staff interviews; the substantial changes in the national safeguarding framework between 2005 and 2015; the evidence from the Badman Review of compliance with that framework; and evidence of cultural change within the school. Following consideration of the details of the report the senior management team: 54 Andrew Norfolk The Times 10th October 2015 FINAL 13.1.20 Page 111 of 112 ➢ Adjusted the content of the compulsory safeguarding training for all staff to place special emphasis on spotting and reporting possible signs of inappropriate or odd behaviour that might lead to or indicate possible physical, emotional or sexual abuse, and how to report any such concerns; ➢ Initiated an annual lecture series on mental health; ➢ Created a new role of Head of Mental Health and Wellbeing (Head of MH&W) as a member of the school’s senior leadership team; ➢ Set up a 'Mental Health and Wellbeing Working Group', which reviewed the school’s PSCHE provision to provide an enhanced curriculum to include life skills, critical thinking, safeguarding and wellbeing education, as well as the traditional PSCHE components (which have included education on anti-bullying and online eSafety); ➢ Commissioned Youth Mental Health First Aid Training for the pastoral staff; ➢ Improved monitoring of mental wellbeing. External Report on Boarding The school’s executive commissioned an experienced independent inspector (Sally Rosser) to review boarding provision at the school. The conclusions were positive but as result refinements were made to practices and procedures focused mainly on the storage and recording of medication. Review of Medical Provision, including an independent report from SAPHNA55 A comprehensive review of medical provision was led by the school’s Chief Operating Officer and in order to ensure appropriate specialist input, a separate visit and report was commissioned from SAPHNA who provided an independent report. SAPHNA concluded that practice was safe and students’ needs were at the heart of nursing care but the nursing role was under-developed and opportunities, particularly in relation to nurse-led health interventions, were likely to be missed. The overall review concluded that medical provision ‘is broadly appropriate’ and recommended a restructure of roles and reporting lines; recording systems and the creation of an overarching medical strategy. These recommendations were accepted and implemented. Review of lessons from an external serious case review St Paul’s School reviewed its own practices and procedures in the light of the published recommendations of the South Bank serious case review. The main changes included: ➢ Changes to the educational trips policy to make sure staff did not attend without a DBS check; ➢ Reviewing interview questions and panels to make sure no sole interviewing took place; 55 School and Public Health Nurses Association FINAL 13.1.20 Page 112 of 112 ➢ Creation of a bespoke system for overseas checks; ➢ Review of educational visits policy; ➢ Review of in house training to ensure that the content includes the modus operandi of sex offenders and to ensure sufficient attention is given in training in respect of recognition, reporting and responses to abuse of young people by persons in a position of trust; ➢ Introduction of online Neutral Notification system so that staff can record possible concerns; ➢ Improving pupil’s awareness of availability of staff members to turn to for advice. Barnardo’s review Before the start of this serious case review St Paul’s School had begun discussions with Barnardo’s Consultancy regarding an independent evaluation of current safeguarding practice and progress since the Badman review. The four key areas addressed by the review were: ➢ The effectiveness of the overall safeguarding system and the various safeguarding arrangements already in place; ➢ The safeguarding aspects of activities offered to boys across both junior and senior schools including boarders; ➢ The targeted activity carried out to safeguard vulnerable groups of children; ➢ The identification and prompt response to child protection concerns. The review took place concurrently with this serious case review, reported in 2018 and its findings have been used to underpin the analysis in this report. The review confirmed the school’s progress in developing sound safeguarding practice and made 33 specific recommendations for further improvement which were developed into an action plan. |
NC52454 | Death of a 19-month-old infant girl in March 2020. The mother was convicted of her murder. Learning was identified around: the importance of recording information accurately and the need to be precise in the language used, to avoid formulaic language and better support understanding of risk; the importance of implementing a holistic assessment of the adult and child which considers predisposing vulnerabilities, risks for the adult and child and the potential impact on and experience of the child in relation to those vulnerabilities and risk; ensure childrens workers have access to expertise in adult factors such as mental health and substance misuse which may affect their care of a child; address any gaps in understanding between childrens services practitioners and adult mental health services; and the need for empathetic curiosity and doubt about what parents say on topics which are inherently sensitive. Recommendations include: review correspondence sent out to patients when they are offered an intervention specifically in relation to waiting well whilst on the list; and explore models of integration between adult and childrens health and social care services so that the services can undertake joint assessments of adults with parental responsibilities who have issues including mental health problems and substance misuse.
| Title: Child safeguarding practice review for SN20. LSCB: Nottinghamshire Safeguarding Children Partnership Author: Colin Green Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review for SN20 1. Executive summary. 1.1. This review concerns Jean who was 19 months old when she died in 2020. Her mother was subsequently charged and convicted of her murder and received a life sentence. Jean and her mother were involved with a range of children’s social care and health services and Jean’s mother with adult community and mental health service. The focus of concern was Jean’s mother’s vulnerability due to mental health and substance misuse problems and the impact these might have on Jean’s care. At no stage were there concerns about the development or standard of care of Jean. The review concluded that Jean’s death could not have been anticipated or predicted. 1.2. The review has highlighted issues in how children and adult health and social services work together. There is a need for better joint working to improve access to the expertise held within each service and to improve the quality of assessments of adults with parental responsibilities. Improved assessment will help the implications of adult issues to be fully considered in relation to an adult’s parental responsibilities and appropriate help provided. The review also highlighted the negative impact of long waiting lists for service in adult mental health service. 2. Reason CSPR undertaken 2.1. As Jean was a child who died and the cause of death was abuse or neglect Nottinghamshire Safeguarding Children Partnership undertook a ‘rapid review’ of the case immediately following Jean’s death as required by Working Together to Safeguard Children (2018). The ‘rapid review’ concluded that this case met the criteria for a serious safeguarding case; a child had died, and her mother had been charged with criminal offences relating to the death. The rapid review had highlighted issues regarding the way children and adult 2 services had worked together and considered that additional learning would be gained by undertaking a more detailed review. The decision of the rapid review was that a local child safeguarding practice review was required and this decision was endorsed by the strategic leadership group of Nottinghamshire Safeguarding Children Partnership. 3. Jean – pen portrait. 3.1. Jean was described by her Family as a child who was always happy, funny and mischievous. She was into everything and would leave nothing alone. She was able to wrap members of her family round her finger and cried if she did not get what she wanted. She was affectionate and sociable and liked to mix with other children but was wary of men. She enjoyed her food. She was generally healthy and well but small for her age. 4. Family Composition 4.1. Sarah Mother Mid-twenties Jean Child Maternal Grandparents (MGPs). Jean and Sarah lived with MGPs for part of the review period until they secured their own accommodation close to MGPs home. Younger siblings of Sarah living with MGPs. Adult sister of Sarah. Lived nearby and active in support of Sarah. 5. Chronology of multi-agency work with Sarah and Jean. 5.1. The period covered by the review is 1st January 2018 (early in Sarah’s pregnancy with Jean) to Jean’s death in 2020. There are several important events outside the review period. These are: • Sarah was sexually abused aged 7 yrs. This was not perpetrated by a member of the family household. The abuse was disclosed during Sarah’s mid-teens and investigated by the Police but the abuser was not prosecuted or convicted. Sarah was supported by her parents. • Sarah reported historical domestic abuse with a previous partner. • Sarah had taken an overdose in 2016 and was seen by the rapid response mental health team and directed to the Improving Access to Psychological 3 Therapies (IAPT) service and her GP for further help. Sarah wanted help with anger and mood problems. Sarah was reported as having had mental health problems including depression and anxiety from adolescence. 5.2. Sarah’s pregnancy was medically uneventful but Sarah reported it as emotionally difficult. Jean was born at full term and in good health. Sarah did not disclose who Jean’s father was and this person played no part in Jean’s life. Sarah was living with her female partner and her partner’s children when Jean was born. Sarah brought Jean for immunisations and made regular use of her GP for her own and Jean’s health needs. The universal services they were in contact with expressed no concerns about Jean’s care and development up to March 2019 when Jean was nine months old. 5.3. In March 2019 Sarah took an overdose of paracetamol and over the counter sleeping tablets. She informed her partner who called an ambulance. The relationship with Sarah’s partner broke down while Sarah was in hospital following the overdose. Sarah and Jean moved to live with Sarah’s parents and siblings. 5.4. The overdose led to the first of three referrals to the Multi-agency Safeguarding Hub (MASH) over a three-week period. The MASH made enquires including with the family about how Jean’s safety was ensured and where she was at the time of the overdose. After these enquiries it was decided by MASH that no further action was needed on this first referral given the support for Jean and her mother from their family. The trigger for the overdose was not clear. There seemed to be several factors including Sarah’s drug use and her relationship with her ex-partner. 5.5. The second referral was from maternal grandmother (MGM) concerned about Sarah taking cocaine, the extent of this drug taking and its impact on Jean. Sarah said she had a diagnosis of anxiety and depression and that she had been referred to the local provider of substance misuse services. At the time of the referral MGM was doing most of the parenting of Jean, and both Sarah 4 and Jean were living with MGPs and being supported by them. MGM made a further contact with MASH a few days later reiterating her concerns about Sarah taking cocaine and that Sarah had not attended her appointment with the substance misuse service. Following this referral and considering the evolving picture given by all three referrals, a social worker was allocated to undertake a Child and Family Assessment. The MASH assessed that the Tier 4 threshold was met given the concerns about drug use and whether Sarah could safely parent Jean. The thresholds document is available at pathwaytoprovisionhandbook.pdf (nottinghamshire.gov.uk) 5.6. The assessment involved two visits to the family home where MGM and Sarah were spoken to and Jean was observed. The assessment concluded that Jean had a supportive and loving family within which she was thriving. However, there were concerns about Sarah and that she had not parented on her own before. Sarah said she would accept support. The assessment was clear that if Sarah did not engage and continued to use cocaine then social care would need to be involved. 5.7. The recommendation from the assessment was for support to be provided to Sarah and Jean from the Family Service, an early help service, when Sarah and Jean moved to their own accommodation close to Sarah’s parents’ home. The case was to remain open to a social worker until the handover to the Family Service. This approach recognised that Sarah needed support in relation to guidance and boundaries, general parenting and budgeting and the continued concerns about her drug taking. It recognised the strength and level of support and care Sarah and Jean received from their family including their concern about Sarah’s drug taking. The Family Service case manager worked with Sarah and encouraged her to attend the substance misuse programme to help her cease cocaine use. With this encouragement Sarah did attend the substance misuse service. 5.8. The Family Service case worker organised a Team Around the Family (TAF) meeting in August 2019. The records show there was active liaison between 5 Sarah, the Family Service case worker, substance misuse worker and community health services. Sarah and Jean moved to their own home in July 2019 which was close to the MGPs. In July 2019 Jean had her 8 to12 month developmental review where it was assessed she was developing appropriately and was described as a happy social child with positive interactions. The next developmental review would be when Jean was 2 to 2½ yrs. 5.9. In July 2019 Sarah said she was having thoughts of harming someone. In the Family Service visit that followed the practitioners were reassured as to Jean’s safety and Sarah agreed to refer herself to mental health services. On 5th August Sarah contacted by telephone the IAPT, which is part of the Primary Care Psychological Therapies Service, and said she felt she was now getting psychotic and while she did not want to hurt anyone, she got very angry and paranoid. Sarah said she occasionally went out armed with a knife. She said she was looking for someone to stab. The reason she said this had not happened was because she went out at night and could not find anyone. In response to this the IAPT service contacted the Police who attended. This was following the IAPT service’s usual protocol for someone reporting risk to others. The service also called the crisis team for mental health intervention for an urgent psychiatric assessment. 5.10. The Mental Health Crisis Team would not visit because of the perceived risk i.e. that Sarah was armed with a knife. Three Police officers attended with Tasers. The Police found Sarah not armed. She had told the Police she was experiencing thoughts of harming someone and felt that she needed help. The Police did not assess Sarah as a threat to herself or others. Jean was at her MGPs home during these events. The Police sought help from the Street Triage Team but they could not help as Sarah was in her home. No mental health service was provided to Sarah on the day of this crisis. Following this crisis, the GP referred Sarah to the local mental health team who discussed this referral on 12th August and agreed Sarah should be accepted for assessment. This assessment took place in November 2019, a wait of three months. 6 5.11. This episode led to a further referral to MASH from the Family Service worker. After review, it was agreed with the Family Service that they should continue to work with Sarah and Jean. The social worker discussed the concerns with the Family Service worker and decided that the criteria for Level 4 was not met as other services were meeting the Family’s needs. The criteria for level 3 and 4 are in brief: • Level 3 Targeted Early Help– Children and young people where there are significant concerns over an extended period or where concerns recur frequently. • Level 4 Specialist – Children and young people who are very vulnerable and where interventions from Children’s Social Care are required. 5.12 The Family Service were concerned about the safeguarding issues and agreed that they had a plan in place to address these. Following these events Sarah engaged with the Family Service and the service felt progress was being made. The information those working with Sarah had was that her drug use was reducing and that the work with substance misuse service had been helpful. This was based on Sarah’s self-reporting of her drug use. After the TAF meeting in October 2019 Jean was stepped down to the universal level of Health Visiting service which meant no active role for the healthy family team until the next developmental review. 5.13. In November 2019 Sarah and Jean transferred from the Family Service to the Children’s Centre Service. They continued to have an allocated key worker who was from the children’s centre. Sarah and Jean were already attending stay and play at the children’s centre. This was a familiar local service for Sarah and Jean. 5.14. In November 2019 two CPNs saw Sarah for assessment. This was the assessment arising from the GP referral and crisis in August 2019. The outcome of the assessment was that Sarah was placed on a waiting list for Distress Tolerance and Stabilisation Therapy (DTST) and was provided with 7 the contact details of the mental health crisis team. The likely wait for the DTST service was twelve months. The CPNs assessed that they did not think there was a risk to Jean or that Sarah would act on her thoughts of harming someone. One of the CPNs who had seen Sarah made a referral to MASH. The CPN wanted to share information and this was seen as a contact in the MASH. The information from the CPN was not seen as new by the MASH. The concerns shared had been previously considered and there was an existing plan in place to address the concerns. Following enquires by MASH the case was closed to MASH with the key worker from the Children’s Centre Service continuing as lead professional. The continued allocation to a lead professional recognised there were concerns and that the family were seen as “level 3” meaning they needed intervention and coordination of a multi-agency plan. 5.15. The children’s centre worker worked with and saw Sarah and Jean regularly over the following weeks. This was both at their home and at the children’s centre. The children’s centre worker made positive observations of interaction between Sarah and Jean and of Sarah’s handling of Jean. Sarah was said to be receptive to suggestions made by the children’s centre worker about her care of Jean. 5.16. In December Sarah talked to the children’s centre worker and the substance misuse service worker about dark intrusive thoughts and that cocaine was an escape from her negative thoughts. Sarah said she was using cannabis but not using cocaine. The children’s centre worker believed this and saw no indications of cocaine use. Sarah’s family did not observe or see any evidence of cocaine use. Sarah said Jean was a protective factor for her by which she meant the consequences for Jean of Sarah doing something to harm someone acted as a restraint on her behaviour. 5.17. Jean was seen at least once a week by professionals outside the family, usually at the children’s centre. The substance misuse service and children’s centre workers’ concerns were about Sarah’s mental health and not the care of Jean. Just before Christmas the children’s centre worker contacted the 8 community mental health team who agreed to contact Sarah but they were not able to contact her. The children’s centre worker also made an appointment for Sarah with her GP. In late December Sarah saw the Advanced Nurse Practitioner at her GP surgery who was concerned about Sarah’s mental health. Sarah’s GP wrote to the community mental health team saying that Sarah felt her mental health was deteriorating. The community mental health team considered the GP letter and advised that the crisis team could support if urgent intervention was required. Sarah did not want to go to the crisis team as they called the Police the last time she contacted the mental health services. 5.18. Sarah’s own concerns about her mental health and the concerns about her mental health of the children’s centre and substance misuse workers increased in late December 2019 and January 2020. Sarah told her former substance misuse worker in early January about her thoughts of killing someone and that her intrusive thoughts were more frequent. She also said she felt she could not be totally honest with agencies because she said they would have worries about her parenting of Jean. The substance misuse worker discussed the information with the community mental health team who advised Sarah had been referred for DTST and that if Sarah needed support, she should go to the crisis team. The CMHT did not see the information from the substance misuse and children’s centre workers as new information but reflections of the issues covered in the November 2019 assessment by the CMHT. 5.19. The last contact by the Family Support worker was in late February 2020 which was at Sarah and Jean’s home. This visit did not indicate any concerns about Jean’s care. Jean died in early March. 6. Information known to only one or two agencies. 6.1. There was significant information known to the Police service about Sarah which was not known to other agencies and which suggests important aspects of Sarah’s life which were not visible to those trying to support and help her. 9 This information included allegations of deception, theft (£40), Sarah giving someone where she worked cocaine and obtaining £11/12K from an older man. None of this information led to charges against Sarah. None reached the threshold where Police would submit information to CSC as none were seen to raise safeguarding concerns about Jean. 6.2. Information within NHS and Family Support. • Referral of Sarah for repair of septum damaged by cocaine use. This damage was not visible without examination. The children’s centre worker saw this as historical and not reflecting current cocaine use. • Broken nose from an altercation in December 2019. 7. Information only available after Jean died that was found as part of the Police enquiry. 7.1. In the month before Jean died Sarah had 20 or more contacts about obtaining controlled drugs in particular cannabis and cocaine. Immediately before Jean died the contacts suggest purchase of cocaine and Xanax tablets. Sarah said she was helping others obtain drugs as she had contacts for supply and these were not for her use. 7.2. When the Family home was visited after Jean’s death there was a broken cot and clutter. It looked like there were no cleaning routines. Sarah’s family do not agree that the home was in a poor state based on their subsequent clearance of the home. They did agree it was untidy. 8. Family contribution to this review. 8.1. MGPs, Sarah’s adult sister and Sarah were interviewed. All family members have been seriously affected by Jean’s death. Jean was a much-loved grandchild and niece. 8.2. Sarah’s Family were aware of her emotional and psychological vulnerability and consistently provided her with practical and emotional support. They saw Sarah as vulnerable in other ways for example poor awareness of risk e.g. 10 presence of a hot object or drink near Jean not being recognised as a risk and poor management of money. The Family accepted Sarah was gay and this was not an issue for them or in their view for any of the services who worked with Sarah. Sarah agreed her sexuality was not an issue for her family or led to any discriminatory practice from the services who worked with her. 8.3. The Family saw Jean nearly every day and said she spent a lot of time in her MGPs house but did not sleep there. The Family link Sarah’s mental health problems to the abuse she suffered as a child which Sarah disclosed at 15yrs. The Family saw Sarah’s cocaine use as self-medication and were concerned about money going on drugs and not on Jean’s care. The Family were aware of Sarah’s previous drug use as she told them or they found drug paraphernalia not because they identified her as under the influence of drugs. The Family said Sarah was emotionally very up and down and that her relationships reflected this as she was either “all in” or the relationship was failing. 8.4. The Family view is that Sarah was not listened to about her mental health problems. They saw the substance misuse and children’s centre workers as trying to help Sarah and that both had helpful relationships with Sarah. The Family view was that Sarah would not act on her intrusive thoughts and the thoughts of harm were linked to the person who abused her not to Jean or her Family or others. In early 2020 Sarah’s sister thought she was dealing with money better and her drug use was better. 8.5. Sarah said she was pleased to be pregnant with Jean. Sarah gave a history of two overdoses before the one on March 2019 at ages 16/17yrs and 21 yrs. She confirmed the significant impact of the abuse she suffered aged 7yrs and that when she disclosed the abuse when 15yrs there was no prosecution. Sarah was supported by her immediate family. Sarah regularly felt very low and on bad days Jean went to MGPs. This could be up to 2 or 3 times a week. 8.6. Sarah’s view of her contacts with mental health services reflected that she did not get the help she sought. In March 2019 following her overdose she wanted to be sectioned but as Sarah recognised that she needed help it was not 11 appropriate to section her. In August 2019 the intrusive thoughts were constantly in her head but the response was the Police came and not a mental health service. The November 2019 assessment Sarah described as alright but was followed by knowledge that she would be waiting a year for the service she was assessed as needing. Sarah said that later in 2019 the thoughts about stabbing someone became more intrusive and she was again seeking help. Sarah wanted to talk to someone who would help her understand why she was thinking as she was and that would help change her mindset. She wanted to understand what was going on in her head. Advice to contact the crisis team she did not find useful as her previous experience was, they would not come to her and the Police were called. Sarah wanted someone to talk to about her thoughts not an emergency response. Sarah said that in November 2019 to January 2020 she was otherwise feeling better with a good working relationship with her children’s centre worker and with her mother. 9. Relevant research, policy and other reviews. 9.1. Relevant areas of policy and research • The importance of an identified key worker/lead professional for effective early help/early intervention services is well established. There is a growing body of evidence from the Early Intervention Foundation, Local Government Association and ISOS study of enablers for an effective partnership based early help offer, the evaluation of the troubled families programme and other evaluations of the importance of an effective key worker in delivering early help to children and families.1 • A trauma informed approach across all services may enable earlier identification and intervention for adult survivors of childhood abuse. There are strong links between experience of childhood trauma and 1 Realising the Potential of Early Intervention. The Early Intervention Foundation October 2018. The key enablers of developing an effective partnership based early help offer: final research report. Natalie Parish & Ben Bryant ISOS Partnership. Commissioned by the Local Government Association March 2019 and National evaluation of the Troubled Families Programme 2015-2020: Findings Evaluation overview policy report Ministry of Housing Communities and Local Government March 2019. 12 adverse childhood experiences for example as described in Young Minds publication on Adversity and Trauma Informed practice. 2 • The long-term negative impact on adult mental health and wellbeing of childhood sexual and other abuse is well understood as one of the most harmful of adverse childhood experiences (ACEs). The impact of ACEs is described in the EIF publication Realising the Potential of Early Intervention and their report on ACEs.3 9.2. The evidence on the impact of adverse childhood experiences including sexual abuse on adult mental health is strong but of itself it does not help practitioners know how to address these issues in practice when working with a child and their family. The Triennial Reviews of Serious Case Reviews, Child Safeguarding Practice Review Panel report for 2020 and the chapter on assessing parents by Murphy and Rogers in The Child’s World ed. Horwath and Platt provide valuable advice and guidance on how practice with a parent with Sarah’s difficulties could be improved. 9.3. Key points from the Triennial Reviews Serious Case Reviews are: • The importance of the child’s voice which for very young children like Jean means practitioners reflecting on and imagining what life was like for her. This goes beyond what was done which was to consider her development and health and physical care all of which appeared good. • Maternal mental health, which was a common feature of the cases reviewed by the Child Safeguarding Practice Review Panel, was sometimes not recognised or factored into the overall assessment. The 2 Adversity and Trauma-Informed Practice A short guide for professionals working on the frontline by Rebecca Brennan, Dr Marc Bush and David Trickey, with Charlotte Levene and Joanna Watson. June 2019 Young Minds, Anna Freud National Centre for Children and Families and Body & Soul transforming trauma with love adversity-and-trauma-informed-practice-guide-for-professionals.pdf https://youngminds.org.uk/media/3091/adversity-and-trauma-informed-practice-guide-for-professionals.pdf 3 Adverse childhood experiences What we know, what we don’t know, and what should happen next EIF February 2020 Dr Kirsten Asmussen, Dr Freyja Fischer, Elaine Drayton & Tom McBride https://www.eif.org.uk/report/adverse-childhood-experiences-what-we-know-what-we-dont-know-and-what-should-happen-next 13 Triennial Analysis of SCRs for 2014-2017 found 47% of the cases notified the mother had mental health problems. • Avoiding using generic phrases such as ‘children doing well’. Inaccurate or imprecise language does not support critical thinking and can give false assurances when viewed by other practitioners. • The role of suicide attempts as indicators of risk. • The importance of recognising the interaction of mental health and other risk factors e.g. drug use, childhood abuse, criminal behaviour. 9.4 The chapter on assessing parenting and working with adult orientated issues in The Child’s World4 raises questions about how well Sarah’s needs were understood and the impact of her mental health and emotional difficulties on her care of Jean. These issues include: • Sarah’s availability physically and emotionally, her understanding and ability to act in response to Jean’s needs. • The impact of Sarah’s mental health on her predictability and behaviour in relation to her response to Jean • When Sarah was not well Jean went to MGPs. Whether this entirely understandable response of MGPs masked the degree of difficulty Sarah was experiencing in parenting Jean? • The importance of assessments that combine adult and child frameworks so that the adult orientated issues are assessed in their own right and for their impact on the child. 10. Single agency learning and conclusions. 10.1. Youth, Families and Social Work (YFSW) The YFSW agency report reflects that the service responded with care and proportionately to the information presented. The consideration of the information provided to the MASH was proportionate and the decisions made were carefully considered. There was good liaison with partners and management oversight of decisions on when assessments should be 4 Basarab-Horwath, J. A., & Platt, D. (Eds.). (2019). The child's world : the essential guide to assessing vulnerable children, young people and their families (Third). Jessica Kingsley. 14 undertaken and what service should be provided to Sarah and Jean. The Family Service and then the children’s centre worker offered Sarah and Jean a key worker service which was essential to ensuring good communication with partners, with the family and ensuring there was coordination of the work with the family. The transfers between social work team, Family Service and then children’s centre worker were all well-handled. When the CPN contacted MASH in November 2019 the opportunity for a direct discussion between the CPN and the children’s centre worker was not taken. Such a conversation might have been used to explore further the CPN’s assessment of Sarah and the impact on Jean of living with Sarah having thoughts of harming others. 10.2. The YFSW files were described as in good order with updated chronologies and detailed observations of Jean. Learning was identified in relation to the use of language and the need to be precise, for example that the case was stepped down to Level 3 because there were no safeguarding concerns when it would have been more accurate to state that there were no immediate safeguarding concerns. The use of the term ‘effectively working’ described engagement rather than necessarily positive or sustained change. 10.3. The YFSW agency report notes that with hindsight it is clear that Sarah was selective with information she gave and was not providing information in areas she was most worried about or aspects of her behaviour e.g. her contacts with the Police described in 6.1. The continued involvement of the children’s centre worker reflected concern about the impact on Jean of Sarah’s mental health difficulties and vulnerability. This case was worked with Sarah’s consent. This is usually the most effective way to engage parents and help them change and develop. The observations of Sarah’s parenting of Jean were positive which gave no basis for intrusive challenge. Sarah was well supported by her family which was correctly seen as a strength and protective for Jean. 10.4. With hindsight more probing could have been done about Sarah’s fluctuating mood and her intrusive thoughts of harming others and the impact these might have on Jean. There was not a detailed reflection on what it was 15 like for Jean to be with her mother when she was experiencing intrusive thoughts or in one of her regular periods of feeling down or of what Jean may have experienced when her mother took an overdose and was separated from her or was otherwise unavailable to Jean. 10.5. The practitioners in the Family Service and the children’s centre workers are not Social Work qualified and work in services where the clear remit is to work alongside and with the grain of parents’ areas of need and focus. Family support and children’s centre workers are dealing with a lot of parents who are experiencing poor mental health and who have had difficult histories. However, they would not routinely work with parents who are experiencing intrusive thoughts or complex mental health issues. They would not have had the training or confidence to discuss potentially complex mental health issues with Sarah or her experience as a survivor of sexual abuse. The children’s centre worker had a Level 3 Child Care Diploma Qualification. Their grade was 7b of the Notts. County Council competency framework which is one tier up from entry level staff. The children’s centre worker did raise and had a full discussion about their concerns in supervision and with mental health services. 10.6. In this case the critical challenge was how to work with parents with mental ill-health and access support for their distress and substance misuse. These were not staff with expertise in mental health and they relied on the experts in the CMHT for guidance. There was a gap between the CMHT and the children’s workers. The CMHT were not part of the TAF meetings because Sarah had no allocated worker in the CMHT who could have been invited and while the mental health assessment of November 2019 had been shared with Sarah’s GP, Sarah’s consent would have been needed for it to be shared with any other professionals. Consent for sharing with the children’s centre worker or other professionals was not sought from Sarah. There was no opportunity for a full discussion and reflection on all the information CSC, CGL and community health services had about Sarah and Jean with the CMHT. 10.7. The YFSW report did not make any recommendations. The report identified the need for practitioners to use more precise language in their 16 recording when describing children and parents’ needs, how these are met and the work undertaken with them. 10.8. Police The Police report sets out the contacts with Sarah. It makes no recommendations. Except for the contact in August 2019, when the Police were contacted after Sarah had said to the IAPT service that she felt like stabbing someone, all the contacts were with Sarah in relation to possible offences of dishonesty or related to drugs or disputes between Sarah and other adults. The incident in August 2019 was described by Sarah’s family as well handled by the officers who attended. 10.9. The issue from these contacts except for the August 2019 contact which led to a referral to MASH is whether a referral should have been made or information should have been shared in relation to the occasions Sarah came to Police attention for a variety of possible offences. These were all adult related matters. They did not appear to significantly impinge on Sarah’s role as a parent. It would not have been normal practice for the Police to refer or share information from such contacts. Had Jean been subject to a child protection enquiry or on a child protection plan then this information would have been shared. The Police view was that the current guidance on information sharing gets the balance right between protecting privacy and sharing information to safeguard children and adults. The review panel endorsed this view. 10.10. Substance misuse service The substance misuse service is the local service of a specialist national provider. Its services were commissioned by Nottinghamshire Public Health Service. The substance misuse service works with its clients by consent. They provided Sarah with one of their programmes designed to help people reduce and end their substance misuse. The substance misuse practitioner worked with the Family Service worker and then the children’s centre worker and were part of the TAF. The service depends on self-report for assessing their client’s level of substance misuse except where drug screens are needed for clinical 17 purposes or they are specifically requested which was not the case for Sarah. The substance misuse service worked well with partners and there were no recommendations for action. 10.11. Local Hospitals The agency report shows good standards of care to Sarah and Jean in their contacts with this service and no recommendations for action. 10.12. GP Services The GP report highlighted the volume and differing formats of information recorded within primary care records. This is the benefit of a single electronic record but it does make identifying key information or understanding trends inherently more difficult for those using the records. The report gives the example of Sarah’s emergency department attendance in December 2019 which resulted in four discharge letters to the GP. Sarah and Jean made regular use of their GP and the GP practice was proactive and responsive in ensuring Sarah and Jean had timely medical services. The practice did not initiate a multi-disciplinary safeguarding practice meeting for Sarah and Jean. There was no trigger for such a meeting to be initiated. The GP report identified the need to record safeguarding practice meetings on individual patient records rather than as separate minutes. The Practice has heightened awareness across their staff group of the significance of the impact of mental health and substance misuse on parenting capacity. Nottinghamshire Healthcare NHS Foundation Trust 10.13. The Health Care Trust provided services to Sarah and Jean from the Healthy Family Team and CMHT. 10.14. The Health Family Team services to Sarah and Jean were provided on the universal level of need reflecting that Jean was a healthy child who appeared to be developing well. The report reflects on whether Jean should have been on the Universal Partnership Plus level of service when Jean was referred to CSC. However, it is hard to see this made any difference as the children’s health team liaised with CSC and took part in TAF meetings. The 18 report reflects on the limited curiosity about Sarah’s mental health and its impact on Jean. The report recommended that the service should standardise the process with regards to thresholds for decision making when placing children on Universal Services. This action has been completed. 10.15. The report on the CMHT service to Sarah is detailed and focuses on the assessment of Sarah’s needs, Sarah being placed on the waiting list for DTST, management of patients on the waiting list, how far consideration was given to Sarah’s role as a parent and the liaison with practitioners in partner agencies. The most significant issues were: • Reference to Jean as a protective factor within risk assessments and running records. The risk formulation did not explore how a baby could be a protective factor or ascertain the context of Sarah’s anger in relation to her care of Jean. The risk assessment focused on Sarah’s perspective. There was no picture of how Sarah’s rapid mood changes and her periods of anger might have impacted on Jean. There was overall a lack of curiosity about the day-to-day functioning of Sarah as a parent to Jean and the impact of her mental health difficulties on Jean. • There were weaknesses in members of the mental health team’s understanding of how the MASH referral process worked and there was no record of the referral made to the MASH in November 2019 in the mental health team electronic record. • The contacts between mental health services and practitioners working with Sarah and Jean in December 2019 and early 2020 are described. The report noted the reliance on the Crisis Team or reference to A & E or MIND or Samaritans as the places where Sarah should seek help while on the waiting list. The lack of direct contact with Sarah by the CMHT and limited discussion with those who were working with Sarah were barriers to any reassessment of the level of risk she might have been at or risk she posed to others or the level of her need. From Sarah’s perspective none of this was useful as she wanted someone to talk to about her troubling thoughts and what was happening in her head. There was no reflective discussion 19 with the practitioners who were in contact with Sarah but a referring up and down which led nowhere. • The report identified weakness in the documentation of Sarah’s needs and how her mental health needs might impact her parenting of Jean. The documentation stated that there were no risks as Sarah said she would not harm her child. It was not recorded where Jean was when Sarah was experiencing the periods of anger for which she was seeking help. • The escalating concerns of others in December 2019 and January 2020 were not further considered within the mental health multi-disciplinary team. There was not a fuller exploration of Sarah’s mental health needs including detailed discussion with those calling to express concerns. 10.16. The Mental Health Service has taken the following actions: • Reviewed the existing waiting list to assess need and prioritise. • Undertaken work to implement a waiting well strategy across local mental health teams with minimum standards for contacting people on the list. • Improved training for the mental health services duty workers • Commenced an Internal Complex Review (Adult Mental Health Services) due to be completed by the end of July 2021. • A nationally led transformation programme for community mental health services is being implemented in Nottinghamshire; it is accompanied by a significant investment to increase service capacity, reduce waiting times and improve services. The programme will deliver many improvements including a named worker for every individual on a waiting list. 10.17. The report makes the following recommendations: • Review the correspondence (letters) sent out to patients when they are offered an intervention specifically in relation to waiting well whilst on the list. • Review the clinical risk formulation training to ensure that the term ‘protective factors’ is clearly defined in relation to what should and should not be considered a protective factor. Also enhance/change to the risk 20 training to further reinforce the importance of think family and child safeguarding as part of risk formulation. • Issued guidance to Mental Health Duty Workers with regards to escalation within the service. 11. Partnership conclusions. 11.1. The services to Sarah and Jean were delivered within accepted practice in nearly all services. Much of what was delivered would be considered good e.g. community health services including GP, substance misuse services, YFSW assessment and services and the Police response to mental health crisis. There was positive and regular communication, including TAF meetings, when needed between YFSW including MASH, Family Services, substance misuse services, Children’s Centre and GP. There was communication by all of these services with the CMHT but the CMHT was not part of the team around the family and communication was related to specific events or points of assessment or efforts to escalate for further mental health service intervention. 11.2. There was communication and engagement with Sarah and Jean’s wider family who were supportive of Sarah and Jean and actively involved in their lives. Sarah was rarely seen alone and in retrospect agencies reflected that this may have made it more difficult for both practitioners and Sarah to discuss her mental health or other more intimate parts of her life. This was not an obvious issue at the time as practitioners saw the involvement of Sarah’s family in her and Jean’s life as positive and an indication of the active support Sarah had for her care of Jean. 11.3. There were important aspects of Sarah’s life which were not known to those working with her or to her Family. This information held by the Police would not be disclosed to YFSW or health practitioners under current information sharing guidance. The partnership after careful reflection agreed that the current guidance does not need to change. Widening what can be shared without consent risks creating unmanageable quantities of shared 21 information which could obscure rather than illuminate where safeguarding effort needs to be placed. 11.4. There were weaknesses in the response of community mental health services. However, they worked within their usual norms for managing demand and providing a response to those assessed as not acutely ill. Sarah was not assessed as mentally ill and requiring the level of service where the Care Programme Approach would have been applied. The service relied on Sarah to use the pathways available. These did not address her needs and the level of distress she was experiencing. 11.5. The information suggests that Sarah was a vulnerable woman who had experienced mental health difficulties for some years. The abuse she suffered as a child was probably an important part of the mental distress she was suffering as an adult. Sarah told others about her feelings of anger and how she felt like harming someone and how she might do this, with a knife. Sarah expressed a general wish to harm an unspecified someone but it was not explicitly considered whether this might include her child. Sarah was seen as a loving parent who expressed the view that having a child was a restraint on her acting on her angry impulses. This was the accepted view of those working with Sarah and of her family. Based on information available the assumption was made that Sarah would never physically harm her child – those working with her would have found this unthinkable. 11.6. Sarah saying she would not harm her child was relied on without a consideration of the wider context for her distress and how this might impact her care of Jean. There were indications she was more distressed in late 2019 and early 2020. She did tell people about her distress and what might help her deal with this distress but this was not identified by CMHT as more serious than when she had been assessed in November 2019. She remained on a waiting list and without a helping response to her distress. She was advised to access services which gave an emergency response and which she had no confidence would address her needs. This was the approach of the mental health service to managing more demand than they could meet. 22 11.7. There were no indications to anyone that Sarah would kill her child. 12. Partnership Learning 12.1. The following are suggested as areas of partnership learning: • The importance of holistic assessment of the adult and child which considers predisposing vulnerabilities, risks for the adult and child and the potential impact on and experience of the child in relation to those vulnerabilities and risk. • The availability to children’s workers of access to expertise in adult factors such as mental health and substance misuse which may affect their care of a child. • The gap in understanding between children’s services practitioners and adult mental health services. • The need for attention to adults’ parenting role when in contact with adult mental health services. • The importance of recording which is accurate and precise in the use of language, avoids formulaic language and better supports understanding of risk, areas of concern and impact on the child. • Children should not be described by professionals as protective factors for their parents – they cannot protect their parents. If parents say their child is a protective factor because their parental role places restraint on their behaviour that needs to be recorded clearly as the parent’s statement and evaluated as part of the assessment of the parent and child’s needs and level of risk each may be subject to. • The importance of good case transfers involving personal contact between practitioners and practitioners and clients/patients. • The importance of identified key workers in all services including early help services. • The need for empathetic curiosity and doubt about what parents say on topics which are inherently very sensitive and where many will struggle to be honest, not least due to fear they may lose their children, e.g. substance misuse, financial circumstances, mental health. 23 • Whether there can be an over reliance on wider family when they are positively engaged. This can lead to families feeling they are being left to get on with caring without sufficient support. Assessments need to consider what it is reasonable for families to be able to provide including what other demands there are on the caring capacity of the family. 13. Recommendations 13.1. The safeguarding children partnership should explore models of integration or ways to develop closer working between adult and children’s health and social care services so that the services can undertake joint assessments of adults with parental responsibilities who have adult issues such as mental health problems, substance misuse, victim or perpetrator of domestic abuse. The services need to enable each service to have access to each other’s expertise. 14. Learning already implemented. 14.1. The Nottinghamshire Healthcare NHS Foundation Trust has implemented the following actions: • Standardised the process with regards to thresholds for decision making when placing children on the Universal Services part of the Healthy Family Team caseload. • Reviewed existing waiting list to assess need and prioritise. • Undertaken work to implement a waiting well strategy across local mental health teams with minimum standards for contacting people on the list. • Commenced an Internal Complex Review (Adult Mental Health Services) due to be completed by the end of July 2021. • The transformation agenda has given significant investment in services as part of a national programme. The ambition is that this translates into a named worker for every individual on a waiting list. 14.2. The GP services have: • Changes have been made to ensure that safeguarding practice meetings about a patient are recorded on individual patient records. 24 • The practice has heightened awareness of the significance of the impact of mental health and substance misuse on parenting capacity. • The GP National Contract has been implemented and post-natal checks now include a requirement to ask open questions around maternal mental wellbeing. 15. Action timeline for implementation of learning and development. 15.1. The Child Safeguarding Practice Review will be shared with the Learning and Workforce Development group of NSCP for dissemination via the existing NSCP learning and improvement framework. This will include • Summary provided in ‘Safeguarding Children Today’ seminars. • The content of core safeguarding training will be updated with the learning from this review. • Learning will be disseminated through the multi-agency training pool. • A briefing at the NSCP Forum. • Specific briefings to Strategic Leadership Group, Safeguarding Assurance and Improvement Group, Child Safeguarding Practice Review group, Child Protection Chairs, Local Authority senior management meetings, elected members, CCG lead health learning events. • Briefing in relevant publications. Work on progressing the dissemination of the learning will commence immediately and be an ongoing process over the next 12 months. The requirement for further work will be reviewed at the end of this period. 15.2. It is recognised that the recommendation (see 13.1) requires an in depth consideration of system options. This work will be taken forward through a working group of senior managers from across the Partnership and include representatives from Children’s Social Care and Adult Mental Health. Initial work will commence immediately, and a more detailed plan will be drawn up once options have been assessed. 25 Colin Green Independent Review Author 2nd July 2021. |
NC046125 | Death of a 12-week-old boy in March 2014 as the result of Sudden Unexpected Death in Infancy (SUDI). Child E was found on a makeshift bed on the floor of a caravan and was not breathing; he had been sleeping with two siblings, a cousin and his maternal aunt. Child E was Looked After at the time of the incident and had been placed, with his twin brother and two older siblings, in the care of his maternal aunt. Both parents had been arrested for burglary offences and were remanded in prison at the time of the incident. Family are from an Irish Traveller background and had lived in a number of different Local Authorities in London and the South East of England. History of: parental offending; parental drug and alcohol misuse; and maternal mental health problems - mother had post-traumatic stress disorder (PTSD) following the death of her husband 13-years previously. Identifies key issues, including: children's poor school attendance; flawed decision not to hold a pre-birth assessment; and the impact of culture on the decision to place Child E and his siblings with maternal aunt. Makes recommendations, including: London local authorities to develop a collective and holistic response to safeguarding transient families; and NHS England - London to review the format of Root Cause Analysis reports, which did not fully lend themselves to the serious case review process.
| Title: Child E: serious case review. LSCB: Bromley Safeguarding Children Board Author: Alex Walters Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. BROMLEY SAFEGUARDING CHILDREN BOARD CHILD E SERIOUS CASE REVIEW FEBRUARY 2015 1 TABLE OF CONTENTS PAGE 1. INTRODUCTION 3 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 3 3. METHODOLOGY USED TO DRAW UP THIS REPORT 6 4. CHRONOLOGY OF KEY EVENTS 6 5. THE FAMILY 9 6. THE AGENCIES 10 7. KEY ISSUES 21 8. CONCLUSIONS AND LESSONS LEARNED 25 9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW 26 9.2 Recommendations to Bromley Safeguarding Children Board 26 APPENDIX A COMPOSITION OF SCR PANEL 28 APPENDIX B DETAILS OF THE INDEPENDENT REVIEWER/AUTHOR OF THIS REPORT 29 APPENDIX C TERMS OF REFERENCE FOR THIS SERIOUS CASE REVIEW 30 APPENDIX D PRINCIPLES UNDERLYING THIS SERIOUS CASE REVIEW 32 APPENDIX E SUMMARY OF AGENCIES RECOMMENDATIONS 33 APPENDIX F REFERENCES 37 APPENDIX G GLOSSARY 38 Contact Details: Bromley Safeguarding Children Board (BSCB) Bromley Civic Centre, St. Blaise Building, Stockwell Close, Bromley BR1 3UH Tele: 020 8461 7816 Email: [email protected] Web: www.bromleysafeguarding.org 2 1. INTRODUCTION 1.1 This Serious Case Review concerns the tragic death of Child E at the age of 12 weeks in March 2014. At the time of his death, Child E was Looked After (in care) by Bromley Children’s Social Care and placed with his twin brother, Child D in the care of his maternal aunt, Ms P. Unknown to professionals, he was staying in a caravan due to Ms P locking herself out of the home address for a few days. In the early hours of 5th March 2014, Child E was found on the makeshift bed on the floor of the caravan and was not breathing. Child E had been sleeping with his 2 siblings, a cousin and maternal aunt Ms P. 1.2 The Coroner’s report has subsequently confirmed in July 2014 that the cause of death was Sudden Unexpected Death in Infancy (SUDI) and decided that there would be no Inquest and no criminal proceedings have been instigated. The SCR Panel agreed to continue with the SCR Process given that it was clear that there was learning for agencies. 1.3 Child E was one of twins born to parents on 10th December 2013 who also have 3 older children. The family are from an Irish Traveller background and had spent most of their lives moving between and living in a number of different Local Authorities in London and the South East Area of England. There is a very large extended family; mother is one of ten siblings, two deceased, all of whom have families and live in the south east of England. 1.4. Both parents and an older sibling Child B were arrested on September 2013 for burglary offences and both parents were remanded to prison. Child B was also arrested with his parents and remanded to Local Authority Foster Carers. The other two siblings - Child A and Child C were placed with maternal aunt - Ms P initially under S. 20 arrangements (voluntary agreement). Bromley Children’s Social Care services subsequently initiated care proceedings on all five children. 1.5 Both of Child E’s parents have criminal convictions and have spent periods of time in prison and both were known to have a history of drug and alcohol abuse. 1.6 Following the birth of Child E and Child D, the Local Authority obtained an Interim Care Order (ICO) on 12th December 2013 and the babies were placed with Ms P on 19th December 2013.They remained with Ms P until the death of Child E in March 2014. 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 This case was referred by the Rapid Response meeting to the Local Safeguarding Children Board in Bromley (BSCB) where Child E was subject to a Bromley ICO. On 27th March 2014 the Serious Case Review Committee of the Bromley Safeguarding Children Board (BSCB) met to consider whether the criteria for a serious case review were met. 2.2 There is a legal requirement, as defined in statutory Guidance, Working Together to Safeguard Children 2013, to undertake a serious case review when abuse or neglect of a child is known or suspected and • either a child has died, 3 • or a child has been seriously injured and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.3 At its meeting, the Serious Case Review Committee concluded the criteria for a serious case review were met as Child E was a looked after child who had died and neglect at that point was suspected. The Independent BSCB Chair agreed with their recommendation. 2.4 The purpose of a serious case review, as set out in Statutory Guidance, Working Together 2013, is to identify improvements, which are needed, and to consolidate good practice in order to help prevent deaths or serious injury. 2.5 BSCB decided to appoint a Serious Case Review Panel to oversee the process and act as the Reference Group. It was chaired by Helen Davies, the Independent Chair of the Bromley Safeguarding Children Board. Its function was to manage and oversee the conduct of the review. The membership of the SCR Panel is set out at Appendix A. The Board appointed an independent reviewer, Alex Walters to lead the review and to write this overview report. Further details are at Appendix B. 2.6 In total nine Individual Management Reviews (IMRs) were requested from the following agencies which had substantial contact with child E and his family and there was also a Health Overview Report commissioned by Bromley Clinical Commissioning Group (CCG.) • The Whittington Hospital that provided ante-natal, labour and post natal care to mother of Child E and Child D • Croydon General Practitioners - provision of primary care services to Child E, his siblings and extended family • Croydon Health Care Trust - Provider of community services providing health visiting services for Child E and Child D and Croydon University Hospital. • Croydon Schools and Learning providing services for Children A, B, C, F and G. • Bromley Children’s Social Care Services • The Metropolitan Police • Children and Family Court Advisory and Support Service (CAFCASS) • Bromley Legal Services. • Bromley Health-Care Provider – provided initial health assessment of Child E and sibling, Child D. • A Health Overview Report 2.7 In addition, background reports were requested from agencies with less significant or less recent information: • Holloway Prison (where mother on remand) • Lewisham Hospital providing ante-natal services to mother • St George’s Hospital providing paediatric intensive care services to Child E • Bromley Children’s Social Care regarding Child E’s sibling - Child B • Bromley Youth Offending Service – providing services to Child B. • Croydon Housing Department providing services to Ms P • Croydon Children’s Social Care providing services to the family of Ms P • Bromley Drug and Alcohol service providing services to Mother. • Belmarsh Prison (where father was on remand) 4 2.8 This report was written in anticipation that it will be published. Consequently, the information in the report is limited so as to: 1) take reasonable precautions not to disclose the identity of the child or family 2) protect the right to an appropriate degree of privacy of family members 2.9 Terms of Reference for this SCR are at Appendix C. Child E was the main subject of the review but the three siblings - Child A and Child C and Child D and the two children – Child F and Child G of maternal aunt Ms P - were included. Child B was not included as he was not in the care of Ms P during this period. Its principal focus was from 3rd September 2013 (when both parents were arrested) until 10th March 2014 (the day of the Rapid Response meeting). However, all agencies were asked to provide a summary of all significant events and relevant family history outside the specific timescale and to consider any safeguarding issues for Child E’s older siblings. 2.10 Not all of the IMRs addressed the terms of reference, which is an issue explored in the report. All the authors of the internal reviews were independent of the case management, and conducted interviews with staff involved with Child E and his family. 2.11 Following consideration of the combined chronology of events and the Internal Management Reviews, the independent reviewer and the BSCB Business Manager met at a learning event with eleven professionals who had worked with Child E and/or his family. They included Bromley Local Authority social workers, CAFCASS, YOS and staff from the Education Traveller Service and the school attended by child E’s siblings in Croydon. This provided a valuable opportunity to gain their perspectives of their work with child E’s family and to consider lessons learned. 2.12 After the first draft of this report had been compiled, the Independent Reviewer and the BSCB Business Manager met with seven of the IMR authors in order to seek their views on preliminary findings and on recommendations. All of their comments have been included in this Overview Report and the discussion led to some additional recommendations and learning for individual agencies. 2.13 All of the practitioners involved earlier in the process were offered a further opportunity to discuss the draft report with the Independent Reviewer and this offer was taken up by two front line social work practitioners. Both social work practitioners felt that the report described the case and the issues from their perspective and no changes were suggested other than a few factual accuracy issues. They both felt that they recognised the learning from this SCR process and that included the learning for BSCB on how to involve practitioners in future SCRs. 2.14 Attempts were made throughout the SCR process to involve the family and finally resulted in the Independent Reviewer meeting with both the mother and father in their respective prisons. Neither parent identified any agency actions that might, with hindsight have been helpful to their family or any actions that might have prevented the death of Child E. They acknowledge that this was a tragic death, which has impacted significantly on themselves and their wider extended family, but were both positive that their children were cared for within their wider traveller community. 5 3. METHODOLOGY USED TO DRAW UP THIS REPORT 3.1 This overview report relies on: • The agency IMRs and background reports • Subsequent discussions with the SCR Panel which met on five occasions • Dialogue with the IMR authors • Discussion at the learning event in July 2014 with front line practitioners • Discussion at the follow up meeting in September 2014 with IMR Authors • Follow up discussion with two social work practitioners • The views of Child E’s parents • Following permission of the court, the Independent Reviewer read the court bundles in their entirety. 3.2 This report consists of: • a factual context and chronology • commentary on the family’s input to the SCR • analysis of the part played by each agency • closer analysis of key issues arising from the review • conclusions and recommendations 3.3 The conduct of this review has not been determined by any particular theoretical model. However, the review has been carried out in keeping with the underlying principles of the statutory Guidance, set out in Working Together 2013. These are at Appendix D. 4. CHRONOLOGY OF KEY EVENTS 4.1 This section of the report briefly provides a summary of the family context and key events from August 2013. Further detail is then provided at appropriate points throughout the report. Chronology Bromley Children’s Social Care had received two referrals from local police during March 2013 regarding this family. These referrals led to an initial and core assessments being instigated but the case was closed on 24th May 2013 following unsuccessful attempts to locate the family in Bromley. On 26th July 2013 the case was re-opened following mother’s arrest on drugs and driving offences and the case remained open while the social worker undertook a core assessment. On 3rd September 2013 problems escalated when again both parents were arrested and mother was admitted to Lewisham Hospital having tested positive for cocaine and opiates. Child C was found in the back of the car with parents on their arrest. Local police placed Child C and Child A with her maternal aunt Ms T in Croydon. A number of family’s names were given who might have been able to provide care for the children. SW1 began the task of contacting and arranging police checks on those family members. 6 6th September 2013 - scan at Lewisham hospital confirms mother is pregnant with twins (24 weeks). . Father and Child B charged with 46 conspiracies to commit burglary with the intent to steal. Mother charged with driving offences. Child B remanded to Local Authority care and placed with foster carers as bail conditions stipulated he was not to be placed with a family member. Father and Mother remanded to prison. 16th September 2013 - mother’s EDD confirmed as 27th December 2013. Drug & alcohol abuse may lead to earlier delivery. Mother moved to Holloway Prison. LBB First Legal Planning Meeting held with decision to institute legal care proceedings. Decision to refer for Family Group Conference (FGC). SW2 to complete court statement by 19th September 2013. Child A and Child C are officially accommodated Under Section 20 of the Children Act 1989. 1st October 2013 Child A arrested shoplifting in Croydon and bailed to Ms P address. 1st October 2013 Child A and Child C move to Ms P without social care involvement in the decision. LAC review 1 held on three oldest children – Child A, B and C at Bromley Civic Centre. 9th October 2013 - LBB Second Legal Planning Meeting held. 11th November 2013 - LBB Third Legal Planning Meeting held. Commissioning request made by Children’s Social Care for Independent Social Work assessment of aunt Ms P. 13th November 2013 - Fax to GP requesting medical information on Ms P. This request suggests it was the 2nd fax to the surgery in this regard. 29th November 2013 - Completed DBS form received from aunt Ms P, signed off and sent to DBS. 4th December 2013. Holloway Board held to consider application for mother and baby placement, which was refused. 9th December 2013 - Family Group Conference held. 10th December 2013 - Child E & Child D born at Whittington Hospital by elective caesarean and transferred to SCBU. 12th December 2013 - 1st Court Hearing in the Care Proceedings - Interim Residence Order granted to Ms P in respect of Child A and Child C. Child E and Child D are placed on Interim Care Orders; no order for Child B. Children’s Social 7 Care provided Court Statements and a written Care Plan which recommended an ICO and that Child E and Child D were placed with experienced foster carers whilst family assessments undertaken. The case was deferred until 18th December 2013 as this plan was not agreed and further family assessments requested. 13th December 2013 - Mother discharged from Whittington Hospital to Holloway Prison. 18th December 2013. 2nd Court Hearing agreed to Child E and Child D being placed with Ms P still under an Interim Care Order whilst family assessments undertaken. 19th December 2013 Discharge planning meeting at Hospital and Child E and Child D moved to Ms P. 23rd December 2013. Statutory LAC visit undertaken by duty SW. 30th December 2013.New Birth Visit by Health Visitor. 6th January 2014. Statutory LAC visit by duty SW to Child E and Child D. LAC review of Child E and Child D at home of Ms P. 20th January 2014 Child E and Child D noticed at Mother’s Court appearance. 24th January 2014 Mother discharged from Holloway Prison on bail. . First set of immunisations for Child E and Child D and 8 week check by GP. 17th February 2014 Permanency planning meeting held. Decision to seek a family placement or adoption for Child E and his sibling Child D. 18th February 2014 Mother in Police custody for breaching bail. 26th February 2014 Mother re-arrested for breaching her curfew. 28th February 2014 Mother pleads guilty to driving offences and remanded in Holloway Prison until sentencing on 15th April 2014. 3rd March 2014 Initial health assessment and Adoption Medical undertaken of Child E and Child D. Meeting at Primary School involving Ms P to support improvement in attendance. 4th March 2014 - second set of immunisations for Child E and Child D by GP. 5th March 2014 - Child E admitted to hospital in early hours of morning with cardio-respiratory arrest. Child E was transferred to PICU at another hospital but his condition deteriorated and Child E died later that day. 10th March 2014 - Rapid Response meeting held and referral to BSCB SCR Sub Committee. 8 5. THE FAMILY’S INVOLVEMENT IN THE SCR PROCESS Child E’s Mother 5.1 Child E’s mother was informed of the Serious Case Review process by the Chair of the Serious Case Review Panel and subsequently invited by the Independent Reviewer to contribute to this review. The initial responses were negative however Child E’s mother then requested to meet with the Independent Reviewer and this meeting at HMP Send Prison took place on 24th October 2014. Mother was supported by a member of a voluntary organisation who provide services in the prison. At this meeting the mother was very clear about a number of concerns, some of which were outside the remit of this SCR. The Independent Reviewer advised the mother to make formal representation of her complaints to the Prison Ombudsman which she was subsequently supported to do. The Mother raised issues about the delay in being informed of the admission of Child E which resulted in her not being able to hold her baby before he died; the response of the prison officers at this visit and the fact that neither parent were allowed to attend Child E’s funeral. 5.2 As a result of the concerns identified by the mother, the Independent Reviewer wrote to both HMP Holloway and HMP Belmarsh in November 2014 to inform them and allow them the opportunity to respond and also made a further request for information from Children’s Social Care in Bromley. Responses were received in late December 2014. It is clear that there are differing recollections of events. In relation to the first concern regarding the time delay, Children’s Social Care explain their attempts to contact HMP Holloway and HMP Belmarsh by phone from approximately 2 pm and finally made contact with HMP Holloway about 5 pm. The reality was that it took Children’s Social Care time to clarify Child E’s condition and the medical level of concern and they then experienced difficulties in contacting the prisons. It is very unfortunate and highly distressing for the mother that Child E had died in this period. HMP Holloway are clear that the prison officers who accompanied the mother to hospital behaved appropriately but were concerned at the large family presence which required them to take protective action. Both HMP Belmarsh and HMP Holloway are clear that the decision not to allow either parent to attend Child E’s funeral was due to risk assessments that the risk to prison officers and public safety was too great from the extended family and this decision was supported by the police. The mother is clear that she felt decisions were made as a result of their traveller culture. These issues are beyond the scope of this SCR and need to be raised with the relevant complaint body, which the Independent Reviewer understands is in process. 5.3 The mother did however state in the meeting that she was pleased that all the children had been placed initially and now permanently within the wider extended family traveller community. She did not identify any agency actions which might have been helpful to the family or might have prevented the tragic death of Child E. 9 Child E’s Father 5.4 Child E’s father was informed of the Serious Case Review process by the Chair of the Serious Case Review Panel and subsequently invited by the Independent Reviewer to contribute to this review. The Independent Reviewer met with father at HMP Chelmsford on 24th September 2014. At this meeting the father made some helpful points for this review to consider. He was clear that his culture would absolutely expect that if the parents were unable to care for their children that they should be cared for by their extended family. He was therefore very positive about the decision that the court made for Aunt P to care for all four of his children in December 2013. And, stated that he was glad that his children had re-engaged with school. He was very distressed that he had not had contact with Child E before his death and was critical of Children’s Social Care for not enabling this to take place. The Independent Reviewer has followed this up and was informed by Children’s Social Care that the lack of contact was a) due to the need for Belmarsh Prison to have evidence of birth certificates and babies not being registered until 11th February 2014 and b) the limit to numbers of children visiting at any one time and the older children were prioritised and c) their understanding that Ms P would be taking the children to visit their father. Although very distressing for the father, the prison restrictions could not be altered. He was also critical of the decision to remove Child C and Child D from Aunt Ms P’s care following the death of Child E but accepted that this was due to the uncertainty regarding the cause of death. He was very positive that all four of his children are placed within the wider extended family. He did not identify any agency actions that might have prevented the tragic death of Child E. Child E’s Aunt 5.5 Child E’s aunt - Ms P was informed of the Serious Case Review process by the Chair of the Serious Case Review Panel and subsequently the Independent Reviewer attempted to make contact by phone and through the relevant Traveller Liaison service. It was however confirmed that the family were travelling around the UK and did not respond to direct phone contact. The mother gave the Independent Reviewer another mobile phone number at the visit on 24th October 2014 for Ms P. A number of voice mail messages were left but no response received. 6. THE AGENCIES 6.1 The Metropolitan Police 6.1.1 The IMR and chronology provided by the Metropolitan Police was considerably delayed. This was due to an initial oversight within the police as the IMR request was not passed on to the relevant internal team and then by the volume of work within the SCR team. The Serious Case Review Panel were concerned at the impact of the delay and the Chair made robust representation about the impact of the delay. 6.1.2 The IMR was received on 30th September 2014 - some 3 months later than the other agency IMRs. The IMR details historical Police conviction information on Mother, Father and Aunt Ms P and describes police involvement during the period of SCR review. 10 6.1.3 There is clear evidence demonstrated in the IMR that the Police responded appropriately to all contacts with the family, recognised the impact on the children, undertook good risk assessments and shared information appropriately with Children’s Services using the established Merlin Police notification system and direct contact. 6.1.4 The IMR Author identifies that there was good practice demonstrated in terms of a pro-active response to the incident at the bail application hearing for mother in January 2014 when Aunt Ms P was challenged and there were concerns that Child E and Child D were left unattended. 6.1.5 Additionally the Independent Reviewer recognised good practice in the evidence of police challenge to Bromley Children’s Social Care on the decision to cancel the Initial Child Protection Conference in September 2013. 6.1.6 There are no recommendations for the Police Service in the IMR. The Independent Reviewer agrees that this is appropriate. However there is clearly significant concern at the delay in completing the IMR by the Police Service and the impact this has had on the process and timeframe of this SCR process. There is therefore a recommendation in this SCR to the Metropolitan Police to ensure sufficient capacity to respond to IMR requests. 6.2 The General Practitioners in Croydon 6.2.1 Ms P had been registered with the GP Practice since 1994 and as a permanent patient since 2002. Her own youngest two children had been registered relatively recently with the same GP Practice and subsequently Child E and his three siblings were registered. The GP Practice had undertaken routine immunisations, developmental assessments and clinical appointments. 6.2.2 The IMR clearly identified that the GP Practice had not responded to a request from Bromley Children’s Social Care on 12th November 2013 requesting urgent information on Ms P and her own children. The response was finally provided 4 months later. The IMR report author identifies the failure in the administrative systems within the GP Practice to respond to requests for information; to cover for sickness absence and the lack of a safeguarding culture in order to “Think Family” and identified staff who had received insufficient safeguarding training. 6.2.3 The IMR Author identifies that the impact of not sharing information in a timely manner was that the information about Ms P’s medical history was not shared and did not therefore inform assessments of her ability to care for initially two and then four additional children. Ms P had a history of Post-Traumatic Stress Disorder since the sudden death of her husband 13 years previously and dependence on diazepam. 6.2.4 The GP Practice received the discharge summary from the Whittington Hospital following the birth of Child E and his sibling but links were not made with their knowledge of Ms P. 6.2.5 The IMR Author identifies clear learning for the GP Practice in ensuring the compliance of all GP Practice staff with mandatory training and their role in safeguarding and the need to think family. It recommends that communicating 11 effectively with Children’s Social Care and other professionals involved in the safeguarding process should be undertaken in a meaningful and timely manner. There should be management oversight arrangements including case discussion and the GP Safeguarding Lead having the overview of reports for Children’s Social Care and solicitors involved in safeguarding children matters. The Health Overview Author has recognised this vulnerability and makes a recommendation for the CCGs to review safeguarding training and compliance for GP practices. The Independent Reviewer is confident that the IMR has picked up the key learning and that the Croydon CCG responsibility to address the performance management is addressed. 6.3 Whittington Hospital 6.3.1 This hospital provided ante-natal, labour and post natal care to mother. The initial IMR did not identify learning but following discussion with the IMR Author by the SCR Panel and Deputy Designated Nurse, recognition of practice, which could be improved, was identified. The hospital first became involved with Child E’s mother on 23th September 2013 following referral from Holloway Prison. She was at that time on a methadone programme .She was known to have a history of alcohol abuse and depression. Her health was a cause for concern during the latter stages of her pregnancy as she was not eating or sleeping well and was of low mood felt to be due to her recent bereavement of her own mother. 6.3.2 Delivery of Child E and Child D was on 10th December 2013 by elective caesarean and the twins remained on the ward with mother until 13th December 2003 when mother was discharged back to the prison. They were monitored for neonatal abstinence syndrome. Child E and his sibling were then moved to SCBU (Special Care Baby Unit) and later discharged to Ms P on 19th December 2013. 6.3.3 The circumstances that led to the decision to discharge mother on 13th December 2013 were not entirely clear in the IMR. The Children’s Social Care and Holloway Prison IMRs describe the social worker receiving voice messages from mother meant for someone else, which requested money and car seats, and there was therefore a perception that there might be an attempt to abscond with Child E and his sibling. There was a discussion between the hospital and the Prison but the decision to discharge mother was made by the hospital with some limited discussion with Children’s Social Care who had an Interim Care Order on Child E and his sibling at this point. This was later confirmed to involve contact with the Bromley Out of Hours Service as this decision took place on a Friday evening. This was clearly felt to be a crisis and a potentially risky situation for Child E and Child D and therefore the decision would seem to have been appropriate. 6.3.4 Child E and his twin were discharged on 19th December 2013 after a discharge meeting involving Ms P, a social worker from Bromley Children’s Social Care and a nurse. The discharge summary was sent to the GP in Croydon but not to the Health Visitor, which was a breakdown in communication and did not clearly state that the carer for the twins was Aunt Ms P. 6.3.5 These issues have been recognised by the IMR Author and Health Overview Author and a resulting recommendation is for a new recording tool, which is currently being used to improve communication and documentation to track actions taken. In addition there is a further recommendation in relation to training based on the 12 recognition of the need to ensure increased professional curiosity by midwives. The Independent Reviewer is satisfied that the key learning has been identified. 6.4 Croydon Health Services NHS Trust 6.4.1 This Trust provided health visiting and hospital services to Ms P and the children. The health visiting service first became aware of Child E and his sibling from Bromley Children’s Social Care on 20th December 2013 with detailed information being provided including the date of the first LAC review on 6th January 2014. A new birth visit took place on 30th December 2013 and again on 29th January 2014 and they were seen at the Health Centre for immunisations and weighing. There were 2 visits to the Emergency Department of the hospital during this time period for Child D which were unremarkable. 6.4.2 The IMR describes a universal partnership service being provided which is an enhanced service given the circumstances of the children’s legal status and additional vulnerabilities (i.e. being a twin; having spent time in SCBU; mother was drug dependent and they were placed out of Borough). The IMR author felt the new birth visit was within time frame of the relevant health guidance for Looked After children given the Christmas holiday period. But, the Health Overview Author felt this was not the case and the new birth visit should have been prioritised and has made recommendations to the respective CCG/Local Area Team to undertake regular monitoring of timescales for new birth visits. The Independent Reviewer agrees that this will provide useful monitoring. 6.4.3 There is an additional shared view that there was no pro-active communication between the Health Visitor and the social worker or vice versa which given the vulnerability of the family situation is surprising and the Health Visitor did not attend the LAC review on 6th January 2014 which would have provided a useful information sharing forum. This issue has been subsequently accepted by the IMR Author and incorporated into the recommendations. The Independent Reviewer is satisfied that the key learning has been identified. 6.5 Bromley Healthcare - provider of health services to Looked after Children 6.5.1 This IMR identified that the Initial Health Assessment and the Adoption medical were carried out at the same time and fulfilled statutory requirements. However there was a delay in the LAC Health Team being notified of Child E and Child D becoming looked after which resulted in the Initial health Assessment also being delayed. The Health Overview Report author has identified this as an issue for the Health provider and LA to improve communication channels. The Independent Reviewer is satisfied that the key learning has been identified. 6.6 Health Overview Report 6.6.1 This report was commissioned by Bromley CCG from a designated nurse in another London CCG and although no longer required by guidance provided a very helpful oversight of the health IMRs and identified and confirmed the key issues and areas of learning. 6.6.2 This first area identified the delay in the Initial Health Assessment for Child E and Child D which took place 10 weeks after they became looked after and there are 13 recommendations for the provider, Bromley CCG and the Local Authority to address and improve communication procedures. 6.6.3 The second area identified the delay in the new birth visit and the lack of information sharing from the Hospital with the HV. There are recommendations for the CCG/Local Area Team and the provider to improve administrative arrangements and to ensure monitoring is in place. 6.6.4 The third area identified the lack of response from the GP practice to the request for information from Bromley Children’s Social Care, which was felt to be due to ineffective administrative processes and lack of a safeguarding culture. This has been addressed by additional recommendations to review safeguarding and compliance for GP practices. 6.6.5 The Independent Reviewer is satisfied that the key learning has been identified and addressed in these recommendations, which supplemented the recommendations, and learning identified by the IMR Authors. 6.7 CAFCASS 6.7.1 CAFCASS became involved with the appointment of the Children’s Guardian on 25th November 2013 after the LA had applied for an Interim Care Order on Child A, B and C. The Guardian appointed a solicitor for the children. The Guardian undertook all actions required, met with the children and liaised with the relevant professionals. The children’s views were clearly set out in all documents and contact arrangements recommended. The IMR Author provides clear evidence that the guardian was culturally aware and sensitive in her practice and responded in a timely and appropriate manner to concerns raised by the viability assessments and the incident in court in January 2014. 6.7.2 The IMR Author advises that the Guardian was relatively new in role but with considerable LA experience and had received an appropriate level of induction, training and co-working a case. The Guardian received situational supervision from an enhanced practitioner and had a mentor from within the team in addition to line manager. The IMR identifies a number of areas of good practice around quality of liaison and management arrangements. 6.7.3 The learning identified relates to broader issues already identified in IMRs nationally for CAFCASS and include the need to ensure assessments cover all relevant areas and greater scrutiny of the LA oversight. The learning has been shared with the practitioner and her manager and there are no specific recommendations. However the view raised by the SCR Panel was that the Guardian could have challenged the placement with Ms P, which was agreed at court on 18th December 2013, as there was no DBS check available. The view from CAFCASS was that this was the least disruptive option for Child E and sibling D and Child A and Child C had already been in placement for 3 months and the care provided by Ms P demonstrated no concerns. However following this discussion, the CAFCASS IMR was amended to recognise the need to check DBS records and this has been included as an additional learning point and has been added to the CAFCASS National Learning Log. 6.7.4 The Independent Reviewer is satisfied that the key learning has been identified.14 6.8 Croydon Education Service 6.8.1 The IMR covers contact with a number of education services in Croydon - School admission; Primary school; Home tuition; Education Welfare and the Traveller Education Service. Croydon Education Welfare Service had been previously involved with Ms P and her family in relation to her two children, Child F and Child G and had issued School Attendance Orders in May 2013 however the education welfare function was then undertaken through the school buying this service from a private provider. It is therefore not known if Bromley Children’s Social Care knew the information about Ms P’s own historic difficulties in relation to her children attending school. The Independent Reviewer requested further information on the process and criteria used for school attendance orders. 6.8.2 The IMR identifies some communication omissions and missed opportunities to share information particularly in relation to safeguarding concerns. The primary school did not refer two incidents to Bromley Children’s Social Care – one involved the children not being collected from school. This was on the date of the first care proceedings hearing and another family member failed to collect the children. The second occasion was the day before the death of Child E when the school noticed bruising on Child C’s legs. The explanation from Ms P was that this was due to Child C climbing in through a bathroom window as the family were locked out of their flat. This would appear to have been the case given what subsequently became known but the IMR author identifies that there was no action taken by the school. This demonstrates a lack of professional curiosity and there is no evidence that the school confirmed if the situation had been resolved and the impact on Ms P with 6 children for whom she was caring. 6.8.3 The IMR Author also identifies that the home tuition service did not notify Children’s Social Care when it was believed Child A was missing and not accessing tuition and this did not comply with the Croydon Procedure for safeguarding children missing from home/care. 6.8.4 The IMR challenges the fact that the school attendance for all four of the children other than Child C never increased over 50%. Croydon Local Authority have introduced new procedures from April 2014 to include LA investigations when school attendance falls below 80% irrespective of the provider of the education welfare function. This would appear to be an appropriate and robust response to the issue raised in this IMR in relation to the overarching role of the Local authority. 6.8.5. The IMR identifies a number of areas of good practice and makes a number of recommendations concerning procedures and reminders to all education staff to contact the MASH (Multi-agency safeguarding hub) helpline for advice on whether to refer issues. 6.8.6 The Independent Reviewer is satisfied that the key areas of learning have been identified and the recommendations are robust. 15 6.9 Bromley Children’s Social Care 6.9.1 Bromley Children’s Social Care became involved in March 2013 but closed the case in May 2013, as they were unable to locate the family. They then became involved again in July 2013 following mother’s arrest for drugs and driving offences and a core assessment was commenced. 6.9.2 The IMR and chronology detail the significant number of meetings that were held in relation to this family in this short period of four months and all of these meetings and processes met the statutory timeframes. These include two LAC Reviews; three Legal Planning meetings; two Permanency Planning Meetings; a PEP meeting (Personal Education Plan); a Family Group conference; a discharge planning meeting and a complex statutory meeting. 6.9.3 The revised IMR following a request for further information and analysis from the SCR Panel and Independent Reviewer however clarifies that there were occasions when statutory timescales were not met: i) the decision to accommodate Child A and C should have been made on 3rd September 2013 not 16th September 2013 – as a result the Care Plan and Placement Plan were out of time. ii) the full stage 2 connected person’s assessment was commissioned 10 weeks after placement of Child A and Child C. iii) LAC visits to Child E and Child D did not all meet statutory timeframe. 6.9.4 The IMR identifies much positive practice undertaken by SW1 and SW2 and subsequently SW3 and SW4 in engaging with the children and the family in a sensitive manner, the quality of the assessments and the significant amount of liaison and checks undertaken with other agencies and at least five other Local Authorities. The IMR rightly emphasises the complexity of these family arrangements which was exacerbated by many of the family members having similar names and that the level of movement between Local Authority areas meant obtaining a clear chronology and factual information was extremely challenging and time consuming. 6.9.5 The IMR does however recognise the impact of where processes/systems did not work effectively or in a timely manner or decisions were with the benefit of hindsight flawed. 6.9.6 The first issue relates to the decision not to undertake an Initial Child Protection conference on Child E and Child D which was planned for 25th September 2013. This was a decision by the Group Manager in the Quality Assurance function as it was felt that it did not meet the criteria as Child A, B and C were already looked after and a pre-birth conference was not considered necessary. This clearly resulted in a missed opportunity to have a multi-agency focus on planning and assessment for Child E and Child D and may have been the opportunity to share some of the key information. The IMR Author has made a recommendation for the Quality Assurance Team to consider decision making on pre-birth conferences when older children are looked after. This is fully supported by the Independent Reviewer. 6.9.7 The second issue relates to the delay and the process for requesting a connected person’s assessment of Ms P. The internal processes for commissioning this 16 assessment were not effective. This resulted in an unnecessary and significant delay in a full assessment of Ms P as a carer for all 4 of the children for whom she was responsible. 6.9.8 The Independent Reviewer has identified that the Stage 1 viability/suitability assessment undertaken by SW2 covered much of the content required such as the children’s wishes and feelings and information on historical contact with Ms P and her family from Children’s Social Care in Croydon. However it did not contain detailed information from Croydon Education Services on the previous involvement with Ms P’s own children. It did not contain information on Ms P’s medical history as there had been no response from the GP but does state that Ms P stated she wasn’t taking any prescribed medication. The information from the police stated there were no concerns about child care but was not a full police record and the DBS was outstanding. The number of aliases used by Ms P and the need to obtain fingerprints had delayed this process. 6.9.9 The IMR Author confirms that processes for the commissioning of connected person’s assessments were reviewed and revised prior to the initiation of this SCR. There is a recommendation for these to be published as part of the Children’s Social Care Procedures Manual. This recommendation is fully supported by the Independent Reviewer. 6.9.10 The third issue relates to the delay in undertaking a Family Group Conference. This is within Bromley Children’s Social Care procedures as a requirement in initiating care proceedings. It was allocated to a coordinator by 1st October 2013 but didn’t actually take place until 9th December 2013. This may well have been due to difficulties in contacting family members. However, the IMR Author makes a recommendation that the outsourced Family Group Conference service is reviewed to ensure improved timeliness is achieved. This recommendation is fully supported by the Independent Reviewer. 6.9.11 The fourth issue relates to the delay in initiating care proceedings. The IMR author provides evidence of the timeframe for the completion of court statements, which were signed off by the Head of Service on 3rd October 2013. The 2nd Legal Planning meeting was held on 9th October 2013 where it was stated that the intention was to issue proceedings the week beginning 16th October 2013. However, at this meeting there was an unconfirmed report raised about the possible risk to professionals from a wider family connection to a serious criminal network and a recommendation that a professionals meeting is held before the start of any proceedings and risk assessments undertaken. This strategy meeting was held on 29th October 2013 and no further evidence was found but this caused a delay in issuing the care proceedings by 3 weeks. The impact of this was that although the older children were in placement the planning and assessments of family members for Child E and Child D were not progressed in a timely manner whilst recognising the significant workload that this entailed. The Independent Reviewer recognises that these were unusual circumstances but it is clear that aspects of the care plan should have been progressed during this period and recommends that there should be enhanced scrutiny of the management oversight of cases in care proceedings. This is included in the agency IMR recommendations. 6.9.12 The fifth issue relates to the delay in case transfer between the Referral and Assessment Team and the Safeguarding and Care Planning Team. The case 17 transfer report was completed on 13th November 2013 and the case was intended to be transferred to SW5 at an earlier point. However SW5 left the LA suddenly, which required a change of allocated social worker to SW3 (for Child E and D) and SW4 for Child A, B and C The record shows the case allocated to SW3 on 20th November 2013 and to SW4 on 18th December 2013. The second Legal Planning meeting on 9th October 2013 describes the intention of a joint visit between the social workers to meet the children and family, which then did not take place. The IMR Author makes a recommendation that the transfer protocol between teams is reviewed and additional direction is given to social workers on joint handover visits. It is the view of the Independent Reviewer that there were two issues at this time which are both unusual and difficult to anticipate and which led to the delay in issuing care proceedings for this family. The first was the unexpected departure of the social worker who was identified to take on the case and the second was the potential risk to professionals identified and which needed to be explored. There are no recommendations in relation to this but it is worth considering if the pause in initiating proceedings was necessary whilst additional information and risk was being explored as is addressed above. Impact on the court decisions: 6.9.13 The impact of this delay was significant in that SW3 and SW4 by their own admission were not well prepared for the court appearance on 12th December 2013. The initial statement of SW3 states” the social worker’s view is that their needs would not be met if they were to remain with mother in prison as she is unable to prioritise their needs…however as a holding position the LA agree to Child E and Child D remaining with mother whilst the assessment of the wider family is undertaken”. The case was deferred until 18th December 2013 for family suitability assessments to be completed and for further exploration of a mother and baby placement in prison. 6.9.14 At the court hearing on 18th December 2013, the positive suitability assessment on Ms U and Mr V (aunt and uncle) was provided. However police checks provided at court indicated that there was an unknown criminal conviction and concerns about a member of the household. Therefore it was not felt to be an appropriate placement. The choice at that point for the placement of Child E and Child D was for foster care or placement with Ms P as the prison mother and baby placement had not been pursued further as an option. The mother and wider family supported placement with Ms P. and the family’s legal representatives pro-actively argued for this. The key issue is that the LA at that point had no evidence that this placement was not appropriate (i.e. that Child E and Child D would not be safe with Ms P). They had no updated information from the GP, School or police/DBS and Child A and C had been in placement since 1st October 2013. Consequently following a great deal of debate, checks and negotiation, the LA and Guardian agreed with the placement outside of the court although it is clear that there was a high level of concern from the LA at how Ms P could manage caring for 6 children including new born and vulnerable babies. SW3 and SW4 described the pressure they felt under from the family’s legal representatives and the constant challenge that they didn’t understand and lacked knowledge of traveller culture. It is recognised by the Independent Reviewer that this would have been a particularly challenging court environment with the reality of two 8-day-old baby twins requiring placements in the week before Christmas. 18 6.9.15 The IMR makes a number of additional recommendations for the service, which address the need to review how some of the administrative work identified in this case could be better managed to reduce the pressure on social work staff. It also recommends a review of the electronic filing system to address the anomalies of recording differing on individual children’s files. There is a recommendation around a review of caseloads for social workers to ensure they are not excessive and that they are appropriate to the individual’s level of experience and that the pattern of visiting is assessed and proportionate to the level of need above the minimum standard. These are all appropriate recommendations and supported by the Independent Reviewer who is satisfied that the learning has been recognised. 6.10 Bromley Legal Services 6.10.1 The IMR Author makes a clear observation that pre-proceedings planning in relation to assessments of the extended family would have been beneficial in this case. The IMR report expresses concern that the court statements and reports were not served in a timely manner and the instructions from Children’s Social Care were not always clear. 6.10.2 The recommendations in the IMR are for improved processes pre-proceedings and the need for clearer planning and instruction for Children’s Social Care. Following discussion at the SCR Panel, it has been agreed that Children’s Social Care and Legal Services will look at developing a joint action plan in response to their shared recommendations to ensure that future care proceedings processes are clear and evidenced. 6.11 Holloway Prison 6.11.1 The Briefing report confirms the involvement between Holloway Prison and the support provided to mother as she was clearly identified as vulnerable and their liaison with other agencies. 6.11.2 The key issue in relation to the learning is the request by mother for a mother and baby placement and the process that was followed by Holloway/Islington Children’s Social Care. Mother applied on 11th October 2013 and reports were requested from internal probation, medical reports, Personal Officer report, Security report and mandatory drug testing (MDT). Bromley Children’s services were contacted on 31st October 2013 and a request made for an assessment for suitability to the unit prior to the Prison Board meeting on 4th December 2013. 6.11.3 Social worker 2 responded on 1st November 2013 and explained the case was transferred to another social worker - SW5 and forwarded the e-mail. On 13th November 2013 a reminder e-mail was sent and on 25th November 2013, SW3 wrote confirming she was now the allocated social worker and wrote again on 3rd December 2013 to say that the LA Care plan was to seek an Interim Care Order on Child E and his sibling and for them to be placed with either the extended family following assessment or with foster carers. 6.11.4 The Prison Board met on 4th December 2013 - the medical and probation and MDT reports were not available. The reasons why the LA was intending to seek Interim Care Orders on Child E and Child D was shared. The outcome was that the Board could not recommend a place on a mother and baby unit as the LA was issuing 19 care proceedings. However, mother was advised that if the LA application was unsuccessful then she could re-apply. The Serious Case Review Panel were unclear whether it was policy for the offer to be refused if there were current care proceedings. The Independent Reviewer had further detailed conversation with the link social worker for Holloway prison and reviewed the policy document issued by NOMS (National Offender Management Service). It does state that if the child/other children in the family are subject to care proceedings then this is likely to be a reason for refusal but that if the position changes, then there can be a re-application from the mother. 6.11.5 The second key issue is the discharge of mother on 13th December 2013 following the birth of Child E and Child D. The Holloway briefing is clear that following the information shared by the social worker there was a risk that Child E and Child D might be taken and arranged for additional staff to attend the hospital and for mother to be removed to another ward. It is then stated that the hospital decided to discharge mother who was initially reluctant to leave but was eventually persuaded to leave. There was some concern that Bromley Children’s Social Care had not been involved, but subsequent information confirmed that Bromley Out of Hours Service were informed and that this decision, given the potential risk, was appropriate. 6.11.6 Following the initial court hearing on 12th December 2013, SW 3 e-mailed the Islington social worker to request a place on the Mother and Baby unit as the LA plan for foster care had been unsuccessful in court and the Court had asked the LA to request a place on the mother and baby unit whilst assessment was undertaken of family members. The response by Islington on behalf of Holloway was to request an additional updated report outlining the request and identifying how any potential risks could be mitigated on the unit. This report was never received as the decision was made at court on 18th December 2013 to place children with Ms P. This was a briefing report and no learning identified which is appropriate in the view of the Independent Reviewer. 6.12 Croydon Children’s Social Care 6.12.1 The report from Croydon Children’s Social Care identifies their first involvement with the family in 2008. Further referrals were received in 2009 and 2010 identifying that the children were out of school and concern was expressed about a number of risk factors - parental substance and alcohol abuse; mental health, housing and children not attending school. The parents refused to engage and the case was closed, as the Section 47 threshold was not felt to be met. A further referral was made in July 2010 but by that point the family had left Croydon. Croydon LA made referrals to two other Las where there were possible connections. It is acknowledged by Croydon Children’s Social Care that with hindsight there should have been a more proactive response by Croydon LA to the concerns raised. 6.12.2 It appears that the family had further contact with two other London Boroughs Children’s Social Care but the cases were closed following referrals, however, the risk to the children from the parental lifestyle was apparent. 6.12.3 The Serious Case Review Panel discussed the issue of the impact of families moving between Local Authorities and the challenges for any LA undertaking an assessment of need/risk. The need for a collective responsibility across LAs to be 20 exercised where there are concerns, which cannot be addressed formally as the family moves on was discussed and a proposal that this Serious Case Review should make recommendations to the pan London Safeguarding Children Board to commission further work on developing a collective response to sharing information on children within families who move frequently. Of course this is not just restricted to traveller families but all families whose continued movement causes difficulties. This is therefore a separate recommendation by the Independent Reviewer. 7. KEY ISSUES 7.1 Ethnicity and Culture 7.1.1 The children in this family were part of the Irish travelling community and were brought up as practising Catholics. The numbers of Gypsies and Travellers in the UK are unknown and they are not a homogeneous group. The term “traveller” or “gypsy” can refer to Gypsies, Irish Travellers, Scottish Travellers, Roma and others. The 2011 Census for the first time allowed people the opportunity to declare their ethnicity as Gypsies or Travellers and some 58,000 did so. That is likely to reflect significant under-reporting. A support group for these communities, Friends Families and Travellers (FFT) reports that, by combining direct counts of caravans, school records and other recording, there are government estimates of 300,000. Whatever the numbers, Romany Gypsies and Irish Travellers are recognised as ethnic groups and as such fall within the remit of the Race Relations Act and the Human Rights Act. 7.1.2 This ethnic group is believed to be the most deprived group in Britain in relation to health and education outcomes and there is substantial body of research to support this. They are also a group that experiences widespread discrimination. In one study, profiling the nature of prejudice in England, Gypsies and Travellers were highlighted as the minority group about which people felt least positive. Media reports about Gypsies and Travellers have often reinforced a lack of understanding and the existence of negative stereotypes. Many of their negative experiences remain unreported and invisible. Consequently, feelings of injustice and persecution are understandable. In this context therefore, professionals involved with Child E and the family needed particular experience and understanding of the culture when working with the Traveller community. This is to ensure that cultural expectations around education, gender roles and lifestyle are fully explored in relation to the children’s placement and the necessity of professionals to be aware of the familial and religious context that emphasised the indissolubility of marriage, and the role of women within that system and the awareness that for some travellers “education at secondary level can be seen as a threat to their culture” with the fear that a traveller child could lose their identity, and expectation that girls and boys should socialise separately. 7.1.3 All the children, except Child C, in the care of Ms P have shared with both teachers and professionals that they do not want to go to school nor understand why they have to. It is recorded that Child A had not had any formal education since the age off 11.There is however much evidence to show that the children’s needs were sensitively considered by professionals, for example Child A received education from a tutor rather than attending the pupil referral unit, and this was more culturally appropriate. 21 7.1.4 It was also explicit that the family was very opposed to any of the children being placed in foster care. There is recognition that foster carers are not usually recruited from traveller families, and it can be difficult to ensure a traveller child’s cultural needs are met and hard for a traveller child who has been in foster care to be re-assimilated into the traveller community. 7.1.5 The Health Overview Review Author felt that issues of ethnicity and culture were not evident in all assessments by health professionals. It is the view of the Independent Reviewer, that overall all professionals involved with the family were culturally aware of the traveller community and sensitive to the impact of this on the children. There was recognition that school attendance was not promoted within traveller families and that there was an extremely high expectation that traveller families would care for the children within their community. The fact that Ms P came forward to care for such a large number of children was seen as less remarkable in this community, where there would have been a strong expectation that she should do so. 7.1.6 The Children’s Social Care IMR and the meeting with the professionals implies that the Court had an absolute view that Child E and Child D should be placed within the extended family of travellers. The Legal services IMR makes the point that recent case law has reinforced the guidance of the Children Act 1989 that children should be placed within the family if at all possible. The court would therefore wish to be provided with the assessments of family to enable placements to be made in the best interests of children. The difficulty in this case was that these assessments had not been concluded partly because of the issues identified already around delay and party because there were a large number to be undertaken. This resulted in a placement within the extended family with Ms P which was strongly felt by professionals not to be in the best interests of Child E and Child D given their level of vulnerability and that Ms P was already caring for 4 other children as a single parent. 7.2 Communication There are a number of examples identified through the SCR of poor multi-agency communication and information sharing which is summarised below: 7.2.1 The Whittington Hospital held a safeguarding discharge meeting on 19th December 2013 but did not send any notification to Croydon Health Visitors of discharge. 7.2.2 The Whittington Hospital did send a discharge summary to the Croydon GP but it was not clear that the foster carer was Ms P as the name was missing from summary. 7.2.3 Croydon GP – request made for family information on Ms P on 11th November 2013 by Bromley Children’s Social Care but no response was received until March 2014. The impact was that this information was not available to inform the assessment and decision to place with Ms P on 18th December 2013. 7.2.4 Bromley Children’s Services notifies Croydon Health Visitor of the placement of Child E and child D but there was no pro-active communication from the Health Visitor following the new birth visit or from the social worker and the Health Visitor did not attend LAC review on 6th January 2014. 22 7.2.5 Croydon Education Services had background information on Ms P and had issued a School Attendance Order on Child F and Child G but this info was not known/shared with Bromley CSC or not considered as part of the assessment. 7.2.6 Ongoing difficulties for Bromley CSC to contact prisons where parents were placed as well as challenges of following up information requests from a large number of different LA and agencies. 7.2.7 Croydon Education (School) did not refer two incidents to Bromley CSC - one when children not collected on 12th December 2012 and Ms P not contactable and the second when bruising noted on Child C legs on 4th March 2014 and account of having to climb through window as locked out. This was the day that Child E dies that evening. There was a third concern regarding the front door to Ms P house being unlocked on 6th December 2013 which was known to SW3 who was no longer involved in the case. 7.3 Timeliness of assessments 7.3.1 New birth visit by HV delayed to Child E and Child D. 7.3.2 Delay in Initial Health Assessment for Child E and Child D. 7.3.3 Delay in process for connected person’s assessment by Bromley Children’s Social Care on Ms P – the impact was insufficient information on Ms P to inform court in decision making on placement with Ms P. 7.3.4 Not all social work visits to Child E and Child D met statutory timeframes. 7.4 Care Planning 7.4.1 The decision not to hold pre-birth Initial Child Protection Conference in hindsight was flawed as would have provided multi-agency forum for decision-making. 7.4.2 The Case transfer process was ineffective and led to hiatus in care planning for Child E and Child D. There was no joint handover visits. 7.4.3 The delay in issuing care proceedings. Impact of perceived threat posed by this family and wider family network contributed to a 3 week delay whilst a professional’s risk management meeting planned and held on 29th October 2013. 7.4.4 The delay in holding the Family Group conference contributed to delay in family assessments being undertaken in a timely way. 7.4.5 Mother’s pregnancy with Child E and Child D was known in September 2013 and plan for twins to be born by caesarean also known in advance of 10th December 2013 delivery. Family members had been put forward but none of the viability assessments had been undertaken to enable clear planning by Children’s Social Care. 23 7.5 Organisational issues 7.5.1 Children’s Social Care - The delay in case transfer between teams in Children’s Social Care which was exacerbated as Child E and D were due to transfer to a Senior Practitioner in SCPT (Safeguarding and Court Proceedings Team) who then left the employment of the LA. 7.5.2 CSC/Bromley Healthcare - the delay between the two organisations communication resulted in the initial health assessment being delayed. 7.5.3 Croydon GP - The system within the GP practice for responding to requests for information was ineffective and the GP did not respond to request in a timely way. 7.6 Additional issues identified by the Independent Reviewer 7.6.1 Emerging low-level concern about the care of the children with Ms P appears not to have been recognised/shared/discussed between Social Workers, Guardian or Independent Social Worker (involved to conclude the assessment of Ms P). This included an assessment of home safety and Ms P’s behaviour at mother’s bail hearing. In addition, the reality that none of the 4 children were actually regularly attending school. However it is likely these concerns would have been recognised and shared as the placement continued. 7.6.2 Information sharing between Local Authorities. It is clear that this family was known to a number of different Local Authorities primarily within the London area over a period of years but no LA had been successful in responding to the concerns raised about the children including non-school attendance and the impact of the parents’ lifestyle on their children. Although it is understandable, on an organisational level it doesn’t make sense for a continued start again approach with families who continually are moving between Local Authorities. This issue is contained in a recommendation for BSCB. 7.6.3 NHS England, London were using a new format /template for IMRs which was intended to combine the Root Cause Analysis approach with the SCR approach. The general view including that of the Independent Reviewer was the reports were not user friendly and did not lend themselves to addressing the SCR TOR (Terms of Reference). There is therefore a recommendation for the BSCB on this issue. 7.7 The Children’s Voices 7.7.1 Overall there is evidence from all the IMRs that Child A, Child B and Child C were encouraged and able to share their views on their placements and plans being developed for them in relation to contact with their family and siblings and their education. Care was taken by professionals to engage sensitively and develop relationships with the children. Children’s Social Care IMR identifies evidence of excellent engagement with Child A despite high levels of mistrust but recognises that the older children were often spoken to in very stressful situations with multiple relatives nearby, and there is limited evidence of any direct work tools used to understand their wishes for the future or their previous experience of safeguarding risks although this was carried out with Child B. 24 7.7.2 Child E and Child D were new born babies. The IMRs describe how their wishes and feelings were measured by their attachment to their main carers and evidence of that interaction which was for the most part overwhelmingly positive. There is evidence of concerns that Ms P and Child A appeared to be assuming lead responsibility for Child E or Child D respectively and the impact and appropriateness of that was raised. The practical sleeping arrangements in the family home were actively monitored and the children’s weight and development monitored appropriately. There was some concern that Child E and Child D suffered with severe nappy rash, which may have been missed by professionals, but there is no current evidence to support this. The Coroner’s report describes nappy rash but the adoption medical on 3rd March 2014 states that there was no nappy rash on either Child E or Child D. 7.7.3 Observations were clearly recorded by Children’s Social Care of the contact arrangements and the impact on Child E and Child D including practical advice and support. 7.8 Effective professional practice 7.8.1 There were some good examples of effective professional practice identified by all agencies. All professionals appear to have been very aware of the cultural issues within this family and were sensitive and thoughtful in their approach and there is evidence of persistent engagement with the family in challenging circumstances. 7.8.2 Contact arrangements, although logistically challenging, were maintained for all the children with each other and mother - (other than Child C with mother) and were well supported. 7.8.3 Child A, Child B and Child C did engage in education. Although this may not have been at a level that professionals would have wished, it was clearly a positive improvement. The level of support provided was high in terms of free bus passes, uniform etc. 7.8.4 Child A, Child C, Child E and Child D were placed and maintained within their extended family traveller community. 7.8.5 Child B was felt to be very positively responding to his placement with foster carers and engaging well with education. 7.8.6 There were excellent assessments and court statements undertaken by social workers informed by clear analysis of issues and risks and informed by research. 8. CONCLUSIONS AND LESSONS LEARNED 8.1 The death of Child E was found by the Coroner to have been a SUDI (sudden unexpected death in infancy) and it is not felt that it was caused by neglect but there was a modifiable factor of co-sleeping. However none of the professionals were aware that Ms P and the children had been sleeping in the caravan for at least two nights and that the sleeping arrangements were chaotic. The cause of death was confirmed 4 months into the process of the SCR and the SCR Panel debated as to whether the SCR should continue. However the overwhelming view was that the 25 process should continue as an SCR and it should identify the lessons learned and be formally published. 8.2 It is important to state that none of the practice issues identified in this Serious Case Review contributed to the tragic death of Child E. However undertaking this Serious Case Review process has clearly highlighted learning for all agencies and areas of practice which could be improved. Most of these areas of practice have been identified by the agencies themselves and some have already been addressed. 8.3 The Review has also recognised the systemic challenge to the wider system of how to respond to a community, who are mobile and where there is no opportunity for sustained engagement by professionals and seeks to make a recommendation to begin to address this issue. 8.4 A key issue for this SCR was the decision to place these babies with Ms P and the impact of culture on this decision. It is the view of the Independent reviewer that the court was following statutory guidance and case law to place children within their extended family wherever possible. The Local Authority for the reasons outlined previously in this report did not have sufficient evidence to dissuade the court from this decision. It has however been suggested by the IMR Authors that it may be useful for the Court to receive this Serious Case Review and consider the learning identified, with which the Independent Reviewer agrees and this is therefore a recommendation to BSCB. 9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW Each of the agencies who contributed IMRs for this process, the Health Overview Report and the individual practitioners have all identified a number of areas of good practice and areas of learning and improvement. Agencies have not waited for the completion of this review in order to address issues arising from this case. The Independent Reviewer accepts and endorses all of the recommendations made by agencies. These are attached as Appendix E. Therefore the following recommendations are made for the Bromley Safeguarding Children Board. Recommendations to Bromley Safeguarding Children Board. 9.1 Bromley Safeguarding Children Board to disseminate the learning from this Serious Case Review to all staff and partner agencies. 9.2 Bromley Safeguarding Children Board to recommend to Croydon Safeguarding Children Board that individual agency action plans developed through this SCR process for Croydon agencies are discussed and robustly monitored. 9.3 Bromley Safeguarding Children Board to ensure there is robust governance and monitoring of the individual agency and BSCB Action Plans that can evidence the impact of improvements to practice. 9.4 Bromley Safeguarding Children Board to share the learning from this Serious Case Review with the London Safeguarding Board and request that work is commissioned to consider how London LAs can develop a collective and 26 holistic response in order to safeguard the children of families that move between Local Authorities. 9.5 Bromley Safeguarding Children Board to request NHS England – London review the format for Root Cause Analysis Reports used for completing the IMRs, which did not fully lend itself to the SCR process. BSCB to feed back the outcome to the London Safeguarding Board. 9.6 Bromley Safeguarding Children Board are provided with the Joint Children’s Social Care and Legal Services Action plan developed in response to this SCR and assures itself that processes for Looked After Children in care proceedings are being reviewed and improved. 9.7 Bromley Safeguarding Children Board and Croydon Safeguarding Children Board to consider if all the public health information on co-sleeping needs to be revisited and requires further promotion. 9.8 Bromley Safeguarding Children Board to share this Serious Case Review and the learning it identifies with the local Family Court. 9.9 Bromley Safeguarding Children Board to request that the Metropolitan Police monitor their response to IMR requests and meeting SCR timeframes to ensure full compliance. 27 APPENDIX A: COMPOSITION OF SCR PANEL • Helen Davies, Independent Panel Chair • Deputy Designated Nurse, NHS Bromley Clinical Commissioning Group • Assistant Director, Safeguarding and Social Care, London Borough of Bromley (LBB) • Assistant Director, Legal services LBB • Designated Paediatrician, Bromley Clinical Commissioning Group • Consultant in Public Health Medicine, LBB • Business Manager, Bromley SCB • Lead Officer for Education Safeguarding, LBB • Detective Chief Inspector CAIT, Metropolitan Police • Senior Service Manager, CAFCASS In attendance: • Alex Walters, Independent Reviewer 28 APPENDIX B: DETAILS OF THE INDEPENDENT REVIEWER/AUTHOR OF THIS REPORT Alex Walters is a qualified social worker with 32 years’ experience in children's services and currently works independently as a consultant for improvement work across children's services. Alex has been a children's services adviser for the DfE and was also part of the Children's Improvement Board team working with LAs in need of improvement for their safeguarding and adoption performance. Before these national roles she had a range of management roles in local authorities, including 6 years as Assistant Director. She has been the Independent Chair of two Safeguarding Boards since 2011 and has overseen the publication of eleven SCRs. 29 APPENDIX C: TERMS OF REFERENCE FOR THIS SERIOUS CASE REVIEW Methodology The agencies identified in Section 9 are required to prepare: 1. A chronology of the agency’s contact with the children and family using the BSCB chronology template. 2. An analytical Individual agency Management Review (IMR) report covering: a) A narrative of the agency involvement; b) An analysis of the involvement identifying any areas of good practice as well as lessons to be learned; c) Recommendations which are drawn from the lessons to be learned by the agency. 3. An action plan addressing any learning arising which has been agreed by a senior manager. All authors of IMRs will be independent of the case and have had no direct or managerial involvement with the family. The other agencies set out in Section 9 will be required to submit a Briefing Report. A combined agency chronology will be produced. Professionals involved with the family will be invited to a learning event after the IMRs have been submitted. A further meeting for professionals will be held after the first draft of the Overview Report has been completed. The Independent Reviewer will lead the review and produce an Overview report suitable for publication. The BSCB serious case review committee will act as a reference group and will be responsible for developing an action plan in response to any recommendations. Scope of SCR The SCR will consider the following issues in relation to the case: • Did agencies communicate effectively and work together to safeguard and promote the child’s welfare? • Were there any cross border issues, and if so, how were they addressed? • What assessments were completed, and were they timely and of adequate quality? • Were the decisions and actions that followed assessments appropriate? • Was the level and extent of agency engagement and intervention with the child and family appropriate? • Were the children’s views and wishes sought and taken into account in assessments and planning? 30 • Was information known by any agency about mental health issues and substance misuse for any of the 3 adults, or concerns about neglect? If so, was appropriate consideration given to how these impacted on parenting capacity? • Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted upon? • Were any safeguarding issues identified in respect of the children identified in Section 7 and acted upon appropriately and in a timely way by all agencies? • Were there any organisational or resource factors which may have impacted on practice in this case? • Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 31 APPENDIX D: PRINCIPLES UNDERLYING THIS SERIOUS CASE REVIEW The conduct of this review has not been determined by any particular theoretical model. It has been carried out in keeping with the underlying principles, set out in the statutory Guidance, Working Together to Safeguard Children 2013: • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children. Identifying opportunities to draw on what works and promote good practice; • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process; • Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections; • The review will recognise the complexity of safeguarding children and seek to understand not only what happened but why individuals and organisations acted as they did. 32 APPENDIX E: SCR CHILD E - SUMMARY OF AGENCIES RECOMMENDATIONS Bromley Healthcare 1. The GP to complete the proforma in the PCHR for the 6-8 week review to ensure this is accessible for the LAC Medical rather than depending on a carers verbal report. 2. Referring Social Worker to ensure that Forms PH and Forms M and B are provided for the assessment. Whittington Hospital 1. Staff training on documentation. 2. A discharge planning checklist. 3. Name stamps for all staff. Croydon GP Services 1. Develop a robust system for child protection and safeguarding which processes the flow of information appropriately, gives consideration to the safeguarding lead GP having an overview of reports and includes the need to ensure that when these are requested by social care and/or solicitors, they are completed to an appropriate standard and submitted in a timely fashion. 2. All staff to access safeguarding children training at the appropriate level in order to increase awareness, understanding and how they can be better engage in multi-agency processes to safeguard children and young people. 3. All staff to access safeguarding adult training at the appropriate level. 4. Arrangement for management oversight for cases of concern within the practice to be developed. 5. Implementation of the Case Reflection Model with a specific focus on this case in the first instance. 6. Improve systems of communication with partners including Health Visitors and the CCG safeguarding team in order to share and discuss cases of concern. Croydon Health Services NHS Trust 1. The IMR author would recommend that the Looked After Children Policy Statement and Guidance for Croydon Health Services 2012 needs to be reviewed and updated particularly in relation to the role and responsibilities of health professionals who are involved with Children Looked After. 2. Information related to parental responsibility, consent and birth registration to be more explicit and included in Safeguarding Children and Looked After Children training. 33 3. Staff need to be reminded of their responsibilities to ask about the relationship of the adult who attends clinics and appointments with children to the child. Lewisham and Greenwich NHS Trust There is no recommendation to come out of the review of the expectant mothers stay in Lewisham Hospital. Health Overview Report Bromley CCG endorses all recommendations proposed by provider organisations. In addition the following recommendations are made: 1. Compliance with timescales for new birth visits and Initial health assessments (IHA’s) should be monitored quarterly by the relevant CCG. 2. Bromley CCG to ensure provider organisations comply with IHA timescales. The % of IHA’s completed within 28 days of coming into care is a useful health indicator demonstrating positive health outcomes through early identification of health needs. 3. All providers to assure Bromley CCG that their safeguarding/ LAC procedures have been strengthened to explicitly set out who information should be shared with and by whom. 4. All providers to assure Bromley CCG that assessment of equality and diversity issues is included in their Safeguarding Children and LAC Health Guidelines and evaluated through clinical audit. 5. Bromley CCG to undertake a review of the arrangements for Looked After Children against the statutory guidance to ensure that systems for promoting and meeting health needs are in place. 6. Bromley CCG/Croydon CCG/ NHS England to review safeguarding training and compliance for GP practices. CAFCASS 1. Where kinship care is considered for the children, the children’s guardian should ensure that a full DBS check has been undertaken. If the children have already been placed, then the guardian should ensure that the LA obtain this as a matter of urgency. Metropolitan Police This report makes no recommendations. Bromley Children’s Social Care Services 1. The transfer protocol between teams is reviewed and additional direction is given to social workers on joint handover visits to families. 34 2. Recording protocols revised to ensure relevant recordings are copied across all siblings, CSC should look at updating case recording system to one that supports ‘family’ files. 3. Child Protection Service reviews decision making on Pre-Birth Conferences where older children are already looked after. 4. Caseloads in SCP teams are reviewed to ensure workers have agreed to allocation of new cases and no workers are subject to excessive workloads of multiple Court Proceedings and /or number of infants under 2 years old and that caseload is linked to capability. 5. CSC to review supervision tools and care plans to; • always have columns to identify dates for completion of tasks • Clearly name responsible officer for actions. • ensure space for reflection is identified. 6. Process for completion of ‘Connected Persons’ Assessment are written up and published on procedures manual. 7. Timing of visits by Social Workers is always assessed in supervision to ensure high risk situations have necessarily greater visiting patterns than the minimum prescribed standard. 8. All open cases have completed and up to date plans, and where necessary, Working Together Agreements with family members. 9. The initial period of work covers the Social Workers undertaking an enormous variety of tasks some of which might have been more appropriately dealt with by unqualified staff: • Arranging prison visits • Arranging to read files elsewhere • Contact arrangements. 10. Review the process for the outsourced FGC service, with a view to accelerating the timing of first family meetings to ensure outcomes can be actioned more quickly and match more clearly Court expectations. 11. Review use of our wider resources in Education, health and housing to ensure that in such complex cases we reduce the workload on the Social Workers themselves. 12. Legal officers provided a written note to all Legal planning meetings with clarity deadlines for court action. 13. All staff to be reminded of the importance of key statutory dates for: • CIN assessments and visits • CP assessments and visits • LAC assessments and visits • Fostering assessments and visits. 14. Completed minutes to be promptly added to case files and circulated to participants. 35 15. All agencies to be reminded of escalation processes where timely information is not received. Bromley Legal Services 1. There should be a review of the arrangements for transferring cases from the Referral Service to Safeguarding Service. 2. Procedures should be put in place to ensure more effective pre-proceedings planning. 3. Statement, care plans, reports, Court orders and other important correspondence should be uploaded to Carefirst. 4. There needs to be compliance with Court orders and directions. Croydon Education Services 1. If children are placed in care when their parents are arrested or imprisoned, both the carers and schools should be signposted to resources such as I-HOP, funded by the Department of Education by the relevant Virtual School or Social Care to ensure the needs of the children are considered and planned for. This should also be included in the care plans and PEPs. 2. If carers own children have attendance issues or especially SAO, a multi-agency plan including the view of the school may assist in developing a strengthened and robust support system to ensure school attendance. The carers could be requested to sign an agreement that if the school attendance falls below a certain agreed level, that their suitability as carers may be reviewed and they may face court fines or prosecution, according to locally agreed EWS procedures, rather than relying on verbal assurances to professionals that they will bring the children to school. 3. The Croydon Procedure for Safeguarding Children missing from Care and Home should be revised with regard to Keeping Children Safe in Education Guidance and school duties regarding missing children procedures, taking into account revised local police procedures and categories of missing. The new guidance to then be circulated to all Croydon Schools and the Virtual School. 4. Schools should be regularly reminded to contact the MASH helpline to discuss any concerns of abuse/neglect if they are unsure if they should refer or not. The MASH updates to schools and the DSL training and DSL Forums delivered by Croydon CFL. 5. Croydon schools to be reminded annually via the School Bulletin of the procedures when children are not collected from school and to notify the Virtual School and Social Care if applicable. 6. When Local Authorities place children in care, including kinship care or issue ICO, an assessment of the suitability of the accommodation and a visit to the property should be undertaken jointly with a relevant housing representative. Any security or access and egress issues should be included in the assessment and repaired as a matter of urgency if children may be at risk. Any professionals, including education who visit the home should be reminded of the responsibility to follow up any such concerns if noted during a visit. 36 APPENDIX F: REFERENCES This report has been generally informed by the following publications: • Working Together to Safeguard Children (Department for Education 2013) • A Study of Recommendations Arising from Serious Case Reviews 2009 to 2010 by Marion Brandon et al (Department for Education 2011) • New Learning from Serious Case Reviews: a 2 year report from 2009 to 2011 by Marion Brandon et al (Department for Education 2013) • First Annual Report-National Panel of independent experts on Serious Case Reviews (Department for Education, 2014) 37 APPENDIX G: GLOSSARY BSCB Bromley Safeguarding Children Board CAFCASS Children and Family Court Advisory and Support Service CCG Clinical Commissioning Group DBS Disclosure and Barring Service EDD Expected Date of Delivery ICO Interim Care Order IMR Individual Management Review SCR Serious Case Review LAC Looked After Child(ren) i.e. in the care of the local authority LBB London Borough of Bromley PICU Paediatric Intensive Care Unit SCBU Special Care Baby Unit. TOR Terms of Reference YOS Youth Offending Service 38 |
NC045631 | Serious injury of a 7-month-old baby. Child W was taken into care on an emergency order following the incident and mother's partner was arrested on suspicion of assault. Before Child W was taken into care, family had made frequent visits to both GP and Accident and Emergency with concerns about Child W's health. Maternal history of: domestic abuse, depression, non-attendance at appointments for herself and her children and providing inconsistent information to professionals. Mother's partner had a history of: alcohol misuse and anxiety related illnesses. Identifies learning, including: agencies need to be more proactive to fulfil their safeguarding role; professionals need a wider understanding of the significance of injuries in young babies; agencies working with families should routinely enquire about and challenge adults where risks emerge about living arrangements, relationships and care; management and recording of strategy meetings needs to be consistent; communication within and between NHS agencies needs to be clearer; and there needs to be a way for agencies to flag known risks posed by adults without convictions.
| Title: Overview report of the serious case review in respect of Child W. LSCB: Manchester Safeguarding Children Board Author: Hester Ormiston Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Overview Report of the Serious Case Review in Respect of Child W MSCB Independent Chair: Ian Rush This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 30th September 2013. i Contents Page No. Introduction ................................................................... 1 Overview of What Was Known................................................. 8 Single Agency Involvement ...................................................... 10 Analysis ................................................................... 25 Summary ................................................................... 37 Challenges ................................................................... 44 ii Glossary A & E Accident and Emergency CCNT Children’s Community Nursing Team CCS Children’s Community CHS Community Health Services CMFT Central Manchester University Hospitals NHS Foundation Trust CPS Crown Prosecution Service CSC Children’s Social Care DfE Department for Education DNA Did Not Attend FRT First Response Team (part of CSC) FWIN Force Wide Incident Number GMC General Medical Council GMP Greater Manchester Police GP General Practitioner HV Health Visitor IMR Individual Management Review LSCB Local Safeguarding Children Board MNHS COR Manchester NHS Commissioning Overview Report MSCB Manchester Safeguarding Children Board NHS National Health Service OCD Obsessive Compulsive Disorder OOH Out Of Hours OPUS Operational Policing Unit System PAHT Pennine Acute Hospital Trust PPIU Public Protection Investigation Unit (Police) SCR Serious Case Review SCRSG Serious Case Review Subgroup TOR Terms of Reference WT Working Together to Safeguard Children Page 1 of 46 1. Introduction a. Circumstances that led to this Review 1.1 On 12th July 2012 MW (Child W’s mother) took Child W to Hospital 1 as the child had a swollen right foot. The foot was X-rayed and as no sign of a fracture was found Child W was discharged home. The X-ray was reviewed on 13th July 2012 when a number of healing fractures were identified. 1.2 DR16 (a radiologist) also checked a previous X-ray taken on 29th June 2012 at Hospital 2 when none of the current healing fractures were identified. 1.3 The recent history of medical intervention was that MW had taken Child W to Hospital 1 on 3rd June 2012 reporting that the child had sustained a bruise when the child’s seven year old half sibling (SS2) had let the child fall from the sibling’s knee onto a hard surface floor. Child W had vomited once but not lost consciousness. On examination there was a 2 x2 cm bruise right tempero-occipital region (right lower side and back part of the head) but there was no swelling. After four hours observation, Child W was discharged. 1.4 The next day MW returned to Hospital 1 (4th June 2012) and reported that Child W had vomited and she had seen blood in the baby’s mouth. A CT scan was normal and Child W discharged on 5th June 2012. 1.5 On 7th June 2012 MW returned to Hospital 1 with Child W reporting that the child was lethargic, irritable and not feeding. Child W was observed to be well but blood tests revealed a possible bacterial infection which was treated intravenously. Child W was discharged home on 10th June 2012, with daily administration of intravenous drugs for a further five days by the Children’s Community Nursing team (CCNT). 1.6 On 26th June following a consultation with GP3, MW took Child W to Hospital 1 for a paediatric assessment of a non-blanching rash to the leg and a swollen foot. A further course of intravenous antibiotics was prescribed to be administered by CCNT. 1.7 On 27th June 2012 SN4 from the Health Visiting team visited Child W at home as follow up to the visit to Hospital 1. MW gave SN4 a full description of the hospital visits and outcomes but said she was still concerned that there was no clear diagnosis. In view of the tenderness of Child W’s feet and the non-blanching spots, SN4 advised MW to take Child W to Hospital 2 for assessment. 1.8 On examination Child W was found to have a bruise on the right lower back and a swollen and tender left foot. The unexplained bruise and some of the history (reported bruise on Child W’s thigh three months earlier) led to referral for skeletal survey, ophthalmology assessment, medical photographs, urgent social service referral, safeguarding nursing referral, as well as medical examination for Child W’s half siblings. The skeletal survey was completed on 29th June 2012. It identified Page 2 of 46 compressed fractures to Child W’s left tibia two to four weeks old, and a possible chip to the bone of the left foot. A strategy meeting was held on 28th June 2012, but because of the absence of key staff a second strategy meeting was held on 29th June 2012. The outcome of the meeting was ‘no further action’ as MW had been consistent and appropriate and the bruise was considered as accidental. However it was also noted on the strategy minutes that Childrens Social Care (CSC) would complete a core assessment. 1.9 The review of the 29th June X-ray carried out on 13th July 2012 revealed a healing fracture on the first metatarsal and healing fractures on the 2nd to 5th long bones in the foot. SW1 took MW and Child W back to hospital for a further examination by DR13. This identified that the child had a red mark to the side of the lip, a torn fraenum and a laceration in the genital area. This was recorded to be an acute injury which was found to have fresh blood indicating a possible assault that had ‘happened today.’ 1.10 At the strategy meeting it was agreed that the children, Child W, SS1 and SS2 (Child W’s half siblings) should be made subjects to police protection and that MW and MPW (her current partner) should be arrested on suspicion of assault. 1.11 A further strategy meeting on 20th July identified a further fracture to the left forearm bone. 1.12 The circumstances of the incident were considered by the Manchester Safeguarding Children Board (MSCB) Serious Case Review Sub Group (SCRSG) on 3rd August 2012 when it was recommended that an SCR panel should be convened. The Independent Chair of Manchester Safeguarding Children Board, Ian Rush ratified the recommendation on 4th August 2012. b. Terms of Reference 1.13 Working Together to Safeguard Children (WT) 2010 states that any Serious Case Review (SCR) must do the following: • establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children; • identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence; • improve inter-agency working and better safeguard children. 1.14 The SCRSG agreed a number of key lines of enquiry which incorporate the expectations of Working Together 2010 as Terms of Reference (TOR). These were considered at a preliminary meeting of the Independent Chair of the SCR, the Independent Author of the Overview Report, the SCR Business Support Officer, the Chair of Manchester Safeguarding Children Board, a Consultant Paediatrician who was a representative from the SCRSG and the MSCB Media and Communications Manager on 13th September 2012. Page 3 of 46 1.15 The TORs were amended slightly and it was agreed that MSCB would write to four neighbouring Local Safeguarding Children Boards (LSCBs) where previous partners of MW and MPW live to inform them of the SCR and to invite them to consider whether their area had any information that would be relevant to the TOR. 1.16 The agreed TOR are: 1. Review the decision making relative to Child W's marks and injuries observed between 30th April 2012 and the 13th July 2012. This to include marks or injuries observed during home visits and attendance at GP's surgeries and hospitals. 2. Review the apparent opportunities for challenging decision making and why this did not happen. 3. Evaluate the planning, recording and decision making at the strategy discussions on the 28th June 2012, 29th June 2012 and the 13th July 2012. 4. To what extent did agencies and services take account of issues such as: race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 5. To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of Child W? 6. Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children. 7. Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence. 8. Improve inter-agency working and better safeguard children. 1.17 Before any agency was asked to provide an Individual Management Review (IMR) a number of Manchester agencies were asked if their records held any relevant information about the children or adults considered in the review, within the timescale of the review. Neighbouring LSCBs were also contacted for information about the family (see paragraphs 1.33 to 1.36). 1.18 Those contacted includes all NHS providers in the Manchester area and NHS Direct, as well as: • Manchester Housing Department; • Sure Start and Early Years; • Manchester Education Department; • NSPCC; • MARAC; • CAFCASS; • Greater Manchester Probation Service; and • Manchester Adult Social Care. 1.19 Correspondence was received from: • Manchester Education Department; • NSPCC; • Christie Hospital; • Greater Manchester West Mental Health NHS Foundation Trust; Page 4 of 46 • Manchester Mental Health and Social Care Trust. Only Manchester Education Department provided some information which is included in Section 2 of this report. c. Timescale for the Review 1.20 Events were reviewed from Child W’s date of birth until 13th July 2012 (date Child W and the half siblings were taken into police protection). d. Membership of the Review Panel 1.21 The Serious Case Review Panel was made up of: • Detective Sergeant, Greater Manchester Police (GMP); • Deputy Designated Nurse, NHS Manchester; • Consultant Paediatrician, Designated Doctor, NHS Manchester; • Interim Head of Safeguarding, MCC Children’s Social Care; • Project Team Manager, NSPCC; and • Independent SCR Chair. 1.22 The Independent SCR Chair was Mike Tarver and each meeting has been attended by the Independent SCR Author, Hester Ormiston, who wrote the Overview Report and Executive Summary. Mike Tarver is a registered Social Worker (Health & Care Professions Council) with experience of senior management of a wide range of local authority services spanning over 30 years predominantly in the fields of Safeguarding and Looked After Children. During this period he was Head of Child Protection in two inner city local authorities for 11 years where he had extensive experience of coordinating the work of Area Child Protection Committees including numerous ‘Part 8 Reviews’ for which he was the overview writer. Since 2006, he has worked independently as a project and Interim Manager and Consultant covering a broad spectrum of work in both Children’s and Adult Services across the North West. He has recent experience of chairing several serious case reviews and authoring Individual Management Reviews. He has been the appointed Independent Chair for a North West Safeguarding Children Board since January 2010. 1.23 Hester Ormiston is an Independent Consultant who completes work across the range of social care services. Miss Ormiston was a qualified Social Worker who previously worked in social work and social work senior management posts as well as the (previous) Social Services Inspectorate for 30 years. Miss Ormiston has previous experience of chairing an Area Child Protection Committee (as was), chairing Serious Case Review panels and as author of overview reports. Page 5 of 46 1.24 Both Mr Tarver and Miss Ormiston are independent of all the agencies concerned and neither the Independent SCR Chair nor the SCR Author is employed by any local authority or agency, only undertaking commissioned pieces of independent work. The panel has been supported by the MSCB Business and Performance Manager and the MSCB SCR Business Support Officer. 1.25 The Panel received IMRs for the following agencies: • Children’s Social Care (CSC); • NHS Manchester (NHS); • Greater Manchester Police (GMP); • Central Manchester University Hospitals NHS Foundation Trust (CMFT); • The Pennine Acute Hospitals NHS Trust (PAHT). Each author of the agency Individual Management Review reports was asked to focus on Child W but also to take account of any historical, critical safeguarding concerns in relation to other children in the family and any known partners of Child W’s Mother. 1.26 A preparation session was held for the IMR Authors and the agency manager responsible for quality assurance on 4th October 2012. All IMRs have been prepared by staff or managers who have not had direct or line management contact with the families. Each one has been countersigned by heads of service or equivalent. The panel has considered each IMR, offered comments and following some revisions found them to meet the expectations of Working Together 2010. 1.27 The Serious Case Review Panel met on the following dates: • 12th September 2012; • 13th November 2012; • 6th December 2012; • 17th December 2012; • 8th January 2013; • 20th February 2013; and • 12th March. Each meeting lasted between three and four hours. 1.28 The SCR was completed in more than six months from the notification to Department for Education (DFE) as one of the IMR authors became ill and it took some time to find a replacement author. DFE was notified of the delay on 14th January 2013 when it became clear the timescale could not be met. The draft SCR overview report was presented to MSCB on 11th April 2013 for consideration of how to respond to the challenges presented instead of recommendations. Following the Board it was agreed that the Overview Report would include the Board’s responses to the challenges within the report with a further delay until the end of July. Page 6 of 46 e. Genogram Each IMR contains the details of the family that were known to that Agency. The complete genogram for the family is included below. KEY: Red Line Maternal Line Blue Line Paternal Line Black Line Subject Green Line Subjects Step Siblings Dashed Line Separated Child W Father to Child W (FW) Father to Step Siblings (FSS) Mother’s Partner (at time of incident) (MPW) Mother to Child W (MW) Step Sibling (SS1) Step Sibling (SS2) Page 7 of 46 f. Family Involvement 1.29 At the commissioning meeting held on 13th September 2012 it was agreed that it would be appropriate to offer some involvement to family members. However it was recognised that there was the potential for criminal proceedings and that making contact might interfere with evidence. As the GMP investigation continued it was considered likely that MW would be a prosecution witness and so while the SCR Chair wrote to notify her that the review was taking place, no invitation to meet could be offered until either a trial had been completed or the CPS had recommended no further action. 1.30 Just as the review was near completion the Local Authority was given the formal record of a Finding of Fact hearing, held in March 2013, which arose from the Care Proceedings in relation to Child W and siblings. The panel Chair had been advised by the police representative that a final decision about any possible prosecutions in this case would not be made until the outcome of this hearing. 1.31 As a result of the Finding of Fact, CPS recommended no further action, all three children returned to MW on 28th May and so arrangements were made for the Chair to visit MW on 5th July 2013, accompanied by the MSCB Business and Performance Manager. 1.32 The meeting was distressing for MW as she had realised with hindsight that MPW could have injured Child W, to the extent that her children were in care for 11 months. She also now realises that staff in the two hospitals should have managed Child W's care differently and that the injuries to her child ought to have been identified sooner. MW conceded during interview that the children were regularly left in MPW's care but she never suspected him of harming them during this period. Page 8 of 46 2. Overview of What was Known 2.1 Paragraphs 2.2 to 2.5 give information about the family members that was in agency records but was not known to the key professional staff who examined or made decisions about Child W in the timescale of this SCR. Paragraphs 2.6 to 2.13 give information about the family circumstances recorded during the timescale of the SCR. 2.2 MW had lived with three partners before her relationship with MPW began. One (FSS) is the father of SS1 and SS2 who lives with another partner and her two children in a Greater Manchester LSCB area. The housing records suggest that the new partner was pregnant in July 2012 but there is no other relevant information on the household. FSS has had no contact with SS1 and SS2 for several years (last known contact September 2008). A second partner was ExPMW but agencies have not recorded any significant details about him and the dates of him living with MW are not known. 2.3 The other ex-partner of MW is FW, the father of Child W. Records indicate that after some significant domestic abuse from him, MW left FW and has not returned. He is not named on the birth certificate. FW has two children by a previous partner (born 2006 and 2009). He currently lives with PFW, her two children and two children from the partnership (born 2008 and 2011). From the dates of birth of FW’s children it seems that FW lived with MW for only a short while and his long term partner is PFW. The family has been known to Children’s Services in the LSCB area and there are three recent episodes of domestic abuse recorded by GMP in 2012. 2.4 MPW used to live with his partner (ExMPW) and their child (CExMPW) in another LSCB area. CExMPW has regular contact with MPW. ExMPW had reported one incident of domestic abuse from MPW and that he misuses alcohol. MPW had attended Accident and Emergency (A&E) in the LSCB area on 1st May 2012 with chest pains. 2.5 There are more detailed records of MPW in another LSCB area where his mother lives. He is well known at the GP practice where he has been supported to manage his long term problems with anxiety, obsessive thoughts and alcohol use. He has completed a course of cognitive behavioural therapy to help him manage his Obsessive Compulsive Disorder (OCD) in 2011. He was allocated a high intensity mental health service in April 2012 but did not attend. The practice did not know there was a baby in the home of his current partner, but did know about CExMPW. 2.6 The medical history of SS1 and SS2 was recorded when the family changed GP practice in April 2012. The notes show that SS1 had visited the GP practice 11 times for immunisations, developmental checks and self-resolving illnesses (plus three Did Not Attends (DNAs) for immunisations) and had been taken to A&E eight times with two admissions for short term illnesses and two assessments by the Out Of Hours (OOH) service. 2.7 SS2 had been taken to the GP practice 15 times for immunisations or self-resolving illnesses (plus one DNA for immunisation). One contact resulted in the referral to the Eye hospital. The GP records did not show if SS2 attended the Eye hospital but had Page 9 of 46 noted four missed appointments with the Orthoptist. Additionally SS2 had two hospital admissions, one for the extraction of six teeth, the other for a non-specific illness and two presentations to A&E. 2.8 The number of NHS attendances is normal for children of these ages, but SS2’s teeth extraction is commented on in TOR 4. 2.9 The second GP practice knew that MW had a history of non-attendance, as that was the reason she had been asked to cease her registration with them in October 2010. 2.10 The Health Visiting (HV) service (CMFT Community Health Services (CHS)) had provided primary care services to MW for SS1 and SS2. On the first visit for Child W full records were made about FW, the reason for lack of contact with MW and her relationship with MPW. The records include that MW’s parents live nearby and support her. There is little information on the home with the only relevant comment being that the ‘home is noted to be clean and comfortably furnished, baby equipment seen in the living room’. Child W was noted to be clean and well dressed. 2.11 Manchester Education Department was the only ‘trawled’ agency with information about the family. The department passed on information from the school of SS1 and SS2. The summary noted that at times the children were absent or late to arrive. Both are achieving below the expected standard for their age, but are well behaved and both try hard. The information given about school attendance and parental involvement indicated there was no need for the agency to provide an IMR. 2.12 Within the timescale of the review MW, MPW and Child W were seen by a high number of staff from NHS agencies. This included two GPs, PN1 and the OOH service from NHS Manchester, as well as many staff from CMFT acute services, CMFT CHS services, and PAHT. 2.13 The IMR for the HV service is the only one giving the recorded family history of MW, and Child W. Other NHS agencies will have asked for recorded information about the family history but only noted the recorded information that focussed on the current presentation in the IMRs. Page 10 of 46 3. Single Agency Involvement 3.1 Greater Manchester Police (GMP) 3.1.1 The IMR was written by a detective sergeant from the Major Crime Review Unit and countersigned by a Force Review Officer. The author’s role in conducting reviews includes an examination of practice to ensure that investigations are being managed effectively and that there is compliance with local and national policy; this review process should identify good and weak practice at an organisational level which will improve future investigative practice. 3.1.2 The IMR lists the sources of information as: Electronic records: • The Operational Policing Unit System (OPUS). OPUS links with a number of other computer systems in GMP, such as the Public Protection Investigation System; • The Cyclops Document Management System used in the Safeguarding Vulnerable Persons Unit and Public Protection Investigation Units (PPIU) to store investigation files and case conference files; • The Crime Recording System; • The Police National Computer. 3.1.3 The above databases have provided the IMR author with material relating to: • Relevant incident logs or FWINS (Force Wide Incident Numbers), which are created when an incident is reported to the police; • Relevant crime reports; • Relevant individual and address records of family members of Child W; • Relevant material held in the Public Protection Investigation System, such as investigation files and case conference files relating to Child W; • Material held in relation to previous Serious Case Reviews involving GMP. 3.1.4 The paper records used are: • Public Protection Investigation Unit (PPIU) records and associated documents relating to Child W; • Notes made by police officers involved in the PPIU investigations; • Police officers’ notes of strategy meetings held for Child W. 3.1.5 The author has also checked practice against the relevant policies and procedures, namely: • GMP Safeguarding Children Policy and Manual of Guidance 2010; • The National Crime Recording Standard 2002; • Working Together to Safeguard Children March 2010; • PPIU Divisional Handbook March 2012. 3.1.6 As a result of reading the records the author has interviewed four staff members for some clarification of the detail. The staff members were: Page 11 of 46 • Police officers from a division of PPIU who were involved in potential non-accidental injury investigations relating to Child W; • Police supervisors from PPIU; • Police supervisors from the Public Protection Division. 3.1.7 GMP provides policing services to the whole of Greater Manchester and so have information on the database not only on MW and MPW but also on FW, FSS and ExPMW (previous partner of MW), PFW (a previous or current partner of FW) and ExMPW (the previous partner of MPW) and their child, CExMPW. 3.1.8 Prior to the timescale of the report GMP have a number of records relating to MW, her previous partners and MPW. MW contacted the police: • Six times about damage to her property between July 2003 and May 2008; • Four times when FSS was at her property drunk, wanting access to SS1 and SS2 between May 2005 and September 2008 (after their estrangement); • Three times between June 2008 and July 2009 about a verbal threat of assault, theft of her mobile phone and ExPMW (when no longer her partner) arriving drunk and wanting access to the home. None of these events resulted in arrests or further action. 3.1.9 GMP records on FW indicate convictions for dishonesty and violence from 1990. However the first incident of domestic abuse was when MW reported an assault in May 2011 when she was eight weeks pregnant. FW was prosecuted but the case was dismissed. MW has told the police that she has not seen him since this incident and he has not had access to Child W. 3.1.10 GMP records on MPW, other than the current arrest, are brief. When he was 14 years old in December 2001 he reported his mobile phone had been stolen. Prior to his relationship with MW there was one incident between MPW and ExMPW in May 2010 just after the birth of CExMPW. An argument between the two of them about MPW taking CExMPW to visit his parents had escalated. The situation was resolved by MPW leaving the house. 3.1.11 In the timescale of the report, other than three brief incidents involving FW, GMP only had contact with the family members when the strategy meeting was arranged on 28th June 2012. Two officers from GMP attended this meeting and the reconvened meeting on 29th June 2012. 3.1.12 Following the second strategy meeting it was confirmed to the supervising officer (DS1) that there was no evidence to support a police investigation. The GMP records note the bruise to Child W’s back was accidental and the fracture found on the skeletal survey was consistent in age and explanation with Child W having been dropped accidentally by the half-sibling. The rash on the feet was considered to be viral allowing discharge after the strategy meeting. Page 12 of 46 3.1.13 The next contact was attendance at a strategy meeting on 13th July 2012. A different officer attended from GMP. The officer having heard the details of the current injuries and the healing fractures from the skeletal survey agreed with the outcome to make the children subject to police protection and for the arrest of MW and MPW. 3.1.14 The IMR is concise and presents the information clearly and objectively. The key area of learning relates to not challenging the medical opinion based on inconclusive medical evidence in the strategy meeting. The author observes that it is difficult to challenge when a decision to take any further police action hinges on medical evidence but GMP still have a responsibility to take part in a Section 47 investigation as appropriate. 3.1.15 The other issue raised in this SCR relates to the recording of the strategy meetings. The IMR author attached three appendices, an extract from the PPIU Handbook which complies with WT 2010, and two versions of paperwork used by GMP when an officer attends a strategy meeting. Although there are recording formats some officers choose to record in their daybooks. This variation is unacceptable; a point which has already been made in a previous GMP IMRs (Manchester 2007 and 2008, and Rochdale 2009) and is discussed in detail in TOR 3. 3.1.16 The GMP IMR has one recommendation, to agree one format for the force to use for internal records of strategy meetings. 3.2 Children’s Social Care (CSC) 3.2.1 The IMR was written by the Central Area Safeguarding Manager and the Central Area Assistant Safeguarding Manager and countersigned by the Assistant Director, Safeguarding Provision. The authors used the MiCare electronic case file records to prepare the report. One author also interviewed SW1, AP1, TM2 and AP2 and had a telephone discussion with SW2. Following the interview with TM2, further information was submitted to the authors by e-mail. 3.2.2 Other than a record of the incident when FW was reported to have assaulted MW when she was eight weeks pregnant, the first contact for CSC was notification that Child W had an unexplained bruise and had been admitted to CMFT on 28th June 2012. The admission was related to possible meningitis but CSC began the process for assessment with allocation to SW1 and arranging a strategy meeting for that afternoon. 3.2.3 Cons1, who had asked SN1 to contact CSC was unable to attend the meeting and had not completed the paperwork, so the meeting was unable to make a clear decision. All agencies present agreed to a working arrangement for SS1 and SS2 to stay with MW’s father, while MW and her mother stayed at hospital. The meeting was chaired by SW2 in the absence of a team manager or advanced practitioner; she was the most experienced social worker available but this was not compliant with the MSCB or CSC procedures. Page 13 of 46 3.2.4 Following the strategy meeting TM2 telephoned Cons1 expressing concern that the bruise could not be explained by the incident of being dropped and checked that a full skeletal survey would be available for the re-arranged strategy meeting on 29th June 2012. 3.2.5 The second strategy meeting which was chaired by AP1 reached agreement; (although the notes indicated a further possible historical injury of a chip on Child W’s left foot and an injury to the back of the left knee); that there was no reason for further investigation. SW1 as the allocated social worker began a core assessment on 5th July 2012. 3.2.6 MW contacted SW1 on 10th July as she was still concerned about Child W’s swollen feet. SW1 advised her to seek further advice. The next contact was the request to arrange the strategy meeting on 13th July 2012. 3.2.7 The strategy meeting discussed all the current and historical injuries. As SS2 was at the hospital, the child was asked about the occasion when Child W was dropped. SS2 said Child W had landed on the head and so this incident could not have caused the bruise, chip or fracture discussed on 29th June. 3.2.8 The IMR raises the relevant issues. The strategy meeting arranged for 28th June did not include information from the GP practice and only partial information from Hospital 1. There was incomplete information about MPW, and on the basis of MW saying she never left Child W, the meeting considered only MW as a possible perpetrator. At the time of the June meetings, although old enough, SS1 and SS2 were not interviewed. 3.2.9 The strategy meeting of 29th June became diverted by discussion of the cause of the bruise and did not discuss the swollen foot. This was important as Child W was non mobile and so all possible causes should have been discussed. Cons2’s view that ‘on the balance of probabilities’ the injuries were accidental was accepted without challenge. Although the IMR states that AP1, the chair of the meeting, knew the meeting had been reconvened, the IMR states that she did not have the notes from the meeting on 28th June and did not know it was a different consultant who had raised concerns the previous day. The panel were concerned that this may not be accurate as there would have been some introductions made at the meeting and TM2 must have had the notes the previous day prior to the phone call to the hospital about the skeletal survey. 3.2.10 The format for recording a strategy meeting does not give prompts to ensure all relevant enquiries have been made and this allowed the meeting to be led to a view of probable accidental injury as suggested by Cons 2. The meeting did not discuss the concerns of unexplained bruising that led Cons 1 to ask for the strategy meeting. 3.2.11 In March 2012, all relevant CSC staff were circulated with the requirements for the recording of strategy meetings. This included the expectation that the notes of a meeting would be copied and circulated to each agency within 24 hours, and entered Page 14 of 46 on to Micare within seven days. For these two strategy meetings, the notes were entered onto Micare, but not copied to other participants. 3.2.12 The IMR identifies some key areas of learning: that it is essential that the chair of strategy meetings must be prepared to cover all relevant areas of enquiry and if necessary challenge medical opinion. This should include a greater understanding of the range of opportunities for perpetrators and wider exploration of the family history and relationships. 3.2.13 The factual information in the IMR is clearly presented. The IMR notes that CSC was not compliant with the expectations of WT 2010 or MSCB. However the panel are of the view that the second author has struggled to complete the report to demonstrate how the learning will apply to the agency as a whole. 3.2.14 There are three recommendations: • briefings for staff who may be involved in strategy discussions; • a requirement for all present to sign the document and agreed actions with circulation at the meeting; and • uploading of the template onto Micare within five days, or immediately in critical cases. NHS IMRs 3.3 NHS Manchester 3.3.1 The IMR was prepared by two named doctors for child protection in Manchester as the first author was absent through sickness from the beginning of October and a second author was identified towards the end of the month (26th). The report authors used the General Practitioner computer notes for Child W, MW, SS1 and SS2 for preparation and interviewed GP3 and GP5. Additionally the authors took advice from a GP member of Manchester GP Safeguarding Steering Group. 3.3.2 The chronology demonstrates regular contact by MW for her own health with the GP surgery or GP out of hours service. There were eighteen contacts plus her new patient assessment (but two DNAs) between the 1st January and 4th July for a wide range of complaints and concerns. She had some diagnostic tests but on a number of occasions the outcome was ‘no further treatment’. 3.3.3 The chronology also shows that MW took Child W to the surgery eleven times as follows: • 25th January 2012 when MW reported the child was snuffly and short of breath; was seen to be healthy except for oral thrush and prescription given; • 2nd February 2012, reason for visit not given but oral thrush still evident as well as mild nappy rash; appropriate care described and prescriptions given for both complaints; Page 15 of 46 • 27th February 2012, for first set of immunisations; MW reported a ‘clicky knee’ and was advised to report it to the GP when examined for the 8 week check noted as due at the end of February; • 8th March 2012, MW took Child W, with MPW to out of hours doctor as she reported a spreading rash to the child’s face and neck, and some bruises to the bottom and thighs; a ‘cause of concern’ form was planned to be completed as an unexplained bruise was seen on the right thigh. Diprobase cream prescribed for the skin; MW was asked to monitor the bruise and take to the child GP in a week for a review; • 19th March 2012, attended with MW and MPW for 8 week check, (three weeks late); examination revealed no abnormality of the child’s ‘clicky’ left knee; • 26th March 2012, second set of immunisations given; • 30th April 2012, Child W was seen for the first time by the new practice, when MW took the child with MPW, SS1 and SS2, reporting diarrhoea and vomiting, plus redness to the bottom and genital area; the examination was completed by PN1, who noted MW wondered if the redness was caused by MPW bathing the child in too hot water, but also a crescent shaped bruise mark on the tongue; MW said Child W had bitten on a dummy; redness attributed to thrush and use of anti-fungal cream advised; tests taken on stools which were normal, and MW asked to return for results; described diet as including solids but no record of advice on timing of weaning; third set of immunisations were given; • 14th May, MW telephoned for advice as Child W still not well, but there was no answer when GP1 returned the call; the matter was followed up by GP3 on 15th May and Child W examined, (although not recorded that the nappy area was checked); GP3 diagnosed upper respiratory chest infection and advised to return for weight check in seven days; • 23rd May, MW with MPW took Child W to the surgery and reported to GP3 their attendance at A&E on 21st May; advised to continue to encourage feeds and to use the antiviral cream as prescribed by Hospital 1 for the Herpes on the lip; • 26th June 2012, MW telephoned GP3 to discuss the hospital admissions linked with loose stools and a rash on Child W’s legs; after examination later that day, GP3 requested a paediatric assessment to understand the cause of spots on the inner left ankle and left arm; • 9th July 2012, MW had a planned telephone conversation with GP3 and updated on hospital attendance, noting that a possible fracture had been found and None Accidental Injury (NAI) discussed; GP1 examined Child W on 10th July 2012 and prescribed an ointment. 3.3.4 In February 2012 MW began the process of changing her GP registration back to that of GPs 1, 2, and 3 where she had been removed from the list because of non-attendance at appointments. MW, SS1 and SS2 were accepted by the practice on 2nd April 2012, with summaries of the two children’s attendances at surgeries and hospital recorded. 3.3.5 The chronology shows that the relevant GP surgery was notified of each presentation at Hospital 1 and Hospital 2 except the detail of the visit on 25th May 2012 to Hospital 1 is not recorded. Page 16 of 46 3.3.6 The IMR notes that MPW was present with MW on six occasions when she took Child W to one or other of the GP practices, (out of 11 visits). 3.3.7 The IMR draws out a number of issues that could have been followed up differently by the GP practice. These can be summarised as: • Querying the frequent attendance; • Completing a formal Mental Health assessment when MW had her ‘new patient’ assessment which would have identified the previous prescription, or some follow up after the prescription of anti-depressants was given; • Consideration of domestic abuse when MW said she was depressed and described her bruising on her abdomen; • Lack of follow up to Child W’s bruise seen by OOHs both by the OOH service and by the GP when the notification was received on 9th March, with no consideration of possible causes; • Lack of consideration of possible evidence of neglect for SS2, as the child had missed four appointments with the Orthoptist, and had six teeth extracted; • The IMR notes it is good practice for a baby to be examined by a doctor if there is diarrhoea and vomiting as on the 30th April visit; • On the same visit, there was no consideration of cause of the bruise to Child W’s tongue or the redness in the nappy area; • The eight week check (completed when nearly twelve weeks) should have included a whole assessment of presentations and admissions, prescriptions and concerns. 3.3.8 In particular there were seven occasions (23rd February, 9th March, 15th May, 23rd May, 8th June, 13th June and 9th July) when it would have been appropriate to either discuss the family with the HV service, or to ask for a follow up visit to provide support. 3.3.9 With hindsight staff at the GP practice can identify some possible indicators by MW of NAI. For example on 30th April MW stated clearly that Child W had been alone with MPW when the bruise on the tongue was seen and the redness in the nappy area; on 9th July, the GP should have been alert to the suggestion of NAI raised by MW on phone. A referral should have been made to CSC or to the on call paediatrician for consideration of the cause of the swollen foot either following the telephone call or the next day (10th July) when he examined the swollen foot. At the time (10th July), the GP practice was not aware of and had not been invited to the June strategy meetings and this omission exacerbated the lack of awareness of possible NAI. 3.3.10 The IMR identifies some key areas of good practice and learning: • Provision of good care for both MW and Child W in terms of prompt returned telephone calls and appointments; but the IMR highlights: • The importance of knowledge of the signs of physical abuse of a young baby; • Improved communication with the HV service, especially at a time of further structural change in primary and secondary NHS services; • Recognition of the importance of highlighting important historical information in GP records; and Page 17 of 46 • Acceptance of the role of the GP in strategy meetings. 3.3.11 The panel also considered that some consideration of the pattern of presentation with illness or injury of the mother and child together would have been beneficial within the practice, possibly as a case study. 3.3.12 There are four recommendations which should ensure that: • All staff in the OOH’s service and GP practices are adequately trained in safeguarding, including alerts to injury in non mobile babies; • There is regular established communication between professionals in the primary health care teams (GPs, HV and midwifery services); • Communication from OOH service to the GP practice should be clear with explicit follow up action highlighted; • GP records are read coded and flagged to highlight key information on domestic abuse and mental health history. 3.4 Pennine Acute Hospitals Trust (PAHT) 3.4.1 The IMR was prepared by the Named Doctor for Safeguarding Children and was countersigned by the Head of Safeguarding for Pennine Acute Hospitals Trust. The records used to write the IMR were: • Full medical and nursing notes; • Medical report by DR 13 which was compiled following review of GP records; • Accident & Emergency notes from ‘Symphony’ electronic system. Child W was born at Hospital 1, (a hospital within PAHT) following a normal delivery weighing 4265 grams. Following the birth, in the timescale of the SCR, MW went to A&E services three times concerned about her own health, first shortly after Child W’s birth with pains and shortness of breath, and a couple of months later (in March) with a long standing chest infection. 3.4.2 On the same day in March MW also attended A&E about an hour later with MPW, reporting he had collapsed after feeling dizzy. A history of Obsessive Compulsive Disorder (OCD) was noted, but no treatment was given and he was advised to see his GP. 3.4.3 MW took Child W to A&E at Hospital 1 seven times on: • 7th February 2012 with a snuffly nose, reported blue lips, sleepy, feeding less and with oral thrush; after observation the child was discharged with no follow up; • 21st May 2012 with a swollen mouth and lip ulcer, a diagnosis of herpetic lesion was treated orally with community follow up; Child W was noted to be well; • 3rd June 2012 when dropped by SS2; Child W had vomited once and had a 2 cm bruise on the back of the head; following observation the child was discharged and the HV notified; • 4th June 2012 for readmission as Child W had blood in the mouth when the child vomited; a CT scan was normal and presentation matched the explanation so Child W was discharged; Page 18 of 46 • 7th June 2012 seeming lethargic, irritable, feeding less, with a rash; although Child W seemed well the child was referred to the paediatric team where pin point petechial rash on both upper arms, an ulcer under the tongue and under the left upper lip were observed. Following blood tests which showed high infection ‘markers’, intravenous antibiotics were prescribed with follow up from the community nursing team and continued oral treatment for thrush; • 26th June 2012 when swollen warm sore feet with a nodular pattern on the soles, non blanching spots on the left inner ankle, and a few purple spots on left upper arm and right lower thigh were observed. The blood tests were normal but blood cultures were taken and a further set of intravenous antibiotics were prescribed; and • 12th July 2012 when MW was concerned that Child W still had swelling and puffiness over the dorsum of the right foot but no tenderness; an X-ray apparently revealed no fractures. 3.4.4 When MW took Child W to A&E on 12th July she did not indicate that MPW was also present in A&E with pain on the left side of his chest, radiating down his arm. He indicated he had just been treated for costocondritis and reported his recent attendance at A&E and that he was awaiting a psychiatric appointment. He said he had relationship difficulties and problems with a child but did not mention MW and Child W’s presence. 3.4.5 As indicated in paragraph 1.9 above when the X-ray of Child W was reviewed a number of fractures were revealed and MW was asked to bring the child back to the hospital. A full examination revealed the injuries noted in the same paragraph. 3.4.6 The IMR notes some examples of good practice. The thorough approach of DR13 and exploration of all available information by DR16 is commended and will be used as an example of ‘what good looks like’ throughout the Trust. 3.4.7 Other staff were less good in checking, questioning and ensuring all available historical information was used as part of a diagnosis. This is particularly the case in relation to asking about caring responsibilities and relationships. The attendance of MW and MPW on the same day in March, and later in July at the same time could have raised questions about the care of Child W and the family relationships. 3.4.8 The learning in this IMR is linked to the concerns in paragraph 3.4.8 and is set out in two recommendations: • To use the case in a half day training event focussing on good practice; and • To develop a strategy to ensure establishing caring responsibilities of patients is part of the routine assessment. 3.5 Central Manchester University Hospitals NHS Foundation Trust (CMFT) 3.5.1 The IMR was written by the Named Nurse, Safeguarding Children (Community Services) and the Named Doctor, Child Protection (Acute Services) and was countersigned by the Medical Director/Lead Director for Safeguarding. Page 19 of 46 3.5.2 The introduction gives helpful information on the organisation of services within Hospital 2. The acute hospital based services and Children’s Community Services (CCS, which include the HV services and CCNT) in Community Health Services are separately managed. Both parts of the agency provided services to Child W, but it is important to understand that at the time of the events communication between the two would be as if they were completely separate agencies. The IMR has separated the events and actions into separate sections to facilitate understanding. 3.5.3 The records used from the HV service were: • Manchester Health Record (community): with subsections relating to a. Chronology of significant events b. Family and social record section c. Adult health section d. Nursing record (child health section); • Manchester Child Health System; • Safeguarding Children Team (community) consultation documentation. The author also interviewed five staff, two managers and three practice staff. 3.5.4 The records used from CMFT were: • CMFT Patient Nursing and Medical records; • CMFT Safeguarding nursing team records; • CMFT Paediatric Emergency Department Integrated Medical and Nursing Record. The author also interviewed Cons 1, Cons 2, and CPN and looked at practice as expected in the CMFT Child Protection Policy and Child Protection Practice Guidance. 3.5.5 The initial paragraphs in each section provide helpful information on the organisation of the specific community and hospital services. The CHS section gives demographic data on the area of Manchester where Child W lived and the current planning for future community services. The data suggests that the area has statistics which show there is a lower life expectancy and higher mortality. Manchester is ranked as the 4th most deprived local authority and the area where Child W lived is one of the most deprived areas in Manchester. The HV service had provided some continuity to MW, with SN4 consistently providing a service from 2004 but this is in the context of the service having caseloads considerably higher than national recommendations. Children’s Community Services 3.5.6 The IMR gives some historical information on the pre-school years of SS1 and SS2. While there were some missed appointments and delays in immunisations, MW sought advice and followed it appropriately. In relation to MW’s health, the only notes on her are in relation to a chest infection and support to stop smoking in 2004. 3.5.7 The records for the HV service indicate first contact within the timescale for this review (after receipt of routine birth and midwifery records and a visit to the clinic Page 20 of 46 on 20.01.12) was the primary home visit on 31st January 2012. MW took Child W to the GP’s surgery and the clinic for routine immunisations and checks. The next contact (SN4 and StuN) was the follow up primary home visit on 26th March 2012, following a failed (although arranged) appointment on 6th March 2012. Child W’s progress was appropriate with the only concern a mention of loose stools. MW was advised to seek advice at the clinic if this continued. Most of the visit was taken up with MW describing her own health, and her view that neither her GP nor secondary services were fully considering what might be wrong with her. Her description included possibly pneumonia, feeling depressed and pelvic pains. 3.5.8 SN4 followed up the visit with a consultation with a health visitor and then telephoned MW on 27th March to advise to either go to A&E or to her GP to ask for a second opinion about her health. MW was not receptive to either of these suggestions and reported that additionally she had stabbing pains in her legs and calves. SN4 advised MW to go to A&E and suggested what she should ask about when seen. 3.5.9 MW followed the advice and attended A&E the same day. An X-ray confirmed MW’s lungs were clear and so Child W was able to have the BCG vaccination the following week as the child had not been in contact with anyone with a lung infection. MW was not in for the next planned visit on 17th April but attended the clinic on 27th April. Child W was making good progress but MW reported that Child W had had some sickness and diarrhoea. 3.5.10 MW had not taken Child W for the BCG on 4th April but did attend for further immunisations on 30th April and the BCG on 2nd May 2012. 3.5.11 On 14th May MW telephoned SN4 to say Child W had been unwell for a few weeks, seeming lethargic, not feeding and sleeping a lot. She was advised to go either to her GP, the clinic or A&E. On 18th May MW took Child W to the clinic and reported that the child was gagging on food, (but not the information given to SN4). Child W’s weight was improving from the last visit, but MW was asked to bring the child back in four weeks to check. 3.5.12 CCS (the CCNT) received information from Hospital 1 about the attendance and admission for observation as Child W had a swollen wound on the mouth on 21st May 2012. There was a further notification of the visit to Hospital 1 on 3rd June. The CCNT followed up this notification of admission to hospital by telephoning both the hospital and the home. Child W had been readmitted on 4th June as the child was vomiting, following being dropped by SS2. Hospital 1 sent a safeguarding alert/referral asking for follow up as Child W had a head injury and was under 12 months old. 3.5.13 On 11th June the HV service was notified of a further admission on 7th June as Child W was lethargic and had a rash. This and the notification from 23rd May listed previous admissions including one on 7th February when Child W was recorded as unwell. Page 21 of 46 3.5.14 The next information was a referral for administration to Child W in the community of intravenous antibiotics on 26th June. Not aware of this, SN4 visited on 27th June. The records have a full description given by MW of the events and illnesses of Child W over the last few weeks, as well as a record of observing some purple/brown non-blanching spots in patches, such as near the left inner ankle, on the right thigh, and on the left arm. SN4 noted that Child W’s left foot appeared to be swollen and was hard to the touch in parts due to the swelling and that there was a pink line across the middle of the sole of the foot. Child W’s right foot also appeared to be swollen and Child W was no longer weight bearing. SN4 was concerned about Child W’s presentation and advised MW to take the child to Hospital 2. 3.5.15 Following presentation at Hospital 2 HV1 attended the strategy meetings on 28th June and 29th June. The records of the meeting note agreement with discharge and the plan to complete a social worker core assessment, with clinical follow up of the rash and health visitor follow up. 3.5.16 HV1 visited on 3rd July and found Child W to be well, except for a swollen right foot. MW was advised to take the child to the GP. The family was also waiting for an appointment to follow up on the leg fracture. 3.5.17 HV1 made a series of notes as she was informed by CPN that Cons2 following the strategy meeting on 29th June was reviewing the injuries of Child W with Hospital 1. HV1 then attended the strategy meeting on 13th July 2012. 3.5.18 The IMR identifies some good practice in the community services: • Positive use of the team’s skill mix; and • Regular communication and a high standard of written records. 3.5.19 However there is some learning: • Robust and regular communication between the HV service and GP is essential to ensure both services have a clear picture of the history and current presentation of a family; this is not included as a recommendation as the HV Task Force, established to deliver the national HV Implementation Plan has already recognised the need and has asked its Partnership Task and Finish Group to develop a good practice guide. The IMR does not note that this is even more important as the HV service at times suggested MW should take Child W to A&E, and to a second hospital; • Improved dating and evidence of screening of information received from other NHS agencies; and • A mechanism is needed to ensure a history of domestic abuse is known by key community NHS staff. Acute services 3.5.20 The initial paragraphs describe the management of diagnostic care in the paediatric unit in Hospital2. This is helpful as it gives the context for why Cons1 was not able to attend the strategy meetings on 28th and 29th June 2012 and the pressure of work experienced by the ‘hot week’ consultant (Cons 2). The ‘hot week’ consultant is the Page 22 of 46 lead consultant for all general paediatric admissions and inpatients for that week. The ‘hot week’ consultant also oversees the daily ward round, allocating patients to be seen by the assisting consultant or attending registrar. 3.5.21 The first contact with Hospital 2 acute services was on 27th June 2012 following advice from SN4 who had visited as a follow up to the Hospital 1 visit of 3rd and 4th June. MW took Child W to Hospital 2 as she was concerned that there was no improvement in the swollen feet and rash. Although Hospital 1 had taken blood tests MW considered they were not taking her concerns seriously as she had presented Child W with the same symptoms three weeks earlier. 3.5.22 On presentation, the Junior Doctor (SHO1) referred Child W to the more senior doctors in the paediatric team because the baby seemed well in itself but had apparently persistent symptoms. When Child W was examined by the registrar (Reg1), the bruise on the back was noticed with no explanation of cause from MW. However the registrar omitted to mention the bruise to the consultant and so Child W’s care was managed by the assisting consultant (Cons 1) on 28th June, rather than the more experienced consultant, Cons 2. Reg1 and Cons 1 identified that the bruise could have been non accidental, and also were concerned that the purpura and swelling of the foot could be an inflicted injury. The observations and exploration of causes were well documented and explained to MW. 3.5.23 Cons 1 had left full notes of her reasons for beginning the process of investigating the bruise (and a previous mark mentioned by MW) as NAI and briefed Cons2. Neither consultant was able to attend the strategy meeting on 28th June as they only had ten minutes notice, but Cons 2 attended on 29th June 2012. 3.5.24 By the time of the strategy meeting, MW had met Cons2, expressed her concern at the lack of diagnosis, was plausible in her description that Child W was never left by her, and the bruise had faded, the swollen feet were improved and the rash subsiding. Cons2 cancelled the intravenous drugs and further tests linked with an infection and planned instead to investigate the possibility of an underlying bleeding disorder. 3.5.25 A skeletal survey done on 29th June showed a healing fracture of the left shin bone, about 2 – 4 weeks old and a possible chip fracture of the corner of the growth plate at the tip of the lower end of the shin bone. There was a recommendation for a follow up skeletal survey in particular with follow up of the left ankle and foot. The CT head scan was normal. 3.5.26 Discussion at the strategy meeting did not consider either the chip fracture or that the opinion of Cons1 as described in the referral for CP investigation may have differed from Cons2. With no disagreement, it was decided that the follow up would be the social work core assessment and follow up of the fracture and Child W was discharged home that day. 3.5.27 Cons2 when writing a summary of events for the records considered it would be helpful to include and reflect on information from Hospital 1. He contacted DR12 on Page 23 of 46 2nd July 2012 who agreed to seek the records and report back to Cons2. Cons2 was going on holiday on 7th July and as he had not heard back from DR12 by 6th July he alerted CPN, who in turn spoke to HV1, SW1 and her counterpart in Hospital 1. 3.5.28 The next contact was on 13th July 2012 when the safeguarding team at Hospital 2 was alerted to the presentation of Child W at Hospital 1 with a number of injuries. A further check was made of the skeletal survey from 29th June and a further injury was noted on Child W’s left foot. 3.5.29 The author of the IMR acknowledges that opportunities to protect Child W and prevent the further injuries recorded on 13th July were missed and that it is important that this review is used to learn and improve. The IMR includes commentary on the expected standards for an open approach to unexplained injuries by staff at different levels of qualification and experience. All medical terms are clearly explained so that non-medical readers can understand the significance of observations and test results. 3.5.30 The recommendations for each section of the IMR are set out together in section 7. As indicated CHS had only two recommendations, 7.1 a) and b): to ensure that information is shared consistently between staff, and that information from other parts of the NHS are reviewed and recorded in a timely on receipt. 3.5.31 The recommendations for the acute services are more extensive as the IMR author recommends a review of how the workload is managed in paediatric services. This should be combined with some specific training on patterns of injury for general paediatricians and safeguarding nurses. There should also be a review of training and peer review for individual consultants and a review of the role of the Safeguarding Nurse to ensure a more active contribution to decision making. 3.5.32 The IMR also, as with other reviews, recommends standardised record keeping for strategy meetings. 3.6 Manchester NHS Commissioning Overview Report (MNHS COR) 3.6.1 The Manchester NHS Commissioning Overview Report was written by the Deputy Designated Nurse and Designated Doctor for Safeguarding for NHS Manchester. It has been counter-signed by the Medical Director. 3.6.2 The authors have used the information from the three NHS IMRs, an integrated NHS chronology, interviews with the authors and panel discussion to prepare the report. In particular the chronology and discussion has identified a number of themes that are expanded on within the report. 3.6.3 The report confirms that each NHS IMR has met the expectations of WT 2010 and that as the SCR has continued the authors have monitored progress of the individual recommendations made in their reports. The authors endorse the analysis and recommendations of the individual NHS IMRs. Page 24 of 46 3.6.4 The authors have summarised the presentations of and communication about Child W and have identified the six occasions when there was a missed opportunity. These are on 8th March, 30th April, 26th June, 29th June, 6th July and 9/10th July with a possible missed opportunity on 7th June. These occasions are noted in detail in the report and are all commented on in the analysis in section 4 of this report. 3.6.5 The MNHS COR identifies eight key areas of learning: • The role of the GP in child protection processes; • Communication within the primary health care team; • Communication between health service providers; • Vulnerability of babies; • Working with plausible parents including the role of the male in a household; • Section 47 medical assessment and over reliance on medical opinion; • Functionality of S47 strategy meetings including chairing and recording; and • Practice standards for paediatric consultants. 3.6.6 MSCB will be familiar with these areas of learning from previous SCRs and the authors of MNHS COR considered that it would be helpful to consider a different approach to ensuring action from all agencies. Only two additional recommendations have been made as recent MSCB SCRs have made recommendations on a number of points which are discussed further in section 5. The new recommendations are: • NHS Manchester commissioners (now transferred to NHS England) of health visiting services to ensure that the current review considers the findings in this case around corporate caseload management and communication with GPs; and • Primary care commissioners to ensure safeguarding training to GPs and provider training programmes are strengthened further to ensure that the plausibility of parents is embedded in training programmes and The Core Info: ‘Bruising in Children’ and ‘Fractures in Children’ focusing on learning around the specific vulnerabilities of babies is embedded into training programmes. Page 25 of 46 4. Analysis 4.1 Review the decision making relative to Child W's marks and injuries observed between 30th April 2012 and the 13th July 2012. This to include marks or injuries observed during home visits and attendance at GP's surgeries and hospitals. 4.1.1 GMP and Manchester CSC had no opportunity to observe any of Child W’s marks and injuries independently of NHS agencies at the two strategy meetings. TM1 in CSC was concerned after the first strategy meeting that there was insufficient information on the unexplained injuries. She telephoned Hospital 2 to ensure that a consultant would be present the next day and that a full skeletal survey would be completed. 4.1.2 The individual IMRs indicate that there were a number of occasions when NHS staff could or should have made different decisions about possible causes and treatments. The agencies did not demonstrate the ‘healthy scepticism’ recommended by Lord Laming in his review of child protection systems in 2009. 4.1.3 The first occasion (although prior to the timescale of the TOR) was when the Out of Hours (OOH) service identified an unexplained bruise on the back of Child W’s right thigh on 8th March 2012. The matter was notified to the GP on 9th March, but not highlighted, and the service left the responsibility for review with MW. The recording suggests that NAI was not considered by the examining doctor, although recognised by the triage nurse, as there is no record of a conversation with MW about possible causes. The OOH service followed up the notification with telephone calls. The MNHS IMR considers that the OOH service should have been more proactive at the time of presentation. This is the first missed opportunity referred to in MNHS COR. 4.1.4 Child W was seen by the GP practice five times between 30th April and 13th July, and additionally MW spoke to the GP on the telephone four times in this timescale. On 30th April Child W had marks and injuries for which MW offered PN1 implausible explanations. While PN1 was thorough in checking causes of some of the presentation, (further tests and weighing), the information given should have raised queries of NAI and triggered a referral to the GP for further assessment. There was no questioning of who might have cared for Child W, or checking the relationship of MPW. This is the second missed opportunity referred to in MNHS COR. 4.1.5 MW took Child W to the GP on two further occasions, 15th May, and 23rd May, reporting the attendance at Hospital 1 on 21st May. On both visits treatments appeared appropriate for a single visit, but when taken with the record from 30th April and the visit to hospital, it could have prompted some further investigation of MW’s concerns about loss of weight, poor feeding and continued cold or chest infection. Although PN1 had recorded the unexplained red area in the bottom and genital area there is no record of further examination during these two visits. Page 26 of 46 4.1.6 From the date of transfer from the midwifery service whenever the HV service saw Child W, the child seemed well and the weight was satisfactory. MW had reported a number of minor illnesses but these were not evident on contact. 4.1.7 During this timescale (before the events of 27th June) the HV service had seen MW with Child W at clinic on two occasions (2nd and 18th May). There was one telephone conversation with MW on 4th May, when MW was advised to take Child W to the GP, A&E or a walk in centre. 4.1.8 The assessments and treatments for the first three contacts with Child W by Hospital 1 (on 21st May, 3rd June, and 4th June) were all managed well with appropriate decision making. With hindsight, the presentation on 7th June could have been a missed opportunity. 4.1.9 On 26th June MW took Child W to the GP with swollen feet and a rash. The GP could not identify a cause and so contacted Hospital 1 to ask for a paediatric assessment. At Hospital 1 there was no X-Ray and NAI was not considered although the rash could have been caused by a firm pressure on the foot. The treatment was a further course (previously prescribed on 7th June) of intravenous antibiotics administered by the Children’s Community Nursing Team. This is the third missed opportunity referred to in MNHS COR. 4.1.10 On 27th June the HV service did a follow up home visit and found the marks were in a number of places on Child W’s body. SN4 also observed that both feet were swollen, tender and Child W was unable to weight bear. During this visit and the attendance on 18th May, MW made a number of comments about Child W marking easily. SN4 correctly advised MW to take further advice on the cause of the swollen feet, but did not consider NAI. Additionally there was no consideration of the reason why MW might be stressing that Child W marked easily a possible pointer to identification of unexplained injuries. 4.1.11 When MW took Child W to Hospital 2 on 27th June, following the examination the consultant (Cons 1) was concerned that there was evidence of NAI. Child W had an unexplained bruise on the right lower back as well as the swollen feet. Cons 1 noted the reasons for concern and checked the detail of the fall on 3rd June to confirm the bruise on the head was accidental. She began the process of a child protection investigation noting ‘whilst no explanation is offered this is highly likely to be an inflicted cause’. Cons 1 also organised immediate and full follow up with ophthalmic tests, a skeletal survey and a scan. Decision making at this point was appropriate however Cons 1 was unable to attend the strategy meeting, convened in accordance with MSCB Safeguarding Procedures and held on 28th June. 4.1.12 On 29th June when the strategy meeting was reconvened, chaired by CSC, and attended by Cons 2 decision making was poor. The professionals present knew that Cons 1 had noticed a bruise on the back when examining Child W on the 27th June and had contacted CSC to convene the strategy meeting. There was limited clinical evidence, but there was the bruise on a non mobile baby, as well as one actual and one possible bony injury. It has been noted in research (Dale, P., Green, R. and Page 27 of 46 Fellows, R. (2002) What really happened?) that experienced paediatricians, health visitors and GPs may not detect or suspect non accidental injuries especially in young babies. However it is even more important to weigh the evidence in these circumstances. The mind-set of the meeting should have been to exclude NAI and not to be swayed by MW’s evident concern. The decision to discharge Child W was overly reliant on medical opinion which had not included discussion with a consultant radiologist and a consultant orthopaedic surgeon which was expected NHS practice, or with the GP which would have been good medical practice. This was not standard practice in strategy discussions at the time. However a decision was made for CSC to complete a core assessment. This is the fourth missed opportunity referred to in MNHS COR. 4.1.13 On 3rd July the HV service did a follow up home visit. Child W’s right foot was still swollen and MW was angry that Hospital2 had identified a leg fracture, not found by Hospital 1. The HV advised MW to take Child W back to the GP and to stop using the baby walker. MW, although she spoke to the GP about a matter for herself on 4th July, did not make contact about Child W until 9th July and arranged an appointment for 10th July. 4.1.14 Other NHS staff were unaware that Cons 2 had reflected on the strategy meeting of 29th June when he wrote up the records. He asked for further information from Hospital 1, but had not received it by 6th July, and was due to go on holiday on 7th July. He telephoned the CPN to note he was reconsidering his opinion and wanted to review the previous notes. CPN notified the safeguarding team at Hospital 1, and HV1, but took no action. This is the fifth missed opportunity referred to in MNHS COR. 4.1.15 MW also telephoned the SW who was completing a core assessment about her concerns on 10th July saying that she was due to see the GP that day. The SW had stressed that MW should ask the GP to refer Child W for a further assessment as she needed to understand the cause of the swollen feet. At the last attendance at hospital more attention had been focused on the bruise. 4.1.16 The GP saw Child W on 10th July and was aware of the hospital attendances and involvement of CSC as MW referred to the query about NAI in her conversation with the GP. Although there was sufficient medical concern as well as the possible NAI, he did not make a referral for a paediatric assessment or notification to CSC. This is the sixth missed opportunity referred to in MNHS COR and a failing on the part of all the agencies. 4.1.17 Two days later MW took Child W back to Hospital 1 as she continued to be anxious. She had spoken to the HV, the SW and the GP but no one seemed to be interested in finding the cause and treating the swollen feet. Following examination and an X-Ray in the clinic, there was no obvious cause. Routine review of the X-Ray on 13th July together with a review of the 29th June skeletal survey from Hospital2 led to a complete examination and listing of injuries as noted in paragraph 1.9. At this point the indicators for NAI were completely clear and decisive action was taken to protect Child W and the half siblings. Page 28 of 46 4.1.18 In all of the instances described, not just in the strategy meeting of 29th June, there is no apparent recognition of the age of Child W and the implausibility of any bruise or injury being accidental leaving Child W unprotected possibly from as long ago as early March 2012. All bruises in a non-mobile baby should be treated as suspicious. The MNHS Commissioning Overview report draws attention to another recent MSCB SCR NHS commissioning report which noted ‘All agencies involved in safeguarding should be aware of the high level of vulnerability of babies, should be especially vigilant and should have a low threshold for taking action if there are concerns about welfare.’ 4.1.19 The MNHS Commissioning Overview report concludes that the missed opportunities described above are evidence that there is a continuing lack of awareness at multi-agency strategy meetings of links with child protection when considering the cause of a number of injuries and illnesses in a small baby. However there are wider implications within the NHS for safeguarding children that will be noted later in the report. 4.1.20 Additionally the MNHS COR notes that the decision making at the strategy meeting on 29th June was inadequate. The tests commissioned by Cons 1 were cancelled by Cons 2 and Child W should not have been discharged in view of the fact that there was a disagreement between consultants. 4.2 Review the apparent opportunities for challenging decision making and why this did not happen. 4.2.1 Opportunities to challenge decisions were limited other than during the multi agency strategy meetings of 28th and 29th June. The only other opportunities were within the GP practice. The GP practice arrangements should ensure that a practice nurse refers a baby with Child W’s symptoms for attention from either himself or a specialist. This would have given the opportunity for a wider discussion about Child W’s presentation. 4.2.2 The GP could have noted that the OOH service notified the GP practice of an unexplained bruise without taking further action, or highlighting their concern. In the absence of any alert on the GP records, MW’s concern and openness was taken as reassurance that she was a caring mother who was seeking explanations. The GP was unaware of previous domestic abuse and did not query MW reporting bruising on her abdomen on 26th March, when none was evident. The NHS Manchester IMR recommends that the GP practices should continue with their work on improving their methods of flagging and read coding key elements of treatments and family events that may be future indicators of the need for investigation. This review, following the CPS decision of no prosecution raises wider concerns about the limitation of flagging and read coding to alert agencies of a possible risk to babies. This is commented on in Section 5. 4.2.3 The MNHS COR sets out the opportunities for NHS staff to challenge MW and MPW about how Child W was cared for. There have been a number of structural changes Page 29 of 46 which have altered the relationships between primary care services. It is important that whatever the agency structures, there are regular opportunities for primary care staff to discuss shared patients. This should allow for noting such information that MW was at times unreliable about her children’s care. It was recorded that MW missed two appointments for immunisations and was not at home for two pre-arranged visits. This had been a previous pattern when she was on the list of GP3. Because MW seemed to seek advice and treatment appropriately the less good element of her parenting was overlooked. The MNHS COR draws out that MW was left to challenge NHS staff, rather than the staff taking responsibility themselves. 4.2.4 When MW took Child W to Hospital 1 on 26th June the child had been referred by the GP as he was concerned that the swollen feet persisted with no explanation. Although two doctors saw Child W there was no consideration of further tests to identify the cause. The IMR suggests that at this point one doctor should have challenged and asked for an X-Ray of the feet. 4.2.5 However the main lack of challenge was at the two strategy meetings. On the 28th June in the absence of the referring doctor it seems that the concerns of Cons 1 were not discussed. The meeting, while appropriately adjourning for the attendance of a consultant did not ensure all the relevant history of the family and specific care of Child W would be available for the next day. 4.2.6 On 29th June Cons 2 attended the strategy meeting. The concerns of Cons 1 were not discussed. Cons 2 was confident with his explanation that the marks or injuries were not NAI, noting that the bruise which was discussed was not a ‘slap, hit or finger marks’. DC1 asked specifically how the injuries were accidental but accepted without challenge, as did the CSC chair, the reasoning of Cons 2 that his view was ‘on the balance of probabilities’. Within the SCR, HV1 agrees that she should have challenged this view, should have asked for discussion of the information from Cons 1 and made sure that each illness and injury was considered separately (see TOR 3). 4.2.7 While HV1 is noting this, the view of the SCR panel is that the CSC Chair of the meeting and CPN (the hospital based child protection specialist nurse) also had responsibility for ensuring that the decisions were consistent with the age and development of the baby. The meeting should have considered each injury and all possible perpetrators. There is considerable evidence from research (Burton 2009) and SCRs (Brandon et al 2008, Dale et al 2002; Reder and Duncan 2004;) that fixed views are influential in decision making about a child’s circumstances. The research found that professionals were found to have disregarded, dismissed or ignored contradictory information including parental behaviour if it did not confirm their original view of the family circumstances. This tendency should be managed through critical reflection and challenge, using peer group mentoring, supervision, management oversight and challenge from the multi-agency perspective. 4.2.8 The confidence of Cons 2 was overly influential as, while he reflected later that there was cause for further inquiry, he did not discuss the matter with the Named Doctor, leave his report for follow up, or transfer care to another paediatrician. The panel however was very aware of the deference, in this case to NHS professionals, often Page 30 of 46 present in multi-agency meetings that create an environment where it is difficult to challenge. This may have particularly relevant in this case as the social worker chairing the meeting was not at the correct grade. The panel’s view is that all present in a strategy meeting have a responsibility to ensure the decisions take account of uncertainty and are child focussed. The MNHS COR demonstrates how the other NHS staff may have been reassured that the medical view was accepted by CSC and GMP, while equally, these agencies will have been reassured by the lack of challenge from the HV and CPN. 4.2.9 WT 2010 says in paragraph 2.6.3 that all health professionals not only should: contribute to child protection conferences, family group conferences and strategy discussions; but should understand risk factors and recognise children and young people in need of support and/or safeguarding; it is important to note the wording is ‘contribute to’ not ‘lead’ the discussion. 4.2.10 The meeting ended with a decision not to pursue a Section 47 investigation but for CSC to begin a core assessment. 4.3 Evaluate the planning, recording and decision making at the strategy discussions on the 28th June 2012, 29th June 2012 and the 13th July 2012. 4.3.1 It is evident from all the IMRs that the process prior to and within the strategy meetings was not compliant with the expectations of WT. The relevant extract from paragraph 5.56 is ‘there should be a strategy discussion involving local authority children’s social care, the police, health and other bodies as appropriate (for example, children’s centre/school or family intervention projects), in particular any referring agency. The strategy discussion should be convened and led by local authority children’s social care and those participating should be sufficiently senior and able, therefore, to contribute to the discussion of available information and to make decisions on behalf of their agencies. If the child is a hospital patient (in- or out-patient) or receiving services from a child development team, the medical consultant responsible for the child’s health care should be involved, as should the senior ward nurse if the child is an in-patient. Where a medical examination may be necessary or has taken place a senior doctor from those providing services should also be involved.’ 4.3.2 In this instance the GP was not informed of either meeting, or asked to provide any background information. On 29th June the radiologist who could have advised on the findings from the skeletal survey nor orthopaedic staff were invited to provide any information for the meeting. It is difficult for many NHS staff to attend meetings at such short notice. The General Medical Council (GMC) guidelines which took effect on 3rd September 2012 expect that if the paediatrician or GP is not able to attend information will be available to the meeting. The responsibility of the doctor is to ‘try to provide relevant information about the child or young person and their family to the meeting, either through a telephone or video conference, in a written report or by discussing the information with another professional (for example, the health visitor), so they can give an oral report at the meeting.’ Child protection procedures expect Page 31 of 46 the HV or nursing service, as well as the CPN will attend the strategy meeting having gathered and collated the relevant NHS information. 4.3.3 The outcome of the meeting on 28th June ensured that all three children were protected but did not identify where further helpful information could be gathered in preparation for the next day. This meeting was chaired by a social worker of less experience than expected by paragraph 9.10 of MSCB procedures and this may have contributed to the limited discussion. It is to the credit of CSC and attending agencies that the strategy meeting was held so promptly. However WT 2010 allows up to three days and taking more time to plan the meeting may have ensured all relevant information was available and the meeting could have been chaired by a social work practitioner of correct status. The panel observed there could be a number of reasons for this. It is noted in the MNHS COR that the reason the meeting was convened so quickly could have been pressure to release the bed in the hospital or panel thought that as it was a Friday staff would be reluctant to leave the matter over a weekend. 4.3.4 Paragraph 5.59 of WT 2010 states that ‘Any information shared, all decisions reached and the basis for those decisions should be clearly recorded by the chair of the strategy discussion and circulated within one working day to all parties to the discussion. Local authority children’s social care should record information in the child’s file which is consistent with the information set out in the Record of Strategy Discussion (Department of Health, 2002).’ 4.3.5 The IMRs indicate that each person attending made their own notes (in each case GMP, CSC and HV notes were full and factual) but there was no shared note and the meeting did not follow an agenda that allowed full discussion of the circumstances of Child W, the injuries and the care. The GMP IMR notes that there is differing practice across Greater Manchester Police divisions and as this has been a longstanding problem, GMP staff have found different solutions to the difficulty. 4.3.6 The specific matter of circulation of strategy meeting minutes has been a recommendation in a previous recent MSCB SCR. The SCR Author could not find the Record of Strategy Discussion identified in WT 2010 paragraph 4.3.4. Efforts were made to identify any formats from neighbouring LSCBs to Manchester that would ensure the discussion and recording is thorough and results in a full record. Recent work almost concluded for MSCB should resolve confusion between the agencies. 4.3.7 The different agency records show that: • There was no shared record of people present or reports used in discussion; • Information on the previous ‘pinch’ mark (bruise seen at OOH service on 8th March) was not given; • The observations and concerns of Cons 1 were not discussed at the 2nd strategy meeting but other people present did not know there had not been any conversation between the two consultants; • At this meeting the possible chip fracture was discussed but Cons 2 said it was not confirmed as an injury, (information from the radiologist would have assisted here); Page 32 of 46 • The fracture on the left lower leg was considered by Cons 2 to have been caused by the fall from SS2’s lap on 3rd June after his interview with MW. This conclusion was not consistent with the records held at Hospital 1 about the injuries observed when the fall was investigated; • There was no discussion about the context and position of the fall; • The bruise was considered to be caused by either the use of the baby walker, or catching on a door handle. It was accepted as not Non Accidental Injury (NAI) as it was not a fingertip bruise, slap or pinch; however no professional had seen Child W in the baby walker to see if the bruise was consistent and the only mention of a bruise being caused by a door handle was in the CSC records; • Cons 2 considered the evidence shows that MW is plausible and she reports and follows advice; • Cons 2 indicated that the swollen feet and petechial bruising were being treated; • As noted in paragraph 5.4.5 of the MNHS COR there was no overview of the family circumstances and history; and • The records held in agencies of 13th July suggest the meeting was chaired by DR13. 4.3.8 Finally, at the July 13th strategy meeting, no records were shared. The CSC record of this meeting was found towards the end of the review process but had not been entered on the system as required. All other agencies made their own detailed records. In particular the notes from DR 13 are extensive. As preparation for this strategy meeting, DR13 requested records from the GP surgery. The MNHS COR draws out the key point that in contrast the June meetings lost the expected focus on the child as the basis of all discussion. At the end of the meeting there was no plan to inform the GP of the outcome. 4.3.9 The GMP IMR notes that different sets of notes could cause difficulties in any criminal proceedings. The police are required to inform CPS of any information which may be of interest to the defence either because it undermines the prosecution or assists the defence. If the strategy notes from different agencies are contradictory a prosecution could be jeopardised. 4.4 To what extent did agencies and services take account of issues such as: race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 4.4.1 The records from each agency have recorded MW as White British and English speaking. CMFT had explored further and recorded that MW and MPW were claiming benefits but had no financial difficulties and had noted that there were no communication difficulties. The ‘Social record’ used by HV services is very helpful in providing context to family situations giving good information on MW’s previous partners and the fathers of her children. 4.4.2 Both the HV services and GMP had recorded that MW was a competent mother, with a note in the GMP IMR that she ‘knew her children’. CMFT IMR notes that with hindsight the HV service can see an unusual dependence on the NHS for a parent of Page 33 of 46 two older children. The CSC IMR acknowledges that MW may have been reticent about her relationship with MPW to prevent changes in their benefit claims. 4.4.3 Two IMRs identified some concern about the thoroughness of the records in those areas which give context to possible safeguarding matters. CSC IMR acknowledges that there should have been consideration of MW’s history of domestic abuse. The GMP IMR asks if agencies would have acted differently if the presentations to the GP and hospitals had been in a more sound economic area. 4.4.4 Agency responses in a known deprived area of Manchester form the key issue for this TOR. NHS Manchester IMR comments that the GP surgery completed a lifestyle assessment on MW (which is not required), but failed to include a mental health assessment and so missed the previous prescriptions of anti-depressants. The practice did not complete health assessments on SS1 and SS2 (also not required) when they transferred in to the GP practice. However the GP did respond to MW’s financial situation by giving a prescription for a routine ‘across the counter’ medication as, with a child under one year she had free prescriptions, when she had no money. 4.4.5 Economic status can be the cause of discrimination. IMRs from a number of agencies in a previous MSCB SCR indicated that there are areas of Manchester where lack of regard for culture might have had an impact on the services provided. The family lived in a part of Manchester where historically there have been lower aspirations for achievement in school and employment. In this context agencies have demonstrated less concern for a child’s wellbeing than the expectations set out in Every Child Matters. 4.4.6 However the wider context of MW was missed. The MNHS COR draws the different elements together, and also notes that the HV service and GP3 did not consider together the historical missed appointments (including for SS1’s sight), the four appointments missed for Child W in 2012 and the delays in acting on advice when MW was apparently very concerned about her child. Additionally MW failed to follow advice and continue treatments for her own health. 4.4.7 Perceptions of MW’s parenting appeared to influence the agencies in accepting the outcome of the strategy meeting on 29th June. She was seen as an experienced, competent parent with NHS staff not noting or acting on her assertion ‘that Child W marks easily’ (18th May and 27th June). A further difficulty for NHS staff was that MPW was often present at appointments or during home visits making it difficult to ask MW about any concerns in the family relationships. While the HV service knew of his status, there was no exploration by any NHS staff of his own history or caring responsibilities. It is now known that he has a lengthy history of seeking help for his anxiety and cocondrosis and that he is known to abuse alcohol. The MNHS COR notes in 5.5.4 the detail of how little staff asked about him or his role with Child W. 4.4.8 Both SS1 and SS2 had hospital admissions for teeth extractions. This is seen as ‘not unusual’ in this area of Manchester. Figures show that the North West is the worst region for childhood tooth decay and Manchester has the worst record in the North Page 34 of 46 West. The comparative figures for five year olds in the year 2007 – 08 are as follows (Sourced from Office for National Statistics): • Percentage of children with decay experience (i.e.: with one or more obviously decayed, missing (due to decay) and filled teeth) – England 30.9; North West 38.1, Manchester 51.4; • For those children with decay experience, the average number of obviously decayed, missing (due to decay) and filled teeth per child – England 3.45; North West 3.8; Manchester 4.63. 4.4.9 The SCR panel was concerned to hear that Manchester health authorities and the utility companies have resisted the introduction of fluoridisation in the water supply ignoring the evidence that demonstrates significant health improvement. Not only are many children disadvantaged by this policy (enduring pain and the trauma of hospital admissions), but there must be a high cost to the NHS. In Birmingham the percentage of tooth extractions has halved since the introduction of fluoridisation. 4.5 To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of Child W? 4.5.1 Some issues relating to communication have been noted in previous TORs; for example, not inviting the GP to or informing of the strategy meetings, and the absence of the notes made by Cons 1 for use in the discussion. The GMP IMR contrasts the quality of discussion on 13th July with that of 29th June. The IMR indicates that if all the information available from primary care and Hospital 1 on MW and MPW had been discussed, the context of the injuries would have been seen very differently. 4.5.2 The MNHS COR notes that if background information on the whole family had been available, the strategy meeting would have seen some less good parenting by MW of SS1 and SS2, with a longstanding pattern of missing appointments. MW’s determined presentation with Child W on consecutive days could have suggested a different purpose of drawing the injuries to the attention of the NHS (and by telephone to CSC). 4.5.3 The GPs and HV service have considered whether there should have been more communication between them. The Manchester NHS IMR lists the events when it would have been appropriate to check with the HV service or to ask the HV service to make a follow up visit. In both IMRs the professionals acknowledge that there were opportunities missed, and the NHS Manchester IMR author considers it would have made a difference to their management of Child W’s needs. For example, the HV service did not know about MW’s previous episode of depression, or that she had asked for a further prescription after Child W’s birth. 4.5.4 The MNHS COR confirms that this poor communication was an important element in Child W being left unprotected for some weeks. Additionally the report identifies the three missed opportunities when the GP and the occasion when Hospital 1 should have notified CSC. Page 35 of 46 4.5.5 As noted in paragraph 4.4.7 above, MW’s persistent presentation to NHS agencies clouded any view that there might be safeguarding concerns. Reading the integrated chronology demonstrates the less caring approach at times to the care of Child W. For example, MW discussed a series of concerns with SN4 on 14th May, but did not follow the advice to take the child for immediate assessment by a doctor until the next day when she telephoned GP3; the HV saw the swollen foot on 3rd July (knowing of it from the strategy meeting on 29th June) and advised MW to take Child W to the GP. MW did not take Child W until 10th July. 4.5.6 While not attributing blame to the other agency, both the GP and the HV service had confidence that they would be contacted if other professionals had any concern. The trigger for concern had of course been overlooked when the GP did not follow up the unexplained bruise as a matter to be followed up when alerted by the OOH service. The HV service had the historical information on domestic abuse and if asked to follow up the unexplained bruise may well have escalated concern into child protection systems. Communication did not feel necessary as MW always reported back. However it should not be the expectation that the parent is the message taker between professional staff especially where there are identified concerns. All professional staff should acknowledge their own responsibility for safeguarding and that of each agency. 4.5.7 Factual information was sent routinely by Hospital 1 after presentations at the hospital, but it was sometimes received some days later, and did not include any context, or raise any concerns that might have been discussed. 4.5.8 Even when the GP referred to Hospital 1 for further assessment, there was no feedback to the practice, and the practice did not seek it presumably confident that a written report would arrive at some time. 4.5.9 Hospital 1 did not seek any feedback when Child W was brought in again on 12th July, and CMFT had not sent across any outcome following the events of 27th – 29th June. This meant that Hospital 1 had no information on the safeguarding concern until the 13th July when DR 16 asked for the relevant information from the skeletal survey when he reviewed the X-Ray. 4.5.10 The routine communication by Hospital 1 with CCNT for administration of intravenous antibiotics and with Hospital 2 on 27th June, when MW took Child W was good, meeting the expected standards. Equally communication between the different staff in the HV service and the communication between CCNT team and the HV service was good. Hospital 1 also commended CSC and GMP for quick responses when contacted with safeguarding concerns. 4.5.11 The SCR panel agrees with the author of the PAHT IMR that the practice of DR13 on 13th July and the subsequent medical report and action taken to safeguard Child W was of exemplary standard and should be highly commended. 4.5.12 However the PAHT IMR notes some less good practice in relation to attendances at A&E by both MW and MPW. Neither adult was asked at any time about caring Page 36 of 46 responsibilities. This was poor especially as on one occasion MW had only recently given birth and MPW indicated on 12th July that his stress could be caused by ‘child and relationship’. This contravenes PAHT policy. 4.5.13 The MNHS COR once again draws attention to the lack of focus on the child’s well-being (paragraph 5.4.5) and makes the link to the need for open communication. At the strategy meetings on 28th and 29th June communication was poor. The meeting made decisions without resolving the difference of opinion between Cons 1 and Cons 2, with no information from other key NHS staff including the GP. This difference should have been resolved or discussed with the Named Doctor. The meeting on 29th June relied heavily on medical evidence that said ‘on the balance of probabilities it is not NAI’ instead of considering the vulnerabilities of a young baby. Any unexplained injury should be investigated as a cause for concern. However there was no discussion with the Named Doctor about this uncertainty either. 4.5.14 Finally on no occasion did the GP take responsibility for Child W’s wellbeing when the practice had a number of opportunities to contact NHS colleagues to share information or ask for the family to be checked or monitored more closely. Equally the HV service, who at times recommended MW should take some action using different NHS agencies, did not notify or explain the reason for any recommendation to the GP. While there is an option of ‘choice’ in the NHS with a young baby it may be more important to ensure continuity of treatment. At least if communication had taken place, it would have become obvious to the GP much earlier that MW may have needed more support to care for Child W and that at times her story changed in some important details. Page 37 of 46 5. Summary – What do we Learn? 5.1 There are six key messages to take from this SCR. These are: • All agencies have a proactive responsibility for safeguarding children; • A wider understanding of the significance of injuries in young babies is needed in all agencies; • There should be more routine enquiry and need for challenge of adults where risks emerge about living arrangements, relationships and patterns of care; • Consistent multi-agency citywide agreement and guidance on how strategy meetings are managed and recorded should be developed urgently ensuring full compliance with relevant statutory regulation and guidance; • There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies; and • Identification of how to flag significant risk from those without formal convictions. 5.2 The MNHS COR describes how there were six missed opportunities for NHS staff to identify or rule out non accidental injuries. The other agencies (CSC and GMP) also missed opportunities to investigate fully unexplained injuries in the strategy meeting on 29th June. The difficulty at times was an assumption that another agency had conclusive information, or that the contextual information on the family was not important. 5.3 The panel were mindful that the recommendations in the IMRs echo or are similar to those in previous SCRs presented to MSCB. This SCR demonstrates that while agencies have taken steps to implement previous recommendations, babies and children may still be at risk in situations where agencies could and should take responsibility for further challenge and investigation. 5.4 In discussion the panel considered that making repetitive recommendations would not be helpful, but instead should draw attention to the possible repetition and seek reassurance from MSCB that lessons have been and will continue to be learned in the multi-agency forum with full multi agency ownership. 5.5 In preparation of this report the author has had access to two recent independent reports commissioned by MSCB to examine the process of SCRs from 2007 but also to look at similarities in the circumstances of the children reviewed and the recommendations made. MSCB has considered both reports and so appreciates that the matters raised in paragraph 5.1 may be familiar to the Board. 5.6 MSCB has a thorough process for implementing multi-agency recommendations. Historically, when SCRs were signed off by the Board, single and multi-agency recommendations were monitored by staff within the MSCB Business Unit. They would collate evidence that the recommendations had been implemented. The evidence would then be archived into a folder in a secure database and a summary of progress entered onto a master schedule. MSCB would then receive periodic progress reports. This process has recently strengthened and currently when an SCR is signed off by the Page 38 of 46 Board each agency is forwarded a template to complete with evidence of progress on the implementation of single agency recommendations. Staff within the MSCB Business Unit have responsibility for populating templates on progress of the implementation of multi-agency recommendations. Progress reports on the implementation of single and multi-agency recommendations are received by MSCB approximately six months following the sign off date. Wider understanding of the significance of injuries in young babies is needed in all agencies 5.7 In this SCR, all three NHS IMRs and the MNHS COR recommended some training or briefing on patterns of injuries in young babies. Previous SCRs have recommended inclusion of some specific elements within the single or multi-agency training. Recommendations have been made in five SCRs about missed appointments, and in three about ‘silo’ thinking, and both of these are relevant in this SCR. 5.8 ‘Child protection concerns not identified’ was relevant in some reviews with ‘missed appointments’ often a key indicator. Part of the commentary in this SCR on responses from agencies includes the lack of understanding of the significance of missed appointments by MW for herself and the children, both during the timescale of the review and historically. There has been a thorough approach to implementing past recommendations with, for example, NHS Manchester developing a pathway on missed appointments to prevent further examples of risks to children being overlooked. The Manchester hospitals have also implemented similar pathways and are currently reviewing how they can be simplified into combined documents. 5.9 More important is the lack of recognition by a number of NHS professional staff of probable non accidental injuries in a non-mobile baby. WT 2010 requires all LSCBs to ensure relevant staff are trained to recognise the indicators of abuse. Clearly for Child W there were a number of themes of which missed appointments and unexplained bruising are only two. MSCB had responded to similar concerns in 2010 with an up dated level 1 multi-agency training as well as a separate Child and Young Person Development Course. This is not mandatory and none of the staff involved in the relevant strategy meetings had attended it. MSCB is planning much wider circulation of the details of the course but NHS agencies expect such training to be included in agency courses. Managers at Hospital 2 have developed some training in response to another recent MSCB SCR which should improve recognition. 5.10 ‘Failure to recognise safeguarding responsibilities’ was also identified in previous reviews. There is a tendency for agencies to think in ‘silos’ not recognising their responsibility to consider parenting capacity. The MSCB revised the core safeguarding procedures in 2010 to stress the wider responsibility for recognition of child protection concerns. The revised multi-agency level 1 training also included the key message of responsibility for safeguarding in all agencies. Some agencies have developed this further with MCC Strategic Housing providing safeguarding sessions for registered social landlords and a system of Housing Safeguarding Champions. This recognises that contact with safeguarding is a rare occurrence for staff in some agencies and a forum provides support. Page 39 of 46 5.11 The evidence following the decision not to take the 8th March unexplained bruise into the child protection system supports a commonly held view that left unchecked, inflicted injury in young infants is likely to continue and to escalate in severity. Further when concerns do arise it is unacceptable for parents, no matter how plausible, to be entrusted alone to pursue the investigation as was the case on 9th July. 5.12 This SCR also demonstrates the key role played by general paediatricians in recognising and responding to suspected non accidental injury. General paediatric consultants are central to child protection and their understanding is essential; but with current workloads a better system is needed to support them to identify and support the full investigation of unexplained injuries. There should be more routine enquiry and need for challenge of adults about living arrangements, relationships and patterns of care 5.13 Discussion in panel centred on how little agencies knew of the relationship between MW and MPW, and how they shared parenting responsibilities between them. However as the review has progressed it has become clear that at times MW was less reliable than her presentation suggested, with: • some lack of following of advice; • different descriptions of Child W’s symptoms; • concentration on her own health at times; and • not acknowledging how much MPW took responsibility for care. 5.14 The MNHS COR sets out some expectations that any adult presenting at A&E should be asked about caring responsibilities with a standard question included in A&E recording systems. However the paediatric, GP and HV services should have enquired more about MPW’s role in the home, especially as he was present on a number of occasions. Some questioning may have uncovered MPW’s stress and the potential for stress when caring for three step children. Since June 2010 this element (details of the father and role in child care) has been included in maternity booking sessions and NHS Manchester children’s assessments. 5.15 However as well as some factual information a recent MSCB recommendation was ‘Training needs to be developed to assist practitioners in challenging parents and patients when key indicators of risk have been identified’. 5.16 Obviously this theme is only relevant if the risk or injury has been identified. CMFT has specific training on challenging parents when key indicators of risk are present. Children’s Social Care has amended the Social Work Handbook and provide specialist training on the role of fathers and males as part of the training for completion of Core Assessments. Compliance with the Handbook is monitored. Practice guidance on risk assessment was implemented from September 2010. 5.17 The recommendation in the NHS Manchester report will provide some additional information, when GP practices read code or flag previous history, and treatment, to highlight risk indicators. A previous recommendation has been ‘Flagging of children and Page 40 of 46 their families to indicate they are “at risk” should be promoted, as has been recommended. The death of a child should be included with flags placed on the records of parents and other siblings.’ There has been great improvement in use of flagging supported by the GP Steering Group. As GPs are independent practitioners MSCB cannot require this action but should identify the best method of active promotion so that the implications are understood. 5.18 ‘Flawed assessment’ has been noted locally as well as in Ofsted evaluations when there is a dearth of information about fathers or male figures in the household. Even if the events in March had proved inconclusive an investigation could have raised some of the issues to identify the risk factors in Child W’s family. MSCB understands the ease with which agencies can concentrate on the positives as happened at the strategy meeting of 29th June, and was echoed by the GP and HV service when MW was discussed as part of the preparation of the IMRs. 5.19 The other element that was not spotted by agencies was MW’s apparent concern and wish for diagnoses. It is only with the opportunity to see the integrated chronology that this is fully clear, but the MNHS COR has identified each opportunity when there should have been further questioning or investigation. 5.20 ‘Difficulties engaging some families’ is a familiar theme for SCRs. MW was difficult in that she was clearly very worried about Child W, but was unable to give clear messages about any concerns she had from her relationship with MPW. With hindsight it may be that she 'engaged selectively’ with the agencies. There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies 5.21 The heading discussed in paragraphs 5.13 to 5.20 can only be remedied if there is good and regular communication whenever there is an unexplained situation relating to the care of babies and children. 5.22 This review has found some excellent written agency records, specifically in the HV service, Cons 1, DR13, ophthalmology and radiology. However until the strategy meeting on 13th July, the pattern of presentation of Child W and historical information was not taken into account. Importantly regular communication between the GP and the HV service was missing. An early check would have identified the discrepancies. In particular when the HV service recommended MW should take Child W for immediate attention, the GP should have been verbally notified and had the concerns explained. 5.23 The GP practice has accepted that they ‘took a back step’ when secondary services were involved, and while the GP has a primary responsibility, secondary services could have provided more contextual information for the GP to add to their records. Neither the HV service nor the GP reviewed notifications with any questioning. There appears to have been a belief that because the family were not hidden and appeared to be Page 41 of 46 proactive in seeking medical review this decreased rather than increased the need for information sharing and clarification. 5.24 Equally there was poor communication between Hospital 1 and Hospital 2. Clarity on the reason for presentation and previous treatments are essential at CMFT where by necessity as a regional centre, any examination and diagnosis will involve multiple professionals to deliver the care for any individual patient. 5.25 Communication is often raised in SCRs. A previous MSCB SCR recommended ‘that a joint health information sharing system should be developed and implemented across all Manchester Trusts that addresses the lessons learned in this serious case review.’ This would be a huge piece of work and while there has been much progress, there is still work to do. The relationships between the different community, acute and specialist services in Manchester are complex, but some work has been completed to ensure a joint pathway for maternity services. In relation to communication between primary and secondary care, the procedures for sharing information have been revised to provide written information to the GP practice within 48 hours of a hospital attendance. There is current consultation on an electronic system to notify of attendance at emergency services. 5.26 A number of elements outlined in paragraphs 5.22, 5.23 and 5.24 have recently been reported to MSCB within the MNHS COR for a recent SCR which stated: ‘This suggests that following protocols is not sufficient to effectively protect a vulnerable child. The CMFT IMR author comments that it was the actions of health staff which enabled the timely detection of the child’s injuries. However, the author feels that surveillance by health staff and multi agency liaison should have prevented the harm occurring and detection once it had occurred was too late. Other recent SCRs have highlighted the role of GPs in safeguarding and the important part they can play in the process. In recognition of this a GP child protection steering group was set up in Manchester to advise on the implementation of recommendations. Previous recommendations include flagging of GP records of children subject to a child protection plan and their families. These recommendations have already been implemented. There is work ongoing to increase GP involvement in child protection case conferences. There is a programme in Manchester to train all GPs in safeguarding and to provide an enhanced level of training for the identified GP safeguarding lead in each practice. The NHS Manchester IMR author recognises the need for further development of the role of the GP in her recommendation to flag at risk families and not restrict flagging to children subject to a child protection plan. There is work currently taking place to ensure GPs are informed as soon as possible by fax when a child has had a child protection medical in any setting in Manchester so that they do not have to wait to be informed until the full report is ready which may take several days. Under the new arrangements for commissioning set out in the Health and Social Care Act, GPs* will be responsible for commissioning services and monitoring the quality of safeguarding services. They will also have a statutory duty to sit on the MSCB. They therefore need to be kept fully informed of safeguarding issues affecting their patients. This has to be considered by both partners in health and by other agencies. The author and Designated Nurse meet regularly with the GP Steering Group and with the nominated Page 42 of 46 Responsible Officers for the Clinical Commissioning Groups to continue to highlight safeguarding issues in general practice.’ *now implemented through Clinical Commissioning Groups 5.27 In the light of such a recent discussion the panel considered further multi-agency panels would not be helpful but that MSCB must satisfy itself that previous recommendations are being implemented in a robust manner. The MSCB noted there is already progress which will contribute to this challenge: • The work on HV and GP pathways and communication have already set up a pilot which includes an Early Years New Delivery Model; and • The HV Task Force has had accepted an increase of 71 whole time equivalent staff by 2015. Consistent citywide multi-agency agreement and guidance on how strategy meetings are managed and recorded is urgently needed. 5.28 This heading is also a repeat of previous recommendations but the panel strongly consider that there is no reason that prevents full and early implementation of a robust mechanism for strategy meetings. All the IMRs comment on the crucial role of the strategy meetings in this SCR. 5.29 The panel is aware that a number of strategy meetings (as acknowledged in WT 2010) are telephone conversations between GMP and CSC. However the panel’s view is that if following some investigation, there are still unexplained circumstances, a meeting should be arranged with a NHS representative to ensure appropriate information sharing from all relevant NHS services. 5.30 The panel appreciates that this proposal will require some multi-agency discussion. However the importance of agreement cannot be stressed too much as Child W was subjected to some serious abuse because the system currently in place was inadequate. 5.31 Comments from GMP have already been included in paragraphs 3.1.15 and 4.3.9. Examination of the notes of the strategy meetings on 28th and 29th June showed some poor recording, with the records not signed or dated, people present not recorded, and pages unnumbered. The requirement should be: • a competent chair, appropriately experienced to manage the complexity of the case; • timed to include relevant agency representatives; • following a routine format; • with less reliance on medical evidence, rather a challenge for explanations of bruises or markings; • a greater questioning of who has cared for a child, and their background; • with discussion based on full information from NHS staff who have seen the child as part of their routine service or as an acute episode. Page 43 of 46 5.32 The current MSCB procedures for managing and recording strategy meetings are not as clear and helpful as they could be (paragraphs 9.12 and 9.11) and revision following discussions should be completed. 5.33 The procedure should stress that all participants have equal status and a professional from any agency can check detail. When strategy meetings are held in a hospital the role of the CPN should be understood by all present. This should allow a better challenge of plausible parents and of the view that there will not be abuse where a family is socially stable and settled in the community. 5.34 MSCB at the January 2013 meeting had agreed to commission a report, with the initial one available for the board at the end of January 2013 outlining: a) Is sufficient priority and time being invested in S47 meetings? b) Are the right people invited? c) Do those who need to know receive the plan? E.g. GP, Examining Paediatrician, School, Health Visitor? d) Is every child considered for an ‘Achieving Best Evidence’ Interview and the rationale for a decision recorded? 5.35 As indicated in paragraph 3.2.12 the panel do not consider it to be helpful to make another recommendation when there is apparent activity in a number of agencies. The Safeguarding Practice Improvement Group (SPIG) has set up a task and finish group which has almost completed the work on a pro forma and flow chart. The panel was unsure how this links with the proposed joint audit by GMP and CSC of eight weeks of strategy meetings described in CSC IMR paragraph 7.1.4. As part of another recent MSCB SCR, PPIU are developing a pack for use in GMP. The strategy meeting is where the focus is specifically on making key decisions about the child and so the SCR panel sees it as crucial that some priority is given to finding solutions. Identification of how to flag significant risk from those without formal convictions 5.36 This is the final lesson for this SCR in ‘what we have learned’. It introduces an element for MSCB to consider that has not been raised in previous SCRs. The panel had a long discussion about the limitations of current systems to alert staff in any agency raising a concern about a child being at risk. The difficulty is that once CPS has made the decision to not proceed with a prosecution there is no mechanism of alerting a professional to the concern. It was felt that there should be wider consideration of how NHS agencies in particular but also the police and social care can be alerted to the risk presented. Conclusion 5.37 The panel in light of the evidence from the agency reports agreed that the injuries to Child W, possibly from March 2012, and certainly from the end of June 2012 were preventable. If agencies had considered information about MPW and taken into account the detail of MW’s sometimes contradictory presentations, it is possible that Child W would have been considered as ‘at risk’. However this judgement is made with hindsight and the severity of the assaults could not have been predicted. Page 44 of 46 5.38 Instead of a list of recommendations the panel asked MSCB to consider this report (April 2013) and that agency representatives on the Board should agree how to bring evidence of change to future boards to demonstrate the messages and learning of the recent SCRs have been integrated into all agencies. MSCB met again on 9th May to plan their response to the six challenges set out below. A brief summary of the proposed timetabled programme of implementation is included below and MSCB will submit the detailed plan as the action plan. 6. Multi Agency challenges 1 - All agencies have a proactive responsibility for safeguarding children This is an overarching responsibility for MSCB. It is important that each agency contributes and does not assume that one role or agency has a greater responsibility than others. For this reason it is essential that all agencies adequately identify the responsibility for safeguarding children in each agency’s procedures. SCRs have commented on the human bias of optimism when an agency knows a parent over some time, or is making an assessment when there is a ‘plausible or compliant parent’. It is important that this tendency is well understood, objectively managed and appropriate action taken. Question: How will MSCB ensure that each agency has robust procedures that are effectively used to protect children and then demonstrate/satisfy itself that all relevant staff and professionals are proactive in discharging their safeguarding responsibilities effectively? 2 - A wider understanding of the significance of injuries/symptoms of injury in young babies is needed in all agencies It is important not only to ensure that all staff in all MSCB member agencies understand the vulnerability of young babies, but that explanations and context will contribute to an objective assessment of probable cause. This SCR has demonstrated that even highly qualified medical and nursing staff can overlook the likelihood of inflicted injuries in non-mobile babies. It is important that staff appreciate there may be no evidence of an injury but there will be symptoms of pain, or discomfort which could also have a medical cause. The MNHS COR identifies the difficulty of raising issues when there is a professional deference within health and to health professionals by other agencies, so MSCB has to help create a culture where openness to challenge, when there is uncertainty, is expected by all agencies. Included in the challenge to colleagues at child protection meetings is the promotion of a healthy and non-judgemental approach to seek more specific explanations from parents. This expectation can be difficult for the more senior as well as the junior staff and so there should be a system of rigorous support for quality supervision/mentoring across agencies. Question: How will MSCB make sure that the use of training and briefing sessions is integrated into practice and seek evidence of the openness to challenge within child protection meetings? Page 45 of 46 3 - There should be more routine enquiry and need for challenge of adults about living arrangements, relationships and patterns of care Any assessment of risk or vulnerability has to be based on clarity of information on the roles and relationships within the family. In this instance the role of MPW was unclear both in relation to his care giving and frequency of presence. The review has not considered the role of MW’s parents but it is known that they also provided support. All agencies should check at initial enquiries and in assessment interviews about who lives in a household, frequency of visits of partners not living at the home, and their role in care giving. For this to be completed routinely staff must understand how the nature of adult relationships contribute to uncertainty of strengths for caring for babies and young children. Question: How will MSCB satisfy itself that all agencies have systems for routine enquiry that can be used as an evidence base when risk or vulnerability is identified? 4 - Consistent multi-agency citywide agreement and guidance on how strategy meetings are managed and recorded should be developed urgently There have been previous recommendations about strategy meetings. This panel asks MSCB to give clarity to their expectations for future strategy meetings with a revised multi-agency procedure which complies with statutory guidance that has MSCB approval. As there will be regular changes of staff it is important that compliance with the multi-agency procedures is monitored. Question: How will MSCB ensure the management of strategy meetings is continuously compliant with revised and agreed multi-agency procedures? 5 - There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies NHS agencies must have some expectations for staff to communicate to GPs verbally and in writing when they have a first or unexpected contact with a child. When a child is taken to different hospitals there is a responsibility to communicate in a timely way with the GP but also to seek information either from the GP or the other hospital on previous presentations. It is important with the city having a complex arrangement of health care that there is continuing evidence of improvement. The panel discussed the possibility that MSCB might consider requiring a full review of communication systems from the health agencies. Question: How will MSCB satisfy itself that there are robust and timely communication systems between community services, GP practices, out of hours services and acute services? 6 - Identification of how to flag significant risk from those without formal convictions The panel discussed how agencies decide when and how to share information especially with CSC or GMP when there is some evidence of non-accidental injury. The limitations of current systems became clear when CPS decided not to pursue a prosecution. The outcome is that an adult, who has been the subject of police investigation in relation to significant Page 46 of 46 harm to a child but has not been prosecuted or convicted, is living in the community but agencies have no knowledge of the history. This is complicated in this particular case where MPW has an address in another Greater Manchester local authority and a birth child in a third authority area. Information about the arrest and investigation, together with access to forensic information will be available locally through GMP Force Intelligence System and nationally though the Police National Computer. However this will only be available at the point of an enhanced CRB check, or a strategy meeting. It is more likely that information would be available through GP flagging or read coding. However the issue is wider than MSCB or even the North West. Question: What action could MSCB take to raise the matter for wider discussion or action? Summary from the draft implementation programme from MSCB: MSCB has started a number of pieces of work in response to this SCR as well as continuing with plans from the recent previous SCRS. This includes: • reviewing all agency safeguarding procedures to ensure they comply with WT 2013; • dissemination of the learning from this SCR particularly in the areas of challenge and understanding of the vulnerability of non-mobile babies; • training and launch (planned for August 2013) of the recently completed paperwork and guidance for chairing and participating in strategy meetings; • continued improvements to arrangements for single processes between hospitals, and clearer expectations of communication between HVs, midwives and MCC Early Years; • strengthening monitoring of compliance with all procedures and in particular testing the robustness of strategy meetings; and • taking advice so that the MSCB can raise at national level the implications for safeguarding when there is no prosecution potentially leaving other young children at risk from a perpetrator. The SCR panel did not meet after MSCB prepared the responses to the challenges. However in discussion the independent chair and author considered some of the responses were not sufficiently robust to prevent further similar future recommendations. The two main areas of concern are: • the planned training on the vulnerability of non-mobile babies across all the relevant agencies; and • how NHS agencies will complete more thorough enquiries about family circumstances to rule out or identify risk factors when there are questions over the cause of injuries or symptoms. Final message: This is an unusual ending for a SCR Overview Report but it has been written in this format in the expectation that all MSCB members will have some clarity about their responsibility to pro-actively improve safeguarding responses to young babies and children. |
NC049424 | Death of a 2-week-old boy in October 2015 due to a non-accidental head injury. Child F was admitted to hospital in cardiac arrest with suspicious head and eye injuries and died some weeks later. Child F was taken to A&E department on two occasions during the week before his death. Mother was a teenager during pregnancy and subject of a child protection plan; her mother was in contact with a man convicted of sexual offenses against children. Father had been involved with probation service May-October 2015 and had prior conviction for burglary and robbery. Father left his accommodation after alleged sexual assault against a child. Identity of father remained unconfirmed until the criminal investigation. Father was convicted of murder. Ethnicity and nationality of family not stated. Learning includes: consider how to mitigate risks arising from pressures on services and organisational change; consider practice for increasing the involvement of fathers and male carers and how agencies help staff resolve difficulties in engaging; ensure multi-agency pre-birth pathways, including for concerns that do not meet child protection thresholds, are being implemented effectively by those working with pregnant women and their families. Recommendations include: audit and review the steps taken to involve fathers and male carers in safeguarding work, including assessments; review the effectiveness of the work of member agencies in relation to families who are proving difficult to engage; ensure that the quality and effectiveness of child and family assessment carried out by the local authority meets its expectations, including pre-birth assessment.
| Title: Serious case review: overview report: services provided for Child F and his family. LSCB: Wolverhampton Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Wolverhampton LSCB Serious Case Review Overview Report Services provided for Child F and his family Independent Chair Wolverhampton Safeguarding Children Board Alan Coe Independent Reviewer and Author Keith Ibbetson Services provided for Child F and members of his family 1 Reasons for conducting the review, focus of the review and agencies involved 2 2 Key events 6 3 Serious Case Review Findings 13 3.1 Could injuries to Child F have been identified at an earlier point? 13 3.2 Arrangements for the identification, referral and assessment of need and risk during pregnancy 16 3.3 Quality of social care assessment, management oversight and the impact of organisational changes 18 3.4 Identification of fathers and the links between services working with different family members 22 3.5 The role of the new birth visit and the lack of information about the family background 23 3.6 Safeguarding arrangements in the district general hospital Emergency Department 25 3.7 Safeguarding of Child F after he had been severely injured 29 3.8 LSCB oversight of the impact of organisational changes 30 4 Recommendations 32 Appendices 35 I Terms of reference and areas of enquiry 36 II Principles from statutory guidance informing the Serious Case Review 37 III How the review was undertaken 38 IV SCR review team 39 V Roles of staff involved 40 VI References 41 2 1. INTRODUCTION 1.1. Between December 2015 and November 2016, Wolverhampton Safeguarding Children Board (WSCB) conducted a Serious Case Review (SCR) in relation to the services provided for an infant, referred to in this report as Child F. At the age of two weeks, Child F suffered a serious head injury, together with multiple fractures. Child F died as a result of the head injury some weeks later. 1.2. The SCR was carried out under the guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. LSCBs are required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.1 This document sets out the SCR findings which, in keeping with the statutory guidance, are published in full. Reasons for conducting the Serious Case Review 1.3. In October 2015 Child F was admitted to hospital in Wolverhampton suffering from cardiac arrest and a suspicious head injury with associated injuries to his eyes. After his condition was stabilised Child F was transferred to the intensive care unit of Birmingham Children’s Hospital where further investigations identified fractures to his ribs and to both legs. All of the injuries were strongly indicative of physical abuse. 1.4. Brief review of agency records by WSCB confirmed that Child F’s mother had been the subject of a child protection plan as a teenager and that the local authority had carried out a pre-birth assessment during her pregnancy with Child F. In the week before his hospital admission, Child F’s parents had presented him twice to the Emergency Department of the hospital in Wolverhampton. The local authority established that the young man who may have inflicted the injuries had himself been in local authority care. 2 1.5. The Serious Case Review Committee of WSCB considered Child F’s history at its meeting on 1 December 2015 and recommended that the circumstances met the criteria for undertaking a SCR on the grounds that the child had suffered serious harm and there was cause for concern about the way in which agencies had worked together to safeguard the 1 Working Together to Safeguard Children (2015), 4.1 and 4.6 2 Until the criminal trial it had not been confirmed that this man was the child’s father; however he was treated as such during the review as he had had contact with services at a number of points. 3 child. Alan Coe, the independent chair of WSCB, confirmed the decision to hold a SCR on 14 December 2015. 3 The focus and scope of the Serious Case Review 1.6. In its initial discussions the review team carrying out the SCR agreed the terms of reference for the SCR and specific aspects of service provision which it wished the review to investigate. These are set out in Appendix 1. 1.7. As scrutiny of records and interviews with staff progressed, the review focused its work on the following topics which form the basis of this report: Arrangements for the identification and referral of need and risk during the mother’s pregnancy (February - October 2015) The quality of the social care pre-birth assessment and the professional and organisational factors that influenced this The approach of professionals to the identification of fathers, male carers and the household composition The role of the health visiting service including arrangements for antenatal visits and the primary health visit (new birth visit) The identification and management of possible safeguarding concerns in the Emergency Department at the district general hospital Arrangements made for contact between Child F and members of his family at Birmingham Children’s Hospital after he had been injured 1.8. The review team scrutinised records of the medical and nursing care of Child F when he presented with serious injuries at Wolverhampton, the police investigation into the cause of the injuries or the medical and nursing care provided to him at Birmingham Children’s Hospital. It decided that there was no need to evaluate the services provided during these contacts any further. 1.9. As the review progressed it became apparent that a number of the agencies involved were undergoing organisational changes during the period when they had contact with Child F and his mother. The SCR has therefore sought to understand whether these had an impact on the provision that was made and how in future the LSCB might work to understand and monitor the effects of such changes. 3 There was a gap of some weeks between the injuries that caused Child F’s death and the legal decision to withdraw medical care. Post mortem findings were not available at the time when the LSCB considered the case. The safeguarding children board has subsequently noted that the Serious Case Review is also required under the regulation which requires a review when a child has died as a result of abuse or neglect. 4 Agencies involved 1.10. The SCR considered the work of the following agencies and contracted professionals: • City of Wolverhampton Council (Children and Young People Services, including the Youth Offending Team) • West Midlands Police • Royal Wolverhampton NHS Trust (maternity, Emergency Department at the district general hospital, health visiting service) • Birmingham Children’s Hospital NHS Foundation Trust (intensive paediatric care for Child F after he was injured) • National Probation Service (West Midlands) GP and primary care services had very limited involvement during the period under review How the review was undertaken 1.11. Details of the principles underlying the approach to review and the steps taken to carry it out are set out in Appendices 2 and 3. 1.12. Early in the review members of the review team met the mother and maternal grandmother of Child F to inform them about the decision to conduct a review and to invite them to contribute after the conclusion of the criminal trial. Information was confirmed in writing and the mother consented to the review of her own and Child F’s medical records for the SCR. 1.13. After the trial the lead reviewer and the LSCB Business Manager held a brief meeting with the mother and other family members. They had moved away from Wolverhampton and had not initially responded to contacts from the review team. On this occasion it was not possible to explore the views of family members in full. The mother felt that generally professionals had tried to help and being doing their jobs; she repeated views previously expressed that she had concerns about the actions of staff in the Emergency Department. These contacts have been explored in detail in Section 3.1 and 3.6 of this the report. The safeguarding children board has made further but unsuccessful attempts to contact family members. 1.14. The father of Child F was informed about the review in writing with the assistance of the National Offender Management Service as he was remanded in custody. He was also contacted via the National Probation Service after the conclusion of the criminal trial but did not respond. 5 Criminal investigation 1.15. Child F’s father was convicted of his murder. His mother was found not guilty of any offences in connection with the injuries or death. 6 2. BACKGROUND AND KEY EVENTS 2.1. This section contains a summary of key events. Limited detail is provided in order to protect the privacy of family members. Some events are described further as part of the evaluation of services in Section 3 of the document. Family background and relationships 2.2. Child F’s mother is in her late teens. Child F was her first child. During her adolescence, the mother was made the subject of a child protection plan because there was evidence that her own mother was in regular contact with a man who had been convicted of sexual offences against children. Child F’s mother and grandmother moved to another local authority in order to avoid engaging with social workers in Wolverhampton. 2.3. After a brief period Child F’s mother ceased to be the subject of the child protection plan. She told a social worker that the family moved back to Wolverhampton during her pregnancy. During the local authority pre-birth assessment in April 2015, the grandmother stated that the sex offender had died. This information was true, but it was not checked; nor was it shared with other agencies. 2.4. The mother and her family provided misleading information about the identity of the father of Child F on a number of occasions. Early in the mother’s pregnancy professionals were concerned about a young male who attended appointments with the mother and was considered to be immature and disruptive. During visits family members described this person as a local youth who suffered from behavioural and learning problems. Later they specifically denied that he was the father of Child F. On another occasion a young man presented himself as the mother’s cousin and denied being the father of the baby. He may have been the same person. The man now acknowledged as the father gave the probation service the family home as his address; but it remains unclear whether he was a full time member of the household before or during the life of Child F. 2.5. The difficulty that professionals had in identifying the father and the steps that they took to overcome them are discussed in Section 3.4. Provision made during the antenatal period and the initial recognition of concerns 2.6. The mother’s pregnancy was confirmed at an early point but the antenatal booking appointment did not take place until fifteen weeks because it proved hard to make an appointment with the mother. At this appointment the community midwife identified a series of social and health concerns as a result of which she referred the mother for 7 consultant-led antenatal care (i.e. antenatal appointments would be held mainly at the hospital and directly overseen by a consultant). 2.7. The midwife also asked the local authority to confirm if the mother was known to social care because she had been very reticent to answer questions about her background or to identify the father of the baby. Linking the information that it identified in its own records with the midwife’s concerns, the local authority treated this as a referral and initiated a pre-birth assessment. 2.8. Further scans and antenatal appointments were offered both at the hospital and at the GP surgery. Between 15 and 30 weeks the mother missed several appointments, though on some occasions appointments were made very close to one another in different locations, so she may not have been clear whether she was expected to attend all of them. From 35 weeks the mother kept all her appointments and no further health concerns were identified. 2.9. During the pregnancy, midwives made referrals to the local children’s centre and to the Family Nurse Partnership, a project with health workers offering parents a high level of support until their child reaches the age of two. The mother declined both offers of help. 2.10. Although the antenatal service remained involved and worked with the mother throughout her pregnancy, it is difficult to draw together a picture of the way in which services planned to meet her needs because after the initial contacts there were a large number of different midwives involved. This is discussed further in Section 3.2. The local authority social work assessment of Child F’s mother 2.11. A community midwife initially contacted the local authority on 21 April 2015, after the booking appointment, identifying a series of concerns about how the mother had presented. The referral was reviewed by social care and referred to a locality team for a pre-birth child and family assessment. This decision was taken because of the history of involvement of the family with social care (summarised above) and the concern that the mother and her family might still be in contact with a sex offender. 2.12. Noting the possible complexity of the case, the allocated social worker liaised with the antenatal service to say that she had provisionally booked a child in need meeting for 18 May 2015 in order to agree a plan of support during the pregnancy. Following a social work assessment visit on 12 May 2015 the social worker decided that the local authority would not need to be involved and that no meeting was required. It was left to other agencies to continue to support the mother and to re-refer 8 the family to the local authority if they had concerns. No steps were taken to coordinate the work of agencies that remained involved. 2.13. Although the social work visit was made in May 2015 it was not written up and authorised by a manager until mid August. The social worker had conversations later in the pregnancy with a midwife and with the Youth Offending Team (YOT) worker. These confirmed that the mother had not accepted the suggestion of a referral to the Family Nurse Partnership. There was no local authority social care involvement during the last two months of the pregnancy and during this period the main contact between the local authority and health services was between the YOT workers and the antenatal service. 2.14. Sections 3.3 of the report considers the assessment undertaken by the local authority and the reasons for the decisions and actions of the staff involved. National Probation Service involvement with the father 2.15. Between May and October 2015 the National Probation Service was responsible for supervising the father of Child F. This followed his convictions for burglary and robbery committed in 2013. The work of the service was focused on his offending. Three early appointments were carried out by the allocated Offender Manager, who was qualified to supervise low and medium risk offenders.4 Later she had a period of sick leave as a result of which the father saw a series of duty officers. This disrupted the service provided. 2.16. When his contact with the probation service began the father was not living in a household with children or believed to have any significant contact with children. As a result no checks were made with social care. At an early appointment the father disclosed that he had been forced to leave his accommodation because of an allegation of sexual assault against a young child. His offender manager confirmed with the police that there had been insufficient evidence to pursue this allegation. No enquiries were made with the local authority to find out more about the allegation or the father’s family circumstances. 2.17. In May 2015 he also disclosed that his girlfriend was pregnant. He also later mentioned plans to go on holiday with members of his extended family who had children. No steps were taken to evaluate whether there might be safeguarding concerns for the unborn baby or other children that he had contact with. Immediately after the birth of Child F the father 4 https://nationalcareersservice.direct.gov.uk/job-profiles/probation-services-officer 9 told his offender manager that the mother and child might be coming to live with him. 2.18. Probation service contact was exclusively with the father. This was part of a pattern whereby agencies worked exclusively with one partner without confirming the identity of the other partner or being able to explore the extent to which they would together be able to meet the needs of a baby. This is explored further in Section 3.4. Youth Offending Team involvement with the mother 2.19. In July 2015 the Youth Offending Team (YOT) became responsible for supervising the mother on a Referral Order following her conviction for shoplifting. This is a standard youth justice disposal and is designed to lead to a tailored intervention package. There was a delay in setting up this programme as the mother missed appointments. 2.20. From early July the the school nurse attached to the YOT had contact with antenatal services and the mother’s GP. As the pregnancy progressed the focus of the work shifted away from the mother’s offending towards trying to help her prepare for the birth of her child and to make arrangements for support services to be put in place. Supervision and engagement in reparation and work focused on offending were limited due to the late stage of mother’s pregnancy. This was accepted by the Referral Order Panel that was overseeing the work. 2.21. In contact between the allocated social worker and the YOT worker in mid July 2015 it was confirmed that social care would not be involved with the family. It was noted that there were ‘no concerns’ about mother’s possible exposure to the convicted sex offender. The social worker made it clear at this point that the mother had declined to take up the referral to the Family Nurse Partnership. 2.22. The YOT worker made a home visit late in the pregnancy during which the mother and maternal grandmother were seen. Although they gave her a lot of help, the YOT workers were unable, despite making several enquiries, to establish the identity of the father. Shortly before the birth the YOT explained to the mother that it had been agreed to schedule the next visit after the birth of the baby. This was in line with the relevant youth justice national standards. Birth and post-natal follow up 2.23. Child F’s birth was uneventful. The midwife who delivered him remembers there being anxiety about the progress of the delivery and tension between family members during the birth. She told the SCR that this was within levels not uncommon during a birth. When Child F was 10 checked there was concern that he had jaundice which resulted in him being kept in hospital for treatment. 2.24. Child F was discharged home at 4 days. Follow up at home was made by community midwives and support workers on four occasions over the next six days. No concerns were identified during these visits and by the final visit Child F had gained weight above his birth weight, in line with normal expectations. First presentation at Emergency Department 2.25. At eight days Child F was taken by his mother and father to the Emergency Department (ED), with a rash giving the history that he had had a temperature. He was seen by an experienced paediatric ED consultant. His temperature was normal and he showed no signs of being unwell. As his mother said that he had had a temperature during the birth, the consultant decided to admit Child F to the paediatric assessment unit for observation overnight in order to eliminate any risk that he might be suffering from blood poisoning. 2.26. After waiting for some time the parents left the ED, discharging the baby before he could be admitted. Due to a misunderstanding over which consultant needed to be informed about the discharge and how that should happen, there was a delay in the ED consultant being told. Arrangements were made for a visit by a midwife at home the following day. This took place (it is one of the visits described in paragraph 2.24) and no concerns were identified. Primary (new birth) visit by the health visitor 2.27. The primary health or new birth visit was made by the allocated health visitor at the age of ten days. There had been no pre-birth health visiting contact. This would have been indicated for a woman in these circumstances but the health visiting service records show that no final confirmation of a viable pregnancy was received from the antenatal service. 2.28. The new birth visit coincided with the last of the visits made by a midwifery support worker to weigh Child F. This meant that the visit lasted longer than normal and that the health visitor was able to see Child F without any clothes on, though she would not have been expected to carry out a physical examination. She observed nothing out of the ordinary and she was aware of Child F’s weight gain. 2.29. During the visit the health visitor saw the mother, the maternal grandmother of baby and a young male who introduced himself as the mother’s cousin and participated in the care of the baby. The mother was asked about the child’s father and was told that the mother had 11 minimal contact with him and that she wasn’t happy to disclose his details. 2.30. The health visitor observed an alert, well baby and positive interaction between the mother and infant. The baby fed well. The visit covered all of the expected areas of infant and maternal health with the exception of the hearing test. This was because the health visitor felt the visit had gone on too long and the infant was too distracted for the test to be reliable. 2.31. It was noted that the mother had declined the offer of involvement in the Family Nurse Partnership during the pregnancy. However at the visit she signed a form for information sharing and referral to the children’s centre and agreed to participate in the normal health visiting and baby clinic programme. Two further visits were scheduled to take place in November 2015 in line with the normal local arrangements. Second presentation at Emergency Department 2.32. At 12 days (two days after the primary home visit) Child F was taken to the ED by his mother and a man whom the hospital took to be the father. Child F was physically examined first by a very experienced ED staff nurse, then by a junior doctor. The parents reported three problems: 1) a history of pain or swelling in Child F’s leg; 2) they said that he sometimes ‘looks like he has stopped breathing for few minutes and then recovers’ and also 3) that he had not opened his bowels for two days. The father referred to problems that had been identified with the child’s leg during pregnancy and after the birth and also referred to the family’s previous concerns about the difficulty that a nurse had had taking blood from Child F’s foot. 2.33. The junior doctor undressed Child F and gave him a very detailed physical examination, finding no signs of pain or injury to the leg and nothing else of concern. He documented the examination systematically and discussed his findings with the consultant who was in charge of the ED that evening. All three staff members told the SCR that they were aware of the possibility of safeguarding concerns given the reported presenting complaint and the age of the baby. All were reassured by the results of the examinations and the interaction observed or described between the parents and the baby. The consultant offered to see Child F himself but he and the junior doctor agreed that this was not necessary. Feeling that these were most likely anxious and inexperienced parents who might benefit from some further reassurance, an appointment at the ED paediatric clinic the following morning was made. 2.34. Child F was not brought to this clinic. Like her colleagues the ED consultant who was running the clinic was initially concerned by the age of the baby and the report of the initial presentation. She too was 12 reassured by the very thorough account of the examination, though she assumed wrongly that the consultant had also examined the baby as well. Child F was discharged from the clinic and emails were sent to the midwives and health visitors. No discharge or non-attendance letter was prepared for the family GP. Final presentation of Child F to the Emergency Department 2.35. There was no further professional contact with Child F and his family between this ED attendance and the point two days later when he was brought by ambulance to the ED gravely ill. Subsequently the following injuries were identified: a very serious head injury together with associated severe damage to the backs of the eyes; several fractures to the legs and several fractures to the ribs. All were extremely suspicious and indicative of an abusive assault by an adult 2.36. The head injury would have caused Child F’s immediate collapse and is therefore likely to have occurred in the hours before the parents called the ambulance. The other injuries are likely to date from the same episode. Expert medical opinion is that one of the fractures to Child F’s leg may have been caused earlier, though that is by no means certain. 2.37. West Midlands Police began a criminal investigation immediately the suspicious injuries were identified. 2.38. Child F subsequently required intensive care as a result of the head injury. He died when this was withdrawn with the agreement of the High Court four weeks after being injured. 13 3. SERIOUS CASE REVIEW FINDINGS 3.1. Could injuries to Child F have been identified at an earlier point? Introduction 3.1.1. Child F suffered catastrophic head injuries shortly before he was brought to hospital. Expert medical opinion is that he suffered other non-fatal fractures to his legs and ribs during the same assault. He had one fracture in his leg which may predate these injuries, indicating that there may have been an earlier assault. 3.1.2. Child F’s father has continued to deny responsibility for causing his death. It is therefore not clear whether the parents were aware of the danger that could arise from shaking a small baby, for whatever reason. The SCR will therefore recommend that action is taken by the safeguarding board and its member agencies to ensure that information about the danger of shaking a baby are made available to all prospective and new parents in Wolverhampton. Evidence identified by the SCR 3.1.3. The SCR has considered whether the possible earlier injury might have been detected during contacts between professionals and Child F. In her contribution to the SCR, Child F’s mother expressed concern that his injuries had not been identified when he was taken to hospital. 3.1.4. As it was the last contact that he had with professionals before the injuries that caused his death, attention has focused on Child F’s attendance two days before being fatally injured when his parents brought him to the Emergency Department (ED) giving the history of concerns about his legs. 3.1.5. However it is important to note that there had been a number of other contacts prior to this during which professionals closely observed Child F. The day before he attended ED, Child F had been undressed and weighed by a health support worker in the presence of his health visitor who was undertaking the primary health (new birth) visit. No signs of injury or concerns were noted. 3.1.6. Three days prior to that Child F had been brought to the ED with a rash and reported temperature. On that occasion he had been undressed and examined by a paediatric ED consultant and found to be well. The next day when seen by a midwife at home he was also well. 3.1.7. Review of the hospital records and interviews with the staff involved during Child F’s second ED attendance show that the parents’ accounts varied, referring at different points to a sore left leg, a swollen leg and the baby crying when the leg was touched. At the same time the mother 14 described how since birth he had had ‘problems with both legs’; the father reported that Child F had been identified as having short legs in scans during the pregnancy, though he said that ‘nothing had been done about it’; he also referred to the difficulty that midwife had had taking a blood sample shortly after the birth, causing bruising to the baby’s foot. 3.1.8. In the ED Child F was examined by an experienced ED nurse and then by a junior doctor. He in turn discussed the findings with the ED consultant. Neither examination found evidence of swelling, soreness or bruising. Records of both examinations refer to a contented, apparently well baby who was feeding normally and being apparently well cared for. On that visit, no x-ray was taken because the clinical examination did not point to any injury or pain. No check was made of the mother’s obstetric records to see if there had been concerns during the pregnancy or on the post-natal ward or to verify the father’s account. 3.1.9. The conclusion was that Child F’s parents were young, inexperienced and anxious and an appointment was made for them to attend the paediatric follow up clinic the next morning where they would be able to have a longer conversation with a Paediatric ED Consultant. 3.1.10. Given the history provided by the parents (and particularly taking account of the inconsistencies in their descriptions) and with the benefit of the information and expert assessment that is now available, the review recognises that Child F’s leg may have been injured before this attendance. If that was the case it is possible either that one or both parents knew of an incident that might have caused the injury and wanted the child to be checked over or that one parent was concerned about the leg being sore without knowing why that was, but wanted reassurance or an explanation. The leg may also have been injured prior to the contacts with health visitors mentioned in Sections 3.1.3 and 3.1.4 above though on neither occasion did either parent mention a sore leg. 3.1.11. To improve future service provision it is useful to consider whether any more could have been done during the second ED attendance and whether it might have led to the detection of an earlier injury. Commentary 3.1.12. It is very difficult to identify a fractured limb in a small baby. Immediately after such an injury a baby may be very distressed, followed by a period of a few hours when the affected limb may be sore when touched. After this there may be no symptoms. 3.1.13. Fractures of small children are often very difficult to recognise on x-ray and open to misinterpretation. Evidence of the existence of many fractures in small children can only be detected by the accumulation of 15 new material growing around the site of the injury as the bone heals. These signs of healing usually appear after 7 – 14 days. 3.1.14. The best clinical practice when evaluating possible injuries to very small children is therefore to x-ray the site of the pain or reported injury when it is presented and then to arrange for a second x-ray after a period of several days. In relation to Child F it is very unlikely that any injury would have been identified if he had been x-rayed during this ED attendance. Given the need to delay a second examination until possible signs of healing would have begun to be visible Child F would not have been x-rayed again before he was fatally injured. 3.1.15. During the second ED visit staff should have looked at the previous ED record. It would also have been useful for the ED to have accessed Child F’s birth records and his mother’s obstetric records to establish if there had been previous concerns about his legs. Interviews with staff suggest that although the department is often extremely busy, on this occasion there would have been time to do this. It was not considered because it was not at the time part of the established practice in the department. 3.1.16. The decision to offer a follow up appointment the next day showed that the doctors who saw Child F recognised that his parents were young and anxious and may have needed reassurance and guidance. At the time staff seeing a child out of hours in the ED sometimes referred children to a clinic the next day. The hospital has discontinued this practice, recognising the potential harm that might arise in some instances from doctors deferring a judgement about the safeguarding of the child. Summary 3.1.17. Expert opinion is that the majority of Child F’s injuries occurred as part of the assault that caused his death. There is one fracture that may predate this event, though that cannot be stated with certainty. Signs of this fracture are very unlikely to have been identifiable before the assault that caused his death because the healing would not have been sufficiently advanced. It is therefore not possible to say that different management of Child F when he attended ED on this occasion would have led to the identification of his injuries or prevention of further injuries. 3.1.18. However the conclusion that there were no safeguarding concerns was reached too quickly on the second ED visit. Though the evidence is that it was carried out competently, too much reliance was placed on the medical examination of Child F – which proved normal - and insufficient account was taken of the concerning and inconsistent history given by his parents that an immobile baby may have shown signs of having an injured leg. 16 3.1.19. These events highlight the complexity and the lack of certainty that health professionals have to deal with when making judgements about risk to small children in the ED. There are wider lessons for the identification, clinical management and the organisation of possible safeguarding concerns in emergency departments. These are addressed further in Section 3.6 which draws on useful wider research on this issue and makes recommendations about the oversight of safeguarding practice in the hospital. 3.2. Arrangements for the identification, referral and assessment of need and risk during pregnancy Introduction 3.2.1. This section of the report considers the action taken by agencies during the mother’s pregnancy to identify the support needs of parents and to assess possible risk to the baby after the birth. The pre-birth assessment undertaken by the local authority is dealt with separately in Section 3.3. Evidence identified by the SCR 3.2.2. The community midwife identified concerns about Child F’s mother at the antenatal booking appointment, which was at 15 weeks. These were: her age; reported previous pregnancies (bearing in mind her young age) and a reported history of unexplained ‘blackouts’ she said had never been reported to a doctor or investigated. The midwife referred the mother for ‘consultant led’ care (i.e. a combination of hospital appointments with obstetricians and midwives, as well as community midwife appointments at the GP surgery). The referral was to a consultant recognised as having interest and experience in caring for women with identified mental health difficulties or social risk factors. 3.2.3. At the booking appointment the mother was asked routine screening questions about mental health and domestic abuse and the records indicate that she did not provide any significant information. There is no evidence in the records that screening over mental health or domestic abuse was repeated later in the pregnancy as is often considered to be good practice. 3.2.4. Following this appointment the midwife made contact with social care to find out whether the mother was known to the local authority and with a request for information. Concerns identified by the midwife who undertook the booking appointment were followed up by the allocated midwife. Further discussions with social care stressed that the midwives had found the mother very difficult to engage and unwilling to consider the sort of services that might assist her. Together with the information 17 that it already held in its records, this led the local authority to decide that it needed to undertake a pre-birth assessment (see section 3.3). 3.2.5. The social care pre-birth assessment visit was undertaken on 12 May 2015, after which the social worker contacted the community midwife to say that the local authority would not remain involved with the family and that no child in need meeting would be held. The social care assessment is discussed further in Section 3.3. 3.2.6. In the absence of a child in need meeting or social work involvement there was no coordination of the activity of agencies. Antenatal appointments were offered both at the hospital and at the GP surgery. Between 15 and 35 weeks the mother missed a number of these appointments, but usually responding to reminders or rescheduled appointments. On some occasions appointments were offered soon after one another at the hospital and the GP surgery. This may have made it difficult for the mother to understand why she needed to attend them all. 3.2.7. The health visiting service did not make an antenatal visit to the mother, which might have been helpful. Health visiting records show some sharing of information from the antenatal service (which is part of the same health trust); however the health visiting records do not contain confirmation that the pregnancy was planned to continue to term, usually sent at about 20 weeks. Interviews with staff suggest that the mother would not in any event have been allocated to a pre-birth visit as these were not being offered at the time. 3.2.8. The Youth Offending Team continued to work with the mother and had some contacts with the community midwives. 3.2.9. Overall the family remained uncooperative and difficult to engage, until the final few weeks of the pregnancy. This was a young pregnant woman for whom there should have been some form of coordinated working. This could have been provided by an Early Help Assessment and the allocation of a lead professional from among the agencies that remained involved.This should have been considered as an outcome of the local authority assessment. 3.2.10. As all of the agencies had found the mother difficult to engage it would have helped to agree arrangements to share information between agencies. This might have highlighted some of the discrepancies in the information provided by the family. A recommendation is made in relation to this. Actions member agencies and the LSCB should take 3.2.11. Overall there was insufficient clarity about the means by which concerns arising in the antenatal period are identified, assessed and referred. The Care Quality Commission conducted an inspection of health services for children in Wolverhampton while this case review was 18 taking place. This found comparable shortcomings in a range of cases. There was also a lack of leadership in relation to safeguarding. As a result the pathways for recording and acting on concerns were not clear. 3.2.12. The review has been made aware that multi-agency, pre-birth pathways have been revised, including those that deal with concerns that do not meet the threshold for child protection and therefore require collaborative working between health professionals, children’s centres and agencies working with parents (such as mental health services, the YOT).5 This followed the findings of a Serious Case Review published in 2013. WSCB now needs to ensure that this work is being implemented effectively by all those working with pregnant women and their families. 3.3. Quality of social care assessment, management oversight and the impact of organisational change Evidence identified by the SCR 3.3.1. A community midwife passed information about the mother of Child F to the local authority on 21 April 2015. A member of the central referral team had further phone contacts with the allocated midwife and with Child F’s mother. Drawing this together with information about the mother’s previous contact with the local authority, a manager in the team decided that the referral should be allocated for a pre-birth assessment. Responsibility was transferred to the locality social work unit with a decision that a visit should be made the following week. 3.3.2. The initial screening identified concerns in two areas: the way in which Child F’s mother had presented herself during appointments with midwives and also possible risks that might arise from contact with the known sex offender. The circumstances were viewed as potentially very concerning, suggesting that there might be a need for strategy discussion and even a legal planning meeting if the assessment raised doubts about the ability of the family to protect the baby when born. 3.3.3. The assessment visit was made on 12 May 2015 by the consultant social worker who was the manager of the locality unit but also undertook some direct work. The delay was due to the unit workload. Prior to this the manager had had further phone contacts with the midwife, provisionally scheduling a child in need meeting to be held on 18 May 2015. 5 WSCB Interagency Protocol for Unborn children and young babies (2016) https://www.wolverhamptonsafeguarding.org.uk/images/safeguarding-children/children-documents/WSCB_Inter-agency_Protocol_for_Unborn_Children_and_Young_Children_May_2016.pdf 19 3.3.4. At the assessment visit the manager formed the view that the mother had a good network of family support, stable housing and that she was in receipt of the right state benefits. She had now attended her dating scan so the expected date of delivery was known. 3.3.5. Child F’s maternal grandmother denied that she had any contact with the sex offender and said that she believed he was now dead. The social work manager expressed reservations about the grandmother’s capacity to support her daughter during the pregnancy and in caring for a baby. Child F’s mother again refused to identify the father of the child, this time giving a different name to the one previously given to the central referral team. 3.3.6. On the basis of this visit the social work manager decided that no further action was required by the local authority and made a decision to cancel the proposed child in need meeting. The midwife was told this on the day of the proposed meeting. She also told the social worker that mother had been referred to the Family Nurse Partnership (FNP). The midwife was asked to re-refer the case to the local authority if there was a significant change in circumstances. 3.3.7. Although this assessment visit was undertaken in May 2015 the assessment was not written up and authorised by another manager until mid-August 2015. The write up noted that the mother had been referred to the FNP, though by then she had declined contact with the service. 3.3.8. This was a weak assessment, given the referral and the circumstances. It relied almost exclusively on the account given by Child F’s mother and grandmother, without making wider checks of the network or reviewing the history of local authority involvement. It did not explicitly address a number of the concerns identified in the original referral and central referral team management decision (such as the concerns about the mother’s behaviour with other professionals). The assessment accepted that the convicted offender no longer posed a risk, because the grandmother said that he was dead, but there is no evidence that this was checked or that the information was shared with other agencies. 3.3.9. There had been a working assumption, on the part of the central social care referral team and the community midwife, that there would be some form of pre-birth meeting in order to coordinate the input of agencies and work together with the mother. This was cancelled with little information provided as to the reasons and without there being any clear plan as to how the agencies that remained involved would work together. There was a substantial delay in completing the assessment. 20 3.3.10. There were only limited attempts to identify the father. This should have been given more priority given the potential vulnerability of the mother. This is discussed further as it applied to all agencies in Section 3.4. 3.3.11. The final summary of the assessment is misleading in that it states that the mother had been referred to the FNP, whereas it was known that she had declined to be involved by the time the assessment was written up. 3.3.12. There was no proper management scrutiny of the assessment. The manager who reviewed and authorised it was relatively newly appointed to the authority and assumed that because it had been written by an experienced social worker / manager it would be satisfactory. Why did this vulnerability in services exist? 3.3.13. The poor assessment was the result of both individual and organisational weaknesses. In 2014 Wolverhampton adopted a ‘new operating model’ for its local authority social care service. It was inspired by the Hackney model of social work though it had only very limited similarities with the original.6 Wolverhampton City Council created a highly decentralised model of 16 locality units each with a consultant social worker, a small number of social workers (usually three) an unqualified practitioner and an administrator. These units were responsible for managing work from the receipt of a referral from the central referral team and would include child protection investigations, child in need assessments, responsibility for children who were subject to child protection plans and some court work. Children looked after long term were the responsibility of other teams. 3.3.14. The advantage envisaged for such local teams was that they offered children and families fewer changes in allocated social worker as well as the capacity for social work units to form strong links with early help services and other professionals in a small geographical area. The disadvantage of this arrangement is that teams become very vulnerable to gaps in staffing and shortcomings in the quality of workers. Changes in referral rates and the intensity and difficulty of work also have a direct and disproportionate effect on small teams. This was recognised and in early 2015 senior managers in Wolverhampton made a decision to merge locality units, halving their number in order to reduce these risks. 3.3.15. The social work unit dealing with Child F’s family was a busy one traditionally carrying a large number of adolescents and pre-birth assessments. The current manager describes ‘a lot of CSE concerns and 6 Steve Goodmann and Isabelle Trowler (2012) Social Work Reclaimed, http://www.jkp.com/uk/social-work-reclaimed.html 21 a lot of domestic violence referrals…. a lot of the young parents have had child protection concerns as part of their background or have been looked after’. At this time and like other authorities in the West Midlands, Wolverhampton relied to a substantial degree on employing agency workers. From late 2014 onwards the unit experienced gaps in staffing and shortcomings in the quality of some social workers. As a result a backlog of assessments and case allocations built up and the unit manager was forced to allocate many assessments to her own caseload. 3.3.16. By April 2015 when Child F’s assessment was undertaken the team was fully staffed. However this assessment remained as part of a backlog that was only completed in August 2015. A number of assessments remained subject to delays, or were written up some time after the visits had been made. In some cases children were allocated as children in need prior to assessment visits having been made. This hid the difficulties in the team from more senior management oversight because it gave the appearance of reducing the number of children whose assessments were overdue. 3.3.17. Some of these practices were only identified in mid 2015 when the incumbent agency manager was replaced with a newly appointed permanent member of staff who became responsible for this this now happening?wo merged social work units. Discovery of the extent of the difficulties was delayed because there was no proper handover between the two managers. Actions member agencies and the LSCB should take 3.3.18. The quality of the assessment undertaken in this case fell short of the standards which the local authority and the LSCB expect. The SCR is not in a position to provide reassurance about the wider quality of assessment, and pre-birth assessment in particular, either at during the period under review or subsequently. 3.3.19. The local authority now undertakes sample auditing across children’s services focused on referrals and assessments and the quality of visits. The review will recommend that further the audit programme is developed to take account of the specific learning from this review. 3.3.20. The role of the LSCB in relation to wider organisational issues are referred to further in section 3.8. 3.4. Identification of fathers and the links between services working with different family members Evidence from the SCR 3.4.1. The identity of the father of Child F remained unconfirmed until the criminal investigation. 22 3.4.2. Early in the mother’s pregnancy community midwives noted concerns about a young male who attended a number of appointments with the mother and was described as being immature and disruptive. They were concerned about him and reported this to the local authority as part of the referral. During visits family members told the midwife that person was a local youth who suffered from behavioural and learning problems. Later family members specifically denied that this young person was the father of Child F. 3.4.3. The mother gave the central social care referral team a shortened version of the name of the father but refused to give more details. On the assessment visit the family gave the social worker another, abbreviated name but no details. 3.4.4. The YOT was working closely with the mother. Her response to enquiries about the father was to mislead professionals, saying that that it had been a brief relationship and that Child F’s father did not want to be involved. 3.4.5. At the primary health visit (new birth visit) a man presented himself as the mother’s cousin, and was actively involved in caring for the baby, but denied being the child’s father baby. This aroused some concern but there was no further opportunity to follow this up before Child F was injured. 3.4.6. The probation service worked with the father and became aware that he had a partner who was pregnant. No attempt was made to identify her. As the father had a history of sexual allegations against children his risk assessment should have been updated when he made it known that he was having a child, both to consider whether the plan for his probation supervision remained relevant and also to consider whether he might pose a risk. This finding echoes earlier learning for the service from an internal management review of a case in which there had been insufficient curiosity about a young man’s links to children. 3.4.7. In the health service, similar shortcomings in work to identify fathers and male carers were identified by the 2016 Care Quality Commission CQC Review of Safeguarding Children and Services for Looked After Children July 2016. This found that when father’s details were recorded there was no evidence of staff evaluating their role in depth. 3.4.8. Had the father been identified, and had this information been shared between agencies, it is likely to have altered the perception of risk and may have led to different steps being taken to assess risk and coordinate service provision. Why did this vulnerability in services exist? 3.4.9. Child F’s mother and her family deliberately withheld information and misled agencies about the identity of his father. It has not been possible 23 to establish their reasons for doing so because they did not contribute to the review. 3.4.10. Despite the concerns about the mother’s reticence to identify the father and the concerns about the young man who attended some appointments, agencies made only limited efforts to identify the father. Reasons for not doing so were not recorded. It is therefore not clear what priority agencies give, in practice, to the identification of fathers, male carers and family composition. Actions member agencies and the LSCB should take 3.4.11. The value of identifying fathers and male carers has been stressed in research and the findings of SCRs. Often when fathers are identified, little is found out about them.7 Government has promoted the idea that professionals should ‘Think Family’ in which ‘services working with both adults and children take into account family circumstances and responsibilities’.8 However there is a danger that this can become merely a slogan if the practical difficulties of implementing this philosophy are not worked through with and by front line staff. 3.4.12. There is also a tension in public policy over this. Professionals are expected to engage male partners in discussions and assessments while at the same time to exclude men from some appointments in order to create a ‘safe space’ where women can discuss concerns about domestic abuse. 3.4.13. The review has concluded that existing strategies to promote the ‘Think Family’ approach among professionals in Wolverhampton and to increase the involvement fathers and male carers have not been successful and need to be reviewed. WSCB could usefully consider how much it understands about practice in relation to this and how agencies help their staff resolve these difficulties. 3.5. The role of the new birth visit and the lack of information about the family background Evidence identified by the SCR 3.5.1. The new birth visit was made six days after Child F was discharged from hospital and the day after his first visit to the Emergency Department. It coincided with a visit from a health care assistant from the midwifery 7 Marian Brandon, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth, Jane Black (2008), Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005, Department for Children Schools and Families 8 Social Care Institute for Excellence, ‘Think child, think parent, think family: a guide to parental mental health and child welfare’, http://www.scie.org.uk/publications/guides/guide30/introduction/thinkchild.asp , website accessed 7 November 2016 24 service. This meant that Child F was weighed on the same occasion. The timing of the visit fell well within local health trust policies. 3.5.2. The visit is described in Sections 2.28 – 2.31 above. It addressed all of the areas of maternal and infant health that are expected. Hearing tests could not be carried out but were scheduled to take place on a follow up visit. The health visitor planned two follow up appointments in line with the health trust’s expectations. Child F had been seriously injured before the follow up visits could be made but there is no suggestion that anything untoward was missed during the appointment. 3.5.3. The health visitor was not in a position to take full account of the range of social and environmental factors that might have affected the care of Child F. Although it had carried out a pre-birth assessment the local authority had not provided background information about the mother and her family. The antenatal service had provided only limited information about concerns identified in the pregnancy, despite the services being part of the same health trust. There had been no antenatal visit by the health visiting service as these were strictly rationed at the time. 3.5.4. Reservations about the young man who had attended antenatal appointments were not known. This is likely to have been due to the number of midwives who saw the mother, with neither of those involved in identifying concerns early on in the pregnancy remaining involved during the later stages. Concerns also diminished during the last ten weeks of the pregnancy. Actions member agencies and the LSCB should take 3.5.5. It is not clear if the health visitor would have acted differently if more information had been available, but in other cases the sharing of such information will be important. 3.5.6. National guidance currently sets out the schedule of visits and developmental checks currently made by GPs and health visitors as part of the Healthy Child Programme.9 There are discussions nationally about the future of the programme and suggestions that the requirement to make all of these visits may be removed or amended.10 Some commissioners and providers already offer a local interpretation of the guidance based on a smaller number of routine visits. 9 Department of Health (2009) Healthy Child Programme: Pregnancy and the First Five Years of Life 10 Children’s public health 0-5 years – review of mandation letter from Public Health England, 28 June 2016, PHE Gateway number: 2016-106, http://docplayer.net/21420907-29-june-2016-phe-gateway-number-2016-106-dear-colleague-re-children-s-public-health-0-5-years-review-of-mandation.html 25 3.5.7. Particular importance is already attached to the scope and value of the primary health visit as it plays a significant role in determining the number of further visits made and the nature of the contact between the child and health professionals. In this context it is particularly important that the health visitor is as fully informed as possible about any relevant risk factors. An antenatal visit would have been beneficial in this case. 3.5.8. Wolverhampton Public Health has circulated a revised service specification for the Healthy Child Programme. Given the key role of the primary health (or new birth visit) and the potential value of antenatal visits WSCB should ensure that it understands as much as possible about the quality and effectiveness of primary health visits. A recommendation is made in relation to this. 3.6. Safeguarding arrangements in the district general hospital Emergency Department Evidence identified by the SCR 3.6.1. Sections 2.26-27 and 2.33-35 describe the provision made when Child F’s parents brought him to the Emergency Department (ED) on two occasions, four days before the injuries that caused his death and one day before. 3.6.2. On both occasions he was examined and found to be well. On the first occasion a plan was made to admit him overnight for observation to eliminate the possibility of an infection. His parents took him home before he could be admitted but a midwife found him to be in good health when she visited the home the following day. 3.6.3. At the second ED attendance Child F was found to be well but an appointment was made the following day for him to be brought to a follow up clinic because the view was that the parents were inexperienced and anxious and would benefit from reassurance about the baby’s health. They did not bring Child F to this appointment. The hospital arranged for information about the ED attendance to be shared with health staff working in the community but no arrangements could be made for a follow up visit at home before Child F was injured. 3.6.4. Section 3.1 of the report has scrutinised these episodes to determine whether evidence that Child F had been injured or was at risk should have been identified during these visits. 3.6.5. While there is no evidence that the injuries that caused Child F’s death could have been anticipated, evaluation of the two attendances highlights shortcomings in the arrangements for safeguarding children in the ED. These reflect difficulties in practice (described below) that have been found to exist in other emergency departments, though that does not diminish the importance of addressing them locally. 26 Experience and training of staff and the accessibility of guidance documents 3.6.6. There were variations in the training in safeguarding and in the level of experience of the staff involved in dealing with Child F. 3.6.7. The paediatric nurse who agreed to the discharge of Child F during his first visit was on a rotation to the ED and had very limited experience and training. She had received no induction to working arrangements in the ED and would have benefited from more mentoring which she had found was not possible within the resources available. 3.6.8. The nurse was unsure of the procedures relating to parents discharging a child and who she should consult. It is to be found on the hospital intra-net but more experienced staff, including one ED consultant, recognised that they had not known where the guidance on discharge of children against medical advice was located until after this incident. 3.6.9. The junior doctor who examined Child F had limited paediatric experience and had not undertaken level three safeguarding training (which is required of all ED staff). Other staff involved were very experienced (including some of the most experienced in the department) and had received the relevant safeguarding training. However they gave different accounts of the safeguarding training that is provided for ED staff, how successful and well attended it is. A recommendation is made in relation to this. General safeguarding awareness 3.6.10. All of the staff who had seen Child F conveyed clearly to the review that they were mindful of possible safeguarding concerns when they saw him. However this general awareness was not always matched by detailed interrogation of possible risk factors which was in turn not supported by the hospital’s systems. Staff were overly reassured by the fact that the clinical examination found no evidence of pain or injury and insufficiently aware that (for the reasons set out in Section 3.1) an injury in such a very small child might be asymptomatic. The inconsistent accounts of Child F’s injury (see Section 3.1.5 above) should have been addressed more explicitly. 3.6.11. Insufficient attention was given to the fact that this was Child F’s second ED attendance in the first two weeks of his life. The review knows of no solid data on ED attendance among such small children against which to benchmark this; however the double attendance in this case is possibly very unusual. During this visit the parents made very specific references to events that they said had happened in the pregnancy and delivery which they said were relevant to the reported leg problem. These notes would have been easy to access and on this occasion staff would have had time to review them, but his was not considered because it was not customary practice in the ED. 27 3.6.12. At the time of this incident reliance was being placed on asking to return to attend review clinics with a paediatric ED consultant. Whilst this had been presented as being a ‘safety net’ it may have had the effect of placing less onus on those working in the ED to address possible safeguarding concerns. Similar reliance was being placed on the liaison health visitor role to ensure that possible safeguarding concerns were followed up by staff in the community rather than explored in the ED. 3.6.13. Interviews with consultant staff suggested that approaches to safeguarding varied between 1) general ED consultants (not paediatricians) 2) paediatricians working in ED because of their interest in and specialist knowledge of trauma working and 3) paediatricians working outside the ED with a specialist interest in safeguarding. 3.6.14. This has affected practice but will also have an impact on future steps taken to improve safeguarding. For example after the episode under review the ED introduced a template prompting steps to be taken by staff, such as checking old records and noting the number of recent ED attendances. This was referred to as the safeguarding ‘stamp’ because it is printed on top of the ED records. Although the intention was to introduce clear and specific procedures and thresholds, staff interviewed offered different perspectives as to its value, how often it would need to be used, which children it should apply to and how it would work. This interim measure and has now been superseded by a redesigned ED record for children. This demonstrates how any proposed solution always need to be understood by those who who will need to use it, tested in practice, reviewed and improved. Wider difficulties that are inherent to the task of safeguarding children in an Emergency Departments 3.6.15. The sorts of difficulties highlighted in this ED are not unique. Nationally there has been research and discussion about the difficulties that exist in EDs over the recognition and management of possible child abuse.11 Such difficulties are inherent to the problem of identifying and managing child abuse in an ED. These arise from a number of factors including the following: Cases of child abuse are difficult to diagnose The skill of raising concerns with parents is a difficult one to master Apparently minor injuries may be very significant, but most injuries to small children are not the result of abuse Professional intervention relies on collaborative working with colleagues in a number of specialisms and departments and may 11 Sue White et al, ‘Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study’, Health Services and Delivery Research, Volume 3, Issue 4 February 2015 28 make substantial demands on their time (ED consultants, nurses, ED paediatricians and other paediatricians, orthopaedics and radiography) 3.6.16. Researchers have highlighted the perceived tension between what they term ‘precautionary’ and ‘proportionate’ approaches. The former underline the grave potential consequences of child abuse while the latter recognise that relatively few cases of the very large number of children’s attendances are the result of abuse and that most children’s injuries have benign or accidental causes. It is likely that these standpoints may have underpinned some of the views expressed by staff in the ED. 3.6.17. The research has demonstrated that because behaviour among staff in EDs is shaped by these complex factors it cannot be modified simply through the introduction of procedures which make specific actions mandatory. In some instances when apparently ‘clear’ and ‘strict’ procedures and protocols have been implemented, usually in accord with the wish to develop a precautionary approach, compliance with them is low (less than 50%) because they lead to other unforeseen difficulties (or perceived difficulties) such as overload on other colleagues or a large number of referrals that prove not to be confirmed cases of abuse.12 Actions member agencies and the LSCB should take 3.6.18. Since the events that are the subject of this review, the Care Quality Commission has undertaken a review of the health trust’s provision for children and young people, including the ED. Its immediate feedback pointed to shortcomings in services in the following areas: lack of training and awareness; poor record keeping, not assisted by systems and format; a lack of supervision oversight of the quality of safeguarding work, including multi-agency work. Many of the findings mirrored the concerns identified in relation to Child F. 3.6.19. As a result the trust has been developing a substantial plan of action proposing the development of a range of tools and formats for staff, protocols, training and supervision. 3.6.20. It is unlikely therefore that the SCR could make recommendations that would add substantially to the changes that are proposed in these areas. It should be noted that patient safety initiatives are likely to be most successful when they take full account of the experience of front line staff in design and implementation and when there is strong 12 In one hospital White et al found a compliance rate of 45%, even after the implementation of a highly publicised initiative to refer children under the age of one with head injuries for further assessment ( White et al, op cit, page 35) 29 leadership from senior managers at the hospital board level, engaging all divisions in the hospital.13 3.6.21. This report will make recommendations focused on the oversight and coordination of these initiatives by the safeguarding children board which should undertake a regular review of progress. It will also recommend that audit of practice in cases that have been in contact with the ED should form part of its own multi-agency audit programme. 3.7. Safeguarding of Child F after he had been severely injured Introduction 3.7.1. The SCR was asked to consider whether any safeguarding concerns arose during the period between Child F being injured and his death. Evidence identified by the SCR 3.7.2. Child F received paediatric intensive care at Birmingham Children’s Hospital for just over four weeks before care was withdrawn in line with the agreement of the High Court. During this period his injuries, which it was known would cause his death, were the subject of a criminal investigation. Although his father was in custody, Child F’s mother was granted bail and spent considerable periods of time at his bedside. 3.7.3. The steps taken to safeguard Child F during this period presented some difficult challenges, taking into account that he required intensive care; the criminal court had granted his mother bail conditions that allowed her the right to have contact with him but left open the question of how far she should be involved in his care. At the same time his mother was the subject of criminal enquiries. There was a need for a continuous presence of the police at the bedside in order to protect Child F while at the same time monitoring his mother’s behaviour. Medical staff occasionally found this difficult. They also wanted to involve Child F’s mother in his care on the basis that it would assist her in coming to terms with his death, which was always known would be inevitable. 3.7.4. Shortly after his admission to hospital a multi-agency meeting was organised. The local authority social work manager had relatively little time to prepare for this meeting and it did not provide a detailed plan for supervision of contact. This was provided by the police some days later. 3.7.5. Staff involved have told the review that this was an extremely unusual set of circumstances. It was recognised that it took a number of days to work up a detailed plan for contact arrangements because at the beginning of the admission it was not anticipated that Child F would 13 White et al, op cit 30 survive for such a long period of time. Had this been clear a plan would have been developed much sooner. 3.7.6. The review has noted that despite the difficulties social care, police and the intensive care ward sister and consultant kept in close communication and were able to address difficulties as they arose. Since the death the hospital and police have held a round table discussion to debrief over the issues. Although in hindsight they might have done some things differently staff involved should be commended for their management of a difficult and unusual set of circumstances and their willingness to talk through difficulties both during and after events. 3.8. LSCB oversight of the impact of organisational changes on local safeguarding services Evidence identified by the SCR 3.8.1. Organisational factors had a negative impact on the quality of provision in a number of the services provided for Child F. They made it more likely that individual errors would occur, less likely that significant information would not be shared and less likely that errors would be spotted and rectified. 3.8.2. The social care pre-birth assessment was affected by the quality of some staff, the existence of backlog of work and the impact of changes being made to improve an organisational structure that had been found to have flaws. Detail is provided in Section 3.3. 3.8.3. The health visiting service was affected by shortages of staff and restructuring of services made so that services aligned with those of the local authority. It had limited capacity to carry out antenatal visits. 3.8.4. Midwifery provision suffered from shortages of staff leading to there being a large number of midwives involved with the mother. This may well have reduced the likelihood of early concerns being pursued later in the pregnancy. 3.8.5. The probation service had been negatively affected by its restructuring into two services, vacancies and staff sickness. This led to a large number of appointments being covered by staff providing duty cover working with clients who they did not know. 3.8.6. Staff in the Emergency Department have described an increased workload as a result of having assumed responsibility for a larger catchment area, with reduced opportunities for training and induction. The department was actively preparing for a move to a new building during the period of contact with Child F. However there is no evidence that the care of Child F was adversely affected because staff lacked time. 31 Actions member agencies and the LSCB should take 3.8.7. Taken together these changes will have had a significant impact on the quality of provision made in a range of cases, despite the efforts of staff and managers. It is noteworthy that there were parallel changes in a number of agencies, possibly in combination creating a greater overall effect. 3.8.8. The LSCB should therefore consider whether it has sufficient knowledge and oversight of significant organisational developments and their potential impact on service provision. If not , what steps can the board take to make itself more aware? The board should consider what steps it can take to mitigate the risks arising from pressures on services and organisational changes. 32 4. RECOMMENDATIONS 4.1. This section of the report sets out recommendations to individual agencies and to Wolverhampton Safeguarding Children Board. The actions for individual agencies focus on specific areas of practice and management. Actions for the board relate to its responsibility to monitor and challenge the performance of member agencies. Contributing agencies have made other changes in policies and practice during the course of the review. These are reported separately in the safeguarding board response to this review, published alongside this report. Actions for individual agencies 4.2. Royal Wolverhampton NHS Trust should undertake a review of the safeguarding arrangements in the Emergency Department at New Cross Hospital addressing the following areas of practice and management: the engagement of all divisions in plans to improve the safeguarding work of the ED overall awareness of safeguarding and training (including induction training) standards in recording formats to facilitate good record keeping a ‘think family’ approach supervision and leadership. 4.3. Royal Wolverhampton Hospitals NHS Trust should undertake a review of the safeguarding arrangments in antenatal services including the following areas of practice and management: clear standards and procedures for safeguarding standards in recording formats to facilitate good record keeping a ‘think family’ approach supervision and leadership improved quality of referrals with analysis and clear identification of risks. 4.4. City of Wolverhampton Council should audit the quality and effectiveness of local authority child and family assessment, including pre-birth assessment. 4.5. City of Wolverhampton Public Health should ensure that the service specification for the Healthy Child Programme addresses the need to improve the quality of primary health visits, taking account of the need for GPs, antenatal services and health visitors to share information and to provide effective coordination of work with children and families. 4.6. National Probation Service (Midlands) should ensure that risk assessments are updated when there is a change in the circumstances 33 of a supervised offender which may indicate a heightened possible risk to vulnerable children or adults. Recommendations for Wolverhampton Safeguarding Children Board 4.7. Wolverhampton Safeguarding Children Board and all member agencies should review the approach currently taken to providing information to new and prospective parents to ensure that it gives clear messages about the risk of shaking a baby and signposts sources of practical support. 4.8. Wolverhampton Safeguarding Children Board should review current responsibilities and pathways for pre-birth identification, referral and assessment of need in order to determine whether they are clear and well understood and that they are being implemented in the way that the board intends. Clear guidance is required on the use of the Early Help Assessment in the pre-birth period. This should apply to all agencies. 4.9. Wolverhampton Safeguarding Children Board should assure itself that the quality and effectiveness of child and family assessment carried out by the local authority meets its expectations, including pre-birth assessment. 4.10. Wolverhampton Safeguarding Children Board should audit and review the actions that member agencies take to involve fathers and male carers in safeguarding work, including assessments. This should apply across all agencies and reflect the board’s ‘Think Family’ approach. 4.11. Wolverhampton Safeguarding Children Board should ensure that it understands as much as possible about the quality and effectiveness of primary health (new birth) visits and challenges the health commissioners and provider to make improvements if required. 4.12. Wolverhampton Safeguarding Children Board should review the effectiveness of the work of member agencies in relation to families who are proving difficult to engage. 4.13. Wolverhampton Safeguarding Children Board should ensure that it has a detailed understanding of all aspects of the action plan to improve the safeguarding of children in the Emergency Department at New Cross Hospital and the way in which it is being implemented. Audit of practice and outcomes in cases that have been in contact with the Emergency Department should form part of its own multi-agency audit programme. 4.14. Wolverhampton Safeguarding Children Board should develop a strategy that will provide better knowledge and oversight of significant organisational developments in member agencies and their potential impact on service provision. The board should actively consider what steps it can take to mitigate the risks arising from pressures on services and organisational changes. . 34 Appendices Appendix 1 Terms of reference and details of lines of enquiry Appendix 2 Principles from statutory guidance informing the Serious Case Review method Appendix 3 How the review was undertaken Appendix 4 SCR review team and panel members Appendix 5 Roles of staff interviewed Appendix 6 References 35 Appendix I Terms of Reference and details of areas to be considered by the review 1 Overall purpose and terms of reference The purpose of the review is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.14 The specific objectives of the review are 1. To establish what happened 2. To establish why professionals acted as they did 3. To identify and understand the significance of a range of contributory factors that shaped the practice of professionals, including wider organisational factors. 4. To identify any episodes and background factors that may have a direct bearing on the injuries to Child F and therefore may be relevant to a consideration of whether or not the injuries could have been prevented. 5. In addition the review will seek to understand what the case history tells us about the strengths and weaknesses of local safeguarding arrangements (sometimes referred to as using the individual case as a ‘window on the system’).15 6. The review will explore aspects of the assessment of vulnerability, need and risk that it determines are relevant, whether any potential indicators of abuse and neglect were recognised and the provision that was made for the children and other family members. 7. The review will seek to establish whether the multi-agency working met the expectations of the LSCB for a case such as this. In particular did it enable a good overall assessment; coordinated support; identification of discrepancies in information given by the parents; provision of services to meet needs? 14 HM Government (2015) Working Together to Safeguard Children 15 Charles Vincent (2010) Patient Safety second edition 36 Appendix 2 Principles from statutory guidance informing the Serious Case Review method The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. In addition Serious Case Reviews should: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Working Together to Safeguard Children 2015 (Sections 4.9 and 4.10) 37 Appendix 3 How the review was undertaken 1. The LSCB compiled a chronology of key events based on the written and electronic agency records. 2. The LSCB established a review team to conduct the review consisting of the independent lead reviewer and senior staff from participating agencies and commissioners who had not been involved in the work with the family 3. Staff who had been involved in the work with the family and line managers attended a briefing session about how the review would be conducted 4. The review team held individual interviews with members of staff and managers, supported by review of records where this assisted 5. The lead reviewer drafted findings which were discussed with the review team on two occasions 6. After the criminal trial family members were again invited to contribute their experience of the services that they had received, but did not respond 7. The Serious Case Review Panel discussed and agreed drafts of the report and recommendations 8. Staff who had been involved attended a briefing about the findings of the review and asked to comment on recommendations. 9. The report was submitted to the safeguarding children board for discussion and agreement 38 Appendix 4 SCR REVIEW TEAM MEMBERSHIP Independent and WSCB members Keith Ibbetson Independent Lead Reviewer Business Manager Wolverhampton Safeguarding Children Board Administrator Wolverhampton Safeguarding Children Board Review Team Agency Designation Wolverhampton Clinical Commissioning Group Designated Doctor for Safeguarding and Consultant Paediatrician West Midlands Police Detective Chief Inspector (Public Protection) City of Wolverhampton Council Principal Education Psychologist City of Wolverhampton Council Head of Safeguarding Coordinator of Youth Organisations Wolverhampton Voluntary Sector Council and WSCB 39 Appendix 5 Roles of staff interviewed City of Wolverhampton Children and Young Peoples Service Consultant Social Workers Senior Consultant Social Worker Service Manager Youth Offending Team Youth Offending Officer Youth Offending Team Operations Manager West Midlands Police Senior Investigating Officer Royal Wolverhampton Hospitals NHS Trust Health Visitor Team Leader Health Visiting Service Paediatric Consultants in Emergency Department Emergency Department Consultants Junior Doctor Emergency Department Emergency Department Staff Nurse and nurses Paediatric Liaison Health Visitor Community and Hospital Midwives and Support Worker Senior Midwife Birmingham Children’s Hospital NHS Foundation Trust Consultant Paediatrician Ward Sister Probation National Service (Midlands Division) Probation Services Officer Senior Probation Officer 40 Appendix 6 References M Brandon et al, (2009) Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-07, HM Government – Department for Children Schools and Families Department of Health (2009) Healthy Child Programme – Pregnancy and the First Five Years, Healthy Child Programme, https://www.gov.uk/government/uploads/.../Health_Child_Programme Steve Goodmann and Isabelle Trowler (2012) Social Work Reclaimed, http://www.jkp.com/uk/social-work-reclaimed.html HM Government, (2015) Working Together to Safeguard Children HM Government, https://nationalcareersservice.direct.gov.uk/job-profiles/probation-services-officer Public Health England, ‘Children’s public health 0-5 years – review of mandation letter from Public Health England’, 28 June 2016, PHE Gateway number: 2016-106 Royal College of Midwives (2012) Maternal Emotional Wellbeing and Infant Development. Social Care Institute for Excellence, ‘Think child, think parent, think family: a guide to parental mental health and child welfare’, http://www.scie.org.uk/publications/guides/guide30/introduction/thinkchild.asp , website accessed 7 November 2016 Charles Vincent (2010) Patient Safety, second edition White S, Wastell D, Smith S, Hall C, Whitaker E, Debelle G, et al. Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study. Health Service Delivery Research 2015;3(4). |
NC044774 | Suicide of a 17-year-old boy in February 2013. Child F was looked after in supported accommodation at the time of his death. He had previously been a child in need and had moved in to supported accommodation following deterioration in his behaviour and mental health and increasing problems with family relationships. Mother had a history abusive relationships. Child F had a history of: mental health problems; substance misuse; periods of non-compliance with medication and non-engagement with support services and sudden fluctuations in mood and behaviour, especially towards family members. Identifies issues with the assessment, review and management of risk posed to and by Child F; the assessment of Child F's complex needs; the threshold criteria for social care intervention; and inter-agency understanding of child protection processes, medical terminology and the management of domestic abuse concerns. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and puts forwards recommendations. Recommendations include: the safeguarding children board to ensure there are clear multi-agency plans for the management of homeless 16-17-year-olds and to notify the Department of Education about concerns that unregulated service providers are accommodating vulnerable young people; schools to develop use of the Common Assessment Framework (CAF) for permanently excluded pupils; and mental health services to ensure transition plans include provision of a consistent person to support the young person in the transfer from children's to adult services.
| Title: Serious case review: Child F (Case B13): Overview Report LSCB: Bury Safeguarding Children Board Author: Dennis Charlton Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Bury Safeguarding Children Board Serious Case Review Child F (Case B13) SERIOUS CASE REVIEW OVERVIEW REPORT Report Author: Dennis Charlton Date: 21 August 2013 Signed: Date: 21/08/13 Commissioned by: Bury Safeguarding Children Board 2 I can confirm that the Serious Case Review on Child F (Case B13) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Wednesday 21 August 2013. BSCB members agreed to accept the Serious Case Review Overview Report and multi-agency action plan for submission. I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Executive Group will monitor their implementation. Gill Rigg Independent Chair of BSCB Signed: Date: 21 August 2013 3 CONTENTS CONTENTS ......................................................................................... 3 1. INTRODUCTION ............................................................................. 4 2. TERMS OF REFERENCE .................................................................... 4 3. INDEPENDENCE OF THE SERIOUS CASE REVIEW ............................... 5 4. MEMBERSHIP OF THE SCR PANEL ..................................................... 6 5. METHODOLOGY ............................................................................. 7 6. FAMILY STRUCTURE ....................................................................... 9 7. NARRATIVE ................................................................................... 9 8. CRITICAL CASE ANALYSIS ............................................................. 45 9. SUMMARY AND CONCLUSION ........................................................ 77 10. OVERVIEW REPORT RECOMMENDATIONS ....................................... 83 11. INDIVIDUAL AGENCY RECOMMENDATIONS ..................................... 84 APPENDIX 1 - RESEARCH SOURCES ..................................................... 89 APPENDIX 2 - MULTI AGENCY ACTION PLAN – CASE B13 (Child F) .......... 90 4 1. INTRODUCTION 1.1 This Serious Case Review Overview Report is produced in accordance with the Bury Safeguarding Children Board procedures for conducting a Serious Case Review (SCR). 1.2 The reason for this Serious Case Review is because of the death of 17-year old young person (Child F). The young man was looked after by the local authority and placed in supported accommodation for young people aged 16 years and over. On the 3rd February 2013 Child F went missing. He was later found on the 4th February 2013 and had used a cord to hang himself. 1.3 Bury Safeguarding Children Board Serious Case Review Sub-Group met on the 13th February 2013 and made a recommendation to the Chair of Bury Safeguarding Children Board that the case met the criteria for a Serious Case Review. The Chair of Bury Safeguarding Children Board confirmed the decision to undertake a Serious Case Review. 1.4 At the point of completion of the Serious Case Review, the Coroner had adjourned the inquest. There were no other parallel processes. 2. TERMS OF REFERENCE 2.1 The time period over which events have been reviewed is the 1st September 2006 to the 4th February 2013. This time period covers the main agency involvement with Child F and his family from the point that he started attending secondary school. 2.2 The SCR panel agreed the following to be the key lines of enquiry for this review, but also requested that any other relevant information outside of the key lines of enquiry (e.g. historical information on the family to give context/background information) is included: 5 1. How did your agency collaborate and work with other agencies to undertake the following in relation to Child F: • Assess risk • Assess need • Put services into place • Review and manage risks • Measure outcomes 1.1 How was the relationship between Child F and MF and family assessed? 1.2 What consideration did your agency give to the impact of domestic abuse, parental substance misuse and adult offending on the wellbeing of Child F? 1.3 Was information shared appropriately with other agencies and was information shared with your agency appropriately by other agencies? 2. What approach does your agency have to address the issue of young people not engaging/becoming disengaged with your service? 3. What indicators of self-harm/suicidal behaviour were presented and were these fully recognised, assessed and acted upon? 3. INDEPENDENCE OF THE SERIOUS CASE REVIEW 3.1 The author of the SCR Overview Report was Mr Dennis Charlton. He is an Independent Consultant in Child Protection with substantial experience in safeguarding children. Mr Charlton is a former Assistant Director of a local authority Children’s Service. He has undertaken a number of Serious Case Reviews both as an Overview Report author and also Chair of SCR Panels. He is accredited to undertake SCRs using 6 the Social Care Institute of Excellence (SCIE) systems approach. He holds a professional qualification in Psychiatric Social Work. 3.2 The Chair of the Serious Case Review Panel was Ms Hyde. Ms Hyde is Director of The Foundation for Families; a not for profit community interest company established in 2010. Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi agency response to children and young people at risk of sexual exploitation. Ms Hyde is currently the Independent Chair of several Serious Case Reviews and has designed and delivered three innovative Learning Reviews on behalf of local safeguarding children boards. 3.3 All of the Individual Management Reviews were undertaken by experienced managers, who had no direct management responsibility for the case. 4. MEMBERSHIP OF THE SCR PANEL Ms Hyde Independent Chair SCR Panel Service Manager, Safeguarding Unit Children’s Services, Bury Council Acting Operations Manager, Greater Manchester Probation Trust Development Officer, Bury Safeguarding Children Board Lead Officer, Safeguarding for Schools & Extended Services Detective Inspector, Serious Case Review Team, Public Protection Division, Greater Manchester Police Designated Nurse, Bury NHS Clinical Commissioning Group Specialist Nurse-Safeguarding, 7 Community Services Bury, Pennine Care Foundation NHS Trust Designated Doctor, NHS Bury Clinical Commissioning Group Child Safeguarding Lead, Pennine Care Foundation NHS Trust Safeguarding Manager, Bury Adult Care Services Children’s Services Manager, Barnardo’s CAMHS Directorate Manager, Pennine Care Foundation NHS Trust 4.1 The Chair of Bury Safeguarding Children Board is Ms Gill Rigg. 4.2 The Overview Report author attended the SCR Panel meetings as an observer and to clarify any issues arising from the Individual Management Review Reports. 4.3 The SCR Panel received administrative support from a Senior Administrative Support Worker 5. METHODOLOGY 5.1 The Overview Report was undertaken following a systems approach. Analysis of the Individual Management Reviews explored significant events, for themes, that indicated either strengths or weaknesses in multi-agency safeguarding systems. Individual Management Reviews were submitted by: Greater Manchester Police Bury Children’s Services Social Care (including Leaving Care Service and Youth Offending Team) Pennine Care NHS Foundation Trust – Community Services, Bury Barnardo’s Pennine Care NHS Foundation Trust – Mental Health Services (including CAMHS and Early Intervention Service) Bury Children’s Services Learning Division (covering the Schools) Supported Accommodation Provider 8 GP Connexions 5.2 Overall the Individual Management Reviews (IMR) were comprehensive and of a good quality. The exception to this being the report submitted by the Supported Accommodation Provider, which was not completed adequately despite encouragement and offers of support from the Serious Case Review Panel. Regrettably the IMR from the Supported Accommodation Provider failed to follow the terms of reference of the Serious Case Review and as such the contribution from this agency was of limited value. 5.3 Specific Issue Reports were also requested from: Greater Manchester Probation Trust Manchester Mental Health and Social Care Trust Greater Manchester West Mental Health NHS Foundation Trust (The Adolescent Forensic Service) Pennine Acute Hospitals NHS Trust Early Break (a service for young people engaged in substance misuse) Adult Care Services Transition Team 5.4 The Overview Report was written with the intention that it would be suitable for publication without any redaction. It was also written with the intention that it should be used to enhance learning and improve practice. 5.5 MF was informed about the decision to undertake a Serious Case Review. She did not wish to contribute at this stage but asked to be informed about the findings. 9 6. FAMILY STRUCTURE Anonomysed name Relationship to Subject Address Child F subject Address B MF Mother of subject Address A FF Father of subject Address C MP1 Father of sibling FS1 Address D MP2 Father of siblings FS2 and FS3 Address A FS1 sibling of subject Address A FS2 sibling of subject Address A FS3 Sibling of subject Address A 7. NARRATIVE 7.1 Child F started at High School 1 in September 2006. It was recorded that he appeared to make a good start. 7.2 There had been some previous agency involvement when the Health Visitor met with MF in August 2005 (the family had recently moved into the area). MF reported difficult relationships with men throughout her adult life. There was no contact or relationship between Child F and FF, although he had enjoyed a good relationship with MP1 until they divorced. Child F was said to exhibit extreme behaviour including angry outbursts towards his sibling (FS1). He was also said to have expressed wishes to harm himself. MF suggested that “Psychology Services” had been involved in the past. 10 7.3 MF also reported incidents of domestic violence and said there had been separations between herself and her partner (MP2), because of violent incidents. She said that she had previously lived in a refuge for three months but had found it too difficult and returned to MP2. The current situation was that MP2 visited the family home frequently and MF felt that their difficulties could be resolved. 7.4 There were some incidents of physical aggression at High School 1 reported in October 2006 and school identified support services through peer support, and outreach support for anger management. By the end of the year Child F had a high level of attendance but his behaviour was seen as problematic. There were various interventions through fixed term exclusions, referrals for individual counseling to Relateen (a counseling service), and for anger management. Child F also spent time in the school Inclusion Unit. 7.5 There were indications from GP records that MF had received surgery on her nose in June 2008, following two assaults where her nose had been broken. The most recent assault appears to have been around June 2007. Both assaults were caused by her partner (MP2). 7.6 In May 2009 Child F was arrested and cautioned for possession of a small quantity of cannabis. 7.7 Child F was suspended from High School 1 in September 2009 after an incident when he seriously physically assaulted another pupil. This became a permanent exclusion, after the incident had been investigated. 7.8 In October 2009 there was a referral to the Youth Inclusion Support Panel YISP) from The Neighbourhood Anti Social Behaviour Team. This was in relation to neighbour nuisance. The work was aimed at early intervention with Child F, who had been identified as a child showing early signs of anti social behaviour. After some early difficulties in engaging with the family, MF expressed her concerns 11 about Child F, that she was frightened of his aggressive behaviour that seemed worse when he had been drinking. 7.9 Much of the focus of the YISP intervention was on anger management and assisting Child F to integrate with his peers. 7.10 Child F was referred to Bury Child and Adolescent Mental Health Services (CAMHS), by the Education Welfare Officer; the referral highlighted problems with anger and was related to his exclusion from school. MF was sent a letter from CAMHS confirming the referral and requesting that she contact CAMHS. This was essentially an “opt in” mechanism in place at the time. 7.11 An initial appointment was offered by CAMHS in December 2009. Records indicate that this appointment was not attended. A further letter from CAMHS was sent in January 2010, requesting MF to re-book an appointment. 7.12 In January 2010, Child F was one of a group of juveniles who were stopped and advised by the Police regarding anti-social behaviour. No further action was taken. 7.13 Child F and MF attended an initial appointment with CAMHS on the 9th March 2010. Key issues that emerged were: • Anger outbursts since 4-5 years of age • Numerous house moves • Breakdown of MF’s relationship with MP2 • MP2 imprisoned for drug offences • No contact with FF The main focus of work was on anger management and building self-esteem using a life story approach. There was also to be liaison with the Youth Inclusion Support Panel worker. 7.14 School health records indicate that Child F had demonstrated several violent outbursts in school. 12 7.15 On the 15th March 2010 MF contacted CAMHS to inform them that Child F had disclosed that he had experienced auditory hallucinations (hearing voices). He had not mentioned it at a recent appointment with CAMHS because he “had felt daft”. This led to an early follow up appointment on the 26th March 2010. 7.16 On 25th March 2010 Child F had a medical assessment by the Youth Offending Team Nurse. It was noted that he said that he heard voices telling him to hurt people and that he was waiting a Child and Adolescent Mental Health (CAMHS) appointment. 7.17 Child F was seen at CAMHS on the 26th March 2010. The review concluded that a referral would be made to the mental health, Early Intervention Service because of concerns about possible psychosis. 7.18 On the 13th April 2010 the Youth Offending Team (YOT) support worker wrote to High School 2 outlining serious concerns that Child F had disclosed that he was hearing voices that were telling him to harm people and seeing graphic images in his head. The support worker concluded that the concerns were such that Child F was not suitable for YISP intervention. The case was closed on the 3rd June 2010, with the YISP Support Worker sharing these concerns with CAMHS. MF had also complained to school that Child F had not received help with anger management. 7.19 An assessment by the Early Intervention Service, in mid April 2010, concluded that although Child F does experience pseudo hallucinations, he was not suffering from a psychotic illness and the voices were probably generated inside his own head. It was also felt that his paranoid thinking had increased since a physical assault, in a park, in 2008. This was viewed as a significant, traumatic event. Child F was discharged from the Early Intervention Service. This information was passed on to CAMHS. 13 7.20 There were a series of three CAMHS appointments with Child F at school during July 2010, and one appointment with CAMHS at the clinical centre. It was recorded that MP2 had a night at home (presumably on release from prison) and Child F was pleased to see him. At this stage Child F was attending school 2. There were a number of incidents self reported by Child F where he had shown anger and aggression towards staff and peers. GP records also noted Child F having a “moderate depressive disorder”. 7.21 In early July 2010 Child F was reported missing from home by MF following an argument between them. Child F had spent the previous night at a friend’s home but had not returned home that evening as expected. This appears to have been information that was also passed to Children’s Social Care by the Police. It was noted in Children’s Social Care records that the information was for Barnardo’s, presumably because of their role in following up children who had been reported as missing from home. 7.22 As a response to this “missing from home” incident, Barnardo’s sent a letter to the family home offering Child F an interview, but there was no response and the case was closed. 7.23 There was another “Missing From Home” referral to Children’s Social Care on the 12th August 2010 referred to in the Children’s Social Care IMR. This was not recorded by any other agencies and may be a reference to the incident in early July. It appeared that Child F had returned home and said that he had slept in the garden, refusing to say where else he had been. The referral stated that there was “no risk of self-harm or suicide”. The referral was closed by Children’s Social care with no further action. 7.24 Correspondence on GP records suggest that MF had, at this stage, requested her GP to seek a second psychiatric opinion in relation to Child F. 14 7.25 Child F was seen by a Consultant Child and Adolescent Psychiatrist in mid December 2010, because of concerns expressed by the CAMHS practitioner working with Child F that he was describing hearing voices (a male voice speaking to him directly). The voice was instructing him to harm himself and others. Child F also disclosed that MP2 hit him once and threw him into a window. This was recorded in CAMHS documentation as being “father” but the dates suggest that it must have been MP2. Concerns about the safety of siblings were recorded because of the nature of the hallucinations. Child F was referred to the Mental Health, Early Intervention Team. A physical health assessment had excluded physical causation of his presentation with hallucinations. MF was advised to continue high levels of supervision and contact CAMHS if she had concerns. There is no indication that the alleged physical assaults were referred to Children’s Social Care. 7.26 Child F was seen again by CAMHS (Consultant Child Psychiatrist) in mid January 2011. He appeared “no worse” and medication had helped with his sleeping. He was still having command hallucinations telling him to hurt others. 7.27 There was a home visit by the Early Intervention Team on the 20th January 2011. The trauma of the attack on him in 2008 was considered, by the family, to be a significant factor. Accepted by the Early Intervention Team for Cognitive Behavioural Therapy and referred to Psychologist for assessment of trauma. A further assessment home visit, on the 27th January 2011 looked at how Child F was coping with the voices he was hearing and what he thought it made him do. 7.28 Child F was sent home from High School 2 on two occasions in early February 2011 because of anger outbursts. On the 4th February 2011, Child F was reported to have experienced deterioration in his mental state. There is a report of him considering suicide by jumping off a 15 motorway bridge. He was saying that auditory hallucinations (second person command voice) were telling him to hurt himself. 7.29 There was a home visit by an Early Intervention Team practitioner on the 4th February 2011. Child F commented, “he felt that he might as well die to stop the pain”. Emergency support measures put in place to deal with the immediate position (In reach team, Emergency Duty Team). There was a clinic letter from CAMHS (Consultant Child Psychiatrist) hypothesising that Child F may be experiencing drug induced psychosis. 7.30 On the 10th February 2011, Child F was admitted to a specialist mental health hospital unit, on an informal basis. He was continuing to hear both internal and external voices and was on medication for paranoia. It was alleged that he had pulled a knife on a younger brother but Child F denied this. Child F thought that people could read his mind and thought that MF wanted to get rid of him. It was recorded that over the next few days, Child F refused to see MF and MP2 (although MP2 was in prison at this time). 7.31 By the 14th February 2011, Child F was reported as being more settled in mood, although there were some residual psychotic symptoms. Child F indicated that he did not want to live at home when he was discharged. By the 25th February 2011 there were no longer any symptoms of psychosis. In early March 2011, Child F restarted school (High School 2) from the hospital unit. 7.32 On the 15th February 2011 there was a discussion between the Charge Nurse on the hospital unit and Children’s Social Care. Although the records are not explicit this seems to have been a preliminary discussion because discharge from the mental health unit was imminent. There was no one available from Children’s Social Care to attend a meeting on the unit planned for 21st February 2011. Minutes of the meeting were requested. 16 7.33 There was a written referral from the mental health unit to Children’s Social Care, dated the 17th February 2011, outlining that Child F was a patient on the Unit and had thoughts of harming others, including his younger brother FS1. This was essentially a safeguarding referral because of concerns about the safety of the siblings. The attached notes to the referral contains an action point that Children’s Social Care should be asked to provide home support or alternative accommodation. No action was taken by Children’s Social Care other than to record the information. 7.34 On the 2nd March 2011 the allocated social worker (SW1) attended a meeting at the mental health unit to discuss Child F’s discharge from hospital. It was noted that since admission Child F was still reporting he was hearing voices although no psychotic episodes have been witnessed by staff. Child F was refusing to return home to MF’s care. Child F was aggressive towards MF on the unit and had to be restrained to remain on the unit. An Initial Assessment by Children’s Social Care was commenced following this meeting. It was noted that MP2 was in prison and that MF was expecting a baby in seven weeks. 7.35 There was an Initial Care Programme Approach (CPA) meeting on the 8th March 2011. These meetings are used to co-ordinate care and assess the needs of people with severe and enduring mental health problems. The meeting covered Child F’s history, health, housing situation, behaviour and mental health. Those attending the meeting were aware that Child F had reported hearing voices. Child F was offered Connexions support in school (High School 2). There were some difficulties reported with Child F’s behaviour at school and MF also reported that she did not feel safe in child F’s presence. 7.36 A further Care Programme Approach meeting took place on the 15th March 2011 (Discharge Meeting). Key issues were Child F’s discharge from hospital and his unwillingness to return to the family home. On the 17th March 2011 the mental health unit informed the allocated social worker that Child F was being discharged to the care of his 17 uncle (MP2’s brother). Child F and MF were said to be happy about this arrangement. He was discharged on the 18th March 2011. There is no indication of any assessment as to the suitability of the uncle as a carer for Child F. It is unclear from the records exactly how long Child F stayed with his uncle, but the stay is unlikely to have been for longer than a few days. 7.37 The discharge letter from the Consultant Psychiatrist stated a diagnosis of a psychotic episode and also mixed disorder of Emotion and Conduct. 7. 38 Child F was seen in High School 2 by his Connexions Personal Advisor on the 24th March 2011. There was agreement to make a referral, known as a Central Point access referral, for alternative accommodation for Child F. Much of the discussion had been about his unhappiness at home. At subsequent meetings with his Connexions Personal Advisor, Child F talked about the isolation he felt at home. There were also a number of alternatives explored in terms of accommodation. Involvement by the mental health Early Intervention Team during this period in March 2011 also suggested there were ongoing behavioural problems at school. 7.39 A Care Programme Approach meeting (CPA) took place coordinated by CAMHS. Some of the key issues were: • CAMHS had made a decision to close the case • Child F was no longer taking medication • Continued support from Connexions and the Early Intervention Team 7.40 Continued difficulties were reported in High school 2 during these early stages, following discharge. He was seen in school by the Early Intervention Team practitioner on the 29th March 2011 and was reported as being more settled at school. 18 7.41 There were some difficulties in the Early Intervention Team practitioner engaging with Child F during April and May 2011. This seems to have been because of a mixture of examinations and also possibly because Child F was not enthusiastic about meeting. When he was seen in early June 2011 his mood was reported as fluctuating. By early June 2011 he was reported by the Early Intervention Team practitioner to be in a positive mood and rarely heard voices and had no suicidal ideation. It was also recorded that his mood seemed to fluctuate considerably between visits. He was described as being more settled with MF (it is unclear exactly when he had returned to the family home). 7.42 There was a Police referral to Children’ Social Care on the 20th June 2011. The Police had been called out to Child F’s school (High School 2) where he was lashing out at teachers and pupils and punching walls and doors. The referral stated that he does not get on with his MP2 who is on weekend release from prison. He was also said to be unhappy about MF’s new baby. Children’s Social Care did not identify any Child Protection issues. It was also noted that Connexions and a Mental Health Nurse were involved. The Police were informed that the referral did not meet the criteria for intervention. 7.43 During a home visit, on the 22nd July 2011, by the Early Intervention Team practitioner, Child F was reported as finding it hard to be at home, hearing voices telling him to harm others. Child F admitted to suicidal ideation although no intent was noted. One week later when a mental health review was held it was recorded that Child F was denying any psychotic symptoms. He was also being non compliant with medication. His mood was described as predominantly low. 7.44 At the mental health review, held on the 29th July 2011, attended by the Consultant Psychiatrist, Connexions worker and the Early Intervention Team practitioner. It was recorded that Child F was managing his thoughts and denied any psychotic symptoms. He 19 expressed a willingness to remain involved with the Early Intervention team but only through minimal visiting. 7.45 There was a Care Programme Approach meeting in August 2011 (probably 4th August 2011). It was reported that Child F was experiencing better family relationships, that he had joined a cage fighting club as an apprentice. (It should be emphasised that this was a legitimate sporting club activity). Child F was no longer taking medication and was not using drugs. The risk to himself and others was assessed as low. 7.46 Child F was reported missing from home by MF on the 5th August 2011. MF reported that her son was under the local mental health team and that he had voices in his head telling him to kill himself. 7.47 Later that day MF contacted the Police to report that Child F had returned home and was safe and well. He had apparently been with some friends. Earlier in the day Child F had been seen by his Connexions Personal Advisor who reported that Child F was very angry and low, as his housing situation was not sorted. Child F reported that he was not sleeping or eating and was hearing voices. The Connexions Advisor contacted Children’s Social Care by telephone to confirm her actions had been appropriate. At this stage it appeared that Child F was on a waiting list for a housing provider for accommodation. 7.48 Notes from the Early Intervention Team records state that Child F was willing to see the Locum Consultant Psychiatrist from Bury CAMHS on 1st September 2011. He denied any suicidal thoughts but still had thoughts of harming others. 7.49 There was considerable activity by the Connexions Adviser during September and October 2011 focused on facilitating accommodation for Child F and sorting out his benefits. Child F was attending his cage fighting apprenticeship on a daily basis. 20 7.50 MF contacted the Connexions Personal Advisor on the 7th November 2011 to inform them that Child F had “packed his bags and left home”. She was willing to allow him to return home and stated that nothing had happened to provoke his leaving. 7.51 Discussions between the Connexions Personal Advisor and the provider of the apprenticeship, suggested that Child F was unhappy because his “brother” had been drug dealing and MP2 had been home over the weekend, on release from prison, which had caused tension. 7.52 The following day, Child F presented at Connexions as homeless. There was some discussion with Children’s Social Care and the Housing Department, the outcome being that Child F would not be accommodated in the Crash Pad, as MF was willing to have him at home. The Connexions Advisor felt that the Crash Pad was not a suitable environment for Child F. The provider of the apprenticeship offered to accommodate him overnight as alternative arrangements could not be found. 7.53 This same debate continued the following day, with the same outcome, although there was seemingly a total family relationship breakdown, the Housing Department would not offer anything because MF was willing to have him back home. The discussions moved focus with the view that MF had stated that she was afraid of him therefore the Housing Department required a mental health risk assessment on Child F before they could consider possibilities of accommodation. The matter was eventually resolved with a risk assessment being provided by the Early Intervention Team and Child F was allowed to use the Crash Pad for the night. Children’s Social Care records show that Child F was still at the Crash Pad on the 14th November 2011. It is not clear from the records how the placement was arranged. Children’s Social Care closed the referral on the 14th November 2011. The rationale being that Child F was settled at the Crash Pad and had support to ensure that his independence needs 21 were met. This approach by Children’s Social Care was clearly wrong and is commented on in detail in the Analysis section. 7.54 A response letter was received by Connexions from an Assistant Team Manager (Children’s Social Care) on the 15th November 2011. This was in relation to the telephone call from the Connexions Personal Advisor on 5th August 2011. The letter advised that an assessment under the Common Assessment Framework should be started. This suggests that Children’s Social Care did not consider the threshold for intervention as a child in need has been met. This was not an adequate response by Children’s Social Care and is discussed in detail in the Analysis section. 7.55 Child F was seen by his Connexions Advisor on the 15th November 2011. He reported a low mood and suicidal thoughts. He indicated that he intended to stay with maternal grandparents for a while. Child F was said to be negative about his relationship with MF. 7.56 During the latter half of November 2011 a new housing needs assessment was undertaken. There was also a violent incident at the Crash Pad, on the 21st November 2011, where Child F broke furniture and received a written warning about his conduct. There were also concerns expressed by the Crash Pad staff about his mood and not attending to his personal hygiene. 7.57 Child F was seen, on several occasions, throughout November 2011 by his Connexions Advisor. He was reported to be low in mood, missing his siblings and upset about the housing situation. He was reported as commenting that life was not worth living. 7.58 Information from Connexions records, in December 2011, suggests that Child F had been staying out a lot and was in arrears with his rent at the Crash Pad. Child F was also not taking his medication at this stage. By early December 2012 he agreed to go to his GP to restart medication for depression. 22 7.59 Child F failed to attend an appointment with the Early Intervention Team on the 7th December 2011, but did contact by telephone to discuss accommodation. It was noted that he was staying with MF. He was seen by the Early Intervention Team practitioner on the 12th December 2011. He was hearing a voice at this stage but refused hospital admission. An arrangement was agreed whereby he would stay at MF’s home during the daytime and sleep at the Crash Pad at night. Child F declined further visits from the Early Intervention Team practitioner, but agreed to telephone contact. 7.60 Child F was seen by Consultant Psychiatrist (CAMHS). It was recorded that his relationship with his family had broken down and he was living at the Crash Pad. He was diagnosed as suffering from a moderate depressive episode and commenced medication. 7.61 MF contacted the Police to report Child F missing on the 16th December 2011. He had disappeared after learning, from MF, that his mental health was to be assessed as an emergency case. She expressed concern about his welfare as he had been suffering from depression. He was considered to be high risk, as he had recently talked about voices telling him to kill himself. Details of the Police Report were referred on to the Police Public Protection and Investigation Unit, who in turn notified Children’s Social Care. This was dealt with by Children’s Social Care as a “contact” and closed with “No Further Action” required by Children’s Social Care. The rationale being that a Community Psychiatric Nurse was allocated to the case. Child F was taking medication and there were no child protection concerns. This was a very limited appreciation of “child protection” and is commented on in the Analysis section. 7.62 A meeting was held at Connexions to consider Child F’s accommodation needs. The Housing Department, Early Intervention Team and Connexions were in attendance. Discussions centered on the level of support Child F would require for his own tenancy. Given 23 the problems presented by Child F, the idea that he may be able to manage his own tenancy were unrealistic. 7.63 There were further contacts between Child F and the Early Intervention Team between mid December 2011 and mid January 2012. It was recorded that Child F remained well. There was also ongoing contact with Connexions who recorded that Child F had been staying out a lot, is unhappy at the Crash Pad and in rent arrears. He stated his intention of staying with grandparents over Christmas. 7.64 Child F self harmed by cutting on the 30th January 2012, and was admitted to a specialist mental health unit after being seen in A&E. He also disclosed to Crash Pad staff that he was hearing voices and described having very violent thoughts about hurting others. He was also said, by MF, to have been physically aggressive to her, when she was eight months pregnant. 7.65 By the 9th February 2012 there was no evidence of psychosis. There was a Care Programme Approach meeting at the hospital on the 10th February 2012. It was agreed that Child F could return to the Crash Pad. This accommodation was totally unsuitable and discharge to the Crash Pad should have been challenged. Following a risk assessment, Child F indicated that, in the longer term, he wanted his own tenancy. MF had earlier reported that she felt Child F was relapsing because he was worried about coping independently. Home leave from the hospital unit was arranged and he was formally discharged on the 22nd February 2012. The diagnosis at this stage was of an Adjustment Disorder and Dissociative Symptoms. The auditory hallucinations were thought to be stress related rather than “frank psychotic symptoms”. 7.66 Ongoing contact with Connexions and the Early Intervention Team suggested that Child F was frustrated and deflated about progress with accommodation issues. There were also concerns about the strained relationship with MF. 24 7.67 On the 1st March 2012, the Police found Child F on a bridge over a motorway. He claimed to be out for a walk and was taken home by the Police patrol. Child F was reported to have engaged in general conversation with the Police Officer and there were not considered to be concerns about his mental health. Earlier that day Child F’s application for the tenancy of a flat had been unsuccessful. 7.68 Upon arrival at the family home, only MP2 was present, (MP2 had been released from a Prison sentence, on license, in early February 2012). Child F armed himself with a knife from the kitchen and lunged at MP2, making aggressive threats. He later claimed that MP2 threatened to kill him. Child F was arrested, with the Police Officer having to use a tazer stun gun to subdue him. Child F was taken to hospital and seen by the duty psychiatrist. The Police were informed that Child F was not suffering from a psychotic illness but did have depression for which he had been prescribed medication. 7.69 The Crown Prosecution Service reviewed the evidence and authorised that Child F should be charged. Because of the nature of the offence he was kept in custody overnight. The Youth Court concluded that Child F was not safe to be bailed to the Crash Pad and he was remanded to the Care of the Local Authority. The Youth Offending Team worker made an application for a Secure Children’s Home but no bed was available and after liaison with the Children’s Social Care Emergency Duty Team, a foster placement, approved to take young people in emergencies, was secured. Child F was subsequently convicted of common assault and sentenced to a three months Referral Order. This Order was later revoked because of Child F’s mental health issues. 7.70 There was also discussion between the YOT worker and the Strategic Lead for Health and Partnerships about the merits of a Mentally Disordered Panel dealing with Child F rather than him being dealt with through the Youth Court. Further discussion between the Strategic Lead for Health and Partnerships and the Police ruled out the 25 possibility of using the Mentally Disordered Panel because Child F did not have diagnosed mental illness. With hindsight, this was a very narrow understanding of mental illness. 7.71 There was discussion between the Emergency Duty Team social worker and the allocated Community Psychiatric Nurse (CPN). The view of the Community Psychiatric Nurse, according to Children’s Social Care records, was that Child F had never made a serious threat on his own life and was not a threat to his siblings. The Strategic Lead for Health and Partnerships also requested that the CPN expedite a referral for a FACTS Assessment (The Forensic Adolescent Mental Health Service). 7.72 The Police referred the case to Children’s Social Care, the referral being received the following day. The Police were expressing concern that the Crash Pad was not a suitable place for Child F to live. Child F had been living at the Crash Pad for several months at this stage. 7.73 An Initial Assessment was undertaken by Children’s Social Care, commencing 5th March 2012, followed by a Core Assessment. The assessment process did not pick up information that Child F had a difficult relationship with MP2 and the records state “no” to questions about domestic violence and parental drug use as well as “no” to the question about whether he was previously known. 7.74 In March 2012, a Police internal intelligence report was made available for Police Officers coming into contact with Child F or in the event of him being reported missing. The intelligence report was clear that should Child F be reported as missing he should be considered as a risk to himself and others. 7.75 There was a difference of view in early March 2012, between Connexions and Children’s Social Care about whether Child F met the threshold for intervention as a child in need. This followed on from the incident on the motorway bridge on the 1st March 2012. A referral was 26 sent to Children’s Social Care by the Connexions Personal Advisor and after some debate Children’s Social Care agreed to reassess Child F. 7.76 There was an emergency multi-agency meeting held on the 5th March 2012 coordinated by the Early Intervention Team. The main focus seemed to be Child F’s future care status and accommodation. Also referral for forensic opinion was determined. 7.77 A place was found for Child F at a Supported Accommodation residential unit on the 9th March 2012. Child F was taken there by his Connexions Personal Advisor and allocated social worker. The placement was unregulated accommodation in that young people are expected to live there independently and was therefore not regulated by Ofsted. As Child F was no longer remanded in care it was decided that the placement would be under a Children in Need Plan and would be financed through Section 17 payments. This is discussed in detail in the Analysis section. 7.78 On the 13th March 2012 there was a Placement Planning Meeting, including completion of a Missing from Home Assessment. This meeting was attended by MF and the Community Psychiatric Nurse as well as the allocated social worker (SW2) and staff from the residential unit. It was agreed that Child F would remain at the unit for an initial three-month period. It was also noted that an assessment of the risk he posed to his siblings should be completed and taken to a Child Protection Conference. The Police, social worker, Connexions Advisor and residential unit staff were present. It was felt that because of previous incidents, Child F should be seen as high risk should he go missing. 7.79 The Plan was endorsed by the Service Manager Panel, a forum within Children’s Social Care, to ensure placements are appropriate. The allocated social worker was requested to complete the Core Assessment and take it to a Child Protection Conference. The Duty Independent Reviewing Officer was later to decline the request for a 27 Child Protection Conference, because Child F was living away from home and because MF had responded appropriately to Child F and his siblings, the threshold for significant harm was not met. The allocated social worker was advised to complete the Core Assessment and if the situation changed to refer it back for further consultation. 7.80 Early daily records from the residential unit describe Child F as being low in mood and very withdrawn. When MF visited on the 13th March 2012 he appeared angry, stating she was telling lies. This anger shown towards MF was not a totally consistent theme during these early stages of the placement. There is one recording, for example, that indicates his mood picked up after a visit by MF. 7.81 Throughout March 2012, there was ongoing contact between the Early Intervention Team and Child F. His mood appears to have fluctuated and there are reports of Child F “having a bad week” as well as Child F being happy with the new accommodation. By the end of March 2012, the Early Intervention Team recorded that the residential unit felt that Child F was fine and doing well. There were not considered to be any suicidal thoughts. 7.82 A referral was received by Barnardo’s from Children’s Social Care on the 19th March 2012, informing Barnardo’s that Child F had become a Looked After Child and requesting input from the child advocacy service (Children’s Rights Service provided by Barnardo’s). There were some delays in confirming where the placement currently was before it was ascertained that Child F was no longer of looked after status. Due to his age and mental health it was intended that he would be placed in a specialist residential unit, supported by Bury mental health services. The case was closed by Barnardo’s. 7.83 A Professionals Meeting was held on the 26th March 2012. Staff at the residential unit were querying Asperger’s/Autistic Spectrum Disorder. The Early Intervention Team were considering closing the case as 28 they felt that Child F’s difficulties were psychological rather than because of mental illness. The Plan at this stage was to: • Try to have assessment for Asperger’s syndrome - MF in particular was requesting this • Extend placement for a further 3 month period • Longer term move to supported lodgings 7.84 The following day, Child F was reported to be in a low mood and refused to call MF back after she had telephoned him. 7.85 Child F was reported missing, from his supported accommodation, on the 28th March 2012. Child F had informed a support worker that he intended to kill himself. He had also made an attempt to kill himself with a skipping rope a few days earlier. Child F was also seen by his Connexions Personal Advisor and gave a similar account about trying to hang himself. The Police circulated information that he was of medium risk. Later that evening Child F telephoned staff at his supported accommodation to restated his intention to self-harm. He returned to his residential accommodation early the next morning. Child F told a member of the support staff that he wanted MF to suffer and see her crying over his grave. The following day there were no suicidal thoughts reported. In a telephone conversation between the residential unit and the Early Intervention Team, Child F was reported as fine. MF visited him at the residential unit the same day and his mood was described as lifted. Child F went to maternal grandparents for that weekend. 7.86 On the 3rd April 2012 Child F failed to attend a Psychology appointment. Barnardo’s also closed the case because as Child F was not looked after, he was not eligible for their service. 7.87 The YOT worker undertook a risk assessment using a standardised methodology (ASSET Assessment). This was completed on the 4th April 2012. This disclosed that there had been domestic violence in the family for 10 years and that he had lived in a women’s refuge with 29 MF in 2006. Child F also stated that he had intended to harm his MP2 and hated him. It noted that the previous week he had put a rope around his neck with the intention of hanging himself but it had not held his weight. He also said he had been on rail tracks and was thinking about throwing himself under a train. 7.88 The Core Assessment being undertaken at the same time suggested that Child F felt suicidal. The core assessment also noted MP2’s drug dealing and that Child F was frightened of MP2. 7.89 On the 10th April 2012, Child F attended an appointment with a Psychologist - the notes are not explicit but this seems to be the CAMHS Psychologist. 7.90 On the 16th April 2012, the Police were informed, by a friend of Child F, that he was on a bridge over the motorway and intended to jump. Friends and family, including MF, were at the scene. When Child F’s safety was secured he was detained under Section 136 of the Mental Health Act. As he appeared intoxicated he was initially taken to the A&E. He was, after a mental health assessment, discharged to his residential unit. Both Police and the mental health unit referred Child F to Children’s Social Care. 7.91 By the 18th April 2012, Child F was described, by residential unit staff as being in an excellent mood. This was consistent over the next few days and Child F spent the weekend with his grandparents. 7.92 The residential unit recorded that on the 24th April 2012, Child F became agitated and angry as MF was late in visiting him. Child F felt that MF was doing this on purpose to limit his contact time with siblings FS2 and FS3. Child F was described as thumping the walls and banging his head on the window. MF did visit with the siblings, There is no indication whether this had an impact on Child F’s mood. 30 7.93 There was a Child in Need Meeting on the 25th April 2012. Present were the allocated social worker, residential unit staff, Connexions Advisor and Early Intervention Team practitioner. There is no detailed information about the areas of discussion. It was however agreed that Child F was in an excellent mood and the placement would continue. It was confirmed that Child F was not a looked after child. MF also contacted the GP to request a private referral for autism as this would be quicker than going through an NHS referral. Child F had given his written consent for such a referral. 7.94 An updated Core Assessment by Children’s Social Care (entry dated 4/5/2012) gave the following information: • Psychologist and Psychiatrist think he has an attachment disorder • Maternal grand parents no longer able to offer support because of his behaviour • There had been recent contact between Child F and FF - reported by MF as being positive • Child F not registered with a GP locally making it difficult to access GP services • Missed recent appointments with Psychologist • Is currently being assessed for Autistic Spectrum Disorder. MF was very unhappy about the “parental information” on the updated core assessment and wanted it removed. 7.95 Child F was reported missing by staff at the residential unit on the 7th May 2012. A suicide note had been found in his room. He had also phoned MF and told her he was going to commit suicide. The Police dealt with this as “high risk” and located Child F outside his residential unit in the middle of the night. Child F was taken to a local hospital by the Police under Section 136 of the Mental Health Act. He was assessed and found to pose no danger to himself. During Psychiatric assessment Child F denied current suicidal ideation and was thought to be suffering from a depressive disorder of a moderate to severe nature. It was noted that he had stopped taking regular medication. It was felt that Child F would benefit from further psychiatric evaluation 31 but he refused informal admission. He was discharged back to his residential unit and taken there by the Police Officers dealing with the incident. The reporting Police officer graded Child F’s vulnerability as high. 7.96 The build up to the incident seems to centre on a telephone conversation between Child F and MF on the 7th May 2012. MF had apparently cancelled a family day out for the coming weekend. This led to Child F shouting down the phone to MF and smashing furniture and glass before storming out of the building. A few days after this incident, Children’s Social Care submitted a placement request to the Commissioning Team seeking 24-hour 1:1 support. 7.97 Early Intervention Team records show that there was a CAMHS meeting on the 14th May 2012 that Child F refused to attend. There was no representation from the residential unit. The following day Child F was reported as being anxious and agitated, talking about MF in a negative manner. He then made a disclosure about domestic violence towards himself from MF and MP2, as well as neglect and abuse. Child F was recorded as saying “now do you understand why I hate her”. 7.98 A reflection session between the allocated social worker and Consultant social workers took place on the 16th May 2012. Key points were: • The social worker was concerned that Child F was displaying high risk behaviour and the risk of suicide was increasing • The social worker did not feel that the placement was meeting Child F’s needs and he needed specialist care to address his mental health needs • The social worker expressed frustration that health had not always attended meetings and at one point were considering closing the case • It was noted that there may be a need for referral to the Complex Care Panel – because of Child F’s complex needs 32 • There was a need to refer to Extra Mile (Leaving Care Service) and the Core Assessment needed to be updated • There was also a query as to whether Child F posed a threat to his siblings It seems to be, at this stage, Child F was formally accommodated by Children’s Social Care, becoming a Looked After Child. The rationale being that the complexities of the case meant that it was necessary to secure Child F’s status. 7.99 There was a LAC statutory visit on the 17th May 2012. It was noted that Child F wanted to stay at the residential unit until he was 24 years old. It was also noted that Child F had made a disclosure to staff at the residential unit in relation to domestic violence and physical injury to himself by MP2. On the same day Child FS1 also sustained a fracture of his right clavicle and was treated at hospital. 7.100 On the 18th May 2012 a Care Programme Approach meeting was held. Consideration was made to the possibility of an assessment for Asperger’s Syndrome. It was also noted that Child F had failed to attend for his appointment with the CAMHS Psychologist. The Psychologist with CAMHS was later to close their involvement because of Child F’s non-attendance at appointments. There was some discussion about current risks. It was agreed that his present residential unit was a suitable placement but would need to be reviewed if Child F continued to present a risk to himself. Shortly after this meeting a Complex Case Panel report was completed in relation to ongoing joint Health/Social Care funding for the continuation of the placement. 7.101 The Police received a referral from Bury Children’s Safeguarding Team on the 21st May 2012. Child F had made allegations of historical physical abuse against MF and MP2. The allegations had been made to a member of staff at the supported accommodation. A Strategy meeting between the Police and Children’s Social Care took place on the 21st May 2012. It was decided that no further action could be 33 taken as Child F was reported as saying that he would refuse to be interviewed or cooperate with a Police enquiry. MF had apparently been informed of the disclosure by the mental health practitioner and had notified the local authority that she would not allow any visits to the family home, unless reasons were put in writing. Later on the 28th May 2012 MF refused a home visit from Children’s Social Care and refused any discussion. By the 24th May 2012, Child F was adamant that he wanted nothing to do with MF. His mood was recorded as being low at this stage. 7.102 Child F was seen by his Connexions Personal Advisor on the 25th May 2012. Child F shared information that he was having no contact with his family. There appears to have been reluctance on the part of Children’s Social Care to share the reasons why family contact was not taking place with the Connexions Advisor. 7.103 There was some internal discussion within Children’s Social Care asking why the issues regarding Child F’s siblings had not been progressed. This may have been in part because the allocated social worker (SW2) had left the organisation. 7.104 CAMHS received a fax from MF on the 1st June 2012 detailing a list of unusual behaviours that he had displayed since he was an infant. MF was later to write to Children’s Social Care (dated 16th June 2012) outlining her corrections to the Core Assessment. This was appended to the records. 7.105 There was a statutory LAC Review on Child F on the 7th June 2012. The Early Intervention Team records, at this stage, were also indicating that Child F wished to remain living at his present residential unit address. Child F had refused to attend a LAC medical recently. This was followed up with some energy and successfully by the LAC nurse. Key themes were: • Child F expressed that he was doing better without contact with his MF 34 • Child F expressed the view that no one loved him • New social worker (SW3 allocated). 7.106 Barnardo’s received a referral from Children’s Social Care on the 11th June 2012 requesting advocacy, as Child F had become looked after by the local authority again. An initial assessment was undertaken by the Barnardo’s Advocacy Worker BW1). It was noted that Child F was requesting support with contact arrangements and financial entitlements. 7.107 A meeting took place on the 15th June 2012 between the Children’s Social Care Assistant Team Manager, the Community Psychiatric Nurse, MF and maternal grandmother. The purpose of the meeting seems to be to clarify the outcome of Sect 47 enquiries in relation to the children. The following key points came out: • The Core Assessment had concluded that there should be an Initial Child Protection Conference to look at the safety of the other children in the family • There were no ongoing Police enquiries because Child F would not make a complaint • More information was required about MF’s partner • MF denied any domestic violence, drug or alcohol use in the family. 7.108 MF and family moved to a Manchester address (around 16th June 2012). 7.109 Child F had contact with three siblings FS1, FS2 and FS3 on the 26th June 2012. He was described as anxious and excited but emotionally needy. 7.110 There was a LAC statutory visit on the 27th June 2012 by SW3. Child F engaged well with this visit. SW3 noted that Child F processed information very literally. Later there was a serious incident where Child F tried to attack a peer with a metal bar. 35 7.111 There was another angry incident on the 29th June 2012 when Child F was due to stay with his grandparents for the weekend. He had been in an angry mood most of the day and when leaving the residential unit he pulled the van door off it’s runner, became aggressive towards his grandfather and went back to his flat where he smashed up furniture. Later MF collected him and Child F informed staff he was going to grandparents. 7.112 At the 3rd July 2012 the younger children had still not been referred to Manchester Children’s Social Care. 7.113 In July 2012 Child F had been allocated to a Personal Advisor (Extra Mile Leaving Care) who started an assessment. Child F indicated that he planned to go to College in September 2012. Throughout July Child F had some contact with his siblings. Key events were: • He consistently refused to see the LAC nurse • A Learning Difficulty Assessment was undertaken in preparation for College – he started on the 4th September 2012 • The assessment in relation to autistic spectrum disorder was still awaited • There was a statutory LAC visit on the 24th July 2012- care staff felt there were great fluctuations in his behaviour. 7.114 Child F was seen by the Leaving Care nurse. He engaged well and stated that he was feeling quite good. A Health Action Plan was produced. Child F agreed that the health assessment could be shared with the social worker, GP and carer but refused to allow MF to have a copy. 7.115 On the 31st July 2012 staff at the residential unit contacted the Police to report that Child F was in an aggressive mood and had slashed his own arm. When Police Officers arrived, the scene was described as calm. The wounds were superficial and treated by paramedics. Police Officers did not use their powers under the Mental Health Act. 36 7.116 In July 2012 Child F started work at the Extra Mile Project. 7.117 Staff at the residential unit contacted the Police, on the 5th August 2012, expressing concern about Child F, who had been self-harming, and was threatening to kill himself. Police Officers attended the residential accommodation to find Child F in a calm compliant state, with minor cuts to his arm. He was taken to hospital A&E for treatment and his own safety. It was noted in the CAMHS documentation that there were raised concerns about Child F’s low mood and perceptual disturbances (recorded 6th August 2012). 7.118 When Child F was seen by CAMHS on the 8th August 2012 to review the autistic spectrum disorder assessment, it was noted that there was a significant and rapid deterioration, although the residential unit had not reported any concerns prior to this appointment. Child F had suicidal thoughts and increased aggression. It was thought that cannabis use was a likely significant contributing factor. 7.119 There was a LAC Review on the 8th August 2012 that Child F attended. • Child F presented in low mood • Child F reported that the Community nurse had not brought medication as arranged • There were two incidents recently of Child F cutting himself • When asked if he wanted to harm himself he replied “I’m leading up to it” • Child F said he was applying for College and wanted his own place to live • Staff in residential unit to monitor Child F and contact emergency services if necessary 7.120 In mid August it was noted, in Early Intervention Team records, MF was expressing concern about the suitability of the residential unit in caring for Child F. MF had been informed by the residential unit that 37 Child F had been unconscious and covered in vomit after using alcohol and cannabis. He had been taken to hospital by ambulance. 7.121 Child F was seen by the Consultant Psychiatrist and described thoughts and visions of harming others. It was felt that there were symptoms of depression with significant agitation. Child F disclosed thoughts about ending his own life but said he would not act on these thoughts. Child F reported that he was continuing to hear voices. He disclosed occasional use of cannabis. Medication was prescribed for his agitation – staff at the residential unit took responsibility for this medication, which Child F took occasionally, to aid sleep. 7.122 FF and paternal uncle visited him at the residential unit on the 16th August 2012. Child F was very anxious about the contact. They went out for the day to Manchester. Child F was reported as feeling the contact had been strained. There is no indication how this contact had been established and what Child F made of the relationship with FF. 7.123 There was a Care Programme Approach meeting held on the 17th August 2012. Attended by CAMHS (Consultant Psychiatrist), the Mental Health Practitioner from the Early Intervention Team, and MF. (Child F had been invited but did not attend as had a representative from the residential unit). The main actions being: • Child F to remain at his residential unit • He would remain looked after (Section 20) by the local authority • His mood would be assessed by staff at the residential unit before he went out • Police were to be contacted if he was deemed to be at risk. 7.124 There was a visit to Child F, from a new Barnardo’s advocacy worker, on the 28th August 2012. Child F was described as chatty and positive. On the 31st August 2012 another Barnardo’s social worker called at the supported accommodation to see Child F. In the event Child F was not seen as he was involved in a verbal disagreement with staff. A 38 further visit on the 3rd September 2012 was cancelled as Child F was out shopping with MF. 7.125 During the latter stages of August 2012 and the early September 2012, there were a number of mood changes, with Child F reacting badly to daily frustrations often over small events such as the telephone not working. There were occasions reported when he could be threatening and intimidating. Many agency efforts during this period were focused on sorting out Child F’s grants and benefits and stabilising him in College. 7.126 There were various communications between the Barnado’s advocacy worker and the local authority social worker and Child F’s Connexions Personal Advisor, throughout September 2012, seeking to clarify funding arrangements for Child F. Child F started College on the 4th September 2012. 7.127 There was a CAMHS interview with MF on the 12th September 2012 in relation to the Asperger’s Syndrome assessment. A referral was also made by CAMHS to the Forensic Adolescent Consultation Team to seek their expert assessment of the level of risk towards others. It was noted that Child F’s placement may break down and the transition in Child F’s care as he was approaching 18 years of age may change the nature of risk. 7.128 There was an incident on the 14th September 2012 when Child F had returned from contact with MF. He went to his flat and proceeded to smash the furniture. Child F was pacing up and down and crying, stating that he was going to kill himself. He eventually calmed and was placed on 1:1 supervision throughout the night. MF was informed of the events. The following day MF called at the residential unit to see Child F. He refused to see her. 39 7.129 There was a further incident on the 16th September 2012 when Child F was throwing objects around his flat and refused to speak to staff. He calmed down when he received a telephone call from FF. 7.130 Child F had stopped attending College by the 17th September 2012. After four days of attending he had barricaded himself in his room and refused to leave. The Police had been called to get him out of his room. Child F refused to speak to his Personal Advisor (Leaving Care) when she visited. There were clearly concerns growing about his mental health during this period. Child F was refusing to take his medication and was “trashing his room”. There was a specific concern about suicidal ideation with Child F producing a noose that he had formed. There were some positive elements recorded, including contact with FF and paternal uncle. New medication also seemed to help in improving his mood. 7.131 It was noted (18th September 2012),that the local authority social worker had spoken to the Consultant Psychologist for LAC about their concerns about Child F. It was agreed that The Consultant Psychologist would not become involved, as Bury CAMHS already were. Early Intervention Team and CAMHS informed by Children’s Social Care about the level of concern including concern about the quality of the placement. 7.132 In late September 2012, MF reported to the health visitor that she was not suffering domestic violence and had separated from her husband (she had returned to live in the Bury area). MF reported that Child F visited the family home several times a week. It id not appear that issues of risk to the younger children were picked up again. 7.133 In early October Child F reported that he was not taking his medication any longer. He said that he had stopped going to College because he thought people were laughing at him. 40 7.134 There was also a new social worker from Adults Mental Health (Health and Social Care) introduced in October 2012. 7.135 A Professionals Meeting planned for the 12th October 2012 did not take place. There appears to have been some confusion about this meeting. A professionals meeting took place on the 15th October 2012 to discuss planning with regard to transition in Child F’s care. There were concerns expressed about the suitability of the placement at the residential unit. Following this meeting strenuous efforts were made to try to identify a more appropriate alternative placement that would have been able to accommodate him beyond his 18th birthday but at the time of his death no suitable placement had been found. 7.136 Child F was seen by the Mental Health Practitioner (CAMHS) on the 16th October 2010. Recorded as being okay, no issues. Said to be looking forward to a semi pro fight (cage fighting activity). 7.137 Child F was seen by the Early Intervention Team practitioner on the 7th November 2012. His mental state was recorded as stable and no concerns were raised. It was recorded that the LAC Review had been cancelled. During this period in early-mid November there were no reports of Child F having angry outbursts or trashing his room or references to suicidal or violent thinking. 7.138 On the 9th November 2012, during a visit to Child F by the Barnardo’s advocacy worker, Child F again stated that he did not wish to move from his present placement. 7.139 On the 13th and 14th November 2012 there were reports from the residential unit that Child F had been very agitated and displayed aggressive behaviour. The reasons for this are unclear but it was recorded that he required increased staff support throughout the night. Child F made comments about killing himself. 41 7.140 Child F was seen for review by the Consultant Child Psychiatrist on the 16th November 2012. Child F was said to be complying with his medication (anti depressant). No concerns were noted. 7.141 There was a professionals meeting coordinated by CAMHS on the 19th November 2012. New information was shared: • Child F had set fire to “Gran’s” chair when he was 9 years of age • The residential unit had concerns about his cruelty to animals • There had been attempted intimidation of male staff at the residential unit • Child F had been diagnosed with Asperger’s Syndrome 7.142 There was a visit by the allocated social worker and a social worker specialising in transition for vulnerable young people. Child F refused to get out of bed to speak to them. At this stage there were also reports of Child F displaying aggressive behaviour to a female peer and being in a low mood. The case was allocated to a new social worker (SW4) in late November 2012. 7.143 There was a LAC Review held on the 30th November 2012. Focus on amount of support Child F would need through transition period. Child F and MF attended the review. There was to be liaison with Manchester Leaving Care Service and Manchester Early Intervention Team to progress transfer in services for Child. By and large the transfer arrangements seemed to be very smooth. It was also hoped to transfer Child F to more independent living arrangements. This Plan seems unrealistic and is commented on in the Analysis section. 7.144 Joint visit to Child F, on the 17th December 2012, by Early Intervention Team practitioners from Manchester and Bury. Child F refused to see them. 7.145 Child F was also visited by his allocated social worker on the 19th December 2012. There was agreement about small targets such as going to Connexions and picking up his own medication. Plan aimed 42 at Child F moving to a less structured but quieter environment. Child F also met his Children’s Rights Officer on the 19th December 2012 and they discussed goals relating to independent living. 7.146 On 21st December 2012, Child F went to grandparents for Christmas period. He returned to the residential unit on the 24th December 2012 and was angry and aggressive “smashing up” his flat. He refused to speak to grandparents. 7.147 On the 25th December 2012, Child F was stopped from leaving the residential unit. He was carrying a length of rope. Eventually he asked for medication and handed over the rope to a member of staff. 7.148 Child F was arrested for criminal damage on the 31st December 2012. This related to an incident when he “trashed” his room. It is unclear why there was an apparent change in the management of his behaviour on this particular occasion and it was reported to the Police, with residential staff advocating prosecution. He was reported by care staff as being restless all night with a strong smell of cannabis coming from his room. When his room was checked nothing was found. 7.149 In the very early hours of the 1st January 2013, staff at the supported accommodation contacted Police to report that Child F was smashing windows at the accommodation. Child F was reported as having been drinking alcohol and had not been taking his medication. When Police officers arrived, Child F was calm and described as remorseful. All parties agreed that the issue could be resolved through restorative justice and Child F apologised and agreed to clear up the mess and pay for the damage. It was believed that Child F had been angry and upset because MF had sent him a text wishing him a Happy New Year. 7.150 Several hours later, staff at the supported accommodation contacted Police to report that Child F had sent them and MF a text saying that he intended to commit suicide. Child F was telephoned by a member of staff and agreed to return on the condition that he was not “taken 43 away”. When he did return he appeared drunk and claimed he had no real intention of harming himself. Police officers concluded that at that time he posed no risk to himself or others and he was allowed to remain at the supported accommodation. 7.151 FF and paternal grandfather visited him on the 6th January 2013. Child F refused to see them. Child F ran off and threatened to hang himself. He had also put a ligature around his own neck on the 1st January 2013. 7.152 On the 7th January 2013, staff at the supported accommodation contacted Police to report that Child F was intent upon harming himself and was self-harming by biting his own wrists. As Child F had left the supported accommodation, prior to the arrival of the Police, a high risk Missing from Home search was immediately instigated. Child F was later located and detained under Sect 136 of the mental Health Act and taken to hospital by the Police, accompanied by staff from the supported accommodation. Following a Mental Health Act assessment it was decided that it would not be appropriate to admit Child F to a Psychiatric ward. 7.153 Child F and MF were seen by Clinical Nurse Specialist, Forensic Adolescent Consultation and Treatment Team (FACTS) on the 8th January 2013. They were seen again by the Clinical Nurse Specialist on the 14th January 2013. At this meeting Child F disclosed a potentially serious incident of deliberate self-harm on the 1st January 1013, which involved him using a ligature. Following on from this information the Clinical Nurse Specialist contacted both the Consultant Psychiatrist (CAMHS) and the allocated local authority social worker to express concern about Child F’s ongoing thoughts of self-harm and also the plan for him to move to a less supportive environment when he was 18 years of age. Child F was also offered six therapeutic sessions to help with his social anxiety. 44 7.154 The allocated social worker visited Child F on the 11th January 2013 and found him upbeat and chatty. Discussed how difficult he finds it to engage people and his preparation for independence. 7.155 There was a joint home visit by the Early Intervention Team representatives (Bury and Manchester) for discussion about transfer arrangements. Child F was said to be more settled and up beat and chatty. Case transferred to a new practitioner in the Early Intervention Team. 7.156 There were various contacts by agencies throughout the rest of January 2013. Much agency energy was focused on ensuring a smooth transfer of both geographical (Bury to Manchester) and age related services (Child to Adult). It was significant that Child F was refusing to speak to grandparents. He had not been in contact with them since before Christmas 2012. 7.157 Child F was visited by the CAMHS Psychologist, on the 29th January 2013, in order to discuss the Asperger’s assessment. The draft assessment report was shared with Child F who was said to be quiet in response but not distressed. 7.158 On the 31st January 2013, staff at the supported accommodation contacted the Police to report that Child F had smashed a window after threatening staff and other residents. He was arrested for the damage and taken into custody. Staff at the supported accommodation were consulted about possible prosecution and expressed the view that prosecution was appropriate. Child F was charged and bailed to appear at the Magistrates Court. This was quite a significant change in approach by the residential unit. During this period in January 2013 arrangements were also made for a transfer to a new Consultant Psychiatrist in Manchester. 7.159 Child F was reported by care staff as being in an excellent mood on the 1st February 2013. 45 7.160 On the 3rd February 2013, staff at the supported accommodation contacted the Police to report Child F as missing from home. He had been to visit MF but had left her house at 19.00 hours without saying goodbye to anyone. He was recorded as being high risk of self-harm because of his history. The following morning Child F was found hanged from a tree in parkland. Police treated the death as a Special Procedure Investigation but concluded there to be no suspicious circumstances. 8. CRITICAL CASE ANALYSIS How did your agency collaborate and work with other agencies to undertake the following in relation to Child F: • Assess risk • Assess need • Put services into place • Review and manage risks • Measure outcomes Assessment of Risk Early Assessment 8.1 There were some opportunities for an early assessment of risk in this case. It had been identified in August 2005, during health visitor contact with the family, that there were a number of concerns about previous domestic violence and also that Child F was demonstrating aggressive behaviour towards a younger sibling and threatening to harm himself. MF also said that Child F’s behaviour was worsening. 8.2 There was also information given to the health visitor, by MF that she and the children had lived in a refuge for three months because of domestic violence. Historical information indicates that there were some very serious incidents of domestic violence including significant bruising to MF’s body the day before FS2 was born (2004). Because of 46 house moves, between Bury and Manchester, by the family, some of the information about domestic violence may have been lost to an extent, however, by August 2005 at least some of the concerns about domestic violence were known to the Bury health visitor. 8.3 This information should have been shared with the school nurse and the family GP and could have established an early common information base for further collaborative action. There is no indication from any of the records that this information was shared with colleagues. It seems unlikely for example, from examination of the records, that the school nurse ever knew there was a history of domestic violence in the family. 8.4 There was further information about domestic violence incidents, held by the GP, leading to the need for an operation on her nose for MF. The last of the injuries was reported as being caused around June 2007. This information was indicative that domestic violence, even if said to have been caused by an ex partner, was an ongoing feature within the family. Had the GP, health visitor and school nurse shared common information about domestic violence within the family, it may have offered some insight into the challenging behaviour being exhibited by Child F at that time. The information about domestic violence was to have a significant impact on the direction of the case at a later stage. 8.5 There was also information given by Child F to CAMHS, in the early stages of their involvement (16/12/10), that FF had “hit him once and threw him into a window in 2006. The TV got broken and someone set the house on fire”. Although this is recorded as FF, it is clearly MP2, given the dates and the fact that Child F never had contact with FF. 8.6 This adds considerably to the available information about domestic violence and suggests that Child F was living in a household where there was a high level of violence and intimidation. Unfortunately the information was not shared with other agencies. This emphasizes the 47 need for all agencies to collect information accurately, understand the significance of that information and to collaborate by sharing information. 8.7 There were concerns expressed by Child F’s secondary school (High School 1), leading to anger management input. There were some incidents of physical aggression at school reported in October 2006. Whilst Child F’s attendance was good, his behaviour was seen as problematic. There were various interventions through fixed term exclusions, referrals for individual counseling to Relateen, Child F also spent time in the school Inclusion Unit. He was permanently excluded from High School 1 in September 2009. 8.8 At the stage of exclusion, Child F was referred to CAMHS. Given the referral to CAMHS, and the transfer to another school for Child F, it would have been prudent for the school nurse to discuss their ongoing role with the other agencies. This would have encouraged a more collaborative approach and may have led to information about violence within the family being shared. The possibility of a “drop in” arrangement between the school nurse and Child F was too loose to have any impact. 8.9 During the early stages of Children’s Social Care involvement, there was limited evidence of a collaborative approach. There were a number of referrals to Children’s Social Care, prior to Child F’s remand into the care of the local authority. These were determined as being below the threshold for Children’s Social Care intervention. These included referrals for Child F being missing from home, serious mental health problems requiring hospital admission, unsuitable accommodation and threats of suicide. 8.10 There was an increasing build up of concerns, culminating in an admission to a specialist mental health unit, when Child F, expressed both suicidal thoughts and thoughts about harming others. It was only when discharge from the mental health unit was being 48 considered that Children’s Social Care undertook an Initial Assessment. 8.11 Within the Initial Assessment process, Child F was seen by the allocated social worker. There was also evidence that MF, maternal grandparents and professionals had been consulted. 8.12 The Initial Assessment, however, failed to identify any issues of domestic violence, or the issue of MP2’s imprisonment. The conclusion was that there were “no child protection concerns”, was seemingly based on a very narrow definition of safeguarding and did not adequately consider either Child F’s welfare or the welfare of his siblings. The conclusion also suggests a limited understanding of the continuum between children in need and child protection. 8.13 There is a sense that the gate keeping mechanism used by Children’s Social Care in the early stages of involvement with Child F and his family was too inflexible and their primary aim was to protect the agency from resource demands rather than identify children in need. This is an issue that has been identified in research on Serious Case Reviews (Brandon et al 2012). 8.14 In the early stages of Child F’s involvement with CAMHS there was an emphasis on the assessment of risk to others. This was understandable in the context of Child F’s first admission to the mental health unit. Part of the rationale for Child F not being discharged to his home address was to reduce the risk to his siblings. It should be added that Child F did not wish to return home at this point. Had the information about violence by MP2 been understood accurately it may have widened the scope of intervention. 8.15 The placement with Child F’s uncle was dealt with too casually by those professionals working with Child F. There was very little information available about the circumstances relating to the uncle and his capacity to manage Child F. There also should have been 49 more interagency assessment about whether it was appropriate for Child F to be cared for by his uncle, and what arrangements there were in place, if any, for supervision of any contact Child F might have with his siblings. There was also very little monitoring of this arrangement. At an early stage Child F had returned to the family, although the circumstances in which this occurred were not explicit. Ideally there should have been a risk assessment before the return home was considered. 8.16 There were also issues about whether risks were confined to his siblings or were more generalised. Child F, for example, although the extent of this fluctuated considerably, had said since December 2010 that he had thoughts about harming himself and others. There was no indication that his risk to the wider community was considered. 8.17 He had already been permanently excluded from one school because of a violent attack upon another pupil. The significance of this and the wider propensity for impulsive aggressive actions does not seem to have been considered as carefully as it should have been in consideration of placements. 8.18 A much better approach to the discharge would have been for Children’s Social Care in collaboration with CAMHS and the Early Intervention Team to undertake a more systematic assessment about the arrangements for Child F to live with his uncle and also for future placements. The closure of the case by Children’s Social Care on the 4th January 2012 was not appropriate. There were certainly enough identified needs and complexities to warrant a more detailed Core Assessment. 8.19 There was also a possible lack of clarity between agencies about follow up plans after discharge. The Children’s Social Care records there was to be no further action by Children’s Social Care and that High School 2 would undertake a Common Assessment Framework (a mechanism for agency assessments that fall below the criteria for 50 Children’s Social Care involvement). Conversely, CAMHS records say that Children’s Social Services involvement is to be “put in place”. Risk Assessment at the Crash Pad 8.20 Child F packed his bags and left the family home on the 7th November 2011. He presented himself at Connexions as homeless on the 8th November 2011. This was clearly a critical incident that required agencies to be working closely together. 8.21 There seemed to be an impasse initially, based around the fact that MF said he could return to the family home if he wanted. Housing argued that this meant he could not be homeless. From the recorded information there seem to have been protracted discussions between Connexions, Housing Office, Children’s Social Care and the Early Intervention Team in order to access a place for Child F at the Crash Pad. 8.22 Discussions then focused on the level of risk that Child F might pose to other people. A place at the Crash Pad was eventually secured through a mental health assessment by the Early Intervention Team. It is interesting that this is the first time that Child F’s wider risk to other people in the community was considered. 8.23 There are significant issues of escalation of risk that were not adequately addressed by any of the agencies. The Crash Pad is intended as the name implies to be an emergency placement only. Child F remained there until the 1st March 2012 when he was arrested by the Police and subsequently remanded into the care of the local authority on the 3rd March 2012 and placed with emergency foster carers. Some of the wider issues about assessment of need with homeless young people are picked up in the following section (Assessment of Need). The concept of a young man with serious mental health problems living in the environment of the Crash Pad for over six months is unacceptable and may well have added unnecessarily to his poor mental health. 51 8.24 Over November and December 2011, there were a series of increased concerns about Child F’s mood whilst he was staying at the Crash Pad. On the 30th January 2012 he was admitted to the specialist mental health unit with low mood, suicidal ideation and auditory hallucinations instructing him to hurt himself and others. By the 10th February 2012 there was a significant improvement in symptoms and he was discharged. It was agreed that he could return to the Crash Pad following a risk assessment. 8.25 It is difficult to see how a risk assessment could support a return to the Crash Pad, or how a risk assessment could support an arrangement for an extremely vulnerable young man to live in emergency accommodation for this period of time. There should have been a formal challenge about these unsatisfactory arrangements. It should have been clear that the Crash Pad arrangement was likely to increase risk both to Child F and others. Risk Assessment After Remand to Care 8.26 Child F appeared at Court on the 3rd March 2012 for attempting to stab his MP2, following an incident where Child F was threatening to jump from a Motorway Bridge. The Police had returned Child F to the family home and armed with two knives he attempted to stab MP2. The Police had to use a taser gun in order to subdue him. Child F was seen by the duty Psychiatrist at A&E and discharged from hospital to Police custody as there was no evidence of affective disorder or psychosis. 8.27 The risk assessment undertaken by the Youth Offending Duty officer had a solid foundation. The assessment was undertaken using recognised national guidance through ASSET documentation. In the course of the Assessment Child F disclosed that there had been domestic violence within the family for 10 years. Child F also talked about wanting to hurt himself. There was good evidence of 52 appropriate communication and collaboration between the YOT Duty Officer and the Duty social worker. 8.28 Child F was placed initially (as an emergency placement) in a foster placement. Given the emergency nature of the situation, this was a reasonable choice of placement. The risk assessment undertaken by the YOT worker was as full as possible in these circumstances. On the 9th March 2012 he moved to a residential placement, described as “supported lodgings”. As he was not remanded to the care of the local authority and young people were expected to live independently the residential establishment was not regulated by Ofsted. This is covered in more detail in the next section. It should be stated, however, that although there was ongoing consultation between mental health and children’s social care staff about the residential placement there was no real evidence from assessments that the placement was suitable and there was a distinct possibility that an inappropriate placement would heighten risks. 8.29 The level and source of risk was never determined properly. It had been decided in a Placement Planning Meeting held on the 13th March 2012 that the residential supported accommodation should be tried out for 3 months. It was also decided that a Core Assessment should be completed and an Initial Child Protection Conference held. The duty Independent Reviewing Officer declined to hold a Child Protection Conference on the basis that the Core Assessment had not been completed on the siblings, MF had responded appropriately to Child F and his siblings. No information from school had been collected on the siblings, hence the threshold for likelihood of significant harm was not met. 8.30 There are sound arguments that more information should have been collated prior to consideration about a Child Protection Conference. The focus was very much on the risk posed to the younger siblings of Child F. Given that there were consistent reports that Child F had experienced thoughts about hurting people (and command auditory 53 hallucinations) and that he was reported to have held a knife to a younger sibling there were potential risks to the younger siblings that could have been legitimately explored through the mechanism of an Initial Child Protection Conference. Section 47 Enquires, however, should have commenced when Child F was staying at the Crash Pad and having contact with his siblings. 8.31 This was particularly relevant given the likelihood that Child F would spend a considerable amount of time throughout the coming months having contact with his younger siblings. At one stage, for example, there was an arrangement in place for Child F to spend the daytime at the family home, returning to his accommodation at the Crash Pad in the evenings. Presumably this arrangement would have meant a strong possibility that Child F would have contact with his siblings. 8.32 There were also wider risks that had been identified in relation to the younger siblings and MP2. During the course of the ASSET assessment, completed in early April 2012, Child F had disclosed that there had been domestic violence for ten years within the family. This should have led to considerations about the safety of the younger siblings. The focus of any Section 47 enquiries should have encompassed possible harm to the children because of domestic violence. 8.33 These issues do not appear to have been picked up at the time, although they arose again, in May 2012, when Child F made further disclosures about domestic violence to himself inflicted by MP2. This led to a Strategy Meeting between the Police and Children’s Social Care. This was a sensible collaborative approach although a combination of Child F’s unwillingness to formalise the allegations, resistance by MF to allow the social worker (SW2) to visit the children, and poor case management by Children’s Social Care meant that the Core Assessment of Child F’s siblings was never completed. 54 8.34 The move to Manchester by the family, in June 2012 should have lead to a referral being made by Bury Children’s Social Care in relation to concerns about the children. There was no record on information held by Bury or Manchester that this referral had been made prior to the commencement of this Serious Case Review process. This is clearly a significant flaw in communication. It is likely that poor managerial oversight led to this problem. 8.35 Whilst at the Supported Accommodation, there were ongoing assessments of risk. A particularly key point in Children’s Social Care work was a session held, in mid May 2012, with the allocated social worker and consultant social workers. These sessions are designed to allow practitioners to reflect on complex cases. The allocated social worker made a number of points. • The social worker was concerned that Child F would kill himself either accidentally or intentionally • The social worker did not think that the Supported Accommodation was suitable for Child F’s needs • The allocated social worker was concerned about the risk that Child F may pose towards his younger siblings 8.36 Although concerns about the suitability of the placement were brought to a Complex Care Panel and joint funding agreed between Health and Children’s Social Care it was also acknowledged that concerns about the suitability of the placement remained and efforts were being made to find another placement. At the point of Child F’s death an alternative placement had still not been found. Although staff at the Supported Accommodation Residential Unit clearly made considerable effort to safeguard Child F, they were not resourced adequately to meet his needs and did not have the knowledge or skills necessary to manage this very vulnerable young man. 8.37 This issue is covered in more detail in the following section (Assessment of Need). A key point impacting upon finding a suitable placement lay with Child F’s mental health diagnosis. Without 55 the diagnostic status, of a “serious mental disorder”, he would not meet the criteria for specialist placement. This “criteria” seems particularly inflexible and leaves young people, where the diagnosis is as yet unclear, in an extremely vulnerable position. Specific Issues - Assessment of Risk 8.38 Within the timeframe of this Serious Case Review, the Police dealt with eighteen incidents involving Child F. There is good evidence that throughout their dealings with Child F the Police responded both sensitively and appropriately. The potential for self-harm or suicide was taken very seriously. This is illustrated by the incident in April 2012 when it was reported to the Police that Child F intended to throw himself off a Motorway Bridge. The Police closed the Motorway, detained Child F for his own safety and escorted him to hospital. 8.39 There was also clear evidence that the Police took risk assessments by partner agencies seriously and also used their own intelligence about Child F’s previous history to help inform decisions about actions that were required. 8.40 There was also appropriate challenge about the rationale for medical decisions about Child F. Following the incident on the 7th May 2012, when Child F was found by the Police after being reported missing from the Supported Accommodation. As Child F was in an aggressive and volatile state he was detained for his own safety and taken to hospital. The decision of the examining doctors that Child F could return to his Supported Accommodation as he was receiving adequate support in the community was queried by the Police Officer who maintained a position that Child F was “high risk”, that the suicide attempts would continue and Child F may succeed in his attempts. 8.41 There are some significant problems in risk assessment for suicide prevention. Maximising the effectiveness of risk assessment is dependent upon there being good quality reporting systems of those working closely and directly with the young person. Frequent 56 fluctuations in behaviour or mood for example may escape a clinician in the course of a single review or consultation with the young person. 8.42 With Child F, these mood changes were constantly in flux. The Leaving Care Personal Advisor and the social worker for example both commented on how Child F had a different presentation each time they visited. “Sometimes he would be elated and at other times sad and lacking motivation. At his worst his thoughts were negative and he spoke of harming himself”. 8.43 Good quality reporting systems, however, in turn are extremely reliant on having staff who are suitably trained and experienced to pick up on the importance and meaning of changes in behaviour from the young person. 8.44 There had been concerns expressed about the Supported Accommodation because of the capacity of the staff to manage Child F’s difficulties, These concerns were expressed in a number of different areas. • There were some incidents that were not being reported to the local authority allocated social worker. There was one particularly serious incident over the New Year 2013, where a telephone message from the Supported Accommodation Unit had been left for the allocated social worker when the urgency and seriousness of the incident should have led to contact with the duty officer • Reports from the Supported Accommodation had originally been built into the placement agreement on a monthly basis but had not been regularly produced • The level of support seemed less than the 30 hours per week that had been commissioned 8.45 All of these factors meant that there was not always a complete picture given of Child F’s changing presentations that would contribute to a more reliable risk assessment. 57 8.46 Child F presented at hospital on a number of occasions and was seen by duty Psychiatrists. These events occurred when there had been a serious incident and he was detained by the Police for his own safety. Child F was frequently intoxicated in these circumstances and was seen by medical staff who did not know him, were unfamiliar with the detail of his history. This coupled with his complex presentation and needs must have made formulation of a diagnosis difficult. 8.47 The Overview Report author is surprised that Child F was not admitted to hospital following the incident, on the 7th January 2013, when he had been detained and taken to hospital by the Police. On this occasion, Child F had been found by the Police with a shoelace around his neck. The assessment under the Mental Health Act decided that it would not be appropriate to admit him. There had been an incident a few days earlier when he had been found with a ligature around his neck. Child F was seen by practitioners from the Early Intervention Service and the Adolescent Forensic Service. There was no indication from the Serious Case Review documentation that the recent incident on the 7th January 2013 was discussed with him. Assessment of Need 8.48 As would be anticipated, given Child F’s complex needs, there were a number of different agencies, with different foci addressing his needs. 8.49 There were concerns about Child F’s mental health, particularly in relation to psychotic symptoms. This was assessed by the Early Intervention Team. There was also a reassessment when psychotic symptoms persisted, in line with good psychiatric practice. It was identified that Child F required anti-psychotic medication and this was prescribed. 8.50 Child F was also referred for psychological therapy to treat symptoms of stress, following what was considered to be post-traumatic stress resulting from a physical assault he had previously experienced. Child F did not attend for psychological therapy. This seems to be a 58 significant gap in his treatment plan. Some systematic reviews of suicide prevention research suggest for example that “there are promising results in reducing repetition of suicidal behaviour and improving treatment adherence exist for cognitive therapy, problem solving therapy, intensive care outreach and individual psychotherapy” (Mann et al 2005). 8.51 It would also have been relevant to have considered psychological therapy for the impact of living in a violent household had there been a more clear understanding of these issues in relation to Child F. 8.52 From an early stage of intervention, Child F was placed on a Care Programme Approach (CPA) that is used to co-ordinate care and assess the needs of people with severe and enduring mental health problems. Child F was also given advice on the links between cannabis use, alcohol use and psychotic symptoms. His depressive moods were also monitored closely and he was prescribed medication when he met the criteria for a depressive episode. 8.53 There were some significant difficulties in assessing Child F’s needs. There is a good deal of evidence that Child F’s mood and symptoms were prone to very sudden fluctuations. There were also a number of occasions when Child F refused to take medication, making it more difficult to monitor the effectiveness of medication on symptoms. It is difficult to determine from the Individual Management Reviews how the medication was monitored. 8.54 There was additional mental health assessment through the Adolescent Forensic Service (FACTS). At the time of Child F’s death, this assessment was ongoing, although it had been identified that Child F presented with social anxiety and he was offered an initial six sessions to help him deal with this issue. This was a helpful intervention, although help for Child F with social functioning and anxiety should have been identified much earlier. 59 8.55 There was also an assessment of Child F in relation to the possibility of Autistic Spectrum Disorder This diagnosis was confirmed in October 2012 but not given to Child F until January 2013. The delay is thought to be because of capacity pressures due to funding reductions. 8.56 Overall the assessments of need undertaken by mental health services were comprehensive. The involvement of the Early Intervention Team because of symptoms of possible psychosis was appropriate as was the referral to the Adolescent Forensic Service. 8.57 There was evidence of good communication with other agencies through professional’s Planning Meetings and the Care Programme Approach. One element that may have caused some confusion for other agencies was the different diagnoses and that were being suggested. At various times there were suggestions of: • psychotic episode • mixed disorder of emotion and conduct • adjustment disorder • dissociative symptoms • depression • autistic spectrum disorder. • 8.58 It was not always clear from other agency information that all agencies understood the differences between these diagnostic criteria and what it might mean for Child F’s behaviour. 8.59 Although there appears to be a strong emphasis on diagnosis and monitoring of Child F’s progress there seems to be little direct involvement in therapy for Child F. It had been identified, for example that Child F was socially anxious but it was not until the involvement of the Adolescent Forensic Service that sessions for social anxiety were offered. 8.60 Similarly Child F clearly had problems with anger management and impulsivity. There did not, however, appear to be any therapeutic 60 input related to these issues. This raises some questions about cross agency collaboration and whether creative thinking about the role of the Psychologist working with Looked After Children (LAC) would have added therapeutic value. They could have had an important role to play in therapeutic help for Child F and were clearly willing to be involved. The input of psychological therapy should have been reconsidered in April/ May 2012 when it emerged that there had been domestic violence within the family over a lengthy period. 8.61 Referrals to Children’s Social Care about Child F’s homelessness, the lengthy placement at the Crash Pad and his mental health problems should have led to an assessment of need. The fact that they did not has implications for the threshold criteria that Children’s Social Care are operating to determine if children are in need. 8.62 As a homeless young person, there was a duty on the local authority Children’s Service to assess Child F’s vulnerability and to determine whether he needed to be accommodated under Section 20 of the Children Act or supported through Section 17 of the same Act. There was avoidance by Children’s Social Care of these responsibilities until the Criminal Court, in recognising Child F’s vulnerability, remanded him to local authority care. This was a serious shortfall in service provision. It is of concern that Children’s Social Care seemed unaware of the increased risk of self harm because of homelessness. 8.63 Similarly, when the remand period had expired, a decision was made to discontinue Child F’s looked after status. Given the very obvious level of Child F’s needs and his clear vulnerabilities, this was inappropriate. Child F should have retained his looked after status in order to ensure planning and monitoring processes were in place to support him. It was only when the Core Assessment had been completed that the need for LAC status was agreed. 8.64 There was a particularly unhelpful disagreement between agencies around Child F’s needs when he became homeless. It was clear that 61 Child F was vulnerable at this time and the situation called for a collaborative and joint approach from agencies. Initially, however, there was an unwillingness to acknowledge his homeless status (because MF was willing to allow him home). It was only when the debate moved, more realistically to the danger he might pose to others, that progress in obtaining Child F an emergency placement at the Crash Pad was achieved. One of the key lessons from this case is the need for a collaborative strategic approach in dealing with vulnerable young people who are homeless. 8.65 During the period in placement from March 2013, there was evidence of energetic and collaborative efforts in planning Child F’s future care and helping him in the transition to adulthood. His health needs were assessed and addressed by the Looked After Children nurse. His mental health was regularly reviewed by the Consultant Psychiatrist and his medication changed to manage presenting symptoms. 8.66 The allocated social workers (SW3 and SW4) along with the Personal Advisor (Leaving Care Service) and Connexions worker met regularly and exchanged information to support Child F. In particular, there were active attempts to help him manage his social isolation more effectively and involve him in positive activities to improve his social integration. 8.67 There were, however, major issues emerging about relationships within the family that were never addressed by practitioners. The use of empathetic relationships to explore and make sense of seemingly disturbed behaviour is an important tool for the practitioners. There is little evidence in this case that there was a focus on helping Child F unpick many of these feelings, particularly those about MF and his place within the family. There seems no thought, for example, about the sudden introduction of FF and the possible impact of this on Child F. 62 8.68 There was also a lack of appreciation of quite complex heritage issues and the meaning of these for Child F. Although Child F was White British, his younger siblings were mixed race and MP2 was described as mixed race. One of the critical issues repeatedly emerging from this Serious Case Review is Child F’s expressed feeling that he is not part of the family. Although issues of racial heritage were not specifically stated in the terms of reference of the Serious Case Review, it was disappointing that the Individual Management Reviews did not address this important area. Putting Services in Place 8.69 In terms of mental health services, Child F had a comprehensive Care Package. There was evidence of plans in effect to transfer to an equivalent Adults Services package that included. • Consultant Psychiatrist review and medication • Individual therapy, including psychology • Social worker • Accommodation • Regular Care Programme Approach 8.70 Care coordination and coordination of services was well organised. Although there was a need for practitioners to change because of the transfer of services to Manchester, and the move to Adult services, the family and Child F were consulted about these service provision changes. 8.71 Once Child F became a Looked After Child within his residential Supportive Accommodation there was much more of a supportive structure to develop plans for services. The Personal Advisor (Leaving Care) and the allocated social worker (SW3) jointly undertook a needs assessment out of which a Pathway Plan was developed. There was a good deal of emphasis in the Plan to the need for Child F to build up a range of self-help skills as part of the Care Plan. This was sensible given the transition to Adult Services. 63 8.72 The Care Plan was not of a reasonable standard. This is not an issue relating only to this particular case. In general Care Plans, nationally, are not specific enough, with the young person’s needs being central to the Plan. This tends to mean that outcomes desired and actions required are seldom detailed enough to have any real meaning or relevance for the young person. There is also a tendency in complex cases for individual agencies to take on discrete tasks (agency related) without there being a well thought out joined up multi-agency joint response. In the various plans set out for Child F, for example, apart from one brief reference to “life story” work, there is no real indication that any ‘talking therapies” took place in relation to any agencies. 8.73 Reviews for the Care Plan were not within timescales and records of one significant Care Plan review were not written up until two months after the Meeting. This leaves those practitioners working with children without documented plans to refer to. Review and Manage Risk 8.74 In relation to the Police, the review and management of the risk to Child F and others was coordinated by the specialist Police Protection Investigation Unit (PPIU). The response Officers who had dealt with Child F referred incidents to the PPIU. These incidents were then reviewed within the PPIU, particularly in relation to assessment of risk. The referring details of incidents were then sent to partner agencies, as appropriate. 8.75 There was evidence from the documentation that this process was very efficient in ensuring that good quality information reached agencies in a speedy and easy to follow format. It also meant that risk was continually reviewed. This highlights good practice in information exchange. 64 8.76 Mental health services, followed NICE guidance in their management and review of risk. It was recognised that Child F had most of the identified risk factors for self-harm. 8.77 Overall mental health services were well managed, with regular systems for monitoring and review. There was also evidence of the appropriate use of specialist services (Adolescent Forensic Service). Often specialist services brought into a case can offer an objective additional opinion. The identification, for example, that Child F may benefit from work on social anxiety was a useful contribution. 8.78 Transition from Children’s to Adult Services is always a potentially difficult time for the service user (and service providers) in terms of the introduction of new workers, sharing information and ensuring plans stay on track. The impression given, in examining documentation, is that the arrangements for managing transition were relatively smooth and well coordinated, although there were still major decisions to be made about a future placement. 8.79 There are possibly some queries raised about the different diagnoses being applied to Child F. This will have been complicated by the number of Clinicians who saw Child F and the circumstances in which they saw him. The issue is not so much that a formal, firm diagnosis was not made, rather that the diagnostic status has significant meaning for those commissioning services. This issue needs to be examined by Commissioning agencies. 8.80 Risk was reviewed and assessed by Children’s Social Care throughout their involvement from the point of being remanded in the care of the local authority. There was a good use of the social work consultant in reflecting on and reviewing risk when the social worker was expressing serious concerns about Child F harming himself. 8.81 When Child F was first placed in an emergency foster placement it was assessed that he did pose a risk to risk to other children and he 65 was moved to a residential unit. This was a planned and well-managed move in potentially difficult circumstances. 8.82 There should have been an assessment of the risk that Child F posed to his younger siblings. He had clearly resumed contact at the family home during his time at the Crash Pad. The need for such an assessment appears to have been completely overlooked. 8.83 The initial allegations about domestic violence and being physically assaulted by MP2 emerged during the ASSET assessment and were repeated by Child F to staff at the Supported Accommodation Unit in May/June 2012. Although there was a line manager request to commence an assessment through Section 47 Enquiries this did not take place. Similarly when the family moved geographical and administrative localities, the new local authority where the family had moved were not informed of concerns in relation to the family. This was a significant failing. 8.84 Risk assessments were in place at the Supported Accommodation unit, although it was unclear as to their quality or whether plans to manage risks were fully implemented. This was particularly important in the light of his frequent “missing from care“ status. There was a failure to consider the suitability of the accommodation in terms of Child F’s needs or whether staff had the skills or capacity to manage him safely. These issues were raised by both the allocated social worker and MF as well as doubts expressed by CAMHS. The risks in maintaining Child F at this placement should have been part of an ongoing formal assessment. Measuring Outcomes 8.85 The measurement of outcomes in Children’s Social Care was through the Pathway Plan and the Care Plan. As indicated earlier in this Overview Report, the Care Plan was of poor quality and not detailed enough to have real meaning. 66 8.86 The Pathway Plan whilst covering more detail contains a litany of failures to meet Plans. These include “not in education or employment”; “not learning independence skills”. There was no indication of clear intended outcomes and the detailed actions required to achieve those proposed outcomes. 8.87 There were some outcome measures that were partially completed in Mental Health services. These included using a scale to monitor symptoms of psychiatric illness, particularly psychotic disorders. Had this been repeated at a later date it would have offered useful comparative information. Similarly another scale used to measure low mood was completed in December 2011 but was not repeated. Some of the difficulties in administrating these scales may have been due to Child F’s reluctance to complete some treatment modes. 8.88 The Supported Accommodation staff did complete daily records of Child F’s mood, for monitoring purposes but it is difficult to determine how accurate these records were or how useful they were in terms of monitoring Child F’s mood changes. How was the relationship between Child F and MF and family assessed? 8.89 Overall, there was no formal assessment of the relationship between Child F and MF. Connexions had some contact with MF but this was largely for information exchange purposes and mainly dealt with factual information such as benefits. 8.90 During Child F’s early life his behavior towards and interaction with MF were considered along with other developmental assessments. This information, held by community health agencies, is outside the timescale of the Serious Case Review but it does indicate a number of important points: • There was no evidence to support a diagnosis of Asperger’s syndrome within early developmental assessments 67 • Child F had exhibited behavioural difficulties, angry outbursts and aggressive behaviuor. • Child F was described as having a difficult relationship with MF. 8.91 There was regular contact between Mental Health Services and MF. Practitioners were aware that the relationship between Child F and MF had broken down. 8.92 MF was described, by mental health staff, as being consistently warm and caring towards Child F. There was no formal relationship work as part of the therapeutic programme. This was particularly surprising as it was clear, from a reading of the documentation, that many of Child F’s emotionally heightened responses were linked to interactions with MF. 8.93 A reasonable hypothesis, from the available information, would be that there may have been some bonding issues because of the non-involvement of FF. Certainly early records describe a difficult relationship between a very young Child F and MF. The loss of MP1, who Child F viewed as a father and the later impact of domestic violence may have left Child F questioning his place within the family and leaving him with angry feelings towards MF. There are some occasions when Child F articulates this anger, linking it very much to feelings of not being wanted by MF. What consideration did your agency give to the impact of domestic abuse, parental substance misuse and adult offending on the wellbeing of Child F? 8.94 Until May/June 2012 there was very little focus on the impact of domestic violence. This was essentially because domestic violence had not been recognised by key agencies as being a factor in this case. Where it had been recognized information had not been shared between agencies. This suggests a poor understanding of domestic violence and the impact on children, either directly or indirectly. 68 8.95 There was information available about domestic violence. Documentation from health visitor records, in 2005, shows that MF had bruising down the side of her body caused by her partner (MP2). This incident seems to have led to a “refuge being found” but the records indicate that MF went into labour and returned to the family home after the birth. 8.96 There was additional information about domestic violence contained in GP and health visitor records that refer to two serious incidents of domestic violence that occurred in January 2005 when MF suffered a fracture of her nose. The second assault was in June 2007 when MF suffered a nasal injury and was referred to ENT for surgical intervention. Child F was 9 years of age at the time of the first assault and 12 years of age when the second assault took place. Midwife records confirm the assault in 2005. 8.97 There was also information collected about violence shown towards Child F when the CAMHS assessment was undertaken in December 2010. Unfortunately this was recorded inaccurately as FF (not MP2) and as such it is likely that the significance was misunderstood. 8.98 Additional information about domestic violence was available in April 2012 when, in the course of completing the ASSET management assessment, Child F spoke about domestic abuse that had been occurring in the family for 10 years and how he had lived with MF in hostel accommodation in 2006. There is no indication that the significance of this information was acted upon. 8.99 Further information about domestic violence emerged in May 2012 when Child F told his care staff, at the Supported Accommodation unit, he had in the past been kicked and battered by MP2. Child F talked about missing out on his childhood and how home was not a safe place to be. He also alleged that MF was uncaring. There was a sense of Child F feeling that he had never been loved and there was considerable anger towards MF. 69 8.100 The information did lead to consideration between the Police and Children’s Social Care about the need to video tape an interview with Child F for evidential purposes. (Child F refused this and also declined to make a statement). 8.101 It also led to seeking further background information. This showed that although there was no additional information about domestic violence, MP2 had a criminal history of drug use and drug dealing. A decision was taken within Children’s Social Care to update the Core Assessment. Recorded notes show that by 31st May 2012 Children’s Social Care were actively looking at an assessment of Child F’s siblings. 8.102 By the middle of June 2012 MF and the children had moved to Manchester. It is unclear when the exact move took place, however, it is known that MF was informed of the concerns about domestic violence by the Community Psychiatric Nurse at the end of May 2012. It is unlikely that this sharing of information with MF was agreed between agencies and could have had a serious impact on the management of allegations. 8.103 A meeting between MF and Children’s Social Care representatives with Maternal Grandfather and the Community Psychiatric Nurse, on the 15th June 2012, sought to clarify these issues about domestic violence allegations and risk to the children. MF was opposed to the children being seen. 8.104 The opportunity to undertake an assessment was lost through a lack of decisive action and the move to Manchester meant that the local authority would pass over responsibility to another local authority (although this clearly did not happen until the Serious Case Review process identified that this was an outstanding action). There is evidence from Serious Case Reviews, on a national basis, that movement between geographical areas can lead to significant 70 problems in communication and information sharing. This Serious Case Review echoes those findings. 8.105 The key issue that is worrying is that there were extremely significant pieces of information that were not identified by either Children’s Social Care or Mental Health Services until 2012. Both CAMHS and Children’s Social Care had undertaken assessments without uncovering the significance domestic violence. Information was readily available from Health Visitor services and the GP about injuries to MF. This information does not seem to created any concern with the GP or Health Visiting service given that MF had two young children and MP2 returned to the family home in February 2012. 8.106 There are a number of implications. Significant elements of Child F’s behaviour and relationships may have been impacted on by his exposure to domestic violence. Research is explicit about the very serious impact domestic violence can have on children, either through a direct increased risk of physical injury, or the emotional distress of witnessing or being aware of violence (Cleaver et al 2010). 8.107 There can also be a serious impact on the capacity of the carer to fulfill their caring responsibilities to the children. There is an overall impression that Child F’s relationship with MF was strongly influenced by the exposure of the family to domestic violence. 8.108 Apart from immediate action to protect Child F’s siblings in May 2012, there should have been consideration of further work that could have taken place with Child F, as part of his Care Plan and Pathway Plan to address the issue of the impact of domestic violence upon him and how that had in turn damaged the relationship between Child F and MF. This area of work does not appear to have been considered by either Children’s Social Care or by Mental Health services. 8.109 There is also a serious issue about collecting and analyzing assessment material. Had there been discussions between the GP, 71 Mental Health services, Children’s Social Care and Health Visitor services, it is likely that the domestic violence issues would have emerged at a much earlier stage and given context to some of Child F’s responses. There were several opportunities when these discussions could have taken place. During the mental health assessments and the core assessment there were key opportunities to collect and share accurate information. 8.110 In terms of the management of domestic violence issues. There were opportunities to control some of these events. MP2 was released from Prison, on license in early February 2012. There was discussion between the Probation Service Offender Manager and Children’s Social Care as part of the arrangements for where MP2 would live whilst under license. At that time however Children’s Social Care had no information about previous domestic violence and had closed the case. 8.111 Similar discussions between the Offender Manager and the Police Domestic Violence Unit confirmed that there were no domestic abuse incidents recorded. The first occasion the Offender Manager knew about the domestic violence incidents was when information was being collected for this Serious Case Review. 8.112 Had these incidents been known about it would have allowed a robust discussion between the Offender Manager and Children’s Social Care about whether MP2 would have been allowed to reside at the family address. 8.113 There was an additional opportunity to share information in April/May 2012 when the ASSET assessment revealed domestic violence and also when Child F spoke about incidents. The fact that the Offender Manager was not informed that domestic violence was a key factor suggests a lack of understanding by agencies about license conditions in these circumstances. 72 8.114 There is no documented information indicating that parental substance misuse or adult offending was ever considered by any of the agencies involved with Child F in terms of the impact on him. There was some work undertaken with Child F on his use of cannabis and alcohol but that seems to have had minimal impact. Was information shared appropriately with other agencies and was information shared with your agency appropriately by other agencies? 8.115 Generally information sharing between agencies was reasonably good with evidence of regular and routine updating of individual agency involvement and sharing information on key events. As with any case as complex as this, there were some gaps in information sharing. These gaps, however, were critical in this case. • There were a number of examples where information from the Supported Accommodation unit was either not given or the need for urgency of information transmission was not appreciated ( the concerns in early January 2013 for example) • The failure of Children’s Social Care to pass on information to a neighbouring authority when the family moved accommodation, in June 2012, was potentially very serious • The failure of agencies to undertake a full and comprehensive assessment using accurate historical information was to have an impact on the understanding of the case • The action taken to inform MF about concerns about the other children in the family (May 2012) was inappropriate and may have impeded protective responses by agencies • Some agencies such as The Children’s Rights Service were not given information about domestic violence occurring in the family • The Probation Offender Manager was not given vital information about domestic violence that might have led to significant changes in the management of the case. What approach does your agency have to address the issue of young people not engaging/becoming disengaged with your service? 73 8.116 There is good evidence that agencies were persistent in efforts to engage with Child F. In particular the Looked After Children Nurse carefully engaged with Child and the manager of the residential unit, leading to a successful intervention with Child F. 8.117 There was also very good engagement by the Leaving Care Personal advisor and also the Connexions worker. 8.118 Mental Health Services engaged reasonably effectively with Child F, although as with many young people, there were occasions when he refused to be seen or to complete elements of treatment, notably his medication. There was a delay in discussing the diagnosis of Autistic Disorder Spectrum with him. This seems to have been done thoughtfully and sensitively. It seems unlikely that this discussion had a bearing on the suicide. It was disappointing that Child F was unwilling to see the Psychologist for therapy and it would have been helpful to consider other strategies to engage Child F in these therapeutic sessions prior to closing the case. 8.119 There was also ongoing engagement with Children’s Social Care through social workers, the Children’s Rights Service and there were examples of occasions when Child F had disclosed important information to care staff because of their engagement. There were however also occasions when Child F disengaged and refused contact. When this did occur, practitioners continued to actively retain contact with Child F. 8.120 What does stand out however, despite the involvement of numerous professionals, is that there is such little evidence of Child F’s feelings about his relationship with the family and particularly MF being explored. The marked ambivalence in this relationship does come out in flashes of anger during particular events and incidents. There is no indication that specific focused work on this relationship was considered. There should have been cross agency discussions about how to address this area of work. This does suggest weaknesses in the 74 child protection system in multi-agency work for determining where the responsibility for undertaking different elements of work lies. With some activities this will be straightforward, such as prescribing medication or developing a care plan. Other aspects of work, such as relationship input are not as clear and there are distinct possibilities that there will be assumptions about who is undertaking the work, with the outcome that important pieces of work fall between agencies are not adequately completed. What indicators of self-harm/suicidal behaviour were presented and were these fully recognised, assessed and acted upon? 8.121 All of the agencies working with Child F at various times expressed concerns that Child F was high risk of self-harm. There was a long history of Child F threatening to harm himself and suicidal ideation. There were also occasions when there was a reported use of ligatures, including shortly before his death. 8.122 In relative terms Child F was at most risk during his period at the Crash Pad when his status of “homeless” significantly increased the risk factor. 8.123 There were also numerous concerns about mental health disorders including, psychotic symptoms, depression, and adjustment disorder. In particular Child F attended A&E on several occasions following suicidal ideation or behaviour. There was no consistency of follow up from his care coordinator and the Individual Management Review encompassing mental health services rightly points to the need for a protocol to ensure that there is such consistency and that multiple use of Section 136 triggers multi agency planning. 8.124 It was also known that Child F responded poorly to stress factors and had mood swings often with angry and impulsive behaviour. He had, also, from his accounts, experienced violence within his family and felt unloved and rejected. 75 8.125 There was, importantly, a history of repeat attempts and threats of self-harm, often in dramatic circumstances, such as locations on Motorway bridges. Adolescent suicide attempters are at risk for completed suicide theoretically because the attempt(s) break the taboo inhibiting self-harm and make suicide a potential option to problems (Beck – 1996). Elements of this thinking can be seen with Child F adopting self harming and suicidal options at early stages in stressful situations. 8.126 All of the evidence suggests that staff from different agencies took the risk of suicide very seriously indeed. This ranged from a Police Officer commenting on the likelihood that Child F would succeed if he continued his attempts at self-harm to the social worker expressing concern to her manager about the very high level of risk of Child F either killing himself accidentally or on purpose. 8.127 There was potential for some confusion between agencies about the level of risk. There had been a serious incident at the Supported Accommodation on the 18th September 2012 when Child F had completely trashed his bedroom. Child F spoke to the Personal Advisor (Leaving Care team) and he said that he was intending to kill himself and that “he would get it right as he was aware that if he got it wrong he would be sectioned”. On this occasion, Child F handed over a noose made from cable and shoelaces that he had tied together. This caused some alarm leading to a request for a Professionals Meting that took place on the 12th October 2012. It was noted at the meeting that his suicide risk was assessed as low to medium, although it was noted that his risk was heightened when he was intoxicated. 8.128 From a systems approach perspective Child F was in a high risk population. A number of measures would have been needed in order to minimise the high possibility of self-harm. The complexity of managing these different interacting elements was always going to be a serious challenge for agencies working with Child F. Although there 76 were clearly ongoing discussions between agencies and a number of professional and agency meetings, it was difficult to detect a very clear plan that all agencies were working to and had agreed that covered suicide prevention in this case. Such a plan may have included very practical measures such as monitoring of medication, through to psychological therapies, to social engagement activities, through to relationship work and future placements. 8.129 It is clear that many of these elements were present in work being undertaken with Child F. The complexity of how the elements relate to and interact with one another does mean, however, that very tight coordination is required between agency activities. There is not a sense that coordination was as rigorous as it needed to be in this case. 8.130 As important as indicators of self-harming behaviour are the factors that may protect adolescents from repeated attempts or completed suicide. There are some suggestions for example that an improved living environment may be a protective factor. Similarly adequate social relationships, strong support systems and high educational achievement have all been cited as possible protective factors. There was not enough systematic consideration given to some of these protective factors in this case. 8.131 Although Child F was clearly at high risk, current knowledge on the specific risk factors for adolescent completed suicide is not conclusive. The available research suggests that further understanding is needed on the mediating mechanisms of family related risk factors, and the role of anti-social and aggressive behaviour in adolescent suicide (Marttunen et al- 1993). 8.132 Similarly Spirito and Overholster (2003) comment that in general research that has attempted to predict suicidal behaviour has failed. Because of the low base rate for suicidal behaviour in the general 77 population it is not possible to predict that a given individual would make a suicide attempt or complete suicide in the near future. 8.133 The most effective strategy for managing suicide risk may involve protecting high-risk groups at high-risk times. In Child F’s case he was high risk because of his mental health and, for a time, his homelessness. His vulnerability may have been increased because of factors such as an impulsive cognitive manner, poor problem solving skills, ongoing family discord and social isolation. It is probable that for Child F’s high-risk times were triggered by stressful life events. The use of cannabis and alcohol may have had the impact of increasing the likelihood of impulsive or aggressive acts. 9. SUMMARY AND CONCLUSION 9.1 Child F was a deeply troubled young man, who was at high risk of self- harm. He was, however, both bright and articulate. He also demonstrated an insight into his own situation. Despite the efforts of agencies to minimise the risks there were some very clear weaknesses in the coordination and provision of services. 9.2 The lack of involvement of some agencies prior to March 2012 was worrying. In particular, the decisions by Children’s Social Care that Child F was not a Child in Need, despite his homeless status and obvious emotional/psychological turmoil suggests that, if this case is typical, the threshold criteria for acceptance of referrals by Children’s Social Care is too high. This is addressed as Recommendation 1. 9.3 The placing of Child F, for an extended period, during 2011 to March 2012 in the Crash Pad was inappropriate and was likely to increase his loneliness and isolation. It was also likely to increase the risk factors. It was disappointing to note that there seemed to be a professional acceptance that this was the only placement alternative. It was always likely to have a negative impact on any therapeutic progress being made and should have been rigorously challenged. It 78 was also disappointing that there was a lack of coordination between various agencies in identifying appropriate accommodation for Child F at this time. The issue of accommodation for homeless young people is addressed as Recommendation 2. 9.4 Assessments were of poor quality. There was significant historical information that could have offered insight into Child F’s relationships within his family. In particular, the impact of domestic violence was not identified and its significance not understood until May/June 2012. Even then there was no evidence of work being undertaken with Child F or MF to explore the important issue of family violence. There was a continual backdrop, to this case of Child F’s anger towards MF that was never fully explored or appreciated. There was, for example, a particularly poignant discussion in May 2012 between Child F and his care worker where Child F articulated the reasons why he felt angry towards MF and her lack of care towards him. These areas of key relationships in his life needed to be followed up as fully as possible. 9.5 The consistent finding in Serious Case Reviews that historical information is not used properly, suggests that practitioners may not be equipped with adequate skills in collecting and analysing such information. The Munro Review (2011) suggests that there are distinct components in a healthy whole systems approach that: • Enables critical thinking • Provides emotional support • Facilitates effective inter agency working The evidence from this Serious Case Review suggests systems need to be in place to encourage professionalism and critical approaches to practice. This would require both training and developing expertise, supported by systems, including that encourage such an approach. Without this fundamental change it seems likely that assessments will remain a weakness within child protection systems. The issue of historical information is addressed as Recommendation 3. 79 9.6 There was generally good evidence of information sharing between agencies. The complexities of several agencies interacting and information being generated from multiple sources, however, suggests that even where there is a climate of openness and a willingness to share information there is a need for all agencies to be aware that the sharing of information is likely to be a weakness within systems. This is best illustrated through two examples. • Both the GP and health visitor (2004-2007) were aware that MF had sustained physical injuries because of domestic violence. That information was never made available to other agencies. Similarly it was known by the health visitor and midwife that MF had presented with extensive bruising just prior to the birth of Child FS2. This led to the placement in a refuge. This information should have led to concerns about MP2’s involvement with the family and the safety of the children. • When MF and the children moved to Manchester in June 2012, there should have been an automatic referral to Manchester about concerns in relation to domestic violence and the care of the children. There was no documented evidence that such a referral took place. 9.7 There were also some concerns that reports from the Supported Accommodation residential unit were not always adequately reflecting Child F’s challenging behaviour or his mood. In particular the incident on New Years day 2013, when Child F threatened to hang himself was not reported to the Early Intervention Team or the Social Care Duty Officer. 9.8 Although there were established mechanisms for ensuring that plans for Child F were in place, it was not always clear how those individual agency plans came together to form a corporate whole person plan. The LAC Care Plan, for example, was largely generalised and aspirational with very little detail about practical steps that were required. There was also no sense that the Care Programme Approach 80 and the LAC Care Plan interacted with one another, or whether there were areas of gaps in services between the two key plans. 9.9 There is a significant challenge for agencies here in ensuring that different planning mechanisms harmonise and there is a clear understanding of what each agency is doing and how that fits into the actions by other agencies. This requires a really sophisticated understanding of the roles of other agencies and is more likely to occur successfully when there is an established multi-agency mechanism such as a Child Protection Review process. However many cases, such as this one, are equally complex, and do not have the benefit of a Child Protection Plan. A more strategic approach to inter-agency work where there are clear and agreed plans and direction of agency input with monitoring of activities needs to be introduced. This is addressed as Recommendation 4 9.10 Throughout the placement in Supported Accommodation, there were a series of meetings, (co-coordinated by Children’s Social Care or CAMHS), on a two monthly basis. Whilst the meetings were well attended and information was shared, there is a sense of a lack of direction with no clear plans being achieved. Although concerns were voiced and shared, there seems little evidence of a tight, structured understanding of who is doing what and how it fits in with the overall intended outcomes for Child F. It is noteworthy, for example that the assessment visit of the Adolescent Forensic Service Practitioner in mid January 2013 led to the Practitioner expressing concerns about plans to move Child F to a less supportive environment when he was 18 years of age. The concerns, which were realistic, were in relation to his coping abilities and quite correctly challenged the view that Child F could cope more independently. 9.11 A key example of this lack of direction lay with plans for the future placement for Child F. It had been generally accepted by those engaged with Child F that the current placement in supported accommodation was not suitable and that a more specialist placement 81 would be required, preferably where there was therapeutic input. At the stage of Child F’s death a future placement had still not been identified. 9.12 There was a failure to put in place effective Child Protection Plans in relation to Child F’s siblings. This was evident in the lack of a proper investigation into the risk Child F potentially posed to his siblings and also the risks that MP2 posed to the younger children. Even when the risk was identified, actions were not robust or effective. Recommendation 5 9.13 A major concern lies with agencies not understanding the nature and meaning of domestic violence in this case. Although there have been significant developments nationally in recent years about domestic violence, this case illustrates that in practical terms a number of agencies may still not be following appropriate procedures in the management of domestic violence. As research has evidenced that an Analysis of Serious Case Reviews found evidence of past or present domestic violence present in over half (53%) of cases (Brandon et al – (2009). it is extremely worrying, given the prevalence of domestic violence, it was not given the significance it merited in this case. Recommendation 6 9.14 It is of equal concern that there were gaps in agency understanding of key parts of child protection systems. The role of the Probation Service in the management of offenders had a critical role to play in this case. It was clear that some agencies did not understand that role in the context of safeguarding children. Recommendation 7 9.15 There was also evidence that practitioners found some of the mental health diagnostic terminology confusing and at times conflicting. It is clearly important that there is a shared understanding, at a functional level, between agencies of the language being used to describe mental health disorders. Recommendation 8 82 9.16 There have been concerns identified in this Serious Case Review about the use of accommodation for young people who are Looked After Children or Care leavers. This accommodation referred to as ‘supported accommodation” in this Serious Case Review is effectively called “supported lodgings” by providers. This means that the accommodation is not registered with Ofsted and not subject to the same level of regulation as, for example, children’s homes. This is a national problem that should be brought to the attention of Government. Recommendation 9 9.17 This is an extremely tragic case of a young man who through a combination of factors, as outlined in this Serious Case Review, appears to have taken his own life. 9.18 Prediction of self-harm and suicidal behaviour is not a straightforward science and it would not have been possible to predict with absolute certainty that Child F would commit suicide. 9.19 There were however so many repeated attempts and threats of suicide, alongside ongoing suicidal ideation that there is a sense of a very tragic inevitability. This was recognised by several of the practitioners working with Child F. 9.20 Similarly it is not possible to say whether Child F’s death was preventable. It is just not possible to know if different interventions would have had any positive impact on the outcome. 9.21 There are a number of lessons that can be learned, however, to improve services to vulnerable children and young people with similar problems to Child F. The challenge for all agencies is to ensure that those lessons are embedded in practice in the future. 9.22 This Serious Case Review has identified a number of areas where improvements in services and systems can be made. There has been a firm commitment by agencies to work towards implementing the 83 recommendations of this Review. Bury Children’s Social Care, for example, are actively undertaking a review of thresholds for accessing their services. Similarly Mental Health services have commenced work to improve multi agency planning where there are multiple Section 136 orders. This work and the implementation of all of the individual agency and Overview Report recommendations should make a significant contribution to the improvement of services. 10. OVERVIEW REPORT RECOMMENDATIONS 1. Bury Safeguarding Children Board should review the application of thresholds for intervention for Children in Need (S17 Children Act). 2. Bury Safeguarding Children Board should ensure that there are clear and coherent multi-agency plans for the management of homeless young people, aged 16-17 years. 3. Bury Safeguarding Children Board should encourage and contribute to a suitably robust auditing exercise, focused on the accumulation, sharing and interpretation of case histories in the course of multi-agency assessments. The purpose of this audit exercise will be to indicate whether all agencies are making optimal use of the information they hold and whether practitioners engaged in assessments are completing thorough and competent analyses. 4. Bury Safeguarding Children Board should review the different planning processes, for service users, across agencies in order to promote more effective corporate planning for inter agency safeguarding of children with complex needs. 5. Bury Safeguarding Children Board should ensure that all front line practitioners and their managers have the opportunity of learning lessons from this Serious Case Review. 84 6. Bury Safeguarding Children Board should review how agencies have implemented updated procedures and are monitoring practice standards in dealing with domestic violence. 7. Bury Safeguarding Children Board should examine safeguarding training programmes to ensure that there are no significant gaps in learning. 8. Bury Safeguarding Children Board should ensure that forums and mechanisms are in place for practitioners to share information, including the use of basic diagnostic terminology, about child and adolescent mental health. 9. Bury Safeguarding Children Board should notify the Department of Education about concerns, identified in the Serious Case Review, that unregulated service providers are accommodating vulnerable young people. 11. INDIVIDUAL AGENCY RECOMMENDATIONS Mental Health Services 1. A section 136 of the Mental Health Act for a young person aged under 18 years and under should trigger prompt (within 7 days) follow-up by the patient’s own team, ideally the care-coordinator. Multiple use of 136 in brief timescale should trigger multi agency planning. 2. Early Intervention Team (EIT) and CAMHS to ensure robust pathways which provide clarity about roles and responsibilities for jointly working with under 18s. 3. For there to be a protocol developed around the communication of discharges from Tier 4 for under 18s to their Community Psychiatrist. 85 4. To deliver awareness training around Autism Spectrum Disorder to inpatient staff on specialist mental health units and the Early Intervention Team. 5. An internal review should be completed within the Bury EIT service to review the impact on care of the service reconfiguration and any lessons learned be embedded in to future reorganisations within the Trust. 6. For children in looked after placements all attempts should be made to guarantee the involvement of the residential care staff in CPA processes. 7. Transition plans should ensure that a consistent person remains involved with young people for as long as is needed and that review of the pace and subsequent impact of changes to key staff is incorporated into the risk management plan. 8. To develop a CAMHS Directorate forum for consultation/case discussion about young people aged under 18 years who present with complexity and intermittent high risk and who span multiple agencies and mental health services. 9. To improve access to multi-agency training, including knowledge around the impact of domestic violence on children and young people. Connexions 1. Connexions to implement measures to improve information recording on the Core+ database. 2. Good practice identified to be promoted to all staff. Greater Manchester Police 1. A formal and detailed review of the new Mental Ill Health, Mental incapacity and Learning Disabilities policy and guidance is conducted 86 twelve months after inception to ensure it’s effectiveness in protecting those with vulnerabilities through mental ill health or disorder. Bury Children’s Social Care 1. Southwark compliance: The agency should review its practice in respect of young people aged 16/17 to ensure that it has in place • Assessments that focus on the vulnerability of the young person • Interventions that can facilitate mediation between the young person and their families • A robust protocol with housing 2. Quality of assessments: The agency should develop practice standards and a quality assurance process that ensures assessments are of good quality and form a sound basis for planning for children. 3. Management oversight: The agency should develop practice standards and a quality assurance process that ensures management oversight of and involvement in cases is regular and proportionate to the needs of the case. 4. Construction of Care Plans: The agency should consider issuing practice guidance and offering training to social workers, their managers and Independent Reviewing Officers on the proper construction of Looked After Children Care Plans. 5. Reflective practice: The agency should continue the work it has started to introduce reflective practice as a regular element of case supervision. 6. Placements for Young People aged 16/17: 87 The agency should consider raising this issue through the Placements North West planning group and if appropriate at the Regional Safeguarding Strategic Leads group. Barnardo’s 1. To review the referral and allocation systems in the service. Pennine Care Foundation Trust, Community Services Bury 1. All health practitioners who have the responsibilities of assessing the needs of children must complete Level 3 Safeguarding training every three years. 2. Management and Clinical supervision must always include a section where supervisors check that supervisees have not encountered any unreported safeguarding issues and discuss safeguarding aspects of practice 3. Where health practitioners identify they are working with children from the same family eg health visitors, school nurses, children community team, they ensure that safeguarding concerns are shared. 4. To review and develop protocols for the processing of A&E notifications which are received by health visitors and school nurses. GP No recommendations were made. Supported Accommodation Provider 1. Ensure that when working with other agencies, staff need to obtain a named person in the absence of a named professional. 2. Continue with extensive placement plans and risk management. All meetings to be recorded in depth and any cancellations to be recorded. 3. Managers to be trained on writing IMR reports. 88 Bury Children’s Service- Learning (Schools). 1. Schools to be more proactive in seeking information and must record any attempts made to contact other agencies for information. 2. Where invites are received to high level meetings every attempt should be made for a representative to attend. 3. Schools strongly advised of the importance of detailed and accurate record keeping, including some analysis of need and reflection on success of interventions. Use of the SMART system to be further promoted and schools encouraged to use. 4. Develop use of CAF for permanently excluded pupils. 89 APPENDIX 1 - RESEARCH SOURCES Beck, A (1996) Beyond belief: A Theory of modes, personality, and psychopathology. In Frontiers of cognitive therapy ed P. Salkovkis. Guilford Press , New York. Brandon, Marian et al (2012) New learning from serious case reviews. Research Report DFE-RR226. Department of Education. London Brandon, Marian et al (2009) Understanding Serious Case Reviews and their impact: A biennial Analysis of Serious Case Reviews. Department of Education. London. Cleaver, H et al (2010) Children’s Needs – parenting Capacity: The impact of parental mental illness, learning disability, problem alcohol and drug use and domestic violence on children’s safety and development. London. The Stationery Office (second edition). Marttunen, Mauri et al (1993) Adolescence and Suicide: A Review of Psychological Autopsy Studies. Journal of European Child and Adolescent Psychiatry. Vol 2. Issue 1. Munro Eileen (2011) The Munro Review of Child Protection. Stationery Office. London. Spirito, Anthony and Overholser, James C (2003) Evaluating and Treating Adolescent Suicide Attmpters: From Research to Practice. Academic Press. New York and London. |
NC046128 | Executive summary of a review into the death of a 1-year-9-month-old child in February 2012 as the result of severe brain damage. Police were unable to establish how the subject child sustained the fatal head injuries however medical evidence indicated that they were inflicted non-accidentally. Issues identified include: maternal history of depression; and concerns raised by father and paternal grandparents relating to an unexplained burn to subject child's hand and a bruise. Identifies analysis and learning, including: a focus on parental behaviour sometimes diverting professional attention away from the child; GPs treating episodes of maternal depression in isolation with insufficient attention to broader issues of family life, parenting capacity and child wellbeing; and need for professionals to remain alert to safeguarding issues and to think critically and reflectively whilst performing routine professional activities. Makes various recommendations.
| Title: Serious case review relating to a child who died at the age of one year and nine months. LSCB: Kirklees Safeguarding Children Board Author: Carole Smith Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 KIRKLEES SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW RELATING TO A CHILD WHO DIED AT THE AGE OF ONE YEAR AND NINE MONTHS Executive Summary by Dr Carole Smith – Independent Author Approved by KSCB November 2013 This report has been redacted to comply with a Reporting Restriction Order January 20142 SECTION ONE: INTRODUCTION 1.0 When the Chair of Kirklees Safeguarding Children Board (KSCB) made the decision to initiate this Serious Case Review (SCR) the relevant statutory guidance was contained in the 2010 version of Working Together to Safeguard Children: a Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (HM Government 2010). The Serious Case Review was thus guided by Working Together 2010, rather than by the Government’s more recent version of Working Together (HM Government 2013) which was effective from 15/4/13. However, as will evident from the overview report the Review based its work on the principles for learning and improvement which are identified in the 2013 Guidance. 1.1 The requirement for Kirklees Safeguarding Children Board to conduct a SCR was, at the time, detailed in Chapter 8 of Working Together (HM Government 2010) and in the Local Safeguarding Children Board Regulations 2006. The purpose of a SCR as identified in Working Together is to: Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. Identify clearly what those lessons are, how they will be acted on and what is expected to change as a result. Improve intra and inter-agency working and better safeguard and promote the welfare of children. 1.2 In her review of child protection arrangements Professor Eileen Munro recommends that Serious Case Reviews should adopt a systems theory approach to understanding why professionals and agencies respond to child protection concerns in particular ways. A systems perspective directs attention to the context of professional practice such that factors which impede effective professional judgement and decision making can be identified and changed. In summary, it has been realised that human error can be more effectively reduced by looking at the wider organisational factors that influence the individual and identifying which factors make it easier or harder for workers to perform well. This SCR has attempted to understand the context in which professionals practised and to reflect this in its identification of learning and recommendations for action. 2.0 REASONS FOR THE SERIOUS CASE REVIEW 2.1 At the age of one year and nine months the subject child was taken by ambulance to their local hospital in a state of collapse and subsequently transferred to a specialist paediatric intensive care unit. Tests revealed that the child had suffered severe and un-survivable brain damage and the child died on 28/2/12. 2.2 Although the cause of death was later identified as ‘head injury’, there remained uncertainty about how this had occurred. By September 2012, expert medical evidence was beginning to indicate that the child’s head injury had been caused non-accidentally. Medical experts subsequently agreed that non-accidental blunt 3 force trauma to the child’s head had resulted in brain damage which led to the child’s death. Evidence available to West Yorkshire Police showed that the child had suffered the head injury at some time during the night or early morning of 26th and 27th February 2012 when at various times the child’s mother, her partner at the time (not the child’s father) and the child’s maternal grandmother were at the family home. 3.0 TERMS OF REFERENCE AND THE SERIOUS CASE REVIEW PROCESS 3.1 The SCR Overview Panel 3.1.1 KSCB SCR Workstream established a SCR Overview Panel to conduct the SCR. The Overview Panel comprised independent senior professionals from relevant agencies none of whom had any direct involvement in providing services to the child and their family. The SCR Workstream also identified an independent Chairperson, and an independent author to write the overview report as required in Working Together (2010: 8.16 and 8.33). The independent chairperson was Bron Saunders who is also the independent chairperson of KSCB and the independent author was Dr Carole Smith neither of whom had any prior involvement with the agencies providing services to this family. 3.2 Individual Management Reviews (IMRs) 3.2.1 IMRs refer to enquiries about intervention and service delivery, including inter-agency working, in agencies/services that have had a significant degree of involvement with children who are the subjects of a SCR and their families. Such enquiries should focus on what happened and why from a professional and agency perspective and are incorporated into an IMR report. They should aim ‘to look openly and critically at organisational and individual practice’ (HM Government 2010: 8.35) to identify learning, determine what improvements can be made and specify how such changes should be effectively implemented to protect children from harm. In this case the authors of IMR reports were expected to follow guidance in Working Together (HM Government 2010) and the Individual Management Review Handbook provided by KSCB. 3.2.2 In order to provide the SCR Overview Panel with comprehensive information about this case, IMRs including detailed chronologies, were requested and received from the following agencies/services: Mid-Yorkshire Hospitals NHS Trust Locala Community Partnerships NHS England West Yorkshire Area Team and North Kirklees Clinical Commissioning Group Family Support and Child Protection Service, Kirklees Council West Yorkshire Police West Yorkshire Probation Trust Lifeline Kirklees 3.2.3 Additionally, summary reports were requested from the following agencies / services: 4 Kirklees Neighbourhood Housing / HOSS NHS Direct Local Care Direct Specialist paediatric intensive care unit Action for Children Adult Social Care Yorkshire Ambulance Service South West Yorkshire Partnership Foundation Trust 3.3 Important issues in identifying learning from this SCR 3.3.1 Some issues which appeared to be significant from early information available to the SCR Workstream assumed less importance as the Overview Panel conducted its enquiries and other information, while helpful for the learning of individual agencies/services, was not considered appropriate for publication. The SCR Overview Panel thus identified the following issues as requiring particular scrutiny in IMRs and during the Review and as being appropriate for inclusion in the overview report: The child’s needs: were professionals sensitive to the child’s needs and aware of factors that might have a detrimental impact on the child’s wellbeing? Were professionals knowledgeable about indicators of abuse and/or neglect and about what to do if they had concerns about a child’s wellbeing? Mental health issues: to consider mental health concerns where relevant. How far were professionals aware of these issues and how did professionals evaluate their significance in terms of the mother’s parenting capacity and the child’s wellbeing? Significant adults: to consider dates of changes in partners and whether these relate to incidents of mother’s depression/low mood. Were professionals sufficiently alert to the possible impact of changes in the mother’s partners on her mood and parenting capacity and did they explore the parenting capacity of the mother’s partners and their role in family life? Parenting issues: to consider the impact of her own upbringing on the mother’s parenting capacity and her request for help with parenting. Were professionals sufficiently aware of the relationship between the mother’s experience of family life as she was growing up and her parenting capacity? Information sharing and inter-agency communication: to consider whether key information was shared appropriately between agencies and professionals, whether the significance of information was clarified and understood and whether agencies and professionals responded effectively to information. The organisational context: were there any factors in agencies/organisations which acted to impede good practice relating, for example, to resource issues, professional supervision and development, effective management oversight, communication and recording systems? 5 3.4 Time period to be covered by the SCR 3.4.1 The KSCB Workstream concluded that the most appropriate period to be considered by the SCR was from July 2009 when the mother’s pregnancy with the subject child began until late February 2012 which was when the subject child died. 4.0 SUMMARY OF AGENCY INVOLVEMENT WITH THE SUBJECT CHILD AND FAMILY 4.1 The subject child was born in May 2010. Information relating to 2010 indicates that the community midwifery and health visiting services had no concern about the mother and her baby’s wellbeing. The baby was developing well. Although the mother had sought anti-depressant medication from her GP in April, when midwifery and health visiting professionals asked her directly the mother did not report any symptoms of low mood or depression. Mother and baby regularly visited the ‘drop-in’ well baby clinic until September 2010 and spent a considerable amount of time at the local Family Centre. Records indicate that the mother took her baby for appropriate consultations with the GP and also contacted Local Care Direct and NHS Direct for advice when necessary. The only cause for (minor) concern was that the baby’s immunisation schedule was suspended following two missed appointments, although attendance had not been problematic for earlier immunisations. This was remedied by March 2011 when the delayed immunisation was administered. 4.2 Sometime after June 2010 the mother separated from her partner (the subject child’s father) and around October 2010 she began a relationship with another partner who moved in to live with the mother and subject child. The subject child’s father and paternal grandparents maintained frequent contact with the subject child. 4.3 In March 2011 the subject child suffered burn blisters to their hand for which there was no explanation, although the mother took the child to the Emergency Department of her local hospital and attended two appointments for treatment at the follow-up review clinic. The mother and child subsequently visited a medical Walk-in Centre for treatment to the child’s burn. The subject child’s father and paternal grandmother expressed concern to health visitors about the burn, and a bruise which had been observed near the child’s ear some weeks earlier. A health visitor sought advice/consultation from Children’s Social Care (Duty and Assessment) about the paternal grandmother’s concern. Given that the child was receiving treatment and there were no other concerns about the child’s wellbeing, CSC took no further action. 4.4 In June the subject child’s immunisation schedule was suspended for a second time following non-attendance at appointments, although by December outstanding immunisations had been completed. The mother’s GP prescribed a one-month supply of anti-depressant medication for her in June but she did not attend the GP Practice for a further prescription at this time. In July 2011 the 6 mother told a health visitor about the very difficult family circumstances in which she had grown up. 4.5 During 2011 health professionals detected no indication that the mother was depressed, although she admitted to occasionally feeling tearful and low. Apart from the subject child’s burn, health professionals’ records suggest that the child was well cared for and there were no concerns about health, development or wellbeing. 4.6 In January 2012 the mother was again prescribed anti-depressant medication by her GP. Shortly after this a health visitor made an urgent home visit in response to information that the mother was very distressed. The mother told the health visitor that she had been feeling low for months and felt unable to cope. With the mother’s consent, the health visitor consulted Children’s Social Care but given that the health visitor was satisfied there were no immediate safeguarding concerns and had referred the mother to community mental health services, Children’s Social Care took no further action. Information from two subsequent visits by the health visitor and the mother’s further consultation with her GP suggested that her mental health was much improved and she continued to take anti-depressant medication. The health visitor’s observation of the child did not indicate any cause for concern about their wellbeing. 4.7 The subject child was admitted to hospital on 27/2/12 and died early the next day. 5.0 LEARNING FROM THE SCR 5.1 Before the Chairperson of KSCB made a formal decision to conduct a SCR, the Designated Nurse NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups, completed a review of NHS agencies/services which had been involved with this family. Much of the learning from this SCR was anticipated by this review completed in May 2012, which has already resulted in action to improve practice. Learning from the health review and subsequently from this SCR is summarised below: When health or social care professionals become aware that a very young pre-verbal child has suffered an unexplained injury, they should ask questions about the child’s developmental capacity (for example, mobility and dexterity) in relation to the likelihood of its non-accidental occurrence. This should be undertaken with reference to local and national safeguarding procedures and guidance. Professionals should look out for any loss of focus on the child’s wellbeing, which may be prompted by parental distress or other parent/carer characteristics. They should remain alert to the possibility that their concern about a child’s wellbeing may be diminished by their positive perception of the ways in which parents/carers present themselves to professionals. Although health and social care professionals should be familiar with evidence-based knowledge about the potential association between parental family history, mental health and parenting capacity they also need to 7 recognise when such knowledge is relevant and can enhance their understanding in individual cases. Professionals should remember that parenting capacity and the quality of family life are not only related to maternal wellbeing but also to the involvement and wellbeing of fathers/partners and sometimes of extended families and friends. When, as in this case, partners/fathers are relatively invisible, professionals need to adopt an inquisitive attitude about their role in family life. Similarly, professionals should explore parents’/carers’ assertions that they have good support from their extended family and friends. Professionals need the time and opportunity to reflect on case histories so that they can better understand patterns and developments over time in relation to the assessment of parents’ and children’s wellbeing and future planning. They also need to think about how information from other agencies/services might contribute to a full understanding of case history. The Burns, Bruises and Scalds Protocol used by MYHT needs revision so that it is clear and leads to effective practice and it should be re-launched to ensure that newly appointed staff are aware of this guidance. GPs should be encouraged to consider repeated parental episodes of depression in relation to broader issues of family life, parenting capacity and children’s wellbeing. In this context they should ensure (within the constraints of patient consent) that other health care professionals, particularly health visitors, have access to relevant information. GPs should recognise the importance of proactively cross-referencing information with that held by community health professionals in relation to their role in a network of universal health care providers. 6.0 GOOD PRACTICE 6.1 Practice in relation to expected professional standards is identified throughout the overview report. However, the following are notable instances of good practice: When the mother attended the Walk- in Centre following the subject child’s burn, the community nurse sought advice from the hospital Burns Unit about the most appropriate treatment and informed the health visiting service and GP about the child’s attendance and the lack of an explanation for the child’s injury. On receipt of information about the mother’s distressed condition in January 2012, the health visitor immediately made a home visit to assess the mother’s mental health and any safeguarding issues for the child. 7.0 RECOMMENDATIONS ARISING FROM THIS SCR 7.1 Much of the learning from this SCR has already led to changes which are designed to improve practice and which are given detailed consideration in the overview report. Not all of the recommendations arising from this SCR have been included in the overview report because either the identified learning has already led to remedial action or because to do so would require the disclosure of information which is inappropriate for publication. The remaining recommendations are listed below: 8 Recommendations for the Mid-Yorkshire Hospitals NHS Trust: In order to provide clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child, the Safeguarding Team should re-launch the Bruising, Burns and Scalds Protocol to ensure all staff employed since the initial launch in August 2011 are aware of the Protocol. In addition, staff should be reminded of the NICE guidance ‘When to Suspect Child Maltreatment’ which indicates that an unexplained burn should prompt suspicion of child maltreatment. Recommendations for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups: SystmOne team should arrange for an alert/flagging/safeguarding node system to be available for use on GPs’ patient records so all children with concerns can easily be identified with regard, for example, to a failure to attend appointments, failure to attend for immunisations and other appointments such as psychology services when referrals are issued, attendance at hospital Accident and Emergency, parental mental health issues, parental substance abuse and domestic violence. With the assistance of the alert/flagging system currently under development, GPs should adopt a proactive approach to identifying children and parents/carers where potential child safeguarding concerns may be indicated. This should inform consultation at meetings with the link health visitor so that healthcare information can be shared effectively and should also support piloting and scoping the introduction of a model - the Child Safe Global Trigger Tool – for safeguarding children in primary care. Briefing sessions should be delivered to General Practice clinicians that focus on the increased vulnerability of children and young people when they are living in households where there is parental mental ill-health, parental substance misuse or domestic abuse. Recommendation for NHS England West Yorkshire Area Team: NHS England West Yorkshire should do everything it can to ensure that all Kirklees GP Practices routinely request that their patients consent to their health visitors having access to GP health records relating to children and their parents/carers. Recommendation for NHS England: NHS England should consider how best to enhance GPs’ ability to think critically and reflectively about a patient’s history in relation to the way in which this may affect parenting capacity and the identification of safeguarding concerns regarding children. Recommendation for Locala Community Partnerships: 9 A timescale for review of Accident and Emergency notifications by health professionals should be introduced into health visiting and school nursing operational guidelines. 8.0 CONCLUSION 8.1 Although the SCR Overview Panel and the independent author concluded that professionals could not have foreseen or prevented the subject child’s death, this does not mean that this SCR has not identified learning which should lead to improvements in practice. 8.2 At the heart of this learning, as has been identified in so many other SCRs, lies a professional ability to remain alert to safeguarding issues and to sustain a reflective capacity in the midst of routine professional activities. For those professionals who deliver universal services this is a significant challenge when they will come across safeguarding issues in a minority of their cases while occupying professional roles that bring them face-to-face with early signs of parenting problems and child abuse. |
NC048207 | Death of a 14-month-old girl from an apparent drowning in the bath at her family home in August 2014. Child Q was the younger of two children; her sister was born when her mother was 17 years old. This sibling was taken into care in infancy after physical abuse; the father was accused of assault, the mother's role was unknown. Child returned to mother's care under an Interim Care Order and a 12-month Supervision Order. Shortly after the Order ended, mother became pregnant with a new partner; their relationship broke down during the pregnancy but he shared care of Child Q. Mother struggled to prioritise children's needs so children became subject to Child in Need Plans and then Child Protection (CP) Plans. Ethnicity or nationality is not stated. Findings include: professionals not consistently proactive in response to incidents and allegations regarding children on a CP plan; delayed and incomplete handover between some professional groups when families move; the input and cooperation of one of the parents is prioritised at the expense of not engaging the other parent; an assumption that professionals cannot meet together without parents being present which jeopardises opportunities for joint discussion and supervision. Uses the SCIE Learning Together model. Recommendations to the LSCB to consider: feedback from frontline staff about difficulties in working with neglect and the degree to which CP plans for neglect are child-focused; skills of workers to respond in a more child-centred way to incidents/allegations; routine capturing of details about fathers in agencies working with women and children; the need to produce and share the CP plan in a timely way.
| Title: Oxfordshire serious case review: Child Q. LSCB: Oxfordshire Safeguarding Children Board Author: Sally Trench and Anne Morgan Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Oxfordshire Safeguarding Children Board Oxfordshire Serious Case Review Child Q Report authors: Sally Trench Anne Morgan Serious Case Review published 10.01.17 Page 2 of 55 CONTENTS Title Page A Why this case is being reviewed 4 1. Introduction 4 2. Succinct summary of case 4 3. Time frame and key dates table 5 4. Family composition 5 5. Organisational learning and improvement 5 6 Reviewing expertise and independence 6 B Findings 7 7. Introduction 7 8. Appraisal of professional practice in this case: a synopsis 7 9. Overview list 15 10. What is it about this cases that makes it act as a window on practice more widely? 17 11. Findings in detail 18 Finding 1: Child Protection Plans for Neglect do not consistently spell out the specific risks to children and the consequences if the desired outcomes for their improved safety are not achieved. As a result, the professionals involved are less clear and confident about when to take protective action. 18 Finding 2: There is a pattern where professionals are not consistently and sufficiently pro-active in response to incidents and allegations regarding children on a current child protection plan , based on their perception that they ‘don’t have enough evidence’ to pursue the incident. This stops them from following through with any further investigative or protective action, and the opportunity is then lost to investigate the experiences of neglected or ill-treated children. 21 Finding 3: There is a pattern of delayed and incomplete handover between some professional groups when families move, which can result in interruption of the knowledge about the family and the case, and lead to an unintended ‘start again’ for the new professionals, even with families where there has been no change or improvement for some time. 25 Finding 4: There is a pattern where the input and co-operation of one of the parents, normally the mother, is prioritised at the expense of not engaging the other parent (normally father) in the child protection process. This may result in the children not receiving care and appropriate involvement from one of the parents. 28 Serious Case Review published 10.01.17 Page 3 of 55 Finding 5: The commitment to working in partnership with parents in Oxfordshire has inadvertently led to an assumption that professionals cannot meet together, without parents being present, when they have concerns regarding case management. This jeopardises opportunities for joint discussion and supervision. 32 Finding 6: In Oxfordshire, there is insufficient capacity for the effective administration of invitations to CP Conferences, and distribution of minutes and CP Plans. This leads to all the meetings of the CP system suffering from a lack of timely information-sharing and therefore of plans not being implemented in an effective way. 34 Finding 7: There is no agreed use of a multi-agency tool to capture a chronology of significant events, making it more difficult to assess risk to children and parental patterns which demonstrate poor capacity to change. (Tools) 37 12 Additional learning 40 13 Conclusion 41 References 43 Appendix 1: Review methodology 45 Appendix 2: Learning Together methodology and process 48 Appendix 3: The Neglect Pilot (North Oxfordshire) 55 Serious Case Review published 10.01.17 Page 4 of 55 A. Why this case is being reviewed 1. Introduction 1.1 Child Q, 14 months old, died from an apparent drowning in the bathtub at her family home. At the time, Q and her 5-year old half-sister were both subjects of Child Protection (CP) Plans, under the category of Neglect. 1.2 The independent Chair of the Oxfordshire Safeguarding Children Board (OSCB) decided that the death of Child Q met the criteria required to carry out a Serious Case Review (SCR), as set out in Working Together to Safeguard Children (WT) (DfE, 2013): (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died.1 As a result the OSCB commissioned this report. 2. Succinct summary of case 2.1 Child Q was the younger of two children. She had an older half-sister who was living with both her and her mother at the time of Child Q’s death. Child Q’s mother was only 17 when she had Child Q’s half-sister, with her then boy friend. Child Q’s half-sister was physically harmed in her parents’ care, and her father was convicted of assault. As the mother’s role in the abuse was initially unknown, Child Q’s half-sister was removed into foster care for over a year (as an infant), and then, after extensive assessments during court proceedings, returned to her mother, under an Interim Care Order (ICO) and then a 12-months Supervision Order. Mother was required to adhere to a Written Agreement, which stipulated that she should provide adequate care and supervision to this child, and spelled out the (small) number of people with whom she could be left by her mother. This period preceded the scope of this review; however it may be considered relevant in relation to the mother’s parenting skills. 2.2 Shortly after the Supervision Order ended, Q’s mother met her new partner (Q’s father) and became pregnant. Their relationship broke down during the pregnancy, but he was keen to share care of their child Q, who was born in 2013. He and his mother (Paternal Grandmother, PGM) began to look after Q on a regular basis – eventually half of every week – and occasionally had Q’S half-sister to stay overnight as well. 1 Working Together to Safeguard Children, 2013, Chapter 4, Para 12; and Local Safeguarding Children Boards Regulations, 2006 (Regulation 5) Serious Case Review published 10.01.17 Page 5 of 55 2.3 Q’s mother is described as an immature and vulnerable young woman – a parent who loves her children, but who has struggled to prioritise their needs for consistent and safe care. As a result, the children were subject of Child in Need Plans (initially), and then CP Plans. Q’S mother engaged with many professionals, and wanted to ‘show people’ that she could be a good mum. There were, however, a number of negative factors affecting her efforts to change. She had an unhappy personal history, and apparently had no solid friendships, nor committed and positive family relationships, to support her. She suffered from periodic depression, and often became angry or distressed, with the inevitable impact on her parenting, as well as on other relationships. At times, she used alcohol irresponsibly. 2.4 When Q was about 9 months old, the family moved from one locality of Oxford, to another area. This left them more isolated, but Q’s mother and the children were assisted to link into health, school and early help services in their new community. Because of the CP Plan, and the concerns from the network of professionals, the family were often seen two or three times a week by one or other of the workers involved. The death of Q at the age of 14 months was entirely unexpected. 2.5 Whilst this review was commissioned because of the death of Child Q, it was not possible to carry out the process without considering her as part of a wider family. During the review period (dating from Mother’s pregnancy with Q), there were concerns regarding Q’s care, but much of the agency contact with the family related to the parenting of her half-sister and the CP Plans for the children reflected this. The work of agencies with the whole family was therefore covered in the review. 3. Time frame 3.1 The timescale for this review is from October 2012 until Q’s death in August 2014. 4. Family composition Name in report Relationship Mother Half-Sister Q Subject Q’s father PGM Q’s paternal grandmother MGM Maternal Grandmother 5. Organisational learning and improvement 5.1 Statutory guidance on the conduct of safeguarding children case reviews, including SCRs, states that ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. Serious Case Review published 10.01.17 Page 6 of 55 LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (WT, 2013, p.66) 5.2 No case can be said to be ‘typical’. However, the tasks in this case, in response to the circumstances and needs of this vulnerable family, were familiar ones and represent the ‘core’ roles and responsibilities of professionals and agencies, including the areas of early help, family support and safeguarding. The OSCB therefore saw that the SCR of this individual case would offer wider lessons for improvement, especially in dealing with cases of Neglect – already designated as their highest priority in the current year. The review was asked to address the following questions: What light does this case shed on the following areas: How well our CP planning process is working to protect children How well the inter-agency CP network responds to and works with children under 5 (N.b., the review did not compare or contrast the work with services for older children.) How effective agencies are at working with mothers with problems of substance misuse How well we work together in dealing with neglect of children The findings section of this report addresses these questions by an appraisal of practice, and the proposal of general patterns, or systems, operating in Oxfordshire. Not surprisingly, some of these occur not only in Oxfordshire, but more widely in safeguarding networks across the country. 6. Reviewing expertise and independence 6.1 This review was led by two independent professionals, neither of whom has had a connection with Oxfordshire services before. Sally Trench is an accredited SCIE reviewer and experienced SCR Overview author and SCR Panel Chair, with a lengthy background in local authority social work (adult mental health, and children and families). Her qualifications include Diploma in Social Administration (University of London) and CQSW/MA in Social Work (University of East Anglia). Anne Morgan is an independent safeguarding consultant trained in SCIE methodology. She has contributed to numerous SCR and Domestic Homicide Review (DHR) reports and authored a SCR previously. She has a health background (acute and community) with extensive experience in safeguarding and multi-agency work including chairing an LSCB. Her qualifications include SRN/RSCN, HV Cert., MA Child Studies (Law Faculty Kings College London). Serious Case Review published 10.01.17 Page 7 of 55 Both lead reviewers contributed to the writing of the report, with ‘quality assurance’ guidance from SCIE. B. Findings 7. Introduction 7.1 The Findings – the main body of the report – begin with a synopsis of the appraisal of practice. This sets out the view of the Review Team about how timely and effective the interventions with Q and her family were, including good practice but also identifying where practice fell below expected standards. Where possible, it provides explanations for this practice, or indicates where these will be discussed more fully in the detailed findings. 7.2 There is then a section to help the reader move from the case-specific detail to its more general relevance: this section explains the ways in which features of this case are common to other work that professionals conduct with children and families, and therefore how they can provide useful organisational learning to underpin improvement (‘a window on the system’2). 7.3 Finally, the report discusses in detail the 7 priority findings that have emerged from the review. The findings explore how well local safeguarding systems are supporting individuals, teams and whole services to offer effective help to children and families. They also outline the evidence that indicates that these are not one-off issues, but underlying patterns – which have the potential to influence future practice in similar cases. We also consider what risks they may pose to the wider safeguarding of children. 8. Appraisal of Practice: a synopsis Introduction 8.1 This case reflects the challenges faced by many professionals working with vulnerable families, where there is evidence of ongoing neglect, but the case does not meet the threshold for legal proceedings and where, with very high levels of support, the children are seen to be adequately cared for most of the time. One complexity is that such intensive support may inadvertently mask parenting deficits and the potential harm to children, particularly when professionals perceive the parent as attempting to do their best and as not malicious in their actions. The parenting by Mother in this case was neglectful – as reflected in the fact that there were Child Protection Plans for both children and the children were identified 2 Vincent, 2004 Serious Case Review published 10.01.17 Page 8 of 55 as being at risk of significant harm. There were a number of incidents that should have been treated more seriously (for example, when Q’s half-sister was found in the garden at night), whilst the rest of the time the fact that the case went along without major mishap was due largely to a) the support provided by the paternal grandmother and Q’s father, and b) being highly flexible, supportive and making up for gaps in the children’s care. 8.2 The family – Mother and her two children Q (subject) and her half-sister – received comprehensive input from several services, and the children were seen on a regular basis, including routine use of unannounced visits at varying times. The children were regularly described in recordings (all agencies), indicating that they were appropriately held in mind by practitioners. Professionals generally (with some exceptions, noted below) communicated and worked well together, within Team around the Child, Child in Need, and Child Protection frameworks. 8.3 Practitioners saw the mother as a likeable but very immature young woman, functioning more as a teenager than a woman in her early twenties. She wanted the help of professionals to become a better parent, and was described as responsive to advice offered. At the same time, she was often ‘found out’ in keeping secrets about aspects of her life which she wanted to remain unknown to professionals. She could be volatile and challenging at times, but was generally seen as responding to clear boundaries and advice. Unfortunately, there was little sustained change in her parenting behaviour. 8.4 Paternal grandmother and baby Q’s father provided shared care for Q, giving Mother the opportunity to focus on her older child, and some space for herself. Despite this informal ‘respite’ and considerable professional input, there continued to be instances when Mother’s care fell below an acceptable standard, thus creating risks to the children. These risks included physical injuries, through accidents or possible assaults, exposure to unsuitable visitors to the family home, poor supervision of the children and persistent co-sleeping with the baby. These were not always followed up by professionals in a consistent and pro-active way, including spelling out for Mother the potential consequences of her actions. 8.5 The wish to support and engage vulnerable young parents is common to most people working in health, education and social care. For some services, this role is changing and becoming more complex: for example, Children’s Centres now carry out more monitoring of parental behaviour, in line with their rising amount of CP work – a shift from the original ‘open door’ help provided in Family Centres. Reflective supervision and challenge are needed in all agencies to help workers carry out family support and CP roles simultaneously. This case review reflects how difficult this is in cases where neglectful parents are struggling to offer safe care to small children. 8.6 The following appraisal of practice outlines the Review Team’s views about how well professionals carried out their roles and responsibilities in working with this family. It also provides a link to the analysis of why things happened as they did, Serious Case Review published 10.01.17 Page 9 of 55 including the wider systems factors. It is these general findings which allow us to translate the learning from an individual case to the wider work of safeguarding agencies. Appraisal 8.7 Mother wanted a new start and moved with her first daughter to location A about fifteen months prior to the commencement date of this review (September 2012). This period is outside of the dateline for the review, and therefore not commented upon – apart from noting that the family had had a previous, relatively recent move. The social worker (SW1) who had been involved with the previous care proceedings for Q’s older half-sister kept the case open until February 2013. However, all other professionals working with the family changed following this move, resulting in a break in the continuity of care; this change happened again when the family moved in April 2014. When families move, even where there are good handovers, there is an impact on planning and intervention and the risk of a “start again” response amongst professionals. This is explored further in Finding 3. How the case was managed 8.8 The ‘status’ of the case changed a number of times: from allocation within CSC, to Team around the Child (TAC) under the Common Assessment Framework (CAF) process, then, after re-referral to CSC, to Child in Need and eventually CP frameworks. All of these involved multi-agency collaboration, with CSC only briefly absent from the network between February and April 2013 (when the case was managed as a TAC, and not allocated to a worker in CSC). Meetings were held regularly and attendance was good. The Review Team noted that the timing of ‘step down’ to a TAC occurred when Mother was known to be pregnant again, with her new boy-friend. Q’s half-sister’s Supervision Order had only finished in September 2012. The decision to move the case to a TAC discounted the need for a pre-birth assessment, and minimised two recent incidents when the care of Q’s half-sister was not appropriate (including Mother slapping her). The handling of this case throughout has examples of an acceptance of incidents without robust challenge or consequence, and this pattern is considered in Finding 2. The TAC meetings produced appropriate plans for their work with Mother and the children. The Lead Professional was from her local Children’s Centre (CC1), and this reflected its important role in supporting and monitoring Mother’s parenting, comprising both outreach and centre-based activities. For a large part of the period reviewed, Mother used their services very regularly. Professionals saw her involvement with Children’s Centres as absolutely vital, as she needed constant reminders and coaching in order to keep appointments and parent Q’s half-sister adequately. Mother’s immaturity, including her need for constant praise, and Serious Case Review published 10.01.17 Page 10 of 55 professionals’ responses to that behaviour, are consistent themes and are also discussed in Finding 2. Professionals’ responses to incidents 8.9 During the pregnancy with Q, the relationship with Q’s father broke down, much to Mother’s distress. In March 2013 both the Children’s Centre (CC1) and the school (nursery) noted that Q’s half-sister had a black eye. Mother gave staff different explanations for the injury, though they were not aware of these differences. The injury was not reported by either agency to CSC. This meant that there was a lack of ongoing identification of risk and Mother’s ability to protect Q’s half-sister. 8.10 On the 05.04.13 the police received information from members of the public who stated that a mother (no surname given) was seven months pregnant and taking class A drugs. She was also reported to have harmed her daughter. Initially, this referral was not shared with CSC – as it would normally have been. This was because a URN log3 was not raised by the Police Community Support Officer. If this had been done, it would have enabled joint research by Police/CSC to identify the family and undertake a welfare check. This was not a typical response, and does not therefore lead to a finding about police practice more generally, although it does result in a recommendation from the police in their IMR in relation to organisational learning4. 8.11 CSC received the same referral some days later, including the fact that there was a photograph of the bruising on the referrer’s mobile phone. A visit was made on the same day by two Social Workers to investigate the concerns identified, and no bruising was found. The child was spoken to alone, which was good practice. A Strategy Meeting was held the next day and a single agency S475 was agreed. The police were not informed about the photograph of the bruises until 7 days after the strategy discussion, when this information was contained within the strategy discussion minutes. This should have been shared with them at the time of discovery; the fact that it wasn’t appears to have been due to miscommunication between the two agencies. Had the Police known about the photograph, there would have been a joint investigation and possibly a better understanding of the risks to Q’s half-sister. 8.12 The case was allocated within the Assessment Team, and a Core Assessment (CA) was commenced. This uncovered Mother’s alcohol and cannabis use during pregnancy – something she had previously denied. This admission of wrongdoing, only when ‘caught out’, became a pattern in this case, as was non- or partial 3 A URN is created when a new incident is reported to the police which requires police attendance/involvement using the Command and Control IT system. 4 Thames Valley Police must instruct frontline staff that when dealing with information indicating a live Child Protection risk they must arrange attendance at the relevant address urgently as a first response. This would be through creation of a URN, to be followed up by a Child Protection report on Niche. Thames Valley Police should review how they identify and record risk in Child Protection investigations, and other incidents, reflecting that there may be vulnerability and potential referrals for a number of parties. This should include a review of the training methods used for front-line practitioners. 5 Child Protection investigation under S47 of the Children Act 1989 Serious Case Review published 10.01.17 Page 11 of 55 compliance with advice offered. The lack of any consequences when change did not occur, even when the children were on CP plans, resulted in little change in Mother’s behaviour and her ability to parent. This is discussed in Finding 1. The CA gave a good summary account of Mother’s isolation and need for ongoing support, and noted her own disrupted experiences of being parented and her family relationships as a young adult; it described her desire to become a better parent and her engagement with services. This was a good balanced picture of the situation and one shared by all professionals working with Mother. The network reformed under Child in Need procedures. 8.13 Q was born in June 2013. Her health and development gave no cause for concern for the health visitor during her first months, and she was seen to be bonding well with her mother (a feature which continued until her death). In early July, the case moved from the Assessment Team to the Family Support Team, and was allocated to a Family Support Worker (FSW). The level of support for Mother during this summer was very good, and included not just a range of professionals, but also both grandmothers and Q’s father. Mother was seen to be coping. 8.14 On the night of 10.08.13 the police received a referral from a neighbour, who had heard Q’s half-sister screaming in the family’s garden. Police visited and found Q’s half-sister outside the house, and Mother inside, co-sleeping with Q. The house was unkempt, and Mother had been drinking and was very difficult to rouse. Police liaised with the CSC Emergency Duty Team, and both children were placed in emergency foster care under a Police Protection Order. This was an appropriate response, given the risk of significant harm to both children. Non-involvement of Father 8.15 Q’s father, who had Parental Responsibility (PR), was not contacted in relation to the PPO and not asked to provide support, despite the fact that at this time he and his mother generally cared for Q at weekends. He was not made aware of what had happened, or of the CP Plans, until several months later. This non-inclusion of Q’s father at an important early stage reflected the professionals’ wish to keep Mother on board and co-operative, thereby focusing on her, rather than the children’s, needs. The degree to which fathers/male partners are involved in plans for children is discussed in more detail in Finding 4. Flawed information-sharing 8.16 At a discussion on the morning of the 12.08.13, a decision was made for the children to return home, with the proviso that maternal grandmother (MGM) would stay in the family home for 6 weeks. An Initial CP Conference (ICPC) was agreed, to be held at the end of August. Later that same day, a paediatrician examined the children (CP Medicals) and noted bruising on Q’s half-sister’s back and abdomen. The report identified that some of the marks could have been finger-tip bruising; however, verbal feedback from CSC to police did not make this clear, and the police Serious Case Review published 10.01.17 Page 12 of 55 did not become aware of this until much later – after they received minutes from the ICPC. This was another missed opportunity for a joint investigation to take place. 8.17 Strategy meetings at the time were commonly telephone discussions and did not include other professionals apart from the police and CSC. There were normally no minutes provided of these discussions. This review also learned of a routine problem with the timely distribution of CP conference minutes, CP plans and Core Group minutes (discussed in Finding 6). In this case, this had the effect of professionals going without the information they required to assess risk and make appropriate decisions relating to the children, as well as carrying out agreed plans. CP framework 8.18 At the ICPC, both children were placed on a CP Plan, under the category of Neglect. This category covers many different kinds of parental neglect. Thus, in every case, the specific risks to the children need to be clearly named, alongside what is required to keep them safe, what the desired outcomes are, and the consequences of non-compliance. The absence of such clarity was a pattern throughout this case: an example of this was that at the ICPC, maternal grandmother announced that she could no longer stay with the family for the full 6 weeks (she had been there 2 weeks), but there were no consequences for losing what had been agreed as necessary protection for the children when they went home, after the PPO. The CP Plan identified that Mother needed – and was offered – emotional support, including referrals to drug and alcohol services; but there was no consequence when she continued to decline these. It appears that neither Q’s father nor Paternal Grandmother (PGM) was invited or made aware of this meeting and they were therefore unable to participate in the process at this time. Housing is not routinely invited to CP Conferences. This is identified in the section below on ‘Additional Learning’. 8.19 Core Groups did not normally use a chronology or a list of significant events to help assess progress and compliance with the CP plan. Thus, patterns of behaviour – either demonstrating progress or the opposite – were harder to identify. Without a chronology of what had happened between Conferences or Core Groups, some information about incidents remained known only to certain agencies. An example of this is the Core Group on the 09.10.13 which was mainly taken up with Mother’s angry reaction to Q’s half-sister biting another child at school, whilst not mentioning Q’s admission to hospital on the 8th September, which had raised concerns for the paediatrician and occurred only one month after the PPO for both children. At the Core Group meeting on the 06.11.13, Mother’s debts, which were pressing for her, were discussed, but there was no mention of recent incidents (including ‘shouting’ at neighbours with children present) or the growing number of missed appointments/visits to the Children’s Centre. The importance of chronologies, including multi-agency chronologies, for seeing patterns and tracking progress, as well as ensuring that critical incidents are shared, is discussed in Finding 7. Serious Case Review published 10.01.17 Page 13 of 55 8.20 At the November Review CP Conference (RCPC), Mother said she planned to move house again, as she wanted to get away from personal/social problems in her area. Things were not going well for her at this time, and she appeared to have fallen out with a number of people, including her mother. Following the Conference, there were a number of worrying incidents which clearly indicated that Mother was struggling. This RCPC was chaired by a different chair who had not met Mother before, and there was a new SW (SW3) for the family. There was, nonetheless, a continued positive and supportive stance towards Mother despite the fact that she was not complying with all aspects of the plan. Lack of Strategy Meetings or Discussions 8.21 On the 24.11.13 (a Sunday) Q’s father contacted the Emergency Duty Team in CSC, to say that he had visited the house and taken Q at Mother’s request. The house was not in a fit state for a child and Mother had been drinking. He was worried about Q’s half-sister and where she might be. Police responded by visiting the house and corroborated his description. When Mother returned, her presentation confirmed what had been reported. She had been assaulted and had a black eye. Q’s half-sister was being looked after at MGM’s boyfriend’s house. This incident did not trigger a Strategy Meeting, despite both police and CSC involvement; this was a failure to comply with CP procedures. The seriousness of the situation was missed and the risks to the children not properly identified (see Finding 2). On the 26.11.13, when the Social Worker saw Mother, she admitted drinking and smoking cannabis when the children weren’t there. The potential impact of these behaviours on her parenting was not given sufficient weight in the CP Plans. During this critical period, the family’s SW changed, and the family continued to receive an intensive service from the new worker, again with a mixture of support and challenge when Mother was making bad choices for herself and the children. 8.22 In late January 2014 Mother received two black eyes, and Q’s half-sister also had a black eye. A Strategy Meeting or Discussion was again not held. Mother’s descriptions (inconsistent) of how the injuries to herself and Q’s half-sister happened were accepted, and not further explored. In the subsequent Core Group, it proved difficult to go beyond Mother’s description of her collision with a high chair (and Q’s half-sister ‘knocking heads’ with another child). Similarly, when there was, on more than one occasion during the period reviewed, an allegation by Q’s half-sister of being shut in a cupboard or shed, Mother’s denial was accepted after an obvious cupboard could not be identified. The child was not asked to describe the cupboard or show anyone where it was. There were no other kinds of professionals’ meetings held without Mother, which might have offered a chance for all those in the network to receive the same Serious Case Review published 10.01.17 Page 14 of 55 information about previous allegations and incidents. In addition, there was no request made for an opportunity to analyse or speculate together about what was going on in the family home – e.g., Mother’s level of drug and alcohol misuse. The reluctance to hold meetings without parents present reflects general practice in terms of working with families, and is discussed in Finding 5. 8.23 Further concerns were identified on the 10th February 2014 when Mother spent the day in a pub with Q strapped in her buggy, showing a lack of understanding of Q’s physical and developmental needs. Whilst this was dealt with by her SW appropriately at the time, this did not lead to any further “consequence” for Mother or the children – e.g., alteration to the CP plan or legal advice being sought. Legal action in relation to this incident on its own would not have been appropriate, but this was evidence of a lack of positive change. This was an example of how worrying incidents were not considered as patterns, and therefore did not build up an overall picture of the case. Family move and changes of professionals 8.24 At the Core Group in February 2014, professionals were pessimistic about Mother’s wish to move house again – seeking ‘a new start’. They were concerned that she was planning to move to a village where she had no friends or contacts, and where all the services she needed would be ‘new’. They therefore tried to talk her out of it. This was an accurate assessment of the situation. At a home visit in early February 2014, there were more signs that Mother was not coping: the house, normally well kept, was very disorganised and unhygienic, and Q for the first time was described as ‘moaning and hungry’. There had also been another incident of Mother’s volatility towards other parents at the school. The CP Plan was not able to provide protection against the upsets that frequently characterised her life, and the effect these had on the children. The CP Plans increasingly had a ‘cover-all’ list of actions, but without clarity about desired outcomes and consequences for lack of change or progress. Such plans can lead to drift and lack of protection for the children. The challenge in creating effective CP Plans for Neglect is discussed in Finding 1. 8.25 In early April 2014 the family moved as part of a mutual housing exchange. There was good handover by many of the professionals involved, although school and the Children’s Centre did not receive detailed or timely information. The RCPC, as a transfer-in Conference, was attended by both old and new professionals. This was good practice. The move however raised a different set of vulnerabilities because of the complete change of professionals and the challenge for them of gaining a full understanding of the family and its history. There is a risk in these situations, seen in this case, which professionals did their utmost to mitigate – i.e., that the family’s ‘new start’ can be mirrored in the way professionals work with that family, not seeing previous patterns or having limited understanding of ongoing concerns (a pattern discussed in Finding 3). This can be a particular problem when working with neglectful families, who are given yet another opportunity to improve. Serious Case Review published 10.01.17 Page 15 of 55 8.26 After the move, there were some early improvements – e.g., in Q’s half-sister’s school attendance, which had dropped significantly at her previous school. However, following the Core Group in June, the situation changed. Mother’s contact with the new Children’s Centre and health visitor became markedly less frequent and in early July the SW received an anonymous referral about Q’s half-sister having been hit, and Mother’s friends coming round for drinking and possible drug-taking, while Q’s half-sister was left in her bedroom. The referral didn’t mention Q who was possibly with PGM. There was no Strategy Meeting or Discussion regarding this referral. Mother denied the allegations. The SW saw Q’s half-sister alone which was good practice. It was difficult to take this referral forward, as Q’s half-sister denied being hit and there was no other evidence to support the allegation. The SW was concerned about the relationship between Mother and Q’s half-sister, and made several visits in July, some of which were unannounced and at the beginning and end of the day. She had no such concerns in relation to Q, where maternal bonding was seen to be good. An inconsistent picture was found, with Mother struggling at times to keep the household going, and sometimes on top of things. Q was described on one visit as being her ‘normal happy self’. This pattern shows how important a chronology is in cases of neglect – ideally a multi-agency chronology – in order to review and assess risk, both in supervision sessions and meetings such as Conferences and Core Groups. As noted above, the use of chronologies/ Significant Event tables is discussed in Finding 7. 8.27 On 07.08.14, Q was taken to the GP practice, thought to have drowned in her bath. She was transferred to hospital where she was pronounced dead. Medical responses were appropriate and were immediately available. 9. Overview list 9.1 The findings in this case all relate in some manner to working with Neglect, and identify different types of systemic issues that make it more or less likely that such work is done in a timely and effective way. The first two findings are explicitly about patterns in how professionals respond to the challenges involved in this enterprise. The serious implications for children are well summarised by Marian Brandon and colleagues, in their review of Neglect and Serious Case Reviews6, and are picked up in Findings 1 and 2: ‘The fact that neglect is not only harmful but can also be fatal should be part of a practitioner’s mindset as it would be with other kinds of maltreatment. This is not to be alarmist nor to suggest predicting or presuming that where neglect is found the child is at risk of death, but rather to suggest that practitioners and managers should recognize how easily the harm that can come from neglect can be 6 Brandon et al, 2013 Serious Case Review published 10.01.17 Page 16 of 55 minimised or downgraded. In the same way there should be recognition of the harm that arises when neglect cases drift. Practitioners need to have an open mind about the possibility of neglect having a fatal or very serious outcome for a child but deal with neglect cases in a confident, systematic and compassionate manner.’7 9.2 A list of the findings follows below, each showing a category in brackets, which names the type of systems finding it is, according to the SCIE list of categories (Appendix 2, Para. 5). Finding 1: CP Plans for Neglect do not consistently spell out the specific risks to children and the consequences if the desired outcomes for their improved safety are not achieved. As a result, the professionals involved are less clear and confident about when to take protective action. (Communication and collaboration in longer-term work) Finding 2: There is a pattern where professionals are not consistently and sufficiently pro-active in response to incidents and allegations regarding children on a current child protection plan, based on their perception that they ‘don’t have enough evidence’ to pursue the incident. This stops them from following through with any further investigative or protective action, and the opportunity is then lost to investigate the experiences of neglected or ill-treated children. (Communication and collaboration in response to incidents) Finding 3: There is a pattern of delayed and incomplete handover between some professional groups when families move, which can result in interruption of the knowledge about the family and the case, and lead to an unintended ‘start again’ for the new professionals, even with families where there has been no change or improvement for some time. (Communication and collaboration in longer-term work) Finding 4: There is a pattern where the input and co-operation of one of the parents, normally the mother, is prioritised at the expense of not engaging the other parent (normally father) in the child protection process. This may result in the children not receiving care and appropriate involvement from one of the parents. (Professional-family interaction) Finding 5: The commitment to working in partnership with parents in Oxfordshire has inadvertently led to an assumption that professionals cannot meet together, without parents being present, when they have concerns regarding case management. This jeopardises opportunities for joint discussion and supervision. (Management systems) Finding 6: In Oxfordshire, there is insufficient capacity for the effective administration of invitations to CP Conferences, and 7 Brandon et al, 2013, p.82 Serious Case Review published 10.01.17 Page 17 of 55 distribution of minutes and CP Plans. This leads to all the meetings of the CP system suffering from a lack of timely information-sharing and therefore of plans not being implemented in an effective way. (Management systems) Finding 7: There is no agreed use of a multi-agency tool to capture a chronology of significant events, making it more difficult to assess risk to children and parental patterns which demonstrate poor capacity to change. (Tools) 10. What is it about this case that makes it act as a window on the practice more widely? 10.1 Neglect is a major concern for safeguarding children’s networks, both within Oxfordshire and nationally. Locally, over half of Oxfordshire’s CP Plans are under the category of Neglect; the total number of plans has increased 23% over the past 3 years. 10.2 Messages from research 10.2.1 For several years, research by Ruth Gardner8, Brandon et al9, and others have pointed to the challenges of working with neglect, including problems of identification and evidence, of erratic improvements in parenting, and the difficulty of deciding about interventions (‘when is enough enough?’). All these were features reflected in this case. ‘Neglect can be difficult to define because most definitions are based on personal perceptions of neglect. These include what constitutes “good enough” care and what a child’s needs are. Lack of clarity around this has had serious implications for professionals in making clear and consistent decisions about children at risk from neglect.’ (NSPCC, 2012) Added to this is the recognition that working with neglect is evidence that ‘Neglect and emotional harm are some of the most highly stressful and demanding areas of work for individuals and groups of professionals.’ (Gardner, 2008, p.8) 10.2.2 There is also growing evidence from research about the long-term harm to children when neglect is a chronic feature of their lives. This is particularly true for 8 Gardner, R., Developing an effective response to neglect and emotional harm to children, University of East Anglia and the National Society for the Prevention of Cruelty to Children, 2008 9 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., and Black, J., Understanding Serious Case Reviews and their Impact – A Biennial Analysis of Serious Case Reviews 2005-07, 2009, DCSF Serious Case Review published 10.01.17 Page 18 of 55 the under-5s, and under-1 year olds account for 50% of SCRs. Gardner’s key findings included the following statements about the harm done to children: Neglect is a major form of maltreatment that has not yet been effectively addressed. All forms of neglect (physical, emotional, environmental) are associated with measurable developmental damage, including to the child’s emotional and social functioning. This can emerge at the pre-school stage and endure into adulthood. Without effective intervention, neglect can lead to active victimisation of the child both within and outside the family. In some cases this results in multiple abuse and death.’10 These findings highlight the seriousness of the enterprise for LSCBs in trying to improve the lives of children who are being neglected in their families. 11. Findings in Detail Finding 1: CP Plans for Neglect do not consistently spell out the specific risks to children and the consequences if the desired outcomes for their improved safety are not achieved. As a result, the professionals involved are less clear and confident about when to take protective action. In this case, the review team were struck by the way that professionals seemed to be better at naming concerns and requiring changed behaviour from parents than at analysing and describing specific risks of harm to the children. Sometimes what seems obvious does need to be spelled out so that everyone has the same understanding of potential harm. Another linked point was that CP Plans did not consistently spell out what action would be taken, and when, if risks of harm to children were not lowered. This resulted in a lack of clarity about when/how and why to take more pro-active steps to protect the children. How did the issue feature in this case? The CP Plans for both children changed during the course of 2014, when a new template was developed which reflected a change in the way CP Conferences were managed and which underpinned the recording of the plans discussed in Core Groups. This new template was clearer about desired outcomes for the children (now the first column of the plan), and about time scales for action. But these ‘aspirational’ elements remained unbalanced without an explicit description of what the principal risks to the children were if Mother’s parenting didn’t become more consistently safe and child-focused, and 2) what the consequences would be if there were further incidents or not enough progress. When allegations were made or incidents were reported, they were responded to, and Mother was normally admonished. As time went on, the CP Plans became 10 Gardner, ibid, p.7 Serious Case Review published 10.01.17 Page 19 of 55 longer, and something of a ‘cover-all’, in order to address the concerning areas of the family’s life. One result of this was the continuing high level of support being offered in response to Mother’s and the children’s needs. But this was not accompanied by robust analysis of the limited and inconsistent changes by Mother as parent, and the potential harm to the children from long term neglect. The lack of progress was reflected by the persistent list of concerns which did not tend to diminish over time – e.g., that mother had unsuitable people and unfamiliar (new) men visiting her, on one occasion overnight. The concerns were expressed without making explicit their associated risks: in this example, that the children could be physically or sexually abused by a visitor, and that Mother might be distracted by visitors and fail to give adequate physical care and safety to the children. Without this linking of concerns with the impact on the children, there is less likely to be an alert child-centred approach. What makes this an underlying issue? Input from the Case Group members as part of this review process indicated that the thinking and CP Plans in this case were not atypical, and practitioners saw this case as one with a moderate to low level of neglect. The Review Team confirmed there are acknowledged problems locally about effectiveness of work done in neglect cases, and the challenge of constructing a consistent and effective response to potential short-term and longer-term harm. Hitherto, the response to neglect cases has often been to increase the number of named actions in a CP Plan, without a ‘grading’ of risks which make it clear which are the most serious for the child/ren. Physical elements of a plan, such as clean and tidy children (or house), and school or nursery attendance, may be given more prominence than the emotional wellbeing of the children – something which is undeniably harder to assess and measure. Against this background, the Oxfordshire SCB has recognised the need to focus on this form of abuse, and has therefore designated Neglect as their primary focus for improvement in 2015/16. There is a Neglect Pilot underway in North Oxfordshire, which has as part of its remit the testing out and evaluating of the use of the local ‘Neglect toolkit’ which is in use, but inconsistently around the county (for more details about the Neglect Pilot, see Appendix 3). The County Council has also requested involvement in an NSPCC pilot project to address neglect. What is known about how widespread or prevalent the issue is? The common difficulties of working effectively in cases involving neglect are not restricted to any particular team or area, but are considered by the OSCB to be county wide. Significant numbers of children are potentially affected given that half of Oxfordshire’s CP Plans have a category of Neglect. Nationally, the picture reflects that in Oxfordshire. Neglect tends to feature more than any other category in CP Plans, and is the focus of the work with families in many Child in Need and Early Help cases as well. Serious Case Review published 10.01.17 Page 20 of 55 For those higher level cases of neglect, practitioners elsewhere, and in all agencies, have struggled with making effective and timely interventions. Action for Children have identified that about a third of professionals nationally have felt powerless to intervene when they have concerns about child neglect and the same number felt that Government spending cuts have made it more difficult to intervene in cases of child neglect11. In their recent thematic survey of neglect cases in eleven local authorities, Ofsted noted that ‘One third of long-term cases examined on this inspection were characterised by drift and delay, resulting in failure to protect children from continued neglect and poor planning in respect of their needs and future care.12 (N.b., Oxfordshire was not part of this survey.) What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? The OSCB has identified working with Neglect as a priority in its 2015/16 Business Plan. As part of the action plan a pilot in the North area of Oxfordshire, running from January to May 2015, focused on how practitioners can work more effectively to support children, young people and families where there are issues of neglect. It worked specifically with a cohort of children on CP Plans for Neglect (see Appendix 3). Early feedback on the pilot initiatives from both practitioners and families is positive. There are indications of better outcomes for some of the families. The pilot is being evaluated currently and once this is completed, recommendations will be taken forward in terms of improving/changing practice in relation to how practitioners in Oxfordshire work with families where Neglect is a feature. Changes to the way CP conferences are managed better have been further embedded; there is a better analysis of risk, which is based more on the family’s strengths and weaknesses than previously. This approach is being audited regularly to assess improved outcomes for the children involved Why does it matter? A safer system is one where there is shared and agreed identification, and naming, of specific risks for children. Alongside this, there needs to be clarity about the outcomes which would demonstrate progress, and the consequences if these outcomes are not achieved. Without these elements of the work and the planning, professionals are left without a clear framework for protective action, and children are more likely to be exposed to the serious and long-lasting impact of chronic neglect: ‘The perception of child neglect has changed significantly over time. It is 11 Action for Children, 2013 12 Ofsted, p. 4 Serious Case Review published 10.01.17 Page 21 of 55 now recognised as one of the most dangerous forms of abuse because of its harmful and sometimes fatal effects’.13 Finding 1: CP Plans for Neglect do not consistently spell out the specific risks to children and the consequences if the desired outcomes for their improved safety are not achieved. As a result, the professionals involved are less clear and confident about when to take protective action. Children suffering from persistent neglect by their parents are known to be at serious risk of permanent harm. This is a challenging area for professionals, for the many reasons outlined above. Their responsibility to support and guide vulnerable parents needs to be balanced with a very clear analysis of the specific risks to the children, and a plan which stipulates what needs to change and by when, and what will happen if improvements do not happen. A lack of robust response by professionals to uneven or unsustained change will result in drift and further damage for children who are being neglected. In responding to this finding, the Board may wish to consider the following areas: The outcomes from the Neglect Pilot in North Oxfordshire, particularly in relation to CP Plans for Neglect and the more consistent use of Signs of Safety for Conferences and Core Groups An analysis of feedback from frontline staff across Board agencies about the difficulties in working with Neglect Lessons from previous SCRs, case reviews and audits An in-depth multi-agency audit of neglect cases timed to test whether the recommendations from this review and the Neglect Pilot have had an impact’ The outcomes for CP Plans for Neglect: length of time on Plan, incidence of re-Plans, and evidence of improved safeguarding The degree to which CP Plans for Neglect are ‘child-focused’ The impact of pressures within services on the effectiveness of practice in Neglect The role of supervision and training in relation to Neglect, including challenges and best practice. Finding 2: There is a pattern where professionals are not consistently and sufficiently pro-active in response to incidents and allegations regarding children on a current child protection plan, based on their perception that they ‘don’t have 13 Turney and Tanner, 2005 Serious Case Review published 10.01.17 Page 22 of 55 enough evidence’ to pursue the incident. This stops them from following through with any further investigative or protective action, and the opportunity is then lost to investigate the experiences of neglected or ill-treated children. There seemed to be a contradiction in practitioners’ responses to the family in this case. On the one hand many went above and beyond what was expected, yet various incidents and allegations of physical assault were not treated as seriously as the Review Team would have expected. It is not uncommon that it is difficult to get to the bottom of an alleged incident of maltreatment or neglect, and to see what role the parent may have played. There may be little physical evidence of harm to a child, and no reliable witnesses to behaviour which puts them at risk. For this reason, specific processes exist to enable as thorough an investigation as possible. However, in this case, there was a notable lack of use of such processes. How did the issue feature in this case? Professionals encountered difficulties in pursuing incidents/allegations, mainly regarding Q’s half-sister: one was that allegations about physical abuse of Q’s half sister sometimes came several weeks after the fact, when physical signs were no longer present. The other was that Mother had her explanations for Q’s half-sister’s bruises, and her account of what she had or hadn’t done, and ‘stuck to it’, despite questioning or challenge by her workers. Overall, the associated level of concern regarding injuries or bruising meant that these instances were minimised. An example of this response to Mother is when she and Q’s half-sister both had black eyes in January 2014 and her explanation was accepted, despite it being highly coincidental that two people would have this kind of injury at the same time. In addition, the history provided by Mother of how they were sustained was highly unlikely. This, linked with Mother’s history of not telling the truth unless found out, was of concern to professionals, but was taken no further – e.g., by a medical examination of their injuries. Professionals told the Review Team that they sometimes did not believe Mother’s explanations, but did not feel they had enough evidence to do anything but carry on with the CP Plan as before. They felt they were nowhere near the threshold for a pre-court process. This was tautological. Without doing the appropriate investigations, they would not gain the necessary evidence. This was despite the fact that allegations were made from a variety of sources (including Q’s half-sister herself) about her ill-treatment, including Mother slapping her and locking her in a cupboard. Mother herself eventually admitted other worrying behaviour – e.g., drinking and drug use during pregnancy. CSC discussed her daughter’s allegations with Mother, but on a number of occasions (noted in the Appraisal above), they did not consider a Strategy Discussion or Meeting with Police colleagues. Mother was seen as a likeable and very needy young mum who wanted to do well and to become a better parent. This was appreciated by professionals and may have contributed to a general approach of wishing to support and help her develop into a more responsible adult, whilst unconsciously providing a safety net for her at times of difficulty. The outcome of this was that risks to the children were not always Serious Case Review published 10.01.17 Page 23 of 55 identified and analysed in a consistent way. Instead, workers gave her the benefit of the doubt – e.g., about the extent of her drinking and whether this happened when she was in charge of one or other of the children. A view that this was a ‘medium or low risk case’ did not help, in that there was never a sense that these children would reach the threshold for pre-court or court proceedings. The children were already subject of CP Plans, and it seemed there were few other responses available, when Mother did not follow through on agreed actions. One example of this was when the Written Agreement for MGM to stay with the family for 6 weeks, as a protective factor (after the children were removed from home in August 2013) was breached, but no other measure was put in place to ensure the children’s safety, despite the recent very risky incident. What makes this an underlying issue? When the response to incidents in this case was discussed with the Case Group and Review Team members, they were not surprised and did not regard this as unusual, pointing to common constraints about handling uncorroborated stories from parents. These were regarded as a normal aspect of the job: ‘what more could you do if a parent denied X, and there was no obvious way to gather further evidence?’ In such circumstances, professionals would expect to remain alert, but would not necessarily feel they could employ a different form of inquiry. Importantly, discussing this issue surfaced a misunderstanding on the part of practitioners that Strategy Meetings or Discussions do not need to be used for a child already on a CP Plan and are therefore rarely used for such children. It is also common for allegations to come to the notice of agencies ‘late’, thus presenting evidential difficulties for an investigation, and the loss of ‘urgency’. There was a view expressed within CSC that bruises, in particular, are very difficult to interpret. These are common circumstances in families, and have to be managed on a regular basis. What is known about how widespread or prevalent the issue is? A recently published SCR in Lambeth14 contains a similar finding, suggesting the pattern can be found beyond Oxfordshire: ‘When children are already on a child protection plan, there is a tendency for additional concerns not to be investigated through the correct child protection process. The assumption is that this will be addressed at the next child protection conference or core group’. In fact, as the SCR authors make clear, children already on a CP Plan are among the most ‘at risk’ children known to agencies, and therefore more in need of the correct multi-agency procedures being used. What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? 14 Lambeth SCR Child I Serious Case Review published 10.01.17 Page 24 of 55 It has been made clearer to workers in CSC that Strategy Meetings/Discussions should be used as required when deciding how to investigate a CP referral, including for children who are subject of a CP Plan. Why does it matter? A safer system is one where all agencies deal appropriately with incidents and allegations of maltreatment or neglect, following national CP guidance (WT, 2013); where all such investigations focus on the child, and where Laming’s model of ‘respectful uncertainty’ is maintained by professionals throughout. Ruth Gardner’s research (2008) noted the tendency for professionals to stand back in relation to a series of alerts or incidents which signalled Neglect: ‘Professionals were unanimous in feeling that best practice should mean a sensitive but prompt and pre-emptive response to early signs of child neglect (i.e. if in doubt, respond), rather than the current prevalent “wait and see” approach, which was at best potentially damaging and at worst dangerous.’ (p. 7) Finding 2: There is a pattern where professionals are not consistently and sufficiently pro-active in response to incidents and allegations regarding children on a current child protection plan, based on their perception that they ‘don’t have enough evidence’ to pursue the incident. This stops them from following through with any further investigative or protective action, and the opportunity is then lost to investigate the experiences of neglected or ill-treated children. A major part of CP work involves dealing with incidents and allegations about harm to children, often of an uncertain or unclear nature. Professionals need to work together, using all their exploratory powers, to ensure that reports about harm to children are shared and thoroughly dealt with, and that patterns of the same allegations (as in this case) are recognised as of significance. The work must be led by a child-centred approach, which involves alertness, challenge, and robust explorations of alleged harm. There is some evidence in Oxfordshire that this approach is constrained by a perceived ‘lack of evidence’, and therefore no further action is taken in such cases. This is tautological, as it closes the possibility of identifying available evidence, and therefore increases the level of potential harm, which has not been properly understood and responded to. In responding to this finding, the Board may wish to consider the following areas: The understanding of all who work directly with children of the nature of harm in Neglect cases, including incidents of physical abuse or accidents caused by neglect The use of Strategy Meetings/Discussions, including for children Serious Case Review published 10.01.17 Page 25 of 55 on CP Plans, and the inclusion of Health in these The skills of workers in agencies in agencies to respond in a more child-centred way to incidents/allegations The kind of input which would be needed (and achievable) to improve their skills The role of supervision in supporting and challenging workers in Neglect cases The challenges of investigating allegations about physical harm which are a few weeks old Finding 3: There is a pattern of delayed and incomplete handover between some professional groups when families move, which can result in interruption of the knowledge about the family and the case, and lead to an unintended ‘start again’ for the new professionals, even with families where there has been no change or improvement for some time. Changes in professionals working with families are a fact of life, and not only because families move. What this case has highlighted is the vulnerabilities that these transfers carry with them, and the need to be aware of what may be lost at points of transfer when working with complex and difficult cases. How did the issue feature in this case? During the time period covered by this review, the family, who had moved only just over a year previously, moved once again, and the following changes occurred: Three different CP chairs Three Social Workers Involvement by a 2nd and a 3rd Children’s Centre Two Health Visitors At least two GPs This resulted in some information between professionals being lost, especially after the family’s second move. For all new professionals, continuity and a perspective which viewed the case over time had been interrupted; there was an inevitable ‘start again’ for their work, which often comes with picking up the reins of a case already in progress. Some good handovers were made, including ‘old’ and ‘new’ professionals being present at the transfer-in Review CP Conference after the family’s move in spring 2014, an in-person meeting of the Social Workers, and a telephone call between Health Visitors. In contrast, there was minimal information passed from one Children’s Centre to another, and no CP Plan provided from CSC. Q’s half-sister’s school also didn’t receive information about the CP Plan in a timely manner. These two key agencies, who had the most frequent and regular contact with Mother and Serious Case Review published 10.01.17 Page 26 of 55 the children, began their work with little knowledge or understanding of the concerns and risks, and the overall purpose of the CP Plan. What makes this an underlying issue? Discussing how different agencies respond to these moves with the Case Group and Review Team revealed that the systems for transferring information include sending records, and sometimes direct contact between outgoing and new workers. These systems vary across services, and can often be erratic in terms of timeliness and completeness. Face-to-face handovers are regarded as best practice, and can sometimes be achieved, but are vulnerable to pressures of large caseloads and insufficient capacity in teams. Transfer summaries within CSC have not been used consistently in Oxfordshire and this misses the opportunity to pass on a critical analysis of the risks, patterns to be aware of, and the worker’s and supervisor’s views of how the case might progress. The Review Team agreed that there is a tendency for workers to ‘give the family time to settle’, to see what happens in the new situation: in other words, perhaps inadvertently, to mirror the ‘fresh start’ which the family may be seeking and contributing to a period of drift. What is known about how widespread or prevalent the issue is? In Oxfordshire and elsewhere across the country, work with children and families is increasingly characterised by periodic changes in the professionals involved. The reasons for this are usually inevitable: children get older and move from nursery to school, workers change jobs, agencies make new arrangements for allocation of work and lose capacity, etc. Families also move house, sometimes for very good reasons, but sometimes to avoid concerns raised within their neighbourhood and the scrutiny of professionals working with them. This mobility of vulnerable families has been highlighted in a number of SCRs nationally. What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? Oxfordshire already has a system which supports the Independent Chair of CP Conferences remaining with a case after a move within the county. It is now routine for transfers between Children’s Centres to have an in-person handover. The Early Intervention Service (EIS) is now represented at all Initial CP Conferences (including transfer-in Conferences), thus ensuring they have the opportunity to receive essential information about the family and offer additional support to help family and practitioners achieve goals as set out in the child protection plan. Serious Case Review published 10.01.17 Page 27 of 55 There has been a drive in CSC to block transfers of cases where there is no transfer summary provided – the aim being to embed the consistent use of transfer summaries. A number of changes to electronic recording systems are underway in different agencies. A move to new IT system MOSAIC in CSC will allow CSC and the EIS (Early Intervention Service) to share the same system. Health professionals in the MASH have access to the CSC system, but only when they are working there. What are the implications for the reliability of the multi-agency child protection system? There are few ways to prevent change in the personnel who work with children and families, given the myriad reasons for these changes. Therefore, services need to be alert and prepared for the risks in handling cases when they move from one worker, and/or from one setting, to another: these are the vulnerabilities in the transfer of appropriate and full information in a timely way, and in the potential for a ‘new start, or settling-in’ period after transfer, resulting in less pro-active work with the CP Plan. Finding 3: There is a pattern of delayed and incomplete handover between some professional groups when families move, which can result in interruption of the knowledge about the family and the case, and lead to an unintended ‘start again’ for the new professionals, even with families where there has been no change or improvement for some time. There is an inevitability about changes in personnel who work with children and families, for all the reasons outlined above. The need to transfer cases and information, and to get to know new families, is a routine aspect of the work of professionals. This review found some evidence of good transfer between some but not all professional groups which provided for the potential for information to get lost, and historical risk not fully appreciated. In responding to this finding, the Board may wish to consider the following areas: The multi-agency guidelines outlining best practice when transferring cases across areas The use of electronic recording systems within agencies, and potentially across agencies, for sharing information A system for retaining the same Independent Chair of CP Conferences for a family Flexibilities which could be used to retain the same worker across boundaries A template for transfer summaries, particularly in CSC, which could be shared across agencies. This could include a clear description of risks, especially for children on CP Plans (in line Serious Case Review published 10.01.17 Page 28 of 55 with Finding 1). The impact on families of having a change in workers, and managing this change Finding 4: There is a pattern where the input and co-operation of one of the parents, normally the mother, is prioritised at the expense of not engaging the other parent (normally father) in the child protection process. This may result in the children not receiving care and appropriate involvement from one of the parents. It is important, when undertaking assessments and implementing plans of support and/or protection of children, that there is professional engagement with both parents/carers and extended family. Working Together 2013 clearly identified this as a priority, unless to do so would put the children at risk, as do OSCB Procedures for Initial CP Conferences15. And yet in a critical period, this case showed a stark lack of communication, assessment and collaboration with the father, in contrast to the mother. Whilst this is appropriate where the man is considered a risk to family members it is not appropriate in other situations and results in the parent not being able to act as a responsible parent and the children not benefitting from their input16. How did the issue feature in this case? Neither father was consistently involved in this case, although both had parental responsibility (PR) and their details were known to CSC: Q’s half-sister’s father due to CSC’s previous involvement and Q’s father because he was living with Mother when Q’s half-sister returned home to her mother in 2011. Q’s father was not involved in the Core Assessment in 2013 following the first Strategy Meeting prior to Q’s birth as he and Q’s mother had separated. Q’s half-sister and Q (once born) were identified as Children in Need and Mother was assessed as a lone parent reporting no contact and support from Q’s father, even though he and his mother were in fact caring for Q frequently. When Q and her half-sister were placed under Police Protective powers, Q’s father was not informed and not asked whether he could provide safe care for Q. Whilst this was understandable in the very short term – it being the middle of the night and a weekend – he should have been made aware and included in the assessment of risk in relation to Q’s future care. He was subsequently not told about the ICPC which followed from this incident in August 2013, although the CP minutes would suggest that he and his mother had given their apologies. This was not in line with OSCB CP Conference Procedures which state that anyone with parental responsibility should 15 OSCB Procedures for Initial CP Conferences, Section 7 16 Scourfield, J. (2006) The challenge of engaging fathers in the child protection process. Critical Social Policy, special issue on gender and child welfare, 26, 2: pp. 440-449Scourfield, pp. 440-449. Serious Case Review published 10.01.17 Page 29 of 55 be invited verbally by the SW and an invitation followed up in writing. Where required, the Independent Chair should identify the reason for parental non-attendance at the Conference and the non-attending parent’s input and views should be included in the social worker’s report. Non-attending parents should also receive CP Conference minutes. Q’s father and paternal grandmother were not made aware of the CP Plan until after the first RCPC in November, to which they were also not invited. Case Group members explained that Mother did not want Q’s father to be involved or to know about the CP issues. On balance, they took the view that, in order to keep her engaged, they needed to work towards getting her to talk to Q’s father about these matters, rather than their informing and involving him directly. Eventually, Q’s father and his mother were included in the CP process, and PGM attended most Core Group meetings and Conferences. They increased their care of Q and at the time of her death were caring for her for half of every week. Professionals reported that they felt that Q was safe and well cared for when with her father and PGM. What makes this an underlying issue? Social Policy has until recently reflected a view that child care is a woman’s role, and men have tended to be excluded from discussions around care, as well as, in many instances, seen as an actual or perceived risk to children17. Whilst this attitude is changing and men are becoming more involved in their children’s care, the inclusion of men often becomes more complex when the parents are living apart and there is a level of animosity between them, as there was in this case. Some of the Case Group felt that at the time of the Core Assessment and the ICPC (i.e., 2013), this was a not untypical picture, and that fathers could be ‘left out’ in situations where the mother’s engagement and co-operation was prioritised over the father’s. However, there was a countervailing view that this approach has steadily diminished, and there are now many measures in place to promote awareness of and adherence to the CP Procedures regarding inclusion of fathers. The Review Team reported on a small number of complaints from fathers in relation to them not being involved in their child’s care. These complaints were from fathers who wanted to be involved, and may therefore reflect a larger number of other men who were not included, for a variety of reasons. It has not been possible to measure the incidence in Oxfordshire of similar actions as occurred in this case, which is why the finding is posed as a question. However, the fact that this practice was accepted and not challenged by all the professionals involved would suggest that, at least at that time, it was an underlying issue. The need for improved working with fathers was a health recommendation in a recent OSCB SCR published in 201418. Both the Case Group and the Review Team felt that whilst this had been an area of concern, it was now being addressed and less likely to occur in the future. 17 Scourfield, pp. 440-449 18 OSCB SCR Child N 2014 Serious Case Review published 10.01.17 Page 30 of 55 What is known about how widespread or prevalent the issue is? The SCR mentioned above highlighted the lack of involvement by fathers in early midwifery and health visitor intervention. Whilst there are no data available to identify how widespread this is in Oxfordshire amongst other agencies, it is a problem that has been highlighted nationally, and government policy has introduced a number of initiatives to improve fathers’ participation. What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? An OSCB audit took place in 2013 to analyse how well fathers were included in formal CP processes. The Children and Young People’s Board held a parents/carers’ Sounding Board which was well-attended by fathers and men in parental roles. The learning from this was disseminated across all agencies. In 2013, Children’s Social Care included a workshop on involving fathers at its large scale ‘Celebrating Social Work’ event. Good practice from the Family Nurse Partnership project was presented to approximately 50 social care practitioners. Practice is believed to have improved, and there have been fewer complaints from fathers/male partners about being excluded. The following actions address inclusion of fathers more generally, rather than specifically during CP procedures: As a result of a previous SCR all booking appointments for maternity services ask for father as well as mother to attend and all health visiting “First contact” visits request father’s attendance. OUH has taken action to ensure that information about both parents is collected in maternity services. Health Visiting has conducted an audit of the involvement of fathers at key contact points (e.g., New Birth Visit), and this has shown an increase of health visitor involvement with fathers. The Teenage Pregnancy Log book of preparation for birth and early parenting is designed to include fathers as well as mothers (information from the Teen-age Pregnancy Midwife). A key performance indicator for Children Centres is to increase the numbers of targeted groups accessing services from the centres, and fathers are one of these groups. Outreach to fathers by Children Centres in Oxfordshire has increased over the last year but it is acknowledged that there is still more to do. The introduction of a Multi-agency Safeguarding Hub has enabled agencies more easily to share information they have which would include information on fathers. The current CP Conference methodology is being used increasingly by CSC and partner agencies, and this involves looking at both parents separately. Serious Case Review published 10.01.17 Page 31 of 55 OSCB multi-agency training on improving work with young men and boys, commenced in 2014. It covers understanding behaviours, support services and resources so that professionals can work to their best effect. Why does it matter? If fathers are not involved in the CP process and not included in any of the assessments carried out, professionals will proceed without adequate information about either the risks that they represent, or indeed the protective factors they and their family may provide to the child/children involved. This will impact on decisions made and may not necessarily be in the best interest of the child. Finding 4: There is a pattern where the input and co-operation of one of the parents, normally the mother, is prioritised at the expense of not engaging the other parent (normally father) in the child protection process. This may result in the children not receiving care and appropriate involvement from one of the parents. It is important when working with families, as part of assessment and implementation of plans to provide support and/or protect the children, that there is professional engagement with parents and extended family. Working Together 2013 clearly identified this as a priority unless to do so would put the children at risk, as does OSCB Procedures for Initial CP Conferences19. And yet this case showed an initial lack of communication, assessment and collaboration with the father, in contrast to the mother. Whilst this is appropriate where the man is considered a risk to family members, it is not so in other situations. The outcome for the child may be that he/she does not benefit from support and input from the paternal side of their family.20 In responding to this finding, the Board may wish to consider the following areas: The routine capturing of details about fathers in agencies working with women and children in Oxfordshire – including Early Intervention services and in assessments for Child in Need and CP processes – and any increased improvement in outcomes for children since the routine recording of fathers by health visitors Lessons from previous SCRs, case reviews and audits in relation to inclusion of fathers/partners Lessons from other local authorities and LSCBs, as well as from 19 OSCB Procedures for Initial CP Conferences; Section 7 20 Scourfield, J. (2006) The challenge of engaging fathers in the child protection process. Critical Social Policy, special issue on gender and child welfare, 26, 2: 440-449. Serious Case Review published 10.01.17 Page 32 of 55 research, about what works well in including fathers or the partners of mothers The role of Strategy Meetings, Conferences and Core Groups in improving practice – in a safe way for mothers and children The possible use of consultation exercises to assist with this issue Finding 5: The commitment to working in partnership with parents in Oxfordshire has inadvertently led to an assumption that professionals cannot meet together, without parents being present, when they have concerns regarding case management. This jeopardises opportunities for joint discussion, challenge and supervision. Working in Partnership with parents is now the expected norm with them being aware of concerns professionals may have and what is needed to address those concerns. However, there are occasions when it is beneficial for professionals to meet together to address such issues as network functioning, ‘stuck’ cases, etc. In such circumstances, a professionals meeting, peer-supervision or a facilitated network meeting may be required. The usefulness of such meetings, and when they are justified, needs to be understood and agreed among agencies. How did the issue feature in this case? There was good attendance at CP conferences and Core Groups, and professionals reported that they worked well together and challenged Q’s mother. However this case review process has highlighted that some information was not shared in meetings with Mother and some incidents were not discussed in Core Groups (e.g. the trip to hospital in 2013 and the allegation of ill-treatment of Q’s half-sister in 2014). This may have been because of a wish not to upset Mother and keep her on board. The result was that not all professionals held the same set of information. Meetings with service users present do not generally allow for analytical or speculative discussion (e.g. about the level of Mother’s keeping secrets, or what was known about her alcohol misuse), or for robust professional challenge of each other within the professional network. Challenging Mother in meetings also proved difficult. An example of this is when she had two black eyes and Q’s half-sister had one. The Core Group meeting was unable to get beyond her explanation of the causes, despite the fact that her injuries were physically unlikely to have occurred in that way and the likelihood of her and Q’s half-sister having injuries at the same time highly improbable (see link to Finding 2). Another time when a professionals meeting would have been beneficial was at the time of the move in 2014, when not all professionals (in particular school and the Children’s Centre staff) had all the information required to carry out the work expected of them (see also Finding 3). What makes this an underlying issue? Serious Case Review published 10.01.17 Page 33 of 55 Both the Case Group and the Review Team felt that this was not an isolated case, and that it would be unusual for professionals to meet to discuss a case without parents being present, even when it might be useful. There was a clear culture of openness with parents which some Review Team members felt would be threatened by having any meetings without parents (although currently, this is true for Strategy Meetings). A member of the Review Team described how a health practitioner’s request for a professionals meeting had been discouraged by CSC, apparently on the grounds that this would not fit with the principles of transparency. Currently, there is no clear guidance nor agreed criteria for deviating from the important principle of openness and working in partnership with parents. This is unlikely to change unless such criteria can be agreed, for when a professionals meeting can be agreed. What is known about how widespread or prevalent the issue is? The Children Act 1989 and Working Together 2013 both identify the need to work openly and in partnership with parents unless to do so would put a child at further risk of harm. The Review Team and Case Group were in many ways typical of the wider professional respect for these principles. There is a legitimate concern expressed widely in children and families work not to lose the improvements made from a time when parents were regularly left out of decision-making meetings. Social policy has reflected and promoted this view. However, in some cases such as this one, this has resulted in a lost opportunity to share information and provide clarity about the level of risk. The consequences from not holding professionals meetings have been picked up in other SCRs, including the Gloucestershire SCR into the neglect of Abigail and her siblings Bobbie, Charlie and Daisy21, and also identified by the research carried out in Improving Child and Family Assessments in 2011.22 What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? Nothing specific has yet been put in place but both the Case Group and the Review Team felt that this was an area requiring further work. The Review Team were told about the regular use of ‘case mapping’ (usually at the TAC level), when there is a concern about the work in a case being effective. Why does it matter? 21 Gloucestershire SCB SCRs 2014 22 Selwyn, J., Farmer, E., Turney, D., Platt, D.: Improving Child and Family Assessments: Turning Research into Practice; Jessica Kingsley Press, 2011 Serious Case Review published 10.01.17 Page 34 of 55 When cases are drifting, or there is multi-agency professional disagreement or the need for peer supervision/facilitation, it may be helpful for professionals to meet without parents, to debate and analyse what would achieve better outcomes and to agree a way forward. This would also support supervision provided within a professional’s own agency and would provide a space for free thinking, analysis and clarity of vision required in complex cases. Finding 5. The commitment to working in partnership with parents in Oxfordshire has inadvertently led to an assumption that professionals cannot meet together, without parents being present, when they have concerns regarding case management. This jeopardises opportunities for joint discussion, challenge and supervision. A safe system enables partnership with parents and adequate support to professionals. This finding has highlighted a norm which provides the former at the expense of the latter. Where there is no progress in a case, and by extension no improved outcomes for children, there should be the possibility for the network to meet separately to look together at the effectiveness of their work. In responding to this finding, the Board may wish to consider the following areas: The perceived barriers to holding such meetings The possibility of agreed criteria, or terms of reference, for holding a ‘professionals only’ meeting The balance needed with the principle of transparency of working with parents The role of the Board’s escalation policy when professionals are unable to agree a way forward The resources and skills needed for skilled chairing or independent facilitation (when required) of such meetings Finding 6: In Oxfordshire, there is insufficient capacity for the effective administration of invitations to CP Conferences, and distribution of minutes and CP Plans. This leads to meetings in the CP system suffering from a lack of timely information-sharing and therefore of plans not being implemented in an effective way. Elsewhere in this report, we have written about the need to follow national guidance for multi-agency CP work (Finding 2, above), which includes the operation of the CP Conference system. This review has highlighted that locally this system is not functioning efficiently, especially in sending out minutes and plans. This leaves Serious Case Review published 10.01.17 Page 35 of 55 partner agencies with lowered confidence about what they can expect in relation to accurate and timely information-sharing. How did the issue feature in this case? There was delay in timely and consistent sharing of CP Plans and minutes for professionals in this case; for example the minutes of the ICPC were not available for the first Core Group meeting. What makes this an underlying issue? This review heard that this is regarded as typical of what is now experienced from the CP Conference system. The message from both Review Team members and Case Group members was that there are almost always lengthy delays in receiving CP Plans and minutes, sometimes of several weeks. This is particularly problematic for people who have been invited to a Conference, but who were unable to attend. They can be left with no information about risks to the children for a period in which they may be working with the family. The Review Team also commented that agencies generally assume minutes will not arrive in a timely way, and resort to finding ways around this. It is unclear whether colleagues are aware of the minimum standards for these to be distributed – in the Oxfordshire Child Protection Procedures (updated June 2013). CP decisions/plans should be distributed within 1 working day. CP Conference minutes should be circulated within 28 days. Neither of these targets is being met on a regular basis, and Case Group members said that CP decisions/plans do not arrive in advance of the minutes, which take much longer to be completed. The use of a separate document for the CP decisions/plan, which should be sent out separately and in advance of the minutes, is apparently not in place. There were also complaints about the production of Strategy Meeting minutes, and some colleagues (the Police, in particular) said they do not expect ever to receive Strategy Meeting minutes from CSC. They understand that the chair of the Strategy Meeting also has to minute the meeting; normally has several meetings in one day; and therefore has no capacity to produce minutes in a timely way. There are clearly some systems which are obstacles to efficiency. Until recently, there were insufficient numbers of administrative staff to operate to the expected standards. All records (invitations, minutes, etc.) are sent out by paper copy and using second-class post. This is because of concerns about the security of Email. Unfortunately, this can add delays to the receipt of invitations and minutes. What is known about how widespread or prevalent the issue is? Serious Case Review published 10.01.17 Page 36 of 55 In Oxfordshire this was known to be a problem due to a lack of administrative support for CP conferences. It was exacerbated by the increase in children with a CP plan, where numbers increased over the time of the review and have continued to increase to date. Numbers of children with a CP plan in 2012 were 364, numbers in March 2013 were 430 and in 2015 they were 632, a steep increase over a three year period and one which continues currently. Numbers are lower than the national average but higher than statistical neighbours. There has not been an audit in relation to the timeliness of getting conference minutes to family and professionals involved, but it is clearly a known and acknowledged problem. The problem is exacerbated by the use of second class post rather than electronic distribution due to concerns relating to data protection. It is likely that many of the same challenges are experienced in every local authority, where CP work is increasing in volume. Everywhere, the same standards are required, and many of the same pressures on staffing resources are bound to apply. It is not known whether there are more efficient systems in use elsewhere from which Oxfordshire could benefit. What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? The concerns expressed above have been escalated to the Deputy Director for Safeguarding (CSC), who is addressing the problems outlined in this finding. There has been an increase in the number of administrative posts working with CP Conferences, but it is not yet known whether this has had an impact on the finding. The more regular use of Egress, a secure email tool, in CSC (since 2014, and for their providers from May 2015) for sending communications safely is now in place, for the different processes involved in the formal CP framework. What are the implications for the reliability of the multi-agency child protection system? The period which follows the ICPC (and possibly, a transfer-in Conference), in particular, represents an opportunity to work with families in a focused and more intensive mode, at a time when families may be ready to listen to the combined concerns of the professional network. Where there is a delay in receiving the plan there is a reduced opportunity for agencies to consider their roles and what they can offer, in preparation time for the first Core Group meeting (within 10 days). The effectiveness of the work during this period and at the Core Groups is reliant on having the skeleton CP Plan and developing it in partnership with the family and key partners. Finding 6: In Oxfordshire, there is insufficient capacity for the effective administration of invitations to CP Conferences, and distribution of minutes and CP Plans. This leads to meetings in the CP system suffering from a lack of timely information-sharing and therefore of plans not being implemented in an effective way. Serious Case Review published 10.01.17 Page 37 of 55 The reliable operation of the CP Conference system, including other meetings within the CP framework (such as Strategy Meetings), is essential to support the work of professionals with families, and with each other. The CP Plan is the building block to guide the work with families, and a baseline for review against progress. Not to produce or share the plan in a timely way brings considerable problems: that concerns about the children and the purpose of the work remain unclear, and may even minimise the perception of risks. In responding to this finding, the Board may wish to consider the following areas: Feedback and positive criticism needed from partner agencies to identify problems regarding invitations and minutes Capacity issues (number of staff; skills of staff, etc.), and the systems issues (the need to maintain security, the templates/tools available, etc.) The organisational responsibility for CP Conferences and distribution of minutes The method of sending invitations and minutes Lessons from other local authorities about how to achieve the national minimum standards required for sharing CP Plans and minutes Finding 7: There is no agreed use of a multi-agency tool to capture a chronology of significant events, making it more difficult to assess risk to children and parental patterns which demonstrate poor capacity to change. The usefulness of a multi-agency chronology of significant events has been underlined by numerous SCRs, by the Victoria Climbie Inquiry Report, and in other research. In order to assess risk accurately, a tool is required that will identify both past and present concerns, patterns of behaviour, and what interventions haven’t worked in the past. An agreed tool to enable this to occur, such as a significant events form or a chronology, provides professionals with the information which will enable them to do this. How did the issue feature in this case? There were a number of worrying incidents of various kinds that continued to occur in the family/to the children. These were dealt with by different agencies (normally by the SW), and were not always shared in a timely way with inter-agency colleagues. This seemed to make it harder for colleagues to identify a ‘cluster’ of events which might show that mother was going through a particularly low period or difficult time in terms of coping with the children or her own emotional struggles. Serious Case Review published 10.01.17 Page 38 of 55 Integrated chronologies of significant events were not used routinely for CP Conferences or Core Groups as a means of tracking progress (or otherwise). This meant that not all incidents were reported to these meetings, and repeated patterns, e.g., of Mother not telling the truth until ‘found out’, were not always picked up. What makes this an underlying issue? Review Team members acknowledged the importance of chronologies for working with families. Within agencies, these are vital for reviewing progress and identifying incidents and patterns, so that workers and their managers can reflect on what is or isn’t making a difference for the children. Across agencies, they offer a tool for identifying and tracking, so that partners are similarly able to analyse what is going on in a case and what progress has been made. All the agencies involved in this case have a chronology template which is meant to be maintained and used for analysis and review of the work – e.g., in supervision. However, the usefulness of sharing or integrating a chronology with partner agencies is not currently on the table. Even doing so for CP Conference reports and minutes is regarded as not easily achieved. The value of chronologies is agreed, but Review Team members described a number of barriers to making them used more reliably: The introduction of chronologies in ICS was not successful. Social workers found the tools difficult to use, and more recent adaptations (e.g., Frameworki in CSC) are still inflexible, too lengthy, and do not allow the identification of ‘key’ events. In Oxfordshire, there are different models in use, even within agencies such as Health, and a number of new tools are currently being developed. This suggests there will be a period before these changes are bedded in and being used consistently and confidently. There are major caseload and time pressures on workers, leading to a culture which does not prioritise, or insist upon, the maintenance of a chronology – due to the amount of time required and the difficulties described here. This may particularly apply to those cases below the threshold for court proceedings (where a chronology must be produced). One of the drivers for the change in conduct of CP Conferences was the emphasis placed on the family’s strengths and resilience as well as their weaknesses thus engaging the family with the process. Some of the Review Team felt the use of chronologies did not fit well with this model and therefore the same importance was not placed on using them. What is known about how widespread or prevalent the issue is? Within Oxfordshire a chronology is prepared by the social worker for CP Conferences but not distributed with the minutes. This is felt to be too unwieldy to share on a regular basis. Recently, the OSCB have agreed to share and integrate chronologies Serious Case Review published 10.01.17 Page 39 of 55 to cover a short period of time when they feel to do so may provide professionals with a broader picture on what’s happening in a case. Nationally, the requirement to maintain chronologies in CSC has been in place since Lord Laming’s inquiry into the death of Victoria Climbie, and his finding that professionals had failed to recognise patterns in the child’s history. He therefore made the recommendation that Within six months of the publication of the report, directors of social services had to ensure every child’s case file had, on the inside of the front cover, a “properly maintained chronology”23. Long before that, in 1973, the equally seminal inquiry into the death of Maria Colwell concluded that it was essential to keep chronological records of significant events in a case – in order to provide a picture of a child’s history, including risks of harm. But a review of the use of chronologies in Community Care, noted that ‘…more than 30 years after Maria’s death it seems chronologies are still not always managed properly and key opportunities to intervene are being missed.’24 There is clear evidence that the value of chronologies is endorsed, and that attention is being given to how to achieve better practice, including meeting Laming’s recommendation. No doubt some areas are proving better at this than others. But it is likely that the barriers outlined above continue to challenge local authorities and all agencies in the safeguarding children network. What has been put in place in Oxfordshire since this review started which would lead the Review Team to believe that practice is different in Oxfordshire today? Children’s Centres now use chronologies routinely and have done for the last twelve to eighteen months. They are reviewed regularly to assess progress. The OSCB have also agreed a process which has been put in place to carry out a short-term integrated chronology for complex cases. What are the implications for the reliability of the multi-agency child protection system? ‘Abuse and neglect are infinitely more preventable when good chronologies are kept.’ ‘Patterns in social history and behaviour can be detected and something which might appear insignificant in isolation can be identified as a key warning sign in context.’25 23 Lord Laming, The Victoria Climbie Inquiry Report, 2003, Recommendation 58 24 Camilla Pemberton, ‘Danger signs that lay in a timeline. How social workers should use case chronologies’, Community Care, September 27, 2010 25 Quotation from T. Palmer, in Camilla Pemberton, ‘Danger signs that lay in a timeline. How social workers should use case chronologies’, Community Care, September 27, 2010 Serious Case Review published 10.01.17 Page 40 of 55 A child protection system needs to be able to have a reliably accurate picture of the present in the context of the past for all children. Relying on the narrative of records and the personal memories of practitioners is fallible and risky. A safer system is one where chronologies are expected and relied upon as a tool for case analysis, planning and review. As multi-agency chronologies, they provide a far stronger and more effective vehicle for sharing information within the safeguarding children network. They can also assist in preventing a ‘start again’ mind-set, when they are available to new professionals joining a case (see link to Finding 3). Finding 7: There is no agreed use of a multi-agency tool to capture a chronology of significant events, making it more difficult to assess risk to children and parental patterns which demonstrate poor capacity to change. To assess risk accurately a tool is required that will identify both past and present concerns. An agreed tool to enable this to occur such as a significant events form or a chronology provides professionals with the information which will enable them to do this. In responding to this finding, the Board may wish to consider the following areas: The current use of chronologies in constituent agencies An agreed multi-agency policy on chronologies Guidance on how to construct and use a chronology Auditing their use, via internal audits and inspections of services Constraints and obstacles for using a chronology in safeguarding cases The possibility of achieving an integrated chronology for CP Conference reports, using an agreed template 12. Additional Learning 12.1 Misleading records in relation to participants in CP Conferences This review has highlighted a routine mistake in CP Conference minutes, in relation to those who were invited to the Conference. Father and PGM were not informed about the Initial CP Conference, and were not invited. However, in the minutes their names were listed under ‘apologies’ – thus wrongly suggesting that they had been invited but sent their apologies. This would have been misleading for the professionals attending; had they known the true situation, they might have objected to the exclusion of father, who had parental responsibility. Serious Case Review published 10.01.17 Page 41 of 55 Some members of the Case Group confirmed that they had noticed this happening to themselves: when they received minutes, their names were listed as having given apologies, but they had never received an invitation. An accurate system is needed which reflects who was invited/who attended/who gave apologies/who did not attend and did not give apologies. 12.2 Enabling wider participation in CP Conferences and Strategy Meetings The Review Team suggested that, given modern technology, there could be greater flexibility in how to conduct certain meetings, including CP Conferences and Strategy Meetings. Video or audio conferencing would perhaps enable Police Officers, GPs and other health professionals to participate more readily, whilst currently time and distance pressures mean they often cannot attend. 12.3. Housing Involvement in the CP process Housing are not routinely involved or made aware by CSC of children with a CP plan. Housing have already amended their paperwork so that once made aware they can record whether families who move into social housing have children with a CP plan. They will also be agreeing a process with CSC which will enable them to provide input into CP conferences which may include the routinely being asked for a report and provided with minutes. 13. Conclusion 13.1 This systems review has had two principal aims: to report and learn from what happened, and why, in a particular child or family’s story; and to consider what this tells us about the wider safeguarding of children in Oxfordshire, and how this might be improved. 13.2 Overall, the review has highlighted the complexity of working with Neglect. It explored the initial four “research questions” in relation to multi-agency working in Oxfordshire, and identified findings in relation to three of them. The question regarding substance misuse did not result in a finding, as there was no evidence available to suggest that Mother had an addiction to drugs or alcohol. The findings have focused on the learning for Oxfordshire which will improve agencies’ response to Neglect. There were no findings, nor any data captured in the review process, that suggested that any agency’s actions (by commission or omission) could have prevented Q’s death. 13.3 Mother’s care of the children was characterised by workers as ‘low to medium’ neglect, and as such little different from many other families known to agencies in Oxfordshire. All the information available and observations by workers suggested that there was good attachment between Mother and Q. While this did not Serious Case Review published 10.01.17 Page 42 of 55 necessarily mean that Q was not at risk, professionals were understandably more worried about her half-sister, where there was some evidence of emotional abuse and possible physical abuse. 13.4 The contents of this report have been the product of the Review Team and Case Group, who contributed their knowledge and experience in relation to this case, as well as their wider understanding of how safeguarding systems operate in Oxfordshire and elsewhere. They participated in the analytical process with a clear desire to make things work better in future. This was enhanced by the additional information provided by Q’s father and paternal grandmother. It is hoped that this review will support learning and improvement across the safeguarding network, and will lead to better outcomes for children at risk of harm. Serious Case Review published 10.01.17 Page 43 of 55 REFERENCES AND BIBLIOGRAPHY Action for Children; Impact, causes and responses to child neglect in the UK www.actionforchildren.org.uk 2013 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., and Black, J., Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we Learn? – A Biennial Analysis of Serious Case Reviews 2003-2005, DCSF, 2008 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, Pl, Dodsworth, J., Warren, C., and Black, J., Understanding Serious Case Reviews and their Impact – A Biennial Analysis of Serious Case Reviews 2005-07, 2009, DCSF Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., Megson, M., New learning from serious case reviews: a two year report for 2009-2011, Centre for Research on the Child and Family in the School of Social Work and Psychology, University of East Anglia Health Sciences and Research Institute, Warwick Medical School, University of Warwick, 2013 Camilla Pemberton, ‘Danger signs that lay in a timeline. How social workers should use case chronologies’, Community Care, September 27, 2010 Fish, S., Munro, E., and Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Gardener, R., Developing an effective response to neglect and emotional harm to Children, University of East Anglia and The National Society for the Prevention of Cruelty to Children, 2008 Gloucestershire SCB, SCRs 2014 Lambeth SCR Child I LSCB 2014 Lord Laming, The Victoria Climbie Inquiry Report, 2003, Recommendation 58 National Institute for Health and Care Excellence (NICE) Guidance, ‘When to suspect maltreatment’ (CG89), July 2009 Ofsted, Research and analysis: Professional responses to neglect: in the child’s time, March 2014 OSCB Procedures for Initial CP Conferences; Section 7 OSCB Neglect Strategy 2014 Serious Case Review published 10.01.17 Page 44 of 55 OSCB Review of Child N, published on OSCB website, 2014 Oxfordshire Inspection of safeguarding and looked after children – Care Quality Commission/Ofsted – published April 2012 Scourfield, J. (2006) The challenge of engaging fathers in the child protection process. Critical Social Policy, special issue on gender and child welfare, 26, 2: pp. 440-449. Selwyn, J., Farmer, E., Turney, D., Platt, D., Improving Child and Family Assessments: Turning Research into Practice; Jessica Kingsley Press 2011 Turney, D., and Tanner, K., Understanding and working with neglect, Research in Practice and Making Research Count, 2005 Vincent, C.A., ‘Analysis of clinical incidents: a window on the system not a search for root causes’, Quality and Safety in Health Care, 2004;13, pp. 242-3 Working Together to Safeguard Children, DfE, 2013 Serious Case Review published 10.01.17 Page 45 of 55 APPENDIX 1 Review methodology 1. Methodology 1.1 Statutory guidance requires SCRs to be conducted in such in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (WT, 2013, p.67) 1.2 It also requires that the following principles should be applied by LSCBs and their partner organisations to all reviews: there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; reviews of serious cases should be led by individuals who are independent (see section 8 below) of the case under review and of the organisations whose actions are being reviewed; professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. (WT, 2013, pp. 66-67) 1.3 The OSCB wished to try out a new systems approach for SCRs: the Learning Together model (Fish, Munro & Bairstow, 2009), developed within the Social Care Institute for Excellence (SCIE). This model meets the expectation in WT 2013 for SCRs, and other learning reviews, to demonstrate ‘systems principles’ in seeking to capture ‘what happened and why’. The model involves the use of a Review Team of senior managers and a Case Group made up of the professionals involved with the family, who work together with the Lead Reviewers to collect and analyse data about the case and the context for the work carried out. The aim is to identify Serious Case Review published 10.01.17 Page 46 of 55 whether local systems are supporting good multi-agency practice and better outcomes for safeguarding children. As a result, most Learning Together findings tend to focus on systems which operate across agencies. The Learning Together model also includes the views of any family members able to participate in the process. A full account of the Learning Together methodology, and the process used for this SCR, is provided in Appendix 2. 2. Reviewing expertise and independence 2.1 The model relies on reviewing expertise and independence, in the same way that WT 2013 requires independence in at least one lead reviewer for Serious Case Reviews. 3. Methodological comment and limitations 3.1 The Lead Reviewers and Review Team gathered data from all the professionals/agencies involved with the family in Case Group meetings and in individual conversations, 22 in total from five different agencies. These activities yielded a large amount of rich data to support systems learning. There was good attendance at the follow-up meetings and professionals involved participated very positively in the process, reflecting and sharing on their experience. The Lead Reviewers and Review Team members were conscious that this participation was initially very distressing for workers, particularly those who had known the family over time, and had worked with Q very recently. Nonetheless, their feedback was that they valued the opportunity to contribute to learning from a tragic event. We are very grateful to them for doing so. 3.2 The use of documentation, including an integrated timeline and key records from agencies, provided a necessary starting point and context for the case discussions at the workshops. (Details of documentation are given in Appendix 2, Para 10.4.) 3.3 Oxfordshire has carried out a number of SCRs in the recent past and this review provided an opportunity not only to explore a different methodology but to provide some of the Review Team (listed in Appendix 2) with the experience of participating at this level. This was successful, and the feedback from the Review Team was that they, in common with their Case Group members, found the experience a positive one, albeit requiring an intensive input of work from them. They especially valued its collaborative, multi-agency nature. The opportunity for practitioners to appraise their practice collectively was new, and they appreciated the chance to analyse the work done across agencies with the family. The Review Team, of which some members had never been part of a SCR at this level before, experienced some unavoidable absences and changes in membership, and Serious Case Review published 10.01.17 Page 47 of 55 not all members had received training on the SCIE methodology, so that they had to learn while doing the review. Despite all the challenges, the Review Team demonstrated a high level of commitment and a willingness to challenge themselves and each other, in order to generate the learning from this case. 3.4 One of the social workers involved in the case had left the department and was therefore not available to be a part of the process. Her team manager was still in post and able to provide a lot of background information. 3.5 The Review Team were unable to answer the research question in relation to substance misuse. This was because there was no evidence to suggest that Mother had a problem of addiction, although there were concerns at times about her irresponsible use of alcohol and cannabis. 3.6 The police completed their own Individual Management Review (IMR) which was shared with the Review Team. Their officers were not available for the one-to-one conversations which were held with other professionals, but they did attend the Case Group introduction and follow-up meetings as active participants. 3.7 The Lead Reviewers were unable to meet with the Mother because of an ongoing criminal investigation, which means that her views were not available for the review. It is hoped that at some future point, she will be able to contribute in some way and to add to the insights into this case. A conversation was held with Paternal Grandmother and Q’s father. Their participation at such a difficult time was a testament to their commitment to both children and their information provided some insight into what life was like for Q and her half-sister. Serious Case Review published 10.01.17 Page 48 of 55 APPENDIX 2 Learning Together Methodology and Process 1. This review has used the SCIE Learning Together model – a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of WT 2013 now requires all SCRs to adopt a systems methodology. 2. The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3. Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4. The basic principles – the ‘methodological heart’ of the Learning Together model – are in line with the systems principles outlined in WT 2013: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. Serious Case Review published 10.01.17 Page 49 of 55 5. Typology of underlying patterns: To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is assigned its appropriate category, although some could potentially fit under more than one category. 6. Anatomy of a finding: For each finding, the report is structured to present a clear account of: How did the issue feature in the particular case? How do we know it is not peculiar to this case (not a quirk of the particular individuals involved this time and in the particular constellation of the case)? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? What are the implications for the reliability of the multi-agency child protection system? These ‘layers’ of each finding are illustrated in the Anatomy of a Learning Together Finding (below). Serious Case Review published 10.01.17 Page 50 of 55 7. Review Team and Case Group 7. 1 Review Team The Review Team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by at least one and often two independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, and so on. The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review. Agency OSCB Business Manager (SCIE Champion) Specialist Investigator Thames Valley Police SCIE Independent Lead Reviewer SCIE Independent Lead Reviewer DCI Thames Valley Police Senior Manager Action for Children/ Practice Serious Case Review published 10.01.17 Page 51 of 55 Improvement Manager Action for Children Early Intervention Manager Oxfordshire Clinical Commissioning Group Safeguarding Practitioner Oxfordshire Clinical Commissioning Group Named Nurse Safeguarding Children, Oxford Health NHS FT Corporate Secretariat Manager Oxfordshire County Council Safeguarding Children Lead and Patient Experience, Oxford University Hospitals Senior Named Nurse Oxford Health Joint Commissioning Manager for Drugs and Alcohol , Public Health Principal Social Worker Children’s Social Care Oxfordshire County Council 7.2 Case Group The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 20 Case Group professionals, and two family members. Case Group members were invited to an Introduction Meeting (to explain the Learning Together model and the SCR process) and later to an all-day workshop and two follow on meetings. Health: GP (2) Consultant Paediatrician (1) Midwife (1) Health Visitor (2) CSC: Team Manager (3) Social Worker (3) Early Years and Education: Head Teacher, Primary School (2) SENCO (1) Teacher (1) Children’s Centre Worker (3) Conference and Review Service: Independent Chair of CP Conference (1) Thames Valley Police: PC (5) Housing: Serious Case Review published 10.01.17 Page 52 of 55 Housing Officer (2) 8. Structure of the review process: A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The Review Team form the ‘engine’ of the process, working in collaboration with Case Group members. The Review Team held an introductory meeting for the Case Group at the beginning of the process, to explain the Learning Together model and the process they would be part of. Case Group members were then involved via individual conversations, and in two multi-agency Workshops, where they were asked to give feedback on interim/draft reports. The Review Team were involved in collecting and reading data, including a multi-agency chronology and key documents. Together with the Lead Reviewers, they met to analyse the material (5 meetings) and contribute to the findings. 9. Scope and terms of reference 9.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. In this review, we noted and explored the questions (Para 5.2 of the report) which the OSCB had posed as of particular interest. 10. Sources of data 10.1 Data from practitioners Workshop Days were held at which members of the Case Group responded to the analysis of the case and gave feedback about accuracy and fair representation of the material presented. In relation to the emerging findings, the Case Group were asked to comment on whether these were underlying and widespread/prevalent. In other words, could we draw conclusions about whether, and in what way, this case provided a ‘window on the system’? 10.2 Key Practice Episodes and Contributory Factors Following on from individual conversations, the first Workshop Day aimed to piece together the practitioners’ ‘view from the tunnel’ and a selection of Key Practice Episodes (KPEs). These KPEs are significant points or periods in relation to how the case was handled or how it developed. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decision-making at the time. 10.3 Participation The Learning Together model relies on professionals contributing very actively to the review and the resultant learning, as it is their unique experiences which help us understand what happened and why. Serious Case Review published 10.01.17 Page 53 of 55 We know that participation in a case review can raise anxieties and sometimes distress about what has happened to children, and may prompt self-questioning about ‘could I have done something differently?’. In this context, the Lead Reviewers and the Review Team are especially grateful for the willingness of the professionals to reflect on their own work, and to engage openly and thoughtfully in the review. 10.4 Data from documentation The Lead Reviewers and members of the Review Team were given access to the following documentation: The records of the agencies in the case, which were then translated into an integrated chronology Referrals and Assessments Reports for CP Conferences Minutes of meetings: CP Conferences, Core Groups, Strategy discussion CP Plans Information relating to the North Oxfordshire Neglect Pilot. OSCB Child N 2014 10.5 Data from family, friends and community The Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. In this review paternal grandmother and R’s father were able to participate. R’s mother was not able to due to the ongoing police investigation. Serious Case Review published 10.01.17 Page 54 of 55 APPENDIX 3: The Neglect Pilot (North Oxfordshire) The North Pilot, which was developed and led by practitioners from multiple agencies and services, was composed of the following workstreams: • Strengthening the core group function • Providing intensive support to families at critical points • Developing tools to support practitioners and evidence neglect • ‘Think Family’ to support and enable parents/carers • A needs analysis to estimate the extent of neglect in Oxfordshire Within core groups, the pilot trialled initiatives to clarify and share responsibilities for delivering the action plan across the group and to focus on making actions smarter and achievable. Joint visits by practitioners to the family home were encouraged to improve observation and demonstrate to families practitioner and service joint working. To support practitioners, case mapping exercises to understand family situations and reflective core group sessions to resolve differences between professionals or to agree a plan for a ‘drifting’ case were completed. Feedback from practitioners was that this was helpful joint problem solving and more co-ordinated joint working helped to move cases forward. A group of families with very complex needs were offered very intensive family support to help them achieve the actions identified on the child protection plan and to help practitioners and families assess capacity for change. Closer working between Early Intervention and children’s social care was really positive and enabled services to engage with families that have been traditionally hard to engage and support them to make changes. This way of working did achieve positive outcomes for families. A number of the children within these families experienced difficulties around transitions within education settings. A Transitions coordinator and a checklist which was developed to be used at Conferences around educational issues increased the focus on moves into different education settings, ensured that school applications had been made which then helped to ensure that right support was accessed at the new setting from the start. Briefings for practitioners on core groups and has been positively responded to, as has spreading understanding of the case mapping approach to other agencies. The focus of the pilot on neglect has raised the profile of neglect and opportunities, such as briefings and facilitated sessions, has provided space for practitioners to discuss approaches to neglect. To ensure and support a ‘Think Family’ approach, link workers were established in adult services to provide advice and consultation to children’s practitioners, facilitating referrals and assessments of support to meet the needs of parents/carers. Similarly, to support and enable parents/carers to change their family situations and improve outcomes for their children employment support was available from the Thriving Families programme for these families, along with the employment support already provided by Children’s Centres. Serious Case Review published 10.01.17 Page 55 of 55 Further evidence on the value of the Graded Care Profile assessment tool is being sought through an application to be part of the NSPCC national trial of their updated version. |
NC52693 | Death of a 17-year-old boy in January 2022 by apparent suicide. He had experienced several years of poor mental health and was in acute grief after the death of his mother. Learning themes include: agency responses to mental health/safeguarding; family approach to multi-agency safeguarding and mental health; bereavement and trauma; older children and young people living with neglect; recognition of the needs of young carers; multi-agency arrangements for risk management, service provision and children and young people in specialist education. Recommendations for the Partnership include: seek assurance from health commissioners and partners that protocols are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration; referral processes and forms should seek relevant information about family history, especially history of trauma and any concerns about current parental mental health or substance misuse, including appropriate checks to see if parents are known to adult mental health services, when children are being referred; review its guidance on thresholds in order to support practitioners' understanding of neglect, the cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect; produce and promote sector specific good practice guides on understanding the importance of fathers and father figures; seek assurance that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles; review how the Joint Agency Group Supervision process is working across services.
| Title: Child safeguarding practice review: AL. LSCB: Norfolk Safeguarding Children Partnership Author: Malcolm Ward Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review AL December 2022 FINAL FOR PUBLICATION Norfolk SCPR AL – FINAL FOR PUBLICATION 1 1 Introduction 1.1 The death of any child or young person is tragic. The Norfolk Safeguarding Children Partnership offers its condolences to AL’s Family and thanks them for assisting in this Review. 1.2 It appeared that AL took his own life, age 17. He had experienced several years of poor mental health and was in acute grief. The Inquest is awaited. The Partnership will consider any additional learning that comes from the Inquest. 1.3 Norfolk Safeguarding Children Partnership commissioned this Child Safeguarding Practice Review (CSPR)1 to learn from the circumstances of AL’s death. At the Rapid Review2 shortly after AL’s death the complex inter-play between mental health, for either a child or a parent, and safeguarding children was noted as a key area for this CSPR to consider. 1.4 The Purpose of a CSPR is to seek to understand what happened, and why, to assess the effectiveness of local multi-disciplinary child safeguarding systems, and to identify any improvements which may be required in those systems. The principle is to use a systems approach to analyse interventions in the context of the multi-disciplinary system rather than the actions of any one individual or agency. Analysing a single case may indicate the effectiveness of the system as a whole. It is not the purpose of a CSPR to seek to identify whether a critical incident could have been prevented, nor whether anyone is to blame. 1.5 Members of AL’s Family were consulted and gave their views about the family’s needs and the agency responses. AL’s Father was unwell and died before he was able to contribute his views. 1.6 Some of the practitioners or managers who were directly involved met individually with the independent Lead Reviewer and Review Panel Chair. There were also conversations with agency representatives who had not been involved to understand agency systems, responses and structures. A Reflective Practice Learning Event was held for practitioners and managers involved to share their own learning and their responses to the emerging learning that the Panel had identified. Their views are incorporated into the Analysis and Learning in section 5. The Norfolk Safeguarding Children Partnership thanks them for their reflective contributions and acknowledges that the practitioners were also deeply affected by AL’s death. The Review also had access to relevant agency records about the case and local policies and procedures. 1.7 The Review was undertaken by an Independent Panel of senior managers from the agencies involved. It was led by the Head of NSCP Business Delivery and the independent Lead Reviewer. 1.8 The scope of this Review was to understand the multi-agency work with the family between January 2019 and January 2022, when AL died. It was agreed that the work with the whole family, including AL’s older sister and younger brother, and with the parents in their own right should also be considered. The review has also considered relevant family history and agency involvement before 2019 to understand the complexity of the mental health issues in this family. 1 CSPR – a statutory multi-disciplinary and independent review after a child dies or is seriously harmed. Its primary purpose is to learn and identify any changes which may be required in local or national safeguarding systems. See Working Together to Safeguard Children, 2018, Chapter 4 Working together to safeguard children - GOV.UK (www.gov.uk) 2 Rapid Review – a Rapid Review is held quickly after a child’s death or a critical incident in which a child has been harmed to learn about the immediate circumstances, decide if safeguarding actions need to be taken and identity any early lessons and/or actions which may be required. It is parallel to any criminal or coroner’s enquiry and may recommend a CSPR if a fuller review indicated. Rapid Reviews are also governed by Working Together to Safeguard Children, 2018, Chapter 4. Norfolk SCPR AL – FINAL FOR PUBLICATION 2 1.9 The key lines of enquiry set from the Rapid Review were: • Agency responses to mental health / safeguarding, • Family approach to multi-agency safeguarding and mental health, • Bereavement and trauma, • Older children and young people living with neglect, • Recognition of the needs of young carers, • Multi-agency arrangements for risk management, service provision and children and young people in specialist education, • The impact of COVID on support to the Family, and • Embedding learning from previous local CSPRs. 1.10 In parallel to this Review the Mental Health Trust conducted a Serious Incident Investigation. This Review has benefitted from learning from the Trust Investigation. 2 Family circumstances and relevant background 2.1 In January 2019, the Family comprised Mother, Father, AL’s Sister (16 years), AL (14 years) and AL’s Brother (8 years). These titles will be used to refer to them in this report. The Family is white British. 2.2 Father had a separate accommodation address, until Mother’s death in November 2021, but was at the house several days and nights each week and played a key role in caring for Mother and supporting the children, particularly AL’s Brother. It was not always clear to agencies that Father played such a significant role prior to Mother’s death. Sometimes Father was known to leave the home when practitioners visited as he believed his presence inhibited AL engaging in work with practitioners. Father was involved in some actions, alongside Mother with some agencies. After Mother’s death Father was the primary carer for AL and his Brother. 2.3 Mother was described, by Family, as academically high achieving but having serious mental health difficulties from childhood, including serious self-harm and suicidal ideation and actions. She had several years as a psychiatric in-patient and later had community-based treatment. Family say that Mother continued to self-harm, witnessed by the two older children when they were younger, which they found distressing. Concern about self-harm and suicidal ideation or actions were not evident after 2014. She was treated for depression throughout the period under review. Mother was visually impaired from birth and was registered blind in 2014, following an accident to an eye. From that point, according to Family, difficulties in the family seemed to intensify. Her mother (AL’s Grandmother) became her main carer until the Pandemic and difficulties with her own mobility. Grandmother helped Mother to manage her medication, necessary reading and organisation of any correspondence, including about the three children. Mother was diagnosed with Chronic Fatigue Syndrome in 2015. 2.4 Father had a long-term diagnosis of bipolar disorder and anxiety. He also had alcohol dependency. 2.5 The parents separated shortly after AL’s Brother was born but Father continued as a key adult in the household and was described by Family as AL Brother’s main carer. He became Mother’s Carer when Grandmother was no longer able to fulfil this role. AL’s Sister moved out of the family home in 2021. Mother’s death in November 2021 was sudden and unexpected, from natural causes. Norfolk SCPR AL – FINAL FOR PUBLICATION 3 3. Work of agencies supporting the Family and key events 2013 to 2016 There were concerns about Mother’s mental health, suicidal actions (in 2014) and alcohol use, and the impact on the children. Assessments by children’s services in 2013 / 14 led to a period of Child in Need3 support that resulted in some improvements. Late 2014 to 2015 Psychiatric and Psycho-therapeutic Support for AL AL (age 10) showed signs of anxiety and withdrawing from social contacts. He was helped by Child and Adolescent Mental Health Services (CAMHS) in 2015 From 2017 to 2021 Psychiatric and Psycho-therapeutic Support for AL CAMHS worked with AL continuously until summer 2021 (age 16), providing therapy, often at home when he was too anxious to attend clinic and later in 2021 sessions to help him learn to manage his anxiety. When AL was too anxious to join sessions, Mother was advised about managing AL’s anxiety. He was also prescribed medication. There were regular Medical Reviews of his mental state and medication. Progress was gradual and intermittent. There were no reported thoughts of self-harm to professionals. A family member has now said that he did occasionally harm himself. November 2017 AL (13) was educated at home with support from his secondary school. He was unable to attend because of his anxiety. December 2018 AL’s Sister (16) started to receive support from CAMHS because of anxiety. February 2019 AL’s Brother (8 years) was assessed because of ongoing headaches and nausea. No physical causes were found but the symptoms continued. April 2019 Police were called to undertake welfare check on the Sister (16) at Father’s house; he was drunk and she was scared. Children’s Services were informed and gave advice to the parents. October 2019 to January 2022 Change of AL’s education placement (AL had not been at school from November 2017) AL (15) transferred to a specialist online education placement, as part of an Education and Health Care Plan. He continued to be a remote student here, engaging from home, until his death. His education mentor visited him weekly in term time, except during the pandemic lockdowns. November 2019 AL’s Sister (17) re-referred to CAMHS - assessed to have anxiety and depression; she reported suicidal thoughts and self-harming over time. 3 Child in Need - coordinated multi-agency work to support children and families under section 17 of The Children Act 1989, led by children’s social care. See Norfolk Safeguarding Children Partnership Threshold Document: 1.9 Norfolk Thresholds - Norfolk Safeguarding Children Partnership (norfolklscb.org) Norfolk SCPR AL – FINAL FOR PUBLICATION 4 January & February 2020 Refusals of parental consent for Family Support AL was overwhelmed with anxiety; he was not washing or dressing. The education mentor obtained Mother’s agreement to refer the family for Early Help Family Support4. However, Mother then declined assessment or support. March to August 2020 Start of the Covid-19 Pandemic Changes to delivery of services AL’s education continued online but his mentor had to cease weekly home visits in Lockdowns. AL’s engagement with online lessons improved slightly but online engagement with his education mentor was variable. AL and CAMHS: Support continued by telephone. Mother said AL was progressing well with his anxiety management, learning and personal hygiene. Mother declined to proceed with plans for Family Therapy. From August, face to face therapy resumed. Plans started for AL to be transferred from the Under 14s Team to the CAMHS Youth Team. Sessions with the therapist who had worked with AL since 2017 ceased in October. August 2020 Parental decision to decline active CAMHS Services for AL’s Brother AL’s brother (10) had high levels of anxiety, some were said to be Covid related but he continued with abdominal problems and nausea as noted in February 2019. He had been researching how to self-harm. A risk management plan was agreed with his parents but Mother declined active involvement with CAMHS for AL’s Brother. October 2020 AL’s Sessions with the therapist who had worked with him since 2017 ceased. December 2020 AL’s CAMHS Medical Review: AL making only limited progress. January – July 2021 AL started a planned series of sessions to work on managing his anxiety, with a different CAMHS practitioner. Some sessions were delayed as AL was often too anxious or unwell. At Medical Reviews in June and July Mother said that AL was continuing his education; but he was not, in fact, engaging. AL was to be discharged from the CAMHS Under 14s Service (he was now nearly 17). He was understood to be on the Youth Team waiting list. June 2021 Parental refusal for mental health crisis support for AL AL’s mental health was declining. He was not allowing anyone into his room, was not eating and had developed a nocturnal pattern. AL’s sister had moved out. The Education Mentor spoke with the GP who contacted CAMHS but AL was now too old for the Under 14s service. He was said to be on the waiting list for the Youth Service. Mother declined a referral to the Mental Health Crisis Team as she did not think that they could help and as AL was not a danger to himself or others. July 2021 Parental Agreement and later Refusal for Family Support Referral Mother and AL agreed to a referral for Family Support. Mother later declined saying that AL was better. 4 Early Help Early Help is provided to families when a child is seen to have additional needs or vulnerability, perhaps as a parent needs assistance, but where the family does not meet a level which requires social work involvement. Early Help can be provided by a single agency or by several agencies coordinated by a Lead Professional. Norfolk also has a Family Support Team which provides support at this early stage and can coordinate across other agencies involved. See Norfolk Safeguarding Children Partnership Threshold Document: 1.9 Norfolk Thresholds - Norfolk Safeguarding Children Partnership (norfolklscb.org) Norfolk SCPR AL – FINAL FOR PUBLICATION 5 From September 2021 Referral for Family Support with parental consent – concerns about AL and AL’s Brother AL’s Brother had transferred to secondary school and had attendance problems. He had been diagnosed with abdominal migraine and referred to CAMHS for anxiety. He was prescribed medication for anxiety. AL had poor sleep and personal hygiene. Following the Family Support Assessment AL was referred to another social support service; but he later declined this as he did not want to meet new people. October 2021 AL’s engagement with learning deteriorated. He had not been taking his medication. Mother was advised to supervise him because of the risk of suicide if he stored it. Mother pushed for an assessment of whether AL had Autistic Spectrum Disorders. November 2021 Mother’s unexpected death – from natural causes Father was now the sole carer for AL (17) and his Brother (11), both of whom were vulnerable. Children’s Services immediately provided Family Support, visiting regularly. AL was severely affected by his Mother’s death and there were concerns about Father’s alcohol use. The Police were concerned about the home conditions and there was evidence of poor diet. AL’s Sister (19) was struggling to support the Boys; she had moved out of the home in the summer and lived some distance away. November 2021 AL’s acutely distressed after his Mother’s death Father contacted AL’s previous Lead Professional at CAMHS. Father and AL were provided with advice, but Father declined a referral for AL to the mental health crisis team as AL was returning to education. Father had given AL some of his own anti-psychosis medication to help AL sleep at night. Family Support visited the home often to monitor and support the family and advise Father. AL told the Family GP that he was not having thoughts about suicide or self-harm. December 2021 Family Meeting with Father, Sister and the Boys and Family Support Team. Sister (19) was trying to visit each week and stay over one or two nights to support the Family. Wider Family members were in frequent contact offering advice and emotional support to Father and the Boys, but they were unable to visit at that time. December 2021 Emergency services were called to the house on occasions by Family members to check on the Boys as Father was drinking. There were accumulations of rubbish and food waste after New Year. Children’s services continued to visit to support Father in making improvements. A neighbour was offering some support. January 2022 The Family Support Assessment noted the Family’s social isolation, Father’s poor mental health (exacerbated by grief) and ongoing mental health concerns for both AL and his Brother, with poor hygiene and diet. There were inconsistent household routines and different accounts about how meals were provided. Father did not think that there was a problem. Sister was trying to support the household routines. AL’s Brother had school attendance problems which were thought to be as a result of anxiety. The Boys feared Father’s drinking. Father said he was reducing this. January 2022 Referrals were made for both boys to three different health services: CAMHS, 0-19 Healthy Child Programme health assessments and separately for bereavement support work. The Norfolk SCPR AL – FINAL FOR PUBLICATION 6 Intensive Support Team were to visit twice a week for practical support with household tasks and a contingency plan was agreed whereby contact would be made with Family Support or the Children’s Advice and Duty Service if there was a marked deterioration. Plans were in place for the boys to resume their education, which would have also given additional monitoring and support. A referral was made to help Father manage his drinking, which he was using to numb the pain of his loss. He was also referred for bereavement support work. Father and the Boys were advised to use emergency counselling and advice lines if they needed additional support in emotional crises. January 2022 A further Family Meeting, with extended Family members online, the education mentor and the Family Support Practitioner noted Father’s own grief and drinking, AL’s grief and mental health and isolation, and AL’s Brother’s anxiety and school attendance problems. January 2022 AL’s education mentor was concerned about the state of the home and AL’s emotional and poor physical state. The mentor signposted AL to counselling and advice services with whom he could talk by phone or online, but later it was not clear that AL’s phone was working. Father was asked to check this. January 2022 The referral to CAMHS Youth Team for AL was triaged by the Youth Team and he was placed on the waiting list for assessment. Second week of January 2022 AL died. It appears that he had acted to take his own life. Inquest awaited. 4. Views of the Family on key issues and on the services received 4.1 Family members were still grieving for AL and for his Mother when they met with the Lead Reviewer and Chair of the Panel. They shared their views before the sudden and unexpected death of AL’s Father. They wanted to support learning to prevent other families experiencing such tragic loss. The Family members felt disloyal for sharing their thoughts but believed that it was important to do so to ensure that there was understanding and to honour AL. 4.2 Given three deaths in this family in a brief period it is not appropriate to attribute all the statements to specific individuals, nor to include all the information and views given. What follows is a summary of the key information and views which have informed this report. Some of the family’s information has been included in the family background section at 2 above. 4.3 Mother started self-harming from adolescence and had no understanding of how it affected family, friends or later her children. She was proud of her scarring. 4.4 By the time AL’s Brother was born Mother was regularly drinking and self-harming or attempting suicide, resulting in psychiatric treatment. This impacted on the children; it was often the Sister who found Mother on these occasions. Mother’s appearance as a result of the self-harm led to bullying at school. 4.5 Mother would keep irregular hours, if she wanted to sleep all day, she would take night medication in the day. She initially hid her drinking from Family and professionals. Family felt that Mother could be hugely devious and confronting her about her behaviour did not feel possible. Norfolk SCPR AL – FINAL FOR PUBLICATION 7 4.6 The older children shared a bed with Mother well into their primary school years. 4.7 Mother “put on a good spin” for the mental health professionals. Family felt that they showed no interest in the children’s wellbeing or Mother as a Mother. 4.8 After Mother lost her sight, she could not see the mess, so housework was an issue. She would do the laundry but was controlling and prevented the children having the clean clothes. After Mother died a relative and family friend helped clean the house. 4.9 Mother did not want AL’s Sister to be recognised as a Young Carer (2014). 4.10 Family members thought that both parents would lie to social services and that Mother would tell professionals that she would take AL to school, but Family thought that she did not try. 4.11 Mother blocked care coming into the Family. She did not welcome anyone – including family members at times. Mother had to have control, had to be at the centre of things, needed to “control the narrative.” She would not accept help for the children. If Family visited AL was always upstairs under his duvet. Mother would refuse to help persuade him to come downstairs. Mother appeared to encourage AL to stay in his room, not go out, or to have a normal life. 4.12 The parents sometimes shared their different prescribed medications between them. 4.13 After Mother’s death the physical state of the home became much worse. Mealtimes were non-existent. Father would give the boys chocolate saying that they would not eat what he cooked. The Family ate takeaways. Father would wait for the Sister to be there to look after the Boys. Father would drink but might pull himself together if he was expecting someone to call. AL’s experience as seen by Family members (in retrospect) 4.14 AL thought that Mother’s behaviour was normal. “Mother was his world.” “He was so dependent on her that he couldn’t live a normal life without her.” He slept in her bed every night until he became ill shortly after he started High School. He worried about what he would do if Mother died. Mother would tell AL that he was too anxious to go to school and that he was too ill to go out. Mother did not act on what she had agreed with professionals. 4.15 A Family member said that AL self-harmed a little when he was younger, just scratches. He had seen his Mother do it and thought this was a normal thing to do when you were upset. 4.16 Family described AL’s anxiety as AL being withdrawn and uncommunicative. He had unwashed hair and slept in unwashed bed linen. 4.17 After Mother died, AL had frequent phone contact with his Family members. AL would say how much he missed his “mummy” and he would ask Grandmother what Mother was like when she was younger. Grandmother believed that AL was a suicide risk. “He was a complicated young man. He had a lot to say, he just couldn’t say it. He was kind, gentle, sweet…” She hoped that he had never seen any of mother’s suicide attempts. He shared some of his feelings with his Sister and was desperately unhappy. He would sometimes go out with her; he enjoyed going out. Norfolk SCPR AL – FINAL FOR PUBLICATION 8 The Family’s views on the services provided 4.18 AL’s education mentor returned every week: Grandmother said, “I can’t fault the education placement.” 4.19 Professionals believing adults who make things seem normal when they were not. Sister thought children should be listened to. 4.20 Just before AL died, AL’s Sister understood that part of the support plan was for her to go to the house, but she did not think that the plan was specific about what to do when she was there or how she could afford to travel, as she lived a long way away. Between November and January, she would aim to go fortnightly but sometimes she managed to go as often as twice a week. However, she was unable to go in the days before AL died. 4.21 After Mother’s death there was concern about Father’s drinking. Grandmother phoned the house every day to see what was happening and tried to ring children’s workers but they did not always respond. She feared for the safety of the boys; she would phone the police or paramedics for welfare checks. An Aunt was also in regular contact with the Family and services but was living abroad and was unable to return to the UK because of Covid restrictions. 4.22 In a Family Group Meeting, via Zoom, with professionals in early January, the Family members were all asked individually to score how the Father and the Boys were ‘coping.’ Most gave low scores, but the Family felt that their opinions were disregarded and that nothing changed. 4.23 AL’s Sister now believes that she should have been taken in to care when she was younger. She had some help from therapists at school but it was only when she could not manage sixth form that she was assessed by CAMHS. She felt the CAMHS crisis team “was amazing” in helping her. 5 Analysis and Learning In this section Practice notes have been included where there has been recognition of valuable learning but where this is not new learning but a recognition from this case of the need to support and reinforce good practice in frontline work and its management more widely but where a specific recommendation is not required. 5.1 In analysing the work undertaken we clearly have the benefit of hindsight. We must be careful not to use it to unfairly judge the work done but must seek to understand what systems dynamics may have prevented things being known or actions being taken, and why that was so. 5.2 Assessing and responding to AL’s mental health needs over time and in the acute period after his Mother’s death 5.2.1 AL was identified as having difficulties with generalised and social anxiety over several years. His school, educational psychology services, CAMHS, the alternative education provider and children’s services took these seriously. The commitment and continuity by individual practitioners to meeting AL’s needs is noted. 5.2.2 A question has arisen as to whether sufficient attention was given to whether he was also depressed. AL was provided with psychotherapy and medical support from CAMHS over three years and was also prescribed medication to assist him. Norfolk SCPR AL – FINAL FOR PUBLICATION 9 5.2.3 Transition of services The CAMHS Under 14s Services provided good support to AL for more than three years and he was assessed to be making slow and occasional progress, although he had not yet reached a level where he was functioning well. Originally it was planned that he would be transferred to the Youth Team but there was confusion about this and he was later discharged from the CAMHS service, after 5.2.4 receiving behavioural therapy to help him manage his anxiety better. This meant that for a few months AL was without additional psychological support. It was during this time that his Mother died. 5.2.5 Medication Medication was a key part of the treatment for managing AL’s anxiety, especially after his therapy ceased. It was not clear that AL was always consistent with taking his medication and when this was reviewed in intermittent Medical Reviews it was sometimes AL’s Mother who responded on his behalf, Mother also told CAMHS that she was giving him his medication, but later evidence suggests she was not supervising him taking his medication. The responsibility for prescribing AL’s medication was transferred to his GP when AL ceased to be the responsibility of the CAMHS service. AL was assessed to be stable at that time. He was provided with repeat prescriptions but it is not clear if they were collected, or if he was taking them. Nor is it clear if his Father was aware of the need to supervise AL’s medications. It is known that Father gave AL some of his own medication to AL. It is acknowledged that monitoring the use of AL’s medication by professionals was a challenge during the Pandemic as he could not be seen easily. 5.2.6 Assessing the risk of self-harm or suicide Throughout most of the period reviewed, up to Mother’s death, AL was seen as at low risk of self-harm or suicide, although he had at times expressed suicidal thoughts. These were seen in the context of his diagnosis of anxiety and there was inconsistent reporting by Mother who did not believe him to be a risk to himself. AL’s education placement was conscious of a generalised possible risk of suicide and advised Mother about this when she revealed that AL had not been taking his medication. 5.2.7 After Mother’s death there was appropriate concern about AL’s mental state and it was clear that AL was in acute distress and was withdrawing further from family life, but this was also a known pattern of his anxiety. AL denied any suicidal thinking to his GP. He said to the Family Support Practitioner “I want to get better.” His education mentor noted that “AL wants to feel better;” the mentor provided him with information about emergency counselling helplines, although later it was not clear that his phone was working. The education placement also alerted the Children’s Advice and Duty Service (CADS) to a possible risk of suicide. AL, encouraged and supported by his Father, also spoke to his previous CAMHS practitioner; when the practitioner rang him on a later occasion, he said he was feeling better. The CAMHS practitioner advised Father to call the GP if AL were to become worse. Family have said that they were concerned about the risk of AL harming himself because of the level of his grief and that they raised this with services, who were monitoring him. AL was referred for bereavement counselling and to CAMHS because of his acute distress but these services had not started for him when he died. Recommendation 1 Medication supervision The Norfolk Safeguarding Children Partnership should seek assurance from health commissioners and partners that protocols and guidance are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration. Norfolk SCPR AL – FINAL FOR PUBLICATION 10 5.2.8 It would have been useful for non-mental health practitioners to have had access to psychiatric consultation given AL’s vulnerability. Father and AL did speak with one of his previous CAMHS practitioners and were advised to consider a referral to the Crisis Mental Health Team, but Father declined this. A referral was made in early January 2022 to the CAMHS Youth Team and AL was placed on the waiting list for a 28-day assessment. A systemic problem in the service meant that such routine assessments could then take 26 weeks or more. The Family Support Service was not made aware of this possible delay. The level of acute concern about AL was not clear to CAMHS nor was his recent bereavement highlighted as an escalating need. Good practice would be for there to be a conversation between the referrer and the CAMHS service to ensure that full information on which to prioritise the referral is available. The Trust has noted that given AL’s long involvement with the Under 14s team until July 2021 it may have been good practice for them to assess him. 5.2.9 This Review notes that the Mental Health Trust is currently undertaking a review of referral and assessment pathways. 5.2.10 This Review has considered more widely whether agencies and frontline practitioners across services, not just in specialist mental health or GP services, have awareness and skills in this area of openness to recognise self-harm or suicidal ideation. Feedback from the practitioners and managers was that there has been increasing awareness of the mental health needs and risks for young people over the past few years and that this has been heightened by the higher incidence of mental health problems in young people in Recommendation 2 - Referral Pathways for Child Mental Health Services The learning from this Review should be taken into account in the NSFT Review of referral and care pathways and the development of any associated training package for staff. Referral processes and forms should seek relevant information about family history, any relevant history of trauma and any concerns about current parental mental health or substance misuse. Within the Trust, appropriate checks should be made to see if parents are known to adult mental health services, when children are being referred. Practice note: Bereavement is known to increase risk of self-harm or suicidal ideation or actions. When a child or young person who is already showing signs of emotional vulnerability experiences a bereavement they should be offered additional supports and closely monitored. Practice note: When there are acute concerns about a young person’s current mental state consideration should be given to seeking a formal crisis mental health assessment, taking into account the young person’s or the parent’s wishes but making the welfare of the child paramount. There should be active consideration about whether the young person may harm themselves. Full information should be made available to assist the prioritising of such assessments. Norfolk SCPR AL – FINAL FOR PUBLICATION 11 response to the Pandemic. Working Together 20185 and the annual national guidance Keeping Children Safe in Education6 has also raised awareness of this area. 5.2.11 The school and alternative education placement involved in this case have systems in place so that they can recognise and respond to cases where young people show such risks. Norfolk Schools have access to mental health training and appoint mental health champions and can seek advice from crisis specialists when needed. In the Early Help/Family Support Service there is confidence that the mix of skills and competences across staff teams, with the addition of clinical supervision and group supervision, means that practitioners are well able to consider and respond to risk of suicidal thinking. Mental Health First Aid Training is also available. 5.2.12 Evidence here is that AL’s mental health and suicide risk was certainly considered by practitioners working with him after his Mother’s death and steps were taken to support him but there was no evidence found that he was thinking about steps or actively planning to end his life. It is not clear whether it was considered that AL may be concealing his feelings and thoughts from family and professionals as he may not have wanted them to know what he was thinking. It should also be noted that suicidal acts can be impulsive. Evidence available after his death suggests that AL was thinking about ending his life. 5.2.13 The Norfolk Safeguarding Children Partnership has useful practice guidance on Children at Risk of Suicide7, which was updated in 2018. 5.2.14 The Norfolk Suicide Prevention Strategy8 and Action Plan 2016-21 is currently being refreshed. The Norfolk Suicide Prevention Group continues to monitor and analyse patterns of suicides in the County and learn from them. The Suicide Prevention Group will take into account the learning from this Review when reviewing the Strategy and Action Plan from 2023. 5 Working Together to Safeguard Children 2018 – statutory guidance Working together to safeguard children - GOV.UK (www.gov.uk) 6 Keeping Children Safe in Education 2022 – statutory guidance to schools and educational institutions - Keeping children safe in education - GOV.UK (www.gov.uk) 7 5.22 Children at risk of suicide - Norfolk Safeguarding Children Partnership (norfolklscb.org) 8 Norfolk Suicide Prevention Strategy Full Summary Interactive 2016 2021.pdf Recommendation 3 - Practice Guidance to Professionals on Children at Risk of Suicide Norfolk Safeguarding Children Partnership should review this practice guidance to ensure that it is up-to-date and promote it with the dissemination of learning from this Review. Practice note: When there are concerns about a person’s mental well-being or that they may harm themself or may be thinking about ending their life care should be taken not to rely solely on the individual’s own statements or the reassurances of those close to them who may be unaware of the person’s intent. Norfolk SCPR AL – FINAL FOR PUBLICATION 12 5.3 Use of safeguarding children thresholds 5.3.1 During the period under review work with AL’s Family was undertaken by Universal Services at the Tier 3 level of need as agreed within the Norfolk Safeguarding Children Threshold Guide 20199. The guide is a useful resource for local agencies working with children or parents (or carers) to understand the local agreed processes for how to assess and seek help for families with different levels of need. Tier 3 is for Children with complex multiple needs who may need targeted or specialist services. A referral to the Early Help Hub or conversations with the Children’s Advice and Duty Service may be required. Tier 4 is for children in acute need when a referral to Children’s Advice and Duty Service is indicated or direct to the police where there is imminent danger. 5.3.2 At times, when there was concern about AL and later about AL and his Brother, CAMHS or the alternative education placement made referrals for additional coordinated support to the CADS with a view to seeking Early Help or Family Support, at Tier 3, in addition to the services being provided. The referrals were not made on the explicit grounds that AL or his Brother were being harmed or neglected and referrals were generally seeking support, such as supporting AL to go out of the home, rather than a formal child protection response. 5.3.3 Referrals at Tiers 1, 2 and 3 require the consent of one or both parents or of a young person who is of capacity to give informed consent. As can be seen from the summary timeline above (in section 3) in 2020 and 2021 Mother gave consent for the referral to children’s services on several occasions and then withdrew it. It was not until shortly before Mother died in October 2021 that an assessment for Family Support was completed and following that AL was referred to another agency for additional support, which he later declined. After Mother’s death a Family Support Practitioner was allocated to support the Family and a period of intensive work followed. 5.3.4 Should the work with AL’s Family have been under a child protection threshold? Were the children being neglected or emotionally abused? The review team have considered whether at any point the level of need had moved to Tier 4 and should have been assessed as child protection on the grounds that the children were possibly being harmed. 5.3.5 Workers visiting the home prior to Mother’s death did not identify physical neglect by adults, although there were concerns about self-neglect by AL who at times was not washing or looking after himself; this was associated with his chronic anxiety. Other possible causes of his self-neglect were not explored. After Mother’s death there were increasing concerns about physical neglect, including in the provision of meals. See paragraphs 5.3.10 and 5.3.11 for further discussion of the situation after Mother’s death. 5.3.6 Was non-engagement considered sufficiently? Prior to Mother’s death there was a pattern of AL missing therapy or anxiety management sessions at CAMHS and Mother’s excuse was often given that he was “unwell”. A pattern of avoiding contact with professionals was already part of AL’s response to his anxiety. It is not clear that enough thought was given to whether Mother may have been colluding with AL in not attending his appointments. The outcome for AL was that he was not accessing all the help offered or that he needed. This could have been assessed as a possible form of neglect. However, Mother gave the impression of being concerned and committed to AL’s care and improvement. The lack of monitoring of AL’s medication may also have been an issue here. 9 The Norfolk Threshold Guide 2019 - FINAL 200319.pdf - Google Drive Norfolk SCPR AL – FINAL FOR PUBLICATION 13 5.3.7 Mother agreeing to referrals to other services and then withdrawing consent may also be considered as a form of neglect, by denying a child access to services or health care that they need. Yet these were seen in a context of Mother working closely with CAMHS, the alternative education placement and Brother’s school and to be cooperating with suggestions and plans for improvement. She was seen to be committed and involved. Workers were, however, concerned that AL was only improving slowly despite a lot of support: “two steps forward, one step back.” It is not clear that it was explored further with Mother why she would agree to referrals for Family Support Services and then later withdraw her consent. 5.3.8 A possible systems barrier noted by practitioners was that when seeking to refer families to CADS a question is often asked about what the identifiable immediate risk to a child is. It is not clear that this was the case in the referrals for AL’s Family but was seen by practitioners as a possible systems issue. Such an approach may mitigate against considering the longer-term and more amorphous nature of neglect where there may not be a clearly identifiable and anticipated harmful event but there is a need to identify a pattern where parenting may not be good enough to meet children’s needs, including siblings’ needs, over time. This may require greater information gathering and analysis at the edge of the child protection threshold to assess the probability of harm if action is not taken. This has implication for the interaction between referrers and the CADS service and the possible need for challenge between agencies and or escalation to consider a wider range of possibly harmful behaviours, omissions or patterns and not just single harmful events. Practice note: Engaging reluctant families A question arises about the skills required by practitioners for seeking genuine consent for referral on to children’s safeguarding agencies and advising on the possible consequences of not consenting. Practitioners need skills: • in building trusting relationships to make families feel that they are not being judged and are willing to accept support, • that families are finding help through the people who already know them, • that the people who know them and who they trust are introducing other people • and that those people have additional skills and roles to support them to meet their children’s needs. Experience has shown that this is when consent and engagement rise, with better outcomes. It would not always be appropriate to resort to child protection processes to override parental consent as it is likely to alienate and lead to difficulty in meaningful engagement. However, persistent failure to engage with necessary services may require a child protection approach. Norfolk SCPR AL – FINAL FOR PUBLICATION 14 5.3.9 Parental alcohol misuse can be a child safeguarding issue leading to either neglect or emotional abuse. There is no evidence that Mother’s drinking was observed or known about by practitioners. Family members have informed this Review about it. Father’s alcohol misuse was known about by some agencies but not by all until after Mother’s death when it became a matter of concern as it was impairing his ability to care for the boys and was not improving. It could be argued that the child protection threshold of neglect was being crossed but in the context of his acute grief and his, albeit reluctant, agreement to work on his alcohol misuse that a child protection framework may not be needed. However, he was ambivalent and despite agreeing to cut down his drinking was not doing so. He was himself in acute grief and self-medicating with alcohol. It may therefore have been unrealistic to expect him to reduce his alcohol use at that time. 5.3.10 The Review Panel have considered whether there was evidence that the threshold for child protection had been crossed, after Mother’s death. The Panel was considering this in retrospect. There was disagreement; some Panel members felt that the Boys were at risk of significant harm, others that work was being done to improve the situation at home. The practitioners, at the time, were working with the Family to seek to affect change, by offering support and advice. Father, although ambivalent, was seen to be cooperating on some important issues, including agreeing to referrals for the Boys to bereavement services and to CAMHS, getting AL’s brother back into school and to undertake bereavement work for himself. It was known that it was a fragile situation as he was not coping well and continued to rely on alcohol. However, the Boys were distressed and fearful of Father’s drinking, which was emotionally abusive. However, progress was slow and there were incidents of concern when father was possibly not in a fit state to care for the Boys. The Boys were not being fed properly. On one occasion when the police were called they were concerned about the situation and the impact on the Boys but assessed that Father was in a mental state to be able to provide care and that there was no need to remove the Boys. A multi-agency strategy meeting under section 47 of the Children Act, after this incident, would have been an occasion to consider the situation with a different lens given the ongoing concerns. The Family Meeting held just after the New Year recognised the concerns and agreed a plan to achieve better outcomes. Recommendation 4 Recognising the longer term nature of neglect; and parental non-cooperation The Norfolk Safeguarding Children Partnership should review its guidance on Thresholds in order to support practitioners’ understanding of neglect, the long term and cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect. As well as highlighting examples of single significantly harmful events examples can be provided to help practitioners recognise that neglect includes not being brought to appointments, repeated refusal of services, not complying with advice or not administering or monitoring a child’s medication. Practice note: Repeated refusals by parents for access to needed help should be considered as possible neglect and referring agencies should consider the reasons behind such refusals of referrals. If these are found to result in the child’s needs not being met practitioners should escalate the concerns, including refusal to be assessed for help, for consideration at a child protection threshold which would allow wider gathering and sharing of information between services. This would serve to support decision-making about whether the threshold for Tier 4 is being met. It is noted that use of an Early Help Action Plan or other multi-agency forums to support families would also be able to share information, however, these would require parental or young person consent. Norfolk SCPR AL – FINAL FOR PUBLICATION 15 5.3.11 It is not clear to the Lead Reviewer that a move to a child protection approach, with changes of workers, at that point would have achieved more than the agreed Family Support Plan was seeking to put in place. It may also have served to heighten anxiety for the Boys. Clear and short deadlines to Father would have tested his ability to change and if not, then a child protection approach or even considering care for the Boys would have been required. It is not clear if Father was warned that if he did not cooperate more fully, including with reducing his alcohol use, and things did not change quickly then it may be necessary to convene a child protection conference. AL died before these planned services could be achieved. 5.4 Understanding the importance of family history and family dynamics in assessments and interventions 5.4.1 Feedback from the practitioners to this Review has shown that not all of them were aware of the possible trauma that the older children had witnessed when they were younger, in relation to Mother’s self-harm and suicidal behaviour, or later, the impact of parental drinking. They were unable, therefore, to reflect on how this may have impacted the children and take this into account in their plans and assessments of need. Practitioners told us that if they had known about these issues, they would have taken them into account in their work with the children as part of Trauma Informed Practice10 and the importance of understanding and responding to Adverse Childhood Experiences11. The CAMHS practitioners held in mind that AL’s anxiety and behaviour may have had a traumatic cause but the cause did not become clear in the clinical work. They were clear that they would have taken this into account had they been aware. 5.4.2 A question therefore arises about how practitioners can become aware of such traumatic family psycho-social histories and what information is within agency records or can be shared between agencies if the information cannot be gained from or is not shared by families themselves. This clearly raises an issue of consent or authority to share such private information when a family is being assessed below a child protection threshold. 5.4.3 Practitioners are reliant on the information provided by parents and children, or wider family, when compiling a psycho-social history. They are also aware of rights to privacy and that individuals may only share what they want to be known, in the way that they want it to be known. 5.4.4 CADS was clear that in assessing referrals senior and experienced workers analysed the family history available in records in order to decide on appropriate levels of intervention. 5.4.5 This Review has questioned whether within CAMHS there was sufficient recognition that at times different parts of the service were working with different Family members without there being a join up between approaches and a Family perspective. This may have given a clearer picture of a Family where three children were showing emotional difficulties. This may have led to additional thinking about whether Mother declining Family Therapy should have been challenged more or considered as a possible safeguarding threshold matter. Practitioners noted that there are systemic difficulties marrying up records of different family members held within the Mental Health Trust. 5.4.6 For much of the period there was no holistic picture held by any agency of three children from the same Family with chronic and sometimes acute mental health needs over time. An understanding that more 10 Trauma Informed Practice Trauma Informed Practice - Norfolk Safeguarding Children Partnership (norfolklscb.org) 11 Adverse Childhood Experiences ACEs - ACEs are traumatic experiences which can have a long term effect on children’s emotional health; see Adverse Childhood Experiences (ACEs) and Attachment - Royal Manchester Children's Hospital (mft.nhs.uk) and Addressing vulnerability in childhood - a public health informed approach (publishing.service.gov.uk) Norfolk SCPR AL – FINAL FOR PUBLICATION 16 than one child was affected may have led to more questioning about family dynamics and trauma. AL’s education placement did recognise that two children, AL and his Brother, were having difficulties. 5.4.7 Father and the role of Fathers12 Father was an important figure in this Family but key practitioners had little knowledge of him prior to Mother’s death. Father’s GP was unaware that Father had caring responsibilities for children as he was registered with a different GP and at a different address. Father had parental responsibility for all three children but was divorced from Mother and was thought not to be living at the house, yet there was clearly an important parental relationship and he had a significant role. This was recognised and he was involved by practitioners when he was present or on behalf of Mother when she was unable to physically take children to services. However, services saw Mother as being the primary parent. 5.4.8 Before Mother’s death Father was occasionally present when practitioners visited the home and he was accepted as having a role in parenting and was involved in assessments, an Education Health Care Plan Review for AL and with taking AL’s Sister to CAMHS and AL’s Brother to school. His difficulties with alcohol use were not apparent on those occasions. At times he would leave the house as he was aware that his presence could inhibit AL’s engagement with practitioners who were visiting. 5.4.9 Reviews into tragic incidents such as these over time have shown that agencies frequently do not fully appreciate the role of men or their significance to children as they are often not seen or known about by professionals. This is particularly noticeable when fathers are considered to be non-resident. The extent of Father’s role was not clear in this case and it was not fully taken into account until after Mother’s death. A key question was then testing his capacity to change and take full responsibility for the children. This was underway in the period up to AL’s death. 5.4.10 Involvement of wider Family Prior to Mother’s death there was little contact between services and wider Family members. This was appropriate as Mother (and Father) appeared to be cooperating with services and the need for a Family Networking Approach had not yet been identified. It was noted that Family members did on occasion contact services when there were concerns prior to the period under review. 5.4.11 From November 2021, after Mother’s death the wider Family were in shock, compounded by the exact cause of her death not being understood for some time. Key relatives were unable to physically get to the house because of distance and personal health or Covid restraints but maintained frequent contact 12 This Review has benefited from the direct involvement in the Review Panel of the Safeguarding Children Partnership’s Officer who is leading the Partnership’s work to increase understanding of the importance of involving fathers and father figures in safeguarding work. The Partnership’s work to improve practice in this area is commended. Recommendation 5 Understanding the Importance of and Working with Fathers and Father Figures The Norfolk Safeguarding Children Partnership should produce and promote sector specific good practice guides on understanding the importance of fathers and father figures and good practice in working with them, highlighting the expectations of all partner organisations around professional curiosity, engaging, assessing, recording and information sharing when working with all families. This recommendation recognises the positive work already undertaken by the Norfolk Safeguarding Children Partnership to support understanding and improving work with fathers and father figures and seeks to build on and embed the work achieved to date. Norfolk SCPR AL – FINAL FOR PUBLICATION 17 remotely to support and monitor and there was some reliance on AL’s Sister who, although now an adult, was herself still young, vulnerable and grieving. Some support was offered by a neighbour. 5.4.12 Wider Family members were involved in the second Family Meeting remotely and expressed their worries and hopes for more support. Grandmother also called emergency services on occasion. The Plan was that AL, his Brother and Father should be supported in the family home, if possible. The Family have expressed concern that not as much was done as they would have hoped. 5.4.13 How is “Think Family”13 used in services throughout Norfolk? The importance of families is recognised in Norfolk services when parents need additional support. The Family Networking Project14 of One Norfolk and the Stronger Families Project15 recognise the importance of families and that sometimes they may need additional help. In the work with AL’s Family after Mother’s death Family Meetings were used to involved wider Family members. Mother and Father were both vulnerable in their own right, particularly Father. The concept of “Think family, think parent, think child” was introduced by the Social Care Institute of Excellence from 2009 to raise awareness of the need for practitioners working with parents who have mental health difficulties to consider the possible impact on children. It is referenced on the Norfolk Safeguarding Children Partnership’s website under the guidance Children at risk where a parent has a mental health problem16. A question remains, however, how services working primarily with adults, including fathers, who have their own difficulties hold in mind and make assessments when those adults have caring responsibilities for others or for vulnerable children? 5.5 Multi-agency response and coordination 5.5.1 To safeguard children (in both preventative and protective senses) agencies must work singly and jointly to understand family and individual problems and work with them to provide solutions or, if necessary, take other action to protect children from harm, or if suspected self-harm. Joint working of course raises the issue of authority to share private individual and family information, subject to consent or if at a protection threshold dispensing with consent and sharing information proportionately. 13 SCIE Think Family https://www.bing.com/ck/a?!&&p=fa0daf77e9b959aeJmltdHM9MTY2MjMzNjAwMCZpZ3VpZD0wNzkwYjMzMC1jMTE5LTY5YzYtM2QwNi1hMTI0YzBhMjY4ZjAmaW5zaWQ9NTE4Ng&ptn=3&hsh=3&fclid=0790b330-c119-69c6-3d06-a124c0a268f0&u=a1aHR0cHM6Ly93d3cuc2NpZS5vcmcudWsvcHVibGljYXRpb25zL2d1aWRlcy9ndWlkZTMwL2ludHJvZHVjdGlvbi90aGlua2NoaWxkLmFzcA&ntb=1 (Need to tidy up this hyperlink!) 14 Family Networking (justonenorfolk.nhs.uk) 15 Home | Stronger Families Norfolk 16 7.2 Children At Risk Where A Parent Has A Mental Health Problem - Norfolk Safeguarding Children Partnership (norfolklscb.org) Recommendation 6 - Understanding Families in their wider context : Think Family The Norfolk Safeguarding Children Partnership should seek assurance from Partner Agencies, including those working primarily with adults, that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles. Services should have systems in place to recognise the importance of seeing a family in its wider context, including assessing key relationships and obtaining a holistic view of any difficulties in the family, and not focusing solely on individual family members. Systems should ensure that where possible and appropriate family members, including fathers, and other key relatives, should be heard in order to capture important historical information or to understand key dynamics. Norfolk SCPR AL – FINAL FOR PUBLICATION 18 5.5.2 At Tier 2 or Tier 3 of the Norfolk Safeguarding Threshold a Lead Worker may be needed where there is more than one children’s agency in place supporting a family to coordinate the work of several agencies, perhaps through an Early Help Assessment and Plan; this would require agreement and cooperation of a parent. 5.5.3 We have noted that work for the children was done in parallel rather than as one family system, until after Mother’s death. Schools worked independently with Mother, and later Mother and Father; and then Father. As AL came to be provided with CAMHS services it is not clear that there was liaison with AL’s school which continued to offer him an online and home tuition service when he was unable to attend because of his severe anxiety. A Lead Worker to coordinate work across agencies, would have been useful. This would have been possible if an Early Help and Assessment Plan had been initiated but Mother did not consent to this. 5.5.4 When AL’s Sister started work with CAMHS in 2018 there was no family coordination within CAMHS of the work across the siblings with the same parents. This was perhaps a missed opportunity to take a more holistic view. Also, in 2018 AL’s Brother’s abdominal symptoms were first noted and referred to hospital for assessment and found to have no physical cause but as there was no cross agency coordination to consider the possibility that these may have a psychological cause and the parallel with his Sister and Brother having emotional problems was not recognised. A Think Family approach should also lead to consideration as to what may be happening across siblings, when there are similar difficulties and how the difficulties for one child impacts on the others and the complexity for parents dealing with three parallel issues and different services. 5.5.5 A positive opportunity for coordinated leadership came at the assessment for the Education and Health Care Plan in 2019. This was led by the educational psychology services and the relevant agencies were able to contribute their different views about AL, and Mother and AL also contributed so that his educational needs could be identified. There is no evidence however that Father was consulted or thought about at that stage. Father was fully involved in the review of the EHCP shortly before Mother’s death and was able to express his views about his hopes for AL as AL faced his future and needs as a 17-year-old. 5.5.6 From October 2019 there is good evidence of coordination across education and CAMHS for AL with sharing of information and some joint thinking and planning. It appears as if the education mentor took on a de facto lead professional role across these two services. However, AL’s Brother’s school was working alone with Mother and Father to support him not fully aware of the work being done with AL and his Sister. 5.5.7 CAMHS and the education placement worked very well together, sharing information and making referrals to CADS for Family Support. As noted above Mother declined this on several occasions and although further referrals were later made there was not escalation to seek consideration of whether a child protection threshold was met. It is notable that at the referral just before Mother died AL’s mentor also raised concerns about AL’s brother, bringing concerns about the two boys together, for what appears to be the first time. 5.5.8 From Mother’s death the leadership of the multi-agency work was held in one place. 5.5.9 Responding in a family crisis Mother died in early November 2021. The Family Support Service started to work with the Family to complete an assessment of need and the Family Support Practitioner was visiting within two weeks. The Family Support Practitioner had to establish relationships with AL and his Brother and Father, other Family members and the other services involved in order to bring together an Norfolk SCPR AL – FINAL FOR PUBLICATION 19 overview and assessment – including of Father’s ability to parent. AL was initially reluctant to engage, given his anxiety with strangers and his grief. 5.5.10 Intensive work was undertaken and the view was formed that it was better to work with Father to support him as the carer in the Family. He did not fully accept that he had a problem with alcohol, and contingency plans were put in place. 5.5.11 There is a question about whether some services which came to be identified as being needed to support the Family could have been fast-tracked given the circumstances, this includes a service to support Father and his alcohol misuse, although this was unlikely to be a short term solution, and the re-referral to the CAMHS Team. This would require greater flexibility and the ability to make a resource available quickly. It was noted that the Mental Health Crisis Team was available if AL should come to need this but he was not seen to be at such a level of risk. 5.5.12 The situation was compounded by seasonal holidays when services were reduced. 5.6 Engagement on the terms of the adult? The need to keep a child focus and professional curiosity 5.6.1 As noted above there were times when Mother appeared to be controlling the way in which work was done. In retrospect, it is wondered by practitioners whether Mother agreed to referrals for Family Support in order to appease workers but with no intention of proceeding with it. We cannot be sure. Family have noted that Mother could be controlling and have stated in retrospect that she was not always truthful and that she was hard to challenge. 5.6.2 There was often reliance on mother’s accounts of what was happening for AL and his progress with regard to following suggestions for his treatment; especially when AL would not himself engage directly with practitioners. It has been noted above that she often said that AL was too unwell to attend sessions. There was possibly a pattern of both AL and Mother not cooperating with his treatment. It would have been helpful to have explored this more fully to understand whether there was more behind it. The Family has suggested that Mother did not genuinely cooperate with AL’s treatment. 5.6.3 How do we hold curiosity in mind when we see no evidence of progress and reflect on whether there may be other dynamics at work and whether parents are being truthful? There is evidence that Mother was cooperative in a number of areas. She worked with AL’s Brother’s schools on his emotional and physical difficulties leading to attendance issues and appeared committed to addressing these, sometimes suggesting that it may have suited Father for AL’s Brother not to attend as Father liked the company of AL’s Brother. She supported AL in his CAMHS treatment and pushed for him to have an Education Health Care Plan and an ASD assessment. Skilled practitioners when asked about this have said that they believed her to be committed to the children and genuine in her responses. One service noted that when challenged about an incorrect statement Mother became quite angry. In retrospect, however, Family have raised observations about her often misleading professionals and not supporting AL’s treatment as fully as she stated and perhaps even undermining it. We are unable to explore this further given the deaths. 5.6.4 Practitioners across services need to engage with and form professional relationships with children and their parents to assess and provide interventions, particularly interventions which require human interactions and rely on information shared by the individuals concerned. We must assume that parents usually provide honest responses unless there is clear evidence to the contrary but we must also hold in mind that at times parents may not be fully open and may mislead us, either deliberately or unconsciously. Norfolk SCPR AL – FINAL FOR PUBLICATION 20 A manager feeding back to this Review questioned, in retrospect, whether there had been disguised compliance which had gone unnoticed. 5.6.5 The term “disguised compliance” has come into analyses of serious case reviews over recent years to describe such behaviour. Recent analysis the use of the term suggests that it is possibly unhelpful and blaming17. Practitioners need to think more analytically about when parents do not cooperate or cooperate on their own terms and in ways which may not support change or improvement. There is evidence here of Mother seeming to cooperate, which practitioners thought was genuine, but also evidence that AL was not progressing as expected. 5.6.6 This Review suggests that there may have been a need to get further behind what was happening and why and what the underlying problems for AL and his siblings may have been. *Norfolk FLOURISH 18 17 Disguised compliance or undisguised nonsense? A critical discourse analysis of compliance and resistance in social work practice in: Families, Relationships and Societies Volume 9 Issue 2 (2020) (bristoluniversitypressdigital.com) 18 Flourish - Norfolk County Council Practice note: Professional curiosity A number of case reviews into significant harm have identified the need for practitioners across services to be respectfully curious and think more deeply about information received and to ask “why” questions. In busy work environments it can be easier for professional curiosity to be lost. Practitioners must always reflect on information given and whether it is evidence based or if there may be grounds to suspect it and be prepared to seek additional information, to question or to challenge it through respectful working relationships. What is important is reflective thinking about what is happening and whether there may be more than meets the eye. Key aspects of professional curiosity include among other things: • seeking information from a range of sources, including the child, family history and the extended family, including what help may have been tried before, • thinking about the child’s lived experience, and whether it is good enough (See Norfolk’s FLOURISH Materials)* • asking if the information received is evidenced, • looking for patterns, • thinking and asking about why this is happening and whether there are other possible explanations • identifying gaps in information, • using reflective thinking through supervision or consultation • and being prepared to change one’s point of view. Norfolk SCPR AL – FINAL FOR PUBLICATION 21 5.7 Reflective thinking, consultation and clinical supervision 5.7.1 As the analysis above shows this was a complex family. The different and parallel needs of the three children, each with mental health problems, and the longer-term mental health problems of parents and how they affected their parenting were a lot for practitioners to think about. There were a number of good interventions that showed that systems were in place to respond but progress for the children, especially AL, was intermittent and slow. There was no holistic view of the children and family. 5.7.2 This shows the importance of clinical reflection for practitioners. As well as their own analysis there is a need for frontline practitioners to have access to experienced colleagues and specialists who are not caught up in the immediate dynamics of the family interactions. This provides support in thinking in different ways about what behaviours might mean, what further assessments may be needed, or to help confirm that they are on the right track. This is especially important when progress in work seems to be too slow or not moving forward. 5.7.3 Evidence provided to the Review shows that the alternative education placement had consultation available to support the mentor in their thinking about AL and his needs. When the situation seemed to be stuck they were also able to use other external systems for support, for example discussion with CADS to get additional advice. On one occasion this was able to help thinking through that a supplementary referral to youth services was not realistic for AL. 5.7.4 School practitioners have access to advice and reflection from their Designated Safeguarding Lead (DSL) and in this case there is evidence that this worked well. DSLs are themselves supported by The County Education Safeguarding Team which works with networks of DSLs to provide consultation and advice. 5.7.5 Within Children’s Services, CADS has experienced consultant social workers and managers to support triage and analyses of family history . The Family Support Service had supervision in place for the Family Support Practitioner and there are a range of specialists available for co-consultation and through reflective group supervision to support workers. The Family Support Assessment and Plan was overseen and endorsed by a manager. 5.7.6 There was clearly good information exchange and co-consultation between the education mentor and the CAMHS practitioner for AL. 5.7.7 A challenge was that until Mother’s death this was not all brought together in one place for coordination across services to provide a holistic response. In Norfolk there is an agreed and valuable Joint Agency Group Supervision procedure (JAGS)19. Its purpose is to provide a mechanism to reflect on cases which are very complex, feel ‘stuck’, or are drifting. It can be used in work at Tiers 3 and 4 of the Safeguarding Threshold. It provides a reflective space for joint analysis of information, an opportunity to explore what professionals know about the lived experience of the child and should help strengthen the relationship between professionals who are working together with families to secure the best outcomes for children. It had not yet been triggered for practitioners working with AL’s family after Mother’s death. It would have been a useful place for the agencies working with the different members of the family, including Father, to come together with multi-agency supervisory support to analyse the levels of need or risk, the rate of progress and whether different interventions were required. 19 3.16 Joint Agency Group Supervision Procedure - Norfolk Safeguarding Children Partnership (norfolklscb.org) Norfolk SCPR AL – FINAL FOR PUBLICATION 22 5.7.8 As noted above it would have been useful to have had specialist psychiatric or psychological consultation for the assessment and formulation of the Family Support Plan when Father, AL and AL’s Brother, and other Family members, were all in acute shock and grief and there was still uncertainty about the cause of Mother’s death. This may have assisted additional thinking about what kind of responses were likely to be effective given AL’s heightened anxiety and grief, for example, he was perhaps unlikely to have accepted bereavement support from a stranger, yet he would talk with his wider Family members. Specialist psychological advice may also have been useful with regard to Father’s ability to manage his alcohol dependence. 5.8 Bereavement support 5.8.1 Father, AL and AL’s Brother were all seriously impacted by Mother’s unexpected death. In December 2021 AL’s Brother was referred to Nelson’s Journey20 a bereavement support service. AL would have had to make a self-referral to a bereavement service, given his age. Father was signposted to Cruse21 for bereavement support but would also have had to have made a self-referral. A practitioner who knew AL thought that there was a possible gap in bereavement services for a young person like him as he acted emotionally and mentally much younger than the 17-year-old that he was and would have needed a service to meet that. He was also unlikely to self-refer. 5.8.2 AL was processing his emotions and thoughts by talking from time to time to his Family members by phone, which can be a positive way to mourn in the early stages of grief. A useful approach can be to provide those close to children with information about how to support them in the initial phases of shock and grief until they are stronger and later able to consider using a bereavement or counselling service if it is necessary. The Nelson’s Journey materials are a useful resource. Given his reluctance to speak with strangers, including online or by phone, it was considered unlikely that AL would use more formal bereavement counselling. AL was reluctant at first to speak with the new Family Support Practitioner but started to do so briefly during their visits in December. He did speak briefly on the phone to his Previous CAMHS practitioner and in January to his education mentor about his feelings. 20 Information and Guidance | Nelson's Journey | Child Bereavement Help for Norfolk (nelsonsjourney.org.uk) 21 Cruse Bereavement Support (Norwich and Central Norfolk) | Norfolk Community Directory Practice note: in work where there is a high or complex component of mental ill health, for a child or parent, consideration should be given to accessing consultation from a psychiatrist or psychologist to advise the network of professionals on analysis and decision-making about possible interventions and timing. Recommendation 7 - Supporting Reflective Thinking in Complex Work The Norfolk Safeguarding Children Partnership should review how Joint Agency Group Supervision process is working across services, including awareness of it among practitioners and supervisors and further promote it, if necessary. The Partnership should also review with Commissioners and Providers how psychiatric or psychological consultation can be made available to multi-agency networking in cases where there is a mental health component but mental health services are not directly involved. Norfolk SCPR AL – FINAL FOR PUBLICATION 23 5.8.3 As noted above (5.7.8) given AL’s complex mental health, specialist advice on how to support him in this acute bereavement may have been useful. 5.9 Recognition of the needs of young carers 5.9.1 Given Mother and Father’s physical and mental health problems and their possible impact on parenting, a question for this Review was whether consideration was given to the possibility that any of the children should have been considered as Young Carers. This could also have applied to whether the children were caring for each other, given the difficulties the children had. Records show that this was considered in 2014 for the Sister (age 12) but Mother declined a referral. 5.9.2 Father was recognised formally as the Carer for Mother. Given the children’s own difficulties they were not seen to be providing care to their parents, because of their own needs. Practitioners did not think , in retrospect, that AL would have been able to use a Young Carer’s service as he was so anxious about strangers; however, this possibility was not explored at the time. 5.9.3 Practitioners noted a learning point that it is important to consider the question of whether a child is a carer even if it may not be realistic to refer them on to a Young Carer’s service. This would encourage reflective thinking about the possible impact of the disability or health of parents or siblings on children and young people, even if they are not then referred on to a Young Carer’s service. As noted above, there is a caveat that agencies working with the children were not fully aware of the full nature of the parents’ health problems and their possible impact. Services working with Mother in her own right did not refer any of the children for Young Carer’s services. 5.9.4 As part of the review to understand the wider systemic context of provision for Young Carers the reviewers met with leading commissioners and providers of carers services in Norfolk. It was confirmed that the Family had not been referred for services. 5.9.5 A lot of work has been done in Norfolk to raise awareness of the needs of Young Carers with Adult Services and in Schools. Young Carers are being recognised through the school census. There is no strategic lead for planning for Carers across Health Services. Some Primary Care Networks have worked to raise awareness of Young Carers and GPs can now recognise Young Carers in patient coding. Young Carers services have working links with hospitals. 5.10 The impact of Covid on work with AL’s Family 5.10.1 From March 2020 services to the Family could not be delivered face to face during periods of lockdowns, especially when services had to reduce to essentials. AL was used to working only online with his education placement. However, he was still anxious and reluctant to do so when this involved talking or face to face Practice note: Experience from Young Carer’s services has shown that being labelled a “carer” can be a stigma for a child and that young carers often do not see themselves as carers, they see what they do as normal. Another barrier can sometimes be that families feel that there are already too many services to relate to take on another one. It is important to note that a young person can self-refer and has access to the carers’ helpline. Norfolk SCPR AL – FINAL FOR PUBLICATION 24 contact on screen in real time rather than being able to use text chat systems where he had more control. The main change for him was that the weekly visits from his education mentor shifted to online in the first lockdown period and he initially had some difficulty engaging with the mentor in this way. Later the mentor was able to have contact with him in the family garden. 5.10.2 AL’s CAMHS therapy stopped suddenly and shifted to monthly phone calls and visits when later possible. The calls were with Mother as AL would not speak on the phone because of his anxiety, Mother reported AL as being “fine.” AL’s therapist thought that Covid may have stalled AL’s recovery and integration back into the wider world. 5.10.3 As Mother was clinically vulnerable, AL’s Brother’s primary school offered him a school place in March 2020 and from January 2021, but this was not taken up. Mother was engaging with the school by phone and Father collected and returned packs of work for AL’s Brother. Occasionally school staff visited in the garden. The school put in place remote monitoring and reporting processes for all the pupils. AL’s Brother was not noted as of additional concern in these periods. Covid meant that AL’s Brother was out of school from March to September 2020 and, after that, he had school attendance problems because of increasing anxiety. It was also reported that he was anxious “because of Covid”. 5.10.4 Practitioners also noted that Father was present more during Covid and AL’s Brother was said to like having his father there. 5.10.5 None of the key workers working with the Family reported that they had been prevented from working remotely with the Family because of their own isolation or ill-health. However, agencies were clearly under additional pressure. 5.10.6 Agencies were asked to comment on arrangements put in place generally from a strategic and systemic point of view for this Review to gain a wider picture of how the pandemic affected systems as well as this family. The responses provided are rich with learning about organisational planning and responding in a pandemic which goes beyond the scop[e of this CSPR. The Norfolk Safeguarding Children Partnership may wish to use these to inform any future strategic contingency planning for safeguarding systems. 5.10.7 The responses provided show that agencies responded and adapted strategically as the pandemic progressed and occasionally there were staffing problems which required flexibility. A point noted by AL’s Brother’s school was that it was much harder to monitor children who required safeguarding (not AL’s Brother) but this was always prioritised, and reporting systems were developed to manage this. It was also noted that multi-agency work and contact with other key agencies was harder in this period. For agencies which were not used to working remotely this was an important shift. The Mental Health Trust noted that for vulnerable children account also had to be taken of the possible impact that a child’s usual supports and monitoring systems, such as schools or other services, were not available to them in the same way. Systems for prioritising, emergencies and prescribing were put in place. 5.10.8 A useful account of planning and response for safeguarding children by local agencies to the lockdowns and pandemic is included in the NSCP Annual Report 2021.22 22 NSCP-Annual-Report-2020-21_FINAL-for-publication.pdf (norfolklscb.org) Norfolk SCPR AL – FINAL FOR PUBLICATION 25 5.11 Implementing learning from case reviews – measuring the impact of lessons learned 5.11.1 In September 2020, the Norfolk Safeguarding Children Partnership published a Serious Case Review into the death by suicide of a young person. This was a review into work with a different family with different dynamics. The NSCP delivered briefings to staff groups and agencies were asked to take this learning forward into practice as well as work on specific recommendations. 5.11.2 As there were some similar issues to AL’s circumstances the Review Panel sought to ascertain whether the practitioners involved with AL’s Family had been aware of that SCR or the lessons from it and whether they had influenced practice. Few were aware specifically about the case and the lessons. Some were aware that there were occasionally agency or team briefings and some had attended such briefings but did not remember if they had been for this case. Others were unaware. It is noted that it was published and learning was disseminated during the pandemic when practitioners and services were under great strain. 5.11.3 Recommendations from Safeguarding Practice Reviews and other scrutiny is shared and disseminated through the Norfolk Safeguarding Children Partnership Group for all partner organisations to act upon the learning. Multi-agency roadshow workshops are held following the publication of a review. Multi-agency Local Safeguarding Children Groups discuss the learning from SPRs and members feedback to the following meeting on how this learning has been discussed within their organisation. The Multi-Agency Audit Group monitors progress against all scrutiny recommendations and only when there is sufficient evidence will the recommendations be considered as completed. 5.11.4 The Review Panel noted that the Partnership is aware of the challenges of ensuring that practice learning from case reviews and from audits reaches and becomes embedded in frontline practice and is working to improve this all the time. 6 Conclusion 6.1 AL was a child and then young person who was, at times, overwhelmed by anxiety. He seemed to be making some slow improvements but became overwhelmed with grief at the unexpected death of his Mother. Practitioners were concerned about his emotional well-being at the time and steps were being taken to support him and the Family. 6.2 Practitioners worked hard to support him over several years. This Review suggests that AL’s difficulties, and those of his siblings, who also had problems may have been more rooted in family trauma than was understood at the time. Like other reviews before it, it has raised questions about the importance of understanding families, and their history and dynamics including the role of father figures. Father was a key person who played an important caring role but who had his own chronic mental health difficulties which also impacted on the children. It is also important to be curious and to take a holistic view when several children in the same family are showing problems. 6.3 The Review notes the need for interventions to understand as fully as possible significant family history, including any history of trauma and its possible impact (Section 5.4). It is also important to identify key individuals who have a role in the family, including fathers and father figures plus other key relatives. (Section 5.4.7). Norfolk SCPR AL – FINAL FOR PUBLICATION 26 6.4 Section 5.3 explores the complexity of balancing working to engage and support families with the need to hold in mind whether children’s care is good enough, over time. The learning shows the need to hold in mind a wider and longer term view of neglect, beyond incident based or physical neglect but considering if parenting is not meeting children’s needs, including their health or mental health needs. This includes assessing possible behaviours such as unwillingness to cooperate, withholding consent for services, providing misleading information or not taking children to treatment. 6.5 Questions have been raised, in retrospect, about whether the parents were always honest with practitioners, although they seemed to be so at the time. The Review has shown, again, the need for practitioners and their clinical supervisors to hold in mind the need for curiosity and to have an open mind to the possibility that all may not be as it seems, especially when there is no apparent, or only slow, progress. 6.6 Challenges in engaging parents and the need for curiosity beyond the apparent have been noted in case reviews in the UK over several years. Sections 5.3 and 5.6 explore how this may have manifested itself in this case. This is not new learning but is repeated here as a reminder of how important it is to hold it in mind in practice and how challenging it can be for practitioners. 6.7 Section 5.7 reminds services of the need for frontline practitioners to have access to reflective supervision and consultation to aid reflective thinking. The value of multi-disciplinary supervision is noted, for which there is already a valuable model in Norfolk. The importance of having access to specialist mental health advice for children with complex mental health needs or in acute bereavement is noted in paragraph 5.7.8 and section 5.8. 6.8 The work with AL’s family, given the complex and longer term mental health needs of both parents, including alcohol use, serves to remind practitioners in both children’s and adults’ services of the need to think about how an adult’s difficulties can impact on their children or those that they have responsibility for. It is important therefore that services working with adults identity if a vulnerable adult has responsibility for caring for others and what the impact of their difficulties may be. (Section 5.9) 6.9 Family members felt disloyal to AL and the parents in contributing to this Review and wanted to protect AL’s Brother. However, they wanted to ensure that something positive would come from his tragic death and that learning from this Review would be used to improve responses to families with children like AL. 6.10 Leaders and practitioners are asked to review their systems and practice considering the practice learning identified here and to strengthen or change approaches in light of the recommendations made. Malcolm Ward Independent Reviewer December 2022 Norfolk SCPR AL – FINAL FOR PUBLICATION 27 7. Recommendations 1 Medication supervision (see paragraph 5.24) The Norfolk Safeguarding Children Partnership should seek assurance from health commissioners and partners that protocols and guidance are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration. 2 Referral Pathways for Child Mental Health Services (see section 5.2) The learning from this Review should be taken into account in the NSFT Review of referral and care pathways and the development of any associated training package for staff. Referral processes and forms should seek relevant information about family history, any relevant history of trauma and any concerns about current parental mental health or substance misuse. Within the Trust, appropriate checks should be made to see if parents are known to adult mental health services, when children are being referred. 3 Practice Guidance to Professionals on Children at Risk of Suicide (see paragraphs 5.2.5 – 5.2.12) The Norfolk Safeguarding Children Partnership should review this practice guidance to ensure that it is up-to-date and promote it with the dissemination of learning from this Review. 4 Recognising the longer term nature of neglect; and parental non-cooperation (see section 5.3) The Norfolk Safeguarding Children Partnership should review its guidance on Thresholds in order to support practitioners’ understanding of neglect, the long term and cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect. As well as highlighting examples of single significantly harmful events examples can be provided to help practitioners recognise that neglect includes not being brought to appointments, repeated refusal of services, not complying with advice or not administering or monitoring a child’s medication. 5 Understanding the Importance of and Working with Fathers and Father Figures (see paragraphs 5.4.7 – 5.4.9) The Norfolk Safeguarding Children Partnership should produce and promote sector specific good practice guides on understanding the importance of fathers and father figures and good practice in working with them, highlighting the expectations of all partner organisations around professional curiosity, engaging, assessing, recording and information sharing when working with all families. 6 Understanding Families in their wider context Think Family (see section 5.4) The Norfolk Safeguarding Children Partnership should seek assurance from Partner Agencies, including those working primarily with adults, that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles. Services should have systems in place to recognise the importance of seeing a family in its wider context, including assessing key relationships and obtaining a holistic view of any difficulties in the family, and not focusing solely on individual family members. Systems should ensure that where possible and appropriate family members, including fathers, and other key relatives, should be heard in order to capture important historical information or to understand key dynamics. Norfolk SCPR AL – FINAL FOR PUBLICATION 28 7 Supporting Reflective Thinking in Complex Work (see section 5.7) The Norfolk Safeguarding Children Partnership should review how the Joint Agency Group Supervision process is working across services, including awareness of it among practitioners and supervisors and further promote it, if necessary. The Partnership should also review with Commissioners and Providers how psychiatric or psychological consultation can be made available to multi-agency working in cases where there is a mental health component but mental health services are not directly involved. |
NC049236 | Alleged sexual abuse of three siblings by their older brother in July 2015. Child FH lived with his mother, father and three younger siblings. The family is of dual heritage and had been involved with different services, including social services and CAHMS, for a number of years due to the complex needs of FH. From 2007 there were 7 social work assessments including one child protection inquiry. FH had a Statement of Special Educational Needs. There had been serious concerns about FH's behaviour from 2010 including violence to siblings and fire setting, and he was assessed by CAHMS and attended a Paediatric ADHD Clinic. In 2015 FH's mother told the school she was unable to cope and would not have him back after school. Later in 2015 FH's medication was changed and she felt better able to cope and their case was closed. Some weeks later the mother reported to the police that FH had raped his younger siblings. Learning includes: agencies should develop a pathway for the management of children with complex social and emotional needs, linked to aggressive behavioural difficulties or risk to others to address the needs of a small number of children, who do not easily match any diagnostic criteria and may not therefore meet the thresholds for any specific service. Recommendations include: more effective input by paediatricians and CAMHS staff to Child in Need meetings; multi-agency aspects need to be considered to ensure all relevant professionals are identified and invited to contribute to Child in Need meetings.
| Title: Report of the serious case review regarding Family H. LSCB: Hertfordshire Local Safeguarding Children Board Author: Fiona Johnson Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final 14-Dec-17 1 REPORT OF THE SERIOUS CASE REVIEW REGARDING Family H Author: Fiona Johnson Final 14-Dec-17 2 CONTENTS 1. INTRODUCTION 1.1 Background to the review and summary of the case P 3 1.2 Terms of Reference P 3 2 SUMMARY OF FACTS 2.1 Family details P 4 2.2 Earlier events P 4 2.3 Agency Involvement during the review period P 5 3. VIEWS OF FAMILY P 11 4 ANALYSIS P 12 5 CONCLUSIONS P 25 6 RECOMMENDATIONS P 28 Appendix 1: Methodology P 29 Appendix 2: Glossary of Terms & Abbreviations P 31 Appendix 3: Bibliography P 32 Final 14-Dec-17 3 1 INTRODUCTION 1.1 Background to the serious case review and summary of the case 1.1.1 This serious case review (SCR) concerned a boy FH and his three younger siblings. FH was alleged to have seriously sexually abused his siblings. At the time of the review, prosecution was being considered however the decision was made by the Crown Prosecution Service that it was not in the public interest to pursue criminal proceedings despite the evidence meeting the threshold for prosecution. 1.1.2 There was agency involvement with the family from 2007 when FH (aged 4) was referred by to Children’s Social Care (CSC) by the primary school, because of aggressive and disruptive behaviour including attacks on a family pet. In subsequent years, several health agencies became involved and there was a high level of service input from other agencies. 1.1.3 This matter was referred to the Hertfordshire Local Safeguarding Children Board (LSCB) on 7/9/2015 and 16/11/2015 and was considered by the Case Review Group Meeting on 22/1/2016 which recommended that there should be a serious case review (SCR). The LSCB chair, Phil Picton, agreed the same day, that there should be a serious case review as the children had suffered serious harm and there were concerns about the way in which agencies had worked together1. 1.2 Terms of Reference Full details of the review process are included in appendix 2. In summary, an independent lead reviewer worked alongside a review team, composed of senior managers, and facilitated by the chairperson of the Case Review Group. The purpose of the SCR was to review the involvement of agencies involved with the family to understand how professionals had understood the cause and nature of the family’s difficulties, and how effectively they had responded. The focus of the review was to establish whether there were ways in which services for children could be improved in the future. The SCR considered the work of the following Hertfordshire agencies: Health agencies (including mental health, community health and GP services) Schools Police Local Authority Services (including Children’s Social Care (CSC), Thriving Families and Fire and Rescue Services) 1 (Working Together to Safeguard Children, 2015 4:18 p 76) Final 14-Dec-17 4 The time frame of the review was from October 2014, when there was a referral by Thriving Families2 that resulted in CSC undertaking a further assessment of the family’s needs, until late August 2015, when the younger children made the allegations about sexual abuse. 2 SUMMARY OF FACTS 2.1 Family details – all names have been changed for reasons of confidentiality Age at time of allegations Mother 34 Father 50 FH 12 years Sibling 1 10 years Sibling 2 8 years Sibling 3 4 years Maternal aunt 31 years Maternal grandfather 62 years The children have dual heritage, their mother is White British and their father was born in North Africa. Their religious affiliation is not known. Professionals were aware that the children were of dual heritage but there is no evidence that this directly affected professional practice. On occasion Mother explained FH’s behaviour as being in response to racism from peers. In 2014, the family were supported to move to a new house, because of these concerns however this did not resolve the neighbour disputes. FH lived with his mother and siblings in social housing. His mother was a single parent dependent on benefits, who received much support from her wider family. The father and mother separated prior to the review period. The children had no contact with their father and he did not live locally. He was not involved with the children during the period of the review. 2.2 Earlier events 2.2.1 FH and his family were first referred to the local authority in October 2007 when he was four years old. From 2007, there were seven local authority social work assessments (including initial assessments, core assessments and one child protection inquiry) but there was little continued involvement by social workers and the lead in service coordination came from support services including Family Centres, parenting programmes, Targeted Advice Service and, from Summer 2 Thriving Families is a holistic, intensive, family intervention service It is an integral part of Hertfordshire County Council’s early intervention and prevention strategy. The Thriving Families teams work in partnership with agencies such as the police, housing associations and job centres, to improve the lives of the families they support. Final 14-Dec-17 5 2014, Thriving Families. FH had a Statement of Educational Needs3 and attended a specialist school for children with emotional and behavioural needs. He had been assessed by CAMHS in 2010 and was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)4 and was attending a Paediatric ADHD Clinic. 2.2.2 From 2010 there were serious concerns and risks identified about FH which included violence to siblings, fire setting and bizarre behaviour. FH was unpopular or scapegoated by children of neighbours at two addresses, frequently leading to police involvement. In 2011, there were concerns identified about sexualised behaviour between FH and Sibling1 which were assessed and considered to be within the range of normal sibling behaviour. 2.2.3 There were also unsubstantiated suspicions about the behaviour of a member of the wider family towards one of FH’s siblings, who used to stay with him occasionally. The family always denied that there was any cause for concern and say that the child later denied any inappropriate behaviour. 2.2.4 By autumn 2014 the family had moved to a new area, nearer to family members, and the problems with the neighbours recurred. The worker from Thriving Families, who had known the family for over a year, was concerned because there seemed to be little improvement in the family functioning and FH’s behaviour seemed to be increasingly detrimental to his siblings. This concern was intensified when mother reported that FH had tried to strangle his sibling when he was asleep. The worker felt that this action was a safeguarding matter and so made a referral to CSC. 2.3 Agency Involvement during the review period Initial referral and response October 2014 to December 2014 2.3.1 The initial referral from Thriving Families identified that FH was violent towards his siblings and mother and that Mother was saying that she could not cope with FH and that his siblings had started exhibiting difficult behaviour. The duty team response was to undertake a child and family assessment. It was not considered that there should be a section 47 enquiry5. 3 A Statement is a document which sets out a child's special educational needs and any additional help that the child should receive. The aim of the Statement is to make sure that the child gets the right support to enable them to make progress in school. www.specialeducationalneeds.co.uk/statement-of-sen.htm 4 Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. Common symptoms of ADHD include: a short attention span or being easily distracted, restlessness, constant fidgeting or over activity, being impulsive. www.nhs.uk/conditions/attention-deficit-hyperactivity.../Introduction.aspx 5 s.47 enquiry refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’ when they have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm Final 14-Dec-17 6 2.3.2 The assessment was undertaken by a social worker, involved the children and mother, and included consultation with a range of agencies. Information was requested from CAMHS who did not contribute, as the paper files could not be made available within the timescale of the assessment. The assessment identified sixteen risk factors including: the children’s sexualised behaviour; worries that FH would physically harm his siblings; that Mother had little insight into FH’s difficulties and concerns regarding the level of supervision she provided to the children. The social worker also identified factors that reduced the risks including: the support provided by the wider family; that home conditions were good; and that Mother had engaged with the assessment. The assessment included little information from the previous social care assessments, with minimal reference to the child protection investigation in 2012 and no reference to FH having previously been involved in fire-setting. The outcome of the assessment was that the social worker recommended further work with the family via a Child in Need (CIN) plan6 that was mainly focussed on support for mother and building a relationship with FH. There was also an expectation that the siblings would be seen regularly and that their health and educational needs would be met. The plan did not include any further assessment of the emotional and physical risk to the siblings from FH’s actions and there was no involvement in the plan by specialist services such as CAMHS or the paediatrician. 2.3.3 In December 2014 the family was allocated to a children’s practitioner. This worker did not have a social work qualification and was very inexperienced. This was in line with usual practice as CIN work was usually allocated to unqualified staff. The first CIN meeting was held in December and most key community agencies working with the family were invited and attended. The exception being that the community paediatrician was not invited. Mother struggling to cope and risk of harm to children January – February 2015 2.3.4 The police were called out to the family home on four occasions during January and there was increasing evidence of violence from FH to his mother. The second CIN meeting was held halfway through the month and the school agreed to offer FH extended days as a support for Mother. At the meeting, there was also discussion of the risk that FH posed to the younger children and Mother was advised to call the police if she felt that she or the children were at risk and to request an emergency psychiatric assessment. The next time the police were 6 A child is in need if s/he is under 18 and either s/he needs extra help from Children’s Services to be safe and healthy or to develop properly; or s/he is disabled. Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family. This is called a child in need plan. Final 14-Dec-17 7 called to an incident, FH was taken to Accident & Emergency which resulted in the CAMHS Crisis Assessment and Treatment Team7 (C-CATT) becoming involved. Their assessment was that FH did not have suicidal intent or psychosis so he was discharged home with a referral for longer term support from CAMHS. 2.3.5 In January 2015, Mother told both schools, on two separate occasions, that she could not cope with FH and said she would not have him back after school. Both times this information was shared with CSC and Mother was persuaded that FH should return to her care. The mother’s account is that she was not given the option of FH staying in care even for a short respite period. On the second occasion, there was discussion about FH being accommodated in foster-care but the management decision was that this should not be agreed until there had been a psychiatric assessment. A final incident at the end of the month resulted in FH being held in police cells for five hours before being discharged to his grandfather’s care. 2.3.6 During February 2015 file records show increasing evidence that the younger children were experiencing harm and that Mother was struggling to cope and protect them from FH. Mother and maternal grandfather met with the children’s practitioner and the consultant social worker and described abusive behaviour by FH to his siblings which included FH biting Sibling2 and threats to burn the house down. On a separate visit the children’s practitioner observed FH bullying Sibling1 and Mother failed to intervene. These incidents were discussed between the TYSS worker and the children’s practitioner who also informed the consultant social worker (CSW)8 who was her supervisor and some items were reported on to more senior managers. 2.3.7 In February the C-CATT decision was reviewed and a second Psychiatrist confirmed that FH did not have psychosis but recommended an earlier CAMHS appointment. Attempts by CAMHS to see FH were delayed by Mother cancelling an appointment and a letter offering an alternative date being sent to the wrong address. At the third CIN meeting held at end of month the school reported improvements in FH’s behaviour at school but the children’s practitioner reported the bullying incident and expressed concern about the impact of FH’s behaviour on the younger children. She reported that CAMHS had said that in-patient 7 C-CATT is a multi-disciplinary community team of senior clinicians, providing a short-term, intensive and flexible assessment and treatment packages of care for children with complex and challenging mental health problems and at high risk of harm to themselves or others. 8 In Hertfordshire consultant social workers are experienced workers who undertake a senior practitioner role including holding a small caseload of complex work while transitioning into a management position. At this point they provided supervision for less experienced staff as well as being a role model for good social work practice. Final 14-Dec-17 8 assessment was not suitable and suggested that CSC would be seeking a second opinion. At this point the children’s practitioner was receiving minimal formal supervision and limited support because the CSW transferred to another team and there was a delay in the replacement CSW providing supervision. Increased Professional involvement March 2015 2.3.8 During this month there was a significant increase in professional involvement with the family. Following a referral from Thriving Families, the Fire Service became re-involved in March and provided advice to Mother regarding fire safety. The worker from the Fire Service rapidly identified significant concerns about FH and shared them with her supervisor. It was agreed that she would remain involved despite the overall level of need and risk in the case being outside of their usual remit. 2.3.9 Early in March, FH was also seen by the Great Ormond Street Hospital (GOSH) team. He had been referred by paediatrician in September 2014 for a further assessment of possible autistic spectrum disorder (ASD). The staff there were very concerned about FH and the risk he posed to other children. Within two days of seeing him for the initial assessment the GOSH paediatrician had telephoned the community paediatrician and children’s practitioner sharing these concerns, following up the telephone call with an email to the community paediatrician. The community paediatrician replied advising that her concerns were being raised with CSC. The community paediatrician then telephoned, and wrote to the children’s practitioner, expressing concern about FH’s behaviour and the impact it was having on the entire family and suggesting that there was a need to consider residential placement for assessment of FH’s difficulties. Following this the community paediatrician made a referral to CAMHS asking for the transfer of the management of FH’s ADHD from Paediatrics to CAMHS as FH’s needs were more complex and needed input from a psychiatrist. GOSH saw the family again on 23rd March and following that appointment liaised with the CAMHS psychiatrist about a possible referral to the South London and Maudsley NHS Foundation Trust (the Maudsley). 2.3.10 On receipt of that referral the CAMHS psychiatrist contacted the children’s practitioner in mid-March asking for a professional who knew FH to attend an assessment appointment. Unfortunately, neither the children’s practitioner nor the TYSS worker could attend on the date chosen. This meeting was attended instead by the Fire Service worker who had known FH for many years. Following the assessment, the CAMHS psychiatrist changed FH’s medication and, because she was very concerned about the risks that FH could pose to others, she made Final 14-Dec-17 9 a referral to a specialist clinic at the South London and Maudsley NHS Foundation Trust (the Maudsley) for a forensic psychiatric assessment. This referral letter was copied to the children’s practitioner. At the end of the month FH was seen at CAMHS for a ‘Choice’9 appointment, however the outcome of this assessment was not shared with the local authority. 2.3.11 Early in March 2015 Sibling 2 was seen in school with a bruise, said to have been caused by FH. This matter was reported to the children’s practitioner who discussed it with the consultant social worker. Initially there was discussion about the need for a child protection investigation and medical examination however this was not pursued as the team manager’s decision was that no action was required because the injury was consistent with the explanation provided. A further CIN meeting was held at the end of March. CAMHS and the Fire Service were not invited to attend meaning that information shared at those meetings was not passed to GOSH or The Maudsley however Mother reported to professionals that FH had been seen by GOSH and the local CAMHS psychiatrist. Mother reports improvements and case is closed April 2015 – June 2015 2.3.12 There was minimal agency involvement during April and there were fewer requests from Mother with regards to FH. Sibling2 however was observed in school with rope burns on his neck which the local authority came to believe had been caused during play with FH, though his mother told the review that this was not the case. Separately, Sibling2 was seen with a mark on his face, said to have been caused by FH with a lighter. Both matters were reported to the children’s practitioner and discussed at the CIN meeting. At that meeting, Mother reported that FH’s behaviour had improved since his medication was changed by CAMHS and suggested ending work with TYSS as she no longer saw a need for CSC involvement. The TYSS worker had no contact with the family during this month because of planned sick leave and the secondary school did not attend the CIN meeting so the information about FH’s behaviour improving was largely based on Mother’s report. 2.3.13 The final CIN Meeting was held in late June. Mother advised that she was now better able to manage FH because of his new medication. She reported that 9 The Choice and Partnership Approach (CAPA; York and Kingsbury, 2009) is a clinical system that evolved in Richmond and East Herts CAMHS and is now being widely implemented across the UK, New Zealand and parts of Australia. New CAMHS users and their families are invited to an initial ‘Choice appointment’. This appointment is a face to face appointment aimed at identifying what they want help with and reaching a shared understanding of the problems. From there a range of alternatives open to them can be offered, including other services, strategies they can use to help themselves, and any appropriate specialist CAMHS interventions. https://www.mentalhealth.org.uk/sites/default/files/CAPA_PDF.pdf Final 14-Dec-17 10 there was less violence at home from FH towards his siblings and told professionals that FH had been diagnosed by the GOSH team as having ASD, ADHD and hyperkinetic cognitive disorder. The TYSS worker reported that their work with FH was complete. Mother had completed the ADD-vance10 course which she said supported her with managing FH’s Autism and ADHD. No agency formally opposed ending the CIN plan but the secondary school expressed concern and reported that FH’s behaviour in school was deteriorating. It was noted at the meeting that the reports from The Maudsley and GOSH were still awaited however it was still recommended that the CIN plan should cease. Following this meeting the social care team manager endorsed this decision and local authority staff finished work with the family at the end of June. 2.3.14 In June FH’s case was presented at an academic session for health clinicians in Hertfordshire that involved all the medical consultants involved with FH but no one from social care. The Maudsley, psychiatrist emphasised the need for a multi-agency approach and that social care input would be needed. Health agencies express concern about CSC case closure 2.3.15 The GP became aware of the intention to cease the plan in June 2015 and sent a letter to County Hall addressed to the central Child Protection Unit11 expressing concern about the case closure however this letter was not received by the children’s practitioner. In late June, after the CIN plan had ended, the psychiatrist at The Maudsley sent a letter to the CAMHS psychiatrist, copied to Mother, GP and ‘social worker’. This letter described a diagnosis of childhood autism, along with previous diagnoses of hyperkinetic conduct disorder and ADHD. FH was described as a high risk for repeating physically assaulting behaviour towards peers and adults both within the home and community contexts. The letter concluded saying ‘FH’s high level of complex needs and his risk management require a coordinated multiagency approach where his (and his families) needs are clearly identified and allocated. Good multiagency communication is the cornerstone to manage this level of risk and complexity’. This letter was received in CSC after the case was closed, it was uploaded to the system by an administrator in July 2015 but was not seen by social work professionals or managers. 10 ADD-vance is a registered charity founded in Hertfordshire in 1996. It provides specialist information, training and advice for professionals, as well as support for children, adults and families on issues relating to Autism, Attention Deficit Hyperactivity Disorder (ADHD) and related conditions. 11 The letter appeared to have been intended for the Child Protection Statutory Review Service which is the team responsible for chairing child protection conferences and Looked After Children Reviews. Final 14-Dec-17 11 2.3.16 In mid-July 2015 a letter was sent to the local authority from the GOSH team. This was a cover letter for a detailed assessment report that confirmed a diagnosis for FH of Autism Spectrum Disorder with callous and unemotional traits. The letter stressed the risks and the need for close work between the school, CAMHS and paediatric team with continuing involvement by CSC. This letter was also received by CSC after the case was closed. The letter was date stamped in July, but the report was not uploaded to the system until September 2015. In mid-August, the CAMHS psychiatrist met with Mother, FH and the siblings and a further medication review was carried out. Mother informed the psychiatrist that the CIN Plan had ended in June. Mother said she was happy with this as she did not need further assistance. This was the first time that the psychiatrist had been informed of the ending of CSC involvement with the family. Following this appointment, the psychiatrist sent a letter to the GP informing her that CSC had closed the case and saying that she intended to contact them to voice her concerns (she had not done this before the children made their allegations very soon after). The same day she made a referral for PALMS (Positive behaviour, Autism, Learning disability, Mental health service) to work with the family. 2.3.17 Two weeks later Mother reported to the police that her son, FH had ‘raped’ his younger siblings. 3 VIEWS OF FAMILY 3.1 The Lead Reviewer and a member of the Review Team met with Mother, Maternal Grandfather and Maternal Aunt. The Lead Reviewer asked Mother to describe how it was caring for FH and his siblings. Mother described it as ‘a rollercoaster’. She went onto explain how ‘FH’s behaviour would turn when he would become ‘violent, aggressive, and verbally abusive, bite, and punch and kick making it a challenge to even to get him to school’. On one occasion he badly damaged her car. School had reported this behaviour but Mother said that Children’s Services refused to take him into care. Mother then explained that after FH saw the CAMHS psychiatrist and was prescribed new medication, Concerta, he was seen to have changed. ‘…he was hugging his siblings and had calmed down considerably…’ 3.2 The Lead reviewer asked if the family had been helped by the Child in Need Plan. Mother did not feel that it provided much support and she and Maternal Grandfather expressed concern about inaccuracies in the Child in Need Assessment which they said they had tried to rectify but to no avail. They said that the family was looking for support but did not find that either the children’s Final 14-Dec-17 12 practitioner or the TYSS worker provided help. The most supportive service was ADD-vance and that they had learned a lot from their worker. Mother described that when she was under significant pressure in January 2015 and had asked for FH to be accommodated ‘she wanted somebody to listen but there was no contact for 3 days’. Nobody bothered to check up on FH ‘who was still in a hell of a mood’. The children’s practitioner and CSW eventually had come around in January but that visit was ‘just a welfare check’. 3.3 The Lead Reviewer asked what would have helped. Mother said that they wanted FH to be placed in a boarding school, he was statemented around 2011. He was permanently excluded in 2010. MGF said that it needed two adults to manage him. Mother said that she wanted somebody to take FH out of the house as she could not manage him on her own. MGF said he tried to give Mother a break by providing some help for a week. FH always listened to a man. He was ‘uncontrollable in the shops but when he was playing with Meccano he was meticulous and could concentrate for long periods’. Mother said that whenever he had appointments with doctors he behaved very well and that ‘professionals have not seen his behaviour when he has become aggressive’. 3.4 Mother felt that the police felt their hands were tied as it was for Children’s Services to support the family in relation to FH’s behaviour. Mother stated that the children resented speaking to social workers as they often were ‘pulled from their lessons’ and they ‘would not have anything to say’. Mother said that things had got better after FH’s medication was changed and because of this she wanted the CIN plan to end. Very few home visits were being done, between 4 to 6 weeks and not much was being done through the CIN plan. MGF said that there should have been a multi-agency approach and both Health and Children’s Services should have worked together. 3.5 The Lead Reviewer asked when the children first disclosed FH’s inappropriate sexual behaviour. Mother said that it was during the summer holidays in 2015 after CSC had ceased working with the family. She also confirmed that she had no concerns about sexual abuse prior to that time. She said that FH’s behaviour had got worse in July 2015 but because of the past lack of support she could not see the point in re-referring FH to the local authority. 4. ANALYSIS 4.1.1 Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case, why, and what needs to happen to reduce the risk of recurrence. The task for every review should be to answer the Final 14-Dec-17 13 following question: - What light has this case review shed on the reliability of our systems to keep children safe? This analysis should consider significant aspects of practice in the case and identify problematic areas. To understand their relevance to the wider safeguarding system, it is important that the analysis: - identifies whether problems are specific to the case; highlights any relevant information about how usual the problem is perceived to be locally; is clear about why it is important for the LSCB to consider these matters relative to their responsibilities, the risk and reliability of multi-agency systems. The following section considers the areas where analysis of practice in this case has identified problems that are relevant to the wider safeguarding system as it is probable that they are likely to be repeated as they have been described by practitioners as being ‘normal’ practice. 4.1.2 The reason for undertaking the serious case review was the allegation that FH had caused his siblings serious harm through sexual abuse. The extent to which professionals could have been aware of this risk is discussed in section 4.2 which considers the effectiveness of the professional response to child protection concerns about the risk that FH posed to his siblings. 4.1.3 The review has also considered practice within CSC regarding allocation, supervision and management of work. This is discussed in section 4.3 which examines the nature of work allocated to unqualified staff, the supervision provided to inexperienced staff and the distance between frontline staff and managers making casework decisions. 4.1.4 A significant feature of this review was the number of health clinicians involved with FH both in assessment and treatment of his needs. The complex routes to treatment within children’s mental health services and their impact on other professionals are discussed further in section 4.4. 4.1.5 One aspect of the professional work with this family was the absence of joint working between the health professionals directly involved with FH and the local authority staff who were working with all the children. The reasons for this are considered further in the section 4.5. Final 14-Dec-17 14 4.1.6 A key aspect of multi-agency working is the quality of information sharing. In this case there were examples of very good information sharing between police and CSC but other occasions when information was not shared. The quality of information exchange between police and CSC is discussed in section 4.6. 4.2 Professional response to child protection concerns 4.2.1 A central concern of this review was whether professionals could have intervened to prevent the sexually harmful behaviour of FH towards his siblings. It is noteworthy that even with the benefit of hindsight no professional could identify actions or behaviour, during the period of the review, by FH or his siblings that pointed to a clear risk of sexual abuse and this was a view confirmed by Mother and grandfather. There had been concerns prior to the review period of possible sexually inappropriate behaviour between the siblings. These were assessed and, as all the children were young (under nine) at the time of the concerns, this behaviour was deemed to be within the realm of ‘normal’ sexual exploratory play. There was also an investigation into the potentially inappropriate care provided by an extended family member but this had not been substantiated. This review did not examine in detail these matters but there was no evidence (even with hindsight) that the judgements made at the time were wrong. 4.2.2 An interesting facet of the professional intervention with this family was that the agencies who had least direct contact with the family as a unit and no direct responsibility for the younger children were able to formulate most clearly their understanding of the risk that FH posed to their well-being. The professionals at GOSH and The Maudsley and the local paediatrician and CAMHS psychiatrist based their views on information provided by Mother about FH’s relationship with his siblings. Their assessment of FH identified explicit risks to the children of physical harm as well as broader concerns about emotional damage. Those who were most involved treated his behaviour as an extension of ordinary behaviour between siblings, whereas those who were more distant (or more expert) viewed it as being out of the ordinary. 4.2.3 One explanation for this may be that within society generally there is a greater acceptance of peer on peer violence within children than between adults and an assumption is made that such violence has less impact on their emotional well-being. Surveys suggest that ‘more than half of all children experience violence from a sibling in the course of a year,12 and furthermore that ‘…over half of the 12 Finkelhor, David. Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People (Interpersonal Violence) (p. 92). Oxford University Press. Kindle Edition. Final 14-Dec-17 15 children under 10 years old hit by a sibling in the previous year had experienced five or more such episodes during that year’13. 4.2.4 Another aspect of violence within the home was FH’s attacks on his mother. When examining the police reports of the violence between FH and his mother the review team frequently noted that if an adult had acted in that way the alleged perpetrator would have been charged and there would have been a child protection assessment to consider the emotional impact on the children of witnessing such violence. That this was not considered argues that professionals focussed purely on FH and did not consider the impact of his behaviour on his siblings. 4.2.5 Local authority front line professionals were aware of the behaviour but felt unable to intervene. The initial decision to work with the family through a child in need plan may have been an over-optimistic decision however it was legitimate given the expectation of the Children Act 1989 that, where possible, social workers should work in partnership with families at the lowest level of intervention. The plan that was agreed however did not include any further assessment of the emotional and physical risk to the siblings from FH’s actions, despite this being the reason for the initial referral. The focus of the plan was on supporting Mother in parenting FH with little consideration of the potential risk that he posed to his siblings. Removing FH from the family home was considered but was rejected by managers who were probably unaware of the high level of risk because they were distanced from the front-line (to be discussed later). Those professionals working most closely with the family also possibly became immune to the significance of the levels of violence, by virtue of experiencing it so frequently. 4.2.6 Managers did not progress a child protection investigation on one occasion as they considered they knew the cause of the injuries. This suggests that they thought the purpose of a child protection investigation was purely to identify what had happened rather than to assess the risk to the child. Child protection assessments and medicals should not solely describe ‘who did what to whom’ but should evaluate ‘context and cause’ and therefore how to prevent recurrence. It was known that FH had caused the injury to his sibling but a full child protection enquiry would have examined the context for the injury and considered whether and how a recurrence of the injury could be avoided. There was, however, no proper consideration of whether there should be a section 47 child protection 13 Finkelhor, David. Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People (Interpersonal Violence) (p. 97). Oxford University Press. Kindle Edition. Final 14-Dec-17 16 assessment undertaken by a social worker. Furthermore, there was also no consideration of whether the case should be re-allocated to a social worker to bring a greater level of skill and experience to bear on the case. Each incident was discussed in isolation with no evaluation of the overall picture. 4.2.7 It is not certain that if there had been better overall risk assessment the risk of sexual harm would have been identified. There is very little research about young people who sexually harm siblings. O'Brien (1991) found that sibling incest offenders were more likely than to have exhibited behavioural problems associated with ‘conduct disorders, including vandalism, fire setting, physical aggression, cruelty to animals, lying, stealing, and running away.14 In the UK similar small-scale research has identified similar data with Salter et al noting that ‘52% of sexual offenders had been cautioned or convicted for non-sexual offences’15. These studies involve small numbers and are retrospective focussing on young people known to have been involved in causing sexual harm. They show that some children who offend or are violent may present a risk of sexual harm but they do not identify a causal link. They therefore have limited use for the practitioner working with young people who have conduct disorders most of whom will not go on to develop sexually harmful behaviour. 4.2.8 Studies have shown that between one-fifth and one-third of child sexual abuse in the UK involves other children and adolescents as perpetrators and sibling sexual abuse is estimated is the most common form of intra-familial sexual abuse with one estimate indicating that half of all adolescent perpetrated offences involving a sibling. This abuse often goes unidentified with less than 20% of victims disclosing at the time and most of the prevalence data is based on survey information provided retrospectively by adults.16 It is therefore not unexpected that FH’s sexual abuse of his siblings was not identified. However, there was significant evidence of FH presenting a risk of physical and emotional harm to his siblings which was identified by professionals. Throughout the review period many professionals observed FH causing harm to his siblings. These events were recorded and discussed but there was no formal response and it was never 14 Child Abuse & Neglect, Vol. 19, No 7, pp 811-819, 1995 Copyright © 1995 Elsevier Science Ltd Printed m the USA. All rights reserved SIBLING INCEST OFFENDERS NAOMI A. ADLER Department of Psychiatry, North Shore University Hospital-Cornell University Medical College, Manhasset, NY, USA JOSEPH SCHUTZ Department of Applied Psychology, New York University, New York, NY, USA 15 Development of sexually abusive behaviour in sexually victimised males: a longitudinal study (2003) Daniel Salter, Dean McMillan, Mark Richards, Tiffany Talbot, Jill Hodges, Arnon Bentovim, Richard Hastings, Jim Stevenson, David Skuse 16 An evidence-informed operational framework for children and young people displaying harmful sexual behaviours. NSPCC, Research in Practice and Durham University Publication details: [London]: NSPCC. pp 80 View report online http://email.nspcc.org.uk/c/1CpqbWE2fTZx3DTwcW6NRgym Final 14-Dec-17 17 assessed or examined as a child protection concern even though anxiety about this underlay the original referral to the local authority in 2014. A more active response to the risks of physical and emotional harm could have provided the opportunity of consideration of other risks that FH could have posed to his siblings but would not necessarily have led to the risk of sexual harm being identified. 4.3 Allocation, Supervision and Management in Children’s Social Care 4.3.1 At the time of the of the events under review, children’s practitioners (in the main unqualified and inexperienced) were supervised by consultant social workers, who provided guidance and advice but had no decision-making responsibilities. The children’s practitioners were also managed by the team manager who made decisions about casework, such as whether to initiate section 47 inquiries and case closure, and were responsible for applying for resources (via the HARP17 process). Actual decisions about resources and whether children should be accommodated were made by either HARP, Head of Service and or the Operational Directors of Children’s Services (for children 0 – 11 years old) and Director of Specialist Services (for children 12 to 17 years old). The role of staff and managers in the social work team was to provide the evidential basis for such requests. Senior managers report that such evidence is always provided by face to face discussion with e-mail confirmation of the request and decision. This perspective was not supported by more junior staff who reported sharing information with the team manager but having little direct knowledge of how decisions were then made by more senior management. 4.3.2 The decision to allocate an unqualified, inexperienced worker to be key worker for FH was in accordance with accepted practice at the time as child in need work was, on occasions, allocated to unqualified staff (some child in need work was also allocated to social workers). In this case, it failed to acknowledge the complexity of the case history or the clear child protection concerns that were explicit in the referral by Thriving Families. The assessment, furthermore, had indicated that working with this family would be challenging making it unsuitable for an inexperienced worker. An explanation given for this allocation decision was that the team was under pressure with high caseloads. Review of the team records indicates that during this time the team was holding 143 children. There were 6 Social Workers in post (1 CSW, 1 locum, 3 SW’s progressed through the 17 Hertfordshire Access to Resources Panel (H.A.R.P) The Role of the Hertfordshire Access to Resources Panel is to make decisions on placements, Independent provision and support packages for Children and Young People Looked After or Children in Need Final 14-Dec-17 18 academy18 and 1 Social Worker who had stepped up from a children’s practitioner post). Objectively this is not a heavy team workload however there were a high number of newly qualified staff and certainly the children’s practitioner caseload was 25 which was very high given her level of experience. Recent annual workforce statistics produced by the Department for Education have for the first time included details about average children's social work caseloads in each of the 152 local authorities. While the average for England has been calculated at 16.1 cases per social worker, there is a wide variation across local authority areas and Hertfordshire was reported to have an average of 28 per social worker.19 Allocation of work for children’s practitioners has been reviewed and amended during the period of the review and current guidance now states that children’s practitioners should ‘Hold non-complex (low risk) CiN cases’ 20. 4.3.3 A further complication in this case was that the review has been told by staff at all levels that there were concerns about the performance of the consultant social workers (CSWs) which were addressed by them being aligned to new team managers which meant that they swapped their workloads. This decision was not in itself wrong however the implementation of the change, which did not include any formal supervision handover meetings, provided the potential for a loss of supervisory oversight of the children’s practitioner’s workload. Both CSWs were interviewed by members of the review team and it was clear that the CSW who was first involved had a different understanding of the risks within the case from that presented by the CSW who was involved in the latter stages. There was also a gap in the supervision provided to the children’s practitioner. The supervision file evidences that the children’s practitioner did not receive supervision from a CSW between 20.01.15 and 03.03.15 which was a significant period in this case history. It was during this period that the paediatrician from GOSH telephoned the children’s practitioner expressing concern about FH and the local community paediatrician wrote identifying risks and recommending a residential placement. There is no evidence that this contact or the community paediatrician’s letter was shared with managers. 4.3.4 A further significant weakness in the casework management systems was the absence of any professional or managerial input when copies of the reports from The Maudsley and GOSH were received by CSC on 30th June 2015 and 14th July 2016 respectively. These assessments were identified by the local authority early in the case history as being important in determining the nature of support for the 18 Newly qualified staff with a limited caseload and requiring greater supervision 19 http://www.cypnow.co.uk/cyp/news/2003192/dfe 20 Hertfordshire Children’s Services PRACTICE GUIDANCE NOTE Final 14-Dec-17 19 family. Both reports gave very strong recommendations as to the need for continued children’s services involvement with the family; however, it appears that neither were seen by a manager or social worker although both were noted as being received and uploaded onto the data-base by administrative staff. It is surprising and concerning that reports of such importance could be received by the Local Authority but not reviewed by any professional. Administrators processing documents without professional oversight is also evident in the response to the letter from the GP expressing concern at the case closure. This letter was sent at the end of June but was not uploaded onto the system until the end of July and again there is no evidence that it was reviewed by any professional. During the process of the review it was confirmed that this all of this was possible because there was no system and process in place for vetting the contents of such letters. It has been reported to the review team that measures have been taken to prevent such correspondence being uploaded without the knowledge of the Social Work Team and a more comprehensive system will be put in place to ensure that a manager has sight of such letters when they are received. 4.3.5 There were three other decisions made by managers that had a significant impact on the progress of the case. The first was the decision by the service manager to refuse Mother’s request for FH to be received into care. This decision was influenced by concerns about whether there was sufficient understanding of his needs, hence the decision to defer until a psychiatric assessment (referred to in the previous paragraph) was completed. This perspective may have been valid however there was no follow-up by the service manager or team manager to check the progress or outcome of this assessment. 4.3.6 The second intervention was regarding whether to progress a child protection investigation and medical when Sibling2 was seen to have bruising caused by FH. The decision made by the team manager not to progress the investigation via a child protection medical appeared to be a focus on FH’s needs with less consideration of the risks to the siblings (see para 4.2.5 above). 4.3.7 The third intervention was the decision by the team manager to confirm that the CIN plan should be ended in June and the case should be closed to CSC prior to receipt of either of the assessments from GOSH or The Maudsley. Given the previous decision that FH could not be accommodated until such assessments could be completed, this action is surprising. It was driven by Mother’s consideration that she no longer needed support with caring for FH and argues a significant lack of focus on the needs of the younger children. At this time there was little direct contact between the team manager and the children’s practitioners when making such decisions yet the team manager was responsible Final 14-Dec-17 20 for decision-making on all their cases. The expectation was that the team manager would read all CIN meeting minutes and when necessary access case records to inform their decision-making. At this time, she had overall responsibility for over 100 cases, so it is unlikely that when considering closure, she would have recalled the significance of the two outstanding psychiatric assessments and would only have identified this from the minutes of the meetings after a very detailed examination of the file. In any case by the time the team manager was involved, two professionals had endorsed the recommendation for closure reached at the CIN meeting so there was little likelihood of meaningful challenge. The process of case closure thus became a ‘rubber-stamping’ exercise. 4.3.8 The structure of the managements systems in Hertfordshire meant that there was a long chain of command and the CSW was providing guidance to the children’s practitioner without any real authority as all the key decisions were made by the team manager or service manager at some distance from the frontline. There have been changes made to this structure since this time and team managers now chair all first and last CIN meetings and this has been described by practitioners as much safer. 4.4 Care pathways for children with complex conduct disorders 4.4.1 Both local health and local authority professionals told the review team that there was not an effective care pathway for children with complex behavioural problems that may include aspects of ADHD and ASD. It is significant that over a six-month period FH was assessed and treated by five consultant-led health teams. All the teams had separate and significant functions but this case does raise the question as to whether this very complex route to treatment could be improved. This complexity required strong communication within the health system and presented significant challenges for understanding by agencies outside. This was a significant cost to public resources. There was strong communication about concerns between GOSH and the local health teams however there was less positive communication between the local health teams and the wider local multi-agency network. At times, the priority for the local teams appears to have been the search for a definitive medical diagnosis, although this would not have provided a better understanding of the potential risk to the child or his siblings, or aided case management. Achieving a definitive diagnosis for FH (if such a thing existed) offered no guarantee that the safeguarding risks within the family would be resolved and the suggested management plans suggested by the tertiary centres amounted to basic interagency coordination of safeguarding activity that should have been occurring anyway. Final 14-Dec-17 21 4.4.2 Each of the local health teams involved was clear about their role in assessing risk from the point of their service however this sometimes became a process of saying that the child did not meet their criteria rather than contributing to a discussion about how his overall needs could best be met. Thus, CCATT were clear that FH did not have a psychiatric disorder and would not benefit from an inpatient psychiatric admission but did not provide guidance as to what support they could provide or who else could provide suitable services. The local community paediatrician wrote to the children’s practitioner saying that she felt FH would be best cared for in a residential setting but without indicating what sort of provision that might be. The GOSH paediatrician was clear that she felt there were risks to FH’s siblings if he remained at home and advised that there should be consideration of residential provision by the local teams but this was not addressed by CSC or CAMHS in a multi-disciplinary way and each agency approached the issue using their individual thresholds for accessing such service. The fragmented approach FH’s problems rather than the development of an overall solution meant that FH was passed on for further and further assessment whilst effectively leaving his day to day care with the family, and by default, CSC. Overall there was too much focus by the local teams on diagnosis with insufficient consideration of how to manage his care and within that the risks to the siblings. 4.4.3 Within CSC, there was limited knowledge of referral processes in CAMHS and the wider health service, leading to misunderstanding about what services could or should be made available to FH and his family. Even some months after the event, CSC staff understood that the referral of FH to CAMHS had been declined because CAMHS wasn’t the right service for him. In fact, following FH being seen for his CHOICE appointment in April, the consultant psychiatrist took on the care of FH. There was no shared or mutual understanding of how to work with young people with conduct disorders. Local authority staff felt that unless there was a clear diagnosis of a mental illness then CAMHS were resistant to becoming involved and would determine the problem to be best resolved by CSC or the school. CAMHS practitioners confirmed that they considered that as conduct disorders were not immediately life threatening (unlike children with psychiatric problems who were self-harming) and it was also known that they had poor outcomes from CAMHS treatment options, so they would often suggest alternatives to their service. 4.4.4 The reasons for the absence of effective care pathways for children with complex conduct disorders are many however it is likely that a significant factor is that many of these young people are extremely difficult to work with and are often Final 14-Dec-17 22 resource intensive. Effective responses for such young people require, from the start, a multi-agency approach. The needs of these young people can rarely be met from established provision but require packages of support and care that are adapted from within existing resources. This in turn, requires trust and confidence between agencies in order that front line managers and professionals can develop creative and innovative solutions. This requires cultural change within and between agencies with improved mutual understanding of agency thinking and acknowledgement of the limitations of each organisation. From this can come the flexibility in budgets and organisation that is required to develop a range of solutions that go beyond the limitations of any single organisation. 4.4.5 Without this trust and support between professionals and agencies it is probable that there will be resistance to becoming involved and professionals will use thresholds and assessment criteria as a mechanism for avoiding intervention. These responses are often based on criteria that are internally valid but do not assist in addressing the overall needs of the child and family such as the decision by C-CATT that an in-patient admission for FH was unlikely to achieve good outcomes for him. This was a valid decision but it did not make the risk go away and so needed to be supported by a rapid planning process, by all involved agencies, to consider how to best meet FH’s needs whilst enabling the safety of his siblings to be achieved. An approach such as this requires a significant cultural change within all organisations and needs to be underpinned by a shift in service planning at the highest level. 4.5 Joint working between health professionals and local authority practitioners 4.5.1 Throughout the review period two strands of agency intervention with the family progressed in parallel. Local authority staff supported the family via the child in need planning process focussed on support to mother in coping with FH whilst local health professionals pursued a clinical diagnosis for FH via referrals for highly specialist assessments based on family attendance at two hospitals in London. Professionals at GOSH had a very accurate sense of the issues and risks and clearly documented and communicated these to the local health professionals. They understood that the health team were working closely with CSC to address the problems. GOSH only once had direct contact with the children's practitioner at the start of their assessment and except on one occasion did not copy CSC into later communications with the local health team. Two months after the final appointment with FH the local authority was sent a copy of the assessment report. By then the local authority had closed the case. Final 14-Dec-17 23 As a result the report and the covering letter (which urged the local authority to continue to work with other agencies) was not read. 4.5.2 The CIN planning meetings were convened by CSC staff and attended by school staff, health visitor and school nurse, TYSS, and Thriving Families. These are the usual agencies that attend CIN meetings but they did not reflect all the health agencies that were working directly with this family and particularly did not include CAMHS or the community paediatrician. This meant that there was no input to these meetings from the health practitioners directly responsible for managing FH’s treatment for ADHD. A clear focus of any CIN meeting should be consideration of any safeguarding risks for the whole family however as there was great dependence on Mother providing information about the outcome of specialist assessments it is likely that this may not have included full detail about professionals’ perspective about the risks that FH was perceived to present to the other children. 4.5.3 There was no consideration of inviting CAMHS or the paediatrician to attend the meetings despite their involvement being known by the children’s practitioner and there being some communication between the agencies. One explanation given by CSC for not inviting CAMHS professionals to the CIN meetings was that CAMHS did not usually attend such meetings and furthermore the relevant professional would have been the psychiatrist who would not have had capacity for this because of other work commitments. When this was discussed with CAMHS professionals they acknowledged that it was unusual for a psychiatrist to attend CIN meetings however they said that it was possible. Similar views were expressed about the likelihood of a paediatrician attending a CIN meeting. 4.5.4 There were attempts from both sides to work jointly. The CAMHS psychiatrist contacted the children’s practitioner and asked her to attend the initial assessment meeting. This was not possible due to prior commitments. The fire service staff member who did attend, and knew FH historically, was not part of the CIN meetings so did not have recent information about FH’s behaviour towards his siblings. There was no consideration by the CAMHS psychiatrist that she or another CAMHS worker should attend the CIN meeting and similarly whilst it was often identified at the CIN meetings that there was a need for a report from CAMHS this was never achieved. When consulted as part of the SCR CAMHS staff were clear that they could attend CIN meetings but rarely did because their work processes involved clinical appointments that did not easily allow for attendance at outside meetings. There was evidence that the children’s practitioner had attempted to contact the CAMHS psychiatrist but had found this Final 14-Dec-17 24 difficult and informal communications with CSC staff indicate that staff do not invite CAMHS staff to meetings because they have developed such low expectations as to their attendance and input. Whilst the paediatrician did write to the children’s practitioner requesting a ‘professionals meeting’ this was not followed up when the meeting was not arranged nor was there any consideration to a health professional convening such a meeting. 4.5.5 In their work with the family health professionals followed their separate care pathways all of which focussed on clinical appointments. Health interventions often lagged slightly after the crisis that had precipitated increased agency input. At no point did any health clinician convene a multi-agency meeting; instead they passed information to other agencies via telephone or copy letters summarising the outcome of the clinic appointment. This meant there was little direct communication between health professionals and children’s social care professionals at the time that FH’s behaviour was seen to be most problematic. Furthermore, the contact that took place at that time was largely negative and concerned thresholds for service delivery. For professionals in CSC the most difficult period with this family was between January and March 2015. Their main contact at that time was with CCATT and CAMHS and focussed on what service could be provided to resolve the family crisis. This in the main involved clinicians (some of whom had never met the family) telling CSC professionals why they could not offer FH a service. Social care staff also lacked an understanding of possible mental health resources available and the absence of clear multi-agency care pathways meant that social work staff felt powerless to intervene. In this situation, it is unsurprising that when Mother reported improvements in FH’s behaviour there was little energy to question that report. Rather professionals were relieved that an unsolvable problem appeared to have been resolved whereas in fact this was repeating the historical pattern of cyclical interventions. 4.5.6 There is evidence that there was confusion then between agencies about respective roles and responsibilities. The children’s practitioner was thought to be a social worker by the CAMHS staff and the C-CATT Nurse was thought to be a psychiatrist by local authority staff. There was a lack of clarity from CSC staff about the remit of the C-CATT service which is referred to as CAMHS and there was no understanding that the service was separate from CAMHS with different thresholds for intervention. Local authority staff did not understand that the local paediatrician’s referral of FH to CAMHS was to transfer responsibility for managing the ADHD and was not a further request for a psychiatric assessment of FH’s mental health needs. Similarly, there was confusion by local authority staff about the reasons for the psychiatrist’s referral of FH to The Maudsley. Final 14-Dec-17 25 Some of these confusions reflect the inexperience of the children’s practitioner and may have been resolved with closer supervision however most of them would also have been resolved if professionals had explained more clearly to one another what they were trying to achieve, but sadly this was never achieved. 4.5.7 Discussions with both CSC and CAMHS front-line staff identified that there were not many opportunities for direct conversations between agencies which was a limitation of current arrangements. It was acknowledged that this limited professionals’ opportunities for specialist knowledge to be shared and for greater understanding of each other roles and responsibilities. 4.6 Information sharing between Police and Children’s Social Care 4.6.1 Generally it was clear that there was close working between CSC and the Police and when the family was in crisis there was good communication between the CSC Emergency Duty Service and the Police. Scrutiny of the records identified however that whilst the Police often provided good information reports regarding incidents involving FH it was evident that on some occasions information was either passed late or not at all. In early January, there were three police visits to the family because of FH assaulting Mother. These were not reported to CSC until the 20th January when following a further call-out it was decided that a referral to CSC for support should be made and details of previous visits dating back to November 2014 were included in the referral form. 4.6.2 The reasons for this appeared to be that it was for each individual police office to judge whether the information about an event should be shared. In the main it appears that with regards to children the police only report safeguarding concerns and only pass information about wider welfare concerns where there is evidence of domestic abuse. An example that highlights this distinction is that in 2015 and 2014 there were three occasions when FH was assaulted by a peer and none of these incidents was reported to CSC. 4.6.3 The issue for discussion is how the individual police officers identify the information that should be shared. It is likely that all domestic abuse incidents that involve children are reported to CSC. This contrasts with practice in this case where some incidents of assault of Mother by FH were reported and others were not. It is known that in some police forces any incident where the police have contact with a child who they believe needs additional support is reported to CSC. This approach does risk overloading CSC but equally does enable social workers to cross-reference facts that may not in themselves appear to be child protection concerns but in context may indicate risk. In other local authority Final 14-Dec-17 26 areas, there are agreed protocols about what information is shared which is often linked to the MASH arrangements. 5 CONCLUSIONS 5.1 This review was initiated because three children had suffered serious harm because it was alleged that they had been sexually abused by their brother and there was concern about the ways in which agencies had worked together. The review has shown that whilst there was no evidence that professionals had not responded to indicators of sexual abuse there were other aspects of safeguarding practice that could be improved and these are detailed below. Operational Practice Matters 5.2 The review has identified that it can be hard to secure the attendance of senior health clinicians, such as consultants in community paediatrics and CAMHS, at multi-agency meetings about children. Consultation with staff suggests that this reflects a wider pattern and is not limited to this case. Staff indicated that the current pattern may be a consequence of the priority that is given to clinic attendance and the management of waiting lists. The absence of key people from meetings reduces the effectiveness of work with some of the most complex children and undermines collaboration. Social care staff appear to have low expectations about the attendance of certain groups of professionals at child in need meetings and strategy meetings which means that on occasions health staff are not invited to attend. 5.3 During the review several key reports and letters were received by Children’s Social Care and were uploaded onto the client record system without being read by the children’s practitioner or by managers (some while the case was open, others shortly after it was closed). There was no evidence of a system to identify important correspondence and bring it to the attention of managers. It is not known whether this would apply to other cases but as it happened on three separate occasions on this case it seems probable. 5.4. The review has also highlighted the complex nature of management and supervision arrangements within Hertfordshire Children’s Social Care. It is reported that since the period when the events described in this report took place caseloads for children’s practitioners are significantly reduced and that they all receive regular group case supervision and one to one supervision. There have also been changes in the direct involvement of team managers in case work decisions. These changes are relatively recent and may benefit from further review once they have become embedded in practice. Final 14-Dec-17 27 5.5 CAMHS clinicians consulted during this review have indicated that their work would be assisted if children who are subject of a Child in Need plan could be readily identified at the point when a referral is being assessed. This would enable decisions to be made about allocation in a more informed way and could improve prevention of more serious mental health problems. 5.6 Police officers had many contacts with FH during the period under review. This included involvement because of his behaviour in the home and in the wider neighbourhood. On occasion, he was the perpetrator of violence and sometimes he was a victim of crime. Some contacts were reported to the local authority, but others were not and there appeared to be no consistent pattern or criteria (i.e. apparently similar incidents were treated differently) about how and when information was shared. Wider Operational and Commissioning Matters 5.7 Within the local health service there was no clear care pathway for this child who exhibited aggressive and risky behaviour. The focus of family and local health professionals was on obtaining a diagnosis, rather than addressing the day to day risks presented by his behaviour. During the period of the review five paediatric / psychiatric services worked with the child and his family. There was a clear rationale for the involvement of each separate service however when examining the overall pattern this is hard to justify and was confusing for the family and other professionals. Referrals were made for specialist assessments in tertiary centres. This resulted in lengthy assessment reports and diagnostic labels (ADHD, Autistic Spectrum Disorder, and Conduct Disorder with callous and unemotional traits). There is a danger that once a child is referred for an expert assessment, local health professionals will rely on its outcome and do less to resolve the problems. In fact, the care plan that emerged from these assessments was ‘to be aware of the risk and to manage it through close collaboration and information sharing across agencies including the local authority’. Unfortunately during the time it took for the assessments to take place local collaboration and dialogue (which was already not strong) had been closed down. Ironically the time taken for the assessment and the complex nature of the care pathway directly militated against that recommendation from being implemented. 5.8 No pathway can be effective unless culture and attitude support working together and the review has identified that at present there is a significant gap between CAMHS clinicians and CSC staff with regards to joint working and that for this to improve requires a shift in culture on both sides. 5.9 One reason for the number of services and clinicians being involved was that there was no local capacity within the CAMHS services in Hertfordshire to Final 14-Dec-17 28 undertake this assessment or to put in place the treatments recommended by NICE for such children (e.g. multi-systemic therapy). CAMHS services are currently under review which provides an opportunity for developing locally based services that are more flexible and able to be responsive to individual needs in cases such as this. Final 14-Dec-17 29 6 RECOMMENDATIONS 6.1 HSCB to require that Commissioners and health providers should consider how service working arrangements can be revised to enable more effective input by paediatricians and CAMHS staff to CIN meetings. Multi-agency aspects of the problem (including scheduling, invitations, administration) should be considered in developing a solution. The local authority should ensure that all relevant professionals are identified and invited to contribute to CIN meetings and should persist in challenging agencies when there is no input to the CIN planning process. 6.2 HSCB to ask the local authority to provide concrete assurance on its arrangements for the management of correspondence including professional oversight of reports and letters regarding service users. 6.3 HSCB to seek assurance from Hertfordshire Children’s Social Care on the quality of supervision and management arrangements in Child in Need and Family Safeguarding services. 6.4 HSCB to request that the local authority and HPFT should explore a means of providing confirmation that a child is the subject of a CIN plan for CAMHS and other professionals. The arrangement should comply with data protection arrangements. 6.5 HSCB to ask Hertfordshire Police to review the criteria for reporting incidents to the local authority when officers have contact with children whose welfare could be promoted by the provision of services. There should be discussion with the local authority to achieve agreement as to the sort of incidents that should be reported and a mechanism whereby this can be achieved. 6.6 HSCB to require that commissioners across all agencies develop a pathway for the management of children (including young children) who have complex social and emotional needs, linked to aggressive behavioural difficulties or risk to others (these would include those whose histories feature sexualised behaviour, fire setting, sexual abuse and, chronic exposure to domestic abuse). This must address the needs of a small number of children, who do not easily match any diagnostic criteria (or might accumulate numerous diagnoses) and may not therefore meet the thresholds for any specific service. Their needs may be so specific that they cannot be addressed within a traditional pathway. Meeting their needs will require flexibility and the ability to talk and cooperate to create a bespoke solution in each specific case. This must be accepted as a shared responsibility, which must not be avoided because the child falls outside the remit of a particular team or service. 6.7 HSCB to ask commissioners to explore the possible use of CAMHS transformation funding to implement the proposed pathway, to include assessment and development of locally based treatment expertise, in line with NICE guidance. Final 14-Dec-17 30 Appendix 1 Methodology 1 Review process 1.1 The review was conducted in accordance with Working Together 2015 guidance that: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings’. (HM Government, 2015 p74) 1.2 This report was completed based on information provided by staff and managers directly working with the family, who were interviewed by Review Team members. The lead reviewer also had telephone conversations with senior specialist clinicians from Great Ormond Street Hospital (GOSH) and The Maudsley Hospital and was given copies of their assessments. Following comments being received on the final report there was further information received from GOSH and the report was further amended. The review team also had access to reports and recordings from local authority and health staff including the assessment completed by the social worker in October 2014. 1.3 Frontline practitioners were also involved in two meetings where the Lead reviewer shared initial findings from the review. There were productive discussions between the lead reviewer and practitioners about whether the practice identified in the review was usual and how any problems could best be addressed. 1.4 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately, when possible. 2 Parallel processes At the time of the review there was consideration of prosecution of FH for the sexual abuse of his siblings. There were also care proceedings with regards to FH and his siblings who became the subject of full care orders in 2016. At this point, FH was receiving support in a residential treatment unit and his siblings were in foster-care. Final 14-Dec-17 31 3 Family input to the review The lead reviewers and a member of the review team met with the mother, the maternal grandfather and the maternal aunt. As the father had no contact with the children or professionals for the period covered by the review he was not consulted. He was advised however that the review was taking place and will be given the opportunity to see the final report prior to publication. Consideration was given to involving the children in the review, however the criminal proceedings, and their age, made that problematic so, following discussion, it was agreed by the review team that this would not happen, but that the review would critically evaluate the steps that agencies had taken to establish their wishes and feelings. Prior to the publication of the report representatives of the safeguarding board met with FH’s mother and other family members and shared the report with them. They asked for a number of minor changes to be made to the report on matters where their understanding of events differed from the professional records. None of these have affected the findings, learning or recommendations of the report. 4 Methodological comment and limitations The process of the review was comparatively smooth and, despite an active police investigation, it was possible for the Review Team to interview all the front-line staff involved with the family. There were follow-up meetings with front line staff to share immediate findings and whilst these progressed smoothly with CSC staff there were significant difficulties in arranging a meeting with health professionals. This mirrored the difficulties experienced by CSC staff in involving health professionals in case planning. In part this reflects the different nature of clinical work where staff diaries are committed for weeks ahead and professionals are required to give six weeks’ notice prior to changing the date of a clinic. Final 14-Dec-17 32 Appendix 2: Glossary of terms ADD-vance ADD-vance is a registered charity founded in Hertfordshire in 1996. It provides specialist information, training and advice for professionals, as well as support for children, adults and families on issues relating to Autism, Attention Deficit Hyperactivity Disorder (ADHD) and related conditions. ADHD Attention Deficit Hyperactivity Disorder is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. ASD Autistic Spectrum Disorder CAMHS Child and Adolescent Mental Health Services C-CATT CAMHS Crisis and Treatment Team a multi-disciplinary community team of senior clinicians, providing a short-term, intensive and flexible assessment and treatment packages of care for children with complex and challenging mental health problems and at high risk of harm to themselves or others. CHOICE The Choice and Partnership Approach (CAPA; York and Kingsbury, 2009) is a clinical system that evolved in Richmond and East Herts CAMHS and is now being widely implemented across the UK CIN Child in Need - A child is in need if s/he is under 18 and either s/he needs extra help from Children’s Services to be safe and healthy or to develop properly; or s/he is disabled. CSC Children’s Social Care CSW Consultant Social Worker GOSH Great Ormond Street Hospital HARP Hertfordshire Access to Resources Panel LSCB Local Safeguarding Children Board Section 47 Enquiry Refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’. Statement of Educational Needs A Statement is a document which sets out a child's special educational needs and any additional help that the child should receive. Thriving Families Thriving Families is a holistic, intensive, family intervention service. TYSS The Targeted Youth Support Service Final 14-Dec-17 33 Final 14-Dec-17 34 Appendix 3: Bibliography Naomi Adler a. & Joseph Schutz, Sibling Incest Offenders, Child Abuse & Neglect, vol. 19, no 7, pp 811-819, 1995 copyright © 1995 Elsevier Science Ltd David Finkelhor, Childhood victimization: Violence, crime, and abuse in the lives of young people (interpersonal violence) (p. 92). Oxford University Press. Kindle edition. Working Together to Safeguard Children, 2015 Daniel Salter, Dean Mcmillan, Mark Richards, Tiffany Talbot, Jill Hodges, Arnon Bentovim, Richard Hastings, Jim Stevenson, David Skuse, Development of sexually abusive behaviour in sexually victimised males: a longitudinal study. NSPCC, Research In Practice and Durham University, An evidence-informed operational framework for children and young people displaying harmful sexual behaviours. Publication details: [london]: nspcc. http://email.nspcc.org.uk/c/1cpqbwe2ftzx3dtwcw6nrgym |
NC52392 | Serious injuries to a 3-month-old infant in December 2018. Baby L was taken to hospital by ambulance. Subsequent medical assessments concluded that some of the injuries had happened prior to the hospital admission. Parents were arrested and bailed pending further criminal enquiries. At the time of the reported injuries, Baby L and their older half-sibling had been subject to Child Protection Plans and to a Public Law Outline (PLO) process. Baby L's parents had lived separately in several other areas of England prior to meeting in 2017. Father had two children from a previous relationship where there had been concerns about neglect and historic injuries. Mother had a child from a previous relationship; contacts made to Children's Services in relation to Baby L's half-sibling. Paternal history of mental health problems and domestic abuse. Ethnicity or nationality not stated. Learning centres around: the effectiveness of pre-birth and post-birth multi-agency assessment, multi-agency case management, inter-agency communication and information sharing; how well practitioners considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk; barriers to recognising and addressing over optimism in parents. Uses the Welsh Model. Recommendations include: ensure that pre-birth assessments are completed on time by social workers and include all relevant information, and parents' accounts and views are appropriately tested and triangulated by evidence from other sources; ensure that guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice.
| Serious Case Review No: 2020/C8466 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Appendix i – combined chronology of key events Learning Summary in relation to Baby L August 2020 2 | P a g e Table of Contents 1. Introduction 3 2. Scope and methodology of the review 3 3. Brief family background and synopsis of baby’s circumstances 4 4. Key findings 6 5. Recommendations 8 6. Key learning points 10 3 | P a g e 1. Introduction This summary provides learning emerging from an independently led review commissioned by the LSCB in relation to a three-month-old, Baby L who upon being taken to hospital by ambulance in December 2018, was found to have suffered serious injury (a fractured femur, swelling to both legs and five rib fractures). The subsequent medical assessments concluded that some of the injuries had occurred some ten or fourteen days prior to the hospital admission. During that time, Baby L was in the care of their parents, although there had been other wider family members present in the immediate days before. At the time of the reported injuries, the baby and their older half-sibling had been subject to Child Protection Plans and to a Public Law Outline (PLO) process. It is important to note that Baby L has made a full recovery from the injuries and is reported to be developing well while in the care of the paternal grandparents. 2. Scope and methodology of the review The Serious Case Review scope covered information regarding professional involvement with the children for a period of twelve months (late 2017 to early December 2018). A multi-agency review panel chaired by the lead reviewer was established at the outset. The Panel, which met on three occasions, comprised of senior leads from the following agencies and organisations: • Local Authority1 • CCG • NHS Trust1 • Hospitals • Police • CAFCASS • Local Authority2 • LSCB Board Office A ‘Welsh Model’ review was used and included most (not all) of the practitioners involved with the child. The parents did not respond to the Independent Reviewer’s invitation to participate in this process. 4 | P a g e 3. Brief family background and synopsis of Baby L’s circumstances Baby L’s parents are from the Local Authority1 area but, prior to meeting in late 2017, they had lived separately in several other areas of England. The Baby’s father had two children from a previous relationship where there had been concerns about his part in their care (neglect and historic injuries in 2013 and 2017), in addition to domestic abuse and parental mental health issues. He and the mother had separated in 2017 and, for various reasons, the two children were taken into local authority care (Local Authority2) and eventually became subject to care orders and were placed in long-term foster care. A court order was made against father having contact with the two children. During this set of care proceedings, Baby L’s parents commenced their relationship. Baby L’s mother already had a child from a previous relationship prior to meeting Baby L’s father. There had been several contacts made to Local Authority1 Children’s Services and other local authority agencies in relation to Baby L’s half-sibling, albeit not resulting in statutory interventions. In April 2018, a referral was made by Local Authority2 to Local Authority1 in relation to unborn Baby L and their half-sibling. The concerns included amongst other things, that father was a high-risk individual of domestic abuse, he had no contact with his older children (who were subject to Court proceedings) and was now in a relationship with mother and living at the family address. A social worker was allocated, and a single / pre-birth assessment was commenced. Following a period of assessment, in May 2018, at an Initial Child Protection Conference (ICPC), Baby L became subject to a pre-birth Child Protection Plan (CPP) while their sibling was initially subject to a Child in Need Plan (Section 17, CA 1989). Sufficient concerns were identified around potential neglect and possible physical abuse risks to Baby L (unborn) to warrant the implementation of the CPP. At the time of the ICPC, mother advised that she was no longer in a romantic relationship with father and that he had moved out of the family home. Mother confirmed ongoing contact with father (as good friends) and committed to supervise all contact between her now ex-partner and her child (Baby L’s sibling) Following a review of the ICPC’s decisions by the Child Protection Service Manager, in June 2018 a reconvened ICPC for Baby L’s sibling reached the decision that the sibling should also be become subject to CPP. The view was that the same levels of risks applied to Baby L as well as their sibling. In the summer of 2018 Baby L’s father was subject to assessment and intervention by his GP and mental health services, due to a deterioration in his mental health presentation. father was admitted to hospital in June 2018 and by the end of July 2018, he underwent a core mental health assessment at a Local Mental Health Unit (LMHU) 5 | P a g e conducted by a psychiatrist and a community psychiatric nurse. Father mentioned that he did not have the care of his two children who were in the care system; that he had a girlfriend who was giving birth to his child in five weeks’ time and that he was not allowed to have unsupervised contact with his girlfriend’s child. He was diagnosed with depression and prescribed suitable medication. This information was not shared in a timely manner with the Social Worker or any other member of the core group and therefore not included in any risk assessment. In August 2018, the Public Law Outline (PLO) process was also initiated in relation to the children with a 12-week pre-proceeding period being commenced. This course of action was triggered by the parents’ confirmation of being in a relationship and living together alongside information from Local Authority2 that the court proceedings in relation to father’s two older children were finalised. Final orders were made for the children not to return to the care of either parents, in addition, a Contact Order was made preventing father from seeing his two older children. Baby L was born in September 2018 and discharged into the care of their parents. During October and November 2018, parents and Baby L are seen by various practitioners (Social Worker, Health visitor, GPs) and Baby L is reported to develop very well. Both mother and father describe Baby L as unsettled, crying excessively and suffering from reflux and vomiting. Mother was reported as being depressed and the lack of sleep was impacting on father’s mental health. In late November 2018, the Health Visitor noticed marks on Baby L’s body (three-month old baby). Information is shared with the Social Worker, who arranges a visit to the family home the following day. Baby L is seen and some ‘marks are observed’ however no child protection procedures (to include medical assessments) were instigated as per agreed current legislation and procedures. In early December 2018, during the core group meeting, the marks on Baby L were acknowledged and deemed ‘not worrying’. Parents were provided advice regarding the supervision of the children and how to ‘handle’ the baby. Four days later, Baby L, at three months old, was taken by ambulance to hospital. A full skeletal scan showed that Baby L had suffered serious injuries, namely, a fractured femur, swelling to both legs and five rib fractures. Given Baby L was a non-mobile baby, medical opinion suspected the injuries to be non-accidental, with some healing fractures having occurred some ten to fourteen days previously. During this time Baby L’s parents had responsibility for Baby L’s care, albeit Baby L had also been with other wider family members in the immediate days before the injuries. Baby L’s parents gave an implausible and inconsistent explanation to the Police and Children’s Social Care (CSC) as to how Baby L sustained such serious injuries. They were arrested and bailed pending further criminal enquiries; and a Section 47 enquiry was 6 | P a g e initiated. Baby L and their sibling were removed from their parents’ care by the local authority who commenced care proceedings on both children. 4. Key findings The review analysis was considered against six main issues and these, along with the key findings, are presented below. 1. The effectiveness of pre-birth and post birth multi-agency assessment, including the use of historic information, regarding family and parental functioning, in decision making. 1.1 The pre-birth assessment presented at the Initial Child Protection Conference held in May 2018 (unborn) was missing key information around the parents’ parenting histories (including relevant assessments from another local authority in relation to father’s care of his two older children), the parents’ mental health and the children’s lived experiences. This led to an underestimation of risk with father being allowed to remain in the family home while having supervised contact with Baby L’s sibling. It was expected that mother would supervise all the contact. 1.2 An over-reliance by professionals on parental self-reporting and a lack of triangulation and lateral checks with other agencies. 1.3 The Local Mental Health Unit’s (LMHU) risk assessment and management plan was focused on father only without consideration of any potential risk implications to the other adult and children in the family. An assumption was made by the Psychiatrist that because the children were already involved with Children’s Social Care there was no need to share the assessment of the father with them or escalate any concerns. This would only happen in the event of newly identified safeguarding concerns (which these were) rather than to update the childcare professionals on the psychiatric assessment as a crucial part of the wider risk assessment. The same beliefs were reportedly held by other adult mental health workers. 2. The effectiveness of multi-agency case management, planning, implementation and reviewing of the Child Protection Plans: 2.1 The review identified practice deficits in the front-line case management in relation to oversight and compliance with statutory processes. This affected the functioning of the core group, with limited multiagency communication and co-ordination of actions leading to delays in the progress on the Child Protection Plan. There was lack of effective challenge from all the core group members. 2.2 Impact and management of risk within the Child Protection Process is impaired by poor assessments and lack of information sharing and core group activity. 7 | P a g e 2.3 Despite the Independent Child Protection Chair’s recognition of shortfalls in practice across the multiagency group, the formal escalation raised had minimal impact on the progress of the plans. 3. The effectiveness of inter-agency communication and information sharing, including any barriers preventing information sharing in an appropriate and timely manner. Inter-agency communication and information sharing fell short of the required standards for the effective safeguarding of the children. There were: 3.1 Significant lapses in information sharing within the child protection process from the majority of professionals involved; 3.2 Absence of sharing some key information by Adult Mental Health Services and LMHU with Children Social Care and the core group on the father’s mental health and its implications for potential risk to the children and mother. 3.3 There was a lack of information sharing, contribution and attendance to the Child Protection Conferences by a GP practice despite being aware that the children were subject to child protection plans. 3.4 A lack of a robust systems ensuring the entering of safeguarding alerts within the GP practices. 3.5 Lack of appropriate and timely information sharing between local authorities (parenting assessment completed with father by the other local authority was only received in August 2018, almost 4 months since the receipt of the referral, and was not properly considered till December 2018). 3.6 Inappropriate information sharing and transfer arrangements within Children’s Services (use of duty workers). 4. How well did practitioners understand, identify and respond to risks regarding Baby L, in the context of the inherent vulnerability of babies? There was minimal evidence to show that the practitioners involved with the children in November 2018 had considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk. This view is based on the inadequate multiagency response to the reports of bruising/ marks on the baby noticed by the Health Visitor in November 2018. It was identified that: 4.1 The social workers did not arrange a child protection medical for Baby L, consequent to Health Visitors noting some marks on the child on the previous day. This breached existing Local Safeguarding Children Board procedures and there was a missed opportunity to intervene to protect Baby L and sibling. 4.2 There was lack of challenge by the health visitor and the core group to Children Social Care’s decision not to take any further action in relation to the marks on Baby L. 8 | P a g e 5. What are the barriers to practitioners recognising and addressing over optimism in parents? The review identified that: 5.1 Professionals were over-optimistic in their perception of the risk posed by the parents. The parents mostly complied with the limited and uninformed expectations of the professional network. They did not avoid contact with professionals, they attended health and medical appointments, sought medical attention for the children, attended the Initial Child Protection Conference and the reviews. 5.2 Father completed a domestic abuse programme which was seen by that agency in a positive light, albeit not providing a risk assessment. Father also gave himself a score of 7 (Signs of Safety rating) at the Review Child Protection Conference, whereas the professionals gave a score of 9. 6. Were there any organisational and/or agency/multi-agency, systemic factors that accounted for Child 2 suffering serious harm? 6.1 The lead reviewer found no evidence of any systemic or institutional factors accounting for the lack of robust action following the marks noticed on Baby L’s body in November 2018. 6.2 However, as outlined at point 1.3, a training need has been identified across Adult Mental Health Service in relation to their responsibility in sharing information in a timely and systematic way. 6.3 During October and November 2018, both parents were reported to experience fluctuating mental health, struggling with the lack of sleep and challenges brought by a new baby. The review identified a lack of practical support plans being developed with the parents to identify alternative routines to assist and ease the pressures. No arrangements were made to explore the available family and social network able to support the parents More detailed individual agency’s learning points are available in Appendix A 5. Recommendations Recommendation 1 The Local Authority’s Children’s Services should assure the Safeguarding Children Partnership that pre-birth assessments: • are completed on time, • include relevant historical and recent case information (especially any previous parenting assessments) • information is shared between all professionals involved with the children and relevant adults (including adult mental health and GP Services) • contain evidence of the child’s lived experiences 9 | P a g e • parents’ accounts and views are appropriately tested and triangulated by evidence from other sources • are overseen by a front-line manager to the requisite practice standard. • social workers and their managers have liaised and made the relevant lateral checks with all involved agencies, including adult mental health and GP services. Recommendation 2 The Local Authority’s Children’s Services should assure the Safeguarding Children Partnership that child protection plans are: • informed by good quality assessments of risks • ‘tracked’ and subject to robust scrutiny and challenge from the child protection reviewing service, and • overseen by competent front-line managers who can provide effective guidance, support and challenge to their social workers • include the support and provisions available within the children’s family, social and community networks Recommendation 3 The Local Authority’s Children Services should ensure that its performance management data is used to identify, at an early stage, where statutory interventions (visits, core group, social workers supervision) are not being complied with and take timely and appropriate remedial/supportive action that results in the safeguarding of children not being compromised. Recommendation 4 The Safeguarding Children Partnership should be assured by the relevant agencies that their staff are knowledgeable, competent and confident to use the SCP escalation/professional dispute procedures when challenge is necessary with regard to an agency’s decisions and (in)actions. Recommendation 5 The Safeguarding Children Partnership should receive assurance from partner agencies’ safeguarding/internal governance that its guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice Recommendation 6 The NHS Trust1 and the CCG should assure the Safeguarding Children Partnership that the ‘Whole Family’ policy is understood, well embedded and implemented by all its services, especially Adult Mental Health and GP practices, so that any salient safeguarding information on adults is shared with Children’s Social Care social workers, midwives and health visitors. Recommendation 7: NHS England should include GP practices in the second phase of the Child Protection Information Sharing Project (CPIS). However, the CCG reported that this is already being considered by NHS England. 10 | P a g e Appendix A 6. Key Learning Points • All relevant professionals are invited to Initial Child Protection Conferences, especially those who have extensive knowledge of previous case background. • That all single/pre-birth assessments are completed on time by social workers and include all relevant information, especially parenting and trilogy of risk; and do not over rely on parental self-reporting. • That professionals have the requisite experience, knowledge, capacity and managerial support to effectively carry out their safeguarding responsibilities and roles. • That the Child Protection Review system uses effective case tracking to inform Case Conference Chairs of progress with child protection plans and empowers them to mount robust, timely and effective challenge to professionals when appropriate. • That core groups are effective in challenging agency decisions and (in) actions when required, through the use of the Safeguarding Children Partnership escalation/ professional dispute procedures. • All professionals in contact with non-mobile babies to be familiar with the local Safeguarding Children Partnership’s guidance. For the NHS Trust1: • The need to ensure that its ‘Whole Family’ policy and safeguarding procedures (as per the Safeguarding Children Partnership) are well embedded and operational across the NHS Trust; specifically within its Adult Mental Health Services. For Children’s Services: • That front-line Children’s Social Care managers provide effective case management oversight and challenge to their social workers. • The need for Children’s Social Care and the Child Protection Reviewing Service to ensure that the contact details of the GPs of all family members are captured and recorded at the beginning of the single assessment process; and/or at the Initial Child Protection Conference (it is understood that all GP details are now recorded by the child protection reviewing section). For GP Practices: • The need for the GP Practice to ensure that it has the necessary systems/process pathways in place for the correct read codes to be entered in a timely and accurate way onto SystmOne/the appropriate electronic patient record system. • That all GPs, as part of the CCG commissioning and contracting processes, are signed up to and cognisant of their statutory responsibilities and obligations regarding the protection of children, in accordance with Royal College of GP safeguarding policies and procedures. • The need for GP practices to understand and implement the ‘Whole Family’ approach. 11 | P a g e • The need for the GP practices to understand their obligations to share information that is relevant, proportional and compliant with data protection and patient confidentiality, with other Local Authority Children’s Social Care, midwifery and the health visiting services, regarding the safeguarding of children. • The need for the GP practice to remind its clinicians to refer directly to Child and Adolescent Mental Health Service (CAMHS) when appropriate, in respect to children’s emotional and behavioural difficulties, including symptoms of soiling/faeces smearing. |
NC049229 | Serious health and developmental impairment of a teenage boy due to fabricated or induced illness (FII) over a number of years. Child Y and his younger sister lived with their mother, and had moved three times to different local authority areas between 2002-2012, due to domestic abuse by mother's ex-partner. The siblings had a history of poor school attendance and were made subjects of child protection in 2014. In 2015, Child Y had a potentially fatal fall, which resulted in the local authority making an application in the family court. The local authority informed the LSCB that Child Y and his younger sister had attended hospital emergency departments over 250 times over a period of four years, in three different hospital trusts, with no medical causes found for many of the symptoms. Both siblings had undergone a number of medical interventions, including medication, intrusive investigations and surgery. Lessons learned include: the difficulties faced by professionals in working with a family when FII is suspected; challenging the family and coordinating a response were not supported by the prevailing organisational arrangements and culture in which healthcare was provided. Recommendations include: the LSCB should develop and implement pathways for the early identification and management of perplexing presentations, including suspected cases of FII, and for the management of identified cases of FII, including those who are subject to child protection plans; the Department of Health and the Department for Education should be asked to commission national research to establish the prevalence, incidence and case characteristics and outcomes for children who have perplexing presentations or FII.
| Serious Case Review No: 2017/C6969 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Serious Case Review Overview Report Services provided in a complex case of Fabricated or Induced Illness Serious Case Review Chair Consultant in Public Health Independent Lead Reviewer Keith Ibbetson 1 Services provided in a complex case of Fabricated or Induced Illness 1 Reasons for conducting the Serious Case Review, focus of the review and agencies involved 2 2 Key events 7 3 Serious Case Review Findings 17 3.1 How was the child harmed and what was the evidence of Fabricated or Induced Illness (FII)? 17 3.2 Challenges faced by professionals in the health service 20 3.3 Social care management and the coordination of a multi-agency response 32 3.4 Research, professional understanding of Fabricated or Induced Illness (FII) and the limitations of existing guidance and research 37 4 Recommendations 47 Appendices 52 I Principles from statutory guidance informing the Serious Case Review method 53 II How the review was undertaken 55 III SCR panel 56 IV Roles of staff interviewed or in attendance at group sessions 57 V References 58 VI Views of family members 59 VII Flowchart proposed by Bass and Glaser for the medical management of unexplained presentations and FII 60 VIII Medication known to have been prescribed to Child Y 61 2 1. INTRODUCTION 1.1. Between November 2015 and March 2017, the Local Safeguarding Children Board (the LSCB) conducted a Serious Case Review (SCR) in relation to the services provided for a teenage boy, referred to in this report as Child Y. Child Y’s circumstances are believed to be an example of fabricated or induced illness (FII) which has severely impaired his health and development.1 Details of his contact with health professionals and the impact of the treatments that he has received are set out in section 2 of this report. Child Y has a younger teenage sister and her contact with services is also considered, but in less detail. 1.2. The SCR was carried out under the guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.2 1.3. The LSCB has removed identifying features of the health trusts and local authorities that worked with the family from this published SCR report. This is because the specific circumstances make the individuals concerned readily identifiable to many people. Publishing the full report could jeopardise the right of the children to a private and family life and risk causing further harm. Publishing this version of the report will also prevent the published case details being linked with the family court proceedings, in line with the request of the judge who heard the case. 1.4. The full report has been presented to the LSCB and to all participating agencies and it will be used as the basis for briefing and training locally. It has also been shared with central government bodies in the normal way. 1 Section 3.4 of the report discusses the problems associated with defining and understanding FII as well as some limitations of current knowledge. The term FII is used throughout this report because it has been the term used in almost all in UK discussions since 2002. Other terms such as Munchausen Syndrome by Proxy (MSbP) are used internationally and are used in this report when distinguishing the two is required in order to understand a research document or a professional view. 2 Working Together to Safeguard Children (2013), 4.1 and 4.6 3 Reasons for conducting the Serious Case Review 1.5. In July 2015 the local authority brought the case of Child Y and his sister to the attention of the LSCB because of concerns about how the risk to Child Y had been assessed and managed and how agencies had worked together to safeguard him. At that point the local authority was preparing an application in the family court to seek a finding that the children had suffered significant harm. 1.6. The case was formally considered by the LSCB Serious Case Review Group in November 2015, after a period during which agencies compiled case histories. The delay in gathering detailed information was due to the complexity of the children’s circumstances, which will be apparent from the rest of this report. 1.7. At that point the LSCB was informed that: in four years the children had presented over 250 times at hospital emergency departments, with no medical causes found for many of that symptoms repeatedly described there had been a substantial number of medical interventions, including numerous medications, intrusive investigations and surgery the children’s school attendance had been extremely poor for several years with a consequent negative impact on their education the children had moved to Local Authority 1 in 2012 from another area where they had been the subject of a child protection plan in Local Authority 1 they had been the subject of child protection plans from July 2014 during 2015 Child Y had had a potentially life threatening fall from a high building, which was believed to have been accidental; fuller details of this incident had been hard to obtain but the circumstances were potentially very concerning and this had triggered the decision of the local authority to seek legal measures to protect the children The scrutiny of records had only extended to local agencies known to have been involved. Subsequent review found that two other hospital trusts had played a significant role in the case history. It also became clear that the high level of contact between the children and hospital emergency departments went back many years and that the children had lived at addresses or received services in neighbouring local authorities. 1.8. The case review sub-group of the LSCB recommended that the children’s circumstances met the criteria for a SCR on the grounds that they had suffered serious harm and there was cause for concern about the way in which agencies had worked together to safeguard them. It was apparent that there had been a substantial delay in acting on 4 concerns that Child Y was being affected by FII. The independent chair of the LSCB, confirmed the decision to hold a SCR in December 2015. The focus and scope of the Serious Case Review 1.9. Child Y and his sister received a very high level of input from health trusts for over a decade. It was clear that without a disproportionate use of resources it would be impossible to map these contacts comprehensively and to reconcile all of the gaps and discrepancies in records that inevitably arise in such a case. However it was agreed that this would not prevent useful lessons from being learnt. At the outset it was clear that this was not a case in which specific individual errors or shortcomings had been decisive in determining the outcome: rather there were patterns of family and professional behaviour that had been repeated many times, featuring an evolving group of health, school and social care professionals. 1.10. In its initial discussions the case review group agreed to limit the scope of the review to the period between June 2012 (when the family moved to Local Authority 1) and October 2015 (when the local authority made an application in the family court). It also agreed that on the basis of a broadly accurate but not necessarily comprehensive understanding of the case history the review would seek to identify 1) the factors that had shaped professional behaviour towards the family and 2) why it was that professionals had recognised the children’s difficulties but been unable to resolve them. It was also clear that the SCR should seek to understand the value of current local and professional guidance on FII. These topics are the focus of Section 3 of this report. 1.11. The report contains references to the contact of agencies with Child Y’s sister. It is apparent from the records that in many respects Child Y’s sister had begun to present similar concerns to her brother, taking account of the difference in age. Agencies were struggling to respond effectively, even though they were aware and concerned that her behaviour appeared to be following a similar pattern. Although at points it contains references to Child Y’s sister the review does not comment in detail about the provision made for her since all of the relevant learning can be identified in relation to Child Y without the additional but unnecessary disclosure of sensitive information about his sister. 3 3 The focus of the review is on services provided. The review found no significant difference attributable to gender between the response of services to the two children, hence the focus on one child to simplify the presentation. 5 Agencies involved 1.12. The SCR considered the work of the following agencies and contracted professionals: • Local Authority 1 (children’s social care) • Hospital Trust 1 (Emergency Department and Department of Paediatrics and other specialists at two district general hospital sites) • Hospital Trust 2 (Emergency Department, paediatrics and a number of specialist outpatient and inpatient services at the hospital) • Hospital Trust 3 (children’s cardiology, pain management clinic, endocrinology and neurology) • Community Health Trust (school nurse and CAMHS services) • Ambulance Service • GP and primary care services in Local Authority 1 • Two academy schools • Police Service The review also received background information and copies of documents from Local Authority 2, a neighbouring borough where the family lived prior to 2012. The review was also informed by documents which were part of the Local Authority 1 social care record but originally written by staff working in Local Authority 3, where the family lived in a refuge before moving to Local Authority 1. How the review was undertaken 1.13. Details of the principles underlying the approach to review and the steps taken to carry it out are set out in Appendices 2 and 3. 1.14. The review has involved extensive discussion with staff who worked with the family and staff in specialist safeguarding roles in the organisations concerned. In order to be able to understand this case in the context of wider practice over cases of suspected FII the review has also summarised the findings of a number of other Serious Case Reviews, sought data from the NHS on serious incident (SI) reports and from Cafcass on other FII cases in the family courts.4 The author also presented the findings (anonymously) at a conference of designated and named health professionals and to groups of local GPs as part of their annual training programme and has taken account of the views expressed in those forums about the management of FII. 4 Children and Family Court Advisory and Support Service, https://www.cafcass.gov.uk/ Cafcass involvement with the children began only after the end of the period which has been reviewed. 6 1.15. Child Y’s mother was informed about the SCR in May 2016 in anticipation that she would be involved in the review and also help the independent reviewer to understand how best to involve Child Y and his sister. Her views of the services provided are summarised in Appendix 6. Parallel investigations and proceedings 1.16. A local authority application in the family court ran concurrently with the SCR. The LSCB made the judge who was responsible for the conduct of the proceedings in the family court aware of the SCR and the court gave agreement for expert assessments prepared for the family court to be disclosed to the SCR lead reviewer. Their findings assisted the work of the SCR, though this report has not relied on or quoted them. 1.17. There has been no criminal investigation. 7 2. BACKGROUND AND KEY EVENTS 2.1. This section summarises important contacts with Child Y’s family and agencies with safeguarding responsibilities. It lists the main health problems presented by Child Y and the responses of health professionals. It concludes with information available in early 2017 about the extent of actual health problems faced by Child Y during this period. 2.2. Limited detail is provided in some areas in order to protect the privacy of family members. Some events are described further in Section 3 of the document when this assists in the evaluation of services. Family background and relationships 2.3. Child Y was aged 12 when he moved to Local Authority 1 in 2012. His sister was 10. The children have a half-sister who was an adult by this time. 2.4. Between 2002 and 2011 the children lived with their mother in Local Authority 2. During this time the mother made 14 reports of domestic abuse by her ex-partner (the children’s father) to the police. 12 of these incidents were reports of threats and breaches of injunctions and other court orders, usually by contacting the mother or visiting the family home. 2.5. On two occasions assaults were alleged. The mother told the SCR that she suffered a broken finger and an injured shoulder. There is no record of evidence to corroborate the allegations of physical violence (for example reports to other agencies, accounts of witnesses, visits to the GP, or visits to hospital emergency department with injuries). Statements made to the police were withdrawn and no charges resulted. However a MARAC meeting in 2011 categorised the risk to the mother as ‘high’. Experienced social workers working with the children’s father during 2015-16 told the SCR that he could be abusive and threatening, particularly when he appeared to be drunk. 2.6. In late 2011 the family were rehoused to a domestic violence refuge in Local Authority 3 where they lived for a few months. Records do not show why the mother and her children were admitted to the refuge at that point and there were no new, serious reported incidents. The mother told the SCR that moving and concealing her address was the only way she could ensure that the children’s father did not continue to harass her. 2.7. The records (from the period prior to 2012) also show one allegation against the mother of harassment (of a head teacher). 2.8. During the brief time when the family were living in the refuge referrals were made to the local authority because Child Y was being taken to 8 large numbers of medical appointments. He was reported to have taken other children’s blood pressure with a monitor purchased by his mother and had been observed bullying other children. In March 2012 (in Local Authority 3) the children were made the subject of a child protection plan under the category of emotional abuse. In her records and reports the health visitor who regularly visited the refuge had identified this as a possible case of FII. Transfer to Local Authority 1 2.9. In June 2012 the children were discussed at an initial (transfer) child protection conference in Local Authority 1. This had access to records of events in the refuge and assessment reports from the Local Authority 3 social worker. The conference took the unanimous view that the children should be treated as children in need who would be offered services. The case was seen as one of a family fleeing domestic violence where the mother and children needed support. The decision making and interventions planned at child protection conferences in Local Authority 1 are considered in detail in Section 3.3. 2.10. By this time Child Y had had medical assessments and treatments in relation to the following: Chest pains and breathing difficulties Bowel problems Endoscopy and colonoscopy, appendectomy and tonsillectomy His sister was reported to have been a regular attender at an emergency department since being very small. She had repeated reported stomach pains and urinary infections, though subsequent review of all test results shows that no infection was ever confirmed. 2.11. Two hospitals were involved with the children during this period. Hospital Trust 1 was the local district general hospital and had an emergency department; Hospital Trust 2 was located about 15 miles from the family home and provided a range of services (including both emergency medical services, other local services and some specialist services). According to the records reviewed there was no communication between the hospitals over the children at this stage, though both communicated in the usual way with the family GP. The role of the hospitals and GPs is explored in detail in Section 3.2. Provision for Child Y and his siblings as children in need June 2012 – July 2014 2.12. Between June 2012 and July 2014 there were serious concerns over the children’s school attendance (which averaged at between 40 - 60%) and its negative impact on their ability to learn and mix with other children. Efforts to improve attendance were hampered by the fact that absences due to illness and hospital appointments were 9 authorised by GP letters.5 On a number of occasions Child Y complained of severe chest pains during the school day and was taken to hospital by ambulance as school staff, understandably and quite correctly, felt that he had to be medically assessed. School staff attended child in need meetings but despite the fact that health concerns had a direct impact on both children’s education, they had no means of making direct contact with the hospital professionals who at that time were expressing serious reservations about the veracity of the children’s presentations. Section 3.3 considers the early identification of possible cases of FII. 2.13. There were several changes of social worker. In August 2012 the local authority provided a Section 37 report which concluded that the parents were no longer together and that the children were having no contact with their father.6 2.14. After the court hearing the social care team wanted to cease contact with the family, but this did not happen because of the children’s poor school attendance. Health agencies also pressed the local authority to remain involved. 2.15. During this period the children attended hospital very frequently both at ED, sometimes leading to admission, and outpatient appointments. Presentations included reported chest pain, abdominal pain and allergies, urinary tract infections. Child Y underwent exploratory operations over reported testicular pain as well as an urgent transoesophageal echogram (an intrusive ultrasound of the chest in which a sensor is passed into the oesophagus). 2.16. By September 2012 there is evidence that the two hospitals were more aware and concerned about one another’s involvement as a result of which the named doctor with responsibility for safeguarding in the local hospital drafted reports covering discharge and diagnosis which were copied to the other consultants involved as well as the family GP. 2.17. Throughout this period the attitude of social care was that the family should be seen as one that was overcoming the impact of domestic abuse and where the mother was becoming better at meeting the health needs of her children (which were accepted as being ‘complex’). Many health professionals dealing with the family did not know about the reported domestic abuse. Others knew but did not believe that it should be the main focus of concern. 5 Serious concerns about attendance remained until 2015 though later some figures show higher rates of attendance because the children attended projects off the school site that provide education, including at one point when both the children (only one of whom was an inpatient) attended the education unit in a hospital. 6 A Section 37 report may be requested by the court in private family law proceedings (such as a divorce) when the local authority is working with the family. 10 2.18. From early in 2014 staff at the district general hospital regularly discussed the family at psychosocial meetings because of the large number of attendances, appointments and investigations that had not confirmed the existence of any significant medical condition. The meeting in April 2014 suggested that there were grounds for a child protection conference. July 2014 - children made the subject of child protection plan 2.19. In July 2014 both children were made the subject of child protection plans. The child protection conference was convened because of the continuing high level of hospital attendance of both children, persistent very poor school attendance and growing concerns about Child Y’s obesity. The conference was well attended, though Hospital Trust 2 was not invited. It was comprehensively documented, with 94 pages of reports, minutes and plans. Concerns were noted about the apparent lack of coordination and prescription between hospitals and GPs and it was recognised that the child in need plan had not affected any real change. 2.20. The mother had a detailed discussion with the conference chair after the meeting. She explained that she did not mind the children being the subject of a child protection plan but did not like or accept ‘how she was being portrayed’ and refused to accept that the professional concerns were legitimate. This conversation was reflected in the conference record. 2.21. The detailed protection plan ran to four pages and sought to address the problems of Child Y’s obesity and both children’s poor school attendance. It aspired to achieve a coordinated response to medical presentations between GPs and hospitals. The conference reports and minutes do not identify this as being a suspected or confirmed case of FII. The category of registration was emotional abuse. 2.22. The consultant paediatrician from Hospital Trust 1 (who had previously tried to improve the coordination of the health provision) attended the initial conference and offered to convene a meeting of all health professions and trusts at the GP surgery to ensure that health interventions were coordinated. It was decided that this would happen after the current set of investigations of a possible kidney complaint had been completed. It was suggested that Child Y could be dealt with by one GP and one acute trust. 2.23. Shortly after the conference Child Y underwent a cardiac angiogram at Hospital Trust 3, administered as a day patient under full anaesthetic.7 The findings were normal. The hospital also reviewed all of the 7 https://www.medicinenet.com/coronary_angiogram/article.htm 11 previous cardiac tests where reports could be provided and confirmed that Child Y had no underlying heart condition. This exhausted the cardiac investigations that could be undertaken (other than repeating previous tests, which later happened). July 2014 – January 2015: parallel but separate coordination of services through the health service and the child protection plan 2.24. Over the following 12 months, review conferences took place more frequently than was required by guidance and there were regular core group meetings. These were largely attended by the local authority, the children’s schools, the school nurse and sometimes CAMHS, but not the acute trusts, tertiary hospitals or GPs. The conference chair and professionals who attended were concerned that there was no proper overview of the different types of medication being prescribed for Child Y which could be having a detrimental impact on his health. 2.25. The children’s mother contributed to conferences and expressed her concern that ‘she had been made to feel unable to meet the children’s needs’ but that she ‘now feels confident’ about this. She promised to cooperate with plans made by professionals but there is no evidence that over the next nine months any improvement in the concerns originally identified occurred. 2.26. After the initial child protection conference the sole health attendee at child protection review meetings was the school nurse who was asked to coordinate information and interventions from the health sector. The consultant paediatrician from Hospital Trust 1 (referred to above) was not invited to conferences and says he was not aware of the tasks allocated to him in the protection plans. Tertiary hospitals (Hospital Trusts 2 and 3) were also not invited. Section 3.3 considers the role and effectiveness of child protection planning arrangements. 2.27. During this period Child Y was the subject of a parallel series of multi-disciplinary meetings convened by the main health trusts involved, some internal and others involving other health trusts and social care. 2.28. In October 2014 the Hospital Trust 1 convened a large and lengthy multi-disciplinary meeting. At that point Child Y was an inpatient at Hospital Trust 2 because of reported neurological problems (reported back pain, tingling in his toes and fingers and other possible neurological symptoms). 2.29. The following professionals attended: Paediatric Department (Hospital Trust 1) o Consultant Paediatricians (4) o Speciality Doctor in Paediatrics (1) Hospital Trust 1 Emergency Department o Paediatric Lead Nurse 12 o Safeguarding Paediatric Liaison Nurse CAMHS o Child and Family Psychotherapist Ambulance Service (2 representatives) Schools and education representatives (2) School Nurse General Practitioner Local Authority 1 social care o Social worker o Consultant Practitioner Hospital Trust 3 (by teleconference) o Paediatric Cardiologist o Paediatric Pain Nurse Specialist Hospital Trust 2 Consultant Paediatric Gastroenterologist 2.30. The attendance shows both the range of services involved and the scale of the task of coordination. The meeting focused again on the negative social and health impact on the children of repeated hospital attendances and admissions. Child Y was described as ‘fabricating textbook symptoms’ in his presentations. It noted that whilst it had been established that Child Y was not suffering a heart condition the results of gastroenterology and neurology tests were awaited. 2.31. The meeting reached a series of further decisions about management of the case. Plans were proposed as to how Child Y would be treated in future by the ambulance service and in emergency departments. These were to be shared with Child Y’s mother at a meeting with the Consultant Paediatrician from Hospital Trust 1 who knew Child Y best and the family GP. They would then be circulated to the ambulance service and the allocated social worker 2.32. The meeting also made an appeal to social services to stay involved with Child Y because he was having a very abnormal life, missing out on education and normal social interaction. Social services was asked to provide a clear plan for Child Y. Plans continued to be reviewed and updated at the child protection conferences. 2.33. Section 3.2 considers the work of the ambulance service and GPs in detail as part of a wider discussion about the attempts to coordinate provision to the family. Section 3.3 deals with the role of social care. 2.34. During this period Child Y was referred to a number of pain management services. By now he was reporting chest pain, back pain, tingling and general pain in moving and walking due to his weight. The 13 place of services for ‘pain management’ is considered in Section 3.2 alongside that of child and adolescent mental health services. 2.35. The investigation of neurological symptoms showed a degeneration in the spinal cord believed to be linked to Vitamin B12 deficiency. This is a known but rare side effect of the long term use of Nitrous Oxide (gas and air) which had been administered to Child Y by the ambulance service, though there may have been other contributory factors. 2.36. In January 2015 at the end of the admission there was a further discharge planning meeting. The majority of attendees at this meeting were from the Hospital Trust 2 where Child Y was now being treated. They included four members of the Hospital Trust 2 neurology team; a member of the paediatric liaison team; Consultant Psychiatrist; hospital school representative; Safeguarding Advisor and Paediatric Ward Sister. External attendees were the Consultant Paediatrician from Hospital Trust 1 (the same member of staff who had agreed to take a lead in working with the GP and family) and the allocated local authority social worker. 2.37. It was noted that the condition had been treated successfully but that Child Y continued to report pain in his back. Scans showed that neither the location of the pain nor its episodic nature were consistent with the medical understanding of the degeneration in the spine (which had now been treated). Child Y and his mother attended part of this meeting where the proposed care plan was explained to them. Child Y responded by seeking separate meetings with members of the multi-disciplinary team. That evening he walked out of the hospital saying he did not feel safe there, though it was never clear what this meant. He was later returned by ambulance. 2.38. Hospital Trust 2 wrote to everyone involved shortly after the meeting setting out proposed approaches to managing pain that should be adopted by Child Y, the family and the hospital emergency departments. This focused on the use of distraction (e.g. going for a walk), simple pain relief such as paracetamol and the avoidance of Entonox and morphine-based pain relief. On this occasion no specific proposed protocol was agreed for the ambulance service (which had not been invited to the meeting). Again it was noted that the Paediatric Consultant and the GP would meet with the family to assist in implementing the plan. Serious accident 2.39. Efforts to implement this new, more detailed plan were thwarted by events. Two weeks after the meeting Child Y was discharged from Hospital Trust 2. Two days later (31 January 2015) he had an unexplained, accidental fall from the second floor of a high building, fracturing his pelvis. CCTV footage showed that nobody else was 14 present. Child Y denied remembering any details of the event, the circumstances or his motives. The psychiatrist who interviewed him found no evidence of suicidal intention or psychiatric disorder. She was from Hospital Trust 2 and knew both Child Y and his family. 2.40. After a delay of some days in which Child Y’s injuries were assessed and treated, the local authority held a strategy meeting and allocated a new social worker to the case. From this point the social workers and managers involved viewed Child Y as being at considerable potential risk and saw the case as being one of possible FII. As a result they made concerted efforts to gain an overview of the reported health problems and to coordinate services. After a further hospital admission lasting nearly six weeks a further lengthy discharge planning meeting was held. Decision to initiate care proceedings 2.41. A legal planning meeting was held in March 2015 to determine whether the threshold to initiate care proceedings would be met. Legal advice was that it was. The first step was a letter setting out the local authority concerns and formal meetings with the children’s mother. A report was to be commissioned from an independent expert on FII. 2.42. In May 2015 a second planning meeting agreed to discontinue this course of action. Instead of the proposed specialist assessment, the Designated Doctor for Safeguarding for the local area (who had not previously been involved and had only a limited understanding of the case) prepared a report which set out five areas in which progress was needed and confirmed his belief the family was making, or had promised to try to make, progress in each of them. A different local authority manager took the view that this was evidence that the family was cooperating with the child protection plan and the measures proposed to safeguard the children. 2.43. Any such progress was not sustained and it was noted that the mother was no longer cooperating with the proposed plans. At this point an application for a Supervision Order was agreed. There were disagreements between staff and managers in the local authority as to how to proceed, with a series of different middle managers taking different views. 2.44. Care proceedings were initiated in October 2015. Prior to this Child Y was noted to be under investigation for possible kidney problems (which his mother said ran in the family). By now there were concerns that Child Y’s obesity had created a real cardiac risk because of raised cholesterol levels, for which he was prescribed statins. 2.45. Subsequently it has been recognised that Child Y shows symptoms of having become addicted to prescribed pain relief, though suspicions about this were voiced by the local authority earlier. Between March 15 and October 2015 the local authority sought a comprehensive chronology of health service contacts with the family but this could not be provided. An overview of Child Y’s contact with health services 2.46. Child Y’s contacts with the hospitals involved are summarised in Table 1 below. The figures are based on reports by independent experts who have reviewed the medical records. It is very likely that not all records from all trusts have been accessed so this may be an underestimate. Table 1 list of Emergency Department attendances and admissions to Hospital Trusts 1,2 and 3 documented in a report prepared for the family court 8 Year ED attendances (Hospitals 1 and 2) Hospital admissions (three hospitals) 2010 14 6 2011 * 4 2 2012 * 16 7 2013 28 7 2014 88 11 TOTAL 150 33 2.47. At a number of points attempts were made within the child protection planning and the care proceedings to draw together a full chronology and health contact and a list of the medications being taken by the children. This was never achieved during the period under review. Section 3.2 addresses the question of prescribing and control of medication and the role of acute health trusts and GPs in this. The actual conditions from which Child Y suffered 2.48. A paediatric review of Child Y’s health records prepared in early 2016 has found that he has suffered from the following conditions: atopy (allergic reaction in the skin to a variety of substances) bowel disturbance and constipation obesity degenerative disorder in the spine 8 For part of the year the family lived out of these hospital catchment areas. Real totals may be higher as 1) these figures may not include all attendances as some original records may not have been scrutinised and 2) they only include the trusts listed above. Hospital Trust 3 has no Emergency Department 16 2.49. There is no evidence of an endocrinal or other medical cause for his obesity. Both this and the bowel disturbance (which largely presented prior to 2011) are likely to be caused or worsened by poor diet and lack of exercise. 2.50. The degenerative disorder was believed to have been due to a Vitamin B12 deficiency which is a recognised though unusual side effect of the repeated use of Nitrous Oxide (gas and air) which was given to Child Y for reported chest pains. 2.51. Child Y had some allergies but many children and their families manage the sort of allergic reactions described without any significant impairment of functioning. 2.52. It was repeatedly confirmed that Child Y had no heart condition or other cause for his chest pain. His sister has no serious medical condition. Her most common presentation was for possible urinary tract infections, but when systematically reviewed none of the investigations for this condition proved positive. 17 3. SERIOUS CASE REVIEW FINDINGS 3.1. How was the child harmed and what was the evidence of Fabricated or Induced Illness (FII)? Introduction 3.1.1. The treatment of Child Y by his mother is considered to be FII as it is defined within current child protection procedures. The evidence for this is set out in paragraphs 3.1.6 –3.1.17, along with evidence of the harm caused. 3.1.2. The case history raises wider questions about the understanding of FII, research into its prevalence and characteristics and the value of current guidance and procedures. Although health professionals currently working in the NHS told the SCR that this case was ‘very typical’, its history varies in important respects from the profile of FII cases described in the literature and envisaged in guidance. This highlights the lack of recent population-based research on FII and inconsistencies in medical and safeguarding guidance. These issues are addressed in Section 3.4. 3.1.3. Review of this case in the context of wider writing about FII and discussions with the practitioners who were involved leaves no doubt that FII is a safeguarding concern that can cause children serious harm. Many of the difficulties arise from the fact that rather than being a disease with a cause and established treatments, FII is a feature of the interactions between health professionals and parents. In cases that involve older children the child can become an active participant as well.9 3.1.4. Parents in such cases often have complex psychological histories.10 The actions and decisions of health professionals are shaped by a range of organisational and cultural factors, as well as their own knowledge of FII. The meaning of health and ill-health are not static and are in many senses socially constructed. This may influence the behaviour of children who present symptoms of illness. With the advent of the internet knowledge about the symptoms of illnesses (even rare illnesses and syndromes) and their treatment is no longer the preserve of health professionals. 9 Bass and Glaser argue that FII depends on the behaviour and interaction of three parties - parent, child and health professionals. Christopher Bass, Danya Glaser (2014) ‘Early recognition and management of fabricated or induced illness in children’, www.thelancet.com Vol 383 April 19, 2014. 10 Christopher Bass and David Jones (2011) ‘Psychopathology of perpetrators of fabricated or induced illness in children: case series’, The British Journal of Psychiatry 199, 113–118 18 3.1.5. Section 3.4 of the report considers this further in the light of other case reports suggesting that (what is referred to as) FII may increasingly be a presentation of older children. Whether this then ceases to be FII, or is best described as a more complex form of the condition, is a matter for debate. Evidence of Fabricated or Induced Illness (FII) identified by the SCR 3.1.6. FII is defined in the London Child Protection Procedures 5th edition as follows:11 2.1.1 Fabricated or induced illness is a condition whereby a child has suffered, or is likely to suffer, significant harm through the deliberate action of their parent and which is attributed by the parent to another cause. 2.1.2 There are three main ways of the parent fabricating (making up or lying about) or inducing illness in a child: Fabrication of signs and symptoms, including fabrication of past medical history; Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluid; Induction of illness by a variety of means. 2.1.3 The above three methods are not mutually exclusive. Existing diagnosed illness in a child does not exclude the possibility of induced illnesses. The very presence of an illness can act as a stimulus to the abnormal behaviour and also provide the parent with opportunities for inducing symptoms. 3.1.7. Child Y reported ‘pain’ in his chest, arm, stomach, back and testes, as well as allergic reactions, and was presented on numerous occasions for medical assessment and treatment. Despite frequent reassurance that (for example) he did not have a heart condition, Child Y’s mother repeatedly presented him at hospital. Problems were sometimes reported to different hospitals in parallel. 3.1.8. When clinicians tried to set limits to the repetition of investigations and treatments, Child Y and his mother are reported to have complained, sometimes behaved aggressively and then sought treatment elsewhere. 11 http://www.londoncp.co.uk/chapters/fab_ind_ill.html 19 3.1.9. Child Y’s mother misrepresented the outcomes of tests and investigations. For example by misleading doctors that she understood that tests undertaken had revealed ‘a problem with the left side of his heart’ when it had been made absolutely plain that this was not the case. She told the case review that he had had abnormal ECG tests, though the records show no evidence to support this. Any minor ambiguity or uncertainty in what health professionals said was transformed by the family into a belief that Child Y had a serious condition. Presentations were often made to appear more complex or grave by reporting a family history of the condition. 3.1.10. There is no evidence that Child Y’s mother made efforts to address the children’s anxieties about their health. She and her children became increasingly preoccupied with symptoms of illness and disease at the expense of their ordinary social and emotional development. 3.1.11. The review has found no evidence that Child Y’s mother induced illness in the children by poisoning them, mis-administering medication or altering records. However the repeated presentation of children in different settings has contributed to a situation in which doctors have prescribed a very large number of medications with a diminished ability to monitor their interaction or overall impact. This has left family members as the only people with oversight of the very significant number of medications prescribed, though not necessarily of their impact or potentially harmful interactions between them. 3.1.12. At times there has been suspicion that family members have obtained medication that doctors would not prescribe or additional supplies of prescribed medication from the internet. This is speculation based on accounts of the medication that family members have said that they have had at home, but it was never investigated. 3.1.13. Appendix 8 sets out a list of medications prescribed at different points to Child Y. This is drawn from the chronologies submitted to the SCR and is unlikely to be comprehensive. The role of GPs in seeking to maintain oversight of prescribed medication is addressed in Section 3.2. 3.1.14. Health professionals told the SCR that they had been amazed by the knowledge that family members had about drugs, investigations and treatments. As the children grew older they became active participants in the fabrication of illness. They appear to have believed that they were ill and were genuinely experiencing the symptoms they describe. 3.1.15. The recent assessment that Child Y has been addicted to prescribed pain killers for a number of years suggests an additional layer of complexity. This physical addiction may have driven Child Y’s desire for medical attention in addition to and independently of his mother’s 20 belief that he was ill. For example there is evidence in GP records of the 15 year old Child Y insisting that his mother attend the GP seeking stronger painkillers for him. 3.1.16. At times health professionals tried hard not to collude in the provision of unnecessary healthcare but they were defeated by the family and by the complexities of the systems in which they work. This is examined further in Section 3.2. 3.1.17. Regardless of the cause or the role of different parties there is no doubt as to the extent of the harm that Child Y has suffered. This has included: significant loss of school attendance and associated delay in educational and social development; unnecessary medical intervention including intrusive investigation; unnecessary surgery and medication that served no purpose and may have had harmful side-effects. The worst known of these has been a degenerative spinal condition and the development of an addiction to opiates administered by health professionals. 3.2. Challenges faced by professionals in the health service Introduction 3.2.1. This section of the report identifies the specific difficulties faced by health professionals. Section 3.3 focuses on the role of the local authority and the overall management and coordination of safeguarding concerns. This addresses the early identification of what are termed ‘perplexing presentations’ and FII which also centrally involves health professionals. 3.2.2. The health sector in this case consisted of: i. Hospital Trust 1 where the children frequently attended ED, paediatric outpatients and other specialists; this could be thought of as the family’s local hospital, though there is now no such thing as a hospital catchment area ii. Hospital Trust 2 which provides both local acute services (including an ED) and specialist tertiary services; Child Y had two lengthy inpatient stays in this hospital during 2014 – 15 All of the ED attendances cited in Table 1 (page 15) were at these hospitals. Before 2012 the family used both hospitals in parallel. Both separately reported on interventions to the family GP. From 2012 the hospitals became aware of one another’s involvement and began to copy letters and discharge summaries to consultants in the other hospital. From 2014 the family became increasingly hostile to staff at the local hospital and insisted wherever possible on attending the second hospital. This made it more difficult to ensure correct 21 attendance at safeguarding meetings including child protection conferences. iii. Hospital Trust 3 which is a specialist children’s hospital. Both of the ‘local’ hospitals were aware of the involvement of the specialist children’s hospital (Hospital Trust 3) and at points there was discussion about which specialist should see the family iv. GP practices (a more detailed description is provided below) v. Child and Adolescent Mental Health Services (more detailed description is provided below) vi. The Ambulance Service – which attended numerous calls to the family’s home addresses. Efforts by the hospital trusts to avoid duplication of care and unnecessary tests and treatments 3.2.3. During 2013 paediatricians and staff in the ED at Hospital Trust 1 became increasingly concerned about the presentation of the family at their hospital, triggering several discussions at the hospital’s psycho-social meetings. Both general hospitals became increasingly aware of the extent to which Child Y was being presented or taken to different hospitals and made efforts to discourage this. 3.2.4. In 2014 and 2015 large meetings of involved clinicians were convened at the hospitals, leading to two attempts to prepare plans to coordinate the medical care being provided. Neither was implemented because on both occasions they were superseded by events and overwhelmed by the complexity of working with the family. 3.2.5. Hospital Trust 2 held two substantial discharge meetings following lengthy paediatric ward admissions (late 2014 and early 2015). Both meetings prepared detailed discharge plans setting out roles and responsibilities. After the first meeting Child Y fell off a high building, making the plans redundant because of physical injuries. His further admission (to Hospital Trust 2) following that and the sharing of information at the discharge meeting triggered the action of the local authority in initiating legal proceedings. 3.2.6. Sometimes the complexity of the health system enabled the family to thwart the attempts of health professionals to place limits on the number of investigations and treatments. The example of Child Y’s obesity illustrates this. Throughout the period under review Child Y became increasingly obese, to the point where it became a significant health concern. A paediatrician at Hospital Trust 1 undertook basic tests in order to establish whether a hormonal problem was a factor in this. Knowing the family extremely well he took a conscious decision not to refer Child Y to an endocrinologist, fearing that this might trigger a series of further unnecessary investigations and trials of 22 treatments. He was certain that the family was not following advice about diet and that Child Y was very inactive. He strongly encouraged them to attend to these issues and arranged for further advice about diet. 3.2.7. Some months later Child Y was seen in the cardiology department of another hospital. Having established that there were no underlying heart problem the doctors were naturally concerned over Child Y’s weight. Having been told that he had tried to lose weight without success, the discharge letter to the family GP included the suggestion that Child Y should be referred locally to an endocrinologist with an interest in obesity, effectively but unintentionally undermining the first paediatrician’s attempts to avoid further specialist referrals. Efforts to implement medical guidance on FII 3.2.8. The guidance prepared by the Royal College of Paediatrics and Child Health and HM Government both envisage the paediatrician responsible for the child’s care acting as the ‘responsible paediatric consultant’. 12 This person’s role includes preparing a comprehensive chronology to be prepared and for action to ensure that treating clinicians are in regular contact with one another. 3.2.9. The Royal College of Paediatrics and Child Health (RCPCH) guidance suggests that the chronology should include information from GPs and schools.13 Bass and Glaser suggest a specific range of tasks that the paediatrician should undertake, reproduced as Appendix 7 of this report.14 Guidance on FII is discussed in more detail in Section 3.4. 3.2.10. On several occasions senior paediatric consultants in the local hospital or members of the hospital safeguarding team tried to adopt the envisaged coordinating role, but the complexity of the case defied management along these lines. Each time efforts failed so that several months later further meetings were held to renew attempts at coordination. Factors that explain this include: the attempted coordination was happening at a relatively late point in the case history by which time there had been a high level of contact by many doctors for several years 15 during the period under review there was never a point when there was only one consultant paediatrician involved; there was always 12 DCSF (2008) pages 19 – 20; RCPCH (2009) page 19; Glaser 13 RCPCH (2009) Section 5.16 14 Bass and Glaser (op cit) Appendix to the Lancet article 15 In contrast paediatricians told the SCR that they think this approach is effective when dealing with perplexing presentations or possible FII at the early stages, often with very young children and this may account for the small numbers of such cases that now cause very serious concerns. 23 more than one hospital trust involved with Child Y and more than one consultant in each patient record systems were too fragmented to allow this to happen; even in one acute health trust, the use of different record keeping systems made it difficult to keep track of all contacts. the amount of time, effort and administrative support that would have been required to do this was not available and that this was not a task which staff with other significant responsibilities could accomplish when meetings were held different professionals were in attendance because between the meetings the family had presented a different range of symptoms and engaged new clinicians, who were not all aware of previous problems and decisions. 3.2.11. This suggests that unless specific systems are set up and resourced within the local health network it will be extremely difficult for any individual clinician to hold an overview of the interventions and investigations in a suspected FII case, once it has progressed beyond its early phase, especially when as in this case where there are numerous trusts and individual providers, sometimes accessed by the family without reference to one another. 3.2.12. During the care proceedings the local authority found it very difficult to obtain a comprehensive overview of health provision and medication. Even during the period when the SCR was taking place (i.e. long after all agencies were fully aware of the complexity and risk associated with the case, several months after the care proceedings had been initiated granting parental responsibility to the local authority, and after Child Y had spent some time in an inpatient mental health unit) it remained a matter of great concern to the LSCB that the health sector was still struggling to achieve the kind of coordination necessary. It required the intervention of the LSCB chair and very senior managers in several agencies to ensure that meaningful steps were taken towards the creation of such a plan. The role of general practitioners in the oversight and coordination of health care 3.2.13. Government and RCPCH guidance envisage an important role for the GP in identifying possible cases of FII and collaborating with paediatricians to provide information for the comprehensive chronology of events. This case history demonstrates that in a complex or developing case of suspected FII it is likely to be extremely difficult for GPs to have oversight of the care being provided. 3.2.14. Oversight of prescribed medication is dealt with separately below. 24 3.2.15. In the two year period from September 2013 the GP chronology for Child Y contains 102 entries for GP surgery consultations, correspondence and phone communication with specialists and contacts for repeat prescriptions. This includes several periods when he was an inpatient and so would not have attended the surgery. 3.2.16. There is also evidence of a small number of unsuccessful attempts by GPs to exercise a degree of control over treatment of the children because some of the GPs involved had an awareness that the family was dictating the terms of their contact and that this was not helping the children. 3.2.17. It is very likely that the SCR has not been able to access all the relevant GP notes. Child Y and his sister were registered briefly with a GP in Local Authority 3 when they lived in the refuge. There are no significant entries and no reference to safeguarding concerns although the children were briefly subject to a child protection plan during this time. Records from this surgery end in June 2012. 3.2.18. Child Y and his sister were both registered with a local GP late in mid 2013, a year after moving to Local Authority 1. It is not clear whether they had had no GP involvement in the previous 12 months or whether there are other notes that have never been connected to the current GP record. This seems to be the more likely explanation as during this period Child Y had a very large number of ED and outpatient appointments. 3.2.19. If it is difficult to reconstruct the records of such a family for a SCR, where there is a need and the means are available, it will be extremely unlikely that practitioners will do so in the course of their ordinary work with a family, when there may not appear to be any need and there is no additional time to carry out the work. 3.2.20. There was a further change in GP in mid-2015, because the family moved home. It is only in the final GP practice, during a period when the local authority had initiated care proceedings and with the direct support of the Clinical Commissioning Group Designated Nurse for Safeguarding, that the GP practice was able to play a proactive role in efforts to coordinate work with the children. 3.2.21. The difficulty of accessing a comprehensive set of records will have been made worse by the fact that GPs now work very largely from the summary pages of the electronic records. These usually contain a brief synopsis of problems and contacts. They reflect third party contacts, which are particularly significant in a case of possible FII, much less well. 3.2.22. The lack of access to comprehensive GP records made it more difficult for the GP to work with an assist other professionals as this entry from November 2014 reveals: 25 ‘Also discussed ongoing chest pains. Awaiting MRI, under the care of Hospital Trust 2 and Hospital Trust 3 and frequently ends up at Hospital Trust 1 when the chest pains come on at school. (every 2 days). Need to chase his old notes, before any letter can be done for school.’ 3.2.23. Even if all of the notes had been available to the GP, they would not have been in a format that would have aided understanding significantly. This would have required the creation of a chronology similar to (and probably as part of) the exercise required of the responsible paediatrician (see 3.2.8 above). 3.2.24. Effective oversight of care is made more difficult by the large number of GPs seen within individual practices. At one practice during 2013-15 Child Y’s sister saw at least seven GPs. Child Y saw a similar number. The notes suggest that very often problems were presented to the GP receptionist or practice manager as an emergency requiring an urgent appointment. This led to appointments being offered at the end of surgery and / or by locum doctors. In fact the presentations were part of a persistent pattern which would have been better dealt with after a reasonable delay by an identified GP. This would also have allowed the GP concerned to review notes and correspondence and also to try to contact other professionals involved. GPs realised this and achieved it on a small number of occasions. 3.2.25. The children were subject to child protection plans in 2012 (briefly) and from 2014 – 2015. The GP records contain occasional reference to the receipt of minutes but no saved requests for reports or completed reports for child protection conferences. The local authority child protection conference records show GP attendance at one meeting, the initial conference in June 2014. At this meeting it was suggested that as part of the protection plan the family should be dealt with by one GP and one acute trust but there is no reference to this plan in subsequent minutes. 3.2.26. Later records show decisions that a consultant paediatrician twice planned to meet with the GP and the family but this did not happen. Engagement of GPs in multi-agency working was minimal until the local authority initiated care proceedings, by which time the family had moved and registered with a different GP practice. Control and oversight of medication 3.2.27. Appendix 8 is a list of the medications that were evident on a very brief review of his GP chronology during 2013-15. It contains 12 medications for pain relief; several antibiotics; several allergy treatments and vitamin supplements; one medication for the relief of ulcers and one for the reduction of cholesterol. 26 3.2.28. This is likely to be a partial picture as there are certainly other medications prescribed during outpatient appointments and hospital inpatient stays which do not feature in the GP record. Health professionals suspect that the family obtained medication from other sources and Child Y is noted to have been in possession of an Epipen (adrenalin for the urgent treatment of allergic reactions) and a GTN spray (for pain relief) that no one has a record of giving him. 3.2.29. The normal arrangement for hospital prescribing is that the clinician will initiate the medication and the hospital will provide an initial supply. For a period medications may be prescribed without full reference to medication already being taken, however the prescribing clinician will be mindful of the potential conflicts or contra-indications. Discharge or review letters containing details of the medication are then sent to the GP who should have oversight of all the medication being prescribed for a patient. The GP will normally then assume responsibility to prescribe the medication, except for those medicines that guidance determines can only be prescribed by a specialist. 3.2.30. Repeat prescriptions are monitored by the GP practice, but if medication is prescribed from different sources, there may be a delay in the GP knowing about all medications being prescribed. Depending on the circumstances repeat prescriptions will be issued either at a GP consultation or administratively. When multiple medications are prescribed from different sources there is always a risk of error or difficulties in the interaction of medications. 3.2.31. In this case only the family (or perhaps in the end Child Y himself) appears to have had oversight of the medications being taken. Family members appear to have taken medication according to their own view about its value and impact, rather than following advice given. Clinicians relied on the family to say what was being taken and what was working and the family may not have always been honest. 3.2.32. GPs had only a limited oversight of medication, though there were a number of points when the GPs expressed disquiet about the prescribing of some medications, either in principle or in particular combinations. The notes describe consultations that were described as ‘difficult’ when GPs would only give sufficient medication to take the patient through to the next scheduled appointment or a planned review. One more than one occasion GPs recognised the need to review what was happening, but never accomplished this as the situation kept changing, making it difficult to discern a specific intervention to review. In parallel specialists were trying to undertake separate reviews of specific presentations. 27 Tertiary hospitals and specialists 3.2.33. Two tertiary centres treated Child Y. One had a dual role as it also served as a local hospital with an Emergency Department. The role of tertiary centres adds an additional complication to the management and coordination of cases of FII. The following were involved: Hospital Date Department and function Hospital Trust 2 2010 Paediatric gastroenterology and surgery 2013 Paediatric urology 2013 Dental 2013 Referred to Dietetics but refused as out of borough so not eligible 2013 Cardiology 2013 Allergy 2014 Neurology 2014 Anaesthetics and paediatric pain management 2015 Orthopaedics 2015 Physiotherapy Hospital Trust 3 2014 Cardiology 2014 Endocrinology 2015 Neurology rapid assessment unit Once again it is impossible to be certain that there were no other interventions or even different hospitals involved. 3.2.34. Rather than examine each of these contacts, the review has highlighted themes and questions that are relevant to a number of interventions, bearing in mind that health professionals were often perplexed or suspicious about the validity of presentations: Letters referring Child Y to tertiary services were not always explicit about previous investigations, the existence of numerous perplexing presentations and the fact that the children were subject to child protection plans Neither tertiary centre made comprehensive checks with colleagues before initiating investigations, though they did consistently tell the family GP surgery what action they were taking 28 Internal referrals between specialist teams in tertiary centres are often made; this can speed up delivery of services and make a high level of expertise available, but it can reduce oversight by GPs and others who know the child and might lead to unnecessary investigations 3.2.35. There is always a risk that clinicians in tertiary centres will seek the explanation for a child’s presentation in interesting but rare syndromes (of which a growing number exist in every field of medicine) and not recognise the likelihood (statistically much greater) that there are significant social or emotional problems in the family. The literature notes that the labelling of a collection of symptoms and converting them into a disorder such as ‘chronic pain syndrome’ is particularly unhelpful in cases of possible FII, as it creates the impression that a child has a specific disease when in fact the term is merely a shorthand for a combination of unexplained and possibly non-existent symptoms.16 3.2.36. There was great variation in the extent to which clinicians in tertiary centres were engaged in multi-agency discussions. One tertiary centre arranged very useful discharge planning meetings, involving some of the relevant agencies. At other times records indicate that staff in tertiary centres were not aware that children were subject to child protection plans and were not invited to conferences. In one instance clinicians became aware of this through attending a multi-agency meeting, but then did not record this or share the information with colleagues in their hospital. 3.2.37. In discussions with the author a GP expressed concern that some of the discharge letters written about the family by specialists were insufficiently definitive about their findings, leaving the family room to seek further investigations and treatments. The role of the ambulance service 3.2.38. At the peak of its involvement during 2013-14 the ambulance service attended two or three calls per week to the family home. The most frequent condition reported was that Child Y had severe pain starting in his chest and radiating to other parts of the body. As with many of the descriptions of symptoms, there was open suspicion that they followed ‘textbook’ (i.e. internet) accounts. 3.2.39. The service responded to each incident on its merits and gave routine treatments in line with protocols that are set out for particular presentations. Staff dealing with callouts do not have the capacity to 16 Royal College of Paediatrics and Child Health (2009) Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (Section 7.10) 29 review the history of previous contacts at an address or with an individual. 3.2.40. Commonly Child Y was conveyed to the local hospital ED. The ambulance service threshold for taking an apparently sick child to hospital is a low one. A standard part of the treatment for reported chest pain is Nitrous Oxide and Oxygen (gas and air). A possible side effect of the regular and repeated use of this is Vitamin B12 deficiency, which is in turn implicated in the neurological symptoms that Child Y suffered from late 2014. 3.2.41. The ambulance service is able to adopt a tailored approach (known as a patient specific protocol) to patients who present frequently and where standard responses are not perceived as being helpful. More than once multi-disciplinary meetings discussed the potentially harmful effects of treatment with anything more than minor painkillers and the fact that it was unnecessary. Minutes of a meeting held in later 2014 note that clinicians including paramedics should only administer paracetamol or similar medications and avoid the use of Entonox, GTN spray and opiates. 3.2.42. This did not happen because the ambulance service will only introduce an individual patient protocol on the written recommendation of the trust that is responsible for the care of the child and with the agreement of the Medical Director. Although agreed in principle this was not provided because there was a breakdown in communication about the fact that it needed to happen. 3.2.43. On another occasion Hospital Trust 2 issued a letter with very specific advice about the approach to be adopted to pain relief, but did not consider the role of the ambulance service in that communication. The role of CAMHS and services offering psychological therapies 3.2.44. Between 2011 and March 2015 Child and Adolescent Mental Health Service (CAMHS) professionals made six attempts to offer a service to Child Y, the mother or to the family as a whole. These included offers of outpatient appointments at the local hospital and appointments at the local CAMHS service. Both were offered following discussion with paediatricians and staff in the ED. Neither proved successful because the family missed appointments or would attend once and then fail to keep follow up appointments. Child Y’s mother told the SCR that CAMHS had failed to provide counselling services that were included in agreed plans but no evidence could be found to support this in the records. 3.2.45. The lack of engagement is not surprising since the premise of the CAMHS professionals was that Child Y and his family needed to understand that he had no serious illness, and that other factors such as anxiety might be behind his behaviour, while the family was 30 convinced that he had illnesses that health professionals were failing to identify and treat. This gave no scope for any mutual agenda for work. Interventions aimed at changing the family’s fundamental thinking and behaviour about seeking unnecessary health care only gained traction when it was agreed as part of a formal plan made in the care proceedings. 3.2.46. The focus of interventions changed to a degree from 2014 when a number of clinicians referred the family to ‘pain management services’. These will offer advice to patients where there appears to be a psychological basis to reported pain or the reported pain appears to be disproportionate to an underlying condition. There was limited engagement of the family. By this time this is likely to have been explained by the fact that Child Y was most concerned to obtain pain relief medication, rather than find alternative ways of managing pain. Additional cultural factors that made it harder for health professionals to avoid unnecessary investigations and interventions 3.2.47. Discussions with health professional highlighted a further range of cultural and organisational factors that made it more difficult to limit unnecessary interventions and to reach a diagnosis of FII. 3.2.48. Health service reforms made over the last 15 years enable patients to exercise far greater freedom to decide who they have as their GP and where they are referred for treatment. During the same period the health economy has changed substantially, abolishing in effect the established and relatively straightforward relationship between a GP, a district general hospital and tertiary specialists who would tend to receive referrals from a defined area. A wide variety of trusts now offer similar, competing services making it more difficult to limit the number of organisations and services that are involved with a patient and. These factors in combination make it much more difficult for any one clinician to anticipate which services might be involved and to have oversight of the investigations and treatments being undertaken. 3.2.49. Recent decades have seen a diminution in the authority of health professionals. Very experienced and able clinicians told the case review that they find it increasingly difficult to refuse to undertake investigations and treatments. Patients increasingly believe that their role is to act as ‘empowered consumers’ whose right it is to challenge the decision making and advice of health professionals, if necessary using the complaints procedures. 3.2.50. One of the paediatricians who saw Child Y told the review that it is not at all unusual for a patient to present a child at the clinic already having used the internet to research their symptoms and armed with knowledge of the first set of tests that might be required, and 31 sometimes the next set of tests to investigate rarer explanations and syndromes. 3.2.51. Staff in the local hospital ED say that when challenged or refused treatment Child Y and his family became hostile and frequently threatened to complain. When such strategies were unsuccessful they tried to bypass the local hospital. Staff also believe that they became adept at manipulating hospital systems, knowing which clinicians (often the less experienced) would find it harder to resist requests for treatment. 3.2.52. Health professionals believe that their work has become increasingly specialist. As the number of syndromes from which patients may suffer increases it becomes more difficult not to refer a patient on to someone who appears to have more specialist knowledge. 3.2.53. In combination these factors make the recognition of FFI more difficult since it relies on the ability to spot the parent who is manipulating the health system demanding further tests and treatments for their child. In relation to FFI this is seen as an indicator of risk. However within the wider culture it has come to be viewed as socially acceptable, necessary and positive in order to overcome the indifference or intransigence of health professionals who are presented as denying parents the diagnosis they think fits their child’s problem, the medication they believe the child needs or the access to resources that a diagnosis can provide. Parents who battle the system to achieve the diagnosis they believe their child merits and the services that may follow from that diagnosis are often held in high regard. 3.2.54. Taken together these factors have made health professionals much more risk averse and in particular more wary about not undertaking or commissioning a further examination or investigation. This will very often seem like the low risk, ‘what harm can it do?’ option. Clinicians are also likely to be less willing to openly challenge parents if they are suspicious about presentations and symptoms. 3.2.55. Given this context senior managers in the health service have an important role to play in supporting staff who want to refuse investigations and treatments that they believe are not clinically justified or to put explore a possible diagnosis of FII. They however face the same pressure and fear of complaints. 3.2.56. Section 3.4 considers how far current professional guidance assists health professionals in addressing these challenges. 32 3.3. Social care management and the coordination of a multi-agency response Evidence identified by the SCR 3.3.1. In June 2012 Local Authority 1 convened an initial (transfer in) child protection conference about Child Y and his sister, which decided not to make the children the subject of a child protection plan. Social work intervention during the following months focused on the children’s poor school attendance and the preparation of a court report dealing with the parents’ separation and possible contact arrangements. After the court report was completed the local authority sought to close the case but was persuaded that the problem of poor school attendance required continuing involvement. 3.3.2. Health professionals raised concerns on several occasions about the large number of hospital attendances but the view of the local authority was that this was ‘not a case of FII’. In July 2014 the children were made subject to a child protection plan because it was evident that there had been no improvement in the problems caused by repeated medical appointments for which no medical cause could be found and the very poor school attendance of both children. 3.3.3. In March 2015 Child Y seriously injured himself in a fall from a high building. A new social worker and team manager became responsible for the case and immediately viewed this a case of possible FII. Strategy discussions and legal planning meetings began in April 2015, though it was not until November 2015 that a court application was made. The difficulty in considering this as a possible case of FII 3.3.4. It is difficult to understand why the initial child protection conference in June 2012 did not recognise this as being a case of possible FII, particularly as it had been identified as such by professionals in the previous authority and in reports which appear to have been available to the conference. It is possible that these papers were not read by some or all of the participants. There was no paediatrician at the conference, despite the referred problems focusing on the large number of medical appointments. 3.3.5. Close review of the conference minutes suggests that professionals believed that the mother had been a victim of domestic violence whose experience made her vulnerable and lacking in confidence. The children’s behaviour (school refusal and anxiety about their health) could be explained by the exposure to domestic violence. Professionals present appear to have perceived the case history as being one that fitted easily into this common ‘narrative’ that they would have felt comfortable with. As a result the professionals (such 33 as social workers) who were not dealing directly with the family’s unnecessary day to day demands for health care were very sympathetic to the mother and focused on her need for help in ‘meeting the children’s health needs’. It is a concern that it took two years for the accumulating evidence from health professionals to influence the thinking of the local authority. 3.3.6. The provision made for Child Y and his sister during these two years illustrates the difficulties in arriving at a shared understanding that this was a case of FII, despite the fact that a number of the health professionals involved believed that the children were being presented for medical treatments without good cause and on numerous occasions. It may be significant that during this period there were changes of social worker responsible for children, diminishing any overview of the history and the extent of the difficulties. Categorised as children in need the case is unlikely to have been a priority for reflection and discussion in supervision. 3.3.7. The lead professional for the children was the allocated social worker. Health professionals told the review that the social workers did not feel that they were qualified to understand or to take a lead in addressing issues about the children’s health and the family’s relationship with the health service. The large number of health problems and services left health professionals unable to arrive at a clear process for eliminating conflicts and uncertainties over diagnosis so that firmly established safeguarding concerns could be presented to the local authority. 3.3.8. In hindsight health professionals realised that they had organised and attended a significant number of multi-disciplinary and multi-agency meetings about the family but that there had been insufficient clarity about the purpose of the meetings and who should attend them, rendering them all much less useful. It remained unclear who had the responsibility for arriving at the decision that this was a case of FII. Did this sit with the health professionals as a diagnostic one? Or should it be considered as a safeguarding issue from the point at which suspicions were first aroused and thus be a matter for multi-agency decision making? 3.3.9. Resolution of this is fundamental to securing more effective early identification of FII. Recent health sector guidance strongly suggests that health professionals need to identify cases with medically unexplained symptoms (sometimes referred to as perplexing presentations) at an early point and to act collaboratively to coordinate information, confirm or eliminate possible diagnoses. They should then address the lack of a medical explanation or the inconsistency between presentations and medical findings with the 34 parents.17 If the parents cannot accept at this point that their behaviour needs to change the matter should be considered as a potential safeguarding concern. Local arrangements need to ensure that the local authority can feel confident that medical issues have been explored fully. Period of management under a child protection plan 3.3.10. The growing number of hospital attendances and further deteriorating school attendance prompted the local authority to convene a child protection conference in June 2014. By this point Child Y had attended Emergency Departments on more than 100 occasions and been admitted to hospital more than 20 times. Despite the well documented concerns of health professionals highlighting the unnecessary nature of these attendances, the conference focused its discussion largely on areas where professionals felt more comfortable in intervening in family life: the children’s poor school attendance and its negative impact on their academic attainment and social development; Child Y’s obesity and its possible long-term impact on his health. His numerous A&E attendances were noted but described in a way that avoided suggesting that Child Y was being harmed by this. The conference noted concerns about his ‘perception of his health and the impact on his self-esteem’; his mother’s ‘insight into the situation and whether she can deal with the issues and appropriately parent the children’. As he was sometimes aggressive the meeting also wondered whether Child Y was ‘repeating the past pattern of the domestic violence between his parents in his relationship with his mother’. 3.3.11. The children were made subject to a child protection plan but little tangible progress was made until March 2015 when Child Y was seriously injured in a fall. At this time the local authority view changed in part because it was recognised that he could easily have killed himself, but also because this was the first time that staff in the local authority had accepted in full that the children were not ill, with the exception of some difficulties that would have been considered minor in most families and other conditions brought on by health professionals’ interventions. 3.3.12. A service manager who had attended this meeting also noted for the first time that the family had benefited from a housing transfer and disability benefits that might not in hindsight be justified. This was one of the first formal meetings that social care had attended at which Child Y’s mother was not present. There was also a new social worker and manager, who were open to the possibility that this may be a 17 Royal College of Paediatrics and Child Health (2013) Child Protection Companion, Section 13 35 case of FII, became involved. They were able to move away from the existing stereotypical assumptions about what was causing the family’s problems. Conduct of child protection conferences 3.3.13. The child protection conferences that took place between mid 2014 and 2015 had rightly identified the need to bring together a fuller and more coherent account of the family’s contact with health agencies. This was not achieved so that at the beginning of the care proceedings (April 2015) social care had to ask again for a chronology of health contacts, even though there had been several discussions during the preceding 12 months about the need to compile this information. The social worker was also unable to obtain a list of the medications prescribed for Child Y. 3.3.14. These efforts failed in part because of the complexity of the case but also because of very limited health professional representation at child protection conferences. There had been no health attendance at the initial conference in 2012. The GP and consultant paediatrician attended the initial conference in June 2014. From that point, despite the growing concerns about unnecessary hospital attendance, the only health professional attending or providing reports to conferences was the school nurse (and on one occasion a therapist). The records suggest that representation from the local hospital fell away as the family increasingly bi-passed it and went to other trusts, while at the same time health professionals who were becoming more involved with the family were not added to the list of invitees. 3.3.15. With the exception of the initial conference in June 2014 the same person chaired all of the conferences held in 2014 and 2015. She was aware of this difficulty, but found it hard to find a route to engage more senior managers in the health sector about the need for a more coordinated approach. This role was eventually taken on by the Designated Nurse for Safeguarding. 3.3.16. In the meanwhile the child protection plans relied on the School Nurse to compile information from the health sector and ensure a coordinated approach from health professionals. In a case with numerous health trusts and medical specialisms involved reliance should never have been placed on the school nurse, but the approach was not challenged in the meetings or in supervision in any of the agencies. 3.3.17. Discussions in the child protection conferences followed a format which the local authority says has been adopted from the ‘Signs of Safety’ model of safeguarding risk assessment; identifying factors pointing to potential harm, complicating factors, strengths and areas of safety. Participants guided by the conference chair then draw 36 together statements of risk and safety as well as expressing their perception of the level of risk in numerical terms.18 Under each heading material is set out as a series of bullet points, which staff comment on. Similar material appears under several headings and the distinctions between categories are not clear from the written documents. The documentation captures no overall evaluation of risk. It is the responsibility of the core group to develop a detailed plan for the day to day protection of the children. 3.3.18. It is also significant that none of the conference minutes refer explicitly to concerns or suspicions of FII and the conference chair confirmed that she could not recall the term being used in any of the conferences. It is correct that the task of the conference is to identify risks and strengths; however in this case progress was only made when professionals were able to name FII as the possible cause of the problems. The conference chair told the review that the approach used for conferences can be very good, but also very challenging because it is sometimes difficult for professionals to be open and frank about their views. Overall it appears that this model for the conduct of child protection conferences was not well suited to the circumstances of a case of FII. The review has been told that from January 2017 the local authority has introduced a revised template for recording conferences and it may be useful for the authority to see if this case offers further learning. Limitations in the role that could be played by schools 3.3.19. Between June 2012 (when Child Y was 12 and his sister 10) and July 2014 there were serious concerns over the children’s school attendance (which averaged at between 40 - 60%) and its negative impact on their ability to learn and socialise with other children. Efforts to improve it were hampered by the fact that absences invariably related to illness and hospital appointments and were authorised by GP letters. On a number of occasions when Child Y’s school encouraged him to attend, he complained of chest pains during the school day and was taken to hospital by ambulance as school staff, understandably and quite correctly, felt that he had to be medically assessed. School staff attended child in need meetings but despite the fact that health concerns had a direct impact on both children’s education, they had no means of making direct contact with the hospital professionals who at that time were expressing serious reservations about the veracity of the children’s presentations. 18 http://www.signsofsafety.net/signs-of-safety-2/ The SCR recognises that this commentary should not necessarily be treated as criticism of the Signs of Safety approach itself, since it is not in a position to determine whether the approach taken to these conferences is consistent with the model. The local authority is not part of the formal Signs of Safety network. 37 3.3.20. Experience in other cases suggests that poor school attendance due to medical difficulties may be an indication of possible concerns, which should be investigated. However it will be difficult for school staff to do this if they have no direct contact with health professionals, or those health professionals are themselves unsure as to the significance of the child’s presentation. Child Y’s mother told the review that offers of counselling and additional educational support were agreed as part of child in need and child protection plans (particularly for Child Y’s sister) but were not delivered. The most likely explanation for this was that the implementation of plans was disrupted by the large amount of school that the children missed. 3.4. Research, professional understanding of Fabricated or Induced Illness (FII) and the limitations of existing guidance and research Overview 3.4.1. This section of the report places the learning from this case in a wider context by referring to relevant research, learning from other case reviews, NHS Serious Incident (SI) reports, cases of suspected FII in family law proceedings and the published UK medical and multi-disciplinary guidance on FII. 3.4.2. This report uses the term FII, which has been favoured in the UK since 2002, though one of the difficulties with the wider literature is that different terms are used, both historically and internationally. 19 Sometimes the same term has inconsistent definitions. The most recent UK medical guidance urges clinicians to treat FII as part of a wider concern about ‘perplexing presentations’.20 Sometimes during the investigation of possible FII clinicians refer to ‘medically unexplained symptoms’. 3.4.3. Descriptions in the literature of what the condition includes vary. For example, some definitions refer to the motivation of the perpetrator and in particular whether there are financial, material or secondary benefits from the behaviour. A recent UK article suggests that the impact on the child should be treated as the critical issue rather than the motivation of the alleged perpetrator, but there is no consensus 19 The main terms used are FII; Munchausen syndrome by proxy (1977) which was abandoned in the UK in 2002 but remains popular in Europe and the USA; Factitious Disorder by Proxy or ‘imposed on another’ (older American terms); Paediatric condition falsification (widely used in the USA, along with other terms); medical child abuse (in the USA); Factitious disorder imposed on another (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association, 2013.); Induced or Fictitious Illness Spectrum (2009 UK) 20 Royal College of Paediatrics and Child Health (2013), Child Protection Companion, Chapter 13 38 on this. UK medical guidance warns against ‘pseudo-diagnostic’ labels.21 Research 3.4.4. Early research on what was then referred to as Munchausen Syndrome by Proxy (MSbP) took the form of case histories, beginning with papers describing individual and small clusters of cases, some larger series and then studies based on clinic populations (such as children attending asthma clinics and paediatric inpatient clinics in specialist centres). The first frequently quoted population-based study was undertaken in 1996, relying on UK national data from 1992-94.22 This estimated an annual incidence of 0.5 cases per 100 000 children and 2.8 per 100 000 children under the age of 12 months. This was believed to equate to one case presenting per year in a UK health district with a population of a million. A study using similar criteria estimated a rate of 2 per 100 000 children, but no deaths.23 A study with wider criteria for inclusion suggested an incidence of 89 children and adolescents 100 000 children per year (again with no deaths).24 3.4.5. These case examples and population studies led the literature to describe an archetypal FII case characterised by the overstatement of symptoms or falsification of medical data by the parent of a pre-school age child. Allowing for delays in detection of several months or even years, the typical victim was very young. Some studies showed that the adult responsible was more likely to be female (unlike most other forms of physical abuse) and included a disproportionate number of health professionals. 25 3.4.6. Given that many clinicians with an interest in safeguarding told the review that they view fabricated illness as a current and serious 21 Royal College of Paediatrics and Child Health (2009) 22 McClure et al, McClure RJ, Davis PM, Meadow SR, Sibert JR. ‘Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation’. Archives of Diseases in Childhood, 1996; 75: 57–61. 23 Denny SJ, Grant CC, Pinnock R. Epidemiology of Munchausen syndrome by proxy in New Zealand. J Paediatric Child Health 2001; 37: 240–43. 24 Watson S, Eminson DM, Coupe W. Personal communication. In: Eminson M, Postlethwaite RJ, eds. Munchausen syndrome by proxy abuse: a practical approach. 2000: Oxford, Butterworth Heinemann: 17–70. 25 For example: ‘typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of Munchaussen by proxy’. Mothers were perpetrators in 76.5% of cases…’.Mary Sheridan (2003) ‘The deceit continues: An updated literature review of Munchausen Syndrome by Proxy’, Child Abuse and Neglect, 27, 431-51. The author recognises that accounts of published cases do not form a random sample. 39 concern it is significant that there is so little recent research. There has been no UK population based study for more than 15 years. The literature review cited above dates from 2003.26 There are accounts of the psychological make up of alleged perpetrators. The most recent is based on a series of 28 cases referred for psychiatric assessment by the family courts and social care and assessed by the same clinicians spanning the period 1996 – 2009.27 3.4.7. The most recently cited research is a prospective study of children referred for inpatient care in a specialist Italian paediatric unit.28 This identified 14 of 751 (2%) of children referred to the unit as suffering from ‘factitious disorder’ and four children (a prevalence of 0.53%) meeting more stringent criteria for an induced illness (which the study refers to as MSbP). The authors of this study ascribe the higher prevalence to the high level of awareness in the multi-agency team which was trained to look for MSbP in cases being treated by the team, whereas previous studies had been carried out through retrospective review of case records. 3.4.8. The difference in methodology, patient group and cultural context make it impossible to be certain from a single article whether there has been an increase in the incidence of FII. The most striking difference between the Italian and previous studies is the age of the children and the accounts of their behaviour. The mean age in the ‘factitious disorder’ group is 8.4 years and the much smaller (MSbP) group 10.5 years. The detailed case examples of ‘factitious disorder’ described as ‘characteristic’ all feature children aged 11-16. Their histories included false presentations of fever, abdominal pain, lower back pain and dizziness. In all cases the patients admitted the falsification when confronted. There is no suggestion that health professionals are disproportionately represented as carers, though the alleged perpetrators in the very small number of MSbP cases are all women (three mothers and a grandmother). 29 26 Mary Sheridan, (2003) op cit 27 Christopher Bass and David Jones (2011) ‘Psychopathology of perpetrators of fabricated or induced illness in children: case series’, The British Journal of Psychiatry 199, 113–118 28 Ferrara P, Vitelli O, Bottaro G, et al. Factitious disorders and Munchausen syndrome: the tip of the iceberg. J Child Health Care 2013; 17: 366–74. 29 It is also important to recognise in making comparisons that there is a gap of almost twenty years between the studies, which take place within an entirely different health economy and an entirely different cultural context. 40 Learning from case reviews, serious incidents and case examples 3.4.9. A search of the national repository of SCRs identified 11 published SCRs that refer to FII.30 A brief summary of the content is set out in Table 2 below. Of the 11 reports, three (spread over a 10 year period) appear to be confirmed FII cases with comprehensive analysis and recommendations for local services (Cases 1, 9, 11).31 3.4.10. The largest group consist of four cases (Cases 2, 3, 8, 10) in which abuse and illness coexisted in the child and in hindsight the SCR questions whether they might have been cases of FII that were not recognised or assessed. It is this which has led to the inclusion of the case in the keyword search, rather than specific findings about FII. Case 6 sits somewhere between these clusters and it is impossible to place it more reliably on the basis of the summary. 3.4.11. There are three cases in which children were poisoned with illicitly obtained drugs or medication prescribed for the adult (Cases 4, 5, 7) but on the information publicly available it is not clear that these cases would have met the criteria for FII. Table 2 Summary of findings from SCRs mentioning FII Case 1 – describes a severe FII case in detail and identifies both good practice and shortcomings. The difficulties faced by health professionals in obtaining an overview of the case and coordinating their interventions echo those in the current SCR Case 2 – describes a case in which there is both complex illness and abuse – which it is suggested would not meet the definition of FII Case 3 - the death of an adolescent by hanging. It refers to a ‘failure to consider FII as a contributing factor to Child F’s difficulties’ Case 4 – a 9 month old infant poisoned with adult medication; there had been a lot of medical assessments but it is not clear from the summary if this is a case of FII Case 5 – a child age two years suffering from opiate poisoning – previous children removed, mother ‘diagnosed with MSbP’ (though this is not a psychiatric diagnosis) Case 6 a child diagnosed with a rare skin condition aged 4 months but also had other 30https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/national-case-review-repository/ The search was carried out in August 2016 using the NSPCC search tool for the terms FII and commonly used alternatives. As the term FII is used consistently in the UK searching for the term FII revealed all of the cases. Reports that were published in full were read but some predate the requirement for full SCR publication so only executive summaries could be obtained. 31 Case 1 = Thurrock LSCB (2014); Case 9 = South Tees LSCB (2008), Case 11 = Cumbria Child Protection Committee (2004). Case 1 was a learning review, rather than a SCR, but it is the practice of the board concerned to publish all of its reviews. 41 injuries which were eventually attributed to her mother. The child also underwent invasive tests and treatments over several years. The diagnosis of a very rare condition allowed mother to become the ‘expert’ and manipulate health professionals. It is not clear from the summary whether the diagnosis was correct or induced, or whether this remains unclear. Case 7 – a child age 20 months who was poisoned with prescribed medication. The review states that the assessment should have included consideration of FII but it is not clear that this case would have fitted the definition Case 8 – a foster carer /private foster carer who abused a large number of children in her care. As the children had had numerous medical appointments it is hypothesised that this may have been an unrecognised case of FII Case 9 - a 10 year old boy who suffered non-accidental amitriptyline poisoning and underwent unnecessary medical interventions. The child lived with his mother and had many health problems from an early age and multiple GP and hospital attendances, including admissions, contact with psychological services and a paediatrician. He was subject to surgical interventions, and concerns were raised in relation to FII, but they were not assessed. Case 10 – a 9 year old boy who died as a result of salt poisoning. The review suggests that professionals were insufficiently aware of the possibility of FII and did not assess this. Case 11 – A 7 year old who died as a result of FII. The child probably had mild epilepsy (though this diagnosis remains in doubt) and was admitted to hospital a number of times for investigation and treatment. Toxic levels of medication were found in his body on more than one occasion. His mother lied to GPs about his condition to obtain increasing amounts of prescription medication which was then used to overdose him. Mother misled professionals and relatives that the child had a terminal illness. FII caused chronic ill health, withdrawal from school and unnecessary invasive treatment which eventually contributed to his death. The review contains detailed information and recommendations on dealing with suspected FII, including warning signs and barriers to identification. 3.4.12. There is little other recent published critical evaluation of practice. 3.4.13. Statistics provided on Child Death Reviews 32 in England and Wales identify cases in which death has been caused by deliberately inflicted injury, abuse or neglect but do not further distinguish the type of abuse. Any case judged to have been the result of FII should have been the subject of a SCR and a summary of its findings would have been included in the national SCR repository once published. 32 Arrangements are set out in Working Together to Safeguard Children (2013) Chapter 5. 42 3.4.14. The patient safety team at NHS Improvement conducted a search of its Strategic Executive Information System (StEIS) database of reported serious incidents using search terms designed to identify cases of FII and provided the SCR with a summary of cases that had been identified by health trusts under the NHS serious incident procedures since 2005.33 This identified approximately one reported case per year. This should not be treated as an indication of the incidence of FII cases known to the NHS because the main purpose of the reporting system is to identify and learn from cases in which there has been an error or omission on the part of healthcare staff, so not all cases of FII would be reported. 3.4.15. The sample included specific concerns related to FII, such as cases where ‘further illness was induced by a parent whilst the child was an inpatient, or by breaches of confidentiality related to FII, or concern that there were lapses in the healthcare response to suspicions of FII, and in some cases by concern that a parent might also pose a risk to patients other than their child/children through healthcare employment’. Some were reported without further details and may have been suspected or confirmed cases of FII where there were no specific practice concerns. There was insufficient information to comment on the age or any other characteristic of the children involved. The majority of reports indicated that a specialist tertiary centre (including the regional children’s specialist hospitals) had been involved. Although this sample included only a small number of cases, further dialogue with these institutions or more detailed scrutiny of case records were identified as potential avenues of research. 3.4.16. The SCR sought information from Cafcass about its understanding of cases involving FII that were the subject of applications by local authorities in the family courts.34 Cafcass does not collect data that would allow cases of FII to be identified. Soundings among experienced Cafcass practitioners and managers indicate that it is very rare for FII to form the principal grounds for the significant harm threshold to be met and that local authorities more commonly rely on other issues, such as neglect, to prove cases. FII may be an unproven background concern in more cases, though that cannot be quantified. Guidance and procedures 3.4.17. The definition of physical abuse in the UK has historically included poisoning, though not all cases of poisoning will constitute FII and not all cases of FII involve the administration of drugs or poisons. The 33 Communication from NHS Improvement to the Local Safeguarding Children Board (January 2017). 34 Communication from Cafcass (Children and Family Court Advisory and Support Service) to the Local Safeguarding Children Board (January 2017). 43 1999 edition of Working Together to Safeguard Children explicitly referred to factitious illness and MSbP as part of this definition.35 3.4.18. The Royal College of Paediatrics and Child Health (RCPCH) produced the first comprehensive guidance on FII in 2002.36 This drew on the research described above but was also intended to address serious contemporary concerns about the unregulated use of covert video surveillance of families (CVS). These focused on the rights of patients and parents and confusion between activity being carried out for research, clinical management of cases and safeguarding of children.37 3.4.19. In 2008 the government produced multi professional guidance on FII.38 This document can be found on the internet. It is outdated in that it takes no account of changes in practice, research or other guidance since its publication and refers to a number of organisations and arrangements that no longer exist. It is not clear if the intention of government is to update this guidance as current government policy is not to provide detailed practice guidance. 3.4.20. The RCPCH guidance was revised in 2009 to take account of the changes in clinical practice but also as part of a wider exercise to underline the responsibilities of health trusts and professionals in the light of the findings of the enquiries into the deaths of Victoria Climbié and Peter Connolly.39 It seeks to distinguish FII from apparently similar presentations which have different causes. Part of this classification is set out in Table 3. This very helpful differential approach has not so far been reflected in other local or national statutory safeguarding guidance. The guidance does not seek to explain the phenomenon (described in detail by clinicians who contributed to the review and suggested by the most recent research cited above) of an increasing number of older children who present and elaborate false symptoms. 35 Physical harm may also be caused when a parent or carer feigns the symptoms of, or deliberately causes ill health to a child whom they are looking after. This situation is commonly described using terms such as factitious illness by proxy or Munchausen syndrome by proxy. Department of Health, Home Office, Department for Education and Employment, (1999) Working Together to Safeguard Children (p5) 36 Royal College of Paediatrics and Child Health (2002) Fabricated or Induced Illness by Carers 37 At the time the professional standing of a number of the paediatricians most closely associated with developing and promoting practice in relation to MSbP and cot death during the 1980s and 1990s had been strongly challenged in a series of legal cases. 38 Department for Children, Schools and Families (2008) Safeguarding Children in whom Illness is fabricated or induced – supplementary guidance to Working Together to Safeguard Children 39 Royal College of Paediatrics and Child Health (2013), 44 Table 3 Spectrum of cases where FII concerns may arise 40 Starting point: A child is presented for medical attention, possibly repeatedly, with symptoms or signs suggesting significant illness; an appropriate clinical assessment suggests that the child’s ‘illness’ is not adequately explained by any disease. The examples below illustrate the range of possible considerations. Example 1 Simple anxiety, lack of knowledge about illness, over interpretation of normal or trivial features of childhood; may in some cases be associated with depressive illness in carer Example 2 Child’s symptoms are misperceived, perpetuated or reinforced by the carer’s behaviour; carer may genuinely believe the child is ill or may have fixed beliefs about illness Example 3 Carer actively promotes sick role by exaggeration, nontreatment of real problems, fabrication (lying) or falsification of signs, and/or induction of illness (sometimes referred to as ‘true’ FII) Example 4 Carer suffers from psychiatric illness (e.g. delusional disorder) which leads them to believe child is ill Example 5 Unrecognised genuine medical problem becomes apparent after initial concern about FII As with the spectrum of presentations referred to above in medical guidance the concept of ‘perplexing presentations’ is not currently reflected in local or national multi-agency safeguarding procedures. 3.4.21. The RCPCH has also published overall guidance for members on safeguarding.41 The section of this document dealing with FII urges paediatricians to consider FII as part of a wider spectrum of ‘perplexing presentations’ in the hope that ‘early recognition by paediatricians of perplexing presentations with alerting signs, followed by direct observation of the child, might obviate the full development of fabricated or induced illness’.42 This guidance proposes that paediatricians undertake a considerable amount of preliminary diagnostic work, including for example gathering information from schools before considering referral to the local authority. Only clearly diagnosed cases (where all alternative medical explanations have been eliminated) or those where there is believed to be an evidenced threat of suffocation or poisoning or physical harm should be referred to the local authority, the latter early on. 3.4.22. This approach rightly locates the responsibility for resolving health issues with clinicians. It may also reflect some hesitancy on the part 40 RCPCH (2009) page 8 41 Royal College of Paediatrics and Child Health (2013) Child Protection Companion, Section 13 42 Bass and Glaser (op cit) 45 of health professionals to share information and join multi-agency discussions about children without telling parents, until they have eliminated possible alternative causes. It should not do so as all health professionals work within guidance that enables them to share information, including with colleagues in other agencies if they believe that there are safeguarding concerns.43 3.4.23. This case review has demonstrated (3.2.1 – 12) that it is unrealistic to expect paediatricians with full clinical responsibilities to have enough time to coordinate work on a complex FII case. 3.4.24. In contrast, the 2008 central government guidance and local multi-agency procedures tend to advocate early consultation with the local authority and urgent action, because they are based on the notion that a typical case involves potentially severe harm to a very small child, rather than a complex set of interactions between many health professionals and an older child. 3.4.25. It was the intention of the 2008 government guidance that procedures dealing with FII should be integrated into local child protection procedures and this appears to have happened. However there are now considerable differences between local procedures. The London Child Protection Procedures (which should have assisted staff in this case) acknowledge the complexity of FII but then offer few concessions to its specific features, for example indicating that normal timescales for the completion of strategy meetings and child protection conferences should be adhered to. In reality the nature of such meetings in a case of suspected FII are likely to be very different, requiring longer to plan and convene. Research would seem to suggest that genuinely life-threatening cases of FII that need to be dealt with as an emergency are very rare. Other safeguarding procedures do evidence an attempt to respond to the more specific nature of FII.44 Summary 3.4.26. Despite the apparently considerable literature and guidance, there is little research carried out over the last decade on which safeguarding professionals can base their interventions. The lack of a recent population study makes it impossible for professionals to feel confident about the prevalence or incidence of FII, particularly as 43 See for example the General Medical Council Protecting Children and Young people the Responsibilities of Doctors http://www.gmc-uk.org/guidance/ethical_guidance/13260.asp 44 For example the Greater Manchester Safeguarding Partnership guidance offers more detailed and practical support for professionals including for example a template for the coordinating clinicians chronology. http://greatermanchesterscb.proceduresonline.com/chapters/p_fab_ind_illness.html?zoom_highlight=FII#med_evaluation 46 there is so much dispute about definition and criteria for the inclusion of cases. 3.4.27. This is of particular concern if, as the report has argued in Section 3.1, FII is a safeguarding concern that is constructed in the interaction between parent, health professional and child. This would suggest that it has no simple cause and that it might be manifest in different ways at different points in time and in different cultural contexts. 3.4.28. Based on the evidence of the health professionals in this case, in addition to the recognised individual mental health problems that affect parents in FII cases, parents, children and health professionals are all subject to wider societal pressures and influences. However there is little other than anecdotal knowledge about the way in which the wider social factors set out in Section 3.2 impact on FII and the responses of health professionals and others. 3.4.29. Research does not address the extent to which the earlier reported age distribution of FII remains valid or whether it has now become a phenomenon that involves older children and young adolescents who actively participate in the presentation of falsified symptoms. 3.4.30. If growing numbers of older children and adolescents are fabricating their own symptoms it is important to try to understand why. Are they, for example, children who in early childhood experienced the classically described form of FII who are now fabricating illnesses of their own, assisted by the detailed accounts of symptoms and tests readily available on the internet? Or is this a different phenomenon in which society is offering older children and adolescents incentives to adopt a sick role and the information with which to act it out? 3.4.31. Despite its potentially grave consequences we do not know how far FII remains a seriously concerning risk to infants and small children in the way that was initially described in the 1970s – 1990s. There are many unanswered questions. Has the harm subsided because health professionals are now alert to the risks and spotting such cases early? Or are there still severe cases that are not being reported because reporting criteria are not designed to capture all cases or because in cases of FII a large number of health trusts may have been involved but no single trust will view it as a serious case? Or are trusts under-reporting cases where they have contributed to iatrogenic illness? Older studies found that health professionals were over-represented among perpetrators, but has this become less relevant as information about the signs and symptoms of complex and rare diseases are now readily widely accessible? 3.4.32. The review of published guidance has identified a divergence between the professional guidance given to paediatricians and local safeguarding procedures. This may lead different professional groups 47 to approach cases in different ways, in particular over whether in its early stages FII is a medical condition that needs to be diagnosed by doctors or a child protection concern that requires multi-agency management. It may be that it is only through practice experience that trust between professionals will develop. However given the low incidence of FII and the rapid turnover of social care managers in many authorities, it is likely that opportunities for joint working on more than a single case will be rare. 4. Summary of findings and recommendations Introduction 4.1.1. The SCR has highlighted the difficulties faced by professionals in working with a family in which FII was suspected. These proved difficult to overcome despite the fact that a significant number of the professionals involved were concerned that this might be a case of FII and were actively seeking the best ways of protecting the children. Considerable effort went into coordinating work. 4.1.2. These efforts were unsuccessful for more than three years as a result of the difficulty of responding to an unusual and entrenched presentation within complex health and local safeguarding arrangements. Challenging the family and coordinating the kind of response that was required were not supported either by the prevailing organisational arrangements and culture within which health care was provided, or by the way in which agencies with safeguarding responsibilities worked together. The main difficulties in the case did not arise as a result of individual errors. 4.1.3. The SCR proposes that action is needed in five areas. It will be for the LSCB and other agencies to consider these further and determine how to take them forward, by the agencies involved in the case, across London and in some instances nationally. If it is agreed that action can be taken quickly across London there may be less need for specific action in Local Authority 1. If not, local action should be taken. Recommendation 1 4.1.4. The LSCB should develop and implement a pathway for the early identification and management of perplexing presentations, including cases where there are suspicions about FII. Examples of such pathways exist in the research literature (see for example Section 3.4). Given the existence of pan-London child protection arrangements and the likelihood that and suspected FII case will involve heath providers in different localities, these should 48 also be developed across London. In Local Authority 1 this could form part of local guidance on the management of complex cases and should certainly take emerging work on that issue into account. Drafting of a pathway for early identification should take account of the following specific learning from this review A pathway for the early identification and management of perplexing presentations should enable health professionals to explore the causes of medical symptoms, gathering information about the child and family from a variety of sources while at the same time maintaining an open mind about possible safeguarding concerns. The pathway should consider mechanisms for complex cases where a multi-agency group can consider a case and own the diagnosis of FII, rather than it be solely the responsibility of one clinician Such cases rarely involve only one health trust or provider working with the family. The pathway needs to take account of the roles and responsibilities of all of the agencies who might be involved and identify resources accordingly. Any health clinician who is asked to act in a coordinating and lead professional role needs the time, resources and knowledge to carry the task out. Summaries of research and existing health guidance suggests the appointment of lead professional at an early point who is confident in dealing with health concerns, knowledgeable about the range of health providers likely to be involved and has sufficient time to draw together information about the case. The roles of designated and named professionals in relation to ‘perplexing presentations’ and FII should be defined in local procedures Clinicians who are seeking to clarify concerns about ‘perplexing presentations’ and FII at an early point need to be able to draw on supervision and peer discussion Schools need to be engaged in earlier discussion of health concerns in possible FII cases There should be a facility to provide health chronologies at key meetings and to maintain them subsequently. Existing guidance allowing the sharing of information between professionals where there are safeguarding concerns needs to be reinforced. The pathway should recognise the key role of senior managers in 49 protecting staff who are working on such cases and making difficult professional judgements about whether investigations and treatments are necessary. Senior managers need to be briefed about contentious cases, not in a defensive way but in order to be able to support clinical staff who are exploring different explanations including FII or who face complaints when they refuse to be drawn into conducting further tests and surgery. Greater awareness of signs and symptoms of FII is needed in social care. Social care professionals need to be able to consider alternative accounts and explanations of behaviour and not stick rigidly to an established ‘narrative’ in the presence of mounting conflicting evidence The ambulance service needs to increase staff awareness of FII as a possible factor with children who are ‘frequent fliers’ and be able to test whether the circumstances match common patterns of symptoms in FII. Greater awareness is needed of the arrangements for implementing an individual patient protocol in children’s cases Tertiary health providers should be more aware of risks of FII and seek more detailed background information about previous tests and investigations. Recommendation 2 4.1.5. The LSCB should develop a pathway for the management of identified cases of FII (or cases where there is a strong and well-founded suspicion) including those children who are subject to child protection plans. This should apply both in the area where this case occurred and across London Drafting of a pathway for the management of identified cases of FII should take account of the following specific learning from this review Information sharing arrangements (whether they be part of day to day working or part of a child protection plan) need to encompass the whole health economy i.e. including GPs and primary care, community health services, acute sector and tertiary and other specialists. Given the complex nature of FII cases and the large number of professionals who are involved, it is not uncommon for key people to miss some meetings on cases. Information sharing arrangements need to take this into account and ensure that information is shared with all professionals involved including those unable to attend a meeting. When a Child Protection Conference is being held on a case of 50 suspected or identified FII, invitations should be sent to all involved health trusts and to named health professionals staff in the trust. Timescales for calling initial conferences should take account of the need to obtain comprehensive information and good health service attendance Procedures should consider the effectiveness of child protection conferences and core groups and whether there is scope for professional meetings that do not involve parents Chairs and administrators need to be better educated about roles of different health professionals, for example which health professionals could successfully take on a coordinating role in a case of suspected FII. Conferences need to strive to achieve a consistent membership and attendance in complex cases. This can be facilitated by informing the named professionals from the trust about the conference Conference administrators should consult the child’s GP to provide details of all health professionals who need to be invited, including those working with the parents if that will be beneficial The model of child protection conference discussion should match the needs of the case and the specific risks to the child in cases of FII. In such cases ‘engaging’ with services may not be a positive marker for progress or a strength. Recommendation 3 4.1.6. The LSCB should ensure that its training and procedures address particular difficulties that emerged in this case, including: Local procedures to clarify the nature and status of different meetings in complex cases, including cases of FII. This should address the question of who should attend them and when meetings will be held without informing parents Local procedures to agree how parental health records can be obtained when it will assist in the diagnosis of a child’s health condition Specific training and awareness raising for GPs about FII and the difficulties that such cases can pose for general practice and primary care Specific training on the new pathways proposed in recommendations 1 and 2 51 Recommendation 4 4.1.7. The LSCB should ask the Department of Health and the Department for Education to commission national research to establish the current prevalence, incidence and case characteristics and outcomes for children who have either perplexing presentations or FII. This research should draw on current experience of paediatricians and other front line staff so as to have a contemporary rather than a focus on the most serious cases or a historical focus. Recommendation 5 4.1.8. The London Safeguarding Board should update the current practice guidance on FII to take account of more recent guidance from the Royal College of Paediatrics and Child Health and other relevant developments in research and clinical experience. Child protection processes (such as the timing of meetings) should take account of the specific nature of FII. The LSCB and the London Safeguarding Board should invite HM Government to consider issuing updated guidance on perplexing presentations and FII. 52 Appendices Appendix 1 Principles from statutory guidance informing the Serious Case Review method, Terms of Reference and lines of enquiry Appendix 2 How the review was undertaken Appendix 3 SCR panel members Appendix 4 Roles of staff interviewed or in attendance at group sessions Appendix 5 References Appendix 6 Views of family members Appendix 7 Proposed flowchart for the medical management of unexplained presentations and FII Appendix 8 Medication known to have been prescribed to Child Y 53 Appendix I Principles from statutory guidance informing the Serious Case Review method The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. In addition Serious Case Reviews should: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Working Together to Safeguard Children 2015 (Sections 4.9 and 4.10) Terms of Reference and details of areas to be considered by the review 1 Overall purpose and terms of reference The purpose of the review is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.45 The specific objectives of the review are 1. To establish what happened 2. To establish why professionals acted as they did 3. To identify and understand the significance of a range of contributory factors that shaped the practice of professionals, including wider organisational factors. 45 HM Government (2015) Working Together to Safeguard Children 54 4. To identify any episodes and background factors that may have a direct bearing on the harm caused to the children and therefore may be relevant to a consideration of whether or not the injuries could have been prevented. 5. In addition the review will seek to understand what the case history tells us about the strengths and weaknesses of local safeguarding arrangements (sometimes referred to as using the individual case as a ‘window on the system’).46 6. The review will explore aspects of the assessment of vulnerability, need and risk that it determines are relevant, whether any potential indicators of abuse and neglect were recognised and the provision that was made for the children and other family members. 7. The review will seek to establish whether the multi-agency working met the expectations of the LSCB for a case such as this. In particular did it enable a good overall assessment; coordinated support; identification of discrepancies in information given by the parents; provision of services to meet needs? 46 Charles Vincent (2010) Patient Safety second edition 55 Appendix 2 How the review was undertaken 1. The LSCB asked member agencies to compile a chronology of key events based on the written and electronic agency records. Agencies also compiled brief initial reviews of the possible learning for their own agency 2. The LSCB established a review panel to oversee the conduct of the review consisting of the independent lead reviewer and senior staff from participating agencies and commissioners who had not been involved in the work with the family. The review panel was chaired by the Consultant in Public Health for the local authority area 3. The lead reviewer met with the authors of the chronologies to discuss key events and possible learning in more detail 4. The lead reviewer met with a group of managers in the local authority to discuss the case 5. The lead reviewer and the consultant in public health met health staff who had been involved in working directly with the family to discuss their experience and possible learning 6. The review team held individual interviews with members of staff and managers, supported by review of records where this assisted 7. The lead reviewer drafted findings which were discussed with the review team 8. The findings and possible learning were discussed with staff and other representatives from agencies who had worked with the family 9. The reviewer sought wider views on the case by making an anonymous presentation at a number of training events for health professionals, including local GPs 10. Views of Cafcass and NHS England were sought about the wider incidence of reported cases of FII 11. The lead reviewer interviewed the children’s mother to obtain her views about the services provided 12. Further drafts of the report were prepared and circulated to panel members 13. The LSCB Executive group discussed and agreed drafts of the report and recommendations 56 Appendix 3 SCR REVIEW TEAM MEMBERSHIP Independent and LSCB representatives Local Authority Consultant in Public Health (Panel Chair) Keith Ibbetson Independent Lead Reviewer Business Manager Safeguarding Children Board Administrator Safeguarding Children Board Review Team Representatives Agency Designation Police Service Serious Crime Review Group Reviewing Officers Local Authority 1 Principal Social Worker Director Children Services Assistant Director Learning & Achievement Legal Services Hospital Trust 1 Named Nurse Deputy chief nurse Hospital Trust 2 Named Nurse Hospital Trust 3 Head of Safeguarding and Named Nurse Clinical Commissioning Group Designated Nurse for Safeguarding Children Named GP Community Health Trust Assistant Director Children Services Named nurse safeguarding children Ambulance Service Safeguarding Lead Academy Schools Head / Deputy Head 57 Appendix 4 Roles of staff and managers involved in discussions over the findings of the SCR Local Authority 1 Principal Social Worker Service Manager (Children in Need) Independent Reviewing Officer Manager of IROs and Child Protection Conference Chairs Hospital Trust 1 ED Paediatric Nurses, Staff Nurses and Sister Consultant Paediatricians Named Nurse Hospital Trust 2 Named Nurse Named Doctor Hospital Trust 3 Named Nurse Named Doctor Clinical Commissioning Group and Primary Care Designated Nurse Named GP Local GPs (through a presentation and discussion at local training events) Family GP Community Health Trust Named Nurse CAMHS psychotherapist School Nurse Ambulance Service Safeguarding lead Academy Schools Head / Deputy Head Police Service Child Abuse Referrals desk Detective Sargeant 58 Appendix 5 References Christopher Bass and David Jones (2011) ‘Psychopathology of perpetrators of fabricated or induced illness in children: case series’, The British Journal of Psychiatry 199, 113–118 Christopher Bass, Danya Glaser (2014) ‘Early recognition and management of fabricated or induced illness in children’, www.thelancet.com Vol 383 April 19, 2014. Children and Family Court Advisory and Support Service, https://www.cafcass.gov.uk/ Denny SJ, Grant CC, Pinnock R. Epidemiology of Munchausen syndrome by proxy in New Zealand. J Paediatric Child Health 2001; 37: 240–43. Department for Children, Schools and Families (2008) Safeguarding Children in whom Illness is fabricated or induced – supplementary guidance to Working Together to Safeguard Children Ferrara P, Vitelli O, Bottaro G, et al. Factitious disorders and Munchausen syndrome: the tip of the iceberg. J Child Health Care 2013; 17: 366–74. General Medical Council Protecting Children and Young people the Responsibilities of Doctors http://www.gmc-uk.org/guidance/ethical_guidance/13260.asp HM Government (2015) Working Together to Safeguard Children McClure et al, McClure RJ, Davis PM, Meadow SR, Sibert JR. ‘Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation’. Archives of Diseases in Childhood, 1996; 75: 57–61. National Repository of Serious Case Reviews https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/national-case-review-repository/ Royal College of Paediatrics and Child Health (2002) Fabricated or Induced Illness by Carers Royal College of Paediatrics and Child Health (2009) Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians Royal College of Paediatrics and Child Health (2013) Child Protection Companion, Section 13 http://www.signsofsafety.net/signs-of-safety-2/ Mary Sheridan (2003) ‘The deceit continues: An updated literature review of Munchausen Syndrome by Proxy’, Child Abuse and Neglect, 27, 431-51 Charles Vincent (2010) Patient Safety second edition Watson S, Eminson DM, Coupe W. Personal communication. In: Eminson M, Postlethwaite RJ, eds. Munchausen syndrome by proxy abuse: a practical approach. 2000: Oxford, Butterworth Heinemann: 17–70. 59 Appendix 6 VIEWS OF CHILD Y’s MOTHER ABOUT THE SERVICES PROVIDED 1. Child Y’s mother said that the reason the family visited so many hospitals was that the family was always moving around so much. 2. Each hospital had different views on how to treat her son or what medication to give. 3. Staff within and in different hospitals were contradicting each other, so she did not know what to believe and what to do. 4. She had suffered domestic abuse from the children’s father (including a broken finger and an injured shoulder) and harassment at court and at her flat 5. Plans that were agreed and written down were not implemented for example her son saw a therapist and should have also seen a physiotherapist, but nothing materialised. 6. Her daughter had issues at school but did not like to admit that she had trouble with learning. Her troubles affected the whole family 60 Appendix 7 Excerpt from, ‘Proposed flowchart for the medical management of unexplained presentations and FII’ Christopher Bass, Danya Glaser (2014) ‘Early recognition and management of fabricated or induced illness in children’, www.thelancet.com Vol 383 April 19, 2014 Supplementary Appendix Lancet 2014; published online March 6. http://dx.doi.org/10.1016/S0140-6736(13)62183-2 Nominate a lead paediatrician (if child under more than one specialty) Discuss discrepancies with other medical services including GP If parents reluctant for this, explore reasons Compile chronology of involvement with all health services and any social care contacts, noting: Who reported concerns o Whether the reported symptoms and signs were independently observed o What were the medical findings o Whether they explained the reported concerns o Whether they warranted the functional impairment of the child What 3 the outcome was o Whether there has been frequent change of doctors, including due to geographical moves Obtain information about health of siblings Obtain full account 3 or other aids How the child’s reported ill health is affecting family life, including siblings and the parents’ work Elicit the parents’ explanations for the child’s reported ill‐health Carry out definitive, warranted investigations to clarify diagnosis. This may include admission to observe child constantly & requires a multidisciplinary internal planning meeting If parents refuse admission, support for this will be required from children’s social care Talk with child on her/his own to ascertain her/his view, experiences and possible anxieties about their health 61 Appendix 8 Medication known to have been prescribed to Child Y Child Y was not taking all of this medication simultaneously, though it is impossible to track from the medical records exactly when each medication was prescribed, when he took it and how much of any medication he took. Medical or proprietary name Description Amlodipine Used to treat chest pain and other conditions caused by heart disease Augmentin Antibiotic containing penicillin and other antibiotic B12 injections Counteracts reduction in B12 caused by Entonox Cephalexin Antibiotic Chlorpheniramine Antihistamine – reduction of allergic symptoms Co-codamol Paracetamol based pain relief Codeine Morphine based pain relief Co-dydramol Combination pain relief Diazepam Muscle relaxant – anxiety relief Di-hydro codeine Opiate based pain relief Entonox Nitrous oxide Folic Acid Vitamin B9 Gabapentin Anti-epileptic, treatment for nerve pain Oramorph Oral morphine pain relief Paracetamol / Pain relief Promethazine Treatment of allergies Ranitidine Stomach ulcers Simvastatin Statin to reduce cholesterol level Tramadol Opiate based pain relief On one occasion a review at Hospital Trust 2 showed him to be taking the following, not listed above Omeprazole – reduces stomach acidity Protonic - similar Loratidine – for the treatment of rhinitis and allergies At a number of points Child Y was noted to be using a GTN spray (for pain relief). He told ED staff that he had been given it by the ambulance service, but this seems unlikely as the ambulance service will only use this spray for adults, so it may have been obtained elsewhere. He also possessed an EpiPen (one off injection of adrenalin to counter allergic reactions) though it is not clear who issued this. The local hospital does not prescribe this as a ‘take home medication’ and it would normally be prescribed by an allergy specialist. However the GP records contain no evidence of this. EpiPens may be purchased on line. |
NC52339 | Intrafamilial sexual abuse and neglect of four girls in an extended family over a number of years. Learning focuses on: identification of intrafamilial child sexual abuse; harmful sexual behaviours and siblings; intrafamilial sexual abuse by women; enabling children to talk about child sexual abuse and responding appropriately; understanding help seeking behaviour; the sexual abuse of disabled children; recognising the importance of safe adults and the non-abusive parent and family; understanding the motivations and behaviours of adults who pose a sexual risk to children; responding to adult disclosures of sexual abuse in childhood; responding to the needs of parents with learning disabilities; assessment of the connection between parental learning disability and neglectful parenting; the importance of understanding family history. Makes many recommendations including: consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse; reinforce the importance of children's access to appropriate therapy while police investigations are continuing; develop guidance regarding complex and historic abuse investigations; remind Police of the importance of considering a range of risk management measures including sexual risk orders; local and regional safeguarding procedures regarding child sexual abuse need to include the requirement to undertake criminal injuries compensation processes and raise with children and their parents the Victims Right to Review scheme.
| Serious Case Review No: 2022/C9361 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Official Child Safeguarding Practice Review Anya, Rosa, Whitney and Lena1 Jane Wiffin 1 Anonymised names 2 Official This child safeguarding practice review is dedicated to the bravery of all the children involved who were able to speak out to their family or professionals about the sexual abuse that they were subject to by a member of their family. Of course, they should not be responsible for alerting others to the being subject to sexual abuse; it is the responsibility of both family and professionals to recognise the signs and indicators, think about history and behaviour which might indicate sexual abuse and to act appropriately on those concerns. This review is a call to action to address intrafamilial child sexual abuse. 3 Official Introduction Reason for this Child Safeguarding Practice Review (LSCPR) 1.1 This independently led LSCPR2 (will be referred to as this review going forward) was commissioned by the Local Child Safeguarding Partnership because Paul3, an adult, was found to be in possession of, and sharing, indecent images of children. A police investigation was started, and it became clear some of the images were of his daughter Whitney (aged 3). Subsequently Rosa (when aged 14), Anya (when aged 15) who were Paul’s sisters, and his niece Lena (aged 4) spoke about being sexually abused by Paul. Whitney also reported that her father had sexually abused her. This review has focussed on these 4 children because there are known concerns that they have been sexually abused by Paul. There remain concerns that there may be other children who have been sexually abused by Paul and other family members in the past and in the period covered by the review, but this information is not known. It was only when Paul was convicted did Rosa and Anya make allegations of sexual harm by their mother. 1.2 A police investigation took place over a 20-month period; during this time, Paul was in the community, sometimes out on bail with conditions not to have any contact with children aged 16 and under. He eventually plead guilty to several sexual offences against children and received a substantial custodial sentence. Safeguarding action was taken regarding all 4 children and they and their siblings are now living safely with family. They are receiving therapeutic support in recognition of the significant harm they have experienced. It is important that this therapeutic support continues. 1.3 A wider review of Paul’s extended family circumstances provided a picture of long-term concerns about intra-familial child sexual abuse, child neglect, adult learning disabilities, alcohol misuse, domestic abuse, mental health concerns and chaotic family circumstances. 1.4 There are also allegations that Paul was domestically and sexually abusive to the women he formed relationships with and that these women had either learning difficulties, physical disabilities and mental health needs. This review does not cover their circumstances, but appropriate adult agencies have been alerted to their needs and enquiries conducted to ensure their safety and any needs emerging out of the harm they experienced are addressed. 1.5 The agreed focus of this review was agreed to be: 2 A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR)) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children. 3 The family are white/British 4 Official • understanding and responding to complex historical and current inter-generational child sexual abuse, sharing risk assessments and information. • Working with and protecting children and adults with a physical and/or learning disability • Use of Police bail conditions. • Use of chronologies in risk assessments. • Actions following child sexual abuse medicals. • The use of challenge and escalation in multiagency decision making and application of thresholds. The extent to which these were relevant concerns is addressed in the findings section. 1.6 The timescales were agreed to be from March 2017 when there was the first indication that Rosa was being sexually abused to November 2019 when Paul was convicted of sexual offences against children. This timescale was then extended to include the court judgment made in the care proceedings for Anya and Rosa in June 2020 and the further allegations of sexual harm made by Rosa and Anya in 2020 and 2021 as these incidents were considered of relevance to the review. 1.7 The review was led by Jane Wiffin, an independent reviewer who is responsible for authoring this final report. A panel of senior managers representing the agencies involved with the children and their families provided support, information and critical challenge to the development of the report findings. This has not been an easy task, particularly during the public health requirements emerging from CV-19. I want to thank everyone for their dedication, support and enthusiasm for learning. The process was effectively and sensitively chaired by the local designated nurse and ably overseen and managed by the partnership manager as well as the coordinator for the Safeguarding Children Partnership. 1.7 There were many professionals involved with the children and families under review. They have all contributed to the review process through several group interviews and I want to thank them for their time and thoughtfulness. There were also some professionals who had no longer worked for the organisations providing services to the family, and they also wanted to talk about their reflections and perspectives. Working to address the safety of these children took its toll on many of them and the impact of working with complex child abuse cases is discussed in the findings section. 1.8 Specialist advice was provided to the review by Triangle; an organisation with an in-depth knowledge of the needs of children who have been sexually harmed. We thank them for their help Family involvement 1.9 All adult and older children within the different families were invited to contribute to the review. This was facilitated by the social workers involved with the children and managed sensitively. For reasons of privacy, it is not necessary to outline exactly who 5 Official agreed to meet with the lead reviewer and chair. The information they provided chimed with all the other information provided. Their views are incorporated into the review. I want to thank them for spending time with us and for discussing what were clearly painful subjects. About the children and their families 1.10 The family is white/British and although they were described as living in impoverished circumstances, without work, but there is little available information about their economic circumstances. Rosa and Anya: 1.11 At the start of this review period Rosa and Anya were living with their mother, father, and some grown up siblings including their brother Paul. Rosa and Anya’s parents had (undiagnosed) learning disabilities and some health needs. There is evidence that Rosa and Anya’s needs were neglected from early childhood by their parents. Historically, support was provided, their living circumstances and the parenting they received seemed to improve and support would cease. There would be a deterioration in living circumstances or a crisis that needed attention from specialist services and support would be increased. Anya and Rosa lived their lives in a household characterised by chaos, violence, alcohol misuse, with many adults present about whom there were concerns regarding sexual abuse. These concerns were often communicated via anonymous referrals to children’s services and were superficially assessed; the conclusion was that the concerns were not substantiated, and no action was necessary. This review does not focus on the issue of anonymous referrals, but there is growing concern nationally about the lack of guidance regarding referrals of concern related to children by members of the community. 1.12 Anya (aged 11 at the start of the review period) is quite shy and reserved, but when she meets new people, she likes to talk to them. She loves animals. She has communication and learning needs and communicated partly verbally and partly through sign language in her early years, though now has become fully verbal through her own hard work and appropriate support. Neither her parents nor her wider family ever learnt to sign so this limited her opportunities for communication. The sexual and emotional abuse she has experienced over many years has had an impact, and there are times when she feels sad, confused and angry; therapeutic support is helping her make sense of the harm she has experienced. 1.13 Rosa (aged 12 at the start of the review period) is a friendly and lively young person who loves animals and enjoys drawing and crafting. People who know her well say she has a good sense of humour. Like her younger sister, she has communication and learning needs and communicated partly verbally and partly through sign language in her early years, though now has become fully verbal through her own hard work and appropriate support. Neither her parents nor wider family ever learnt to sign so this limited her opportunities for communication in her early years. The abuse she has experienced over many years has had an impact, and there are times when she feels 6 Official sad, confused and angry; therapeutic support is being provided to help her make sense of the harm she has been subjected to. 1.14 Anya and Rosa are currently living in a small residential unit supported by a small group of staff they have known for a few years. They have supervised contact with their parents, grown up siblings and their nieces and nephews. This family time is very important to them. Whitney 1.15 Whitney (aged 4 at the start of the review period) lived her early life with her mother who has some learning needs and her father (Paul) who was domestically abusive to Whitney’s mother which had a negative impact on her mental health. The parents separated when Whitney was very young, and Whitney’s contact with her father (Paul) was supervised by his mother at her home. Whitney’s mother also experienced coercion and control by members of the wider family and this brought Whitney into contact with unsafe and alcohol fuelled chaotic situations and adults of concern. There were concerns about Paul’s alcohol misuse, poor mental health and chaotic lifestyle. The previous history of concerns that Paul may have been sexually abused as a child, may have subjected his siblings to sexual abuse and others to sexual assault was not part of the analysis when thinking about the circumstances in which Paul should see Whitney and where. The reasons for this are considered in the analysis section of the report. 1.16 Whitney (aged 3 at the start of the review period) is described as a happy and friendly child who likes playing with her friends and loves school. She has some speech delay but is catching up quickly through help and support; she is doing well at school. She sometimes feels angry, upset, confused and has nightmares about what has happened to her, and she is receiving therapeutic support to help her in the process of recovery from the harm she has experienced. 1.17 Whitney’s mother has moved to another area and Whitney has started a new school. Whitney’s mother receives support from her wider family. Lena 1.18 At the start of the review period Lena was living with her parents and siblings. Her mother had learning disabilities and her father had some physical disabilities. Lena’s mothers learning disabilities were significant and Lena’s father was asked to be the main carer for the children by children’s services. This decision did not take account of concerns about domestic abuse and coercion and control; something picked up in the findings section. Referrals were made to adult services to provide Lena’s mother with support, but she was always assessed as an individual who did not meet the criteria for help. This is discussed in the findings section. The family were very dependent for help on the maternal extended family; this brought Lena and her siblings into contact with unsafe, alcohol fuelled chaotic situations and adults of concern. Paul is Lena’s uncle. 7 Official 1.19 Lena (aged 4 at the start of the review period) is friendly, chatty and likes running around with her friends. She has some communication and learning needs for which she receives support and appropriate help. She is receiving therapeutic support, and this is helping her feel settled at home. 1.20 Lena and her siblings spent some time with a foster family but are now living with father’s extended family. They see their mother in a planned and supervised way but have no contact with their paternal grandparents or extended family. 8 Official 2. Timeline of professional involvement with four children in this large extended family 2.1 This is a high-level overview of the involvement of the children and their families with services. Inevitably much of the hard work of so many organisations and individuals are not included, but there is evidence of concerted efforts to meet the needs of all the children. 2.2 A timeline of the separate family groups is provided because professionals were not initially aware of the extent of the different family’s interconnectedness, particularly that Whitney, Lena and siblings were looked after by their grandmother (Paul’s mother) and spent large amounts of time in her home with Anya and Rosa; Paul was also resident in this home until August 2018. Anya (11) & Rosa (12) Whitney (3) Lena (4) 2017 May/ June Referral of concern that Rosa was subjected to harmful sexual behaviour4i. After enquiries were undertaken by children’s services it was agreed no action was necessary. Paternal grandmother alleged that Whitney was being neglected by her mother. An assessment5 was completed and a child in need plan6 started. Lena and her siblings were receiving support through an early help plan7 because of ongoing concerns about neglect and their mother’s ability to cope. 2018 Feb There were safeguarding concerns about the baby of a member of the extended family who lived away from home. Rosa and Anya’s parents and one of their grown-up siblings put themselves forward to be assessed as possible family carers. These assessments8 provided a worrying picture of a history of chronic neglect, chaos in the home and the presence of intoxicated and suicidal adults. There was reference made to the long involvement with children’s services, including concerns about Rosa and Anya’s parent’s poor supervision of their children over time 4 Harmful sexual behaviour (HSB) is developmentally inappropriate sexual behaviour displayed by children and young people which is harmful or abusive 5 A Child and Family Assessment addresses the central and most important aspects of the needs of a child / young person, and the capacity of his or her parents or care givers to respond appropriately to these needs within the wider family and community context. 6 This is a plan that sets out what extra help children’s services and other agencies, including health and education, will provide for a child in need and their family. The plan should be drawn up in partnership with the child and their family after a child in need assessment. 7 An early help plan is an action plan to meet the assessed need of a child, young person and their family. 8A local authority viability assessment considers the likelihood of carers being able to meet the physical and emotional needs of the children now and throughout their childhoods; whether they will be provided with stability and boundaries and whether they will be safe. Police and medical checks are initiated. 9 Official and leaving them with adults who posed a sexual risk. Neither Rosa’s parents nor the grown-up sibling was deemed suitable alternative carers. Feb to April Rosa and Anya moved to a residential centre. Two days after arrival there were concerns reported by Rosa’s sister of sexual touching (sibling sexual abuse). Child in need support was being provided to Whitney and her mother. There were concerns regarding bruising to Lena. A child protection medical9 was undertaken and concluded that “a non-accidental cause” could not be completely excluded, despite some plausible explanations by the parents. This medical took place in isolation from information about the wider family circumstances. June The police received information that Paul had uploaded indecent images of children10. Paul was bailed into the community whilst an investigation was ongoing, with conditions to have no unsupervised contact with children under the age of 16 and not to return to his family home; he moved in with his girlfriend. Children’s social care were notified because of Paul’s contact with his own children and children within the family. Soon after Paul’s bail conditions expired, and a working agreement was signed by family members not to allow him to have unsupervised contact with any children. June There were concerns about Rosa and Anya ’s distressed and sexualised behaviour. They were made subject to child protection plans for sexual abuse and there were Keep safe work11 was carried out with Whitney; she reported sexual abuse by Paul to her social worker. It is not clear how this was responded to. It did not lead to any immediate action. Lena and her sisters continued to be looked after by their maternal grandmother. 9 A child protection examination is carried out to look for signs that a child or young person has been abused or neglected. This is different from a clinical examination, which aims to establish what is wrong with the child or young person and what treatment may be needed. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/protecting-children-and-young-people/child-protection-examinations 10 Taking, making, sharing and possessing indecent images and pseudo-photographs of people under 18 is illegal. making’ can include opening, accessing, downloading and storing online content; ‘sharing’ includes sending on an email, offering on a file sharing platform, uploading to a site that other people have access to, and possessing with a view to distribute. https://www.gov.uk/government/publications/indecent-images-of-children-guidance-for-young-people/indecent-images-of-children-guidance-for-young-people 11 The nature of this work was not defined. 10 Official significant concerns about neglect. Historical issues regarding a long history of inappropriate adult sexual behaviours and poor sexual boundaries in the family home were discussed. August Indecent images held by Paul were found to be of Whitney and allegations that Paul had raped Lena were made by other adults in contact with Paul. Paul remained on bail and subject to bail conditions. August Two strategy meetings12 were held to discuss all the children’s circumstances. Health professionals were not invited to the first meeting but were to the second. A comprehensive referral was made for medical assessments of all children. August/Sep Anya and Rosa were already subject to child protection plans13. Anya and Rosa exhibited extreme sexualised behaviour at school and care proceedings14 were initiated. A joint police and child protection enquiry was started and led to an initial child protection conference. There was uncertainty about whether Whitney’s mother had been protective. Over time it was established that she was. The role that paternal grandparents (Paul’s parents) played and how well they kept Whitney safe was not discussed. A child protection inquiry was started for Lena and her siblings. It was decided that the children would be made subject to child in need plans because they had no contact with Paul. Significant concerns about neglect remained. The role that maternal grandparents (Paul’s parents) played and how well they kept the children safe was not considered. 12 The purpose of a strategy discussion is to decide whether the threshold has been met for a single or joint agency (police/children’s social care) child protection enquiry, and to plan this. They happen when it is believed a child has suffered, or is likely to suffer, serious harm. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 13 A child protection plan is drawn up at a child protection conference when it has been agreed that a child is suffering or at risk of suffering form harm. The plan is a written record for parents and carers and professionals which sets out what work needs to be done to reduce concerns about a child(ren), what support and services will be provided and expectations of family members. 14 If children’s services have good reason (‘reasonable grounds’) to believe a child has suffered, or is likely to suffer significant harm, they may start care proceedings. This is the process of applying to the Family Court for a care order or supervision order. 11 Official Sep The Community Paediatrician made a referral for consideration of a child safeguarding practice review because of concerns about all the children. Nov Children’s services held a single agency meeting to map family connections and to bring together historical information. Good practice suggests that the family circumstances should have been considered under the complex abuse procedures15 and comprehensive chronologies commissioned. Nov The referral by the Community Paediatrician was discussed at the group responsible for LSCPR’s locally. The decision was that although there was a long history of concerns, immediate action had been taken to safeguard all the children. There was agreement that there was no need for a historic review and that a police investigation was ongoing. Updates were sought over the next 18 months. Nov An interim care order16 was granted for Rosa and Anya. They continued to have supervised contact with their parents and members of their extended family. Whitney remained subject to a child protection plan. Whitney’s mother was supported by her social worker to renew connections with her own family, and this was helpful for her. Concerns emerged that Paul was having contact with Lena and her siblings, and they were made subject to child protection plans. A further working agreement17 was signed. 2019 Feb Anya and Rosa remained in residential care and the care proceedings were ongoing. Whitney’s mother continued to seek help and support and provided safe and nurturing care to Whitney. Lena’s parents separated. There was insufficient thought given to how mother would cope parenting three young children on her own. April It is not clear whether Lena’s sister allegation of sexual touching by Rosa was discussed with her. Lena’s sister reported sexual touching by Rosa at her paternal grandmother’s house in the past. This was subject to police/children’s 15 https://www.londoncp.co.uk/organised_complex.html 16 This is a short-term court order which means that a child becomes looked after in the care system. An interim care order is often made at the start of care proceedings. It will usually last until the court is able to make a final decision. It can be ended before then if the court decides that the order is no longer necessary. 17 The purpose of a written agreement is to clearly set out required actions a family should undertake to ensure the safety and wellbeing of the child in the case. 12 Official services enquiries. April Lena and her siblings came into care under a voluntary agreement due to evidence that their mother was being harmed and exploited by several men, and they were being exposed to harmful, scary and dangerous situations. May There were concerns that Paul was seeking to gain access to children through masquerading as a member of staff at a swimming pool and adventure park, but although information was sought, precise details could not be established May to August Rosa started talking about witnessing sexual activity by adults when living at home, being sexually abused by Paul and witnessing him sexually abuse Whitney. Whitney made an allegation of sexual abuse by Paul and reported that Rosa and paternal grandmother were present. This was shared with the police. Lena indicated that paternal grandfather had behaved in an inappropriate way. A confused picture emerged. The police were involved, and Lena was spoken to, but there was no clarity about what exactly had happened. Sep Achieving Best Evidence Interview of Rosa (ABE18) Nov Paul was charged with rape of a child and the distribution of indecent images of children; he plead guilty to these charges and received a lengthy custodial sentence. Rosa and Anya remained living at the residential unit. Whitney and mother moved to a new area and Whitney started at a new school. Whitney was provide with Lena and her siblings moved to live with extended family members. Therapeutic support was provided. 18 Achieving best evidence interviews are conducted by police officers or social workers who are specially trained to plan and carry out interviews with children with the aim gathering evidence for use in criminal proceedings and where they are video recorded (VRI) to be used as part of the examination in chief of a child witness. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1051269/achieving-best-evidence-criminal-proceedings.pdf 13 Official therapeutic support 2020: Rosa and Anya January Rosa makes allegation of child sexual abuse by her mother, including that her mother and father colluded with Paul in his abuse of her. These allegations are under current investigation. June A full care order19 was granted for Rosa and Anya, and they remained living in residential care. There was a judgement made that Paul had sexually abused Rosa, Rosa had witnessed the abuse of Whitney causing her emotional harm and Rosa and Anya’s parents had failed to protection them, despite being aware that Paul posed a risk to children. The conclusion was that the parents were not aware of the sexual risk he posed. August The family circumstances were again considered , and a child safeguarding practice review agreed and commenced. Anya and Rosa have continued to talk about being sexually abused by Paul and their mother, actively not being protected by their parents (who are grandparents to Whitney and Lena) as well as witnessing the abuse of their nieces in their family home. The allegations of abuse by their mother are subject to ongoing police enquiries. 19 Care Proceedings begin when children social care has a serious child protection concern about a child. They can go to court to seek a legal order to remove the child from its parents’ care. With a Care Order children’s shares parental responsibility for a child(ren) https://www.legislation.gov.uk/ukpga/1989 14 Official 3. Analysis and key Findings 3.1 The purpose of any child safeguarding practice review (LSCPR) is to identify any improvements that need to be made locally and nationally to safeguard and promote the welfare of children and to seek to prevent or reduce the risk of recurrence of similar incidents occurringii. This Review was commissioned to look at multi-agency practice in the context of inter-generational historical and contemporary child sexual abuse to establish learning about the identification, risk assessment, understanding and management of complex abuse cases. 3.2 The initial impetus for the review was concerns that Paul had sexually abused at least four children including his siblings, daughter and niece. What has emerged is a picture of these children also being subject to emotional abuse and neglect, and witnessing adult behaviours such as domestic violence, inappropriate adult sexual behaviour, adult alcohol misuse, some indications of adult drug misuse, and adult mental health needs expressed in chaotic ways. These must have been frightening circumstances for them all. It is likely that other children have been harmed, and there are allegations that adults in the family, including Anya and Rosa’s mother (grandmother to the other children) and that adult family members were aware of the abuse taking place and did not inform professionals of those concerns. 3.3 The review has focussed primarily on a two-year period from 2017 to 2019, but there is information available dating back almost 25 years of concerns about poor sexual boundaries, possible sibling sexual abuse , domestic abuse, and neglect. It is likely that Paul and his siblings were subjected to sexual abuse by their siblings, relatives and family friends when they were children. This is likely to have had a negative impact on them as adults, including their wellbeing, their health, ability to form healthy relationships and become effective functioning parents. 3.4 This intergenerational history of child sexual abuse reminds us of the importance of improving the professional response to intrafamilial child sexual abuse. The key finding of this review. There are three other key practice themes or findings that have emerged regarding the effectiveness of the professional response to these children and their siblings which are also likely to impact on the circumstances of other children locally and nationally in the future if not addressed. These are addressing child neglect, working with parents who have learning disabilities and how well a family history is incorporated into a contemporaneous understanding of children’s needs and circumstances. Finding 1: Working effectively to address intrafamilial child sexual abuse. 3.5 The first key finding of this review is the extent to which these four children were provided with an effective response in the context of intrafamilial child sexual abuse. Child sexual abuse has had a high profile in recent years, but there are still far more children being sexually abused than professionals are currently 15 Official identifying and safeguarding. A recent analysis of data from a range of agenciesiii reveals that more than one in ten children had been sexually abused by the age of 16; this is much higher for girls (15%) than for boys (5%)iv v. The number of child protection plans for sexual abuse has decreased significantly; there were just 2,600 children on child protection plans under the primary category of sexual abuse across the whole of England in 2019/20. This was despite there being 87,992 identifiable child sexual abuse offences recorded by the police in the same year, and 30,460 children assessed as being at risk. At the same time, there were fewer prosecutions and fewer convictions in 2019/20 than three years ago. 3.5 Researchvi and inspectionsvii have highlighted several challenges in this important work. • Key professionals working with children have been insufficiently supported to gain the knowledge, skills and confidence needed to identify and respond effectively to concerns of child sexual abuse. There is longstanding inconsistency in the availability, accessibility, breadth, and quality of training on child sexual abuse, as well as peer support and supervision in social work, health, education, and policing. • Serious Case Reviews/Child Safeguarding Practice Reviews relating to intrafamilial child sexual abuse identify common themes such as professionals failing to spot signs and indicators of child sexual abuse, not feeling confident to ask children about child sexual abuse or to support children to talk about sexual abuse and being reluctant to pursue concerns of child sexual abuse when an alternative hypothesis, often neglect, is present. • There is lack of clarity about the appropriate professional response to sexual abuse perpetrated by children such as harmful sexual behaviours (HSB) and sibling sexual abuse. • The sexual abuse of children by women is underestimated by professionals, and therefore concerns related to women as abusers are not always addressed. • There is too much focus on the needs of the criminal justice system. The vast majority (more than four-fifths) of police investigations into child sexual abuse do not progress to charge and prosecution, or out-of-court resolutionviii. Despite the very low numbers of cases of child sexual abuse that do progress through the criminal justice system, there is undue attention paid to the need to ensure that talking to children or providing them with interventions does not ‘contaminate evidence and this often inhibits professionals from effectively identifying and responding to sexual abuse; police action can happen separately from the safeguarding response with poor communication and sharing of information. • There is poor identification of “safe adults” or non-abusing parents, an insufficient understanding of the importance 16 Official of assessment and analysis of these adults’ ability to be protective, making sense of what undermines this and what support is needed for them. • There is limited understanding amongst safeguarding professionals (not specialist sexual offending professions) regarding the motivations and behaviours of those adults who pose a sexual risk to children/young people, but who are not paedophiles. 3.6 These factors, which are seen nationally, were largely all present in this LSCPR and will be explored in the context of what we know about Rosa, Anya, Whitney and Lena. This finding covers a number of different aspects of the professional response to child sexual abuse including: • Identification of intrafamilial child sexual abuse. • Harmful sexual behaviours and sibling sexual abuse. • Recognition of intrafamilial sexual abuse by an adult in a family context • Intrafamilial sexual abuse by women. • Enabling children to talk about their worries and particularly child sexual abuse and responding appropriately. • Understanding help seeking behaviour: Supporting children to seek help from professionals. • Recognising and responding to the impact of child sexual abuse • The sexual abuse of disabled children. • Recognising the importance of safe adults/ the non-abusing parent/family • Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people. • Support to families after child sexual abuse has been identified. • Responding to adult disclosures of sexual abuse in childhood. Addressing non-recent child sexual abuse. • The multi-agency response to child sexual abuse. Identification of intrafamilial child sexual abuse a) Harmful sexual behaviours and sibling sexual abuse 3.7 Official statistics suggest that between 20% and 33% of all reported child sexual abuse in the UK involves other children and adolescents as those who have 17 Official sexually harmed. Official figures may, however, under-estimate the true scale of the problem. Sibling sexual abuse is thought to be the most common form of intra-familial child sexual abuse, perhaps up to three times as common as sexual abuse of a child by a parentix. 3.8 Harmful sexual behaviours (HSB) are defined as “Sexual behaviours expressed by children and young people under the age of 18 years old that are developmentally inappropriate, may be harmful towards self or others, or be abusive towards another child, young person or adultx.” (Derived from Hackett, 2014xi). Sibling sexual abuse is a form of HSB with the added complexity of complex family relationships. Language is critical; children20 should not be referred to as “child sex offenders” young abuser’ or ‘an adolescent perpetrators but as children who sexually harm and a child who has been sexually harmed. These are children first. What is important is for there to be an appropriate assessment of the circumstances, relating both to the child who has harmed, and the child who has been harmed. 3.9 Rosa and Anya came to the attention of professionals in 2017 when there were concerns that Rosa had been inappropriately sexually touched by a peer from school and then a much younger friend. A referral was made to children’s social care. The information was reviewed, and a decision made that no action was necessary. Given no assessment was completed, by any agency it is hard to evaluate the seriousness of this concern across the continuum of normal sexual exploration to sexually harmful behaviours. Yet contextually there had been an anonymous referral two-years earlier about Paul being a “paedophile” and living at home with Anya and Rosa. Three years earlier there had been many concerns about Anya and Rosa’s sexualised behaviours which led to child protection plans for neglect, not risk of sexual abuse. The current concerns should have been contextualized alongside earlier concerns of a similar nature. This was not possible because a chronology was not held for the children on the electronic system (an issue picked up in Finding 4 about history) and because of changes to the electronic recording system and the migration of data, some records and assessments were not easily accessible. 3.10 When there were further complaints made about a young child being sexually harmful to Rosa and Anya, it was agreed that no police action was necessary, but a child and family assessment was completed, and Anya and Rosa were made subject to child in need plans. However, the nature of the sexual harm was not established, and links were not made to historic information about Rosa’s sexualised behaviour and the long history of concerns about poor sexual boundaries in the home and allegations of previous harmful sexual behaviours, sexual abuse and historic sibling sexual abuse. This incident was not seen as a possible indicator of sexual abuse which required more exploration. The child in need plan and process got sidelined into concerns about education with a secondary focus on neglect; both pressing 20 When the word child is used, this includes everyone aged 18 and under. 18 Official issues, but the question about whether there were indications of sexual abuse was not asked and the meaning of the harmful sexual behaviours not addressed. 3.11 In April 2018 Rosa and Anya moved to a residential school. Anya immediately (2 days in) spoke about Rosa touching her in a sexually harmful way. Although immediate action was taken, there was insufficient analysis of the possible meaning of this sibling sexual abuse. A further assessment was completed but it did not address or name concerns about sexual abuse; most importantly why it was occurring, what the impact was likely to be and what needed to be done about it was not addressed. An initial child protection case conference was convened, and Rosa and Anya were made subject to child protection plans for sexual abuse, but there was no discussion of sibling sexual abuse and what needed to be done to address it, or the meaning of it in the broader context of Anya and Rosa’s needs. 3.12 Over time Lena has also spoken about Anya being sexually harmful to her and there were concerns that Lena was sexually harmful to her sibling. These incidents were taken seriously, but little actual action was taken to address the concerns, understand the cause of this harmful sexual behaviour in the context of them having been potentially sexually abused, and what action needed to be taken to understand the impact and address the harm. 3.12 There were many concerns of Rosa being sexually harmful to children in her family, and although acknowledged as of concern, but no specific assessment or intervention plans initiated. The evidence is clear that harmful sexual behaviours and sibling sexual abuse needs to be taken seriously, needs to be assessed, understood and addressed. 3.13 Contemporary practice for Anya and Rosa mirrors the professional response to this extended family from many years earlier. There were continual allegations of both sibling sexual abuse as well as children in the wider family being subject to harmful sexual behaviours. These were responded to in superficial ways and there was no assessment of the meaning or action to address the concerns. This shows that professionals need to feel both better equipped and more confident to identify and address harmful sexual behaviours and sibling sexual abuse. b) Recognition of intrafamilial sexual abuse by an adult in a family context 3.14 As has already been covered in the report, the sexual abuse of children by adults is more prevalent than is being currently identified; more children are being sexually abused than professionals are safeguardingxii. This is in part due to professionals relying too heavily on children to report abuse; the evidence suggests that it is important to take a whole family approach to build a picture of a child’s circumstances, including children’s behaviours as indicators of distress and harm, adult behaviours of concern, family history and the grooming behaviour of adults who want to abuse. 19 Official 3.15 In 2017 there were concerns of sexualised behaviour exhibited by Whitney (aged 3) that the nursery she attended believed fell outside of developmental norms. It was good practice that they highlighted this. Whitney’s mother also was concerned and some “keep safe work” with Whitney was undertaken by her social worker, but there was no further assessment or exploration of what this sexualised behaviour was about, who Whitney was in contact with or why it was occurring. There was insufficient reflection about whether this behaviour of concern might be an indication of sexual abuse which required exploration. The complexity of access to the children’s social care and family support recording system made it difficult to access historical records and only a partial picture was formed. Earlier concerns about Paul’s possibly sexually abusive behaviour were not known nor the family history of poor sexual boundaries. The connection with paternal grandmother was not explored and there was a lack of awareness of the concerns regarding Rosa and Anya. 3.16 Concerns emerged in June 2018 regarding Paul viewing indecent images of children (IIOC) rather worryingly referred to as “child pornography” by several professionals from different agencies; the appropriate phrase is indecent images of children (IIOC). There were also concern about Paul engaging in fetish behaviour which focussed on content specifically associated with infants / very young children and extreme vulnerability of sexual partners. There emerged differences of opinion at the strategy meeting to discuss this between social workers and health professionals; a view was expressed (but not recorded) that adults were entitled to engage in whatever sexual activity they wished with consenting adults21; the concept of consent and whether it existed was not discussed. This was challenged by the community paediatrician in the strongest terms and although this was not acknowledged, this challenge appears to have had an impact and a comprehensive referral was made for sexual abuse medicals. This referral provided a good and clear outline of historical concerns. This view that all sexual behaviour is acceptable, and that consent can be perceived without asking pervades this review; the women involved were subjected to emotional, physical and sexual abuse. Consent needed to be questioned. There was a lack of understanding in the original strategy meeting of the existing evidence. Taking a holistic view; there were poor sexual boundaries across this family, which by now were well known. There was a history of sexualised behaviours from children which were of concern and could have been seen as indicators of abuse. There was evidence of past sexual abuse by Paul and concerns about who else had been abused. 3.17 At the first child protection conference for Rosa and Anya it was reported that “there is concern regarding adult sexual behaviour between family members dating back to 2001”. Social workers have been worried about how sexual relationships are managed, supervised and understood by the family and there seems to be an “open house” approach at the family home. This was a clear and 21 Something shared as part of the interviews within this review 20 Official explicit expression of the potential risk of sexual harm to Anya and Rosa though which did not lead to action to explore sexual abuse with them. This is an important reminder of professionals’ being able to consider sexual abuse as a hypothesis and seek a whole family assessment including family history. c) Intrafamilial sexual abuse by women 3.18 In 2018-19, 3.8% of all child sexual abusers were female, based on police reports, Office of National Statistics data showsxiii. This is an underestimation of the nature of the harm children are experiencing. Little is known about the sexual abuse of children by women in a parental rolexiv. The evidence suggests that professionals rarely see or consider this type of abuse, in part due to a lack of knowledge, as well as stereotypical ideas about the role of women in family life and this has led to poor assessment and action for childrenxv. Since 2020 Rosa has made several allegations that her mother sexually abused her. These have been heard by the residential staff that look after her, and her social worker has sought to get action to address these concerns. Rosa was interviewed by the police, but she was not asked about sexual abuse by her mother and action was not taken to address this. There is now an ongoing investigation regarding this. d) Enabling children to talk about their worries and particularly child sexual abuse and responding appropriately. 3.19 There is clear evidence that professionals rely far too heavily on children to tell them that they are being sexually abusedxvi. That is why thinking about signs and indicators regarding the child’s behaviour and wellbeing is important. 3.20 Research suggests there are many barriers to children feeling able to tell someone that they are being sexually abusedxvii. This includes feelings of shame and embarrassment, fear that they may not be believed, or they may not have the language or the capacity to communicate verbally. Children may also not recognise the experience as abusive or are being threatened or manipulated by the person who has abused them. These barriers to talking about sexual abuse are compounded by professionals’ worries about supporting children to speak out. This includes lacking confidence and skills and worries about saying the wrong thing or fears about contaminating evidence in any future criminal proceedings. Children find it hard to speak out and professionals find it hard to discuss sexual abuse with children. This professional reluctance needs to changexviii. 3.21 Children communicate in several different ways about their distress. This is particularly so where children have developmental delay and speech and language difficulties. This was the case for these four children. Whitney and Lena were both quite young and both had speech delay. Rosa and Anya both had mild learning disabilities and used a mix of verbal language and signing. No one in their family had learned to sign, despite being asked to on several occasions in the context of child in need and child protection plans. There was no discussion of whether the parents would be able to learn to sign because of their own learning disabilities and 21 Official no action was taken to address this. This effectively meant that Rosa and Anya were denied an opportunity to communicate. 3.22 When Whitney was exhibiting sexualised behaviours in 2017 it is unclear the extent to which professionals supported her to talk about whether she was being sexually abused. There may have been many causes for this behaviour, but it appears that the approach was to see this as a problem of sexualised behaviour which needed addressing through protective behaviours work, rather than understanding the root cause. 3.23 When there were concerns about harmful sexual behaviours for Rosa and then sibling sexual abuse by Rosa to Anya, it remains unclear the extent to which they were encouraged and supported to speak about sexual abuse. There was a lack of professional recognition of the potential links between sibling sexual abuse/harmful sexual behaviours and intrafamilial sexual abuse. 3.24 It is notable that the school Whitney attended noticed that she was found in the toilets looking over and under the toilet doors at other children. This was a cause for concern and appropriately recorded and shared with other agencies, but she was not spoken to about this by any professional. This meant that the meaning of this behaviour was not known, and the lack of discussion meant that she did not know that someone had noticed her and her behaviour and was concerned about it. This was also true when the family support worker met her at Anya and Rosa’s home. Whitney attached herself to the worker and would not let go. This was noted in records and shared appropriately, but Whitney was not asked about this behaviour, its meaning was not established, and she was not made aware that someone had noticed what appears to be distressed and help seeking behaviour. Best practice suggests that as well as recording concerns about children’s behaviour, it is important to take action to seek to understand its meaning or to have everyday conversations with children about how they are and how they are feeling ( see recent guide to communicating with children: Centre of Expertise for Child Sexual Abuse 2022xix). e) Understanding help seeking behaviour: Supporting children to seek help from professionals 3.25 It is a core ambition of the safeguarding system that children and young people feel able to talk to family, friends, and professionals about any concerns they have. This concept of help-seeking behaviour is important. Help seeking behaviour is a core part of child development, where children learn over time how to seek help, get validated for that help seeking behaviour and learn who can be trusted. It is an essential skill. It is a developmental task which develops over time and is supported by the response of parents/adults. This starts in babyhood when a baby cries and someone responds. Children who are abused, neglected or who receive inconsistent care over time are likely to have underdeveloped help-seeking behaviour or are actively discouraged or prevented from seeking help through threats, intimidation, 22 Official or suggestions of impact on family. It is essential that professionals respond to children’s help-seeking behaviour generally, but specifically in the context of children raising concerns about safeguarding matters. The research evidencexx suggests that children will “test out” the response of professionals before making more serious allegations of harm. It is essential that in a child-centred system children’s concerns are listened to and responded to. 3.26 In 2018 an assessment of Anya and Rosa’s needs was completed in preparation for the initial child protection case conference. This assessment made clear the extent to which Anya and Rosa felt unable to speak to the social worker. Anya told the social worker that she thought her role was to take children away; this was she said her family’s experience. Rosa constantly sought permission from her mother to tell stories of family life, despite overall these being about everyday events. The social worker noted that Rosa and Anya seemed quite nervous when Whitney’s name was mentioned and they said their mother had told them not to talk about Whitney, or any of the other children. On another occasion Rosa spoke about Paul hurting her and when asked how by the social worker it is recorded that she became very anxious. Anya gestured to Rosa “shhshh” putting her fingers against her lips. Rosa responded by saying that the social worker was there to help; Anya said that they would get into trouble if they spoke. This is all made explicit within the assessment but does not feature in the discussion in the subsequent child protection conference22 or in the danger statements23 or child protection plans24. This may well be because all professionals for child protection case conferences locally are required to read the reports provided to the conference in the 30 minutes before the conference starts. This is caused by guidance not always being followed regarding submitting reports days in advance enabling all to prepare. This means that it is difficult for all professionals to fully understand complex circumstances such as outlined for these 4 children. The issue of Anya and Rosa being coached not to speak and being again effectively silenced was not addressed in the plan going forward. 3.27 It is notable in this review that so many children were brave enough to speak about the abuse that they were experiencing, but they were not always heard, or their concerns not always acknowledged and from their perspective not responded to. So often the children’s testimony was branded incoherent, unclear and confused. Of course, in the context of criminal proceedings the burden of proof is set at beyond reasonable doubt. This makes the criminal proceedings a challenge. However, there needs to be more thought about how children’s help seeking behaviour is acknowledged and congratulated. This requires children being told what action is being taken, or not, with an explanation why. There was evidence of this here. Anya and Rosa’s social workers have sought to provide feedback about why action could not be taken and to seek more action to gain testimony. The focus must be on what can be done rather than what cannot; after all, if you take the risk to speak out it is dispiriting to know that no action is possible. It is also important that children are reassured that what happened to them was wrong and that some sort of repair takes 22 23 24 23 Official place. Rosa and Anya’s mother and father have been required to write an apology for failing to protect them. This is an appropriate step. There needs to be discussion by professionals about how the outcomes of abuse investigations are communicated directly to children when they talk about any form of abuse, and this leads to no action (not just criminal action) against those adults. f) Recognising and responding to the impact of child sexual abuse 3.28 The impact of child sexual abusexxi on children and young people’s development and wellbeing is serious and can last throughout childhood and into adulthoodxxii. Sexual abuse can impact every area of a child’s world including their cognitive, social, emotional, behavioural, physical and sexual development.xxiii. 3.29 It is good practice that all the children in this review who have been subject to sexual abuse are now receiving appropriate therapeutic support. This was not an issue for these children, but their circumstances serve as a reminder that some custom and practice has developed where there is a belief that children cannot be offered therapeutic support whilst criminal proceedings are ongoing. This is incorrect, and guidance25 makes this clear. It is also important to recognise the necessity of providing the whole family (excluding the adult of concern|) and especially to siblings’, support and activity to rebuild family relationships. 3.30 However, there is some evidence that the children’s distressed behaviour was not always recognised as an impact of the harm they were subjected to. It is critical for children that professionals take a trauma informed approach. This means recognising and understanding children’s reasonable and normal response to abnormal circumstances. For example, in the reports for the child protection conferences Whitney was described as “trying to take over and dominate” and “she is showing some difficult behaviours”. She is described as presenting as “needy” at times. These description are all in the context of child sexual abuse. At a review conference Whitney is described in a report to “lack emotional resilience and resorts to crying easily and she likes to be in control. Whitney is attention seeking and likes attention from adults”. This was not questioned by the chair of the conference or any other professional. 3.31 When Lena was discussed at an initial child protection conference where concerns were considered about possible child sexual abuse, she was described as presenting with “tummy hurt” or “I feel sick” which was seen as out of character, but also described as “possible attention seeking”. If the phrase “attention needing” had been used instead, this might have led to an approach where this out of character behaviour was explored with her more fully and her appropriate need for care and attention addressed. 3.32 Rosa and Anya have exhibited significant distressed behaviour whilst in residential care. This was of a physically violent nature, and they have also been extremely 25 24 Official verbally abusive, using violent and aggressive sexualised language. This is indicative of the harm they have experienced. The residential unit has established a caring regime to help Rosa and Anya manage their emotional regulation. This behaviour is described as “heightened” rather than “distressed”. The most recent letter to both Anya and Rosa from their independent reviewing officer focusses on their behaviour, rather than the underlying reasons for it and is not sufficiently trauma informed in its approach. Action is being taken with the local authority to promote child focussed recording. 3.32 There were alco continuing concerns about Rosa’s sexually harmful behaviour to herself. This led to visits to hospital on a regular basis. These actions were distressing for Rosa and for everyone supporting her. These incidents were clearly signs of distress and a way of coping. Yet no clear action plan was developed to address this, and this repeated behaviour came to be seen by some as “attention seeking” or at worst annoying. This was not an easy situation to deal with; dealing with children’s distress has an impact on all professionals. Rosa was a care experienced child with the local authority as a corporate parent. Support was put in place in the form of therapeutic support, but the harmful impact of the sexual abuse Rosa had experienced became more of a problem to be solved. A problem of and for her. There is a danger that when professionals are working with children who have been sexually harmed26 that the focus can be on “what is wrong with the child”, as opposed to what “has happened to the child”. 3.33 Anya, Rosa, Whitney and Lena have been provided with appropriate therapeutic support. Their emotional needs are significant because of the severity of the harm they have been subjected to. This support is helping them make sense of their past, their present, understanding the sexual abuse they have experienced and exploring attachment relationships and boundaries. Therapeutic relationships have been built. This support is provided by an external provider and funded by the local authority as part of the children’s ongoing care plans. The resourcing of this support is managed through the local authority funding panel which meets quarterly to agree funding. Therapeutic support needs a six-month warning that funding will change or be withdrawn leading to the end of the therapeutic relationship. It is important to match resource funding arrangements to therapeutic needs for appropriate staged endings for children and young people. g) The sexual abuse of disabled children 3.34 There is clear research evidence that disabled children are more likely to be sexually abused and less likely to be subject to safeguarding processesxxiv. Too often, signs and indicators of potential sexual abuse in disabled children go unrecognised or are dismissed as being caused by their impairments, even when there is no relation between the two. It is therefore important to understand what 26 Or harmed in anyway 25 Official the disability means for the child and their day-to-day functioning, learning style and communication. 3.35 All the children in this review had some form of learning and/or physical disability. They were all receiving appropriate help and support from a range of professionals to address their physical and health needs. There was something of a separation between the work of those professionals seeking to address the children’s disability and health needs and the actions of the safeguarding professionals. There was a wide range of expertise available to safeguarding professionals to help them understand the children’s needs, understand their communication style and to advise on the best way of maximising this. This opportunity was not taken. This needs to be a core requirement of strategy meetings/discussions regarding children with some form of disability (meaning the vast majority); that those needs are discussed, advice is sought from someone who understand their disability needs, what this will mean for any further enquiries, interviews and assessment and how children will be supported to communicate in their preferred style. 3.36 At the child protection conference for Rosa and Anya in 2018 it is recorded that mother was aware that “the girls had a mental age of 4” and this phraseology is used on several occasions in reports. This was an inaccurate report. This description did not enable an accurate understanding of their needs. 3.37 The children’s disabilities and health needs were often quoted as a reason that criminal action could not be taken. Although care was always taken to provide the children who were subject to Achieving Best Evidence (ABE)/Video Recorded Interviews(VRI) with an intermediary, and thought was given to rapport building and meeting beforehand, there was insufficient discussion of the needs of these children arising from their disabilities. Advice was not sought from the residential workers who knew Rosa and Anya well nor from the social workers or those providing therapeutic input. All these professionals had to some extent adapted their approach to enable effective communication. It is not that children with disabilities do not communicate, it is that professionals need to take time to communicate with children in a way that meets their needs. This is particularly important in the context of a trauma informed approach. When Rosa was seen by police officers and an intermediary in 2021, she was able to remember their previous meeting a year ago and outline exactly what they talked about including holidays and pregnancies. When she was then asked, “do you know why we are here” she said “no”. This was interpreted as her not understanding or remembering, rather than this was a difficult and painful subject. We need a more trauma informed approach. 3.38 It is important that advice is sought about the exact nature of a child’s disability, what it means for them, their day to day, their identity, contact with professionals and how effective connections can be made by professionals and disabled children. There is evidence that those that knew all the children well took these steps, but it 26 Official was not consistent across assessments, child protection enquires and strategy discussions. h) Recognising the importance of safe adults/ the non-abusing parent/family. 3.39 When there are concerns about sexual abuse of children, it is critical that safe adults or non-abusing adults are identified, their needs assessed, their vulnerabilities understood, and their support needs consideredxxv. It is critical that there is an assessment of the non-abusing parent’s ability to protect and believe children. Researchxxvi indicates that feeling believed by your main care giver is one of the strongest mediators of the long-term mental health issues caused by sexual abuse. This parent/caregiver will need to play a central role in protecting their children from the person of concern, implementing safety plans and managing risks; they will need to support their child with the immediate and longer-term impacts of their abuse. 3.40 It is also important to understand any vulnerabilities that can be exploited by an adult to make sexual abuse possible. Non abusing parents may be groomed, with those who pose a risk of sexual harm making use of unmet needs for financial and emotional support or they may be being coerced and controlled through domestic abuse. It is important that the non-abusing parent has all the relevant information and that they understand the process of likely adult sexual offending to be equipped to address it. Adults who pose a sexual risk to children often undermine the non-abusing parent’s parenting capacity, seeking to make use of any difficulties they have such as mental ill health, depression and low self-esteem. They can try to become a better substitute parent figure whose role is essential to family life. This requires a good assessment of these factors; understanding the needs and circumstances of the non-abusing parent, considering what of their needs are being met by the adult who poses a sexual risk, what role that adult plays in family life, financial contribution, emotional support and supporting parenting. There is likely also to be a process whereby these adults who pose a risk undermine non-abusing parent/child relationships as well as other family relationships. 3.41 The recent Ofsted thematic review of sexual abuse in the family environmentxxvii has highlighted that there is not enough attention played, or assessments completed regarding the needs and circumstances of a non-abusing parents. There is often insufficient attention paid to evaluating the non-abusing parent capacity and willingness to keep children safe from sexual abuse and their vulnerability to grooming and exploitation which can undermine that safety. 3.42 When concerns arose about Whitney being sexually abused by Paul in 2018, there was a focus on whether her mother had been able to protect her, had known about the abuse and colluded with it. There was no specific assessment completed; this was because no tools or frameworks currently exist locally, and there is inconsistent use nationally of assessment tools to assess the safety provided, needs and circumstances of a non-abusing parent in the context of intrafamilial child 27 Official sexual abuse. A clear plan of action was put in place and Whitney’s mother demonstrated that she was a safe adult and a protective parent. Although work was completed by the social worker to reunite Whitney’s mother with her family to provide support, the overall impact of the sexual abuse of Whitney on her mother was not sufficiently considered. She sought out mental health support herself and was offered group-based support. She attended sessions and found that a member of the group was known to the wider family. This made it impossible for her to talk about what had happened, and in other group sessions she realised that talking about the sexual abuse of a child was not necessarily appropriate. More thought needs to be given to the support needs of the non-abusing parents of children who are sexually abused. 3.43 In contrast to the focus on Whitney’s mother, there was less attention on Whitney’s grandparents and how safe and protective as adults they were. Whitney’s mother sought to separate herself from these adults, who she did not consider safe. However, for a period after it became known that Paul was under investigation regarding the sexual abuse of children in the family and the sharing of indecent images of children, the grandparents were helping look after Lena and her siblings and Anya and Rosa were living in the home. The paternal grandparents were also involved in providing care to other children in their family network without sufficient reflection on whether they were safe adults. 3.44 Rosa has made various allegations about both her mother and father. She has said that her father knew that Paul was sexually abusive and did not alert any professional to this behaviour. Rosa says her mother knew what Paul was doing and was angry with him; Anya agrees with this. Rosa goes further to suggest that her mother was collusive with Paul, helped him to abuse her and was also sexually abusive. This has not been sufficiently addressed before this review but is now being investigated. 3.45 There was insufficient thought about which adults were non-abusing and could provide safety in the context of sexual abuse. There was a dependence on “working agreements27” to set boundaries. These pieces of paper were meaningless, lacked any legal standing and did not take account of family history, adult intentions and their capacity and willingness to provide safety to the children. The evidence suggests that over time many of the adults in this family were either unable to, lacked capacity to or were unwilling to keep children safe. This should have been subject to greater assessment and analysis. i) Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people. 3.46 When addressing child sexual abuse, it is critical that professionals consider, assess and analyse the behaviour of the adult about whom there are concerns about sexual 27 28 Official abuse. Adults in this situation are often described as “paedophiles”; but paedophilia relates to a specific disorder where there is a preference for sexual activity with a prepubescent child. 3.47 Paul was often described as a paedophile, rather than that he had a sexual interest in children, post pubescent children and vulnerable adults. He is part of a group of adults about which there is little research, who sexually harm children and adults. Of course, this group bring their own experiences of trauma, but in addressing their sexually abusive behaviour it is important to understand their motivations, needs and behaviours. 3.48 It is critical that safeguarding professionals are familiar with the evidence base around adult sexual abusexxviii. The most often used framework is Finkelhors 4 preconditions modelxxix. This suggest that there is a process that adults who pose a sexual risk to children go through. The first precondition is motivation to abuse. This can include emotional loneliness, intimacy and relationship problems, hostility and anger towards women, a desire for power and control, poor impulse control, using sex as a coping mechanism and a possible sexual attraction to children. Adults are using sex to get these needs met. The second stage is overcoming internal inhibitors. An adult needs to overcome their internal inhibitors, such as knowing what they are doing is wrong. Professionals need to understand factors that disinhibit behaviour. This can include the use of alcohol or drugs and the development of cognitive distortions to validate behaviour. The third stage is overcoming external inhibitors, finding opportunities to offend, and gaining access to children. The final stage is finding ways of abusing the child, overcoming their resistance. This is achieved through grooming, exploiting vulnerabilities such as a young age, disability, the need for a special relationship as well as threats and coercion. 3.49 Paul abused children and adults. However, he was consistently described as a paedophile. The focus on paedophilia meant that his bail conditions were about children under 16 and he was free to live with a vulnerable adult, without thought that he might sexually abuse and assault her. This was not recognised by most professionals as a concern and consequently not challenged. This was recognised by the Community Paediatricians attending the second strategy meeting who recommended a safeguarding adult referral for the vulnerable woman he was living with while on bail. 3.50 There was considerable concern regarding Paul being out in the community and the impact of this on how safe Whitney felt, and her mother and school were concerned about the impact of this. Paul also sought to gain access to children whilst awaiting police action. This was inevitable. More thought needed to be given to the risk that an adult such as Paul posed to adults and children. The police 29 Official could have considered the use of a civil order such as a Sexual Risk Order(SRO)28. A lack of discussion regarding this was likely caused by changes made to policing locally, including the loss of expertise because of officers with child abuse experience being moved into a wider safeguarding team with attendant loss of expertise. 3.51 There also needed to be more discussion in the many safeguarding meetings and processes about the risks Paul posed to the community, and the impact of the delay in the investigation on the safety and wellbeing of the children he had abused, and the parents charged with keeping them safe. j) Support to families after child sexual abuse has been identified 3.52 There is significant evidence that the discovery that a child is being sexually abused has a profound impact on the child and the whole family. In parents and extended family this can include feelings of guilt that a child was not kept safe, anger at the adult who has sexually harmed, and complexity in family relationships caused by grooming behaviourxxx. Adults who sexually abuse children can deliberately seek to disrupt family relationships, pick out a child for special attention, or scapegoat and marginalise children from trusted adults. This all has an impact on family relationships. 3.53 Once child sexual abuse has been identified, there will be children’s services and police inquiries for the child to cope with, and this also will have an impact on the whole family. 3.54 When concerns became known that Whitney had been sexually abused by Paul, she and her mother was provided with support through a social worker, the school and the health visitor. Whitney’s mother was supported by her social worker to rebuild relationships with her family who provided good support. Whitney is now safe, her mother has provided safe and effective care, and there are no specialist services involved. What is clear, is that as a family they are still coping with the aftermath, and locally and nationally there are limited specialist resources available to address the long-term impact of child sexual abuse on the family, parenting a child who has been sexually harmed, rebuilding relationships and trust. 3.55 In the period when it became clear that Anya and Rosa had been sexually abused by Paul and before allegations were made against their parents of sexual harm, the parents were provided with specialist support to help them understand the impact of sexual abuse on children; the aim was to enable them to respond appropriately to Rosa and Anya’s trauma needs. This was good practice, which has only been undermined by the increasing evidence that the parents knew about the risk Paul posed, may have colluded with him , and in the case of mother may have joined in the abuse. 28 A Sexual Risk Order is an order made by the Court which imposes restrictions on a persons' behaviour that the Court deems necessary for the purposes of protecting the public from risk of sexual harm. https://www.legislation.gov.uk/ukpga/2003/42/part/2/crossheading/sexual-risk-orders-england-and-wales 30 Official 3.56 There were concerns that Lena had been sexually abused by Paul and subject to sexually harmful behaviour by Lena, they were about to come into foster care. Lena and her sisters have now been placed with extended family, and specialist support has been provided. It is important that the long-term impact of child sexual abuse on family relationships and future parenting is kept in mind and planned for. There is a lack of resources locally and nationally to help families understand what the impact in the future will be and where to seek help when issues and concerns arise. k) Responding to adult disclosures of sexual abuse in childhood. Addressing non-recent child sexual abuse 3.57 The difficulties that professionals have in identifying child sexual abuse have already been highlighted, and alongside children feeling unable to tell others about being sexually abused, it is not surprising that only 1 in 8 children who have been sexually abused come to the attention of servicesxxxi. Many children go into adulthood without telling what has happened to them, and without receiving any help and support. This can lead to those adults experiencing poor mental health, substance misuse and difficulties coping with relationships and workxxxii xxxiii. 3.58 The reason this LSCPR was initiated was because of the sexual abuse of children by one adult in this wider family, and allegations that other adults have abused children. What has emerged is a complex family history where several adults have talked about being sexually abused as children. Those adults were assessed as parents, were seen by their GP, assessed as adults with possible care and support needs, and some were frequent attenders at accident and emergency departments because of alcohol misuse, feelings of depression, violence and suicidal ideation. There is inconsistent evidence that they were asked (where the circumstances permitted) about whether anything had happened in childhood that was impacting on them negatively as adults and for this to be factored into an understanding of their needs. 3.59 Paul did talk to some professionals about the abuse he had been subject to, as did Lena’s mother. This abuse was never explored in detail; usually because it was disclosed at a time of crisis when Paul and Lena were extremely intoxicated or distressed. The adults in this family often did not follow up on signposting after these incidents, and so the issue of their abuse was never addressed. There is an opportunity here for the ongoing meetings and discussion about frequent attenders to consider childhood sexual abuse as one of the factors contributing to frequent attendance at hospital. 3.60 There is good recognition that mental health difficulties, adults being subject to violence and problematic substance misuse can have an impact on parenting and the safety and wellbeing of children. This has led to targeted support and services focussed around helping adults with family life and their parenting role. There is 31 Official little such emphasis on the need to understand and address childhood sexual abuse, its impact on the individual and in their parenting role. 3.61 There is local guidance about dealing with non-recent child abuse which may need review in light of this LCSPR. l) The multi-agency response to child sexual abuse Strategy meetings 3.62 Over the course of the review period there were many strategy meetings/discussions convened to consider the circumstances of the four children subject of this review. There is locally a CSA pathway that makes clear the importance of multi-agency attendance at these meetings, including appropriate health and education colleagues. The reason for this is that these professionals can provide expertise generally regarding children’s needs, particularly the requirements of child protection medicals, paediatric assessment and medical examinations in the context of child sexual abuse. 3.63 Multi-agency professionals also provide expertise about the specific needs and circumstances of the children being discussed. This is particularly important where children are to be interviewed through child protection enquiries or police investigations. Information can be provided about a child’s communications needs and style. Education colleagues know children well and can provide a sense of the child’s day presentation and can help ensure the strategy meeting is focussed on the needs of the child. 3.64 Most strategy discussions that took place only included social workers, their managers and police officers. This was despite all the children having extensive contact with health and educational professionals. This meant most of the professionals working with the children were unaware of the detail of the concerns; they knew a strategy meeting had been held and sometimes they knew the outcome. They did not know the detail of the concerns, could not contribute their expertise, contribute to the analysis of the children’s circumstances, or advise about communication style and how best to undertake interviews. This was essential information. These professionals then were left to work with the children and their family in silos, unaware of the seriousness of the concerns, and unaware of the need to look out for signs and indicators of abuse. 3.65 It is also important to note that during the period under review there was inconsistent use of follow up strategy meetings. In complex family circumstances these are essentially for following up on actions, thinking about the outcomes of ABE/VRI interviews ( see that section of this Finding) and seeking to ensure all evidence of child abuse has been collated and understood. 3.66 It is essential that strategy meetings are multi-agency, and that health and education colleagues are enabled to attend. The reasons for this lack of compliance with existing guidance in this situation is not clear. There are pressures on all agencies 32 Official when strategy meetings/discussions need to be convened at short notice due to the immediate risk of harm to a child. Reviews nationally have suggested that it can be difficult for health and education colleagues to find cover at short notice to cover essential teaching and clinics. There is no evidence that this was the case here. This matter of urgency can be addressed by follow up strategy meetings after the emergency. Clearly multi-agency colleagues must seek to understand why they were not invited to a strategy meeting when they become aware that one has been held regarding a child they are working with/know. Ultimately use of the conflict resolution/escalation procedures may be necessary. Clearly there is some work to be done about the importance of multi-agency strategy discussion across the partnership. The importance of child protection medical examinations 3.67 A child protection medical, also known as a CP Medical, a section 47 medical or a paediatric medical assessment is completed where there is concern that a child might have been physically or sexually abused or significantly neglected. The purpose is to establish the holistic health and wellbeing of the child and to establish if there is any medical evidence of abuse or neglect. This should always be discussed at the strategy meeting held about a child(ren) and as part of any child protection enquiries or police investigation. 3.68 In the context of child sexual abuse a medical examination is required whenever a child has made an allegation of sexual abuse, sexual abuse has been witnessed (because, for example, the child has been identified from online images of abuse), or a referring agency suspects abuse has occurred. Guidance describes a medical examination for child sexual abuse as: “…[a] comprehensive assessment considering the physical development and emotional well-being of the child or young person against the background of any relevant medical, family or social history … This enables a full evaluation of the degree of significant harm suffered, or likely to be suffered by the child … Evaluating significant harm in sexual abuse includes not only the documentation of any genital and or anal injury but also any accompanying physical injury, the possibility of a sexually transmitted infection or pregnancy and the short/long term psychological or psychiatric sequelae. This assessment must also lead the planning of any ongoing investigation or treatment required by the child and appropriate reassurance for the child and family.”xxxiv The guidance notes that “the health needs of the child are paramount in approaching any medical examination, whatever the alleged circumstances leading to the need to gather forensic evidence”. 3.69 Medical examinations when child sexual abuse is disclosed or suspected have wide benefits including identifying forensic and evidential findings and providing a holistic assessment of the health and wellbeing of children who have experienced sexual abuse. This includes addressing unmet general, mental and sexual health 33 Official needs, assessing risk (including for self-harm and suicide) and providing feedback and reassurance from health professionals to children and carers. 3.70 There is evidencexxxv that despite the holistic benefits to children of a medical examination, many children are not referred for one. This is due to some misperceptions that their primary purpose is to gather forensic evidence and therefore in situations where professionals become aware of non-recent allegations of sexual abuse or situations where the referral of concern falls outside the timescale for forensic evidence, that a medical assessment is not necessary. Research has also suggested that some professionals feel that the medical examination process may be harmful to children and young people. It’s important that practitioners who engage with children prior to a possible referral for medical examination have the knowledge and confidence to provide information and advice to children and non-abusing parents and carers. Information about the purpose and process of medical examinations has been producedxxxvi. 3.71 In response to concerns in August 2018 that Paul might pose a sexual risk to children, the social worker completed a comprehensive referral for medical examinations for all the children in the extended family he was known to be in contact with. These were comprehensive, provided a full history of what was currently known and the recent concerns. This was good practice. 3.72 When there were concerns about possible harmful sexual behaviours regarding Anya, a decision was made not to refer for a medical, because there “was no need for forensic” evidence. This demonstrated a lack of understanding of the purpose of the medical assessment which is to ensure the wellbeing of a child. 3.73 In early 2018 there were concerns regarding unusual bruising to Lena. Appropriately a referral was made for a child protection medical. This referral did not include full information about the family circumstances , the long history of neglect, or that there had been historical concerns about child sexual abuse. The medical therefore took place in isolation form all other known information. This separation out of information and making a choice about what information should be shared with whom, what information is necessary, does not represent good partnership practice or promote a holistic approach to children. It is not that there was active withholding of information; more that historical concerns had not been established (see Finding 4) and a belief that information was being sought from a specialist who did not need to know wider information to decide about the nature of the bruising. 3.74 Medical examinations are critical for understanding a child’s holistic health needs, as well as part of evidence gathering. There is no evidencexxxvii that children find them distressing, if the child and family is well prepared, and their wishes and feelings acted upon. It is important that those charged with undertaking the medical assessment understand family history of concern and current known issues, to evaluate medical issues in a holistic way. 34 Official Joint police/social work enquiries and ABE/VRI Interviews 3.75 Within this review there were several occasions where either children made direct disclosures that they had been sexually abused or there was video evidence of the abuse taking place. This led to the decision that there would be a joint enquiry between the police and children’s services, with the police being the lead for the criminal investigation and children's social care the lead for the child protection enquiries into the child's welfare and future safety, in line with existing guidance. There have been falling numbers of convictions for child sexual abuse committed by adults. In 2019 -2020 of all the offences reported, only around 5% proceeded to prosecution, and of those around 4% were prosecutedxxxviii. This was despite a rise in reports from the previous year. It is therefore critical that all joint enquiries for child sexual abuse are carefully planned. This starts with the strategy meeting, and a clear ongoing process for continued information sharing across the enquiry. A picture has emerged nationally and locally of the police and children’s social care enquiries happening in parallel from each other, without information being shared, discussion of how to establish evidence and particularly in the conduct of ABE/VRI interviews. What has emerged in this review and others is not so much joint enquiries between the police and children’s social care, but parallel enquiries, which may intersect, or not, at certain points. What is required is genuine joint working. 3.76 The ABE/VRI is an important part of the evidence gathering process. The process of these formal interviews of children is laid out in guidancexxxix. This guidance makes clear the importance of planning the interviews, including taking account of the children’s developmental needs, cognitive abilities, communication needs and though not stated in the guidance, issues related to trauma. This planning includes decision who should lead the ABE/VRI, a police officer or social worker. The decision is to be made in the best interests of the child, but both parties must be trained to undertake ABE/VRI interviews. Once this decision is made, it is also important to seek advice from those who know a child well, including foster carers, residential workers, teachers, speech and language therapists, CAMHS professionals etc, to seek guidance about the best way of communication with this child and making the most of the interview. Intermediaries may also be used. 3.77 Rosa, Anya and Whitney were all ABE/VRI interviewed. These interviews were only ever undertaken by the police, with the appropriate use of an intermediary. There was little discussion of the role that each child’s allocated social worker would play, and it was never considered that a social worker could and should lead the interview. In fact, the social workers for the children were only included once, and that was to transport a child to the interview. This was caused by custom and practice developing nationally and locally that only the police can undertake ABE/VRI interviews because they are criminal processes. The current picture is further complicated by the fact that very few social workers have access locally and nationally to ABE/VRI training. Thus, a circular problem. 35 Official 3.78 The ABE/VRI for all the children were sensitively carried out, and the guidance was followed by pre-meetings before the interview itself. What did not happen was that advice was not sought from those who knew Rosa, Anya and Whitney well and understood their communication needs and style and were aware of their emotional needs. These interviews took place in total isolation. The transcripts were not shared with children’s services and there was no detailed discussion about the content of the interviews beyond “no disclosures” being made. There remains confusion locally about whether the transcripts of these interviews can be shared. In the absence of the social worker being present, it is hard to know how they can fulfil their role to safeguard a child in the future and ensure their welfare needs are addressed, if they do not know what was discussed. 3.79 This review has found that different professionals were told different bits of information by Rosa. The absence of any discussion about the content of the ABE/VRI interviews meant that information was not triangulated. For example, after one ABE/VRI interview Rosa told the residential workers that she had spoken to the police about her mother abusing her and she may well have believed that she had. In fact, the interview had not covered likely abuse by mother, just whether she knew it was occurring. The social worker was told that Rosa had made no disclosures about her mother, but if she had seen the interview transcript, she would have known that this had not been fully covered in the interview, before Rosa brought the interview to a close. This is provided as an example of the importance of a full discussion of all concerns, and a detailed analysis of what was said within the interview, as well as outside of it. There should always be a discussion about the role of the social worker within the interview process. The initial strategy meeting should be clear about planning the whole joint investigation, including the ABE/VRI interview and the detail of the allegations, and what is already known. There should then be a follow up strategy meeting to explore the information shared. It was only when a full chronology of allegations made by the children to different professionals at different times was completed did it become clear that the ABE/VRI created a partial picture. 3.80 The information for this chronology of allegations included the conclusions and analysis contained in the police crime reports. This was detailed information that was not available to any other professional. The outcome of the criminal investigation was shared, but the detailed analysis of why no further action could be taken was not. There remains confusion locally about whether this information can be shared, once a criminal investigation is over. For these children, the emphasis was on them providing the evidence to enable criminal action to go ahead. The conclusion was always that because of the limited nature of the information provided within the ABE/VRI criminal action was not possible. There was not enough emphasis on the police, children’s services and other professionals working together to pool information and evidence, plan the ABE/VRI and compare notes afterwards. It is the role of the multi-agency group to establish all 36 Official evidence available to support the police enquiries and establish a picture of child sexual abuse using all available evidence, not just relying on the child’s testimony. Victims right to review 3.81 In June 2019 Rosa (aged 14) made an allegation of rape by Paul on several occasions. She was interviewed in September 2019 (a significant delay) and then again in November 2019. This information was shared with the criminal prosecution service (CPS) who decided there was not enough evidence to act. It remains unclear how this decision was communicated to Rosa or whether it was made clear to her that she had the right to review the decision. 3.82 The Victims’ Right to Review (VRR) scheme29 enables victims of crime to seek a review of the Crown Prosecution Service decisions not to start a prosecution or to stop a prosecution. The scheme was launched in 2013 and it is also an entitlement included in the Code of Practice for Victims of Crimexl. There are no age restrictions in respect of those entitled to seek a review under the VRR scheme. There are clear criteria for who can submit a request for review on behalf of the victim, including parents or guardians where the victim is aged under 18. Referrals can be made from other appropriate persons connected with the child. 3.83 This advice should have been given to Rosa and a discussion held either in the strategy meetings or her “child in care” looked after reviews about how she could be supported if she wished to challenge the CPS. In adult cases of adult sexual assault, there is always a police family liaison officer who would take responsibility for providing this advice. In child sexual abuse cases, no such role exists, and there is currently a vacuum about who should know this right exists on behalf of a child and who should support them through the process. Criminal Injuries compensation scheme 3.84 One of the key issues emerging in this review is that Rosa and Anya feel there has been no criminal action possible when they have told those adults and professionals around them that they were abused by Paul. The reasons for this are well recorded in the police records and relate to evidential matters. The right to review has been highlighted above, but a further remedy, and a sense of justice for the victims of child sexual abuse is the Criminal Injuries Compensation Scheme (CICS) (2012)xli. This scheme seeks to financially compensate victims of violent crime. A child or young person may be eligible if they have been subject to a physical attack, threats against the person which caused fear of immediate violence or sexual assault to which the child did not consent; these incidents must have been reported to the police, no matter how long ago they took place. The Criminal Injuries Compensation authority provides advice about eligibility. 29 https://www.cps.gov.uk/legal-guidance/victims-right-review-scheme 37 Official 3.85 Applications should always be made as soon as possible and in general, must be made within 2 years of the event giving rise to the claim. However, where the applicant was under 18 at the time of the incident special provision is made regarding timescales as follows: • If the incident or period of abuse was reported to the police before the young person turned 18, a claim will be accepted up to the young person's 20th birthday. • If the incident or period of abuse took place before the young person turned 18 but was not reported to the police at the time, a claim will be accepted within two years of the date when the incident was first reported to the police. 3.86 An application for compensation should be made by the victim. If the victim is under the age of 18, the application must be made by those who have Parental Responsibility. If the victim is subject of a Care Order, the Criminal Injuries Authority will expect any application to be made by the Local Authority named in the order. Where a child is not subject of a Care Order, but may be living away from home, responsibility for making an application rests with those who have Parental Responsibility, whom should be advised to take appropriate advice. This includes a solicitor, Victim Support and the Citizens Advice Bureau. 3.87 The professionals working with Rosa, Anya, Whitney and Lena were not aware of this process. The absence of a family liaison officer from the police in cases of child abuse means this advice is not routinely provided. It is not outlined as a requirement in the local procedures. Professionals need to be reminded of the requirement to consider children’s rights to criminal compensation, and advice about how to achieve this, needs to be included in local procedures. Use of the Complex abuse procedures 3.88 The local child protection procedures make clear the need to convene a complex child abuse strategy discussion and onward enquiries in situations where there are concerns about abuse involving one or more abusers and several children from different households (or other settings). The Strategy discussion/meeting must carefully consider the children about whom there are concerns, other children who may be in contact with the abusers, vulnerable adults and possible victims who are now adults. The reason to hold this discussion in this way is because mapping exercise will need to be undertaken, several different households considered, and potentially multiple interviews and enquiries undertaken. The emphasis here is understanding the connections and reach of abusers and the implications of this for children. 3.89 When the initial concerns were shared about Paul in 2018 there was a first strategy meeting. This was chaired by an appropriately senior manager from children’s services, attended by all the social workers working with the different parts of this 38 Official large extended family and police officers were present. There was no multi-agency representation. This meeting was an opportunity to bring all the information about potential abusers, the number of children who were at risk of harm and family history together. What emerged at this meeting was that there were at least two abusers, Paul and his female partner, a long history of concerns about family members being sexually harmed by those within the family and outside of it; these alleged abusers were still known to adults and children in the family. This should have led to the convening of a complex strategy discussion. Indeed, this was recommended by the consultant community paediatrician who attended a subsequent strategy meeting. 3.90 It has not been possible to establish why this did not take place. The consequence was that concerns of child sexual abuse within this large extended family were investigated separately, with each individual family considered as a unit on its own, the adults in contact with them were not considered, and connections across this whole group not made. A superficial mapping exercise was conducted, but no chronology of the family connections and historic and current allegations undertaken. 3.91 An example of the lack of connections being made was concern expressed about a social club for young people/adults with learning and physical disabilities that Paul and Lena’s mother attended. This is where Paul, who did not have either a learning disability or physical disability, met two women with care and support needs who he abused and exploited sexually. As part of the enquiries undertaken as part of the LSCPR it became clear there were more general concerns regarding safeguarding arrangements within the club; as a community interest company these concerns had been difficult to address. This community interest company has now been designated as a relevant agency under the auspices of Working Together 2018xlii and needing to be compliant with local and national safeguarding processes. 3.92 The lack of connecting the family members and adults of concern together also meant that the social workers working with each family were left with what seemed an impossible task, each trying to make sense of the whole family circumstances from the perspective of separate family groupings. There were times that they came together, but there remained, and to some extent remains uncertainty about information sharing requirements in these situations. There was a perception that information gleaned from one part of the family, could not automatically be shared with those working with another part of the family. 3.93 The convening of the complex abuse strategy discussion would have started those conversations, but the absence locally of any guidance for working with large extended families with a history of sexual abuse, physical abuse and neglect, with multiple potential abusers and many children at risk of harm and what information can legitimately be shared, did not help in this situation. 39 Official 3.94 Evidence emerging from this review is that the complex case strategy discussions are now being more routinely convened. The next step is guidance for working with complex extended families. Recommendation 1: The Safeguarding Partnership should develop a local agreement to ensure the correct agencies are part of strategy meetings. The absence of health representatives from across the health economy and education representatives at these meetings is a serious gap. Recommendation 2: There is a need to consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse. Recommendation 3: There is the need to reinforce the importance of children’s access to appropriate therapy while police investigations are continuing. Recommendation 4. The Safeguarding Partnership should develop guidance regarding complex and historic abuse investigations Recommendation 5. Police should be reminded of the importance of considering a range of risk management measures including Sexual Risk Orders. Recommendation 6. The signs and indicators template commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership. Recommendation 7. The communicating with children about child sexual abuse resource commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership. Recommendation 8. The meeting the needs of parents and families impacted by the sexual abuse of children commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership. Recommendation 9. The local and regional safeguarding procedures regarding child sexual abuse need to be refreshed to take account of communicating with children, building a holistic picture of children’s circumstances, an assessment and understanding of the non-abusing parent, the behaviour of the adult who poses a sexual risk to children, the requirement to undertake criminal injuries compensation processes and to raise for children and their parents the victims right to review. Recommendation 10: There is a need for a regional look at what “joint” child protection enquiries between the police and children’s services looks like in the absence of a national policy or guidance framework. 40 Official Recommendation 11: An information sharing protocol between the police and children’s social care regionally needs to be established regarding what information can be shared in the context of child sexual abuse. Recommendation 12: The Safeguarding Children’s Partnership should develop guidance about how the outcome of assessments, child protection enquiries and police investigations and their progress are communicated in a child centred way to children. Finding 2: A structured approach to child neglect 3.95 Rosa and Anya experienced neglect from when they were born. Their experiences were persistent and pervasive. Support was provided over time, in the form of family support, child in need plans and child protection plans. It is reported that over time the family circumstances improved, but there is little mention of whether Rosa or Anya’s outcomes improved, and there would quickly be a deterioration. This is a very typical circular pattern with the neglect of children, with short term improvements, followed by a deterioration in circumstances followed by increased support and so on. This leaves children living in chaotic circumstances. 3.96 There were concerns in 2017 that Whitney was being neglected by her mother. These referrals were made by Paul’s mother, Whitney’s grandmother. These concerns were addressed quickly through a child in need plan, with good multi-agency involvement and a focus on supporting mother with her mental health needs, substance misuse and to make sense of the domestic abuse she had been subject to. 3.97 Lena and her siblings also experienced neglect from birth. Their mother had learning disabilities, and father physical difficulties. Support was provided, and much like Anya and Rosa the children’s needs were met some of the time, and then there would be a deterioration. 3.98 What was missing for Rosa, Anya, Lena and siblings was a consistent naming of neglect as an issue of concern and a holistic and detailed assessment of neglect. 3.99 The neglect of children by their parent (primary caregivers) is a serious issue which has a significant and long-lasting negative effect on children’s developmental outcomes, their safety, their emotional wellbeing and the impact often lasts into adulthoodxliii. Child neglect is a complex area of practice which requires a structured and analytical responsexliv. Professional practice often focusses on one question; is this neglect- rather than thinking there are several key questions to be answered as outlined within the definition in Working Together 2018xlv. These questions are: • Persistence: what is the history, child’s journey and how effective have efforts to create change for children been? 41 Official • What type of neglect are children experiencing and is it global - present across all domains? o Physical o Emotional o Educational o Supervisory o Health • What is the known impact on the child? • What is causing the neglect • Is the neglect an act of passiveness/omission or is there evidence of a deliberate and targeted approach to the child characterised by commission • What other abuse is the neglect enabling? • 3.100 This finding will explore the extent to which these questions were considered in relation to Rosa, Anya, Whitney and Lena’s family circumstances. How persistent and pervasive is the neglect and have services designed to create change been successful 3.101 There is general national reluctance across the professional network to “name” concerns about neglectxlvi and this was also apparent in this review. This meant that the persistent and cumulative nature of it was not understood for these children. This naming of neglect from its earliest manifestations is important to track the development of neglect over time and to be aware of both positive and negative changes in the outcomes for children. It is part of telling a child’s story, but also thinking about whether interventions designed to make a difference have helped. This can be an opportunity to think about the strengths of families to create change, despite how difficult this can be. Or to recognise that efforts to create change have been unsuccessful and need review both in terms of the appropriateness as well as a parent/caregiver’s capacity, ability and willingness to change in the best interest of their child(ren). 3.102 Concerns about the neglect of Whitney were named and addressed. With Rosa and Anya, the focus was on the state of the home, poor boundaries and sexualised behaviour; neglect was named when the children were subject to child protection plans, but overall concerns were often narrowly focussed on home conditions; this was also true for Rosa and Anya. What type of neglect is occurring? 3.103 It is important to think beyond a child/young person physical environment and how they are physically cared for. Physical care is an important factor and there was evidence that there were problems associated with the physical environment in which the children were living and the physical care they received. This was however just part of the pattern of neglect. There was a general limited focus on 42 Official home conditions for all the children in this review without thinking about their wider circumstances. Rosa and Anya lived in often squalid home circumstances, as did Lena and her siblings. The professional response was to provide support to address this, without seeking to understand in detail what had caused these conditions in the first place. 3.104 Health needs: There were considerable concerns about the fact that Rosa and Anya had not attended the dentist for many years, they often presented with headlice which were not treated. They were underweight and it became apparent that they had no routine around food. Unsurprisingly they gained weight when they attended residential school. Lena was often not brought for routine health appointments. Anya and Rosa’s education needs were not met, they spent time being home educated in unsuitable circumstances. Lena and her siblings appeared at school looking tired and unkempt, impacting on their ability to learn. The supervision arrangements for all the children were of concern. They all spent time at the home of Rosa and Anya’s mother (Lena and Whitney’s grandmother) and there were often parties happening whilst they were there, with many adults, alcohol misuse, and the police being called because of arguments and disputes. When Rosa reported being sexually assaulted by a peer this was not responded to by the parents and over time there was evidence that her parents did not prioritise her safety. In terms of love, care and emotional warmth there were many assertions within reports of Rosa and Anya’s mother’s love for them, without a reflection on the reality that she asked them to keep secrets, not talk about what went on at home, disrupting their help seeking behaviour. There is little information available about the demonstration of good attachment relationships, love, care and warmth for Lena and her siblings by her parents, but there is evidence that their mother would often be late to pick them up from nursery, having reportedly been at the pub, and other incidents where there was an absence of her ability to keep the children’s needs in mind. What is the impact on the child and what action is intended to address this? How will we know it is working to improve child outcomes? 3.105 It is important to be clear about what the impact of parental neglect is on children to ensure that services and support are addressing these and creating change in their developmental outcomes. The impact on Rosa and Anya of the neglect they were experiencing was not articulated and the impact on their development not fully considered. Their learning needs were accepted as part of who they were, not of the abuse they had experienced. Their small physical stature and low weight was questioned, and thought given to its cause, but failure to thrive in the context of long-term neglect was not considered. It is essential that all assessing health professionals are fully aware of all the concerns about neglect and abuse to recognise the potential impact when considering problems with multifactorial causation. What is causing the neglect and have interventions been targeted in these areas? 43 Official 3.106 It is critical in the professional response to neglect that there is an analysis of why the neglect is occurring to target interventions appropriately and be sure that change has occurred. All the children had some learning disabilities, speech delay and health needs, which were too readily accepted by professionals as genetic or developmental, rather than being attributable to the neglect they were experiencing. For example, there were concerns about Anya and Rosa not gaining weight. Professionals worked hard to establish a medical cause, considering their genetic inheritance, medications for epilepsy, and possible psychological difficulties. Their mother reported that there were no issues at home with food, except that they were “picky eaters”. The issue of whether this lack of weight gain was caused by a failure to thrive because of neglect was not discussed. 3.107 There is little evidence that the “why” or cause of the neglect that these children were subject to was sufficiently discussed. For Anya and Rosa, the neglect could have been caused by several different parental factors. Both their parents had significant learning disabilities. There was evidence of substance misuse and previous domestic abuse. This was also true for Whitney in 2017, whose mother also experienced poor mental health, domestic abuse and substance misuse. Her father had experienced sexual abuse as a child, was the perpetrator of domestic abuse, was violent, misused substances and had mental health crises leading to suicidal ideation. Lena and her siblings lived in a household where their mother had experienced sexual abuse as a child, likely associated mental health concerns, she had significant learning disabilities, was subject to domestic abuse and she misused alcohol. Their father had physical difficulties, experienced depression and was isolated. The professional plans for Whitney did address these parental concerns very successfully. There was also recognition of the circumstances of Lena’s parents, but a lack of connection to neglect and an action plan to address causal factors. The reasons why Anya and Rosa were being neglected by their parents received less professional attention. 3.108 Professionals did recognise that the children’s needs were not always being met, and genuinely wanted to improve their circumstances, but they often jumped into providing concrete solutions, rather than stepping back and thinking about what was causing these difficulties and what needed to be done about it. If neglect is to change these causal factors need to be understood in the context of parenting capacity, relationships with children and attachment behaviour to promote the health and wellbeing of children. Is the neglect passive or active: omission or commission? 3.109 Neglect is often seen as passive; parents unable to provide appropriate care to their children due to their own individual difficulties such as learning disability, poor mental health, substance misuse or being a survivor of domestic abuse and the attendant impact on self-esteem and wellbeing. There are occasions when neglect is an active process; the child is deliberately not cared for by a parent, seen as too 44 Official difficult and problematic to be able to be parented, and then blamed for the lack of care they receive. This is a serious issue which causes long term harm to children. 3.110 Whitney’s mother recognised that she had not met Whitney’s needs; she understood through support what had caused this and acted appropriately to create change. She at no point blamed Whitney. Less is known about Lena and her sibling’s parents and the extent to which their neglect of the children was entirely passive, an act of commission. There is certainly evidence that they put their own needs to go drinking or to parties at the extended family home, above the needs of the children. Anya and Rosa’s mother often blamed their behaviour for making it difficult to meet their needs and respond appropriately to their care. She told family support workers that they were unkempt due to their disabilities, and that their behaviour was not caused by a lack of boundaries, but their complex needs. 3.111 It is essential that professionals consider whether the neglect of children by their parents is deliberate, targeted and blaming. As professionals we need to imagine what it is like not to receive the care that you need to grow and develop appropriately, and then for this to be characterised as your own fault because you are too difficult or too damaged. Child blame and a parental focus on the child as the problem to be fixed needs early professional attention. Where parents hold these beliefs, services designed to address neglect are often ineffective because the parent perceives the child to be the problem that needs fixing What other kinds of abuse is the neglect enabling? 3.112 The final area of concern or analysis to address is how does the neglect of children enable other forms of abuse to occur. There is a strong connection between neglect and child sexual abusexlvii. This appears to be caused by factors such as poor supervision, lack of quality parent-child relationships, poor sexual boundaries in the home, domestic abuse, coercion and control and adult needs dominating decision making by parents. 3.113 Poor supervision, a lack of sexual boundaries, use of drugs and alcohol, and the presence of several adults, acceptance it seems of sexual activity, all contributed providing the facilitating circumstances to Paul sexually abusing all these children in the home he shared with Anya and Rosa. Anya and Rosa’s mother and father’s evident need to shut down what Rosa and Anya wanted to tell professionals was both neglect and emotional abuse. 3.114 These were all important questions to ask about the circumstances of these four children. Neglect is multi-faceted. As professionals we need to move from a focus on the physical circumstances that the child lives in or the physical care, they are provided with to thinking about how all developmental needs are met, and the likely impact if they are not. Professionals must consider a parent’s understanding of the need for change, why it is necessary and commitment to change behaviours and unhelpful parenting approaches in the best interests of their child; in essence helping parents hold their child’s need in mind. 45 Official 3.115 The local area implemented a neglect framework and toolkit in 2018. It became clear through interviews that many professionals were not aware of it, and it was not used in any of these family circumstances. Given the complexity of neglect, more thought needs to be given locally to what would make a difference to providing a more effective response to situations where neglect is long term, has been resistant to change, is characterised by parental hostility to help, where parents often lie about or mislead professionals about their and their children’s circumstances. It was evident through interviews with professionals that Rosa, Anya’s and Lena’s parents often provided a false and misleading picture, lied to professionals and denied the presence of unsuitable adults or professional concerns. This was inconsistently acknowledged, acted upon or analysed in the context of both understanding neglect and in addressing child sexual abuse. A culture has grown up around calling this parental behaviour “disguised compliance” as though this is a sufficient explanation of what professionals’ are seeing. What is required is an acknowledgement when parents lie, mislead or avoid, and an analysis of what this means for the child and their circumstances and reflection on the meaning for the parent in the context of their current circumstances. Recommendation 13: A review and audit of the neglect framework and is recommended to determine its impact on the issues raised in this report. Recommendation 14: The reduced frequency of professionals’ meetings locally has been highlighted. Concerns about the validity of such an approach should be addressed and the guidance regarding professionals meeting circulated to partners. Finding 3: Responding to the needs of Learning Disabled adults as parents 3.116 Rosa, Anya, Whitney, and Lena’s parents all had learning disabilities and physical disabilities. As a result of the care proceedings undertaken about Rosa and Anya, it was known mid-way through this review that their parents had IQ’S within the low range of a mild learning disability. This low range, an IQ of 52 for father and 60 for mother puts them both in the category of adults with learning disability for whom parenting would be a known difficulty and they would require considerable support. The level of Lena’s mother learning disability was not known, but professionals understood it to be in the low range. Whitney’s mother had mild learning needs which did not fit the criteria for a learning disability, but which did fall into the category of requiring careful thought about communication and to ensure that information was understandable and comprehensible. 3.117 A learning disability is defined by the Department of Healthxlviii as a “Significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood and may be mild, moderate or severe in nature. 46 Official 3.118 There is good evidence that adults with mild learning disabilities can be and are good parents; however, when their IQ falls below 62 there are likely to be real challenges in fulfilling the requirements of parenting. This parenting can be further compromised where there are additional concerns about mental health concerns, abuse and neglect in childhood and substance misusexlix. Learning disabled parents disproportionately suffer from depression and poor mental health, partly due to societal attitudes, and often poor social networks, but also due to the increased risk that they will have been sexually, physically abused and neglected in childhoodl. There is also evidence that learning disabled adults, and those that are parents, are disproportionally impacted by exploitation and bullying within the community which can further impact on parenting abilityli. 3.119 Parents may have difficulties with reading, understanding complex verbal communication and abstract concepts, telling the time, remembering appointments, retaining information, problem solving, decision making and organisational skills, struggles to understand other’s needs, including children and verbal reasoning. They may find it takes longer to acquire new skills, such as parenting and managing children’s behaviour, and to make use of mainstream approaches to teaching those skills. In this context they need and are entitled to support to fulfil their parenting role. 3.120 Legislation and Guidance makes clear the importance of ensuring that adults with disabilities are supported to fulfil their parental rolelii. The Convention on the Rights of Persons with Disabilities (2006) article 23 (2)liii states “Parties shall render appropriate assistance to persons with disabilities in the performance of their child-rearing responsibilities. This right needs to be set alongside the duty of the State (through local authorities) to safeguard and promote the welfare of children, as set out in the Children Act 1989liv with the welfare of the child being the paramount concern. In essence the support provided to parents’ needs to be child centred and child focussed. It must not replace the parenting role or introduce several adults into the life of a child which can disrupt attachment and the development of core relationships. The support must be consistent, predictable and reflective of normal family life, as far as is possible. This requires a clear plan detailing expectations and boundaries. 3.121 The Good Practice Guidancelv about working with parents with learning difficulties makes clear what best practice looks like: • Appropriate communication: providing easy read versions of reports including visual aids and supplementing written information with clear and straightforward verbal explanations and not using font size 14 or below. • Provision of consistency; adults how are concrete thinkers do not need a multitude of advice from different professionals; there needs to be constancy in approach and advice; this 47 Official could include the use of an advice diary when there are multiple professionals visiting the family home. • An approach which is focused on demonstrating what change looks like and straightforward explanations of concerns and why they are important, particularly in the context of child wellbeing. • Taking time; parents with learning difficulties need more time to build relationships, learn new skills and understand concerns; practice does not always allow this. • Parenting with support; research suggests that parents with learning difficulties need longer term support. This means avoiding the “revolving door approach” • Provision of advocacy 3.122 Addressing the needs of adults with learning disabilities and difficulties and ensuring that there are appropriate reasonable adjustments to services and response is made more complex by the fact that many adults will not have a formal diagnosis. This was the case for the parents of the children in this review. Despite that, all professionals were aware that most of the adults in the family had some form of learning needs and therefore they should have considered the importance of making reasonable adjustments as required by the Equalities Act 2010lvi and the existing best practice guidancelvii. 3.123 There is no evidence that within the early help responses, child in need plans and processes, child protection conferences and plans and looked after reviews that the parents of the children were provide with reports in an easy read format. The current format, small font, single spacing and dense paragraphs would make it impossible for anyone with even a mild learning difficulty, let alone a diagnosed learning disability, to understand. 3.124 When it became clear in 2018 that Paul posed a sexual risk to children, the parents of Rosa, Anya, Whitney, and Lena were asked to sign written agreements not to allow Paul contact. The use of the written medium is not appropriate for parents with learning disabilities and there is no evidence that they understood what the written agreement was about. There is a more general point to be made about the use of written agreements to ensure the safety of children. The fact all the parents signed the documents was interpreted as both an indication of their understanding of the risk posed by Paul, an understanding of the professional concerns and their capacity and willingness to comply. The evidence suggested that none of these factors existed. 48 Official 3.125 Learning disabled children are more likely to be sexually abused in childhood than their non-disabled peerslviii, and in adulthood they are more likely to be sexually harmed, domestically abused, and exploited by partners and others in the community who are more cognitively able than them. This vulnerability to exploitation in adulthood needs careful exploration and assessment in the context of parenting and family life. Lena’s mother talked about being sexually abused as a child, and there was evidence of this in historic records. When she was pregnant with her first child, she was referred to adult services for support as a leaning disabled parent. She did not meet the threshold for services as an individual with care and support needs under the Care Act 2014lix and there remains something of a gap, evidenced by the experiences of several learning disabled parents within this extended family group, of a lack of services targeted at learning disabled parents, and a lack of a protocol or agreement between adult and children’s services. Lena’s mother never got the targeted support she needed. 3.126 More worryingly, Lena’s husband was asked to be the main carer for the children, but also for her. This decision did not take account of how this arrangement might impact on the children, their experience of mothering, or how this enhanced power bestowed on one partner, might exacerbate domestic abuse. There was concern that Lena’s father may have been physically and sexually abusive to Lena’s mother, but there was little analysis of this in the context of his role as main carer. A second family, part of this extended family group, were in the same situation. The vulnerability of learning disabled adults as parents to violence and abuse needs recognition, and an appropriate response. 3.127 The finding in this report looks at the importance of the causes of neglect. It is critical that there is a good assessment of the connection between parental learning disability and neglectful parenting. This is to ensure that the right support is provided, focused on the learning disability itself, including parental understanding of the child’s needs as well as ability to form attachment relationships, but also taking account of other factors such as poor mental health, experience of child and adult abuse, substance misuse, poverty and isolation. A holistic assessment is needed. 3.128 The research suggests that the professional response for learning disabled adults as parents can be to focus exclusively on the learning disability, often seen as a limiting factorlx, and issues such as depression, substance misuse and domestic abuse are not addressed. Both responses are needed. A parent’s learning disability needs to be addressed and reasonable adjustments made, but also other factors impacting on their parenting need to be addressed, in the context of those reasonable adjustments. In this review the learning disabilities were recognised, but not sufficiently responded to. There is also a need to hold parents with learning disabilities responsible for the wellbeing, care, safety and 49 Official love of their children. Researchlxi suggests there are times when learning disabled parents are held to a higher standard than their non-disabled peers, and times when there are lower expectations of care and safety because of the parent’s own needs and vulnerabilities, leaving children at risk of neglect and abuse. It is apparent that both dynamics were at play across this extended family group. Recommendation 15: The Safeguarding Children’s Partnership needs to provide guidance, based on the existing national guidance regarding practical resources for working with and communicating with learning disabled parents. Recommendation 16: The Safeguarding Children’s Partnership should facilitate some discussion between children and adult services locally about how support can be provided to adults with needs that do not met the criteria for adult services support, but where these adults do need help to fulfil their parenting role as outlined within the care Act 2014. Finding 4: The importance of understanding family history to effectively safeguard children and support families 3.129 The final finding of this review related to the importance of history. Rosa, Anya, Whitney and Lena’s parents and extended family have been known to children’s services and the police for over 25 years. This involvement consisted of continuous concerns about neglect, physical abuse and sexual abuse across the generations from Anya and Rosa’s parent’s earliest experiences of parenting to the present day. There is no information available about whether Rosa and Anya’s parents (who were grandparents to Whitney, Lena and her siblings and other children) were themselves known to children’s services and the police when they were children. There is no information about their own family history, or their siblings and parents. This was a significant gap. 3.130 Research and serious case reviewslxii have repeatedly shown that historical information is not given the attention that it should be given in assessing the needs of children. The cause was often because important information was not shared, was missing or lost, particularly when the family moved geographically across boundaries or borders. Or where it was available it was not referred to or not analysed in such a way as to see the emerging pattern of increased risk of suffering harmlxiii. 3.131 When there were concerns in 2017 about the care that Whitney’s mother provided to Whitney, an assessment was completed. The role that the grandparents played in providing care to Whitney was known, but their historical involvement in services due to concerns about their parenting, neglect and sexual abuse was not. This meant there was no analysis about their suitability as alternative caregivers or the safety of Whitney being in their home. It was known that Paul, Whitney’s father, lived in his family home with his sisters, Anya, Rosa and their parents. The 50 Official information about previous concerns about his possible sexualised behaviour, sibling sexual abuse and sexual assault of others was not known. This information was not shared by the parents. This meant that work to increase contact between Paul and Whitney went ahead, with a plan that Paul’s mother would supervise. This lack of information was in part due to changes to the electronic recording system in the local authority some years earlier, which meant some records were unavailable, and partly due to a lack of chronologies and closing reports. There had been a gap of several years since Anya and Rosa and their parents had been formally known to children’s services. The gap was of course a serious one. 3.132 When there were concerns in 2017 about Anya being subjected to harmful sexual behaviours and then evidence of sibling sexual abuse, historical information about the long history of concerns about poor sexual boundaries at home and concerns about Paul and sexual abuse were not known. Anya’s sexualised behaviour and experience of being possibly sexually harmed at school, were seen in isolation from this historical information and the seriousness therefore was not recognised. 3.133 When professionals became concerned about Paul, and the sexual abuse of Whitney, there was discussion of the family history, but there was no mapping across all the different family groups. A comprehensive genogram was not constructed, chronologies of the separate family histories was not compiled, and the connections across the family groupings not highlighted. Many professionals outside children’s services were unaware of the family history and the connections between the families. There were some services, however, who were very aware of the family history, both because they had contact with the adults as children, and because this was a family other families talked about. This information became rumour and supposition, and there was general uncomfortableness across professional networks about what was truth and what was not. Information was often dismissed as being rumour and supposition and this served to undermine a professional analysis of the family history. It is important that professionals check the accuracy of information, and that is why chronologies, closing summaries and transfer records from one service to another is so important. The local authority refreshed its guidance about chronologies, transfer summaries and closing reports in 2020. There has been an emphasis locally on the use of third generation genograms and the importance of family history. What remains unclear is the extent to which information about one family can be used within the records of another family group to whom they are related. There was concern that this somehow breached GDPR30 requirements. This requires clarification. 3.134 These children’s circumstances highlight the importance of family history in understanding children’s circumstances. In his review of serious case reviews from over 20 years ago, Rederlxiv said “the best predictor of present and future behaviour is past behaviour”. 30 51 Official Given that the guidance regarding chronologies, closing summaries and transfer to other services has been updated, no recommendation is considered necessary. Domestic abuse and sexual violence 3.135 There is not a separate finding which relates to domestic abuse and violence; there is not one adult female member of this extended family who was not subjected to sexual violence and abuse over the time under review and in the past. These same women were also subject to intrafamilial child sexual abuse. There is little evidence of the assessment of domestic abuse, or its analysis in the context of parenting, the neglect and supervision of children. Domestic abuse is often referred to as “between the couple, within the relationship or within the family”. These descriptions were inaccurate. Within this extended family there were men who perpetrated abuse, and women were the victims. These descriptions excuse the behaviours of perpetrators, deny the reality of victims, and suggest that domestic abuse is a shared issue, with adults being equally responsible and equally impacted. The impact of Alcohol and Drugs 3.136 There is also not a finding about the role that alcohol and drugs played in the chaotic and abusive nature of these four children’s lives. There are hints across all the records that this was a concern, and certainly contributed to poor boundaries, adults needing hospital treatment and the police being called, but there is little information within the records of the detail of this alcohol use, what part it played in the abuse and neglect of the children. This makes a finding and analysis difficult to achieve in this report. The absence of detailed information and the insufficient recognition of this as an issue that needed addressing is important. Drug and alcohol misuse by parents and family members in the context of children’s needs is a serious issue. Research highlights the negative impact on children’s lives, the negative impact on their development, the ability of adults to meet their children’s needs and the link with abuse and neglect. A good assessment of the use of alcohol and drugs by parents is needed, including the role it plays in undermining parenting and creating the circumstances for abuse. This was absent here. 52 Official 4. Conclusion 4.1 This LSCPR has focussed on the sexual abuse and neglect of four children, Anya, Rosa, Whitney and Lena. As the dedication at the beginning says, the review recognises their bravery in telling professionals about the harm they were experiencing. Some of the adults in their lives were responsible for this harm, either by directly abusing them, colluding with the harm, or not telling professionals about concerning behaviour. Sadly, it is likely that there are other children who have been abused that we do not know about, and there are many adults here who experienced sexual abuse as children and sexual harm as adults. Therefore, the report has focussed so strongly on strengthening the professional response to child sexual abuse and its co-existence with the neglect of children. 4.2 It is important to say that when concerns about Paul sexually abusing Whitney became known, steps were taken to assure all the children’s safety, and over time they have been placed in appropriate homes or residential settings. They have also been provided with therapeutic support to address the impact of the harm on them. There are also many professionals supporting these children as they grow and develop. Too many to name. 4.3 There were many professionals involved with the four children and their families. Many of those professionals were unaware of the complexity of the family circumstances and the historical information. To these professionals all the parents of the children seemed to be well meaning, struggling with their own learning needs, health problems and socio-economic disadvantage. The neglect was not fully recognised, and the sexual abuse not known or not seen. There were many professionals such as social workers, family support workers, police officers, ambulance workers and hospital staff who saw or knew of the distress, the alcohol use, the violence and chaos of the adults and there was insufficient questioning of what this might mean for the children in the background. 4.3 There were social workers, residential staff, health staff and police officers who were involved with addressing the sexual abuse of these children. There was a lot of hard work, and we have heard that at times the task seemed overwhelming. There was not an absence of action here, or compassion, but at times a lack of knowledge about how to deal with issues such as sibling sexual abuse, harmful sexual behaviours, distinguishing what is adult sexual behaviour and what is an indication of poor sexual boundaries, how to build a picture of concern and not rely on children’s testimonies, how to build evidence for criminal proceedings by working as a multi-agency group and the importance of feedback to children along the way. It is striking the extent to which joint enquiries between the police and children’s social care have become independent processes, not benefiting from the work of each other and the way in which social workers are no longer part of the 53 Official ABE/VRI process. These are all local and national concerns that need urgently addressing. 4.4 The lack of a consistent impression or understanding of this large extended family across the professional network was caused by the large amount of information that was viewed or perceived as “gossip” or “rumour” and it was thought that it was not permissible to discuss fully in a professional context, because it was not “official information”. This meant the worries about sexual abuse and poor sexual boundaries were often around but did not surface in professional meetings and their authenticity was not clarified. The other influential factor was that there was lack of open discussion about the concerns that children were often silenced, and that adults did not tell the truth, or actively misled professionals. As one interviewee in the review process said, “if you said the sky was blue, (adult x) would say it was green”. Many professionals talked about this in interview, but it was not present as a concern in records and was not part of the analysis within assessments, child in need reports or plans or child protection reports or plans. This review was not able to explore in depth what this was fully about but represents an important issue in understanding these children’s circumstances and the risks posed to them. 54 Official References i Hackett, S. (2014) Children and young people with harmful sexual behaviours. London: Research in Practice ii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf iii iv https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ v https://learning.nspcc.org.uk/research-resources/statistics-briefings/child-sexual-abuse vi https://www.csacentre.org.uk/index.cfm/_api/render/file/?method=inline&fileID=CCB6D637-308F-4C6F-95DF0AC61E61E3AA vii Ofsted (2020) The multi-agency response to child sexual abuse in the family environment Prevention, identification, protection and support https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/862454/Multi_agency_response_to_child_sexual_abuse_in_the_family_environment_joint_targeted_area_inspections_JTAIs.pdf viii https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ ix https://www.csacentre.org.uk/csa-centre-prodv2/assets/File/Sibling%20sexual%20abuse%20report%20-%20for%20publication.pdf x https://tce.researchinpractice.org.uk/wp-content/uploads/2020/05/children_and_young_people_with_harmful_sexual_behaviours_research_review_2014.pdf xi https://tce.researchinpractice.org.uk/wp-content/uploads/2020/05/children_and_young_people_with_harmful_sexual_behaviours_research_review_2014.pdf xii https://www.childrenscommissioner.gov.uk/report/protecting-children-from-harm/ xiii https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/childsexualabuseinenglandandwales/yearendingmarch2019 xiv Darling, A.J, & Christensen, L.S, (2020). Female child sex offenders. In Child Sexual Abuse: Forensic Issues in Evidence, Impact and Management. Bryce, I., & Petherick, W., Academic Press, Elsevier. 119-134. xvi https://www.csacentre.org.uk/index.cfm/_api/render/file/?method=inline&fileID=7C7BB562-DB13-4C7E-B8C21D04920D6AEF xvii Allnock D. et al (2019). Key messages from research on identifying and responding to disclosures of child sexual abuse The International Centre (University of Bedfordshire) and NSPCC for the Centre of Expertise for Child Sexual Abuse https://www.csacentre.org.uk/resources/key-messages/disclosures-csa/ xviii https://www.csacentre.org.uk/documents/communicating-with-children-guide/ xix https://www.csacentre.org.uk/documents/communicating-with-children-guide/ xxi Independent Inquiry Into Child Sexual Abuse (IICSA) et al. (2017) The impacts of child sexual abuse: a rapid evidence assessment: summary report (PDF). London: Independent Inquiry into Child Sexual Abuse. 55 Official xxii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/ xxiii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/ xxiv Jones, L. et al. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet, 380 (9845): 899-907. xxv https://www.csacentre.org.uk/documents/supporting-parents-and-carers-a-guide-for-those-working-with-families-affected-by-child-sexual-abuse/ xxvi Still, J (2016) Assessment and Intervention with Mothers and Partners Following Child Sexual Abuse: Empowering to Protect xxvii Ofsted (2020) The multi-agency response to child sexual abuse in the family environment Prevention, identification, protection and support https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/862454/Multi_agency_response_to_child_sexual_abuse_in_the_family_environment_joint_targeted_area_inspections_JTAIs.pdf xxviii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/ xxix Finkelhor et all (2016) The Four Preconditions Model: An Assessment. https://onlinelibrary.wiley.com/dAttenoi/abs/10.1002/9781118574003.wattso002 xxx https://www.csacentre.org.uk/documents/supporting-parents-and-carers-a-guide-for-those-working-with-families-affected-by-child-sexual-abuse/ xxxi https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/Protecting-children-from-harm-full-report.pdf xxxii Independent Inquiry Into Child Sexual Abuse (IICSA) et al. (2017) The impacts of child sexual abuse: a rapid evidence assessment: summary report (PDF). London: Independent Inquiry into Child Sexual Abuse. xxxiii https://www.iicsa.org.uk/reports-recommendations/publications/inquiry/interim/nature-effects-child-sexual-abuse/effects-child-sexual-abuse xxxiv Royal College of Paediatrics and Child Health/ Faculty of Forensic and Legal Medicine (2012) Guidelines on Paediatric Medical Examinations in Relation to Possible Child Sexual Abuse. London: FFLM. xxxv https://www.csacentre.org.uk/documents/the-role-and-scope-of-medical-examinations-when-there-are-concerns-about-child-sexual-abuse-a-scoping-review/ xxxvi https://www.csacentre.org.uk/knowledge-in-practice/practice-improvement/medical-examinations/ xxxvii https://www.csacentre.org.uk/knowledge-in-practice/practice-improvement/medical-examinations/ xxxviii https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ xxxix https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1051269/achieving-best-evidence-criminal-proceedings.pdf xl https://www.gov.uk/government/publications/the-code-of-practice-for-victims-of-crime xli https://www.gov.uk/guidance/criminal-injuries-compensation-a-guide 56 Official xlii Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. [. xliii file:///C:/Users/richa/Downloads/Childhood_neglect_and_abuse_comparing_placement_options%20(1).pdf xliv BRANDON, M. et al., 2014. Missed opportunities: indicators of neglect–what is ignored, why, and what can be done? London: Department for Education, DFE-RR404, 46pp. https://repository.lboro.ac.uk/articles/report/Missed_opportunities_indicators_of_neglect_what_is_ignored_why_and_what_can_be_done_/9580058 xlv Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. xlvi https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/419072/In_the_child_s_time-professional_responses_to_neglect.pdf xlvii https://www.researchinpractice.org.uk/children/publications/2016/november/child-neglect-and-its-relationship-to-other-forms-of-harm-responding-effectively-to-children-s-needs-evidence-scopes/ xlviii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/250877/5086.pdf xlix Working Together with Parents Network (2014) Parents with Learning Disabilities – An Introduction. Bristol: University of Bristol, School for Policy Studies. www.bristol.ac.uk/sps/ media/WTWPN_documents/intro-to-parents-with-learning-diffs-july-2014.pdf l Working Together with Parents Network (2014) Parents with Learning Disabilities – An Introduction. Bristol: University of Bristol, School for Policy Studies. www.bristol.ac.uk/sps/ media/WTWPN_documents/intro-to-parents-with-learning-diffs-july-2014.pdf li https://www.mentalhealth.org.uk/sites/default/files/FPLD%20a%20life%20without%20fear%20%28005%29.pdf lii Social Care Institute for Excellence (2007) Working together to support disabled parents. London: Social Care Institute for Excellence. liii https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html liv https://www.legislation.gov.uk/ukpga/1989/41/contents lv Working Together with Parents Network (WTPN) update of the DoH/DfES Good practice guidance on working with parents with a learning disability (2007) https://www.bristol.ac.uk/media-library/sites/sps/documents/wtpn/2016%20WTPN%20UPDATE%20OF%20THE%20GPG%20-%20finalised%20with%20cover.pdf lvi https://www.legislation.gov.uk/ukpga/2010/15/contents lvii Ibid. lviii https://learning.nspcc.org.uk/media/1879/parents-and-carers-views-on-preventing-sexual-abuse-of-disabled-children.pdf lix https://www.legislation.gov.uk/ukpga/2014/23/contents/enacted lx Working Together with Parents Network (2007) Top Tips – If You Think a Parent Has a Learning Difficulty or Learning Disability… Bristol: University of Bristol, School for Policy Studies. www. bristol.ac.uk/media-library/sites/sps/documents/wtpn_top_tips_for_workers.pdf 57 Official lxi https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf lxii https://lx.iriss.org.uk/sites/default/files/resources/Effective%20interventions%20for%20complex.pdf lxiii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf lxiv Reder, P, and Duncan, S. (1999) Lost Innocents: A Follow-Up Study of Fatal Child Abuse. London: Routledge. |
NC52195 | Death of a 2-month-old child due to asphyxiation. Mother found Child NS lifeless in the bed beside her after waking up following a night out. At the time of Child NS' death, children's social care were not aware that there was a new baby in the family. The family had older siblings, some of whom had additional needs, who lived with Mother and Child NS. Father lived nearby. In 2018, school staff made a referral to children's services because of changes in the presentation and behaviour of two of the siblings. A subsequent child and family assessment resulted in no further action. Later that year, the eldest sibling received a serious injury and was made subject to a child in need plan following a section 47 enquiry and child protection conference. The needs of Child NS were not considered as part of this process because the parents had only disclosed the pregnancy to the services necessary to receive antenatal care. Learning includes: information about all members of the family should be sought from GPs during assessments and conferences; assessments of a child's needs should consider any additional needs of siblings; and practitioners need to bear in mind that parents might not disclose key information. Recommendations include: improve the effectiveness of informing parents about the dangers of co-sleeping; consider how to promote the wellbeing of all immediate family members who have experienced a neonatal death; and consider how to ensure the needs of siblings are considered collectively as well as individually.
| Title: Serious case review executive summary: Child NS. LSCB: Sandwell Children’s Safeguarding Partnership Author: Karen Perry Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Executive Summary for publication V1.11.20 Serious Case Review Executive Summary CHILD NS Lead Reviewer: Karen Perry 2 1. Introduction 1.1. This Serious Case Review (SCR) 1 is in respect of Child NS who died aged 2 months. After a night out, which involved drinking alcohol, Mother awoke in the early hours of the morning to find Child NS lifeless in bed beside her. Child NS died due to asphyxiation. 1.2. There was a range of learning from this review. The whole family, fathers and siblings as well as mothers, can be severely affected by a previous neonatal death. Parents who have experienced this are likely to be anxious about any future pregnancy. The risks of co-sleeping with babies are considerably increased when a parent is under the influence of alcohol or drugs; informing them of this verbally and via leaflets is not enough to ensure parents do not do this. Information about all members of the family should be sought from GPs during assessments and provided by GPs to child protection conferences. Any assessment of a child’s needs, and the ability of parents’ capacity to meet them, should consider any additional needs of siblings. This should include consulting other agencies that are involved with siblings, both during assessments and before ceasing Child in Need plans. Practitioners need to bear in mind that sometimes parents decide not to disclose key information (in this case the pregnancy) which might have a major impact on the level and nature of the support offered. Practitioners should ask open questions and probe for details about the support families are receiving. 2. Story of the child and family 2.1. Child NS lived with Mother and older siblings, some of whom had additional needs. Father lived close by and spent much of his time in the family household. Both parents were articulate and knowledgeable about their children’s additional needs and involved in the care of all of them. Child NS was born prematurely. The parents had had a previous child who died after a premature birth. 2.2. In 2018, school staff made a referral to Children’s Services due to changes in the presentation and behaviour of 2 Siblings, who were previously consistently well cared for. The school thought the family might need more support; a subsequent Child and Family Assessment resulted in no further action. 2.3. Also, in 2018 the eldest Sibling, who was a teenager, received an injury in the community which was serious but non-life-threatening; this was during the time when Mother was pregnant with Child NS. However, the needs of Child NS were not considered as part of the S47 enquiries, or at the child protection conference, because the parents had only disclosed the pregnancy to those services necessary to receive antenatal care. The unanimous decision of the child protection conference was for the eldest Sibling only to be made subject to a CIN plan.2 The main component of the CIN plan 1.1. 1 Working Together 2015 states a Serious Case Review should be held for every case where abuse or neglect is known or suspected and either a child dies or is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. Sandwell Safeguarding Children Partnership (SCSP) agreed to undertake this review using a learning model which engages frontline staff and their managers to focus on why those involved acted as they did at the time. The lead reviewer spoke to the parents and their comments are included at relevant places in the report. The SCR took into account multi-agency involvement from the period when mother was pregnant with NS until Child NS died. The report author is Karen Perry who is an experienced social work manager who is entirely independent of the agencies involved in this case 2 CIN plan; services provided under Section 17 Children Act 1989 to support children to achieve or maintain a reasonable standard of health or development or to prevent significant or further harm to health or development 3 was the involvement of the Multi-Systemic Therapy3 (MST) team. Towards the end of 2018 practitioners considered that good progress was being made at home and at school, therefore MST involvement was to cease as a sustainability plan was in place. 2.4. Child NS was born prematurely and discharged home after a month in the neonatal unit. During this same period, there were renewed concerns about the eldest Sibling. Subsequently, as a result of a particularly difficult incident between the eldest Sibling and Mother, an MST therapist made a home visit to review the sustainability plan with Mother. 2.5. When Child NS died aged 2 months, Children’s Social Care were still not aware that there was a new baby, despite the home visits of the MST therapist and social worker in the previous month. Mother had not mentioned a new baby, and neither practitioner saw any baby equipment in the home. 3. Response to neonatal death, unborn children and prematurity 3.1. Loss of a baby shortly after birth is an unexpected, traumatic and life changing event. Research shows that, although the impact is usually most severe for mothers with men feeling that their role was primarily as ‘supportive partner,’ fathers can also be significantly affected but tend to be overlooked by health professionals.4 Records show that the family received support from the hospital bereavement team following the neonatal death of their previous baby. The parents told this review that they did not take up the subsequent counselling referral offered by the health visitor because they had sufficient support from their families. Father told this review that he felt included and that maternity practitioners were sensitive to his feelings too during the antenatal and postnatal period for Child NS. However, the review identified gaps in arrangements for ensuring fathers’ GPs are notified about neonatal deaths and for ensuring follow up if fathers are not present on support visits to mothers. 3.2. Research indicates that children grieve just as much as adults but show it in different ways,5 through behaviour rather than words for example. Supporting children puts additional pressure on grieving parents. The parents told this review that they did not recall being given any advice or information about the potential impact of the death on the children, or how to manage it. However, they felt the school had been caring and supportive especially to one of the Siblings. 3.3. Mother and Father told this review that they thought the antenatal care for Child NS was good physically (medically) and emotionally; practitioners knew both parents were worried about another premature birth. Neonatal unit staff offered reassurance and psychological support; the parents told this review they appreciated that the staff remembered (the death of) their previous child and felt reassured by the system of putting ‘purple butterflies’ in babies’ records where there has been a previous neonatal death. 3.4. There was good take up of antenatal care by Mother. However, Child NS and Mother received a different (reduced) community-based service due to the premature birth; this prevented an antenatal 3 Multisystemic Therapy (MST) is an intensive family and community based intervention for children and young people aged 11-17, which aims to break the cycle of anti-social behaviours by keeping young people safely at home, in school, and out of trouble. 4Gold, K. J., Leon, I., Boggs, M. E., & Sen. A. (2016). Depression and posttraumatic stress symptoms after perinatal loss in a population-based sample. Journal of Women’s Health, 25(3), 263-269. Cited in https://www.2020mom.org/pregnancy-loss-infant-death and https://www.midwiferyjournal.com/article/S0266-6138(19)30217-7/fulltext 5 https://www.childbereavementuk.org/supporting-bereaved-children-and-young-people 4 visit by the health visitor from taking place and the first postnatal visit was very delayed as Mother spent much of her time at the neonatal unit. For similar reasons only one of four attempted postnatal visits by a community midwife was successful. 3.5. Practitioners told this review that there were no inherent concerns about Mother and Father meeting a premature baby’s needs due to them being experienced parents who were responding well to Child NS. However, there was no evidence of any consideration of what the impact of the challenges of caring for a premature baby might have been on the siblings or vice versa. The relapse in behaviour of the eldest Sibling around the time of Child NS’s birth was not known by practitioners caring for mother and baby. 3.6. The Lullaby Trust cites a number of factors associated with Sudden Infant Death Syndrome (SIDS) of which the most significant are smoking and co-sleeping especially after using alcohol or drugs.6 Research7 suggests that the majority of SCRs with SUDI (Sudden Unexpected Death in Infancy)8 involved the combination of parental alcohol or drug misuse and co-sleeping, which is a frequent finding in SUDI more generally. This was true also of the sample of 40 cases of SUDI considered in the recent report from the National Child Safeguarding Practice Review Panel.9 This report found that, as in this case, safe sleeping advice had been given to all the parents in their sample at least once, but concluded that parents do not find these interactions meaningful and had often understood the goal to be to follow the advice most of the time, rather than always. 3.7. It is not known whether co-sleeping with Child NS occurred regularly; practitioners were not aware of any occasions prior to the incident which precipitated this review. However, what is clear is that the advice given was not followed in risky circumstances by parents for whom there was otherwise ample evidence of them going to some trouble to ensure their children’s needs were met. 4. How agencies worked together to support the whole family 4.1 The MST sustainability plan contained all the relevant triggers and reminders of effective previously learnt tactics should concerning behaviours re-emerge. However it could not include the impact of the pregnancy and birth, on Mother in particular, because MST staff were not aware of the pregnancy. The parents told this review that this was not a “concealed pregnancy”; given their previous experience they did not want the pregnancy widely known about until they were sure that it was viable. 4.2 The needs of unborn Child NS were not considered at the child protection conference. The social worker did not contact the GP about parents as part of the assessment; Children’s Social Care managers told this review that information from GPs on parents during a S47 enquiry is not routinely sought10 on the basis that had partners been concerned about parents they should have shared this with Children’s Social Care. This assumes that partners are already aware of all relevant information on GP records, which was not so in this case. The GP reports on the children for the child protection 6 https://www.lullabytrust.org.uk/research/evidence-base/ 7 Garstang, J. J. and Sidebotham, P. (2018) ‘Qualitative analysis of SCRs into unexpected infant deaths’. Archives of Disease in Childhood. doi:10.1136/archdischild-2018-315156. Available at: https://adc.bmj.com/content/104/1 (2018) and Blair, P. S., et al (2009). ‘Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England’. BMJ, 339, b3666. Cited in Brandon M etal (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Department of Education 8 SUDI is a descriptive rather than diagnostic term; death of a child that was not anticipated 24 hours previously (whose cause may or may not subsequently be ascertained. 9Sidebotham P et al July 2020 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm Child Safeguarding Review Panel 10 Nor had the social worker contacted the GP after the school referral regarding siblings 2 and 3 5 conference did not mention Mother, so did not include that Mother was pregnant; practitioners told this review that the report forms did not explicitly ask for this information. 4.3 Each of the siblings with (different and complex) additional needs received good support from the practitioners focused on them. However, those practitioners had limited awareness of the needs of the other children in the family. There were 2 different health visitors for Child NS and another sibling; the Health Visitor for NS told this review that she did not know about the needs of the siblings until she first met Mother nearly 2 months after Child NS’ birth. The school for two Siblings also told this review that they were unaware of the needs of the eldest Sibling until they attended the child protection conference. The CIN meetings for the eldest Sibling only involved practitioners involved with this Sibling. Practitioners told this review that even when professionals working with siblings were invited to CIN meetings they tended not to prioritise attendance. Ante-natal referral forms for consultant obstetric care do not refer to the needs of siblings unless there is a safeguarding concern, which did not apply in this case. Effective use of the recently created Sandwell Unborn Baby Network (SUBN) should support families where there are known parental risk factors or family vulnerabilities. However this would not have assisted in this case because criteria in the current terms of reference do not refer to the needs of other children in the family. 4.1 Whilst a number of practitioners did know that extended family members provided practical and emotional support, their enquiries about support were not successful in identifying the extent of the demands on the family in caring for them. More probing enquiries about the kind of support and from whom might have alerted practitioners to the potential for the additional challenges posed in caring for this premature baby, especially in the context of a previous neonatal death. Any parent may be reluctant to disclose gaps and pressures because, for example, pride, unrealistic expectations of family and friends, underestimating the challenges of a new baby or to avoid scrutiny by agencies - the latter of course being more worrying if there are already safeguarding concerns about the coming baby (which there weren’t in this case). 4.2 The parents gave specific examples of behaviour and support that they had found helpful. This included: honest and direct but sensitive communication; compassion for their losses; making allowances for when they were upset or angry; being given information promptly; being provided with explanations of complex information; and having questions answered. They also appreciated practical support, including from the volunteers who provided activities for their children on the neonatal unit. The parents also gave examples of unhelpful behaviours. These included practitioners who “talked in riddles”, did not return phone calls or cancelled appointments at short notice and made them feel judged. 5. Summary and Conclusion 6.1 Whilst there is some learning regarding the impact of a previous neonatal death on each parent and siblings both during the pregnancy and after a further premature birth, there was no significant deficit in services for Child NS. During the antenatal and post natal period appropriate advice about safe sleeping, including the increased risks associated with consuming alcohol or drugs, was given a number of times. It is not known why the parents did not follow this advice, and agencies were not aware of any occasions where they hadn’t until after the death of Child NS; prior to the death practitioners had no concerns about the care of Child NS. 6 6.2 The triennial report mentioned previously cites research11 which lists risk factors to be balanced with protective factors in assessing the potential for harm to an unborn baby. Risk factors include maternal physical and mental ill health, problematic use of drugs and/or alcohol, and physical violence directed at the expectant mother. Protective factors listed include good, regular ante-natal care, adequate nutrition, income support and appropriate housing, avoidance of smoking and severe stress, and social support for the expectant mother. In this case not only did practitioners believe that none of the risk factors applied, they also considered that all the protective factors were present too. 6.3 Relevant agencies generally worked well together to ensure the individual needs of the older Siblings were met; there were a number of examples of effective support and strong partnership working which included prompt and tenacious responses from a range of agencies and several examples of effective communication with both parents. However, what was missing was a through overview of all the needs of the children, the ability of the parents to meet them as a group of siblings, and the potential impact this might have when a premature baby arrived. However, whilst practitioners might have tried to offer more support had they known about all the pressures on the family, the likelihood is that the parents would have refused this, and there would have been no justification to override their consent. 6. Recommendations To address the multi-agency learning, this Serious Case Review identified the following recommendations for Sandwell Children’s Safeguarding Partnership (SCSP): 1. SCSP should consider how best to review and improve the effectiveness of current approaches to informing parents about the dangers of co-sleeping 2. SCSP should consider how best to ensure that arrangements are consistently effective to assess and promote the emotional wellbeing of all immediate family members who have experienced a still birth and/or neonatal death including siblings. 3. SCSP should consider how best to ensure that the needs of siblings are sufficiently considered collectively as well as individually especially when not all children of the family are subject to a Child in Need Plan. This should include considering how best to ensure that all practitioners are confident in exploring with parents in detail whether they need support. 4. SCSP should ask Sandwell Children’s Trust to consider whether the terms of reference for the SUBN should be amended to include women where other children have significant additional needs. 5. SCSP to seek assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them. This should include seeking assurance from the CCG that this is across all GP practices. 11 Cleaver et al, (2011) Children's Needs - Parenting Capacity - Child Abuse: Parental Mental Illness, Learning Disability, Substance Misuse and Domestic Violence. London: The Stationery Office. |
NC048195 | Two siblings, Child A and Child B, both under 5-years-of-age, removed from the care of Special Guardians after the male partner was found to be seriously physically and sexually abusing them, in May 2015. There had been concerns for the welfare of both children throughout their lives. They both had special needs, as did their birth parents. There had been extensive involvement with health and social care agencies and the Family Court, which had placed the children with a couple, Mr K and Ms L, under a Special Guardianship Order. A number of criminal charges were brought against Mr K and he received a lengthy custodial sentence. Ethnicity or nationality is not stated. Findings: there were overall concerns about the way the local authority approached the task of planning the care of the children; neither of the Special Guardians had any experience of parenting nor with looking after children with disabilities; the particular vulnerabilities arising from these children should have been given greater weight; there were reported injuries which were not investigated. Recommendations for the LSCB: to highlight the particular vulnerabilities of children with disabilities; to require the local authority to look at its arrangements for working with families where there have been long standing child care concerns; the use of family group conferences; the arrangements for assessing whether siblings in care should be placed together or separately; and the use of Special Guardianship with particular reference to the involvement of the Permanent Placements Panel.
| Title: Executive summary for Child A and Child B: serious case review. LSCB: Oxfordshire Safeguarding Children Board Author: Kevin Harrington Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review, Published 01 03 17 Executive Summary for Child A and Child B Serious Case Review Oxfordshire Safeguarding Children Board (the Board) conducted a Serious Case Review (SCR) after it emerged that two young children had been seriously abused by a man. He had been looking after them, with his female partner, under a Special Guardianship Order. The children had previously been in the care of Oxfordshire County Council (the Council) and the Council’s Children’s Social Care (CSC) services had been instrumental in arranging for the children to live with the Special Guardians. This report explains what happened and summarises the key findings of the SCR. Key events Child A and Child B are siblings, both aged under five at the relevant times.. They have a range of physical and learning difficulties. Their parents have learning disabilities and have received social care services as a result. Child A and Child B have siblings who are not cared for by their parents. There is a background of significant contact with child care agencies across both parents’ extended families. Both Child A and Child B have been subject to Child Protection Plans. Both Child A and Child B left the care of their parents as young children and the local authority in due course instituted care proceedings. Child A was then looked after in two foster placements and Child B was looked after within the extended family. The local authority agreed to a family request that there should be a Family Group Conference (FGC) to discuss arrangements for the future care of the children. At this FGC the couple who were to become the children’s Special Guardians came forward. One of them has a distant family connection to the children and they expressed an interest in caring permanently for the children. They had no children of their own and had been together for about three years. CSC assessed the couple and supported their application to the courts to care for the children. The outcome of the legal proceedings was that Special Guardianship Orders were made in respect of both children, with a Supervision Order of one year’s duration to the local authority. The children lived with the Special Guardians for about a year. During that time the family received extensive and specialist services from the local authority and the NHS. At one point one of the children was seen to have bruising which specialist medical staff felt to be consistent with inflicted injuries. This was considered under formal safeguarding arrangements but it was decided that no further action be taken. There were two other occasions when one of the children was seen to have facial bruising. On each occasion a day care provider contacted a social worker who advised that no further action was necessary because the children were exhibiting physically harmful behaviour and therefore likely to have bruises. Eventually the female Special Guardian contacted police. She had found evidence that her partner was very seriously abusing the children, sexually, physically and 2 Serious Case Review, Published 01 03 17 emotionally. Her partner was arrested and subsequently received a lengthy custodial sentence. The children were removed from the Special Guardians and now live with foster-carers (where they are well and happy). Findings of the serious case review A number of learning points and concerns about practice within and between agencies are identified in the SCR. However it is right to say at the outset that there was absolutely no indication that the children might be abused so seriously and extensively, within the Special Guardianship placement. It is also right to say that the SCR recognised that many individual staff across the agencies had displayed great commitment and compassion in their work with these children. The SCR identified an overall concern about the way in which the local authority approached the task of planning the care of the children. There was an unevidenced optimism that various arrangements within the children’s family would meet the children’s long term needs, which were special and demanding. The review found that the option of removing them from their birth family should have been given greater weight at a much earlier stage. There was also a lack of rigour in the Council’s approach to determining what weight should be given to the importance of the children being placed together, when they had spent little time together before living with the Special Guardians. Neither of the Special Guardians had any experience of parenting, nor any experience of looking after children with substantial disabilities and disadvantages, nor any strong, enduring relationships with the children. They almost drifted into the children’s lives yet became their legal parents. The SCR expressed some concerns about how this had happened, firstly in respect of the FGC. The FGC process may not have adequately challenged the emerging plan and in fact may have provided an unwarranted legitimacy to the proposed arrangements. The legal proceedings which culminated in the Special Guardianship Orders were complex. This was related to associated developments across the extended family, and some differing professional views between the Council and the Children’s Guardian about various courses of action. Ultimately however it is agreed that all matters were considered fully and properly by the Court before making those orders. There is no indication that any agency failed to meet any significant statutory or good practice requirements in the legal proceedings. While plans were being made for these children the government was also reviewing the use of Special Guardianship1. That review was prompted by a range of factors including evidence of some matters identified in this review insufficient assessments of prospective Special Guardians no reference to a Permanent Placements Panel when making an SGO plan SGOs being awarded along with a Supervision Order, indicating an inappropriate degree of ambiguity in a permanent placement inadequate support / intervention from agencies post-placement, particularly when new needs or concerns emerge 1 SGR_Final_Combined_Report.pdf 3 Serious Case Review, Published 01 03 17 The government has made a number of changes to the arrangements for Special Guardianship to address these issues. The particular vulnerabilities arising from these children’s disabilities should have been given greater weight. Children with disabilities are known to be much more likely to be abused than non-disabled children. In this case there were concerning aspects of the children’s’ presentation after the placement with the Special Guardians which were noted by staff and might have given greater cause for concern. There was a tendency too readily to conclude that distressed behaviour was a consequence of early neglect and then the changes in the arrangements for the children’s care. Agencies need constantly to remind staff that children with special needs can display similar behaviour to children who are distressed as a result of abuse There was one specific missed opportunity, when one of the children was found to have suspicious bruising and child protection arrangements were triggered. There were aspects of that episode, including medical evidence and concerns about the presentation of the male Special Guardian, which should have prompted a more thorough investigation. Police too quickly came to the conclusion that they could withdraw from the enquiries when there was still a clear possibility that the injuries were inflicted and when some further enquiries could have been made. There were too many attendees at a Child Protection conference. The carers were in attendance throughout which probably inhibited discussion. There were then reported injuries which were not investigated. Overall the desire for the placement to be successful caused routine child protection processes to be disregarded or used with insufficient thoroughness. Recommendations for the Board from the serious case review The Serious Case Review makes the following recommendations to the Oxfordshire Safeguarding Children Board: 1. The Board should use its arrangements for disseminating the learning arising from Serious Case Reviews to highlight the particular vulnerabilities of children with disabilities. 2. The Board should require the local authority to demonstrate that it has used the findings of this review to inform its arrangements for care planning for “looked after” children with particular reference to: Working with families where there have been long standing child care concerns The use of Special Guardianship, with particular reference to the involvement of the Permanent Placements Panel The use of Family Group Conferences The arrangements for assessing whether siblings in care should be placed together or apart |
NC050375 | Non-accidental head injury to an infant just under 8-weeks-old, of Pakistani heritage, in September 2016. Mother disclosed to a GP practice nurse during a routine appointment in July 2016 that father would be violent towards herself and Child L's older sibling, aged 10-months, if the latter would not stop crying. Mother declined to give consent for any referral for support being fearful of further violence. The specialist nurse for safeguarding children was informed and a referral to children's social care was agreed. During an assessment of Child L's sibling, no concerns were raised and mother retracted her allegations. Child L was born prematurely during a visit to Norwich and placed in neonatal intensive care, first in Norwich and then at the local hospital. Child L was discharged home at age 3-weeks. On 30 August children's social care closed the case due to lack of evidence. On 30 September Child L was admitted to hospital with a large subdural haemorrhage, caused by violent shaking. Key findings: good practice by the GP practice nurse; information elicited from mother by practice nurse became diluted during recording; implications for sharing safeguarding information in the case of out of area births. Recommendations include: to develop practitioner guidance on available options when a victim decides to retract allegations of domestic violence; to develop an abusive head trauma strategy to ensure effective prevention of abusive head injury in babies; to obtain assurance that partner agencies fulfil their statutory obligations to ensure strategy meetings take place when necessary and include all necessary partner agencies.
| Title: Child L1: serious case review. LSCB: Manchester Safeguarding Children Board Author: David Mellor Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD L1 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 15th May 2018 Ratified: February 2018 Independent Reviewer: David Mellor MSCB Child L1 SCR Page i Contents 1.0 Introduction ......................................................................................................................... 1 2.0 Terms of Reference .............................................................................................................. 1 3.0 Glossary ................................................................................................................................ 2 4.0 Synopsis ................................................................................................................................ 4 5.0 Contribution of Child L1’s family to the serious case review ............................................ 17 6.0 Analysis .............................................................................................................................. 18 7.0 Findings and Recommendations ........................................................................................ 31 Appendix A: Review Process .................................................................................................... 39 References ............................................................................................................................... 40 MSCB Child L1 SCR Page 1 of 40 1.0 Introduction 1.1 Child L1 was the subject of potentially life threatening injuries when less than two months old whilst in the care of their parents. Whilst pregnant with Child L1, mother had made disclosures to her GP practice of physical abuse by her husband of both herself and Child L1’s elder sibling who was ten months old at that time. Additionally, there were subsequently concerns that Child L1 may have been subject of a non-accidental injury a matter of days before the potentially life threatening injuries were sustained. 1.2 Manchester Safeguarding Children Board (MSCB) decided to conduct a Serious Case Review (SCR) because Child L1 had been seriously harmed and abuse was suspected. The MSCB was also concerned that the risk of serious harm to Child L1 and their elder sibling was not acted upon appropriately and that one or more partner agencies involved in the case considered that its concerns were not taken sufficiently seriously. 1.3 MSCB commissioned David Mellor to be the lead reviewer for this SCR. David is a retired chief police officer and former independent chair of Safeguarding Children and Adults Boards. He has no connection to any of the agencies involved in this case although he served as a police officer in Greater Manchester Police (GMP) from 1990-1999. A review group was established to oversee the SCR and membership of this group and a description of the process by which this SCR was carried out is shown in Appendix A. 2.0 Terms of Reference 2.1 The terms of reference for this SCR are as follows: The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016. The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction. The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1. Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held. The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed. MSCB Child L1 SCR Page 2 of 40 3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Child and Family Assessment (CAFA) The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability. The Common Assessment Framework (CAF) is a process for gathering and recording information about a child in respect of whom practitioners have concerns in which the needs of the child and how those needs can be met are identified. Domestic violence and abuse (DVA) is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological physical sexual financial emotional. Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Independent Domestic Violence Advisor (IDVA) Their main purpose is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members in order to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans. Multi-Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other MSCB Child L1 SCR Page 3 of 40 specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality. SafeLives DASH (Domestic Abuse, Stalking and 'Honour'-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi Agency Risk Assessment Conference (MARAC) and what other support might be required. Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry. MSCB Child L1 SCR Page 4 of 40 4.0 Synopsis 4.1 On the afternoon of 13th July 2016 mother attended GP practice 1 for a pertussis or whooping cough vaccination. She was almost seven months pregnant with Child L1 and was accompanied by her 10 month old child – Child L1’s elder sibling (L2). Whilst receiving the vaccination, mother disclosed to the practice nurse that father couldn’t stand Child L1’s elder sibling crying and would hit both her and the child if the latter wouldn’t stop crying. The practice nurse asked mother if she had any bruises and she showed her three finger bruises near the top of her right arm where she said father had grabbed her. 4.2 Mother said that this violence towards her and Child L1’s elder sibling had been going on since the birth of the child. Mother said she did her best to keep the child quiet but that when she was unable to prevent the child crying, father would “take the child off”. She added that she pleaded with father to simply go into another room and leave her to calm Child L1’s elder sibling but this provoked him into hitting mother for “undermining” him in front of the child. Mother told the practice nurse that the child had been bruised by father and that she was frightened of what further harm he might do to the child. 4.3 As stated above, mother was almost seven months pregnant with Child L1 and was described by the practice nurse as “distraught” when contemplating the harm father might also inflict on this child when born. She said that she prayed every night that God would protect her and her children. She went on to say that father did not allow her to use contraception which explained why there was such a short gap between the birth of the first child and the start of her pregnancy with Child L1. She added that father wanted her to have more children but that she didn’t want further children after her second child was born. 4.4 When the practice nurse began to discuss support for mother such as a women’s refuge, this appeared to increase mother’s distress. She began to say that children should grow up with a mother and a father, adding that without father she had nothing. She began to insist that father was essentially a good man, that he loved both her and their child and that she loved him. Mother showed the practice nurse images of father cuddling both of them. She began to beg the practice nurse not to tell anyone about her earlier disclosures. The practice nurse replied that they were obliged to report what had been said in order to protect the child and mother. The practice nurse said that mother became very distressed at this point and began to change the subject. 4.5 Mother declined to give consent to any referral for support in respect of herself and left the GP practice. 4.6 There is no reference to Child L1’s elder sibling’s body being checked for potential non accidental injuries in the GP practice records of this interaction. However, the practice nurse, who now no longer works within Greater Manchester, has contributed to this review through a MSCB Child L1 SCR Page 5 of 40 telephone interview with the lead reviewer in which they said that mother told them that the child currently had no bruises but, whilst mother was making her disclosures, the nurse had managed to take a look at the child’s arms, legs and back and could see no bruising. 4.7 The practice nurse immediately sought advice from a GP who advised them to ring the safeguarding team at the Central Manchester University Hospitals NHS Foundation Trust (CMFT). The practice nurse also quickly accessed the GP practice’s safeguarding children protocol which they then followed. 4.8 The practice nurse telephoned the CMFT specialist nurse for safeguarding children who recorded a more detailed account of the exchange which had taken place between the practice nurse and mother. (Differences from the practice nurse’s account are shown in italics) The specialist nurse recorded that mother had disclosed that father physically assaulted her every time the child cried. Father was said to ask mother to leave the room and when she refused he hit and punched mother. He was said to have put his hands around her throat. The specialist nurse recorded that mother had showed the practice nurse bruises on her arms where he had assaulted her. Mother also disclosed that father has hit the child many times when she cried. The specialist nurse noted that the practice nurse had not examined the child but mother said the child also had bruises. (Present tense in contrast to practice nurse’s recording which refers to bruising of the child in the past tense) The specialist nurse recorded that mother had begged the practice nurse not to tell anybody as she had nothing in her life except her husband. She had no family or friends in this country. Mother was reported to have come from Pakistan over two years ago. Father is Kurdish and 17 years older than mother. Mother said father was controlling and she stayed at home most of the time. Mother told the practice nurse that she had never previously disclosed the abuse of herself and her child. 4.9 The specialist nurse advised the practice nurse that a referral needed to be made to children’s social care that day as mother had made clear disclosures that not only had father assaulted her numerous times but also assaulted their child. The specialist nurse emphasised the high risk to the child and advised the practice nurse to be really clear about mother’s pregnancy and her high level of anxiety to ensure that the case was managed correctly. 4.10 The specialist nurse also advised the practice nurse to contact the health visitor (who was the 'case holder' for mother and child) but when the practice nurse attempted to do so they were unable to obtain any reply and left a voicemail message requesting the health visitor to contact the GP practice. However, contact was made with the health visitor by the specialist nurse. The health visitor the specialist nurse spoke to documented receiving the telephone call. (Variations in information recorded by the health visitor are shown in italics). The health visitor recorded that the child was not undressed but did not have any visible marks. It was documented that the child may need a child protection medical. Mother was said to be anxious about her disclosures being shared with anyone else, otherwise she said her husband would kill her. MSCB Child L1 SCR Page 6 of 40 4.11 The health visitor then contacted the Central midwifery team as they were unable to find any information about mother on the Chameleon hospital electronic information system. The health visitor spoke to the safeguarding midwife who reported no scan or ultrasound information in relation to mother. The health visitor was directed to the Wythenshawe hospital midwifery team which advised that mother was 'booked' at Wythenshawe hospital and had attended all appointments with her last midwifery contact taking place on 4th July 2016. Her expected delivery date was 26th September 2016. 4.12 The health visitor was informed that mother was covered by the Didsbury midwifery team with whom the concerns arising from mother’s disclosures would be shared although it was agreed that the midwifery team would not be asked to visit her that evening as this could put both mother and the midwife at risk. 4.13 The specialist nurse also discussed the case with the named nurse safeguarding children who agreed with the plan to make a referral to children’s social care and also to share the information with the midwifery team. 4.14 After receiving advice from the specialist nurse, the GP practice nurse rang the children’s social care emergency duty service (EDS) and the call was answered by a contact centre officer in the children’s social care contact centre. The details were recorded on a contact screening (child) record at 4.37pm. The record states that “Mother has disclosed that father gets very angry when the baby cries and he has been doing this since the baby has been born. Father also hits the baby and mother. This is the only detail that mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks mother’s phone. Referrer did not see any injuries on the child and the mother showed her grab marks on her arm”. Also recorded was the reason why consent had not been obtained for the referral which was stated as “Mother is terrified”. Although there was no reference to mother being pregnant, the record referred to mother, father, and both the child and unborn child. After recording this information, the contact centre officer asked the practice nurse to complete and submit a safeguarding children’s referral form. The practice nurse said they queried whether they needed to make a separate referral to any other agency in respect of mother and was advised that this was unnecessary. 4.15 The contact centre officer classed the incident as 'level 5' which triggered an immediate referral to the EDS. The record created by the contact centre officer would then have been sent to the children’s social care out of hours (OOH) inbox. 4.16 The safeguarding referral was then submitted by the practice nurse. It was timed at 4.47pm on 13th July 2016. Under 'key areas of risk of harm and neglect', the following was recorded: “Father gets very angry when the child cries, he can then proceed to hit child and to hit mother if she tries MSCB Child L1 SCR Page 7 of 40 to intervene on the child’s behalf. Mother is 9 months pregnant and very stressed and tearful about how she will protect two children. Baby will be a (gender redacted)”. Under 'actions taken or support provided so far' was recorded, “Mother disclosed to myself during a routine consultation that father hits her and the child and has major anger issues”. Under 'what are you requesting from children’s social care?' was recorded “Urgent referral. Safeguarding issues, concerns about safety”. 4.17 At a later point in the referral document the practice nurse recorded that “mother terrified about consequences of her disclosure. At the moment she does not want intervention as she feels her husband cares about her. She has no family support apart from him, and is very isolated. We are unsure about immigration status. He is very controlling and wants to know who is phoning her. Needs to be handled sensitively, as I do not want to escalate the situation. However once disclosure occurred I had no option but to report it”. Under 'family and environmental factors' was recorded “no family support apart from husband”. 4.18 At some point after submitting the safeguarding referral, the practice nurse received a phone call from an EDS social worker. The practice nurse said that the social worker adopted a “very patronising” tone and allegedly said that this referral had placed the social worker in a difficult situation as any visit they made to mother that evening could place her and the child at greater risk than they currently faced. The social worker is said to have questioned why the practice nurse had not referred mother for support in respect of domestic abuse to which the practice nurse responded by describing their attempts to encourage mother to seek support. The social worker said that they intended to seek advice from the police before taking further action in response to the referral. 4.19 This telephone exchange is not included in the children’s social care chronology so it is not possible to present the social worker’s account of this call. However, an exchange of correspondence between GP practice 1 and children’s social care has been shared with this review. A GP wrote to children’s social care to express concern that the practice nurse’s actions in making the safeguarding referral appeared to have been questioned by the EDS social worker. The EDS team manager replied and offered an apology on behalf of the EDS social worker for any miscommunication which may have occurred during his telephone call to the practice nurse, the intention of which was to elicit additional information. 4.20 The practice nurse – who worked one day each week for GP practice 1 - also left information about the case for the GP practice safeguarding lead (as advised by the specialist nurse) who had not been at work that day and arranged for the focused care worker and a GP to discuss the situation the following day. (Focused care workers work with patients and their families in an effort to address the medical issues they present and any underlying issues.) 4.21 At some point during the evening of 13th July 2016 an untimed referral was sent by the EDS social worker to the police. Under 'details of children' only “unborn Child L1” is referred to. Child MSCB Child L1 SCR Page 8 of 40 L1’s elder sibling is referred to under 'family composition/significant others' along with mother and father. Under 'reason for referral' is recorded “request strategy discussion – to share information and form action plan.” The following additional information is recorded on the referral: 4.22 “Children’s services received contact from health centre detailing that the mother has disclosed that the father gets very angry when the baby cries and he has been doing this since the baby has been born. The father also hits the baby and the mother. This is the only detail the mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks the mother's phone. Referrer did not see any injuries on the child and the mother showed grab marks on her arm. (This appears to be a 'cut and paste' from the information included in the contact screening (child) record). Children’s services have called referrer and asked whether they had attempted to signpost mother towards refuge or Manchester Women’s Aid – mother has refused this support and will not accept help. Mother is very isolated – no family / friends. They have tried to speak to the health visitor for 9 month old – Health Visitor not responding. Mother has refused for the health centre to disclose this to anyone else. Family not previously known to children’s services”. 4.23 On 14th July 2016 the police evaluated the request for a strategy meeting. They recorded that concerns had been raised for Child L1’s elder sibling as mother had disclosed that father gets very angry when the baby cries and had been doing this since the birth of the baby. The police also noted that father hits the baby and mother and that the latter had begged the referrer not to pass this information on. Father was noted to be very controlling and checked mother’s phone. The referrer had not seen any injuries on the child and the mother had shown grab marks on her arm. Again this appeared to be a 'cut and paste' from the information included in the contact screening (child) record. The police did not appear to appreciate that mother was pregnant. This was not mentioned in the referral from children’s social care although “unborn Child L1” is the (only) child recorded under “details of children”. 4.24 The police created a public protection investigation (PPI) in order to manage any further actions arising from the information shared by children’s social care. The information transferred from the original referral from children’s social care onto the PPI is said to be broadly similar to the original referral and contain no errors or omissions, although it has not been seen by the lead reviewer. A crime should have been recorded in accordance with national crime recording standards but was not. Various checks were made which disclosed minimal previous contact with father and no contact with mother. There were no previous PPIs. Contact was made with children’s social care to share this information. 4.25 The police declined the request for a strategy meeting on the grounds that both the police and children’s social care held very little prior information about the family. The police suggested that children’s social care complete a single assessment and added that should mother disclose physical MSCB Child L1 SCR Page 9 of 40 abuse to herself and/or her child, children’s social care should re-refer to the police in order to discuss how to proceed. 4.26 Also on 14th July 2016 the specialist nurse contacted the Multi Agency Safeguarding Hub (MASH) to follow up on the practice nurse’s referral. The specialist nurse was advised that the case had been allocated to children’s social care central locality team 3 based at Longsight. The specialist nurse then contacted the health visitor to request that they urgently contact children’s social care to find out the time of the anticipated strategy meeting in order to ensure that a health visitor was able to attend. The specialist nurse was advised that the case had now been handed over to another health visitor. 4.27 On 15th July 2016 mother’s named midwife at Wythenshawe hospital developed a safeguarding plan which entailed independent domestic violence advisor (IDVA) support being offered to mother. The plan was widely shared and two copies placed in mother’s notes with one copy to be transferred to Child L1’s notes at birth. 4.28 On 18th July 2016 a midwifery domestic abuse support service (MIDASS) IDVA contacted the social worker who had been allocated the case of mother and her child, to offer support to mother should she wish to take it up. (The MIDASS IDVA was allocated to Wythenshawe hospital for a twelve month pilot during 2016/17.) 4.29 On 19th July 2016 the health visitor to whom mother’s case had been allocated contacted the social worker to enquire about the outcome of the strategy meeting. The social worker was on the way to mother and father’s house at the time and acknowledged that they were unsure about how to tackle the situation if father was present. The health visitor mentioned that mother had told the practice nurse that father had threatened to kill her if she told anyone about the abuse. The social worker then said that they would consult with their manager and call the health visitor back. When the social worker called back, they said that the home visit had been cancelled due to the level of risk. This led to the two practitioners developing a plan to invite mother to bring her child to a 9 month development assessment. 4.30 The health visitor also ascertained that the police had declined a strategy meeting and that the social worker was undertaking a children and family assessment (CAFA). The health visitor then contacted the specialist nurse to escalate the matter given that no strategy meeting had been held and mother and her child remained at home with father. The specialist nurse advised that the named nurse had become involved as GP practice 1 had complained about a lack of input into the case from children’s social care. Mention was made of a potential conversation between a GP and a social work team manager and the specialist nurse was to contact the named nurse. 4.31 On 20th July 2016 the health visitor contacted the named nurse and outlined the plan agreed with children’s social care to invite mother and her child for an assessment. The named nurse MSCB Child L1 SCR Page 10 of 40 expressed support for the plan which had to be amended after the health visitor contacted mother who said that she was unable to attend the relevant children’s centre for the 9 month assessment. In the knowledge that father would be working, it was agreed that the assessment would take place in the family home. 4.32 On 21st July 2016 the health visitor and the social worker conducted the planned joint home visit to conduct the 9 month assessment of the child. “No concerns” were said to have been raised over the home environment although mother appeared to be living in a bedroom as the rest of the house appeared to require building work. An absence of toys was noted. Mother denied making any disclosures to the practice nurse on 13th July 2016. She said she was forced to say what she said by the practice nurse. Mother acknowledged that she did tell the nurse that her child cried a lot, especially if mother left the room, but that is all she said. 4.33 The child was weighed naked which gave the social worker an opportunity to check for bruising. No evidence of injuries was noted. Mother was noted to be very isolated and advice was given about local groups she could access. A referral was made to Sure Start for an outreach worker to reduce mother’s isolation. Mother was advised by the social worker that a CAFA was to be completed which would need to include father. The social worker was to visit again during the following week to complete the CAFA and father was to be told that the source of the concern was anonymous in order to try and minimise the risks to mother. Mother was said to look worried about father finding out about the allegation. The social worker also advised mother that if she chose to remain in a relationship with father then this could be considered to be a cause for concern which could lead to further steps to safeguard her child. The social worker encouraged mother to contact them if she needed support. The health visitor was to try and develop a trusting relationship with mother so that she could feel able to disclose any abuse. 4.34 On 22nd July 2016 children’s social care telephoned the GP to advise of the steps being taken to safeguard mother and her child. The action taken by the social worker and the health visitor were described as above, although mother was said to have minimised rather than retracted the disclosures made to the practice nurse. On the same date a GP attempted to contact mother by phone but received no reply and decided against leaving a voicemail message in case it was picked up by father. 4.35 On the same date the specialist nurse rang the health visitor for an update and was advised of the current plan. During this conversation mother was said to have made disclosures to the practice nurse because she thought the practice nurse was her friend. The specialist nurse later contacted the GP to update them and a discussion took place about the possibility of offering Identification and Referral to Improve Practice (IRIS) support to mother. (IRIS is a general practice based domestic violence and abuse training support and referral programme.) This may have prompted the GP’s telephone call to mother. (See paragraph 4.34) MSCB Child L1 SCR Page 11 of 40 4.36 On 6th August 2016 mother gave birth to Child L1 at Norfolk and Norwich University hospital (NNUH). Child L1 was premature (33 week gestation) and of low birth weight and so was transferred to the neonatal intensive care unit (NICU) for observations. Mother was described as “traumatised” following delivery and declined skin to skin contact with Child L1. Mother, father and Child L1’s elder sibling had been visiting father’s elder sister in Norwich at the time mother went into labour. 4.37 Mother was discharged to father’s sister’s address the following day and on 8th August 2016, NNUH contacted Wythenshawe hospital to advise them of the birth and arrange for transfer of Child L1 which took place on 10th August 2016. No safeguarding concerns were noted by NNUH and no safeguarding concerns were shared with NNUH by Wythenshawe hospital. 4.38 The transfer of Child L1 took place at 4pm on 10th August 2016 and the transfer nurse pointed out a Mongolian blue spot at the base of Child L1’s spine to a Wythenshawe hospital counterpart. At 8.15pm the same day mother paid a brief visit to Child L1 but the family made no further visits until 1.30pm on 12th August 2016 when mother made a brief visit and declined to hold Child L1. She advised that the rest of the family were returning to Norwich and would not return until after 14th August. Mother was encouraged to ring Wythenshawe NICU for updates on Child L1. 4.39 Notifications of Child L1’s birth were sent to the GP and health visitor and on 12th August 2016 the health visitor contacted the staff nurse in the Wythenshawe hospital NICU to advise of the current safeguarding and domestic abuse concerns and advised the staff nurse to contact the safeguarding midwife. At this point the Wythenshawe NICU appeared to have been unaware of these earlier safeguarding concerns. Child L1’s birth out of area appears to have been a factor in this although safeguarding alerts are available for all NICU and maternity staff to access. The staff nurse advised the health visitor of the absence of contact by mother and father. The health visitor asked to be kept informed of any developments and details of discharge home. The health visitor also contacted the social worker to update them. The latter advised that an IDVA would shortly be engaging with mother. The social worker also advised that they planned to visit mother and father to commence the CAFA on 15th August 2016 and would use the absence of contact with Child L1 as a pretext for the assessment. 4.40 The same day the health visitor discussed the case in safeguarding supervision with a second specialist nurse for safeguarding children and the current plan was agreed. Also discussed was the possibility of completing a Multi-Agency Risk Assessment Conference (MARAC) risk identification checklist if the opportunity arose. Later the same day the health visitor met the social worker and their team manager by chance. The need to avoid placing mother at greater risk of harm was discussed and the health visitor raised concerns around the increased risks associated with mother having to care for two very young children, the pressure this would place upon the family and how father would respond. The health visitor went on to suggest a professionals meeting with the midwife and hospital IDVA and a plan to support mother whilst Child L1 was on the unit. MSCB Child L1 SCR Page 12 of 40 4.41 On 15th August 2016 the named midwife contacted the social worker to express concern that neither mother nor father had visited Child L1 or telephoned for updates since 12th August. The social worker advised of the planned home visit and also said a strategy meeting was to be arranged. It was also agreed that a discharge planning meeting would need to take place prior to Child L1’s return home. 4.42 At 6.20pm the same day mother, father and Child L1’s elder sibling visited Child L1 and were seen to be affectionate towards the baby. Similar family visits followed each evening with the exception of 21st August 2016. 4.43 On 18th August 2016 mother was seen by a GP at GP practice 1. She complained of lower abdominal pain following the recent birth of Child L1. 4.44 On 21st August 2016 the health visitor contacted the social worker for an update and was advised that no CAFA visit had taken place as the social worker was awaiting contact from mother and father. The social worker planned a home visit for the forthcoming week and would be accompanied by an interpreter to ensure that mother fully understood what was being communicated. 4.45 On 22nd August 2016 the community midwife was unable to gain access to the family’s home address and left a card to say that they would call again the following day. It appeared that major building work was taking place at the family home. After being unable to gain access again the following day, the community midwife was able to complete a post-natal assessment of mother on 24th August 2016. The midwife noted no visible bruising on mother’s legs although her arms were covered. Mother reported that her mood was good and that she had registered Child L1 with the GP. She denied there were any issues in her relationship with father when asked whilst he was out of the room playing with Child L1’s elder sibling. 4.46 On 23rd August 2016 the health visitor contacted the social worker for an update and was advised that the latter had spoken to both parents and father was now aware of children’s social care involvement due to non-attendance at the NICU and relationship concerns. The family had advised that they had had to return to Norwich to register Child L1’s birth which was why they had not attended the NICU initially. The social worker added that no concerns had been raised since the CAFA commenced which was still being completed and said that there was a possibility that the case would be kept open as a Child in Need (CiN). 4.47 On 25th August 2016 a discharge planning meeting took place at Wythenshawe hospital at which it was decided that Child L1 would be discharged on 27th August allowing mother to stay overnight the previous night to receive support and advice on the care of Child L1 from NICU staff. Despite mother’s previous disclosures being discussed in the discharge planning meeting, no MSCB Child L1 SCR Page 13 of 40 consideration appeared to be given to any risk to Child L1’s elder sibling in staying alone with father on the night prior to the baby's discharge. Child L1 was noted to have a “clicky hip” which was to be followed up by an outpatient ultrasound appointment. The family was to be supported by home visits by a neonatal midwife initially and subsequently by the health visitor who was to provide the “universal partnership plus” level of service. (Universal partnership plus is the highest level of support provided by health visitors and entails ongoing support, playing a key role in bringing together relevant local services and helping families with continuing complex needs or additional concerns such as safeguarding, domestic abuse or mental health problems.) Mother’s understanding of English was judged not to require the services of an interpreter for the discharge planning meeting. 4.48 On 28th August 2016 a neonatal outreach midwife made a home visit. Safe sleeping guidelines were discussed in detail (Premature babies are at increased risk of sudden infant death). Child L1 was observed to be wearing a hat and swaddled in fleecy blankets and mother was strongly advised against this practice. There was no mattress in baby's cot and Child L1 was nursed on folded towels which necessitated further advice. However, Child L1 appeared well. 4.49 On 30th August 2016 the social worker made a home visit and no concerns were said to have been noted over mother’s care for both children. The next day another health visitor was unable to gain access for the new birth visit and left a card to say that they would return the next day. The health visitor was able to gain access the following day but only after repeatedly knocking for 30 minutes. Whilst attempting to gain access, the health visitor – who had recently been allocated the case – contacted the social worker who advised that such difficulty in obtaining access was a “common occurrence” with this family. Mother and children were seen in a back upstairs bedroom. The health visitor pointed out the absence of stair gates and mother replied that these had been obtained but had yet to be put in place. (This was rectified by the 15th September 2016 health visitor home visit.) 4.50 On the same day the health visitor received a telephone call from the social worker to say that children’s social care were closing the case due to “lack of evidence” and mother and father’s insistence they had been misunderstood. On 2nd September 2016 case closure was confirmed following completion of the CAFA. It was noted that mother would continue to be supported by Sure Start. (According to the children’s social care chronology, the CAFA did not triangulate all the concerns in relation to domestic abuse, physical abuse and both parent’s failure to regularly visit their premature baby in hospital.) 4.51 On the same date the neonatal outreach service discharged Child L1 after a clinic appointment in which L1 was examined and found to be well and putting on weight. Mother requested the service to remain involved with her for longer and requested a further home visit but this request was not acceded to, although a further home visit by the community midwife did take place on 4th September 2016. MSCB Child L1 SCR Page 14 of 40 4.52 On 6th September 2016 mother visited the GP with a possible urinary tract infection (UTI) and a urine sample obtained and treatment prescribed. No enquiries were made about how the family were coping. 4.53 On 9th September 2016 mother took Child L1 to the GP with “tummy problems”. Treatment was prescribed. 4.54 On 15th September 2016 the health visitor and an outreach worker made a home visit in order to introduce the latter worker and also review Child L1’s weight. Mother said that Child L1 had been getting colic and a discussion took place about how to ease the symptoms. During weighing four small red marks were seen in a cluster on the inside of Child L1’s left ankle. The health visitor also noted darkened skin in the form of a small straight mark above Child L1’s naval. Mother said that the red marks had been caused by the NICU name band which mother had delayed removing. Mother added that these marks had been seen by the GP. The health visitor contacted the GP (GP 3) who confirmed that there was no record of the marks and they did not recall seeing them. The GP agreed to see mother and Child L1 at 2pm the same afternoon. (Child L1’s elder sibling had been seen naked when weighed and no injuries were noted.) 4.55 Mother attended GP practice 1 with Child L1. The GP noted that Child L1 probably had colic. The GP also noted what appeared to be a 3cm long linear bruise on Child L1’s central abdomen running from top to bottom. Three small blanching erythematous (abnormal redness of the skin or mucous membranes due to capillary congestion as in inflammation) marks were also noted around L1's left ankle which appeared to be strawberry nevus (birth mark in the form of a raised red patch). Mother said she had noticed the mark on Child L1’s stomach a couple of days previously but was unsure of what had caused it. She added that father helped out in soothing Child L1 at night and also massaged the child’s stomach. Otherwise Child L1 looked well. 4.56 Given the unexplained bruising in a non-mobile infant and the previous safeguarding concerns, the GP decided that a paediatric assessment was necessary and arrangements were made for Child L1 to be taken to Wythenshawe hospital by their parents. The GP also made a referral to children’s social care. 4.57 When mother and father failed to present Child L1 at Wythenshawe hospital, social worker 3 from the children’s social care EDS contacted the police to share information about the marks noted on Child L1 earlier that day. The police recorded a crime and visited the family home with social worker 3. They noted the red marks on Child L1’s left ankle and a “3cm vertical line above their belly button”. Both parents were said to be co-operative and took Child L1 to Wythenshawe hospital. The police advised social worker 3 to contact the police overnight if any immediate police action was needed once the paediatric assessment had been completed. It is not known why the police did not attend the paediatric assessment. MSCB Child L1 SCR Page 15 of 40 4.58 At 8.40pm that evening a child protection medical was completed by a paediatric consultant who noted an irregular linear brown mark (2cm long by 0.1 cm wide) running vertically down Child L1’s abdomen. Mother said that the mark had not changed for three days. The paediatric consultant felt that this was unlikely to be a bruise, but felt that the mark should be observed and a skeletal survey may need to be considered depending upon the evolution of this abdominal mark. The paediatric consultant also noted the strawberry birth marks on Child L1’s ankle and birth marks and a Mongolian blue spot on her back. Child L1 was later admitted to the paediatric ward for blood samples (which did not reveal anything untoward) and observation to check for any change in the mark on their abdomen. Mother was to stay on the ward with Child L1 whilst Child L1’s elder sibling was to stay in the family home with father. 4.59 The paediatric consultant was informed by social worker 3 that mother had made “an allegation of domestic abuse” against father in July 2016 and that children’s social care had completed an investigation following which the case had been closed. Child L1’s neo natal notes were ordered from the Trust library to check whether the Mongolian blue spot had been noted previously. 4.60 The following day – Friday 16th September 2016 - Child L1 was seen at 10.30 am by a second paediatric consultant who noted the linear mark on their abdomen to be non-blanching and neither fading nor changing colour. It was thought the mark was most likely to be a birth mark. The plan was to review Child L1 again the following day and if the mark was not fading L1 would be discharged. Mother continued to stay with Child L1. Father and Child L1’s elder sibling visited that day. 4.61 On Saturday 17th September 2016 Child L1 was seen at 11.45am by another paediatric consultant. According to an advanced nurse practitioner who had seen Child L1 previously, the abdominal mark appeared redder than previously but also appeared to be fading. The paediatric consultant documented a discussion with mother regarding the manner in which Child L1 was secured in their car seat. Although some communication difficulties were noted, mother declined an interpreter. Mother initially said she used a carrier bag to secure the straps in the baby seat but then said she used the clip fastening. She was unable to demonstrate the action by which Child L1 was secured in their car seat. In any event the paediatric consultant concluded that the straps or buckle from the car seat did not fit with the linear mark on Child L1’s abdomen. Mother also stated that Child L1 was never unsupervised with their elder sibling. 4.62 The paediatric consultant planned to liaise with the other paediatric consultants who had examined Child L1 to discuss whether further investigations were needed prior to a strategy meeting with children’s social care. The police were updated and attended the hospital intending to take photographs of the mark but were unable to obtain consent from mother as she had left the hospital to attend a family celebration. The police made reference to a strategy meeting planned MSCB Child L1 SCR Page 16 of 40 for the next day (Sunday 18th September 2016) which had apparently been deferred until Monday 19th September 2016 to allow for a full skeletal survey to be carried out and the results made available prior to the deferred strategy meeting. The police considered whether there were any safeguarding concerns for Child L1’s elder sibling but decided that that there were none although they documented that this issue could be reviewed following the forthcoming strategy meeting. 4.63 On Sunday 18th September 2016 Child L1 was examined by a paediatric consultant who noted that the linear mark on their abdomen appeared to be fading. There was no change in colouration – which would be typical of a bruise - and so the mark was thought not to be behaving like a bruise. The mark was thought to be vascular in origin. (A bruise is caused when blood vessels break and there is blood visible through the skin. A vascular prominence/mark is when an intact blood vessel is visible through the skin.) The skeletal survey was deferred pending a further discussion with the second paediatric consultant (lead consultant). 4.64 On Monday 19th September 2017 Child L1 was reviewed by a paediatric registrar who saw no evidence of an abdominal mark. The strategy meeting had been deferred until Tuesday 20th September 2016. In the invitation to the health visitor, the meeting was described as a strategy meeting/discharge planning meeting. 4.65 On Tuesday 20th September 2016 Child L1 was reviewed by the second paediatric consultant who concluded that the mark had disappeared from their abdomen. The second paediatric consultant felt that the mark was not a bruise and was possibly of vascular origin. At 2.30pm the same day the strategy meeting took place. Mother attended and again declined an interpreter. 4.66 The marks seen on Child L1’s body were noted to be the linear narrow mark on their abdomen which had been the primary focus of attention; there were also two small brown marks on L1's back, blue discolouration on their back and red marks on their ankle. The marks on the abdomen, the foot and the brown marks on the back were classified as vascular malformations and the blue mark on the back was a Mongolian Blue Spot. Although the mark on the abdomen was classified as a vascular malformation it was unclear what had caused it to appear and it was classed as “unexplained” but not thought to be a non-accidental injury as the mark disappeared rather than changed colour as in bruising. A skeletal scan was considered unnecessary. 4.67 During the meeting information was shared about mother’s 13th July 2016 disclosures. The health visitor disclosed that when they initially saw the marks, mother told her that Child L1 had already seen the GP, which the health visitor said was not true. (Mother had last taken Child L1 to the GP six days prior to the marks being noticed by the health visitor.) It was decided that children’s social care would complete a further CAFA and that Child L1 and their elder sibling would be monitored as CiN with the first meeting to take place within two weeks. The health visitor would continue to encourage mother to engage with Sure Start. Child L1 was discharged into the care of MSCB Child L1 SCR Page 17 of 40 their parents. 4.68 On 28th September 2016 the health visitor made a home visit during which they reviewed Child L1’s weight. No marks were observed on her unclothed body. Child L1’s elder sibling was being cared for by father and was only seen briefly. The condition of the house remained unchanged. A date for the CiN meeting had yet to be arranged. 4.69 The following day mother and Child L1’s elder sibling visited the GP practice. Mother had had abdominal pains which were thought to be linked to irritable bowel syndrome. Child L1’s elder sibling was taken to the GP to begin their 12 month immunisations. 4.70 On 30th September 2016 Child L1 was admitted to Royal Manchester Children’s Hospital (RMCH) after being found unresponsive at home whilst in the care of their parents. A large subdural haemorrhage was observed on a scan and no explanation was given by mother and father. The medical opinion was that Child L1’s injury had been caused by violent shaking. 5.0 Contribution of Child L1’s family to the serious case review 5.1 At the time of writing both father and mother were subject to police investigation of the injuries sustained by Child L1 on 30th September 2016. The SCR review group took the view that it could be beneficial to invite mother to contribute to the review but that this was not possible whilst she remained subject to a criminal investigation. 5.2 The review has been advised that mother has no family members living in the UK. No information about father’s family in the UK has been shared with the review other than the reference to a sister in Norfolk whom mother and father were visiting when Child L1 was born prematurely. MSCB Child L1 SCR Page 18 of 40 6.0 Analysis 6.1 The terms of reference for this SCR are as follows: The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016 The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction. The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1. Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held. The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed. The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016 6.2 Fully documenting mother’s disclosures on 13th July 2016 was no easy task. The disclosures arose unexpectedly during a routine appointment with the practice nurse at GP practice 1. Mother became very emotional as she articulated her fears for both her child and her unborn baby. And once the practice nurse began to steer the conversation towards referring mother and her child for support, mother appeared to have second thoughts and by the end of the conversation was “begging” the practice nurse not to take any further action in respect of her disclosures. She left the GP practice before the practice nurse could carry out anything more than a cursory examination of the unclothed parts of the child’s body. 6.3 In these circumstances the practice nurse was able to obtain sufficient information to identify the following risks to mother, her child and her unborn baby: Father regularly became angry when the child cried and responded by physically assaulting both mother and the child. Mother showed the practice nurse bruising to her arm which had the appearance of three fingers. She said that these marks had been caused by father forcefully grabbing her. Mother disclosed that the child had also sustained bruising as a result of father’s assaults but the child was not examined unclothed in order to check for any current marks. MSCB Child L1 SCR Page 19 of 40 Father had put his hands to mother’s throat on one occasion which may have represented an attempted strangulation. Father was very controlling of mother. He would not allow her to use contraception hence the short gap between the birth of the first child and becoming pregnant with Child L1. He also monitored mother’s phone. Mother was isolated. She had come to the UK from Pakistan “over two years ago” and had no family or friends in this country. She did not leave the family home very often. Her (unknown) immigration status may have been an additional factor deterring her from seeking help. Mother presented as extremely anxious about the impending birth of Child L1 as new born babies inevitably cry which seemed likely to anger father and generate further violence. Mother was said to be anxious about her disclosures being shared with anyone else, fearing that her husband would kill her if he found out. (Threat to kill was only recorded by the health visitor after conversation with specialist nurse) 6.4 Not all of this information appears to have been recorded by the practice nurse. Some of the information was recorded by the specialist nurse from whom they sought advice after mother had left the GP practice. Given the short gap between the practice nurse’s interaction with mother and their subsequent telephone conversation with the specialist nurse, and taking into account the specialist nurse’s experience, it seems reasonable to accord a high degree of reliability to the information recorded by the specialist nurse. The threat to kill was only recorded by the health visitor after their conversation with the specialist nurse on 13th July 2016. 6.5 The safeguarding children referral submitted by the practice nurse should have been completed more fully but addressed several of the risk factors highlighted above with the exception of mother’s bruising, the fact that it had not been possible to fully check her child’s body for bruising, the attempted strangulation of mother, the threat to kill and the refusal of father to allow mother to use contraception although father’s controlling behaviour was referenced. The section entitled 'what are you requesting from children’s social care?' could have been completed more fully and it could have been helpful to state here that it had not been possible to view the child’s unclothed body to check for bruising. It might have been helpful for the practice nurse to have the referral checked over by a colleague more experienced in safeguarding (this was the practice nurse’s first experience of dealing with a safeguarding issue) or possibly the specialist nurse who had been advising. However, the referral provides sufficient information to gain an understanding of the risks faced by mother and her child. MSCB Child L1 SCR Page 20 of 40 6.6 One might have expected this referral form to have been the basis for subsequent information sharing between the agencies which would need to consider how best to respond to this case. Such an expectation would be incorrect. Prior to submitting the referral to children’s social care, the practice nurse contacted children’s social care’s contact centre by telephone and the details of the case were recorded by a contact centre officer. Under the heading 'what has happened?' the contact centre officer recorded the following: 6.7 “Mother has disclosed that father gets very angry when the baby cries and he has been doing this since the baby has been born. Father also hits the baby and mother. This is the only detail that mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks mother’s phone. Referrer did not see any injuries on the child and the mother showed grab marks on her arm.” 6.8 This summary helpfully included the fact that mother had shown the referrer the grab marks on her arm which was omitted from the subsequent referral form. However, the reference to the referrer not seeing injuries on the child was ambiguous as it did not explain that it had not been possible to see the child unclothed. (Even if the baby had been seen unclothed, the absence of visible bruises is not sufficient reassurance that the baby had not sustained significant injuries) The summary makes no reference to mother’s pregnancy although elsewhere on the contact screening (child) form both the child and the unborn child are listed as 'subject children'. 6.9 The summary of the case recorded on the contact screening (child) form was cut and pasted onto the subsequent referral from children’s social care to the police requesting a strategy meeting and was then cut and pasted into the record created by the police. It therefore assumed much greater importance as a vehicle for information sharing than the original referral from the GP practice nurse which appears to have been filed with the contact screening (child) form and shared no further. Reliance on the summary from the contact screening (child) form appears to have contributed to the police not noting that mother was pregnant which would have diminished the risks the police perceived to be present. 6.10 Some of the police officers involved in the decision making in response to the strategy meeting request from children’s social care contributed to this review and said that had they been aware of mother’s pregnancy, the attempted strangulation and the threat to kill, this would have made their eventual decision not to accede to the request for a strategy meeting much less likely. They argued that the original referral from the GP practice nurse was the source document on which decision making should be based rather than the summary created by the contact centre officer. 6.11 However, sufficient information was shared with the police to indicate that the child and their mother had been subjected to, and remained at risk of, physical violence from father. Given the very young age of the child (ten months) and concern over mother’s ability to safeguard them from father given that she had now distanced herself from her earlier disclosures, the decision to decline MSCB Child L1 SCR Page 21 of 40 the strategy meeting does not appear to have been a sound decision on the basis of the information the police had recorded. 6.12 When the officers involved in this decision contributed to this review they referred to the volume of requests for strategy meetings received and the difficulty in resourcing all of them. They also made mention of staffing shortages during this period which may have impacted upon decision making in this case. Pressure on decision making arising from heavy demands and limited resources appear to have been an underlying factor in police decision making and at other points in this case. However, a credible threat of physical violence to a very young child from one parent together with serious doubts about the ability of the other parent to safeguard that child should have led to a strategy meeting which would have provided a vehicle for more complete information sharing about the case, a sounder appreciation of the risks involved and a robust plan of action including a child protection medical. 6.13 Having declined the strategy meeting, the advice given by the police to children’s social care that they should refer the case back to the police should mother make any disclosures during the proposed CAFA appears to have been somewhat unrealistic. Mother had already made very serious disclosures which she had then distanced herself from. Making a re-referral conditional upon her repeating those disclosures appeared to be setting a rather high threshold for re-referral. 6.14 There is no evidence that children’s social care questioned or challenged the police decision to decline the strategy meeting. The lack of a strategy meeting was escalated by a health visitor to the specialist nurse. The named nurse became involved at this point. Concerns were also being expressed by the GP safeguarding lead for practice 1. However, it appears that the plan for the health visitor and social worker to see mother and Child L1’s elder sibling for the 9 month assessment whilst father was not present, for children’s social care to conduct a CAFA and for support to be offered to mother to reduce her isolation largely assuaged concerns over the lack of a strategy meeting. Again no challenge to the police decision to decline the strategy meeting appeared to be considered. 6.15 The whole system for safeguarding children consists of a substantial number of points at which decisions are made. However, some decisions appear to be of greater significance than others and have the potential to exert a higher degree of influence over the direction of the case thereafter. A police decision to decline a strategy meeting appears to be one of these types of decisions which appear to send a signal to other partner agencies. The inference partner agencies appear to draw from a police decision to decline a strategy meeting is that if the police do not consider the risks to be of sufficient concern to justify a strategy meeting, then perhaps partner agencies should recalibrate their perception of the risks down a level or two. Another safeguarding decision invested with greater symbolic importance than it probably merits is the view of a paediatric consultant that a mark on a child’s body is not, or is unlikely to be, a non-accidental injury. As seen MSCB Child L1 SCR Page 22 of 40 earlier, this case also features such a decision which will be discussed in more detail later in this report. 6.16 The 9 month assessment provided the health visitor and social worker with the opportunity to weigh the child naked and establish that there were no signs of bruising. This provided a degree of reassurance to agencies but was not an adequate response to the disclosures mother had made of the baby being hit and having had bruises. There appears to have been a lack of understanding in all agencies about the vulnerability of small babies. Disclosures of physical abuse to babies, even in the absence of bruises, should result in referral for a child protection medical including a skeletal survey. 6.17 GP practice 1 decided to use every subsequent contact with mother to attempt to further engage her and offer support. Mother was expecting her second child in the near future and so further contact with her was expected. The GP who was the safeguarding lead for the practice contributed to the review via a telephone conversation with the lead reviewer and said that the GP practice found it challenging to ensure that every contact with mother was used as an opportunity to engage with her and to explore family functioning. The GP said that the heavy reliance on part time and locum staff together with the demands of the GP practice also being a walk-in centre made it challenging to ensure that all staff were aware of concerns about mother and her children. 6.18 The planned CAFA was interrupted by the premature birth of Child L1 and was not completed until 2nd September 2016 when a decision was taken to close the case. The children’s social care chronology does not provide any details of the meeting with mother and father which must have been an important element in the assessment. It is assumed that this took place on 30th August 2016 when the social worker made a home visit and “noted no concerns over mother’s care for both children” (Paragraph 4.49). This comment excludes any reference to father and in focussing exclusively on “care” for the children, omits any reference to the parents ability to “safeguard” the children. The decision to close the case was inconsistent with earlier indications from children’s social care that the case would be managed as a CiN, and nor did it appear to be consistent with the further concerns which had emerged since mother made her initial disclosures to the GP practice nurse which are set out below: Mother had claimed that she had been forced to make her disclosures by the practice nurse. This was not a credible position to take and was undermined by the bruising noted by the practice nurse. Mother remained in a relationship with father which children’s social care advised her was a cause for concern in that she was not prioritising the safeguarding of her children. (This seemed to be a very substantial concern which did not diminish in any way). MSCB Child L1 SCR Page 23 of 40 Access for home visits was very challenging. The community midwife made two no access visits and a health visitor made one such visit. The health visitor only gained access on a subsequent occasion after knocking for 30 minutes which the social worker described as a common occurrence for this family. This difficulty in gaining access did not appear consistent with mother’s isolation and her comment to the GP practice nurse that she rarely left the family home. The family home was undergoing substantial building work and seemed likely to contain potential hazards particularly for Child L1’s elder sibling who would have been mobile by this time. Yet the fixing of a safety gate on the stairs only happened after prompting from practitioners. The possibility that the premature birth of Child L1 may have been linked to domestic abuse did not appear to have been considered. A 2016 meta-analysis found that domestic violence doubled the risk of preterm birth and low birth weighti. (1) The absence of visits or telephone contact with Wythenshawe NICU between 10th and 15th August 2016. The reason given by the family for their physical absence from the NICU during this period was the need to return to Norwich to register Child L1’s birth. There was no legal reason to return to Norwich to register the birth although it is accepted that mother and father may not have been aware of this. It is unusual for a mother to leave a premature baby and some indications of attachment issues may have been apparent in mother’s reluctance to have skin to skin contact (Paragraph 4.36). Additionally, her fears for the harm father might inflict on the newly arrived baby, which she articulated to the practice nurse (Paragraph 4.3) may have led her to distance herself from Child L1. The birth of Child L1 unquestionably increased risk. As a new born baby L1 was certain to cry. Father was said to be unable to stand Child L1’s elder sibling crying which was the trigger for his violence towards the child and mother. The birth of Child L1 appeared to be a source of significant anxiety to mother which seems likely to have affected the behaviour of her very young children. 6.19 According to the children’s social care chronology, the CAFA on which the decision to close the case was based, did not triangulate all the concerns in relation to domestic abuse, physical abuse and both parents’ failure to regularly visit their premature baby in hospital. (Paragraph 4.50) This also raises a question mark about the quality of supervisory oversight of the CAFA. 6.20 The premature birth of Child L1 out of area created some challenges in ensuring that neonatal staff in both Norwich and subsequently Wythenshawe were aware of the prior safeguarding concerns relating to this family. Two copies of the safeguarding plan developed by midwifery had been placed in mother’s notes with one copy to be transferred to Child L1’s notes at birth MSCB Child L1 SCR Page 24 of 40 (Paragraph 4.27). As Child L1 was born out of area this transfer of the safeguarding plan to the new born baby’s patient notes did not occur. By the time Child L1 was transferred to the Wythenshawe NICU from Norwich, mother had been discharged and was therefore no longer a patient. As a result, mother’s patient notes were not opened by Wythenshawe NICU and so the opportunity to transfer the safeguarding plan from her notes to those of Child L1 was temporarily lost. 6.21 However, had neonatal staff at Wythenshawe checked the safeguarding folder on their shared drive they would have found the safeguarding plan under mother’s name. The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction. 6.22 Mother made disclosures of domestic abuse by father to the practice nurse on 13th July 2016 which were very concerning. She alleged that father became angry when her first child cried and hit both her and the child. This had been taking place for the whole of her first child’s life. She showed the practice nurse bruising on her arm which appeared to be an indication that she had been forcibly grabbed. She said that father had put his hands to her neck in an apparent attempt to strangle her or threaten strangulation and had threatened to kill her if she disclosed the abuse. Father was alleged to be very controlling in that he would not allow her to use contraception and monitored her phone. Mother was extremely isolated having come into the UK from Pakistan over two years previously. She said she had no family support in the UK. It was of concern that mother’s (unknown) immigration status may prevent her from seeking support in case this led to her being required to leave the UK. She expressed extreme concern about how the impending arrival of her second child would make the existing situation much more dangerous for her and her children. The risks of domestic abuse she faced therefore appeared high. 6.23 However, once the practice nurse began to suggest support options mother might access which appeared to indicate to her that she, or father, may need to leave the family home, mother began to reconsider her earlier disclosures. She began to present an alternative view of father as loving provider and emphasised the importance of her children having a mother and father. She began to beg the practice nurse not to share her disclosures further and attempted to change the subject. 6.24 The practice nurse was presented with a very challenging dilemma in that mother had quite unexpectedly made disclosures of domestic abuse which were very serious and appeared credible. She had later implored the practice nurse not to take the disclosures any further. The practice nurse took the view that mother was no longer consenting to any referral for support in respect of domestic abuse and focused their attention on the safeguarding concerns for the child and their unborn sibling. Although the practice nurse sought appropriate advice on the steps they needed to take to safeguard the children, they did not appear to seek or appear to be offered advice on further options they could consider to address mother’s disclosures of domestic abuse. The practice nurse asked the contact centre officer whether they needed to complete any additional referral in MSCB Child L1 SCR Page 25 of 40 respect of the domestic abuse disclosed by mother and was apparently advised that the referral to children’s social care would suffice. 6.25 GP practice 1 is an Identification and Referral to Improve Safety (IRIS) practice. As previously stated IRIS is a general practice based domestic violence and abuse training support and referral programme. Training for the practice had been completed in February 2016 although the practice nurse had not received it. The clinical training focuses on the health impacts of domestic abuse, identification through specific clinical enquiry, appropriate response, referral and recording. It involves two two-hour sessions for all practice clinical staff, including GPs, doctors in training, practice nurses, nurse practitioners, and health-care assistants. There is a one-hour training session for reception and administration teams which focuses on understanding domestic abuse, confidentiality and facilitating patient care and safety. 6.26 The IRIS advocate educator also provided the GP practice’s patients with emotional and practical support, carried out risk assessments and enabled safety planning. This advocate educator liaises with the GP practices and provides feedback on the outcome of referrals. Patients of IRIS trained GP practices can they had not received the IRIS training, the practice nurse seems to have given priority to the issue of consent and perceived the absence of consent from mother as a barrier to referring her to any services which support the victims of domestic abuse. 6.27 At the learning event to which practitioners involved in this case were invited there was a discussion of whether the practice nurse could have been supported to complete the SafeLives DASH risk assessment. Practitioners accepted that formally completing the risk assessment in mother’s presence whilst she was initially making her disclosures would not have been feasible. However, practitioners felt that completing the DASH risk assessment was an option even after mother had withdrawn consent to any referral for support. It was felt that this could have been completed after mother had left the GP practice using the information she had disclosed earlier. 6.28 Many important questions from the DASH risk assessment would have been answered in the affirmative such as whether the victim had been injured, felt frightened, was isolated, was pregnant, controlled, financially dependent, whether there had been threats to kill, attempts to strangle and whether the abuser had hurt anyone else including a child in the family. A MARAC referral could have been considered even though it may not have been possible to fully complete the risk assessment, as policy allows a MARAC referral on the grounds of “professional judgement” irrespective of the risk “score” which emerges. 6.29 Representatives of GP practice 1 were present at the practitioner event and questioned whether it was a reasonable expectation of a practice nurse to retrospectively complete a DASH risk assessment in such challenging circumstances. As stated earlier, the practice nurse has contributed to this review. The practice nurse pointed out that they worked one day per week at the GP practice at the time which they said made it difficult to access all the potential training MSCB Child L1 SCR Page 26 of 40 required for their role. In any event the IRIS training the GP practice had received emphasised the overriding importance of consent which appears to have strongly influenced the practice nurse’s actions. However, the IRIS process applies only to cases assessed as medium risk and below. High risk cases coming to the attention of GP practices can only be dealt with under the DASH process. However, whilst IRIS training has made GP practices aware of the SafeLives DASH risk identification checklist and the fact that consent is not essential in high risk cases, the training has not previously taken members of GP practices through the process of completing a DASH and making a MARAC referral. 6.30 If it may have been unrealistic to expect the practice nurse to complete a DASH risk assessment, a question for reflection is whether it would have been possible for either children’s social care or the police to have considered completing a DASH risk assessment in these circumstances? The contact screening (child) form completed by children’s social care when the practice nurse initially telephoned the EDS contact centre on 13th July 2016 includes a section on domestic abuse which was not completed by the contact centre officer. The MASH manager has advised this review that the contact centre officer would not be expected to complete the domestic abuse section of the contact screening (child) form but it has not been possible to identify where responsibility for completing this section resides. It is an area which would benefit from greater clarity. 6.31 Had a referral to MARAC been made by the GP practice or any other agency in response to mother’s 13th July 2016 disclosures, an IDVA would have been notified and considered how best to make contact with mother and the case would have been discussed at a MARAC meeting at which a multi-agency action plan would have been developed – although mother may have decided not to engage with it. The MARAC process would have taken place concurrently with the Section 47 enquiry to address the priority issue of the violence to the child. 6.32 A GP appears to have attempted to make contact with mother by telephone to discuss IRIS but having received no reply does not appear to have followed this up subsequently. IDVA support from Wythenshawe hospital appeared to be a feature of subsequent planning and on 12th August 2016 it was said that an IDVA was to be shortly engaging with mother although this did not appear to happen. 6.33 Mother’s fairly rapid distancing of herself from her disclosures to the practice nurse appeared to create confusion for practitioners involved in this case. The way in which mother portrayed the disclosures then began to change over time. Initially her stance was that she did not wish to pursue her disclosures. Later she said she made the disclosures to the practice nurse because she thought the practice nurse was her friend. She also alleged that the practice nurse forced her to make the disclosures. She also minimised and denied the disclosures before appearing to settle on having been misunderstood. (Mother’s first language is Urdu but was considered to have a good understanding of English by practitioners.) There appears to be an absence of single and multi-MSCB Child L1 SCR Page 27 of 40 agency guidance on how practitioners should respond to disclosures which are retracted or with which the victim does not wish to proceed. The police have a policy for dealing with taking retraction statements from victims of domestic abuse who decide they no longer wish to proceed but this only applies to victims who have made an initial statement of complaint to the police. The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1. 6.34 The initial response to the marks noted on Child L1 was highly effective. The health visitor quickly arranged for mother to take Child L1 to the GP practice when the marks were noted. GP 3 made a prompt referral for a child protection medical at Wythenshawe hospital and when mother and father failed to attend with Child L1, children’s social care and the police made a home visit which led to the child being taken to the hospital. 6.35 Thereafter there seemed to be an overriding focus on the opinion of a series of paediatric consultants on whether the mark on Child L1’s abdomen could be non-accidental. Ultimately the paediatric consultants concluded that the mark did not behave as a bruise would be expected to and concluded that although the mark was “unexplained” it was not a non-accidental injury. In this case and many others, undue weight was placed on a consultant paediatrician providing a definitive view on whether an injury is accidental or non-accidental. As stated in Paragraph 6.15 this is the type of safeguarding decision in which great symbolic importance is invested. Clearly it is an important decision because the view of a paediatric consultant that an injury to a child is accidental or non-accidental is likely to have a substantial impact on the future direction of the case. However, the view of the paediatric consultant is often regarded as definitive when in fact it is just one important element in making a judgement about safeguarding concerns. 6.36 The strong focus on whether the mark was non-accidental or not may have obscured the substantial risk factors present in this case which are set out in Paragraphs 6.3 and 6.18. The three paediatric consultants involved attended the practitioner learning event and concurred with the view that a definitive opinion on the origin of the mark on Child L1’s abdomen may have been invested with more significance than was merited. The first paediatric consultant to examine Child L1 reflected that the information about previous safeguarding and domestic abuse concerns which were shared with them by children’s social care was much more limited than the actual level of concerns. The designated doctor safeguarding children for the CCG is a consultant paediatrician and was a member of the SCR review group in this case. The designated doctor safeguarding children reflected that in their experience it is common for the paediatric consultant carrying out a child protection medical to receive insufficient information about relevant safeguarding concerns. The designated doctor safeguarding children felt that this situation had been tolerated to such an extent that it had become accepted practice. 6.37 The paediatric consultants were not well served in their decision making by delays in accessing the paper records of Child L1 to establish whether any of the marks on L1's body had been present at birth. The review has been advised that such hospital patient records are now available MSCB Child L1 SCR Page 28 of 40 electronically, although any records requested which pre-date the introduction of electronic records in the summer of 2017 remain accessible only as paper records. 6.38 It would have been helpful for a strategy meeting to have been convened on the evening on which the child protection medical took place at Wythenshawe hospital rather than deferring this for five days by which point the hospital was ready to discharge Child L1. The strategy meeting thus became a combined strategy meeting/ hospital discharge planning meeting and clarity of purpose may have been diminished as a result. 6.39 Research indicates that physical abuse is rarely a single event and that many children who suffer inflicted head injury have suffered from previous episodes of physical abuseii. Therefore it may have been useful for the mark on Child L1’s abdomen to have been viewed as a potential “harbinger” injury, i.e. an injury to a non-mobile child which could precede further potentially more serious injuries. “Harbinger” injury research suggests adopting a lower threshold for requesting a skeletal surveyiii. In this case a skeletal survey was under consideration by the paediatric consultants for several days before being rejected as an option. Having said that, the skeletal survey subsequently obtained after Child L1 was admitted to hospital with a subdural haemorrhage just ten days after hospital discharge following the concerns over the mark on their abdomen, disclosed no healing fractures from old injuries. Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held. 6.40 Working Together states that a “Local authority children’s social care should convene a strategy discussion to determine the child’s welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm”. 6.41 Although the information which accompanied the request for a strategy meeting did not present a sufficiently full picture of the risks presented to mother and Child L1’s elder sibling and omitted that fact that mother was seven months pregnant with her second child, there was sufficient information to conclude that Child L1’s elder sibling was suffering, or likely to suffer, significant harm given that mother had disclosed that father had been physically assaulting a ten month old child since birth because he couldn’t stand the child crying and that mother had been unable to prevent this physical abuse. 6.42 The grounds on which the police declined the strategy meeting were insubstantial and the suggestion that further disclosures from mother should trigger a re-referral to the police seemed unwise given the fact that mother had already made significant disclosures from which she had subsequently emphatically distanced herself. The fact that disclosures had been made relating to injury to a baby should have heightened concern and suggested incomplete aware of the particular vulnerability of babies. MSCB Child L1 SCR Page 29 of 40 6.43 There was no challenge or questioning of the police decision to decline a strategy meeting. Whilst concerns were expressed by health practitioners over the absence of a strategy meeting, which were raised with children’s social care, no direct challenge of the police decision appeared to be contemplated. A key component of an effective system for safeguarding is that practitioners feel empowered to challenge partner agencies decisions. It is also important that there is a process available for resolving professional disagreements which practitioners are aware of and have confidence in. 6.44 There were further opportunities to convene a strategy meeting prior to, or at the point of discharge of Child L1 from Wythenshawe NICU (Paragraph 4.47) when additional concerns had arisen over the initial absence of contact between the family and their premature baby and on the evening of 15th September 2016 when the initial paediatric examination of Child L1 took place. (Paragraphs 4.57 – 4.59) 6.45 The purpose of the strategy meeting which took place prior to Child L1’s discharge from hospital after the mark on their abdomen had been monitored for several days appears to have been less than clear. Managers and practitioners who participated in the learning event for this SCR spoke frankly of their confusion over the purpose of this meeting. The meeting was believed to be a review strategy meeting by children’s social care who incorrectly understood an earlier strategy meeting to have taken place; the consultant paediatrician understood the meeting to be a discharge planning meeting; and the health visitor believed the meeting to be a combined strategy/ hospital discharge meeting. 6.46 As in an earlier SCR completed by this lead reviewer for MSCB, the police advised that they receive many requests from children’s social care for strategy meetings and that it was not possible to accede to all such requests because of workload pressures. The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed 6.47 The GP practice nurse appropriately escalated the disclosures made by mother on 13th July 2016 to GPs, including the GP who was the practice safeguarding lead, the specialist nurse who provided essential advice and guidance given that this was the practice nurse’s first experience of handling a safeguarding concern, and the named nurse. 6.48 When it became clear that the police had declined a strategy meeting following mother’s initial disclosures, the health visitor, specialist nurse, named nurse and GP were involved in expressing their concerns to children’s social care who had initiated the request for a strategy meeting, but, as previously stated, not to the police themselves. 6.49 The CAFA initiated following mother’s initial disclosures was relied upon by children’s social care in making their decision to close the case. Children’s social care acknowledge that the CAFA MSCB Child L1 SCR Page 30 of 40 insufficiently triangulated the information available and appeared to give insufficient weight to the further indications of risk which had arisen since the 13th July 2016 disclosures by mother. This suggests that managerial oversight may have been less thorough and searching than would be expected. 6.50 The GP practice 1 safeguarding lead has advised this review that when they saw the discharge summary following the paediatric admission to Wythenshawe hospital from 15th-20th September 2016, which they understood to refer to a birthmark which was fading, the GP said they struggled to make sense of this as birth marks do not normally fade over a period of days. However, the GP added that they perhaps felt that as a GP it was not appropriate for them to challenge the judgement of the consultant paediatrician. The GP also observed that one can begin to doubt oneself when a specialist comes to a different conclusion to oneself. 6.51 None of the differing professional opinions resulted in the use, or consideration of the use, of the MSCB protocol for escalating concerns and resolving professional disagreements. MSCB Child L1 SCR Page 31 of 40 7.0 Findings and Recommendations Good practice 7.1 The GP practice nurse did well to elicit a significant amount of information from mother about the risks she, her child and unborn child faced from father in quite challenging circumstances in that mother, whilst in a state of distress, made a series of disclosures before beginning to distance herself from them. As previously stated the practice nurse has advised this review that addressing the 13th July 2016 disclosures was their first professional experience of taking action to safeguard a child. 7.2 The GP practice nurse also received excellent support and advice from the specialist nurse and from the GP practice generally. 7.3 At times there appeared to be a vacuum in leadership in this case as the police declined the initial strategy meeting request and children’s social care closed the case after a less than satisfactory CAFA had been completed. To a large extent, health visitors 2 and 3 stepped in to fill that vacuum and provide a lead to ensure information was shared (particularly with maternity services), to obtain updates and prompt action to be taken. 7.4 The development of a safeguarding plan for mother and her unborn child by maternity services was an appropriate response to mother’s 13th July 2016 disclosures. 7.5 The response to the unexplained mark on Child L1’s abdomen by the health visitor and the GP practice was prompt and effective, and after the parents did not present Child L1 at Wythenshawe hospital, the joint home visit by children’s social care and the police was purposeful. The process by which the disclosures made by Child L1’s mother became diluted which contributed to less than satisfactory decision making 7.6 The information elicited from mother by the practice nurse on 13th July 2016 presented a very concerning picture of the risks that mother, her child and unborn child faced from father. However, this risk information became “diluted” during the process by which it was recorded and shared which was a contributory factor in the police decision to decline a strategy meeting. 7.7 Although the inexperienced GP practice nurse did well to obtain the information they did from mother in the circumstances, the safeguarding referral they completed did not fully reflect the seriousness of the situation and could have been more specific in stating what children’s social care were being asked to do. 7.8 Surprisingly the safeguarding referral is not treated as the source document which is the basis of information sharing thereafter. Of much greater significance is what is recorded within the children’s social care contact centre. The summary recorded by the contact centre officer from MSCB Child L1 SCR Page 32 of 40 telephone contact with the GP practice nurse became the definitive account of the case which was shared with EDS, the children’s social care locality team and the police and unfortunately that summary omitted reference to mother’s pregnancy. 7.9 SCR review group members commented that partner agencies making a safeguarding referral to children’s social care are actively encouraged to ring the details through to the contact centre prior to submitting the safeguarding referral. If it is indeed standard practice for safeguarding referrals to be rung through to the contact centre and before being submitted as a formal safeguarding referral, then it appears unwise to place greater reliance on the information recorded by the contact centre officer than on the information contained in the formal safeguarding referral. In this case the information recorded in the formal safeguarding referral provided a more accurate account of the circumstances than the record created by the contact centre officer. It seems likely that the formal safeguarding referral completed by the practitioner involved in the case would generally be a more reliable source of accurate information than the record of a telephone call with that practitioner written down by a contact centre officer. No disrespect to the professional competence of contact centre officers is intended in making this observation. 7.10 Several practitioners who contributed to the learning event for this SCR expressed the opinion that they would feel more secure making decisions on the basis of the formal safeguarding referral which they described as the 'source' document. This seems a reasonable position to adopt. One way forward may be to attach the original safeguarding referral to all relevant communications about the case. In any event, it is suggested that MSCB request children’s social care to review the practice by which they record and disseminate information arising from safeguarding referrals to ensure that what is recorded and shared is as accurate and comprehensive as possible. Recommendation 1 That MSCB request children’s social care to review the practice by which they record and disseminate information from safeguarding children referrals in order to ensure that what is recorded and shared with partner agencies is as accurate and comprehensive as possible. Strategy discussions/meetings 7.11 Notwithstanding the deficiencies in the information shared, the grounds on which the strategy meeting was declined by the police do not stand up to scrutiny and the threshold the police suggested for re-referral back to them made any re-referral unlikely. 7.12 Workload pressures and staffing levels appeared to be factors in the decision to decline this strategy meeting. However, strategy meetings are important. The absence of a strategy meeting resulted in a lack of direction in this case. The police disengaged and children’s social care’s response lacked urgency and direction. A leadership vacuum developed which the health visitor service admirably attempted to fill by active engagement in the case, efforts to prompt children’s social care and effective information sharing. MSCB Child L1 SCR Page 33 of 40 7.13 In a safeguarding system in which pressures on partner agencies are likely to remain at a high level, it is important to take steps to ensure that strategy discussions take place when they are needed and include all relevant partner agencies. It is suggested that greater use is made of video and teleconferencing to hold virtual strategy meetings. MSCB may wish to encourage agencies to adopt this approach and monitor the impact. Recommendation 2 That MSCB obtains assurance that partner agencies fulfil their statutory obligations to ensure strategy meetings take place when necessary and are inclusive of all necessary partner agencies. Response to disclosure of domestic abuse by mother 7.14 Once mother declined offers of support from domestic abuse services offered to her by the GP practice nurse on 13th July 2016, and then began to distance herself from her disclosures, the GP practice nurse took the view that absence of consent prevented them from taking mother’s disclosures of domestic abuse further. The practice nurse concentrated on taking action necessary to safeguard Child L1’s elder sibling by completing and submitting the safeguarding children referral. It is interesting to note that whilst the practice nurse was able to readily access advice on safeguarding Child L1’s elder sibling, an equivalent source of advice on domestic abuse did not appear to be available at that time. 7.15 The nurse’s GP practice is an IRIS practice. Paragraphs 6.25 and 6.26 describe the key elements of IRIS. It appears to have been a very successful vehicle for raising awareness of domestic abuse within GP practices across Manchester. The practitioners who attended the learning event felt that the IRIS training for GP practices emphasised the overriding importance to gain consent to refer to the IRIS service which appears to have strongly influenced the practice nurse’s actions, although they had not personally accessed the IRIS training. (Paragraph 6.29) As stated earlier the IRIS process applies only to cases assessed as medium risk and below. Mother’s case appeared likely to be considered a high risk case (Paragraph 6.28 suggests that many of the DASH check list questions would have been answered in the affirmative). High risk cases can only be dealt with under the DASH process. However, although the IRIS training is said to be very clear that consent is not required for a MARAC referral, attendees have not been shown how to complete the DASH risk identification checklist. This may have led to a lack of confidence in, and familiarity with the DASH process which was evident from the comments of members of GP practice 1 who contributed to the practitioner learning event. 7.16 It is understood that future IRIS training and refresher training for Manchester GP practices will ensure that attendees are taken through completion of the DASH checklist, along with the learning from this SCR and the emphasis that the DASH checklist can be completed with or without the patient. MSCB Child L1 SCR Page 34 of 40 7.17 This review suggests that multi-agency and single agency policies on domestic abuse may lack clarity on the steps for practitioners to consider when victims make domestic abuse disclosures and then decide that they do not wish to pursue or decide they wish to retract their allegations. This is not an uncommon feature of domestic abuse cases and the police have a policy for obtaining retraction statements from victims of domestic abuse who have previously made a formal statement but subsequently decided to withdraw it. The policy advises on the need for officers to consider whether the victim was withdrawing their allegation of their own free will and to further consider the victim’s support needs. However, in this case mother began to distance herself from her disclosures a very short time after making them. As previously stated where the victim is considered to be at high risk of domestic abuse, a MARAC referral can be considered irrespective of whether the victim consents although obtaining victim consent is considered highly desirable. Where a case falls below the high risk threshold, there appears to be an absence of guidance for practitioners. It would be helpful to make use of the learning from this case to develop guidance for practitioner on options available to them should a victim decide not to pursue or decide to retract allegations of domestic abuse. Recommendation 3 That MSCB shares this SCR overview report with Manchester Community Safety Partnership and requests that partnership consider developing practitioner guidance on options available to them when a victim decides not to pursue, or retracts allegations of domestic abuse. This will also be integrated into the IRIS training programme. 7.18 It would be helpful if any such revised practitioner guidance could be completed in time to accompany the dissemination of learning from this case. 7.19 Manchester Clinical Commissioning Group commissions the IRIS service and will seek assurance that the IRIS GP practice training adequately equips GP practice staff to complete DASH risk assessments and make MARAC referrals. (See Paragraph 7.16) 7.20 In this case the domestic abuse section of the contact screening (child) form completed as a result of the telephone conversation between the GP practice nurse and the contact centre officer was left blank. (Paragraph 6.30) It is unclear where responsibility lies for completion of the domestic abuse section of the contact screening (child) form where a safeguarding children referral includes concerns of domestic abuse. It is suggested that MSCB obtain clarity on this issue. Recommendation 4 That MSCB request children’s social care to reinforce the importance of completion of the domestic abuse section of the contact screening (child) form where a safeguarding children referral includes concerns of domestic abuse. MSCB Child L1 SCR Page 35 of 40 7.21 This review has been advised that a new model for addressing domestic abuse known as 'Safe and Together'iv is being implemented across Manchester which may have helped practitioners respond to mother’s disclosures in a different way. The focus of 'Safe and Together' is that systems should support keeping children with the non-offending parent in cases in which domestic abuse is alleged. The 'Safe and Together' approach characterises existing practice as inadvertently blaming the non-offending parent and holding them to account for safeguarding their children from the behaviour of the offending parent whilst failing to hold the offending parent to account for their behaviour. 'Safe and Together' consists of processes of mapping perpetrator patterns of behaviour and mapping the non-offending parent’s protective strategies in order to develop the strongest possible partnership with that non-offending parent in order to enhance the safety and wellbeing of the child or children of the family. 7.22 In this case mother appeared to begin to distance herself from her disclosures on 13th July 2016 when options for providing support to her and Child L1’s elder sibling began to be discussed with her. Her comment that children should have a mother and a father (Paragraph 4.4) implies she may have been fearful that she and her child may have needed to leave the family home if she continued to make disclosures. MSCB may wish to monitor the impact of the 'Safe and Together' programme on efforts to safeguard children from the frequently harmful effects of domestic abuse. Role of GP practices in addressing safeguarding children and domestic abuse concerns 7.23 In the weeks that followed mother’s 13th July 2016 disclosures, it was clear to GP practice 1 that they were going to have further contact with mother given the impending birth of Child L1. The safeguarding lead for the GP practice saw these further contacts as opportunities to reach out to mother, check on her welfare and that of her children and possibly encourage her to repeat her disclosures. This approach does not appear to have been successful. Several contacts with mother did take place but opportunities to offer support to mother were often not taken. The GP safeguarding lead for the practice has contributed to this review and observed that internal communication within the practice was complicated by the practice also being a walk in centre which meant that there was less “down time” for informal information exchange. The GP safeguarding lead identified the practice’s heavy reliance on part time staff and locums as another factor. Additionally, the GP practice did not seem to be drawn into multi-agency plans for supporting mother and safeguarding her children. 7.24 The lack of strategy discussions generally in this case and the absence of involvement of the GP practice in the only strategy discussion which did take place may well be factors in the lack of engagement of the GP practice in multi-agency working. However, one would have expected it to have been possible to ensure that every contact with mother was seen as an opportunity to support her by flagging her patient record and coding those of Child L1 and their elder sibling but the review has received no evidence that this was done. MSCB Child L1 SCR Page 36 of 40 7.25 The challenge of fully engaging GP practices in the safeguarding children agenda is not a new one. However, the involvement of GP practice 1 in contributing to the learning from this SCR has been impressive. The MSCB may wish to reflect upon how the learning from this review should inform efforts to further engage GP practices in the safeguarding children system. Out of Area births – implications for sharing safeguarding information 7.26 Out of area births such as Child L1’s premature birth in Norwich appear to represent a challenge to systems for sharing safeguarding information. No evidence has been provided to this review that Norwich University Hospital requested mother’s records and so would have been unaware of her previous disclosures. By the time Child L1 was repatriated to Wythenshawe hospital’s neonatal unit, mother was no longer a patient so her patient records which contained the safeguarding plan for Child L1 were not referred to. The neonatal unit only became aware of the safeguarding concerns when contacted by the health visitor. The review has been advised that steps have been taken to prevent this situation recurring by advising maternity staff in cases where a new born baby is repatriated from an out of area hospital to check the mother’s patient records and to also to check the safeguarding file on the hospital’s shared drive in which they would also have found a copy of the safeguarding plan under mother’s name. The MSCB may wish to obtain assurance that systems by which Manchester maternity services access safeguarding information in respect of out of area births are robust and adhered to by staff. The MSCB may also wish to share a copy of this SCR overview report with Norfolk LSCB so that they are aware of the role played by Norwich University Hospital in this case. Recommendation 5 That MSCB obtains assurance that systems by which maternity services in Manchester access safeguarding information in respect of out of area births are robust and adhered to by staff. Recommendation 6 That MSCB shares a copy of this SCR overview report with Norfolk LSCB so that the latter board is aware of the role played by Norwich University Hospital in this case. The response to the unexplained mark on Child L1 7.27 The marks discovered on Child L1’s body, particularly the mark on their abdomen, promptly led to a child protection medical. Child L1 was admitted to Wythenshawe hospital for five days in order that the development of the mark on their abdomen could be observed to clarify whether it was a birthmark, a bruise or a mark of vascular origin. As stated earlier the outcome of this careful examination of the mark by three paediatric consultants appeared to become the sole focus of professional concern whilst the wider risk picture, of which the suspicious mark was just one important element, received much less attention. 7.28 All three paediatric consultants contributed to the SCR practitioner learning event and the first paediatric consultant to examine Child L1 remarked on the very limited information they received MSCB Child L1 SCR Page 37 of 40 from children’s social care about previous and current safeguarding concerns about Child L1 and their elder sibling. (Paragraph 6.36) The designated doctor safeguarding children for the CCG has advised this review that in their experience, a paucity of safeguarding information has become the accepted norm for paediatric consultants embarking upon a child protection medical. This is an undesirable state of affairs because a lack of information about safeguarding risks puts the consultant at a disadvantage when communicating with the parents and also makes it less likely that the presence of a harbinger injury will be considered. (Paragraph 6.39) 7.29 The MSCB may wish to enquire how widespread is the problem of paediatric consultants being provided with insufficient information about safeguarding concerns ahead of child protection medicals in order to consider what action to take. Recommendation 7 That MSCB enquires how widespread is the problem of paediatric consultants being provided with insufficient information about safeguarding concerns ahead of child protection medicals in order to consider what action to take. Comprehensiveness of Child and Family Assessments 7.30 The CAFA which was the basis for children’s social care decision to close the case in respect of Child L1 and their elder sibling was insufficiently comprehensive with continuing and fresh concerns appearing not to be fully taken into account. The inadequacy of the CAFA appears to have gone unchallenged. MSCB may wish to request children’s social care to make use of the learning from this case in their process for quality assuring CAFA completion. Recommendation 8 That MSCB requests children’s social care to make use of the learning from this case to challenge the quality assurance process for CAFA completion. Lack of challenge 7.31 Effective safeguarding systems need practitioners to be prepared to challenge decisions in a constructive manner and processes for resolving professional disagreements. 7.32 There is no evidence that the police were challenged on their decision to decline the strategy meeting following mother’s disclosures on 13th July 2016 despite the fact that several agencies expressed surprise that no strategy meeting was taking place. Had there been a challenge, it seems likely that some of the risk information which had not been shared with the police, particularly the fact that mother was seven months pregnant, may have led to the police decision to be reviewed. An effective safeguarding system need practitioners who are prepared to challenge decisions in a constructive manner together with processes for resolving professional disagreements. MSCB may wish to reflect on the absence of challenge to the police decision to decline a strategy meeting in this case. And given the fact that several agencies expressed concern about the police decision yet MSCB Child L1 SCR Page 38 of 40 none of them directly approached the police, GMP and partner agencies may wish to reflect on the extent to which they are open to and invite challenge from partner agencies. Preventing abusive head trauma in babies 7.33 Abusive head trauma which is most commonly known as shaken baby syndrome is the leading cause of death and long term disability for babies who are harmedv. Research suggests a demonstrable relationship between the normal period of peak crying in babies and the incidence of babies subject to abusive head trauma (AHT). There is a higher level of cases of AHT in the first month of life, a peak at 6 weeks of age and a decline in cases during the third to fifth month of a baby’s life. 7.34 When Child L1 sustained abusive head trauma they were just short of eight weeks old and had been suffering from colic which would have caused an increase in their crying. Excessive crying in babies can be difficult to manage for parents and they need to be advised on how to manage episodes of prolonged crying. In light of this case, MSCB may wish to obtain assurance that the local strategy to prevent abusive head trauma in babies is as effective as possible. Recommendation 9 That MSCB seeks to influence the developing Greater Manchester abusive head trauma strategy in order to ensure the strategy to prevent abusive head trauma in babies is as effective as possible. Longstanding concerns 7.35 When this report was presented to the subgroup of MSCB which, amongst other things, is responsible for scrutinising Serious Case Review reports, concern was expressed that several of the areas of learning arising from this review had also featured in earlier Serious Case Reviews. Issues such as strategy discussions not taking place when justified, lack of challenge to partner agency decisions and the provision of incomplete safeguarding information to paediatric consultants were considered to be longstanding concerns. Previous attempts to effect improvements in these areas were considered to have been less than successful. The subgroup touched upon the particular challenges faced by partner agencies operating in Manchester but concluded that there needed to be a renewed and sustained effort to address these longstanding challenges. MSCB Child L1 SCR Page 39 of 40 Appendix A: Review Process Process by which SCR conducted and membership of the SCR review group A review group of senior managers from partner agencies was established to oversee this SCR, which was chaired by the independent lead reviewer. The membership of the review group was as follows: Consultant Paediatrician, Central Manchester University Hospitals NHS Foundation Trust Service Manager, Manchester Children’s Services Detective Inspector, Greater Manchester Police Head of Nursing – Safeguarding, University Hospital of South Manchester NHS Foundation Trust Named Nurse – Safeguarding Children, Central Manchester University Hospitals NHS Foundation Trust Acting Designated Nurse – Safeguarding Children, Manchester Health and Care Commissioning Policy and Performance Officer, MSB Business Support Officer, MSB David Mellor, Independent Lead Reviewer. It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Specifically, it was decided to adopt the Welsh concise child practice review methodologyvi which focusses on recent practice and places strong emphasis on engagement in the SCR of practitioners and managers involved in the case. Chronologies which described and analysed relevant contacts with Child L1 and their family were completed by the following agencies: Central Manchester University Hospitals NHS Foundation Trust Greater Manchester Police Manchester City Council Children’s Services NHS Manchester Clinical Commissioning Groups University Hospital of South Manchester NHS Foundation Trust. MSCB Child L1 SCR Page 40 of 40 The review group analysed the chronologies and identified issues to explore with practitioners and managers at the learning event facilitated by the lead reviewer which was extremely well attended by representatives of the various disciplines involved in this case. The lead reviewer then developed a draft report which reflected the chronologies and the contributions of practitioners and managers who had attended the learning event. Two key practitioners who had since left their positions contributed to the review via telephone conversations with the lead reviewer. With the assistance of the SCR review group, the report was further developed into a final version and presented to MSCB. It has not proved possible to engage mother or father in this SCR as at the time of writing they are both subject to an ongoing police investigation into the injuries sustained by Child L1. Contact with Child L1 or their elder sibling was not appropriate because of their very young age. References i Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13928/full ii Retrieved from https://www.nspcc.org.uk/services-and-resources/research-and-resources/2014/head-spinal-injuries-core-info/?_t_id=1B2M2Y8AsgTpgAmY7PhCfg%3d%3d&_t_q=head+injuries&_t_tags=language%3aen%2csiteid%3a7f1b9313-bf5e-4415-abf6-aaf87298c667&_t_ip=10.99.66.5&_t_hit.id=Nspcc_Web_Models_Pages_ResearchReportsPage/_33e039c9-f723-4883-bbb2-87dfa5f1d4d4_en-GB&_t_hit.pos=1 iii G/THUR/CPD3 Harbinger injuries in serious physical abuse H. Smith1, V. Coupes2.1Central Manchester and Manchester Children's Hospitals, Manchester, UK; 2Fairfield General Hospital, Bury, Manchester, UK iv Retrieved from http://endingviolence.com/our-programs/safe-together/safe-together-overview/Safe and Together v Abusive head trauma: mechanisms, triggers and the case for prevention – presentation by Dr S. Smith March 2017. vi https://www.nspcc.org.uk/preventing-abuse/child-protection-system/wales/child-practice-reviews/ |
NC52237 | Unexplained death of a 4-month-old baby boy in November 2018. Mother had experienced domestic abuse prior to her pregnancy and had to flee from her abuser, father of Child D. Before Child D was born Mother moved from one local authority area to another, where she lived in a refuge for women experiencing domestic abuse. Mother was isolated with limited social support, and no family; concerns about her alcohol consumption. Following eviction from the refuge, Mother and Child D were housed in temporary accommodation in the neighbouring local authority. The accommodation did not contain a cot, and none was provided. Initially Police treated Child D's death as a Sudden Unexplained Infant Death however because of Mother's demeanour and behaviour she was arrested on suspicion of neglect, due to alcohol abuse whilst in charge of a child. Coroner noted cause of death as unexplained and that there were signs consistent with asphyxiation. Ethnicity and nationality not stated. Learning includes: assessing the needs and risks of families experiencing domestic abuse is a complex task; some practitioners are still not confident about using escalation; practitioners do not always record important information which results in significant information not being shared when required; there is a tendency for some practitioners to minimise the significance of parents using alcohol and being over optimistic about reports by parents of their alcohol consumption. Makes no recommendations but raises questions to Newham Safeguarding Children Partnership and Waltham Forest Safeguarding Children Board.
| Title: Serious case review: “Child D”. LSCB: Waltham Forest Safeguarding Children Board Author: Dave Peplow, Fran Pearson and Suzanne Elwick Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Waltham Forest Safeguarding Children Board Serious case Review “Child D” Authors Dave Peplow – Independent Scrutineer Waltham Forest Local Safeguarding Children Board Fran Pearson – Independent chair Newham Local Safeguarding Children Board Suzanne Elwick, Head of Strategic Partnerships LBWF February 2020 2 Contents 1. Introduction and the reason for the review 2. Methodology and agencies involved 3. Findings, learning and board response 4. Individual agency learning Glossary 3 1. Introduction and reason for review Under Working Together 2015, the Independent Chair of the Waltham Forest Children Safeguarding Board agreed to the recommendation from the One Panel (multi-agency forum that takes referrals for local or statutory reviews and makes recommendations against the statutory criteria to the independent chair) to undertake a Serious Case Review for Child D who sadly died in November 2018. This serious case review concerns the unexplained death of a four-month-old baby boy (Child D) and the services provided to Child D and his Mother, during her pregnancy and over the four months of Child D’s life until his death in late 2018. His Mother experienced domestic abuse prior to her pregnancy and had to flee from her abuser, the father of the child. Mother then lived in east London and was isolated with a very limited support/friends, and no family. It is imperative that her identity is protected so while the review took account of all Mother’s personal circumstances and identity, this report does not include these details. Mother has been living in Newham when she booked for her pregnancy and before Child D was born, she moved to Waltham Forest where she lived in a Refuge for women experiencing domestic abuse. When Child D was four months old and at the time of his death Child D was in the sole care of his Mother and living in temporary studio accommodation in Hackney, sourced by London Borough Waltham Forest Housing. During the period under review she disclosed to her GP and other health professionals her experience of domestic abuse; both physical and emotional, and identified that Child D’s father was the perpetrator. Mother was living in the local women’s refuge where she fled due to domestic abuse. Shortly before his death, Child D and his Mother were evicted by the refuge due to her breaching the licensing agreement. Alternative temporary accommodation was sourced by Waltham Forest Housing and found in the neighbouring borough of Hackney. The accommodation provided was a small studio room with a single bed. The room did not contain a cot, and none was provided. The usual practice at this time would have been if there had been a request for a cot it would have been provided by the property managing agent. Police officers attended the address following the report of Child D’s death and treated it as a Sudden Unexplained Infant Death however because of Mother’s demeanour and behaviour she was arrested on suspicion of neglect, due to alcohol abuse whilst in charge of a child. The coroner gave the cause of death as “Unexplained” and noted that there were signs consistent with asphyxiation, an undiagnosed brain condition. 4 Family Involvement Mother was informed by hand delivered letter that a review had been commissioned and of its purpose. She was subsequently approached and spoken with about contributing but felt too grief stricken to take part. Services have subsequent loss contact with Mother. 2. Methodology and agencies involved This review has been carried out in a way that reflects the principles of a systems-based approach. The review seeks to understand why things happened in the way they did. Broadly this means using this case as a ‘window on the system’, asking the question: What does Child D’s experience tell us about how systems work? The aim is to look for areas that relate to systemic issues, which will lead to changes in practice. The focus of this review is very much on learning and improvement. The final report has been authored by Dave Peplow, Fran Pearson who are independent of the partnership and Suzanne Elwick, who is employed by the Waltham Forest, is independent of the services reviewed, using information generated by an independent reviewer who has previous experience of leading Child and Adult reviews. The review period is from November 2017, when professionals first became aware that the Mother was pregnant, until November 2018, when the Mother contacted emergency services as Child D had died. The Review Group was made up of senior managers from all those agencies that were involved with Child D and his Mother in the twelve-month period before his death. The Review group met with the Independent Reviewer to consider emerging issues and took part in the two workshops with frontline practitioners who knew Child D and his Mother. The Review Team appreciate the professional, open and honest way all concerned conducted themselves throughout the process. The agencies involved were: Newham • London Borough of Newham Children’s Social Care (NCSC) • Newham Vulnerable Women’s Team (Maternity) provided by Barts • Perinatal Mental Health Team in Newham (Cognitive Behavioural Therapist & Psychiatrist) • Newham Primary Care (GP) 5 • London Borough of Newham Adult Services (NAS) Waltham Forest • London Borough of Waltham Forest (LBWF) Multi Agency Safeguarding Hub • LBWF Housing • Women’s Aid-Waltham Forest Refuge • Waltham Forest East London (WEL) Clinical Commissioning Group • North East London Foundation Trust (Health Visiting and PIMMHS) • Primary Care Bart’s Health Trust • Newham University Hospital • Whipps Cross University Hospital London Metropolitan Police • Specialist Case Review Group 3. Findings and learning points The following section considers the key areas where analysis of practice in this case identifies system level issues that are relevant to the wider safeguarding system. Comment on housing practice in relation to the risks of co-sleeping There was extensive discussion in the review process about the availability of suitable housing and the complexity of this issue in inner city London where housing stock is extremely limited. The accommodation provided to Child D and his Mother was considered appropriate by LBWF Housing and complied with the legislation for a Mother and small child. When Mother was in the refuge there was a Moses basket for Child D. As highlighted in the significant dates table and in finding 4 there were many occasions when Mother chose to place Child D on the bed rather than in the moses basket. At the time Child D and his Mother moved to temporary accommodation, the independent housing provider of the accommodation had a practice of not providing cots due to incorrect information regarding the risk of Sudden Unexplained death in Infancy. In December 2018, the Director of Public Heath for Waltham Forest, in his role as chair of the child death overview panel provided the latest public health information regarding Sudden Unexplained Death in Infancy and the risk of co-6 sleeping to the provider, and together with the LBWF housing this practice has now changed. LBWF housing now ask the managing agent of the accommodation to always provide a cot in relevant circumstances. Findings Finding 1 Assessing the needs and risks of families experiencing domestic abuse is a complex task that local children safeguarding system in Newham need to support professionals with, in order to create the best chance of a consistent and child-centred response Finding 2 For more than five years both safeguarding partnerships in Waltham Forest and Newham have promoted and reviewed the use of escalation processes. This case highlights that some practitioners are still not confident about using escalation Finding 3 In Waltham Forest and Newham some practitioners do not always record important information which results in significant information not being shared when required. Finding 4 There is a tendency for some practitioners in Waltham Forest and Newham to minimise the significance of parents using alcohol and being over optimistic about reports by parents of their alcohol consumption. Finding 1 Assessing the needs of families experiencing domestic abuse is a complex task that the child safeguarding system leaders in Newham need to support professionals with, in order to create the best chance of a consistent and child-centred response How are these issues evident in this case? A referral was made to NCSC by Newham University Hospital on the 19.12.2018. The presenting issues to be addressed were domestic abuse and mental health, in the context of a pregnancy where Mother was seeking to leave Child D’s father, the alleged perpetrator. The case was allocated for a single assessment under S17. The assessment was being conducted with Mother’s consent and therefore would appear to be a under S17 of the Children Act as a child in need assessment, rather than S47 as child in need of protection. Although the allocated social worker can clearly recall a home visit and assessment, there is no record of the visit or the assessment nor the rationale for the assessment framework being that of a Child in Need. It is clear from the limited available records and through conversations with the social worker and practice lead, that the issues of domestic abuse and mental health were not fully explored with Mother. Further information should have been sought to establish a 7 more accurate picture of Mother’s situation and the risk to the unborn Child D. The collating and verification of information is integral to a good assessment process and good decision-making. Women who are exposed to domestic abuse during their pregnancy (research shows domestic abuse is likely to be exacerbated by pregnancy) that have higher levels of fear and anxiety with higher levels of miscarriage and lower birth rates. Research tells us that women are at higher risk of harm when they leave a violent relationship, but this was not explored or recognised. One of the most important reasons women don’t leave is because it can be incredibly dangerous. The fear that women feel is very real – there is a huge rise in the likelihood of violence after separation. 55% of the women killed by their ex-partner or ex-spouse in 2017 were killed within the first month of separation and 87% in the first year (Femicide Census, 2018) Application of the nationally adopted and recognised Domestic Abuse, Stalking and Honour based Violence (DASH) risk assessment would have provided a recognised framework for establishing the level of risk to both Mother and child. This assessment was being completed under s17 as a child in need. A good assessment may have established that a pre-birth single assessment under S47 was appropriate. In line with Newham’s policy on pre-birth assessments (both s17 and s47) the main purpose of the pre-birth assessment is to identify: • What the needs of the new-born are? • What risks are posed? • Analysing the capacity of the parent/s to respond appropriately to the baby’s needs • How historical concerns might impact on safe parenting • Reducing the risks The assessment completed by the social worker did not comply with the policy in that risks were not identified that were knowable at the time if the social worker had demonstrated curiosity in discussions with Mother and had liaised with midwifery. This was a missed opportunity to establish the necessary rapport with Mother and for information to be elicited, which in turn was compounded by a decision made by the more experienced social care professional supporting the social work and overseeing the quality of practice. This decision was to close the case and was a further missed opportunity. The rationale was that Child D’s Mother withdrew consent thereby ending an assessment process being completed under Section 17. It is arguable at this point that based on all the information knowable that the case could have met the threshold for a Section 47 Children’s Act inquiry in terms of safeguarding the unborn 8 child. There is no record that consideration was given to the Mother being referred for assistance through coordinated ‘Early Help’. Newham’s Pre-birth procedures (2017) indicate that a child may be referred for assessment as early as 6 weeks gestation and that triage research should include details of the expected delivery date (EDD). All pre-birth referrals are required to have a multi-agency meeting within 14 days of allocation. In this case the pre-birth protocol was not followed. No research was conducted and there was no multi agency meeting. This was poor practice. The three contacts to adult services in Newham, from Mother herself, Mother’s psychiatrist and Mother’s GP were included as part of the chronology produced for the review which provided significant information regarding the risks to the unborn child. The review was advised that this information was not seen by the workers in NCSC at the time the decision was made to close the case. This raises additional concerns regarding the approach to working with families in Newham and awareness of child safeguarding in adult services. Does this happen in other cases? The recent Ofsted Inspection of NCSC highlights that: Many children benefit from good-quality assessments, although the quality is variable, and some assessments are poor Children in need of help and protection in Newham receive services which range in quality from requires improvement, to good, to poor. Why does it matter Children living with domestic abuse form the majority of work for children social care and therefore it is vital that as a partnership we get this right “Domestic violence, which includes that aimed at children or other adults in the household, was the most common factor identified at end of assessment for children in need at 31st March 2018 (Characteristics of children in need: 2017 to 2018 England)” Questions for the two Newham Safeguarding Partnerships Newham Safeguarding Children’s Partnership In line with the improvement actions agreed by all partners following the January 2019 Ofsted inspection of local authority children’s services: how do the statutory partners understand their respective roles in supporting a system where “proportionate intervention [is] understood and consistently applied by the multi-9 agency partnership and within social care. Records of action; decision and rationale are clear and up to date”.? In line with the improvement actions agreed by all partners following the January 2019 Ofsted inspection of local authority children’s services: how do the statutory partners understand their respective roles in supporting a system which “Embed[s] use of Safer Lives tool to identify and assess risk of levels of domestic violence to inform safety planning and support for children and parents.”? Newham Safeguarding Adult’s Partnership Board What is SAB’s current understanding of the confidence and competence of all professionals working with vulnerable adults to identify and pass on safeguarding concerns about children including unborn children in line with Working Together to Safeguard Children 2018? How familiar are board members with the agreed joint protocol Working Alongside Families in order to support parents and carers with good mental health and wellbeing which is joint between East London Foundation Trust and Children’s Social Care? Could its principles be extended across a wider group of adults’ professionals? https://proceduresonline.com/trixcms/media/1770/joint-mental-health-protocol-final-version-oct-17.pdf WFSCB Board response to Finding 1 This action is for Newham as this was not felt to be an issue in Waltham Forest evidenced by the recent Ofsted which stated: “Children assessed to be at risk from domestic abuse receive effective interventions to safeguard their welfare. There is a range of strong and flexible services provided for children and adults. Social workers appropriately assess the risks associated with domestic abuse and honour-based violence. This information is well analysed, and results in sustained interventions. The local authority recognises that there is more to do in ensuring the actions agreed at MARAC meetings are implemented in planning for children.” In addition, in Waltham Forest Safe and Together model is being rolled out across the partnership. Safe and Together (SaT) model is an approach designed to improve the way that safeguarding systems respond to families affected by domestic abuse. It provides a framework for partnering with domestic abuse survivors and 10 intervening with domestic abuse perpetrators to enhance the safety and wellbeing of children. SaT has had international success in changing services’ responses to domestic abuse, increasing the number of children who remain safely with their non-abusive parent and decreasing re-referral rates into services. Newham Safeguarding Children Partnership (NSCP) response to Finding 1 Newham children’s social care has strengthened its training offer in systemic approaches to relationship- based practice. The approach privileges direct work with children, young people and adult family members and will enable practitioners to be clear about the purpose of their interventions, develop their skills to build meaningful relationships and build confidence in using tools to assess and support families to make and sustain positive change. This will support the improvement in the quality and consistency of assessments ensuring they are analytical and proportionate. Dedicated practitioner workshops focussing on the three key themes of assessment, planning and direct work are being delivered to all practitioners and managers. These workshops are supported by coaching sessions to embed the learning. The training programme for Newly Qualified Social Workers has been updated to follow the journey of the child, featuring assessment of need throughout. Experienced Social Workers are given the opportunity to attend. Multi agency assessments and interventions are supported and informed by the borough’s dedicated domestic abuse service, Hestia. This is a community-based service, co- located within services across Newham including the Multi Agency Safeguarding Hub (MASH), Newham University Hospital and police stations Within Newham Adults Services, the front door Access team have received briefings and guidance on how to ask appropriate and probing questions, for screening safeguarding cases where there are children involved or believed to have been involved. A checklist of points to consider is being developed in conjunction with the East London Foundation Trust Mental Health services. The Working Alongside Families in order to support parents and carers with good mental health and wellbeing joint protocol is currently being revised and will be relaunched in May 2020 for Mental Health Awareness Week, 18th - 24th May. 11 Finding 2 For more than five years both safeguarding partnerships in Waltham Forest and Newham have promoted and reviewed the use of escalation processes. This case highlights that practitioners are still not confident about using escalation. How are these issues evident in this case? This case identifies seven occasions when practitioners could have escalated their concerns in relation to the outcome of their referrals which did not lead to the assessment they requested. None of the practitioners escalated to the service receiving the referral or within their own agency. Potential opportunities to escalate: • Jan 2018 – Cognitive Behaviour Therapist makes referral to NASC • Feb 2018 – Mother’s psychiatrist makes referral to NCSC • Feb 2018 - GP makes referral to NASC • April 2018 - WX Midwifery makes referral to WFMASH • May 2018 – Newham Hospital midwifery contacts NCSC regarding case being closed as Mother not agreeing to assessment • Oct 2018 - WF Refuge x2 referrals to WFMASH In Waltham Forest there has been an escalation process in place for over 5 years and this is promoted at all training and events and is on the front page of the WFSCB webpage. Escalation has also had its own spotlight bulletin in June 2019. Waltham Forest strategic boards has a comprehensive learning and improvement practice work programme which includes multi-agency audits, which are conducted alongside statutory and local learning events. Lack of escalation is an issue that has repeatedly come up in audits and reviews consistently over the last 5 years, despite the escalation process in place. In Newham escalation is promoted via newsletters across the partnership and is a standing agenda item at the Newham LSCB performance and quality assurance subgroup where they look at themes / outcomes etc. The practitioners and managers who were part of the review reported that they were aware of the escalation process in their borough and felt it was widely promoted. Despite this, it is evident that practitioners do not generally escalate. 12 Does this happen in other cases? The issue of lack of escalation is a common finding in reviews in the experience of the authors of this review and discussion in national fora. However, there is no data which routinely captures this information. Nationally in the latest Triennial Review of Serious Case Reviews 2011-2014 we learn that most children subject to an SCR were not involved with the child protection system through a child protection plan or a court order, although many were receiving services as ‘children in need’. Many of these children and families had also been known to children’s services in the past, and as such should be considered by agencies as having recognised and potentially long-lasting vulnerability or risk The review found lack of escalation to be a factor Professionals in all agencies working with vulnerable families must be persistent in their practice, maintaining consistent support for the family and vigilance towards meeting children’s needs. This includes pursuing non-engagement, seeking advice, and escalating concerns where appropriate, as in the following case “(Page 147) In discussion with practitioners and managers in the workshop they advised that they were aware of the escalation process and felt it was well publicised in both Newham and Waltham Forest. Why does it matter A safe and effective safeguarding system depends on practitioners who are confident to engage in constructive challenge with their colleagues. At times as practitioners we may disagree about threshold judgements and/or the appropriate course of safeguarding action. Practitioners working with children, adults and families in often complex situations can have different opinions and views on the best way to provide support. Discussion and debate, in a multi-agency context with colleagues, along with constructive challenge, enhances and develops understanding and knowledge. This leads to a fuller assessment and should be part of everyday practice. If practitioners do not escalate, do not take opportunities for constructive challenge and debate, their concerns remain unchallenged which could lead to children remaining at risk and this is a significant risk to the multi-agency safeguarding system. 13 The Triennial review comments that practitioners need to feel confident and empowered to escalate and that: “Building cultures of support and empowerment needs strong organisational leadership within Local Safeguarding Children Boards and in their constituent agencies. “(page 205) Questions for Newham and Waltham Forest boards 1. How can Newham and Waltham Forest boards build cultures of support and empowerment to enable practitioners to feel confident to routinely escalate appropriately? What will each individual senior leader/board member do in their agency to build this culture? 2. How are Newham and Waltham Forest boards going to monitor if practice has improved and what will they do if practice does not improve? WFSCB Board response to Finding 2 Waltham Forest Safeguarding Children (WFSCB) and Safeguarding Adults Boards (WFSAB) recognise escalation as a theme in both local and national reviews. Alongside this SCR, escalation is also a theme of a recent Safeguarding Adult Review. WFSCB and WFSAB discussed the need to learn more about the use of escalation. At present we are only aware that lack of escalation is often a theme in cases that are reviewed. We do not know if escalation is being used appropriately in other cases. Agencies agreed to monitor escalations for a 3-month period to aid and add to our understanding. Escalation is to one of four themes for the improving practice programme of work and is due to be delivered through the Strategic Partnerships Unit in March – May 2020. The Board agreed that there is a need for the escalation process to be promoted by all agencies through multiple routes such as email signatures or screen savers, to direct practitioners to the WFSCB and WFSAB escalation process. Actions o All agencies to record, for a 3-month period, details of escalations for child and adult cases that occur, as far as they are able from 27 January 2020 to 27 April 2020 14 o Strategic Partnerships Unit’s next resource pack for improving practice will specifically be around escalation. This will include a practitioner’s survey and learning resources to meet different learning styles which can be used for self-study, in supervision and in team meetings including good practice case studies and training exercises, o Escalation process link to be added to the MASH signature and to referral form. NSCP response to Finding 2 Newham Safeguarding Children Partnership has an established escalation policy This has recently been updated and will be relaunched across the partnership to drive compliance. A rolling programme of briefings are being delivered across the partnership where the policy will be promoted. Newham Safeguarding Adults Board (NSAB) acknowledges that effective escalation both within the local authority and its partner agencies requires immediate review. Escalation has been included in the 2019/20 work programme for the Performance and Quality Assurance subcommittee. Adult Social Care will lead on a draft Adults Escalation policy scheduled to be completed by the end of the 2019/20 year. The NSAB has agreed that there is a need for the escalation process to be promoted by all agencies. Its implementation will be monitored through the Performance and Quality Assurance subcommittee. Adult Social Care operate Reflective Practice bi-monthly sessions targeted at front line staff, which are an opportunity to learn lessons from case reviews. A case study on escalation is in development for the start of the 2020/21 year. Finding 3 In Waltham Forest and Newham practitioners do not always record important information which results in significant information not being shared. How are these issues evident in this case? In this case there are at least 7 incidents where important information was not recorded by practitioners working with the family: 15 • No record made by the attending police officer for the basis of his decision in relation to the alleged assault against Mother, which he recorded as a landlord/tenant dispute • One Newham Police contact where a Merlin was completed but not shared with NCSC in line with policy. • No record of a home visit taking place by the NCSC social worker • No record of the assessment completed by the NCSC social worker • No record in the Health Visitor’s record of a request for monitoring by WFMASH • No record of phone calls in WFMASH, by the Refuge to business support in WFMASH • Gaps in the Health Visitor records based on indicated HV contact from others. Does this happen in other cases? It is reasonable to assume that any authority is likely to have a variable level of practice. This is a challenging area of practice because we do not know what we do not know. The issue of recording is linked to that of information sharing. If information is not recorded, it cannot be used to inform further assessments and multi-agency discussions and cannot be shared with others. The issue of recording information, sharing information and multi-agency working are all discussed in the Triennial Review and feature frequently in serious case reviews. Record keeping is also linked to professional codes of practices and is a professional standard as well as a safeguarding issue Why does it matter Why it matters is because: “No single professional can have a full picture of a child’s needs and circumstances. If children and families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action.” (Keeping Children Safe in Education 2018 p.5) This quote relates to children in education and is used as it comprehensively illustrated the point about recording information 16 The context of education provides a useful context for understanding the importance of recording. Kent County Council illustrates this clearly in their guidance which can be translated to any setting for a child: Accurate and up to date recording of child protection or welfare concerns is essential for a number of reasons: • It can help educational settings identify child protection or welfare concerns at an early stage • It can help settings identity patterns of concerns • It can enable settings to record seemingly minor issues to build a more complete picture of what life may be like for their learners • It helps settings to monitor and manage safeguarding practices, including decision making, actions taken and agreed joint strategies with other agencies • It can provide evidence to support professional challenge, both within educational settings and when working with external agencies • It can support settings to demonstrate action taken to reduce impact of harm to a child • It helps to evidence robust and effective safeguarding practice in inspections and audits. (Kent County Council Safeguarding record keeping guidance for education settings Sept 2018) Questions for the board 1. How do agencies assure themselves that their staff are recording appropriately? This is asked in the context of “not knowing what you don’t know” which may not be the usual way, in which single agency audits ask the question. Are agencies able to complete spot checks to assure themselves. For example, Police cross-checking a child was present with MERLIN being sent. 2. How are Newham and Waltham Forest boards supporting practitioners to improve their practice in recording? WFSCB Board response to Finding 2 Agencies all regularly undertake audit activity to assess the quality of assessments. Due to the nature of these audits they cannot always confirm if any information is missing. Agencies discussed other ways of highlighting and raising awareness with their practitioners about the importance of record keeping Care Grow Live: has time dedicated to analysing the quality of notes as well as internal record keeping and provides internal training for staff. 17 NELFT: The Safeguarding Team multi-agency referral form (MARF) audit asks specific questions regarding both internal escalation in NELFT and external escalation within social care on records where a MARF has been completed. Police: The training cycle going forward includes a focus on response officers and safeguarding issues which will have an emphasis on recording accurately if children are part of the family – not just present at the time. Actions o All agencies that sit in MASH to identify how they provide feedback to staff from their agencies on the quality of recording on the referrals that come into MASH. MASH Strategic Group to oversee this. o CSC already include discussion with the practitioner as part of the audit process. Audits to include a question about the accuracy and quality of the recording as this can be tested out by the manager when they discuss with the practitioner. o Barts Health to undertake a spot check audit matching case records to referrals made and identify if record keeping is the same on both NSCP response to Finding 3 All training referred to in Finding 1 includes a focus on effective recording for Newham Children’s Services. For Newham Adult Social Care (NASC), they have an established programme of case file audits which are undertaken by ASC managers and seniors. Accurate and concise recording is a significant criteria of the audits and the outcomes and themes of the audits are presented to the Newham Quality and Governance Board where improvement plans are agreed. In addition to this, NASC have the following training as part of the 2020-2021 programme: • Court Room Skills & Report Writing (for Court of Protection) • Legal report writing • Care Act workshops and peer learning sessions 18 Finding 4 There is a tendency for practitioners in Waltham Forest and Newham to minimise the significance of parents using alcohol and being over optimistic about reports by parents of their alcohol consumption How are these issues evident in this case? On at least eight occasions practitioners mentioned alcohol as an issue of concern in relation to the Mother of Child D. However, at times this was often alongside a comment about historical or “not dependent on” without any other evidence or commentary to back up the statement: • 8 Nov 2017 – Police record notes that Mother “under the influence when assaulted” • 15 Feb 2018 – Perinatal psychiatrist advised NCSC that Mother “has historical alcohol problems” • 28 Feb 2018 – Contact with NASC from GP which includes information from letter from same psychiatrist of “history of heavy alcohol use but didn’t think she was dependent, and Mother says she hasn’t drunk since the pregnancy” • 10 Sept 2019 – residents in the Refuge report to staff that they are concerned for Child D as they have seen Mother drunk while caring for him. Mother declines referral to alcohol misuse service and denies that she has a drinking problem. The HV is advised of this by the Refuge staff. • 4 Oct 2019 – other residents disclose concern about Mother smelling of alcohol. When discussed with Mother she appears drunk and unsteady on her feet while holding Child D. Referral to WFMASH advises of potential alcohol use but doesn’t include Mother appearing drunk in the morning while holding Child D or that she went out and came back at 2am. • 5 Oct 2019 - WFMASH discuss referral with Mother who denies any difficulties with alcohol or leaving Child D alone for longer than 5/10 mins. Refuge worker speaks to WFMASH and expresses concern about Mother being drunk all day • 31 Oct 2019 - health visitor spoke with Mother about her drinking but did not include this in the actions for Mother which did include smoking cessation, attending Toy Library and accessing counselling. • 9 Nov 2019 – Mother calls the on-call refuge manager at 12.30am and is speaking incoherently and the manager suggests Mother may have been under influence of alcohol. Mother advises call was a mistake. When the issue of current alcohol was raised by or with practitioners there was a tendency to “believe” Mother’s account. For example, when Mother was referred to 19 WFMASH by the refuge, when WFMASH spoke with Mother they accepted Mother’s account that she was not drinking much and only left Child D for 5/10 minutes although the refuge worker reported this differently. When the Health Visitor spoke with Mother after speaking with the refuge worker, she too accepted that Mother said she only drank occasionally. When the refuge spoke with WFMASH they did not give the full explanation of Mother’s drunken behaviour. Does this happen in other cases? Locally in Waltham Forest alcohol was the third highest potential risk factors identified at end of assessment 1 April 2018 – 31 March 2019. Both the Triennial Review of SCR and the NSPCC learning from case reviews identifies alcohol and assessment of parent’s alcohol use as a contributory factor. The NSPCC research evidenced that assessment tended to often focus on the issues faced by parents who misuse substances without considering the impact on their children And identifies further that Substance misuse by a parent or carer is widely recognised as one of the factors that puts children more at risk of harm. The biggest risk posed to children is that parents, when under the influence of drugs or alcohol, are unable to keep their child safe (including overlay through co-sleeping and accidents caused through lack of supervision). NSPCC learning from case reviews Nov 2013 Significantly in the Triennial Review research the deaths of 31 children (out of 93 children that died) were presented as Sudden Unexplained Death in Infancy. Most of these children died while co-sleeping with a parent or in other dangerous sleeping arrangements, such as on a sofa, on soft bedding, or in make-shift bedding. Many of these families appear to have led chaotic lives, with frequent house moves, periods of homelessness, or inappropriate housing. Substance and alcohol misuse were common (Triennial Review page 59) Where parental mental health problems co-exist with other risk indicators, particularly domestic abuse, but also including drug or alcohol misuse, or social isolation, this should prompt a further assessment of the child’s safety (Triennial Review page 84) 20 Why does it matter Alcohol is a social accepted “drug” and the volume and amount of consumption by individuals varies in society and as such will vary amongst practitioners. This may influence how some practitioners view the use of alcohol by people when they are experiencing stressful situations such as Mother did. As a society we do not have a shared view on what is too much alcohol, (aside from the public health information about how to keep health risks from alcohol to a low level) we do not have a shared view as a partnership. Together with the lack of shared view is a tendency to want to support women with children in difficult circumstances. In this case it appears to have led to an over optimism, minimising and lack of challenge. When Mother spoke about her historical drinking difficulties there is no evidence to suggest this was explored. There was no questioning of how someone who had an addiction or problematic drinking pattern was able to suddenly end when she became pregnant. There was not discussion about the reason in the first place for the drinking, which may have been part of her coping strategy to deal with her experiences of abuse. There is no record of practitioners being curious about Mother’s ability to suddenly stop drinking and/or what she was using know as a coping strategy. Is there a lack of awareness amongst practitioners about the significance of addiction and how difficult it is to address addiction? The context and extent of alcohol use was minimalised by the Refuge in the initial written referral to WFMASH. When the health visitor and Refuge drew up a plan for Mother, they excluded alcohol from the list of areas of attention and therefore missed an opportunity to link Mother’s alcohol use to concerns about her parenting. When asked about her alcohol consumption Mother minimalised it herself and reported very low alcohol intake. This was not the view of the Refuge staff and residents who witnessed Mother drunk on several occasions including first thing in the morning, The rule of optimism and lack of professional curiosity together leads practitioners to trust parents self-reporting about their consumption despite evidence from others that this is not the case. This is emphasised in the NSPCC learning from SCR which highlights the importance of clear communication with parents about the risks advising that Some parents said they did not feel that the risks of co-sleeping had been explained in such a way that they had fully understood them, or had been able 21 to take them on board (Parents who misuse substances: learning from case reviews, NSPCC, 2013) If practitioners were not able to explore with the Mother of Child D the extent of her alcohol consumption, they may also not have had the opportunity to discuss with Mother fully, in a way that she was able to understand, what the risks were to Child D. Questions for the Newham and Waltham Forest boards 1. What is the board’s understanding of all practitioner’s ability to probe, explore and challenge parents as appropriate, about their relationship with alcohol? 2. How confident is the board of the knowledge of all practitioners about addictive behaviours, and the challenges of becoming sober or practicing harm reduction, particularly in relation to pregnancy and post birth? 3. Is the board confident that there is a shared partnership view of what is harmful and non-harmful use of alcohol? WFSCB Board Response to Finding 4 WFSCB notes the important practice point of “what happened in the past being an indicator of the future”. This is not to say that individuals cannot change but requires practitioners to be extra curious and triangulate information. In this case, the Mother had a long history of using alcohol and had previously had a conviction relating to being intoxicated whilst executing her role as a carer. Additional work to be undertaken to further support practitioners with having challenging conversations and improving understanding harmful use of alcohol. WFSCB note that Care Grow Live now have a presence in MASH so extra support is on offer at the point referrals are being discussed and also on the ground for CSC staff to have advice on active cases. Actions o WFSCB to further promote the bitesize video guide on alcohol use which contains practical advice around having challenging conversations with adults about their alcohol use. o Strategic Partnerships Unit outreach and improving practice work will explore directly with front line practitioners the challenges and barriers they face in having challenging conversations and also gather good practice ideas and 22 what would help practitioners. Results will be fed in to a seven-minute briefing that will be circulated widely o WFSCB to circulate widely the training offer from CGL each quarter on raising awareness of alcohol and substance use. o Strategic Partnerships to include messages around alcohol use with the 16 days of Activism in November 2020 o Strategic Partnerships to ensure that resources, training and awareness around alcohol use and challenging conversations is included within the Safe & Together training o Barts to raise awareness across the partnership of the Alcohol Reduction Nurse based at Whipps Cross Hospital NSCP response to Finding 4 Change Live Grow (CGL) is the commissioned and integrated provider of drug and alcohol treatment services in Newham. CGL have strong operational and strategic links with Adults, Children and Young Peoples Services, providing training across the partnership through the Newham Safeguarding Children Partnership. The risks associated with being overly optimistic will be incorporated into this training. Within Adults Services, alcohol and substance misuse is a concurrent theme among a number of NASC customers. Social Care professionals work closely with (CGL) to support customers to reduce addictive behaviours. Adult Social Care Workforce Development will commission suitable training in 2020/21 on alcohol use to upskill frontline practitioners. 4. Summary of learning taken by agencies at the time. The following action plans have been shared for inclusion in this report. We are aware that other agencies have completed plans that can be made available to each Board. Waltham Forest MASH WFMASH conducted a file audit of 100 cases as a result of this case and has implemented an action plan which includes: 1 All actions assigned to Social Worker are checked by the manager to ensure completion 23 2 Assessment and information gathering should test out what parents are saying and respond back to practitioners 3 Checks on cases where other Local Authority (LA) are mentioned and if checks were completed with the LA 4 Checks on closed cases to see if threshold was appropriate 5 Duty social worker put into place with business support to field telephone calls 6 Business Support staff to complete case notes each time a professional call on a case and case note alert to the management team to review new information. Waltham Forest Housing has an action plan in place 1 The placement officer must review the information on the appropriate system, Northgate/Jigsaw. Any vulnerabilities, MASH referrals, Social Services Referrals, must be recorded on the Assessment Needs Form (ANF)- A note must be added to the system to confirm the review 2 Any issues that are identified as conflicting/incorrect must be brought to the attention of the relevant caseworker for remedy. 3 The client with the assistance of an officer if necessary, must undertake completion of the Assessment Needs Form (ANF). The information provided on the form must be crosschecked with the client. 4 The household composition must be confirmed, full names, dates of birth, medical needs. Details of any supporting services must be recorded, name and contact details of the supporting officer/worker. 5 Review the details of the property on the void’s spread sheet 6 Contact the supplier, confirm the property size, how many people it is intended to accommodate 7 Confirm that a cot will be made available once the booking is confirmed to any household that has a baby and requires a cot 8 If a household refuses a cot, the officer must update Northgate/Jigsaw/TA Checklist with the household’s reason/s for refusal, e.g. they have their own cot. 9 Any referring agencies should be advised of the placement once the booking is complete if necessary. 24 10 Details for the managing agent and the TA team for the purpose of on-going contact should be given to the household at the booking. Health Visiting Services have completed a health development action plan, which focuses on 1 Record Keeping 2 Use of DASH in assessing Domestic Abuse 3 Escalation process 4 Caseload weighting and Case management 25 Glossary BRAG ratings definitions o Red: There is a potential child protection issue (e.g. serious injury to the child). Requires immediate action, and information from MASH navigators is expected within 2 hours. o Amber: There are significant concerns, but immediate action is not required (e.g. on-going domestic violence issues in the household). Requires information from MASH navigators within 6 hours. o Green: There are concerns regarding a child's wellbeing, but these do not meet statutory requirements (e.g. poor school attendance). Requires information from selected MASH navigators within 24 hours. o Blue: There is no safeguarding concern and the issue can be dealt with by a Universal service. No MASH response required. Advice or referral to a Universal service may be provided. DRM –Daily Risk Management Meeting Waltham Forest -The DRM meeting provides the framework to allow regular information sharing and action planning to safeguard high risk cases being received into Waltham Forest’s MASH front door. Guideline-Practice guidance is a tool for reflective practice and identifies the best of current practice using current research. IAPT - services provide evidence-based psychological therapies to people with anxiety disorders and depression. MERLIN - is a database run by the Metropolitan Police that stores information on children who have become known to the police for any reason. One Panel - The One Panel is Waltham Forest’s Think Family forum, which takes referrals for local or statutory reviews and makes recommendations against the statutory criteria for safeguarding adult reviews and local reviews/national review (previously known as serious case review) to the relevant board chair. Professional Curiosity- the capacity and communication skill to explore and understand what is happening with a family rather than making assumptions or accepting them at face value. Protocol- Protocols (and procedures) are sets of rules – they are MUST DO’s. Post-Traumatic Stress Disorder (PTSD) is a type of anxiety disorder triggered by traumatic events in a person’s life such as real or threatened death, severe injury or sexual assault. 26 Section 17 Children Act 1989 -(1) It shall be the general duty of every local authority (in addition to the other duties imposed on them by this Part)— (a) to safeguard and promote the welfare of children within their area who are in need; and (b) so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. VAWG Violence Against Women and Girls |
NC52807 | Siblings J and K (aged 16-years-old and 12-years-old) reported missing in September 2021.The referrer expressed concerns about their safety, stating their father had taken the children from the UK and they might be entered into a forced marriage. Learning includes: practitioners' confidence and skills in recognising the warning signs for forced marriage and how to respond; understanding how Forced Marriage Protection Orders (FMPOs) should be used and which agency should take the lead in making an application; raising awareness of both the issue and the warning signs of forced marriage with young people in a school environment; raising awareness of the support that is available from the national Forced Marriage Unit; and ensuring widespread understanding of the 'One Chance Rule' - that practitioners may only have one chance to speak to a potential victim and therefore one chance to safeguard the child. Learning will be developed into formal recommendations. Action taken includes: children's social care to lead on FMPO applications related to children; training for the social care workforce to ensure all workers have an up-to-date understanding of the risks and indicators for forced marriage; a whole system transformation in the local authority to prevent multiple handovers; improved processes by police within the Force Control Centre to enhance safeguarding and ensure warning markers are accurate; education safeguarding leads to ensure warning signs of forced marriage are increased across education settings; and steps taken by the Intensive Prevention Service to disseminate national guidance on forced marriage and raise the profile of the Forced Marriage Unit.
| Title: Recognising and responding to warning signs for forced marriage: the importance of the ‘One Chance Rule’: local child safeguarding practice review of J and K. LSCB: Staffordshire Safeguarding Children Board Author: Zoë Cookson Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Recognising and responding to warning signs for forced marriage: the importance of the ‘One Chance Rule’ Local Child Safeguarding Practice Review of J and K Independent Lead Reviewer: Dr Zoë Cookson December 2022 1 Contents 1. Introduction and Executive Summary 2 1.1 Purpose of this Review 2 1.2 Overview of Case 2 1.3 Definition of Forced Marriage 3 1.4 Summary of Learning from this Review 3 2. Methodology and Process 5 3. Analysis and Identification of Learning 6 4. Recognising the warning signs 6 4.1 The warning signs for forced marriage 6 4.2 Survey results: knowledge and understanding of forced marriage 7 4.3 Knowledge and understanding within individual agencies 8 4.4 Warning signs in this case 8 5. Responding to the warning signs 10 5.1 Survey results: Confidence in responding to forced marriage 10 5.2 Initial response to warning signs in 2018 10 5.3 A missed opportunity to stop the children leaving the country 12 5.4 Forced Marriage Protection Orders (FMPOs) 12 5.4.1 About Forced Marriage Protection Orders (FMPOs) 12 5.4.2 No application for an FMPO in 2018 13 5.4.3 Application for a retrospective FMPO in 2021 14 5.4.4 Knowledge and understanding of FMPOs in Staffordshire 15 5.5 Limitations on action once children have left the country 15 5.6 The role of culture and religion 16 5.7 Responding to Warning Signs: Good Practice 17 6. Through the child’s eyes 18 6.1 Capturing the voice of the children 18 6.2 Disguised Compliance 19 6.3 The impact of Covid-19 restrictions 19 7. Multi-agency working and communication 20 7.1 Multi-agency working and communication 20 7.2 Closing the Case 21 7.3 Multi-agency working and communication: Good Practice 22 8. Advice, Guidance and Training 22 8.1 Understanding the role of the national Forced Marriage Unit (FMU) 22 8.2 Survey results: Guidance and Training in Staffordshire 23 8.2.1 Survey results: guidance 23 8.2.2 Survey results: training 23 8.3 Challenges to upskilling staff where there are capacity constraints and workforce instability 24 9. Actions Taken to Date 25 10. Conclusion 27 10.1 Developing the Recommendations 28 2 1. Introduction and Executive Summary 1.1 Purpose of this Review This purpose of a child safeguarding practice review is to explore how practice can be improved to prevent, or reduce the risk of, a repeat of similar incidents. Reviews seek to understand both what happened and whether this reflects systematic issues in either policy or practice that could be addressed to better safeguard children. A review is not designed to hold individuals or organisations to account.1 1.2 Overview of Case 1.2.1 Reported Missing and Risk of Forced Marriage Siblings – J (aged 16) and K (aged 12) – were reported missing to Staffordshire Police in September 2021. The referrer expressed concerns about their safety, stating their father had taken the children from the UK and the referrer believed they might be entered into a forced marriage. Police checks confirmed that the two siblings had boarded a plane one month earlier and had subsequently travelled onwards to another country and remained outside of the UK. Multi-agency action was initiated to attempt to retrieve the children, including a Forced Marriage Protection Order. At the time of concluding this review in December 2022 the Forced Marriage Protection Order had been unsuccessful at persuading father to return the children to the UK. It was not known whether the children had been married. However, following liaison with agencies, both children returned to the UK in January 2023. There is no evidence that they have been married. 1.2.2 Prior Agency Involvement J (then aged 13) and K (then aged 9) first came to the attention of agencies in May 2018 when father’s abusive and violent behaviour towards the children was reported. The referrer also said that father was planning to take the children abroad over the summer and the referrer suspected the intention was for J to be married. This led to a Section 47 enquiry and the children being removed from father’s care via an Emergency Protection Order. The children were initially placed in foster care and then with their aunt and uncle. (Mother died in 2017.) A subsequent assessment found significant gaps in father’s parenting capacity. There was no mention of forced marriage in this assessment. Father engaged well with parenting work and the children returned to his care under Placement with Parents regulations in March 2019. Progress appeared to be positive and a Children in Care Review agreed to revoke the Care Order in December 2019: due to Covid restrictions this did not take place until July 2020. No concerns were identified in the period the children were registered as Children in Need and their case was closed in January 2021. 1 There are other processes for this purpose including employment law, disciplinary procedures, professional regulation and – in exceptional cases – criminal proceedings. 3 1.3 Definition of Forced Marriage2 A forced marriage is a marriage that takes place without the full and free consent of both parties. Force can include physical force, as well as being pressurised emotionally, being threatened or being a victim of psychological abuse. Forced marriages are not the same as arranged marriages. In an arranged marriage families take the lead in selecting a marriage partner but the couple have the free will and choice to accept or decline the arrangement. Forced marriage is recognised in the UK as a form of domestic or child abuse and a serious abuse of human rights. 1.4 Summary of Learning from this Review NOTE: At the time of concluding this review in December 2022, the children remained outside of the UK and it was not known whether they had been married. The children returned in January 2023 and there is no evidence that either has been married. While this case has not resulted in a forced marriage, the learning identified by examining the case remains relevant and should be considered in order to ensure children in Staffordshire are safeguarded in the future. Recognising the Warning Signs • Many warning signs for forced marriage were evident in 2018 and identified by practitioners at the time. Unfortunately, the issues around forced marriage were lost when the case transferred to another social work team after the Interim Care Order was obtained. Indeed, social care staff involved in taking the case forward were not aware of any warning signs for forced marriage. • Given practitioners frequently have ‘one chance’ to prevent forced marriage this is concerning. There is a need to ensure all practitioners in Staffordshire understand the warning signs and indicators for forced marriage. It is equally important that warning signs are appropriately logged and information shared between teams and agencies so all practitioners remain vigilant about potential risks. Responding to warning signs • There was a missed opportunity to apply for a Forced Marriage Protection Order (FMPO) in 2018. A confusion over “threshold” requirements demonstrates that some practitioners in Staffordshire do not understand what is required to obtain a FMPO and do not understand how they work. Whilst it is probably not practical for every practitioner to be knowledgeable about the detail of this uncommon area of practice, it is crucial that all have a basic understanding and know how and where to seek accurate advice. • The decision to use an Emergency Protection Order (EPO) to address both the issue of physical/emotional abuse and forced marriage allowed the concerns around forced marriage to be lost, especially as these issues were not explicitly recorded in any of the formal case documentation. The Staffordshire Safeguarding 2 This definition is taken from government guidance: https://www.gov.uk/government/publications/forced-marriage-protection-orders-fl701/forced-marriage-protection-orders 4 Children Board multi-agency guidance on forced marriages that has been referenced to support the use of an EPO was withdrawn by the Board in November 2021 but is still being used by children’s social care. Children’s social care are developing their own guidance with the Safeguarding Board now signposting practitioners to best practice that sits within national guidance. • A more formal and robust approach needs to be agreed within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, this should be children’s social care. • Historical information about potential risks around forced marriage was not considered when children’s social care responded to an enquiry from Greater Manchester Police via the MASH (multi-agency safeguarding hub). Case files were reviewed but these did not explicitly record concerns around forced marriage. This was a missed opportunity to stop the children travelling in 2021. This also highlights the importance of good case recording. • There was a lack of appreciation amongst partner agencies of the one chance rule (see section 5.5). The lengthy discussions regarding possible ways to retrieve the children demonstrates the commitment of practitioners from all agencies to safeguarding the children. However, it also reveals a lack of understanding of the harsh reality that very little can be done once children have left the UK. The importance of prevention – and the implications when this fails – needs to be highlighted to practitioners. Through the child’s eyes • In 2018, the children told practitioners that they did not want to travel to the country of father’s origin. They were not asked whether this was still the case in 2020/21 and were not given the opportunity to express a view of who should have care of their passports. Where historical concerns have been raised, there would be benefit in exploring the child’s views on these before a case is closed. • It would also be worth considering how to raise awareness of the warning signs and indicators for forced marriage with children in schools so they know what to watch for and are confident to share any concerns with teachers. Multi-agency working and communication • Representatives from the children’s schools and from health do not appear to have been invited to Strategy meetings and did not, therefore, have the opportunity to contribute. The rapid application for an Emergency Protection Order also meant that the normal multi-agency child protection processes were effectively skipped and the children moved directly into the looked after system. In Staffordshire, other agencies can contribute in writing to Child In Care Reviews but are not invited to attend meetings about looked after children. This limited opportunities for multi-agency discussion in this case. Children’s social care are planning to hold meetings with other agencies about looked after children in between Child In Care reviews and this was welcomed by agencies participating in this review. • The issue of forced marriage was not revisited at the time of the discharge of the Care Order or the closure of the case. Where historical concerns have been raised, it is crucial that these are revisited before a case is closed. 5 Advice, Guidance and Training • The experience of this case would suggest that there is a need to raise the profile of the national Forced Marriage Unit (FMU) with safeguarding partners in local areas. Advice from the FMU’s helpline regarding whether the children were likely to be at risk of forced marriage (based on the evidence available at the time) may have led practitioners to be more professionally curious and prompted them to pro-actively follow up risks of forced marriage alongside the serious abuse and neglect that the children were suffering. • However, any actions to raise the profile of the FMU in local areas needs to be very clear regarding the Unit’s remit. Staffordshire’s experience demonstrates the importance of making safeguarding practitioners aware of the limitations of what can be done once children have left the country. • At a local level, relevant guidance and training is needed to ensure all practitioners in Staffordshire are able to recognise the warning signs for forced marriage and are confident in how they respond. This can only be effective if practitioners have the time to both attend training and to reflect on potential warning signs when they encounter them. 2. Methodology and Process 2.1 A systems-based approach, consistent with Working Together to Safeguard Children 2018, was adopted for this case. Throughout the review efforts have been made to understand how actions and events were perceived at the time and to avoid hindsight bias. 2.2 An Independent Reviewer (Dr Zoë Cookson) was appointed to lead the review process, chair all relevant meetings, facilitate the Practitioner Learning Workshops and author the final report. She was supported by a Review Team made up of local safeguarding practitioners from key agencies and representatives from the national Forced Marriage Unit. 2.3 The Review Team agreed the review would cover the period 1st May 2018 to 31st March 2022. This timeframe covers two distinct time periods: • the period from when J and K first came to the attention of agencies to the date when they were reported missing, and • the period where agencies sought to take action after the children left the UK. 2.4 The review drew on the initial scoping information submitted by agencies to the Rapid Review alongside individual agency analysis of learning related to the agreed Key Lines of Enquiry, and a multi-agency chronology of events. 2.5 A short survey was distributed to practitioners involved in safeguarding across Staffordshire3 in order to ascertain their knowledge and confidence of issues around forced marriage. 297 responses were received. This survey provides a snapshot and useful insight into the knowledge and confidence of the workforce around this unusual area of practice. However, it should be noted that there is a risk of bias as practitioners chose whether they wished to respond. There was also particularly high response rate from schools and a disappointingly low 3 The survey was cascaded via the representatives on the Review Team. The closing date was deliberately chosen to be before it was widely known that this review was taking place. 6 response from the local authority. The responses from the local authority were examined separately and it was found that responses to all questions largely mirror the overall survey responses. The only variance was the response to the question around awareness of forced marriage guidance, where 33% of overall respondents to the survey replied they were not aware of forced marriage guidance and 59% of the local authority respondents said they were not aware of such guidance. 2.6 Two reflective Practitioner Learning Workshops were held with frontline practitioners. The first sought to obtain first-hand experience from those working with the children and their family, and to also understand the context that practitioners were working within. The second gave these frontline practitioners the opportunity to comment on the emerging learning and explore the contextual factors in more depth. 2.7 The Independent Reviewer completed separate interviews with the Police and with representatives from the Forced Marriage Unit. 2.8 When the review commenced the older siblings of J and K were approached and invited to participate in the review. No response was received from them. When the children returned to the UK in January 2023, all members of the family were invited to participate in the review. They declined to be involved apart from one of the siblings. The Independent Reviewer subsequently had a brief telephone conversation with this sibling of J and K. 2.9 While it was not possible to engage with the children, the review did consider the extent to which their voice was heard by the practitioners interacting with them. 3. Analysis and Identification of Learning 3.1 Introduction Despite being an uncommon area of practice, it is crucial that practitioners across agencies are able to both recognise the warning signs for potential forced marriage and are confident how to respond. The review of this case reveals a varying level of knowledge and confidence in the workforce in Staffordshire. There are examples of good practice but some evidence of a lack of understanding of both the warning signs and the tools available to respond to potential forced marriage. This includes a misunderstanding of Forced Marriage Protection Orders (FMPOs) and a failure to appreciate (before this case) the limitations on the actions that can be taken once children have left the country. While this may paint a bleak picture, in responding to this review, many agencies have openly acknowledged the lack of knowledge and confidence amongst their staff and have displayed an eagerness to empower and upskill staff. Indeed, many actions have already been implemented to address this. 4. Recognising the warning signs 4.1 The warning signs for forced marriage The government’s multi-agency guidance on forced marriage4 lists a number of warning signs and indicators for forced marriage – these are summarised in the table 4 Foreign, Commonwealth and Development Office / Home Office ‘Multi-agency statutory guidance for 7 overpage.5 The guidance is clear that, whilst the factors set out in this diagram may be an indication that someone is facing forced marriage, it should not be assumed that it is a forced marriage simply on the basis that someone presents with one or more of these warning signs. These signs may indicate other types of abuse that will also require a multi-agency response, or in some cases they may indicate other issues. Summary of warning signs and indicators of forced marriage 4.2 Survey results: knowledge and understanding of forced marriage 76% of respondents (226 individuals) to the forced marriage survey conducted for this review felt they knew what warning signs and indicators to look for in relation to forced dealing with forced marriage and Multi-agency practice guidelines: Handling cases of forced marriage’ (Updated 28 July 2022) 5 These tables are taken from the multi-agency training on forced marriage delivered via the Virtual College. 8 marriage. However, when asked about awareness of the ‘one chance’ rule, this dropped to just 27% (79 individuals). Given the high proportion of respondents reporting knowledge of warning signs, it is slightly surprising that roughly the same number – 73% (218 individuals) – said they were not aware of the related ‘one chance’ rule. The implications of this, and the ‘one chance’ rule, is considered later in this report. 4.3 Knowledge and understanding within individual agencies As part of this review, agencies considered the knowledge and confidence of their workforce when encountering potential forced marriage. While some staff were found to be knowledgeable on the subject, often because they worked in specific roles or particular geographical areas, many other staff had limited or no understanding. All agencies identified that action needs to be taken to ensure all practitioners are confident responding to issues around forced marriage. 4.4 Warning signs in this case A number of the warning signs and indicators for forced marriage were evident in 20186: • Concerns about forced marriage were raised at the time of the initial referral in May 2018. (It is worth noting that this is recorded differently by agencies: Police records state the referrer was “concerned that father is planning to marry off older sibling”, while social care records report him saying “father was planning to take them [the children] overseas in August 2018 but he didn’t know why”). • Father had plans to take the children to the country of his origin in the summer. • Father was reported to have purchased a valuable set of jewellery for the children – potentially a wedding set – and had arranged for the children to have ears pierced. • The original referral noted that the children were not allowed contact with their family and were not permitted to go out. 6 Other warning signs and indicators are evident in the information available to this review (such as a statement in 2021 that father disliked “westernised” culture): these have not been included as it is not clear whether this was known in 2018. 050100150200250300350Awareness of 'one chance' ruleKnowledge of warning signsKnowledge and understanding of Forced MarriageYesNo9 • Father was known to be applying for passports for the children. (He later denied he had received these and, when his possession was confirmed, was reluctant to hand these over). • There is a family history of making marriage matches at a young age. • At a Strategy discussion in August 2018, concerns were noted about the attitudes of the children’s uncle and aunt, who were Regulation 25 foster carers for the children, to forced / arranged marriage. (It is worth noting that education and health representatives were not invited to join the Strategy meeting and were not, therefore, involved in these discussions). When interviewed at school in May 2018 about the reported safeguarding issues, neither of the children mentioned potential forced marriage. However, this is not surprising as it is unlikely the children would have been told if this had been father’s intention. The duty social worker who responded to this case has since left the local authority so it is not possible to establish which warning signs they identified. However, at the time of the referral, this duty social worker is reported in the records of several agencies to be actively following up potential forced marriage. The Police also identified the risk for forced marriage and followed the associated protocols (discussed below). The actions by the duty social worker to follow up issues around forced marriage led to internal discussions around forced marriage within children’s social care (discussed in the next section). Unfortunately, the issues around forced marriage were lost when the case transferred to the Court and Care Planning team. The work of all subsequent social care practitioners, including the allocated social worker, was focused exclusively on the physical abuse and emotional harm the children were suffering. These practitioners were not aware that any warning signs for forced marriage had been identified in this case and were not informed of the previous conversations around forced marriage. Some of the warning signs are referenced in the formal parenting assessment but they were not recognised as indicators of potential forced marriage and the social worker responsible for this assessment was categorical that forced marriage was not considered. Recognising the Warning Signs - Learning Many warning signs for forced marriage were evident in 2018 and identified by practitioners at the time. Unfortunately, the issues around forced marriage were lost when the case transferred to another social work team after the Interim Care Order was obtained. Indeed, social care staff involved in taking the case forward were not aware of any warning signs for forced marriage. Given practitioners frequently have ‘one chance’ to prevent forced marriage this is concerning. There is a need to ensure all practitioners in Staffordshire understand the warning signs and indicators for forced marriage. It is equally important that warning signs are appropriately logged and information shared between teams and agencies so all practitioners remain vigilant about potential risks. 10 5. Responding to the warning signs 5.1 Survey results: Confidence in responding to forced marriage When asked about their current confidence when dealing with a presenting or perceived concern around forced marriage, the majority of respondents selected the middle score (3). However, more reported relatively low confidence than reported high confidence. 5.2 Initial response to warning signs in 2018 The risk of a forced marriage was identified at the time of the initial referral. Despite this being an uncommon area of practice, some frontline practitioners were initially pro-active in their response. In the joint action that followed the referral, the Police followed Karma Nirvana protocols which included taking fingerprints, photographs and DNA for ID purposes, and placing an alert onto the Police National Computer (PNC). Records of the schools attended by J and K respectively demonstrate that potential risks around forced marriage were effectively shared with key partners. The primary school recorded an allegation that father was planning to take the children overseas in the summer holidays for older sister to be married. The secondary school recorded that the social worker had shared concerns regarding father buying the children a lot of gold jewellery and planning to take them abroad in the holidays. Both schools were, therefore, able to watch for warning signs. Cafcass were also sighted on the possibility of the eldest girl being at risk of forced marriage, noting at the time that father had applied for passports and purchased jewellery despite both children indicating they did not want to travel to the country of father’s origin. An initial Strategy discussion took place between the duty social worker and the police representative in the MASH (multi-agency safeguarding hub), with a follow up Strategy discussion attended by the duty social worker, social care team manager and three 327913344902040608010012014012345Confidence responding to Forced Marriage issues (1 being low and 5 high)11 representatives from Staffordshire Police CID.7 The outcome was an agreement to apply for an Emergency Protection Order (EPO). This decision to apply for an EPO was in line with the with local guidance on forced marriage in place at the time which stated that: “If a child is in immediate danger, it may be necessary to consider removing them from the family home by means of Police Protection Powers or an Emergency Protection Order.”8 However, it is not possible to establish whether forced marriage was discussed at the Strategy meeting. There is no explicit reference to forced marriage in the notes of the meeting and the rationale for action refers to “disclosures of physical harm, verbal and emotional abuse” and a “lack of protective factors within the home”. An additional threat is noted of “children being taken overseas permanently with father”. If forced marriage was considered as part of these Strategy discussions (which appears likely), the fact that it was not mentioned in the formal records had significant consequences for the case. The initial focus on forced marriage was rapidly overshadowed by immediate safeguarding concerns for the children’s welfare based on the significance of the physical abuse and emotional harm the children were suffering. Indeed, key social care practitioners, including the allocated social worker, were not aware of any previous conversations around forced marriage and did not know that the police had followed Karma Nirvana protocols due to potential concerns. These practitioners pointed out that there was no mention of forced marriage in either of the children’s files. Although social care were no longer following up issues around forced marriage, the Cafcass Guardian was not satisfied by father’s assurances that he had no plans to take the children to the country of his origin. The Guardian, therefore, recommended that the children’s passports be held by the local authority for the duration of the time that the children remained subject of the Care Order. This action ensured that the risks in relation to forced marriage were managed during the period the children were in care. The EPO and subsequent Interim Care Order meant that the normal multi-agency child protection processes were effectively skipped in order to protect the children. An unanticipated result of this was that inter-agency communication about the children shifted to focus solely on the looked after process, communication with the police stopped, and no further consideration was given to issues around forced marriage (see sections 5.4.2 and 7 below). A breakdown in communication within the police also meant that some police officers were left believing that issues around potential forced marriage were still being 7 The notes of the Strategy meeting suggest that contact was also made in advance with the duty Safeguarding Nurse. The formal record of the Strategy meeting further states that “agencies such as education have been contacted to inform the strategy discussion and this is to be recorded” but it has not been possible to verify or establish the content of any conversations. 8 Staffordshire Safeguarding Children Board (joint guidance with Stoke-on-Trent Safeguarding Children Partnership), “Guidance for children who may be particularly vulnerable: forced marriages”. This guidance was removed from the Safeguarding Board website in November 2021 following a wholescale review of its multi-agency policies, procedures and guidance. This considered feedback from practitioners, data on the number of people accessing specific guidance, and capacity within the business team to ensure documents were relevant and up to date. The Board now signpost practitioners to best practice contained within national guidance on forced marriage. Children’s social care have chosen to keep this local guidance and have transferred it to their internal document library. They are, however, in the process of developing their own guidance. 12 explored. This led to some confusion over whether or not a Forced Marriage Protection Order was in place when the issue arose again in September 2021 when the children were reported missing. 5.3 A missed opportunity to stop the children leaving the country The PNC markers placed on the children’s records following the initial referral in 2018 were still in place when the children left the country in 2021.9 These alerts were picked up in August 2021 by police at Manchester Airport who contacted Staffordshire Police with information that father and the children were booked on a flight to a country outside of the UK. Due to the imminent departure of the flight there was very little time to establish the full facts. However, the Staffordshire MASH confirmed that the case had been closed in January 2021 and there had been no concerns since. The social care files were reviewed but, as noted above, these did not explicitly mention forced marriage. Warning signs for forced marriage are mentioned in the file but, as with the parenting assessment, these were not recognised as such. No consideration was, therefore, given at this stage to the historical concerns around forced marriage that had led to the markers being placed on the PNC. However, children’s social care are confident that the assessment and evidence to support the ending of the Care Order would have meant that there was insufficient evidence to prevent the children travelling. Police and social care in the MASH agreed that the markers should be removed. A request was made to speak to the family around their intentions and confirm there were no issues from the children. This request to speak to the family was, however, purely precautionary as there were no recorded concerns at the time. This conversation did not happen: Greater Manchester Police have a large volume of requests and need to justify intervention, especially if this involves holding up a flight. The markers had been removed so it was assumed there was no reason to speak to the children. If the markers had still been in place, Greater Manchester Police would have held up the flight in order to speak to the children. A Forced Marriage Protection Order (FMPO) would have prevented the children being taken out of the country and made this conversation unnecessary. 5.4 Forced Marriage Protection Orders (FMPOs) 5.4.1 About Forced Marriage Protection Orders (FMPOs) A Forced Marriage Protection Order (FMPO) is unique to each case and contains legally binding conditions and directions that seek to change the behaviour of a person or persons trying to force someone into marriage. The aim of the order is to protect the person who has been, or is being, forced into marriage. The court can make an order in an emergency so that protection is in place straightaway. 9 There was an email exchange about the markers in October 2019 in which children’s social care responded to a query from the Police whether the markers were still required. In another demonstration of the fact that issues around forced marriage had been dropped, the social care team manager confirmed no risks had been identified with the girls and the markers could be removed. The Police Officer confirmed receipt of this message. However, due to an oversight, the markers were not removed. 13 Someone who disobeys a court order can be sent to prison for up to 2 years for contempt of court, while breach of a Forced Marriage Protection Order is also a criminal offence with a maximum sentence of 5 years’ imprisonment. The FMPO does not criminalise anyone unless it is breached. A FMPO is bespoke to the circumstances and each case is considered on its own merits. There is no national threshold and, although judges have different perspectives, the threshold they accept tends to be low. A description of the warning signs with a rationale for concerns is often sufficient. Hearsay is acceptable. An applicant is expected to explain exactly what is requested and why. For example, removal of passports to prevent travel overseas. There appears to be limited understanding of Forced Marriage Protection Orders among many agencies and practitioners in Staffordshire.10 This is evident in both the decision not to apply for a FMPO in 2018 and the delays obtaining a retrospective FMPO in 2021. 5.4.2 No application for an FMPO in 2018 In response to the warning signs identified by the duty social worker, children’s social care sought legal advice about a FMPO. The evidence for a FMPO was considered: given the age of the children, and the fact that the primary referral related to physical abuse, advice was given that the quickest way to safeguard the children would be to use an Emergency Protection Order (EPO). As noted earlier, the use of an EPO was agreed at Strategy meetings between children’s social care and the police and this was in line with guidance at the time. The recording of the decision not to progress a FMPO was poor and created misunderstanding within a number of agencies. Formal police records were not amended to reflect the discussions at the Strategy meeting to apply for an EPO rather than a FMPO. Police records were, therefore, left stating that children’s social care were going to consider a FMPO and there was no further action for the police as no crime had been committed. This created some confusion when files were reviewed in 2021 following renewed concerns around forced marriage. The decision around a FMPO does not appear to have been shared with the girl’s schools. Records of the primary school that K attended were left noting an intention to apply for a FMPO, although they state the Police were going to lead the application. Children’s social care records did not make any reference to risks around forced marriage. The EPO was seen as a way of preventing possible flight risk and, to support this, father was required to handover the children’s passports and any identification documentation. However, the rationale for this was not recorded. Based on the information in the case files, the allocated social worker from the Court and Care Planning team understood that the requirement to handover the children’s passports was to prevent father taking the children out of the country while the local authority had 10 Those involved in this case, and this review, do now have a much better understanding. Some steps have already taken place to increase understanding in the workforce with other actions planned (see section 9 of this report). 14 concerns about his parenting. At no time was this social worker given any indication that the action had been taken in response to issues around forced marriage. All knowledge of the previous discussions around forced marriage appear to have ended at the point the Interim Care Order was obtained the case handed over to another social work team. Changes have been made within children’s social care that should prevent this happening in future. In October 2021, the local authority completed a whole system transformation that prevents multiple handovers. Under these new arrangements, the social worker who initiates the proceedings retains responsibility and, thereby, retains knowledge of the issues in the case. While this is a positive development, it does not replace the need for good case recording. The EPO did effectively safeguard the children from being taken abroad until after the Care Order had been discharged. However, the use of an EPO rather than a FMPO offered no protection when the original concerns about forced marriage were lost within the social care system. A FMPO with conditions that prevented overseas travel could have prevented the children being taken abroad in 2021. 5.4.3 Application for a retrospective FMPO in 2021 When the issue of potential forced marriage of J and K arose again in 2021, it took two months to obtain a FMPO. This suggests a lack of understanding of the options to tackle forced marriage, including FMPOs. The national Forced Marriage Unit were approached on the day of the 2021 Strategy meeting and they advised Staffordshire practitioners to apply for a retrospective FMPO. Although this would have no legal status outside of the United Kingdom, there was a hope that it would act as a lever to persuade father to return the children. There was some reticence to do this due to concerns that a FMPO would place the children at heightened risk of harm. Instead, practitioners within Staffordshire tried to explore alternative actions to retrieve the children and the Police sought external advice from an independent specialist consultant. There were conversations about ‘children and families across borders’ and ‘international social services’. There was an initial belief that the Foreign, Commonwealth and Development Office would be able to complete ‘safe and well’ checks on the children, and a request for the British High Commission to intervene to retrieve the children.11 It took time to establish that none of the options discussed were practical. The reality is that father has not broken the law by taking the children out of the UK as he has parental responsibility. The situation would be different if the children were adults as they could say they were being held against their will. The children were made Wards of Court on 10 November 2021 and a FMPO was finally applied for (by children’s social care) and granted on 19 November 2021, almost two months after the children were reported missing. Challenges were then experienced serving the notice on father. On 16 December the High Court granted the order could be served by WhatsApp. Further confusion followed about how to implement the levers in the FMPO. For example, one of the main levers identified was to prevent father accessing money and his assets in the UK but there were challenges establishing what these are. This was due in part to misunderstanding 11 The Forced Marriage Unit had to explain that the British High Commission do not carry out welfare checks and any attempts to do so would be of limited value and could put the girls at risk. 15 of individual agency roles and the legal processes that they have to follow to obtain information. For example, as there was no criminality involved, the Police had to obtain a court order to identify what assets father has. 5.4.4 Knowledge and understanding of FMPOs in Staffordshire Feedback and informal conversations during this review revealed a lack of understanding of FMPOs amongst some staff in Staffordshire. There are email records from police officers in 2018 stating that they felt there was sufficient evidence for a FMPO but the officers attending the Strategy meeting agreed an EPO. The legal advice to proceed with an EPO rather than a FMPO appears to have been around expediency and the fact that the primary concern was around the physical and emotional abuse the children were suffering. However, multiple participants in this review expressed a belief that a FMPO was not applied for in 2018 because “thresholds” could not be met. There are, in fact, no formal thresholds for FMPOs, and colleagues within the national Forced Marriage Unit believe it is likely that the warning signs identified at the time would have been sufficient for a judge to grant a FMPO. FMPOs were discussed at the Learning Event held for this review and none of the practitioners present had knowledge of the application process for FMPOs, their value or how they could be used. Children’s social care managers believe this cohort of practitioners are not representative of the social care workforce. They cite the fact that seven FMPOs have been obtained in Staffordshire since 2016, with the most recent being obtained in October 2020. The Rapid Review for this case also identified confusion over who is responsible for applying for a FMPO in Staffordshire. There appears to be an informal understanding that children’s social care will apply where a child is concerned and the Police will apply on behalf of adults. At the time of the Rapid Review, it was thought that this may have led to neither organisation acting. Further investigation has established that action wasn’t taken because it was agreed by social care and police that an EPO should be applied for. However, this does not remove the need – identified in the Rapid Review – for a more formal and robust approach regarding who will lead on FMPO applications when they relate to children. 5.5 Limitations on action once children have left the country Whilst working together closely and sharing information between agencies, there was considerable confusion over the attempts to retrieve the children in 2021 which led to the significant delay in obtaining the retrospective FMPO. As outlined above, this was due to the wish from all agencies to take action and the time it took for practitioners to fully appreciate the limitations on what can be done once children have left the country. The experiences of agencies trying – and failing – to find a solution to retrieve the children underlines the importance of taking action to prevent children from being taken out of the country in cases where there is a risk of forced marriage. It also highlights the importance of the ‘One Chance’ rule – that practitioners working with victims of forced marriage and honour-based violence may only have one chance to speak to a potential victim and thus they may only have one chance to safeguard the child.12 12 More information on this ‘One Chance’ rule is available in the Forced Marriage resource pack 16 In the case of J and K practitioners had more than one chance but these were lost. This resulted in two British children being potentially at risk in a foreign country and UK agencies having no powers to return them to the UK. 5.6 The role of culture and religion 5.6.1 Consideration of culture and religion in this case This review explored the workforce’s awareness of the impact of culture and religion and considered whether there is any evidence of cultural bias in this case. This included consideration of whether the desire to be culturally sensitive led issues to be overlooked.13 Practitioners working on this case were sighted on issues of culture and religion. For example, the Intensive Prevention Service recognised that father had not always resided in the UK and that English was not his first language. This – coupled with advice from the social worker – led to the inclusion of work around what is deemed appropriate and legal in the UK in terms of parenting. Wherever possible, parenting programmes were translated into father’s language. To ensure religiously aware practice, visits were also arranged to avoid prayer times. Social workers described how they were required to challenge behaviours that father considered normal (such as the children sharing the same bedroom as father and K sharing the same bed). However, these practitioners stated they were also mindful of the need to be considerate of cultural practices such as the family tradition of arranged marriages, prompting a discussion of the distinction between a forced and arranged marriage. There was a strong view from the social work practitioners that the use of a Forced Marriage Protection Order would have been disproportionate given the evidence available. This view was not shared by the Review Team. It is likely that the view of practitioners was shaped by their lack of understanding of FMPOs (see section 5.4.4). In written feedback after the Learning Event, several practitioners reflected on the need to be more inquisitive with families in order to better understand their culture and potential risks around forced marriage. This included a suggestion to formally explore past experiences of marriage within the family. 5.6.1 Consideration of cultural bias in the safeguarding workforce While issues of culture and religion were explored, there is insufficient evidence to conclude whether there was any cultural bias in this case, positive or negative. This prompted the Review Team to undertake a wider assessment of potential cultural bias in Staffordshire’s safeguarding workforce. Each member of the Review Team agreed to investigate and gather a range of evidence that enables senior leaders, managers, and designated safeguarding leads to test assumptions/perceptions of cultural bias in their organisation. The following questions were used as a starting point: • Is there any evidence of cultural bias in your organisation (conscious or unconscious)? 13 This form of cultural bias is summarised in the NSPCC Learning briefing ‘Culture and faith: learning from case reviews’ (June 2014) 17 • How have issues of cultural bias been examined in your organisation? • Are there processes/systems in place or have any actions been taken to mitigate systemic cultural bias? • Are there any examples of good practice? • Are there any potential barriers that would limit the organisations ability to provide evidence of the above? The evidence considered included: impact of supervision / peer support / case discussion; any dedicated audits examining this issue; case studies; feedback from children and young people; feedback from frontline practitioners; actions that have been taken to address potential cultural bias and any evaluation of these actions; impact of training; inspections / external peer reviews / QA visits etc; and evidence in minutes of meetings of issues around culture being actively considered. Various approaches were taken to completing this investigation. The exercise found that most organisations have comprehensive processes and procedures, including ways of mitigating cultural bias, and there was no evidence of systematic bias. In the strongest responses, there was a recognition of the fact that there will always be issues with individuals and most organisations had proactive ways of tackling this when it was identified. Many agencies also had specific initiatives around culture and religion, such as the national ‘Police Race Action Plan’ launched in May 2022 and the ‘Inclusion Schools’ programme delivered by North Staffordshire Combined Healthcare Trust on behalf of the Integrated Care System. The only issue worth noting (from both the investigation by Review Team members and conversations with practitioners in relation to this case), was where the diversity of the workforce was sighted as a factor that can prevent cultural bias. Having members of a team from a similar background, and working in an area where staff are familiar with cultural practices and religious traditions, can aid understanding. However, it must not be seen as sufficient to mitigate cultural bias. Indeed, there is a danger that this can give a false sense of security, creating a risk that important safeguarding concerns are overlooked. 5.7 Responding to Warning Signs: Good Practice ✓ The duty social worker shared the concerns regarding potential forced marriage with both the children’s schools and this was clearly recorded. ✓ Good practice is also evident in the way Police followed the force policy in relation to possible honour-based violence/forced marriage in 2018. Responding to the Warning Signs - Learning There was a missed opportunity to apply for a Forced Marriage Protection Order (FMPO) in 2018. The confusion over “threshold” requirements demonstrates that some practitioners in Staffordshire do not understand what is required to obtain a FMPO and do not understand how they work. Whilst it is probably not practical for every practitioner to be knowledgeable about the detail of this uncommon area of practice, it is crucial that all have a basic understanding and know how and where to seek accurate advice. The decision to use an Emergency Protection Order (EPO) to address both the issue of physical/emotional abuse and forced marriage allowed the concerns around forced marriage to be lost, especially as these issues were not explicitly recorded in any of the formal case documentation. The Staffordshire Safeguarding Children Board multi-agency guidance on 18 forced marriages that has been referenced to support the use of an EPO was withdrawn by the Board in November 2021 but is still being used by children’s social care. Children’s social care are developing their own guidance with the Safeguarding Board signposting practitioners to national guidance. A more formal and robust approach needs to be agreed within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, this should be children’s social care. Historical information about potential risks around forced marriage wasn’t considered when children’s social care responded to the enquiry from Greater Manchester Police via the MASH (multi-agency safeguarding hub). Case files were reviewed but these did not explicitly record concerns around forced marriage. This was a missed opportunity to stop the children travelling in 2021. This also highlights the importance of good case recording. There was a lack of appreciation amongst partner agencies of the one chance rule. The lengthy discussions regarding possible ways to retrieve the children demonstrates the commitment of practitioners from all agencies to safeguarding the children. However, it also reveals a lack of understanding of the harsh reality that very little can be done once children have left the UK. The importance of prevention – and the implications when this fails – needs to be highlighted to practitioners. 6. Through the child’s eyes 6.1 Capturing the voice of the children When concerns were initially reported in 2018 consideration was given to the fact that the children may be scared that father would find out and may not feel comfortable speaking to police and the social worker. Interviews were held at their schools without father present. Children’s social care responded quickly when the children confirmed abuse. The EPO to protect both children from further harm was based on their views. During their time in foster care, both children were spoken to regularly and seen on their own. The children’s views were used to inform the assessment and both children were very clear that they wanted to return to father’s care in 2020. Cafcass identified strengths in the engagement of both children in care proceedings. They were visited by their Guardian and by the solicitor in the initial proceedings. The children also had the opportunity to write a letter to the Judge on both occasions. The Intensive Prevention Service (IPS) reported that their practitioner regularly reviewed solution focused scaling with both children. Their views on family life were captured, specifically once they returned to father’s care. Both shared that their father was more relaxed, interacted better with them, and that they were enjoying family activities such as going shopping. The children were also less restricted with who they could see and were pleased to be able to have friends over. The IPS service confirmed that they spoke to the children on their own. However, this was only during visits to the family home. On reflection, they feel it would have been beneficial to also speak to the children outside of their home environment. 19 The children did not report any concerns about forced marriage but it was unlikely they would have known. One of the schools at the Learning Event suggested there could be benefits in highlighting the issues to pupils so they are mindful of warning signs and confident to share any concerns with teachers. Practitioners working with the family – including Social Workers, their Independent Reviewing Officer and the Intensive Prevention Service – all felt confident that the children’s views guided the decisions being made about their future. 6.2 Disguised Compliance The Learning Event explored issues of disguised compliance. (Where parents appear to co-operate with practitioners in order to allay concerns and stop professional involvement). The front-line practitioners who worked directly with father and the children, strongly felt that the progress made by father was genuine and that the children’s interactions with father that they witnessed was entirely natural. The fact that both the children’s Guardian and the court supported the revocation of the Care Order would indicate that they agreed with this view. These front-line practitioners pointed out that their work was focused on potential physical abuse and emotional harm to the children (as issues of forced marriage had not been shared with them and were not in the case files). They were not, therefore, looking at the issue of disguised compliance in relation to forced marriage. In his interview with the Independent Reviewer the older sibling stated that, while he could understand why the narrative fitted with forced marriage, this was not father’s motivation for taking the children overseas and forced marriage was never an issue. Practitioners who were not directly involved in the case have questioned whether the children really wished to be with father, suggesting father’s controlling behaviour may have influenced what they said. The Review Team strongly felt that the timing of events supported a case for disguised compliance around the issue of forced marriage: the children’s case was closed to children’s social care in January 2021 when Covid-19 travel restrictions were in place and these were not lifted for most destinations until summer 2021 when the children left the country. Social care managers have responded to this by pointing out that during 2019/20, prior to the decision to revoke the Care Order, there were four visits with both children where they were spoken to alone. Records show that the children were asked on every occasion if they had worries about anything and they said they did not. Cafcass noted a missed opportunity to speak to the children and their older siblings in 2020 when it was known to agencies that father was visiting family in the country of his origin. The issue of forced marriage was not revisited at the time of the discharge of the Care Order (see section 7.2 below). Cafcass noted another missed opportunity – to ask the children at this point who they felt would be best placed to have care of their passports. 6.3 The impact of Covid-19 restrictions The Covid-19 lockdown restricted the monitoring of the children and their relationship with father. The children were offered a school place but father declined. When the primary school queried this, father’s decision not to send K to school was supported by the social 20 worker. This decision meant that Cafcass were only able to see the children at home where father was present. GP and Out of Hours services were also operating remotely using telephone consultations. Social work contact was remote and the last statutory review was held virtually using Microsoft Teams. The children weren’t seen in person and were instead on the video call along with their father. The social worker reported that the children were as active in their participation as usual. However, this reliance on remote contact significantly limited the children’s opportunity to express any concerns or dissent. (Although, there is no evidence that they had concerns or dissenting views). The court hearing was adjourned more than once due to Covid. This caused a considerable delay in terms of permanency for the children but may have had the unanticipated consequence of protecting the children from being taken overseas. There is also one example of the pandemic affecting training opportunities. Twenty practitioners from children’s social care had been booked to attend a national Forced Marriage Conference in July 2020. It was intended that these staff would become practice champions for forced marriage in the service. Covid-19 restrictions meant the conference was cancelled. Through the child’s eyes - Learning In 2018, the children told practitioners that they did not want to travel to the country of father’s origin. They were not asked whether this was still the case in 2020/21 and were not given the opportunity to express a view of who should have care of their passports. Where historical concerns have been raised, there would be benefit in exploring the child’s views on these before a case is closed. It would also be worth considering how to raise awareness of the warning signs and indicators for forced marriage with young people in schools so they know what to watch for and are confident to share any concerns with teachers. 7. Multi-agency working and communication 7.1 Multi-agency working and communication There was good initial sharing of information between the police, children’s social care and the children’s schools about the potential risks around forced marriage. There are also good examples of information sharing between social care and the schools during the period the children were subject to the Care Order. The schools raised their concerns as they occurred and escalated absences in a timely way. In August 2018, this led to a Strategy meeting to discuss father trying to speak to, and photograph, K outside school when his contact was supposed to be via phone. However, the schools do not appear to have been invited to attend the Strategy meeting.14 14 Notes from the social care team manager suggest that education were consulted in advance of Strategy meetings but there are no formal records on file. 21 Inter-agency information sharing during the attempts to retrieve the children in 2021 appears to be good, despite the confusion about the processes and actions that could be taken. There were, however, some significant gaps in inter-agency communication and information sharing. For example, the GP was aware they were looked after children from hospital records rather than formal notification.15 The GP did not know the children had been reported missing until the Designated Nurse requested information for the Rapid Review. Information had not been shared with the GP and he was not invited to Strategy discussions. The GP knew the family well and could have provided an insight into J’s health needs. In terms of the specific issue of forced marriage, there was a significant breakdown in communication following the Strategy decision to apply for an EPO rather than a FMPO (see section 5.4.2). The EPO and Interim Care Order meant that the normal multi-agency child protection processes were effectively skipped in order to protect the children. The move direct to an EPO moved the children into the looked after process, limiting multi-agency involvement. In Staffordshire Child In Care Reviews are attended by the child, parents, foster carer and IRO. The focus is on the review of the care plan and whether the placement is meeting the child’s needs. Other agencies can contribute to the report but they do not attend. Other partners questioned this at the Learning Event as they are active participants in equivalent meetings in other areas. For example, given their involvement in a child’s life, schools felt that they could add important insights. Other partner organisations felt that they could have contributed to this case and this may have helped ensure that issues of forced marriage were considered. Social care managers explained that Child In Care Reviews were established in this way in response to feedback from the Staffordshire Children in Care Council around 2015/16. Cared for children highlighted concerns about practitioners attending their meeting and wanted the process to be more child focused and child friendly. Agencies such as schools are not, therefore, invited to the meetings although they can contribute to the social work report that is shared with the IRO. They can also share information in Personal Education Plans (PEPs) and looked after child health assessments. Children’s social care are currently developing plans to hold meetings with other agencies about looked after children in between Child In Care reviews. This was welcomed by agencies participating in this review. 7.2 Closing the Case The issue of forced marriage was lost when the duty social worker handed over the case in 2018. A potential risk of forced marriage was not, therefore, revisited at the time children’s social care came to close the children’s case. Cafcass had been aware of the original issues around forced marriage but their submissions to this review acknowledged that the risk of father taking the children out of the country was not considered when the Guardian recommended that the Care Order be revoked. 15 The name of the GP is included on the minutes of the Strategy meetings held in May 2018 but there is no evidence of engagement with him. The fact that the GP reported he was not aware the girls were Looked After would suggest there was no direct communication. 22 The other agencies who had been sighted on forced marriage as a potential issue (police and schools) were not involved in multi-agency discussions around the case and there was not, therefore, a forum for conversations to be held around this. Practitioners taking part in the Learning Events felt that processes should be in place to ensure all the issues that were raised as part of the original referral are reviewed whenever plans to revoke a Care Order or close a case are being developed. (However, as noted earlier in this report, several of these practitioners do not feel that there was any evidence at the time that would have prompted different action to be taken.) This should be standard practice. This did not happen in this case as discussions around forced marriage were not included in formal case documentation and were, therefore, overlooked. 7.3 Multi-agency working and communication: Good Practice ✓ Good initial sharing of information about the potential risks around forced marriage between the police, children’s social care and the children’s schools. ✓ During the period the children were subject to the Care Order, the children’s schools raised their concerns with children’s social care as they occurred and escalated absences in a timely way. Multi-agency working and communication - Learning Representatives from the children’s schools and from health do not appear to have been invited to Strategy meetings and did not, therefore, have the opportunity to contribute. The rapid application for an Emergency Protection Order also meant that the normal multi-agency child protection processes were effectively skipped and the children moved directly into the looked after system. In Staffordshire, other agencies can contribute in writing to Child In Care Reviews but are not invited to attend meetings about looked after children. This limited opportunities for multi-agency discussion in this case. Children’s social care are planning to hold meetings with other agencies about looked after children in between Child In Care reviews and this was welcomed by agencies participating in this review. The issue of forced marriage was not revisited at the time of the discharge of the Care Order or the closure of the case. Where historical concerns have been raised, it is crucial that these are revisited before a case is closed. 8. Advice, Guidance and Training 8.1 Understanding the role of the national Forced Marriage Unit (FMU) The national Forced Marriage Unit (FMU) is a joint Foreign, Commonwealth and Development Office and Home Office unit which leads on the government’s forced marriage policy, outreach and casework. It does this by operating a public helpline to provide advice and support to both victims and potential victims of forced marriage and practitioners dealing with cases. The Unit also undertakes an extensive training and awareness programme targeting both practitioners and potential victims and carries out a range of work to raise awareness. The role of the national Forced Marriage Unit was not widely known in Staffordshire in 2018 and not fully understood when the Unit was contacted to help support the retrieval of the children in 2021. 23 As outlined earlier, there was surprise and confusion amongst practitioners in Staffordshire that the Unit was not able to take more proactive action to retrieve the children. While feedback shows the Unit’s advice in 2021 was helpful, this confusion highlights the importance of ensuring that local safeguarding practitioners understand the limitations on what can be done once children have left the country. 8.2 Survey results: Guidance and Training in Staffordshire The low profile of the FMU within Staffordshire may be partially due to limited guidance and training on this topic. While only a snapshot, and in no way statistically robust, the survey conducted for this review found that a third of respondents were not aware of any guidance on the topic while 70% had not received any training around forced marriage. 8.2.1 Survey results: guidance Only 17% (51 individuals) reported awareness of local guidance on forced marriage within their organisation, while half (147 individuals) stated that their organisation uses national guidance. One third of respondents (33%) said they were not aware of any guidance on forced marriage in their organisation. 8.2.2 Survey results: training The vast majority of respondents to the survey had not received any training around forced marriage. Those that had received training were split roughly equally between external and internal training. Historically, Staffordshire Safeguarding Children Board has not offered specific training on forced marriage as there has never been any demand. Organisation Forced Marriage guidance LocalNationalNone24 8.3 Challenges to upskilling staff where there are capacity constraints and workforce instability During discussions at the Learning Events, frontline practitioners involved in this case recognised that they need to improve their understanding of the warning signs around forced marriage. They agreed that it is important to upskill all staff on this topic and felt this needs to be ongoing and high-profile given the issue is relatively rare. Suggestions included high-visibility posters in offices and home screen messages on computers alongside formal training. However, despite this desire to improve their understanding of issues around forced marriage, practitioners expressed concerns about how this could be achieved given current work pressures. Staffordshire has recently implemented a transformation programme and frontline practitioners shared strong views that this has had a negative impact on practice. These practitioners described a working environment where managers are overstretched and, therefore, forced to focus on the front door and immediate safeguarding with limited or no time to consider cases that are being closed. Prior to transformation, practitioners felt they could access meaningful reflective supervision but stated that since transformation this is limited. Changes in working practices post Covid-19 have also reduced opportunities to share and learn from colleagues in an office environment as the majority of conversations now take place by phone and email. Practitioners reported that many experienced staff have left and there is an increasing reliance on agency workers. Practitioners felt that these pressures have created a working environment where meaningful training on topics such as forced marriage is impossible. Social care managers acknowledged that the significant changes following the implementation of the transformation programme have unsettled staff. However, they highlighted that there has been a year on year decline in referrals into children’s social care in the last five years and there are currently 200 less children in the system than previously. There has been a noticeable increase in the complexity of these referrals during and after the pandemic but managers feel the new structures put them in a better place to respond to these. 4247208050100150200250InternalExternalNoneTraining Recieved25 The changes were designed to reduce identified silo working and to reduce the number of times a case is handed over between teams. The changes should prevent children and families having to retell their story. Work is ongoing to fully embed the model. Schools shared that they also have capacity concerns due to funding constraints. For example, EAL (English as Additional Language) staff are now frequently working in classrooms as Teaching Assistants instead of their previous roles. Advice, Guidance and Training - Learning The experience of this case would suggest that there is a need to raise the profile of the national Forced Marriage Unit (FMU) with safeguarding partners in local areas. Advice from the FMU’s helpline regarding whether the children were likely to be at risk of forced marriage (based on the evidence available at the time) may have led practitioners to be more professionally curious and prompted them to pro-actively follow up risks of forced marriage alongside the serious abuse and neglect that the children were suffering. However, any actions to raise the profile of the FMU in local areas needs to be very clear regarding the Unit’s remit. Staffordshire’s experience demonstrates the importance of making safeguarding practitioners aware of the limitations of what can be done once children have left the country. At a local level, robust guidance and training is needed to ensure all practitioners in Staffordshire are able to recognise the warning signs for forced marriage and are confident in how they respond. This can only be effective if practitioners have the time to both attend training and to reflect on potential warning signs when they encounter them. 9. Actions Taken to Date Areas for immediate improvement have been identified by both the Review Team and individual agencies during the course of this review. Many actions have, therefore, already been taken: these are summarised in this section. 9.1 Lead agency when applying for a Forced Marriage Protection Order (FMPO) This review identified confusion within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, it has been clarified and agreed that this should be children’s social care. 9.2 Children’s social care This review found a lack of knowledge around forced marriage amongst some social care staff. The Principle Social Worker will be holding a practice forum and learning lunches for the workforce to ensure all of the workforce have an up-to-date understanding of the risks and indicators for forced marriage. In October 2021, the local authority completed a whole system transformation that prevents multiple handovers. Under these new arrangements, the social worker who initiates the proceedings retains responsibility and, thereby, retains knowledge of the issues in the case. This should prevent the breakdown in communications that happened in this case and which allowed the issues of forced marriage to become lost once the Interim Care Order was obtained. 26 9.3 Police The markers on the Police National Computer were not updated during this case. Staffordshire Police have taken action to improve supervision and processes within the Force Control Centre to enhance safeguarding, including a detailed action around ensuring flags and warning markers are accurate. Supervisors are checking decisions and open incidents, escalating responses when necessary, and an audit process is in place to identify concerns and inform learning. 9.4 Education 9.4.1 Education Safeguarding Leads Education safeguarding leads have taken action to ensure that knowledge of both the warning signs for forced marriage and of FMPOs is increased across all education settings. The forced marriage section on the Staffordshire Learning Net16 (which contains safeguarding information accessible to Designated Safeguarding Leads and deputies) has been expanded: • Forced marriage had formed part of a wider honour-based violence category but is now separate, making it more visible to users. • The expanded content includes training links from the Virtual College, YouTube videos (to be shared with children as appropriate as part of a comprehensive PSHE package), posters which can be displayed in settings, and details of organisations and charities who provide support. • A PowerPoint presentation provided by the Forced Marriage Unit (FMU) has been added to this section which includes clear definitions of a FMPO and the role, responsibilities and limitations of the FMU. • Information from Staffordshire Police, and their guidance on how to report concerns directly to them, has been incorporated. A reminder has also been added that forced marriage is included in the threshold model and that any concerns must be referred into Staffordshire Children’s Advice and Support service. Forced marriage has been added to the revised Level 4 DSL training slides for use from the 1 September 2022 for both new and existing DSLs. This training has been extended from half a day to a full day’s training for new DSLs allowing greater content to be covered. A 7-minute briefing on forced marriage has been developed by education safeguarding leads. This will be shared with DSLs this academic year and they will be encouraged to use this for staff training and induction days, share with safeguarding governors and in other staff meetings. Staffordshire’s education safeguarding leads are recommending that training is completed on a regular basis ensuring that, even if cases are infrequent, knowledge and confidence is not diminished and the message remains clear that “it could happen here”. This was communicated in the Autumn DSL briefings and reiterated in the Level 4 DSL training. All DSLs are being encouraged to consider using the FMU slides in staff meetings and staff training days so that all staff are confident and remain vigilant. 16 It is worth noting that the content on the Learning Net was expanded after the completion deadline for the questionnaire sent out as part of this review to ensure that this did not influence results on existing knowledge 27 9.4.2 School The high school the children attended already had strong safeguarding practice. The forced marriage element in their training has been strengthened in response to this case and they are using case studies to help make the learning real to staff. The school operates a robust ‘if in doubt act’ policy. They proactively monitor all students with an emphasis on those from cultural backgrounds who are vulnerable or whose families are vulnerable / have had past issues during the primary stage. They have a dedicated Friday morning meeting where the three Designated Safeguarding Leads consider all cases in depth: where there is even a minor doubt the school consults with outside agencies. The school also has a ‘no fear’ approach in their interactions with parents. Since the lifting of Covid-19 pandemic restrictions, there has been a large increase in the number of Asian families traveling to visit family overseas (half of all pupils are Asian). The school routinely talks to parents and carers to establish the reason for these visits. School staff ask for proof of tickets, return flight bookings etc. Staff have to be a little fearless about this but parents are usually very cooperative. 9.5 Health This review found that the GP and associates require additional training and increased understanding of forced marriage and FMPOs. To identify the level of need, this area of safeguarding has been added as a question to the annual safeguarding audit issued to primary care across Staffordshire. The Integrated Care Board (ICB) safeguarding team will soon have a reference area on the GP365 system, the intranet for all primary care practices across Staffordshire. This will be a ‘go to’ reference area, accessible from every computer in primary care. Forced marriage information will be included along with the contact details of ICB safeguarding staff for advice and guidance. Once fully developed and adopted the integrated care record (known locally as One Health and Care) should also allow practitioners involved with individuals at risk to have some visibility of the involvement of social care or other healthcare providers. 9.6 Intensive Prevention Service The Intensive Prevention Service have disseminated national guidance on forced marriage to all practitioners and have also taken steps to raise the profile of the national Forced Marriage Unit with these staff. This includes ensuring staff have the Unit’s public helpline number to access advice and guidance. All staff have been asked to book on the Forced Marriage Unit’s training for Social Care Staff. Attendance will be reviewed as part of team meetings and tracked through supervisions. A Reflective Session will be organised to offer a space to discuss the training and to help build on the team’s learning. 10. Conclusion This review has identified important learning regarding both practitioners’ confidence and skills in recognising the warning signs for forced marriage and the way they then respond to these warning signs. 28 There is particular learning for the Staffordshire system around Forced Marriage Protection Orders (FMPOs), including the need to understand how these can and should be used and which agency should take the lead in making an application. (It has been established that for children this should normally be the local authority children’s social care service). Whilst there is much good practice in terms of viewing events through the child’s eyes (particularly in relation to physical abuse and emotional harm), it is recognised that there is always more that could be done. In relation to forced marriage, there could be significant benefit in proactively raising awareness of both the issue and the warning signs with young people in a school environment. Advice, Guidance and Training is an integral part to all of the above: this includes appropriately raising awareness of the support that is available from the national Forced Marriage Unit. This will, however, only be effective if practitioners have the time to undertake training, the capacity to reflect on their practice, and the opportunity to seek advice and guidance through supervision and peer conversations. Perhaps most important of all is the need to ensure there is consistent and widespread understanding of the ‘One Chance Rule’ – that practitioners working with victims of forced marriage and honour-based violence may only have one chance to speak to a potential victim and thus they may only have one chance to safeguard the child. In the case of J and K, practitioners had more than one chance but these were lost. This has resulted in two British children being potentially at risk in a foreign country and UK agencies having no powers to return them to the UK. 10.1 Developing the Recommendations This report summarises the learning from this review. This learning will be developed into formal recommendations which should be read alongside this report. The recommendations will be developed by staff within Staffordshire to ensure that they fit within the context of wider operational and strategic developments in the county. This will ensure that recommendations make a real difference to the way children are safeguarded in Staffordshire. Recommendations will be focused on outcomes and will be clear what is required of relevant agencies and others, both collectively and individually, and by when. The formal recommendations will be endorsed by the three statutory Safeguarding Partners. As members of the Review Team, the Forced Marriage Unit are aware of the learning related to the understanding of their role. This national learning will also be shared with the independent Child Safeguarding Practice Review Panel who have a remit for national learning. |
NC52219 | Injury of a 12-week-old girl, taken to hospital in January 2017 with a skull fracture. Parents stated that Mother dropped Child K during a domestic abuse incident. Police attended the family home one day prior to Child K's hospitalisation, where Sibling disclosed physical and domestic abuse by Father. Parents and Sibling were interviewed by police and children's services. Following Child K's injury, parents were convicted of 'causing injury to a child' and given community sentences; Child K and her Sibling were made the subject of care proceedings. Parents had a history of contact with children's services and police due to domestic abuse and physical abuse by the Father. Child K's ethnicity or nationality are not stated. Learning includes: although guidance and procedures do not differentiate between day time and out of hours child protection situations, in practice out of hours services cannot fully replicate daytime services; inter-agency strategy discussions should be held whatever the circumstances for child protection enquiries; clarify in emergency situations if children are protected and accommodated under Section 20 or Section 46 of the Children Act 1989; written agreements, asking that one parent ensures there is no contact between another parent and their children, may not be realistic and may provide false assurance in cases of domestic abuse. Recommendations include: consider how effective current police structure is in ensuring that Warwickshire Police can fulfil their roles as stated in Working Together 2015; Warwickshire Police to consider whether officers involved in child protection investigations have sufficient participation in interagency safeguarding training.
| Title: Serious case review report regarding a child to be known as Child K. LSCB: Warwickshire Safeguarding Children Board Author: Nicki Pettitt and Cornelia Heaney Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Report Regarding a child to be known as Child K Contents 1. Introduction page 1 2. Methodology page 2 3. The case being considered page 2 4. Analysis page 3 5. Conclusions page 12 6. Learning and Recommendations page 13 1. Introduction 1.1.1 The Warwickshire Safeguarding Children Board (WSCB) decided to undertake a Serious Case Review (SCR) in respect of a child to be known as Child K in April 2017. They recognised the potential that lessons could be learned from this case about the way that agencies work together to safeguard children in Warwickshire. 1.1.2 Child K was 12 weeks old when she sustained a skull fracture. The parents state that Mother dropped Child K during a domestic abuse incident. They did not seek medical attention for Child K until 3 days after the incident. It does not appear that there will be any long-term health or developmental impact on Child K from her injury. Both parents made ‘guilty’ pleas in respect of ‘causing injury to a child’ and were given community sentences. 1.1.3 It was agreed that the SCR would consider in detail the professional involvement with Child K and her family during the bank holiday weekend 31.12.16 – 2.1.17; the date of the domestic abuse incident until the strategy meeting regarding Child K’s injuries1. The review is therefore evaluating the effectiveness of Warwickshire’s arrangements to safeguarding children out of hours. 2. Methodology2 2.1.1 Independent lead reviewers3 were appointed to undertake the review. They had access to the key single and multi-agency documents in the case and met with practitioners involved with the family in a number of reflective sessions where the case was discussed. The pre-disposing risks and vulnerabilities4 that were known at the time were considered, in order to understand the case. This is followed by the consideration of the preventative and protective actions taken, in order to understand the interventions. 1 The scope of the review is three days in order to identify learning for the agencies involved and for the WSCB from the professional involvement undertaken during those days. The background information known by agencies prior to these dates was also shared with and considered by the review. The decision to review these dates took into consideration the lack of significant agency involvement with the children prior to this time, and the recognition of the potential to learn lessons from the way agencies worked together during the timescale being considered. This was a proportional and focused response to the need to review the case. 2 The Government guidance Working Together 2015 states that SCRs should be conducted in a way that; • recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. Consideration has been given to whether it is necessary to ‘identify improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice’. The review has also clearly identified ‘what lessons are to be learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result’.2 3 Nicki Pettitt is entirely independent of the WSCB and its partner agencies and is an experienced chair and author of serious case reviews and safeguarding adult reviews. Cornelia Heaney is the WSCB manager and is independent of the case. 4 Triennial Analysis of Serious Case Reviews 2016, Sidebotham, Brandon et al, Department of Education 2 2.1.2 The agencies that had involvement were asked to reflect on the agency specific learning. 2.1.3 The lead reviewers visited Child K’s mother to discuss the SCR and she reflected on the work undertaken with the family during the timeframe of this review. Her views are included in this report. Child K’s father has been written to about the report and the lead reviewers have offered to have a telephone conversation with him about the professional interventions at the time. Both parents will be informed of the conclusions of the review and the WSCB’s response prior to publication. 2.1.4 Drafts of this report were shared with those involved as well as with the Special Cases sub-committee of the WSCB to ensure collaboration and ownership. The recommendations were written by the lead reviewers and Special Cases. 2.1.5 This report has been written in the anticipation that it will be published in full,and contains only the information that is relevant to the learning established during this review. 2.1.6 The children are the subject of care proceedings and are living with extended family members prior to the final hearing. 3. The Case 3.1.1 For the purpose of this report, the following family members are relevant: Family member: To be called: Child K (12 weeks) Subject child Mother of Child K Mother Father of Child K Father Mother’s son (Age 8) Sibling Mother parents Maternal Grandparents Father of Sibling Sibling’s Father 3.1.2 The family were known to a number of agencies in Warwickshire. Father had convictions for unrelated matters and was known to mental health services for anxiety and depression. When Father had been living with other families in the past, children’s social care (CSC) were involved due to domestic abuse where Father was the perpetrator, and concerns about physical abuse perpetrated by Father. In one case, this resulted in a child protection plan, and in others multi-agency domestic abuse management plans (MARAC5 and MAPPA6) were in place due to the assessed high risk of serious harm. 3.1.3 Mother’s relationship with previous partner/s had resulted in five domestic abuse calls to the police between 2008 and 2014. The report of the incident in 2008 stated that Mother had been drinking. There was police involvement between Mother and Sibling’s Father on one occasion in 2016 due to issues regarding contact with Sibling. Letters of advice were sent to Mother from CSC and on one occasion there was telephone contact with a social worker. 3.1.4 There was no reported domestic abuse between Mother and Father prior to 31.12.16. 3.1.5 Sibling’s school had shared no concerns about him. He has contact with his father. 3.1.6 Complications during her birth led to a 2 week stay in hospital for Child K. No concerns or needs were identified by the midwives or the health visitor following her discharge home. Other than a 5 Multi-Agency Risk Assessment Conference 6 Multi-agency public protection arrangements 3 missed appointment with the health visitor due to a house move, Mother engaged with all ante and post natal support and Child K was immunised. 3.1.7 The family moved house when Child K was around 2 months old. This was into a social housing property where the tenancy was solely in Father’s name. Father had made a request for social housing for him and Child K, stating he was to be the baby’s only carer. This may have been a fraudulent application7. 3.1.8 In the early hours of the morning on Saturday 31.12.16, Father called the police to state that Mother was intoxicated (due to alcohol) and needed to be removed from the home. Sibling was spoken to by the attending uniformed police officers and he stated that Father had his hands around Mother’s throat that night. The next morning, when other officers attended, Sibling said that the night before he had been dragged by Father and that he had a bruise on his leg. Mother was left with the children when Father was taken to the police station to be interviewed about the potential domestic abuse earlier that morning, and the uniformed officers passed Sibling’s allegation to CID colleagues. 3.1.9 Sibling was interviewed but did not sustain the allegation. CSC EDT (Emergency Duty Team8) made a written agreement with Mother that Child K would stay with Maternal Grandparents overnight, and that Sibling would go to his father. It became apparent the next day that the written agreement had not been adhered to however and Father made it clear to the EDT social worker who telephoned that he would not stay away from the children. The issue was discussed with a senior manager and it was agreed by CSC that it did not meet the threshold to enforce the plan, but that a full assessment should be undertaken after the bank holiday period. 3.1.10 The following day Father sought medical attention for Child K who had a swollen head. He stated Mother had thrown the baby on the floor in the early hours of 31.12.16. Mother and Father have since stated that Mother tripped and fell with the baby in her arms. 3 Analysis 3.1.11 To analyse the professional involvements and interventions with the family, consideration has firstly been given to the predisposing vulnerabilities and risks in the case, that were known or knowable to professionals involved at the time. This is followed by the preventative and protective actions taken by the agencies involved at the time. Predisposing vulnerabilities: Child K was a young baby who was entirely dependent on the care provided by the adult/s responsible for them. It has been established in previous SCRs that the frailty of babies is often under estimated by professionals and parents/carers9. At birth Child K had some complications that led to a two week stay in the special care baby unit. Child K was pre-verbal and could not tell professionals about her life-experiences or what had happened to her. Father had stated that he didn’t want another girl as he had daughters from a previous relationship. This may have made Child K more vulnerable. It is not known how long Father had lived with Sibling or the quality of their relationship other than as reported by Mother. Mother had been in relationships before where it was believed that there had been domestic abuse. Mother may therefore be vulnerable to abusive partners. Mother disputes this, stating that 7 This is outside of the scope of this review, but is being considered as a supplementary review due to the potential to learn lessons from the response to Father’s request for housing. 8 EDT provides an adult and children social care emergency social work service at night, at weekends and on all public and local-authority holidays. 9 The Ofsted report: ‘Ages of concern: learning lessons from serious case reviews’ provides a thematic analysis of 482 serious case reviews that Ofsted evaluated between 1 April 2007 and 31 March 2011. 4 she acted to protect herself and her child when a previous partner had been violent and terminated the relationship. It is known that women are more vulnerable to domestic abuse when they are pregnant and when they have a new born baby. Mother was on maternity leave from work and the family had recently moved home. Father told the police that the family had financial pressures. Father had a history of involvement with mental health services due to anxiety and depression. He was receiving no support at the time of the incident. 3.1.12 It is recognised that the adults predisposing vulnerabilities may pose a predisposing risk to the child. The following additional risks have been identified: The risks in the case: At the time of the reported domestic abuse incident Mother was said to be extremely drunk by the attending police officers. Mother denied that there was any violence in her relationship with Father, although Sibling had stated that he saw violence early in the morning of 31.12.16 and marks were noted on Mother’s neck. Mother was insistent to professionals that Father was a good man and that he treated her and Sibling well. This was felt by professionals to be erroneous at the time, and following the injury to Child K Mother has stated that Father was in fact emotionally abusive to her, although this was not known at the time. Mother was observed to be coaching Sibling to report that Father was ‘good to him’. Police and CSC have evidence of a domestic abuse incident between Mother and another partner where she was said to be drunk. Father has a history of domestically abusive relationships and of alleged physical abuse to children (described as ‘chastisement’ in records). This includes children in his care being made the subject of child protection plans. The family home was described by those who attended as cold and sparsely furnished, with no covers on the bedding. Child K was said to be in a dirty baby-grow and soiled nappy. Mother was found to be co-sleeping with Child K the morning after the domestic incident and following her heavy drinking. At the time, Mother refused to make a statement to the police in regards to domestic abuse or the alleged assault on Sibling. Sibling stated to Police during the night that Father had ‘dragged him around like a dog’ that evening, and that he was called ‘a fairy’ and ‘a wimp.’ He had a red mark on his shin. During the ABE interview he backtracked, and those present interpreted what he disclosed as ‘rough handling’. Neither adult’s account of what happened during the early morning of 31.12.16 was consistent. Mother and Father provided inconsistent accounts of who the home belonged to and who lived there regularly. This demonstrated a lack of honesty, and also meant it was not clear whether the home could be a place of safety for the children when the working agreement was being devised. 3.1.13 There was evidence of protective actions from the family when considering the case: Protective actions – family Although very delayed, Father eventually took Child K to a clinic for medical treatment. 5 Sibling went to his father’s home overnight 31.12.16 – 1.12.17. Mother believed she was protecting her children by seeking to avoid a confrontation with Father about his wish to return home on the 31.12.16. Maternal Grandparents acted to ensure their grandchildren were safe by providing a home for them from the evening of the 2.1.17. 3.1.14 During the involvement of professionals with the family, there were both preventative and protective actions taken by the agencies involved. There were also further opportunities to ensure protection that were not taken. Protective and preventative actions – agencies Prior to the incident (around the time of Child K’s birth) routine domestic abuse questions10 were asked of Mother by health visitor and midwives and she answered ‘no’. The uniformed police officers who first attended the 999 call spoke to both the parents separately. Father appeared sober, was calm, and was comforting a crying Child K. The parents denied any physical violence, however Sibling told the police officers that there had been a fight and that his step-father had put his hands around Mothers neck leaving a mark. On considering this, they still felt that Father was best placed to care for Child K and Sibling overnight as Mother was so drunk and in the early hours of the morning they had limited options for alternative care. Before making this decision they checked with Sibling that he was happy to stay with his step-father, he said he was. They took Mother to the police station with the intention of taking a statement when she had sobered up. An awareness of good practice in responding to domestic abuse was shown by the uniformed officers. After a shift change at 7 am on 31.12.17, where a large number of cases had been handed over, Mother was spoken to. She continued to deny any domestic abuse and would not make a statement. She was returned home by the police to care for the children, with the intention that Father would be taken to the police station to provide a voluntary interview. The police handled the return of Mother and removal of Father sensitively, with a police officer waiting with the children in the minutes between Father leaving and Mother returning to the property. This ensured the parents did not see each other. The officer waiting with the children spoke to Sibling who made his disclosure that he had been physically harmed by Father. The decision was therefore made to arrest Father rather than take a voluntary statement and the investigation was handed over to CID in a timely verbal handover prior to the written information being available. Two suitably trained CID officers were asked by a detective sergeant on duty to visit the family and negotiate with Mother to undertake an ABE11 interview with Sibling. They were clear this was now a potential criminal investigation and that as Father was in custody they had limited time to undertake the interview. It is also best practice to secure an account as soon as possible from a young child to prevent any further contamination of the child's account and to enable it to be as easy as possible for that child to provide a recollection of events. They were aware there had been a domestic incident the night before, but this was not the focus of their involvement. The impact of this protective action however was reduced by being planned and carried out in isolation from EDT. The CID officers had intended to ask Mother to accompany Sibling for an interview, but it was clear that Mother was trying to influence what he was saying about what happened. She kept reminding 10 Routine enquiry means that health visitors and midwives ask all pregnant women and new mothers whether they are experiencing domestic abuse during routine contacts, whether they show signs of it or not. This has been common practice since 2006. 11 The principles of ABE (Achieving Best Evidence) are set out in the Youth Justice and Criminal Evidence Act 1999 (YJCE). The interviews are visually recorded and used for: evidence gathering for use in criminal proceedings, the examination in chief of the child witness, and to inform child protection enquiries under Section 47 of the Children Act 1989. 6 him it was ‘only play fighting’. The officers recognised the impact that Mother’s behaviour could have on the interview with Sibling, and that she should not be part of it. As Mother was happy for him to be interviewed without her there, he was taken alone by the police to be interviewed with Mother’s permission in writing12. They had requested that another family member be contacted to accompany Sibling. Mother stated Maternal Grandmother would do it, but she was unwell and there was no one else. No consideration was given to contacting Sibling’s Father. Despite it being a busy day, a lot of police resource was allocated to this case. At the police station two further CID officers were tasked with interviewing Father regarding the allegations and they agreed to do this following the result of the ABE interview. CSC EDT were contacted and asked to attend the ABE interview to support Sibling. It is good practice for a child to have a supportive adult present when giving a witness statement. The reasons for using a professional rather than Mother to support the child were clear to the CID officers, but because EDT had not been involved up to this point, and had not been able to observe Sibling and Mother together, the EDT manager did not have the full picture and believed it would be more supportive for Sibling to have his mother present in the building. It would be very unusual to take such a young child for an interview without someone they knew. The EDT Manager therefore arranged for a social worker to visit Mother and bring her to the interview suite. This delayed the arrival of the social worker to assist with the ABE interview. The CID officers developed a rapport with Sibling. While they waited they made drinks and toast for Sibling and engaged with him about football and school. They described him as friendly and chatty and that he didn’t appear at all anxious. Developing rapport would be expected to improve the likelihood of the child speaking freely in their ABE interview. The EDT social worker conducted an assessment interview with Mother, but this was brief because she was aware that Sibling was waiting for them at the interview suite. Mother stated that there had been no physical violence to her the night before or at all in her relationship with Father. If anything, she said, she would have attacked him and he may have pushed her away. She had marks to her face but stated these were due to the baby scratching her while feeding. She also spoke about the excellent relationship between Sibling and his ‘step-father’. She explained that there had been a disagreement the night before about Sibling needing to go to bed, and that he was picked up and put to bed by Father, but this was not inappropriate in the circumstances as far as Mother was concerned. The uniformed officer who held the baby while waiting for Mother to return on the morning of 31.1.17 told the review that she had noticed that Child K was not very responsive and that her head seemed soft and an odd shape. She had been told by Father that the baby was premature when born and she thought this might account for what she saw. The officer discussed this with her supervisor on her return to the station. They did not think it was anything significant however, and this information was not shared with CID or recorded until a statement was taken following the hospital attendance on 2.1.17. The EDT social worker also saw Child K and stated she seemed well cared for and was calm and settled during the time the EDT social worker was with them, which was some hours. She had a hat on for most of the time, as it was December. The social worker stated with hindsight that she had thought Child K’s head was an unusual shape, but nothing to make the EDT social worker concerned. Child K was described as feeding normally and Mother, although tired, responded to her appropriately. On arrival at the interview suite, the EDT social worker and CID officer spoke and it was agreed that Mother would not sit with the child during the interview, but would be in the next room with another officer who was making notes. Sibling was interviewed, giving him the opportunity to tell the police officer and social worker about 12 The police officers stated that taking Mother and Child K with them too would have been difficult as they do not have car seats in their cars. However the EDT social worker pointed out that Mother had a car and that she used the car seat from there when she transported them. 7 things at home that he was unhappy about. However he did not maintain the allegation during the interview. He had a red mark on his shin however and the Police took a photograph of this injury following the interview. This was to capture an image of this potential evidence in case any further evidence became available later. The Police officers noted a change in Sibling’s demeanour when Mother arrived, and believed her presence in the next room restricted his willingness to speak. The professionals had a reflective discussion following the ABE interview and made a shared assessment of risk. The social worker had looked at the CSC database, CareFirst, and noted concerns about domestic abuse in Father’s previous relationships and about Father’s mental health. This is good practice. They assessed that without intervention there was a risk of further domestic abuse during the weekend. When making decisions on 31.12.16 both the EDT social worker and the CID officers considered the following: History of domestic abuse with previous partners of both parents Mother was denying this was a violent relationship, and was trying to get Sibling to say the same Mother seemed to be cooperating with the plan for the weekend Sibling did not sustain his allegation and the injury was small and Sibling said it was not from the incident Father was said to not live with the family full time They did not feel they could let the family go home without taking any action, but did not think there were grounds for police protection or emergency protection of the children. A plan was made for the children to be cared for elsewhere and the compromise of a written agreement was put in place. The social worker drafted a working agreement with Mother which stated that the children would be cared for by their maternal grandmother for the rest of the bank holiday weekend. Mother agreed and signed the agreement. In principle this was a suitable protective plan. Contact details for Grandmother were requested, but the social worker did not seek to make contact with her at the time of setting up the agreement, which undermined the integrity of the plan. The EDT social worker met with Father at the police station on his release to seek agreement to the working agreement, but he stated that he was not intending to cooperate with the written agreement and would not sign it. This further undermined the integrity of the plan. Father was released without charge in relation to the physical assault on Sibling. Father was on Police Bail for the domestic abuse allegations. The police officers making this decision were aware of the written agreement and the understanding that he would not have any unsupervised contact with the children at that stage. The criteria for bail conditions were not met in regards to the on-going domestic abuse investigation, and a domestic violence protection notice13 are not considered when bail is in place. Later that evening the social worker attempted to contact Maternal Grandparents to clarify that the children were there and explain the written agreement, but found she had the wrong telephone number. (It was later established that Mother had also given her the wrong address.) The 1.1.17 was a Sunday. There were a number of attempts by EDT staff to contact Mother, and when they spoke to her on the telephone it became clear that Child K was at home and also possibly Sibling. Father came to the telephone, stated they were not willing to cooperate with the agreement made, and hung up. The EDT social worker had a discussion with the EDT manager who then spoke to the duty group manager and it was agreed there were no grounds to undertake 13 Crime and Security Act 2010. DVPOs enable the police to put in place protection for the victim in the immediate aftermath of a domestic violence incident. Under DVPOs, the perpetrator can be prevented from returning to a residence and from having contact with the victim for up to 28 days, allowing the victim a level of breathing space to consider their options, with the help of a support agency. They provide the victim with immediate protection. 8 emergency action. The police were not informed of the change in the situation or the decision made. Child K’s injury was established on the bank holiday Monday 2.1.17. The safeguarding implications of her injuries were quickly identified by the Acute unit staff. EDT were informed by the ambulance service. The parents were arrested and held in custody that evening, Child K was in hospital and Sibling was considered in a timely way. A plan was made by EDT and police that Sibling would be cared for by Maternal Grandparents. There was some confusion however about the children’s legal status, with the police believing the children were accommodated under s2014 and EDT believing the children were in police protection15. In fact neither were in place. Mother told the review she was held in a cell for almost 24 hours, and that she had not been given any update on her baby’s condition, despite requesting this hourly. She was aware that Child K was in surgery and she was incredibly worried. The review has requested that Warwickshire Police consider the impact on Mother of what happened that night, and how they can ensure that parents in police custody are given updates on their children, particularly if they are seriously ill, as in this case. 3.1.15 The review has established that the following areas require further analysis and provide us with the learning in this matter: The context: Police reorganisation 3.1.16 The review has identified that there were contextual issues which had an impact on the case. There had been a reorganisation of Warwickshire Police around 6 months previously which had an impact on the experience of officers who undertake investigations into child abuse allegations, and which may have had an impact on this case. Rather than having a standalone service for child protection within CID, child abuse investigations and police responsibilities under the Children Act 1989 and Working Together 2015 are now held within mainstream CID services. (Although it is acknowledged that the previous child protection teams did not cover weekends and bank holidays, which would have caused issues in this case.) The detective sergeant who was on duty on the 31.12.16 stated she does not have enough staff who are trained and experienced in child protection and in undertaking ABE interviews at any time, particularly on bank holidays. On the weekend in question however she had two officers who had the required training and she asked them to take on the case. There was a degree of urgency as Father was in custody, and because Sibling was just 8 years old. The officers however did not question what had been agreed prior to their involvement and they were not aware that there had not been a strategy discussion and that the expectation was that they would request one of CSC EDT social worker when they arrived at the interview suite. This might be due to a misunderstanding, inexperience, or a lack of understanding of procedures. (See below.) 3.1.17 EDT explained to the review that the reorganisation has had an impact on their relationships with those police officers undertaking child protection work. They now come from a much bigger pool of detectives who are inevitably less experienced in this type of work. The issue of suitability for the particular type of work was also discussed. The changes have made it harder to ensure good relationships between social workers and police officers, quality joint child protection work, and the meaningful involvement of CSC professionals in what may be seen as a police task. The police accept that just 6 months into the redesign there were issues, but that the investment in mainstream CID will lead to a better service as more officers are trained in child protection and gain more experience. 14 S20 Children Act 1989, where children are accommodated by the Local Authority with the agreement of a parent. 15 Police Protection s46 Children Act 1989, where a police officer has reasonable cause to believe that a child would be at risk of significant harm unless action is taken immediately s/he may: remove the child from the situation and take them to a place of safety or take action to prevent the child's removal from a place of safety, for up to 72 hours. 9 Out of Hours provision 3.1.18 As the work was not undertaken during the hours of 9 – 5 Monday to Friday, and was therefore ‘out-of-hours’, there were added complications. The lack of a strategy discussion to consider Sibling’s allegations prior to the visit to the home to see the child and to request an interview was said to be because the MASH had not been involved as they would be in office hours16, and that decisions ‘out of hours’ are often made without a formal strategy discussion or meeting. (See below) 3.1.19 The shift changes that happened during the early morning, then through the daytime and evening of 31.12.16, also had an impact both for the police and for EDT. A number of different uniformed and CID officers were involved, along with a number of EDT social workers. This may have led to a confusion regarding who had oversight of the processes and procedures that needed following, such as the need for a strategy discussion. (See below.) One of the police detective sergeants spoken to stated she had not been aware of contact between another sergeant and EDT on 31.12.16 until later in the day. From speaking to those involved that day it is still not entirely clear who did speak to whom that morning. Those involved are not entirely sure from memory. So much was happening that records were done later in the day as a summary rather than a blow-by-blow record of telephone calls and discussions. This is the reality. The same could be said for the evening of 2.1.17 when Child K was in hospital and Sibling was placed with grandparents without any legal remit such as police protection or S20 being in place. While this did not result in any issues for these children, the potential for difficulties to have arisen must be noted.17 3.1.20 The police were undertaking two investigations on the 31.12.16, one in regards to the domestic abuse and one in regards to the physical abuse allegation by Sibling. This added further confusion. For example regarding whether Father had been bailed or not. He had been for the domestic abuse but not for the child abuse. Learning: • There has been an impact on relationships and experience out of hours due to changes in the way Warwickshire Police now responds to child protection. • The nature of out of hours work, with linked capacity and continuity issues, means that professionals have to make decisions as a holding plan in an evolving situation. • Practice guidance and procedures do not differentiate between day time and out of hours situations when a child protection allegation is made. However it is unrealistic to think that out of hours services can fully replicate the daytime services. Strategy meetings: 3.1.21 Working Together 2015 states that ‘whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children’s social care, the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary’. It goes on to state that ‘children's social care should convene a strategy discussion to determine the child's welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm. The discussion should be used to: share available information; agree the conduct and timing of any criminal investigation; and decide whether enquiries under s47 of the Children Act 1989 should be undertaken.’ 3.1.22 Working Together states that it is the responsibility of CSC to convene the strategy discussion and make sure it: 16 Although it is not the case that all day time child protection referrals will be taken by the MASH. Child protection referrals on cases already open go directly to the responsible social work team. 17 When children are placed away from their parents for child protection reasons, it is expected that this is formalised by a s.20 agreement, or court order, which gives the carers the status of foster carers; or police protection. http://localgovernmentlawyer.co.uk/index.php?option=com_content&view=article&id=21474%3Aplacing-childr%20en-with-family-members&catid=54&Itemid=22 10 considers the child's welfare and safety, and identifies the level of risk faced by the child; decides what information should be shared with the child and family (on the basis that information is not shared if this may jeopardise a police investigation or place the child at risk of significant harm); agrees what further action is required, and who will do what by when, where an EPO is in place or the child is the subject of police powers of protection; records agreed decisions in accordance with local recording procedures; and follows up actions to make sure what was agreed gets done. CSC should also lead the section 47 enquires and assessment of the child's welfare where joint enquiries take place. It is the responsibility of the Police to: discuss the basis for any criminal investigation and any relevant processes that other agencies might need to know about, including the timing and methods of evidence gathering; and lead the criminal investigation where joint enquiries take place. CSC did not take responsibility for a strategy discussion to plan S.47 enquiries in relation to Sibling’s disclosure and the police did not discuss with CSC the plan for gathering evidence for a potential criminal investigation before commencing it. The opportunity to review the plan in a formal way by having a review strategy meeting/discussion following Sibling’s ABE interview, and when it was determined that Father had returned to the home while the children were there, was not taken. 3.1.23 The lack of a timely strategy discussion at the start meant that the conduct and timing of the investigation was not agreed in advance, and this led to a mixed message being given to Sibling about whether Mother would be there for his interview, and to a degree of frustration within both CSC EDT and the police regarding the disagreement that was apparent about Mother’s presence and the subsequent delay in the interview. When Mother and the social worker arrived at the interview suite the social worker and the CID officer planned the interview. Neither the social worker nor the CID officer thought they were having a strategy discussion, but rather a conversation about how best to undertake the ABE interview and manage Mother’s presence. It was shared at the review that Sibling had to be interviewed again after the injury to Child K was established, and this may have been avoided if the original interview had been better planned and joint consideration had been given to whether Mother should be there. The impact on Sibling of repeated interviews was not foreseen but was significant. 3.1.24 There remains confusion about who should have been involved in the strategy discussion and whether in fact there had been one. The DS who asked the 2 CID officers to attend and undertake the ABE interview assumed that the officers would be undertaking a strategy meeting if it was required, but this was not communicated to them. They were under the impression that an allegation had been made and that it was a potential criminal investigation of an assault, and a decision had been made that it could be single agency. There was a degree of urgency as Father was in custody, and as it was the weekend there was no MASH processes to consider. They were aware there had been a domestic incident the night before, but this was not the focus of their involvement and specific questions were not asked regarding this. 3.1.25 The EDT social worker attended the interview suite under the impression that the police had requested an appropriate adult to support Sibling, and they did not stress that a strategy discussion was required in the case of an allegation of child abuse within the family. They stated they may have assumed that the EDT worker who took the referral had recorded the discussion as a strategy discussion, and were unclear when interviewed what had happened prior to their involvement. There is a view within EDT that there is a misconception within the police about the process, which is that the police tend to see the process as a criminal investigation and to consider if a crime has been committed, and that there is little understanding of CSC being the lead agency. 11 3.1.26 It would be good practice when having a strategy discussion to consider all of the children in the household. As there had been no allegations regarding Child K, she was not considered. Those who had contact with her were able to provide their observations, but there was no thought as to whether she was at risk, other than a concern about co-sleeping, and presumably as a child who was present during a domestic abuse incident. 3.1.27 The 2016 triennial study into SCRs states that ‘strategy discussions provide opportunities for information and opinions to be clarified. Appropriate attendance or representation of all relevant professionals is essential so that effective challenge and clarity can take place when ambiguity is identified’. While this is difficult out of hours, a formal telephone discussion could have been requested and taken place either when the case was transferred to CID or when EDT became aware of Siblings allegations. Or at the very latest when the EDT Social Worker arrived at the interview suite. A review strategy discussion could have been held following the ABE interview, when Father was released from custody, and when EDT established that the children were at home with both parents on 1.1.17, in order to share information and plan if any further actions were required. Learning: • Strategy discussions are a central part of the safeguarding process both during office hours and out of hours, and should be held whatever the circumstances to plan both S.47 and criminal enquiries. • If a strategy discussion has not been held and an investigation is underway, professionals should formally escalate their concerns that procedures are not being followed. It is acknowledged however that is hard for professionals to say ‘stop, I don’t agree with what is happening’ in the middle of an investigation, and organisations need to support their staff to do this. • The longer term impact on a child of an investigation that was not well planned is evident in this case. Understanding of procedures and each other’s roles: 3.1.28 It appears that when undertaking an investigation out of hours that the CID officers who undertook the ABE interview are aware that social workers need all the information from an interview in order to make a safeguarding decision for a child, however they do not consider the need for any social work involvement in an ABE interview and criminal investigation other than as providing support to the child. It was stated however that during office hours things are different because the MASH is involved. 3.1.29 As stated above there are views within both the police and CSC EDT about the roles and responsibilities of the other agency that are not necessarily compatible with what is expected in Working Together or local procedures. 3.1.30 When an investigation is required that involves an allegation against an adult who lives with a child, it is important to ensure that the child is protected while the investigation and an assessment is undertaken. Out of hours services are not always able to undertake a full assessment and so they often try to plan to keep the child safe until day time CSC services are able to undertake a fuller assessment. In this case a written agreement was drawn up. (See below). This agreement was not adhered to and the police were not informed of this, although they had been under the impression it remained in place. 3.1.31 There was a joint decision regarding there being not enough evidence following the ABE interview for Sibling to have a medical, which was appropriate. 3.1.32 On the 2.1.17 CSC believed the children were under police protection. The record of the strategy meeting held that day shows agreement that this would be the case. It has been acknowledged that 12 the paper work was not received to confirm this, and the EDT workers stated that this is not unusual as this takes time which is not always available when you are dealing with an emergency out of hours. However to request an email confirming the status is a compromise that would work. Learning: • Relationships between CSC EDT staff and police officers need to be developed across Warwickshire to enable better joint working and an increased awareness of each other’s roles within joint investigations. This will build on the obvious respect and willingness to engage that has been observed during this review. • Clarity is required in emergency situations regarding whether police protection is in place or if S20 agreement is required from parent/s. Written agreements: 3.1.33 The professionals involved in the day following the domestic incident remained concerned about Father’s reaction to Sibling’s disclosures and about the possibility of Father perpetrating further domestic abuse. They had a helpful reflective discussion following the ABE interview. The social worker had looked at the CSC database, CareFirst, and noted concerns about Father being abusive in previous relationships and about Father’s mental health. The EDT social worker agreed with her manager, the police, and then with Mother that the children would go to family members that night. They were aware it was New Years Eve and the social worker felt there was a high chance the parents would be drinking again. Mother gave her parent’s contact details to the EDT social worker. A written agreement was drawn up at the interview suite while the police officers were present. The EDT social worker described Mother as cooperative and that she was confident that Mother understood the working agreement. Mother confirmed her understanding when she met with the lead reviewers. The opportunity was also taken to reinforce that Child K should not co-sleep with her parents, and this was written in the agreement. Although Mother was clear she would stay with Father herself, she agreed the children would have no contact unless it was supervised by the grandparents or a friend. Mother was told that someone from EDT would be in touch the following day. 3.1.34 EDT told the review they often use written agreements in order to make the provisional plan clear to family members until the daytime staff come in and can undertake a full assessment. In this case the plan for the children to go and stay with grandparents was a good one, but it was not discussed with the grandparents beforehand to check that it was convenient to them and to check their level of cooperation with the plan. 3.1.35 When it became evident on 1.1.17 that the written agreement had been broken, appropriate CSC management advice was sought and it was agreed that there was no evidence that the threshold for emergency intervention was met and that when daytime services returned on 3.1.17 they should start an assessment. This view was probably correct; however the information on the change of plan was not shared with the police. 3.1.36 Written agreements can provide a false sense of security. Their effectiveness as a tool to ensure compliance with a plan to protect a child is questionable. There is no reference to written agreements in legislation, statutory guidance or procedures. They are however a tool that is used to enhance understanding of expectations, provide evidence of cooperation or lack of cooperation, and may be used to provide an informal plan for a case before an early help, child in need or child protection plan is in place. They may be a good way of ensuring that the expectations of the parent are written down, rather than just explained verbally, but they do not ensure a child’s safety. 3.1.37 In this case Mother agreed readily to all that the social worker asked, she said she understood the expectations over the next few days, and she signed the agreement. She was very detailed in how she would protect her children. It could be seen as disguised compliance as she did not adhere to the agreement in any way. Father had been clear that he had no intention of cooperating, and it appears that he persuaded Mother to disregard the commitment she had made. Mother had also 13 given false details and did not contact her parents before Father was released, which made the review question her commitment to the plan. 3.1.38 The use of written agreements in cases where there is domestic abuse has been questioned in a 2017 report from Ofsted and the CQC.18 They conclude that the use of written agreements is largely ineffectual as the focus on the written agreement is usually the ‘victim’ and not the perpetrator who is the source of the abuse. In this case the EDT social worker did attempt to gain Father’s support of the agreement, which is good practice. His outright refusal to cooperate made the effectiveness of the agreement questionable. 3.1.39 The Derbyshire LSCB SCR into the death of Ayeesha-Jayne Smith stated that ‘the role of written agreements appears to be common and, yet, it is known that women who are in situations where domestic abuse is a risk will find it very hard to comply with such an agreement.’ There is widespread agreement in both Ofsted reports and in SCRs that the use of written agreements in domestic abuse cases in particular puts unrealistic demands on the victim and is very unlikely, therefore, to protect the children. 3.1.40 In any circumstances where a working agreement may be suitable, support and cooperation needs to be sought from all the participants to the working agreement before it can be considered to have been made. This particularly applies to the agreement of any adults who are providing safety for the children, such as in this case, the maternal grandmother. 3.1.41 Concerns have also been shared about the use of police bail to manage risk in domestic abuse cases. There is recent learning from domestic homicide reviews in Warwickshire that shows that police bail should not be relied on the reduce risk to victims and their children. Learning: • The use of written agreements in cases where there is a possibility of domestic abuse and where the agreement asks for one parent to ensure there is no contact between another parent and the children may not be realistic and may provide false assurance. • Adults whose role in a working agreement is to provide safety to children need to understand their role and be informed about what they are protecting the children from in order for the plan to be effective. 5 Conclusions 5.1.1 The interventions during the period from 31.12.16 until 2.1.17 included good and conscientious practice. There was little doubt that all those involved worked hard and tried to ensure that the situation was dealt with as thoroughly and quickly as possible, with the hope of securing the best outcomes for the children. As stated in the 2016 Triennial Analysis of SCRs, for many of the children who are the subject of an SCR, ‘the harms they suffered occurred not because of, but in spite of, all the work that professionals were doing to support and protect them.’ 5.1.2 It was not known in advance of Father’s disclosure that Child K had been injured during the domestic incident on 31.12.16. No one had mentioned that she had been dropped, and she seemed well when seen by professionals. With hindsight her head was said to have been an odd shape, but this is not unusual in a new born baby, and Father’s assertion that she had been premature provided some context around this. 5.1.3 The risks posed to the children in the household appeared to be around the accumulative risks due to domestic abuse and parental behaviours linked to Father’s mental health and possibly Mother’s drinking, rather than a serious physical assault on a baby requiring emergency action by agencies. 5.1.4 Good practice was evident, and has been outlined above. Most notably, Sibling was listened to, Managers were kept updated appropriately throughout 31.12.16 – 2.1.17, and there was prompt action to protect both children on 2.1.17. 18 The Multi-Agency Response to Children Living with Domestic Abuse. Prevent, Protect and Repair. Ofsted, CQC, September 2017. 14 5.1.5 Learning has been identified about the response to Sibling’s disclosures and this opportunity to consider out-of-hours practice has been valuable. 6 Learning and recommendations 6.1.1 The main issues that have been identified as learning from this case have been highlighted within the analysis section above,. The WSCB SCR Group, along with the lead reviewers, has considered the learning and has identified questions and recommendations for the WSCB in the area thought to be of most importance. 6.1.2 The Triennial Review states that ‘good quality SCRs should incorporate particular characteristics. These include lessons learned which are clearly linked to the findings of the review; findings and questions for the LSCB, to promote deeper reflection on the lessons of the review, and leading to a response and action plan developed by the Board to address that learning; specific recommendations where there is a clear case for change, again with a response and action plan developed by the Board; and a strategy for dissemination and learning of the lessons that will reach relevant practitioners and managers within the Board’s constituent agencies’. 6.1.3 The questions and recommendations for the WSCB are directly linked to the four learning areas of; the context, understanding of roles, strategy meetings, and written agreements. Context and understanding of roles: Recommendation 1 WSCB to consider how effective the current police structure is in ensuring that Warwickshire Police can fulfil their roles as stated in Working Together 2015. Recommendation 2 Warwickshire police to consider whether officers directly involved in child protection investigations have sufficient participation in interagency safeguarding training, as set out in the WSCB Training strategy, in addition to the single agency role specific training provided in house. Recommendation 3 Warwickshire police have informed the review that they have improved systems in place for ensuring Police Protection paper work is completed and shared with CSC. The WSCB should request that an audit is undertaken to ensure this is the case. Strategy meetings: Recommendation 4 WSCB to request a review of strategy meetings to ensure that any child protection concerns coming into the system, but not via the MASH, are meeting statutory requirements. Written agreements: Recommendation 5 WSCB to publicise to professionals the limitations of written agreements, using this case as an example. |
NC52214 | Death of a 9-month-old infant, from heart failure and chest infection in April 2016. Baby KK was born prematurely and experienced health problems including bronchiolitis, sepsis and injuries requiring nine hospital admissions during his life. Baby KK's 2- year-old sibling was born when mother was 17 and father was 20 years of age. The family lived in supported accommodation. Mother frequently accessed hospital ante-natal services during her pregnancy with Baby KK. Evidence of domestic abuse which was not disclosed. Involvement of children's social care and concerns, including two referrals to the NSPCC, about unhygienic home conditions and child neglect. Both children were made the subject of child protection plans when Baby KK was 3-months-old. Uses the SCIE Learning Together model for case reviews, a systems approach which provides a theory and method for understanding why good and poor practice occur. Key findings: need for understanding of roles in partnership working relationships so that opportunities for review and assessment of a child's needs are not missed; tendency for hospital professionals to focus on the presenting illness or injury and not to consider other explanations; limited involvement of hospital professionals in safeguarding work; reluctance of general practitioners to refer directly to children's social care; and the fluctuating nature of neglect and the inconsistent ability of parents may undermine professionals' ability to see and respond to neglectful parenting. Makes no recommendations but poses several considerations for the safeguarding board and partner agencies for the eight findings identified.
| Title: Report of the serious case review regarding Baby KK. LSCB: Surrey Safeguarding Children Board Author: Fiona Johnson and June Hopkins Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final report 15-6-18 1 Surrey Safeguarding Children Board Report of the Serious Case Review regarding Baby KK Authors: Fiona Johnson and June Hopkins SCIE Lead Reviewers Final report 15-6-18 2 Contents 1. Introduction 3 1.1 Why this case was chosen to be reviewed 3 1.2 Succinct summary of case 3 1.3 Family composition 3 1.4 Time frame 3 1.5 Organisational learning and improvement 3 1.6 Methodology 4 1.7 Reviewing expertise and independence 5 1.8 Acronyms and terminology 5 1.9 Methodological comment and limitations 5 1.10 Participation of professionals 1.11 Contribution of the family 6 2. The Findings 7 2.2 Appraisal of professional practice in this case: a synopsis 7 2.3 Views of the parents 15 2.4 In what ways does this case provide a useful window on our systems? 16 2.5 Summary of findings 17 2.6 Findings in detail 18 APPENDICES 45 Methodology 46 Glossary 51 BIBLIOGRAPHY 53 Final report 15-6-18 3 1. Introduction 1.1 Why this case was chosen to be reviewed The Local Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the statutory criteria: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died (Working Together to Safeguard Children, 2015 4:18 p 76) 1.2 Succinct summary of case 1.2.1 This review concerns services provided to Baby KK and the family. Baby KK was nine months old at the time of death and had lived in the community with mother and father. Baby KK was born prematurely and experienced a range of health problems requiring repeated admissions to hospital. Children’s Social Care (CSC) were also working with Baby KK and the family as there were concerns about the care being provided by the parents and from the age of three months Baby KK and Sibling were the subject of child protection plans because of neglect1. The cause of Baby KK’s death was unclear at the time however the post mortem identified the following causes: - 1a Hypoxic ischaemic heart failure following resuscitation from cardiac arrest 1b Chest Infection. 1.3 Family composition Family member Age at the time of the child’s death Baby KK 9 months Sibling 2 years Mother 20 years Father 24 years 1.4 Timeframe The time frame for the review was agreed as being from September 2014 when the family first moved into supported housing until 30th April 2016 when the baby was pronounced dead. 1.5 Organisational learning and improvement 1.5.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into 1 If child protection enquiries show that a child may be suffering or is likely to suffer significant harm, an initial child protection conference will be organised and if the conference decides that the child is suffering (or is likely to suffer) significant harm then the decision will be made for him/her to have a child protection plan. The aim of the plan is to try and stop any harm happening to the child and make things better for him/her. Final report 15-6-18 4 programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’. 2 1.5.2 The Learning Together Review process requires that prior to starting the review the LSCB identifies broad research questions which go beyond the facts and issues in this case, to look more widely at their child protection systems. Specifically, it was felt that it would be useful to examine the following areas: - • How effectively are agencies working together with families where children are on child protection plans because of neglect? • How effective are professionals at achieving change with families where there is disguised compliance? • How effective are professionals at using information and knowledge gained when working with older siblings in assessing risk for babies when all children are the subject of child protection plans? 1.6 Methodology Statutory guidance requires SCRs to be conducted in such in a way which: • ‘recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings’3. It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: • ‘there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process’.4 2 Working Together 2015, 4:7 http://www.workingtogetheronline.co.uk/chapters/chapter_four.html 3 WT 2015, 4:11http://www.workingtogetheronline.co.uk/chapters/chapter_four.html 4 ibid Final report 15-6-18 5 To comply with these requirements, the LSCB has used the SCIE Learning Together systems model5. Detail of what this has entailed is contained in Appendix 1 of this report. 1.7 Reviewing expertise and independence 1.7.1 The review has been led by Fiona Johnson, an independent social work consultant, and, June Hopkins, an independent health consultant, who are both accredited to carry out SCIE reviews and have extensive experience in writing serious case reviews. Both reviewers have had no previous direct involvement with the case under review. 1.7.2 The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. 1.8 Acronyms used, and terminology explained Statutory guidance requires that SCR reports: ‘be written in plain English and in a manner, that can be easily understood by professionals and the public alike’6. Writing for multiple audiences is always challenging. In the Appendix 2 we provide a section on terminology aiming to support readers who are not familiar with the processes and language of the safeguarding and child protection work. 1.9 Methodological comment and limitations 1.9.1 There were some challenges to the smooth running of this review. Attendances at review team meetings was inconsistent, with GP attendance being particularly problematic. The first core group meeting between the review team and front-line professionals was also poorly attended with few health professionals being present. There was good involvement in both meetings however by CSC and housing staff. There were also pressures on the administrative support for the review. 1.9.2 Another difficulty was that it was not possible to involve the parents until late in the review because of civil and criminal matters separate from the serious case review. This meant that the parents’ perspective was only known when the bulk of the analysis was complete and resulted in some significant re-writing of the report during the end stages. 1.10 Participation of professionals The lead reviewers and the review team have been impressed throughout by the professionalism, knowledge and experience that the case group (the professionals involved with the family, from all agencies) have contributed to the review; and their capacity to reflect on their own work so openly and thoughtfully in the review process. All this has given the review team a deeper and richer understanding of ‘what’ happened with this family and within the safeguarding network and ‘why’ and has allowed us to capture the learning that is presented in this report. 5 Fish, Munro & Bairstow 2010. Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 6 WT 2015, 4:11http://www.workingtogetheronline.co.uk/chapters/chapter_four.html Final report 15-6-18 6 1.11 Input of the family 1.11.1 Mother was interviewed by one of the lead reviewers and a member of the review team. She was not willing to talk in detail about the services provided over the full review period and wished instead to concentrate on the support provided to Baby KK at the time of death. 1.11.2 Father was in prison on remand for the period of the review for offences separate from the matters in this case. He was advised of the serious case review and was invited to contribute which he accepted, and a video conversation took place. Final report 15-6-18 7 2. The Findings 2.1 Structure of the report 2.1.1 Statutory guidance requires that SCR reports ‘provide a sound analysis of what happened in the case, and why, and what needs to happen to reduce the risk of recurrence’.7 2.1.2 This section contains 8 priority findings that have emerged from the serious case review. The findings explain why professional practice was not more effective in protecting Baby KK. Each finding also lays out the evidence, identified by the review team, that indicates that these are not one-off issues, but are matters that if not addressed could cause risks to other children and families in future work, because they are issues that undermine the effectiveness with which professionals can do their jobs. 2.1.3 Immediately prior to the findings an overview is provided of what happened in this case. This clarifies the view of the review team about how timely and effective the help that was given to Baby KK and the family was, including where practice was below expected standards. This is then followed by the views of the parents. 2.1.4 A transition section of the report highlights the ways in which features of the involvement with Baby KK and the family are common to work that professionals conduct with other families; and, therefore provides useful organisational learning to underpin improvement. 2.2 Appraisal of professional practice in this case. 2.2.1 This section provides an overview of ‘what’ happened and ‘why’. The purpose of this section is to provide an appraisal of the practice that is specific to the case and it therefore includes the review team’s judgements about the timeliness and effectiveness of practice including where practice was below expected standards. Such judgments are made in the light of what was known and was knowable at that point in time. For some aspects, the explanation for ‘why’ will be further examined in the findings in section 4 and a cross reference will be provided. 2.2.2 This case was concerned with the challenge of working with parents who are not keen to engage with services, where neglect is an issue meaning they choose to live in conditions that can generate a considerable level of risk for their children but where evidencing that this is causing the children significant harm is difficult. In these circumstances it is essential that there is close working across all agencies and this review has identified some areas where the joint working between professionals in health and children’s social care could be improved. It focuses on the relationship between professionals working in the community and those in the hospital and examines some differences in focus and approach that can present challenges for safeguarding children particularly in the context of neglectful parenting. Relevant background history 2.2.3 The parents had been in a relationship for some time and had a child together (Sibling), born when mother was 17 and father was 20 years of age. Prior to the review period the parents had limited involvement with statutory services although the father 7 http://www.workingtogetheronline.co.uk/chapters/chapter_four.html Final report 15-6-18 8 had been known to CSC because of his mother’s neglect of him and was known to the police for suspected violence against family members and had convictions for petty theft and criminal damage. Immediately prior to the review period the couple had lived with paternal grandmother and were re-housed because of the poor home conditions at her house. The mother was also known to have attended a school for pupils with learning difficulties. Start of Review Period 2.2.4 At this point the parents had moved with the Sibling to live in a one-bedroom flat within a supported housing complex. Staff there were working with the parents to help them manage their finances and make benefit claims. Initially the flat was clean and tidy but following the death of the paternal grandfather staff noted a deterioration in the home conditions. They provided additional support, and because they thought the father was grieving, offered him bereavement counselling, which he refused. 2.2.5 Soon after the family moved into the accommodation CSC received a referral suggesting the Sibling had possible contact with a registered sex offender. A social worker (SW1) visited the family and was confident that the parents understood the risk and could protect the child. Therefore, the case was closed to children services. This assessment seemed to the review team to be thorough, and the response appropriate. Hospital care during ante natal period 2.2.6 Within four months of moving into supported housing the mother was pregnant again. She accessed antenatal services in good time and at the initial booking visit was rightly referred to the teenage midwife service. At 17 weeks gestation, the mother was admitted to the antenatal ward with premature rupture of membranes (PROM). The hospital staff rightly explained the potential consequences of having PROM which included miscarriage, premature birth and disability of the baby if born prematurely. There was discussion with the mother about a termination of the pregnancy who was anxious to return home to Sibling. Hospital staff did not pursue this further with her and did not explore why she felt father was not able to care for the child. Staff also did not consider getting her consent to share information with other agencies in order that the family could be provided additional support as such discussions would usually only occur if the procedure (termination) occurred. Mother had almost daily access to hospital ante-natal services to support her with her decision and ongoing pregnancy. Staff in the hospital had routinely asked mother about domestic abuse at admission and on other occasions, which was good practice, but did not consider this specifically as a possible cause of the PROM at this stage or later when mother was re-admitted with abdominal pain reportedly caused by sibling kicking her in the stomach. Following this incident mother was admitted to hospital for bed rest however there was no communication with the GP, health visitor or community midwife about the PROM or mother’s concern about the Sibling or her requests for a termination. Findings 2 and 5 explore why aspects of the communication by hospital staff may seem less pro- active with regards to safeguarding. Deteriorating home conditions and concerns reported to NSPCC. 2.2.7 Whilst mother was in hospital, a neighbour spoke to her health visitor about concerns for Sibling which included; unhygienic home conditions, the child being inappropriately dressed and being fed left over takeaway food. The health visitor advised her to report her concerns to CSC and passed the information on to the allocated health Final report 15-6-18 9 visitor, however neither health visitor checked that the referral to CSC was made, which was poor practice. The first health visitor rightly considered that this was the responsibility of the allocated health visitor, and that worker has left health visiting practice meaning that the review team has been unable to find out why this information was not reported appropriately. 2.2.8 Three days after the neighbour spoke with her health visitor, CSC were informed of an anonymous referral made to the NSPCC raising similar concerns. Social workers attempted to visit but were unsuccessful, however they contacted mother by telephone and she agreed to ‘checks’ being made with other agencies. Following this the social workers spoke with the health visitor and discussed the concerns raised in the anonymous referral. The health visitor reported that she was due to visit to complete Sibling’s one-year developmental check and agreed to check whether there were any concerns. The health visitor visited the next day and completed the developmental assessment which indicated that Sibling was developing within normal limits. The health visitor also recorded that the home conditions were poor. This developmental assessment contrasted with the views of housing staff who saw the child very regularly and who were recording and sharing with professionals their concerns about how the space available for the child (because the parents were choosing to live in one room) could adversely affect the child’s development, particularly her motor skills and speech. Following the visit, a duty social worker contacted the allocated health visitor for feedback from the home visit. She was not available, and the social worker spoke with a colleague who referred to the electronic records. Although the records clearly recorded the poor conditions of the home, the precise details of the information exchanged between the two professionals are not known. The impression the duty social worker was given from the call, as recorded at the time, was that the flat was messy but not unsafe and ‘that the visit had not identified any developmental concerns’. It has not been possible to gain a reason for this discrepancy. The consequence was that CSC took no further action regarding the NSPCC referral. 2.2.9 One week later, CSC received a further anonymous referral via NSPCC which repeated the previous concerns about the poor state of the flat and reported that Sibling had a bruised forehead which the parents said was accidental, but the referrer was unconvinced. Initially CSC responded positively by attempting to visit the family, but when they were unable to gain access, and, following contact with the housing staff, a manager made the decision instead to refer the family for a Team Around Family (TAF) meeting which would be attended by a CSC staff member. This wrong decision meant that the bruise was not seen by a professional and led to a delay in the initiation of the child protection process. CSC accept that this decision was incorrect and report that at this point the RAIS8 teams were not functioning well and that changes since made to the services would reduce the risk of this recurring. This is a matter on which the LSCB may wish to receive a report from CSC providing reassurance about the improved functioning of the Assessment and Intervention Service arrangements. 2.2.10 The TAF meeting did not take place for four weeks which is usual practice where there are not seen to be immediate child protection concerns. The meeting was attended by a Family Support Worker (FSW) who then visited the flat and was shocked by the home conditions. He immediately shared them with his manager who asked the 8 RAIS – Referral, Assessment and Intervention Service, the team within CSC that responded to referrals and undertook immediate assessment work. Final report 15-6-18 10 SW1 who had previously been involved with the family to become involved again, which was good practice. SW1 visited and immediately identified that there had been significant deterioration. SW1 referred the parents to a children’s centre for additional support, contacted the maternal grandfather to see if the family could assist and, when after two weeks there was little improvement in the home conditions, he initiated a strategy discussion9 which agreed that the threshold was met for a section 47 single agency assessment10. This assessment was completed three weeks later and recommended holding an Initial Child Protection Conference (ICPC). This was an effective and timely response to the concerns raised. 2.2.11 Soon after this mother was admitted to hospital for to have the baby and when the social worker visited a week later there was a significant improvement in the home conditions, which was maintained for the next visit one week on. That week Baby KK was born but due to prematurity and infection required specialist neonatal treatment and was transferred to a tertiary hospital11. Mother was also ill with sepsis and followed Baby KK to the tertiary hospital but soon after transfer discharged herself from hospital against medical advice. It is of concern that the communication with the GP about this was only a routine discharge letter and there was no contact with the health visitor, although the community midwife was informed by the hospital midwife and she spoke to mother on day one of discharge from hospital. Other professionals in the community working with the family only realised how ill mother had, been during the review. Initial Child Protection Conference 2.2.12 The ICPC was held on the 24th of July 2015. Both parents were present along with professionals from housing, the children centre, a social worker and the safeguarding midwife from the hospital. The health visitor was unable to attend in person and sent in a written report which was brief and did not capture the full picture of how poor the home conditions had been. The review team felt it was regrettable that a health visitor representative was unable to attend in person to contribute to the information regarding the home conditions. 2.2.13 The Chair at the ICPC gave a balanced summing up of the risks and was clear to the parents that if the recent improvements were not maintained then there would be a need for a further child protection conference. Significant weight was given, however, to the information provided by the children centre worker who had only recently started to work with the family and had only recently visited the home, compared with housing staff who had known and worked with the family on site on an almost daily basis for several months. Additionally, the social worker and family support worker were over- optimistic in their hope that the very recent change in the home conditions would be sustained. The social worker felt that the recent improvement meant that the children no longer met the threshold for child protection. This view was not shared by the housing support officer (HSO) and her manager who believed the threshold for child 9 When there are concerns that a child may be at risk of significant harm, CSC will talk to partner agencies about the child and jointly decide if the threshold for a child protection investigation (see Section 47 below) has been met and who should carry out the investigation – CSC and the police (joint agency) or the police alone (single agency). 10 A Section 47 enquiry is an investigation undertaken when social workers have ‘reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child 11 Once a patient is hospitalized, they may require highly specialised treatment and care within the hospital. Tertiary care requires professionals, usually surgeons, with specific expertise in a given field, to carry out investigation and treatment for the patient. Final report 15-6-18 11 protection was met based on their knowledge of the family and the previous failed interventions tried with the family. They were left feeling angry, and that their work and opinions were undervalued by the chair and RAIS staff, when compared with the opinions of other statutory partners. The issues of relationships between Housing staff and other agencies and how they are mutually viewed is discussed further in Finding 1. The HSO and her manager were unaware that there was a formal process for recording their dissent to the outcome of a conference. If formal dissent had been raised, then there was a ‘formal dissent group’ who reviewed all conferences where a formal dissent was recorded. The ‘dissent group’ has now been dissolved but since this time there has been significant LSCB training regarding individual responsibilities to escalate concerns. Child in Need plan 2.2.14 Following the ICPC meeting professionals from children services, health, housing and early help worked with the family. There was almost daily professional contact with the family. Within the home, there were repeated patterns of conditions improving slightly and then quickly deteriorating. All offers of help from housing to help tidy and clean the flat were declined and professionals observed parents failing to maintain basic hygiene including sterilising bottles. Within three weeks of Baby KK’s discharge from hospital the baby was re-admitted with gastroenteritis and was also treated for both nappy rash and a urinary tract infection before being discharged home the next day. Whilst in hospital, the medical staff concentrated on his immediate physical presentation and expressed their concerns by sharing information with the GP and health visitor. Gastroenteritis can cause nappy rash and be associated with urinary tract infection however there was no apparent exploration as to whether unhygienic home conditions could also be a reason for his ill health. Whilst it is understandable and right that the initial focus was on the medical presentation the reasons that medical staff did not explore further other possible causes is discussed in Finding 2. 2.2.15 A month later Baby KK was taken to the GP for a belated developmental check and whilst at the surgery the GP noticed that Sibling was bleeding in the mouth which, on examination turned out to be caused by a torn frenulum, for which the parents had no clear explanation. The GP also thought that the children were not appropriately dressed. At this stage, the GP was unaware that the children were being supported via a child in need plan as the minutes of the ICPC had not been received by the previous GP. He contacted the duty health visitor as he thought that she was the most appropriate person to talk with. She told him about the child in need plan but even after this discussion he did not report the injury to the social worker or take any further action. The review team considered that this was a failure in practice, as even if the injury was accidental, it may have been a result of poor supervision or neglectful parenting and given the levels of concern about this family all such incidents should have been shared. The issue of GP’s not referring directly to CSC is discussed in finding 3. 2.2.16 Throughout this three-month period there were frequent reports by different professionals of poor home conditions including dirty bottles strewn around with no clean bottles ready for use. On one visit the HSO asked about the steriliser and found it in a cupboard; there were plates of food with mould around the living area plus piles of empty food packaging. As a result, the HSO (with the parent’s permission) took a photo of the home conditions and sent it to the social worker, this was sustained and consistent Final report 15-6-18 12 intervention by these staff in raising concerns about the family. Despite such evidence of concern, it took three months of continued assessment and child in need work before a strategy discussion was held and a further ICPC organised. The challenges facing professional when working in families where neglect is present are explored in Finding 4 Second Initial Child Protection Conference 2.2.17 Three months after the first ICPC, a second ICPC was held and rightly decided that both children should be made the subject of child protection plans. The child protection plan that was agreed was explicit in detailing the strengths and weaknesses of the family and outlined in simple terms the professionals’ concerns about the risks to the children. It also stated that change was needed within speedy time frames and that if this was not achieved then legal intervention should be considered. Following this conference, key worker responsibility was transferred to the Child Protection and Proceedings Team and SW2 was allocated to provide long term support for the family. This social worker recognised that mother could have a learning difficulty and immediately used methods such as pictorial instructions to aid communication with her. 2.2.18 During the month after the ICPC professionals noted ongoing concerns in the care being provided to the children including untreated nappy rash, poor sterilisation of bottles and Baby KK sleeping in a car seat. At the end of the month Baby KK developed bronchiolitis and was seen twice at the hospital where the baby was noted to be in dirty clothes and ‘a bit smelly’. It is not unusual when a child is developing bronchiolitis that they are not admitted at the first attendance as admission only occurs when the child requires additional support. During this time the family would have had open access to the ward and the staff would check that mother had sufficient transport and would be given advice about when to return to hospital. The next day the baby was readmitted to hospital and was diagnosed with bronchiolitis and sepsis. Baby KK’s condition deteriorated rapidly and full resuscitation support was required to keep the baby alive. Due to the level of intensive care that was required Baby KK was immediately transferred to a London tertiary hospital the same day. There was prompt sharing of information between both hospital safeguarding nurses and the social worker. 2.2.19 After 10 days in London, Baby KK was transferred back to the children’s ward at the local hospital. A parent is expected to stay on the ward to care for their child’s routine care. Father stayed with Baby KK, but nursing staff were concerned that he did not wake in the night to feed the baby who was also left in dirty clothes. These concerns were discussed at the weekly hospital safeguarding meeting. This meeting is an opportunity to discuss children who have been to the hospital and ensure information is shared with other agencies, including CSC. Whilst, the safeguarding nursing staff are regular attenders at these meetings, CSC are represented by a duty social worker from the local team which means there is a different professional attending each time who will not know the children discussed in person and may be unfamiliar with hospital systems and terminology12. The weekly safeguarding meetings are well established within the hospital, but routinely only the specialist safeguarding hospital staff attend in person and only occasionally the doctors in charge of Baby KK’s care. There is a heavy reliance on the named nurse/safeguarding team being the main communication route in all safeguarding matters. The potential shortcomings of this system are explored in Finding 5. 12 This has now been changed and the same social worker now attends those meetings Final report 15-6-18 13 2.2.20 As Baby KK became medically fit for discharge the SW2 contacted the hospital named nurse and requested that the baby be kept in hospital for a couple of days longer as the home conditions were unsuitable. It is therefore surprising that although, this was known there was no formal discharge planning meeting involving community health and social work staff to ensure that community support was in place for the baby’s health requirements and the review team has not been able to find an explanation for why this did not happen. It is reported, but not recorded, that there was telephone communication with community health professionals however this was a missed opportunity for hospital staff to meet with all professionals working with the family in the community to gain a mutual understanding of Baby KK’s health needs and to plan jointly how best to manage and assess safeguarding risks post-discharge. It is thought that the absence of this joint planning further reflects the issues raised in Findings 2 and 5. 2.2.21 Prior to discharge, the parents were informed by the social worker that the local authority would be seeking legal advice in respect to the children, and asked them to sign a written agreement, this was good practice. Baby KK was discharged home just before Christmas and during that week there were two visits by social workers and it was noted that the poor home conditions continued, with dirty bottles, nappies and left- over food all over the living area. When a social worker visited soon after Christmas the condition of the flat had further deteriorated, and Sibling had a cold. Baby KK was seen to be sleeping in the car seat. Soon after both children were unwell and were taken to the hospital where Baby KK was admitted for tube feeding as the respiratory illness was making it difficult for the baby to feed. The parents raised the issue of mould as being the reason for the illness but there was no contact made with the social worker to discuss home conditions. Baby KK was discharged home on the 5th of January. When SW2 visited the next day, she was concerned about the home conditions and immediately asked her manager to see the property. At that visit it was decided that the living conditions were unfit for the children and it was agreed that mother and the children would be moved to a bed and breakfast accommodation for the weekend so that father could clean and tidy the flat. Whilst the provision of alternative accommodation for the family was a good intervention to allow father to sort the flat, in reality, he spent most of the weekend with mother and the children, however the result was some improvement in the home conditions. Review Child Protection Conference and initiation of legal proceedings 2.2.22 The review child protection conference took place the next day and correctly decided that the child protection plan should continue. Some of the conclusions recorded in the minutes of the conference appear to contradict the professional contributions to the meeting, as the chair was very positive about the parents in his summing up. Despite intensive support there had been no real improvement in the care provided to the children and concerns were escalating with consideration being given to initiating legal intervention via the Public Law Outline (PLO) process13. This emphasis on the positive aspects of the parents’ care minimised concerns from other professionals and reflected an over-optimistic stance that was taken by the chair of the review. This attitude is not considered to be representative of the whole service. 2.2.23 Given the history of the family failure to sustain changes and the escalating risk 13 PLO – Public Law Outline the framework within which court proceedings are initiated by the Local Authority under The Children Act 1989 – see glossary for more detail. Final report 15-6-18 14 to the children it was appropriate that SW2 and her Manager initiated PLO proceedings. This decision was confirmed by the Service Manager in early January, who recommended a comprehensive parenting assessment, a family group conference and a psychological assessment of both parents to review their cognitive functioning. It was then almost seven weeks before the parents were given the letters of intent14 to formally start the legal process. This was because there were significant delays in the local authority legal section authorising these letters. This was a known problem that is now resolved however the LSCB may wish to receive a report from CSC about how well their legal processes are now working. A PLO meeting was then convened appropriately within two weeks but as father had not obtained a solicitor to represent him this process could only be progressed with mother. To resolve this SW2 and HSO assisted father obtain a solicitor and a second PLO meeting was held a month later. The extent to which the legal process can hinder effective safeguarding of children where there is neglect is considered in Finding 6. 2.2.24 During this period, there were two significant events reported. There was an anonymous referral to the police that reported hearing the parents arguing and suspicion that a child may have been slapped. The police attended and spoke to mother alone initially. No allegations of physical assault were made. Both children were seen by police officers. Sibling was awake and appeared happy, Baby KK was fast asleep in the car-seat. The police correctly shared this information with CSC. 2.2.25 The second significant episode happened a month later when Baby KK was taken to hospital with a left arm injury. The parents reported to hospital staff that the baby’s arm got caught in the cot bars. The Accident & Emergency registrar examined the baby and could find no evidence of bruising or swelling and concluded that it was an accidental pulled elbow that had spontaneously reduced. However, Baby KK was a child subject to a child protection plan with known safeguarding concerns who was under one year of age, and the protocols require that the registrar should have therefore referred the baby to a paediatrician for examination and consideration of immediate referral to CSC. The social worker would have known of Baby KK’s history of sleeping in a car seat and therefore may have challenged the history of the baby reportedly being in a cot. 2.2.26 SW2, after being informed of Baby KK’s injury, was also told by the children’s centre of a possible assault against mother and immediately contacted her. Mother denied that the father had tried to hurt her but confirmed that Baby KK had an arm injury caused by getting it trapped in the cot bars. SW 2 was uneasy with this explanation and rightly contacted the hospital staff to question them about the presentation. The doctor remained adamant that they had no concerns regarding the mechanism of the arm injury, although it was noted that Baby KK was unkempt and possibly overweight. 2.2.27 Given the continuing concern about the mechanism of the injury, it is unfortunate that there was no consideration by the social worker or manager of contacting the LSCB Designated Doctor or the Named Doctor for safeguarding children at the hospital for further advice regarding escalating their concern. This was in part because they both assumed that the registrar, as the expert, knew best and they were unaware of the protocol requiring the child be referred to a paediatrician. It may also reflect a lack of knowledge by those staff about how to challenge medical staff judgement and a concern 14 ‘’letters of intent’ are the letters given to families at the start of the legal process of the public law outline indicating to parents that the local authority is starting court proceedings. Final report 15-6-18 15 that such challenge would not be effective. The reasons for professional reluctance in escalating concerns is further explored in Finding 7. 2.2.28 At this time Baby KK’s breathing problems were worsening resulting in frequent presentations at the hospital. Soon after, the hospital admitted Baby KK for observation and to check on whether mother was using the inhaler properly. It is routine practice that when a child is prescribed inhalers in hospital staff teach parents inhaler techniques and review these at every admission. This is conducted routinely and would only be documented if there were concerns about the technique. A pre-term infant with bronchiolitis can be expected to attend recurrently with wheeze and chest problems. Given that inhalers had been prescribed for almost five months the review team felt that this check was over-due. It was known that mother had attended a school for children with learning difficulties however it is unclear if hospital staff made any adjustment for her understanding. This is an issue that is considered in Finding 8 which discusses the different professional approaches to giving advice and information to parents. This point was also an opportunity to explore whether the wider social conditions were impacting on the parents’ capacity to care effectively for a sick baby. Considering that this was Baby KK’s ninth admission since birth the review team felt more consideration to the support required by the family in the community should have been considered before discharge. The reasons this did not happen are discussed in Finding 2, 5 and 7. 2.2.29 Three days later, on the 29th of April, Baby KK was admitted to hospital by ambulance after being found lifeless and floppy, he was transferred to a London Hospital, but sadly died the following day. 2.3 Views of the Parents Interview with Mother 2.3.1 The lead reviewer met with Mother at a Housing Support Office. She was clear that she did not wish to discuss her relationship with the Father and felt that the focus of the interview should be on the professional interventions with regard to Baby KK. She said that there was mould in the bedroom within three days of them moving into the flat and that this meant that the ‘house was a bit of a mess’ because they were ‘sitting and sleeping in the front room’. She also said that Father ‘didn’t do housework’ so Mother ‘had to do it even when she was meant to be on bed rest’. 2.3.2 Mother said that she felt supported by the Housing Support staff and also the children’s centre however she was unhappy that she was pressurised by the social workers to attend the children’s centre but that there was not similar pressure put on Father. Mother felt that SW1 was of assistance but that SW2 was less helpful although she admitted that she was probably doing her job. Mother said that she felt that even when they cleaned up the flat SW2 was ‘never satisfied that it was good enough’. She said that Father ‘got on okay’ with SW1 but he was very angry and difficult with SW2. When asked if SW2 could have done anything to help manage Father, Mother replied that he ‘was stubborn and he didn’t do things or listen. If he doesn’t like what you are saying he will argue back at you. He would kick off if he didn’t agree and swear.’ Mother did confirm that Father was violent towards her but admitted she had not told Final report 15-6-18 16 any professional about this and said that she never felt safe to do so as she felt that Father was always watching her. She felt that professionals should have realised that Father was violent because of how he spoke to her. 2.3.3 Mother was asked about the support she got in hospital and said that when Baby KK was given an inhaler ‘they showed us once, that wasn’t helpful’ she went on to say that it was ‘really hard to use the inhaler, [the baby] would cry so much that Mother wasn’t sure that [the baby] could take much in because [the baby] was crying too much’. Mother said she spoke to hospital staff who said that he should be okay. Mother said that at the time she thought that it wasn’t working but that hospital staff said it was fine, it was working so she believed ‘what the doctors and nurses say’. Some [of the hospital staff] were really lovely and Mother could ask questions, but some used ‘really long words’ that she didn’t understand. Mother explained that she was dyslexic, she said that she googled bronchiolitis as she didn’t know what it was or how it was caused but she was anxious about this as she knew that ‘Google can’t be relied on’. Sometimes Mother checked with nurses what the doctors had said and said that some were helpful but that others were less supportive. Mother was anxious to understand why Baby KK had died and felt that if he had been given oxygen not just an inhaler then he might not have died. 2.3.4 The Mother also provided information about the child death rapid response process which was shared with the Child Death Overview Panel as it was relevant but fell outside the scope of the serious case review. Interview with Father 2.3.5 The lead reviewer spoke with Father via a video link. Father felt the professionals were not listening to their concerns that the poor home conditions and especially the mould was contributing to Baby KK’s poor health. Father felt the mould was due to a fault with the building and not due to their lifestyle. 2.3.6 Father said that he understood that if he tidied the home and paid the rent arrears then the family would be moved to new accommodation. He said that whilst he did what was asked of him he felt let down that they were not moved. 2.3.7 Father admitted he hated working with social workers as he had experience of them as a child and in his view, they had not changed how they practiced. He also felt at times he was receiving mixed messages about how the professionals viewed the property, with some people at times saying it was good then in the same time-period others saying it was not good enough. 2.3.8 Father was asked about the support the family got from the hospital. Generally, he felt “they did their part”, but just kept prescribing inhalers which had to be given four hourly. However, he felt strongly that at the last attendance at the local hospital Baby KK should have been admitted but wasn’t and within 48 hours he had died. Final report 15-6-18 17 2.4 In what ways does this case provide a useful window on our systems? 2.4.1 The LSCB agreed broad research questions at the start of the process, which go beyond the facts and issues in this case, to look more widely at their child protection systems. The questions are set out at in paragraph 1.5.2 and directly link to the areas covered in the appraisal of practice and the findings 2.4.2 A key area of research was how effectively agencies work together with families where children are the subject of child protection plans because of neglect. This review has identified that it is challenging for professionals to evidence significant harm where there is neglectful parenting and that this may cause delay in the progress of legal proceedings. It has also shown that closer working between hospital professionals and social workers could assist in identifying significant harm earlier and improve safeguarding of children in these situations. 2.4.3 One of the research questions was concerned with how effective professionals are at achieving change with families where there is disguised compliance. This review has highlighted the importance of understanding parents’ capacity in determining whether they are deliberately failing to co-operate with professionals. In this case it was noteworthy that at the time of the review there was still a lack of clarity about how capable the parents were and whether they deliberately ignored advice or did not really understand what was expected of them. 2.4.4 The LSCB was also concerned to understand better how effectively professionals were using information and knowledge gained when working with older siblings in assessing risk for babies. This review has shown that whilst information was known and shared, the key challenge was in being able to interpret the effect on children of the parents’ actions, and in particular, in judging whether this was causing significant harm. Final report 15-6-18 18 2.5 Summary of findings The review team have prioritised 8 findings for the LSCB to consider. These are: Finding Category 1 There is a perception from partner agencies in part of the county that Child Protection & Proceedings teams have a better understanding of the relevance of supported housing input for safeguarding than Assessment and Intervention services, undermining joint working in early intervention. Professional norms & culture around multi- agency working in assessment and longer-term work. 2 Do hospital professionals standardly take a medical and social history only to inform their treatment of the immediate presenting illness/injury rather than also assessing whether the health history raises safeguarding issues? Professional norms & culture around multi- agency working in assessment and longer-term work. 3 Are general practitioners in the county reluctant to refer directly to Children’s Social Care, preferring to consult with fellow health professionals? Professional norms & culture around multi- agency working in assessment and longer-term work. 4 Does the fluctuating nature of neglect and the inconsistent ability of parents to maintain improvement undermine professionals’ ability to see and respond to neglectful parenting? Professional norms & culture around multi- agency working in assessment and longer-term work. 5 Seeing the task of hospital clinicians as to “assess, treat, discharge, and where necessary refer on to specialist services” works for most children but means there may be limited involvement of hospital professionals in on- going safeguarding work even when a child is being admitted repeatedly to hospital, undermining multi- agency safeguarding work to protect children. Professional norms & culture around multi- agency working in assessment and longer-term work. 6 Does the nature of chronic neglect mean that evidencing that deteriorating conditions is increasing harm, make it hard for the current threshold in care proceedings to be met, risking leaving children for over-long periods in substandard care? Patterns in human– tool operation. 7 Is there a culture in the area whereby constructive challenge is interpreted as personal and organisational criticism, fostering defensiveness between agencies and reducing the likelihood that escalation of safeguarding concerns happens when needed? Patterns in human– management system operation 8 The routine method of communication used in hospital settings – namely verbal instructions - does not accommodate limitations to parental capacity to understand the information being given. Professional norms & culture around multi- agency working in assessment and longer-term work. Final report 15-6-18 19 2.6 Findings in Detail Finding 1 There is a perception from partner agencies in part of the LSCB that Child Protection & Proceedings teams have a better understanding of the relevance of supported housing input for safeguarding than Assessment and Intervention services, undermining joint working in early intervention. Professional norms & culture around multi-agency working in assessment and longer-term work. Introduction Supported Housing staff have a key safeguarding role to play, alongside their colleagues in social care, health and the police. Published case reviews highlight that housing services often conduct regular inspections of family homes and have a unique insight into the lifestyles of their tenants. Therefore, housing have a potential wealth of knowledge regarding the family that should be an important source of information when assessments are being undertaken. This is particularly true of Supported Housing staff who mainly work with vulnerable families where there are identified support needs. The complex nature of child protection work means that dysfunctional relationships and poor communication between professionals and, also, the family often occur and can increase risk. How did the issue feature in this particular case? By the time the Initial Child Protection Conference (ICPC) was held in the July the Housing Support Officer (HSO) had been working with the family for over 9 months. In that time, the HSO had established a close working relationship with the parents, this was helped by the fact that the HSO saw the family frequently and at different times of the day. Initially the HSO focus with the parents was to support them with claiming benefits, but within a short period the general poor living conditions within the flat became a major concern. The HSO attempted to support the parents to recognise and improve the home conditions and offered different methods of interventions which ranged from practical help to tidy and clean the flat to the suggestion of a referral for grief counselling for father, but all offers were declined. Over the nine-month period it was noticed by housing staff that there were occasional improvements to the home environment usually in response to an official warning, but, the improvements were never sustained. Following the anonymous referrals to CSC, a strategy meeting was held in June and it was agreed that CSC would undertake a single agency section 47 enquiry. This resulted in SW1 and a Family Support Worker from the RAIS team being allocated to the family, who worked with the parents over a six-week period prior the ICPC being held. Initially there was little progress seen by CSC by the parents in improving the living conditions, and on completion of the section 47 enquiry on the 2nd of July SW1 concluded that sibling1 was experiencing harm and that there should be an ICPC. Final report 15-6-18 20 However, when the ICPC was held three weeks later (10 days following the premature birth of Baby KK) SW1 felt that the recent improvement of the home conditions and willingness of the parents to engage with professionals meant that the need for a child protection plan for both children was not required and that a child in need (CIN) plan was sufficient. This view was supported by all the other professionals attending the conference including the Chair with the clear exception of the HSO and their manager. Interestingly, despite the HSO being the one professional present who had worked with the parents for the longest and had seen how changes made to improve home conditions had never lasted, the Chair appeared to give greater weight to the opinions of other professionals who had only started to work recently with the family, some of whom had never visited the home and seen the home conditions first hand. The HSO manager was so sure that the CIN plan would be insufficient to protect these children that she remarked to the Chair “see you back here in 3 months” which turned out to be the case. How do we know it is an underlying issue and not something unique to this case? The case group on discussion of this matter reported that other agencies also felt that there are closer working relationships and understanding of roles between workers from the Child Protection and Proceedings teams compared with the other early help and assessment teams. When exploring possible reasons for this it was felt that many factors came into play. These reasons could include: • The initial assessment phase is a short-term intervention by a social worker compared with the longer-term work with families supported by child protection plans meaning there are ongoing relationships forged with other professionals working with the family; • The assessment process may focus on gathering information from a range of professionals whereas longer-term work includes more face-to-face meetings and sometimes joint visits • There is greater opportunity within this longer-term work for all agencies to be able to explain their roles and for professionals to gain mutual understanding of skills and knowledge. • The Assessment & Intervention Service discussions with partner agencies are often focussed on determining thresholds for CSC intervention which may be conflictual whereas the involvement of the Child Protection & Proceedings teams has been determined by the child protection conference. How common and widespread is the pattern? This review only involved staff from one are within the area however the reasons given by professionals for the differences in working relations could apply across all of the county. There are other structures for delivering social work services that may ameliorate some of these issues by delivering services without separating assessment work from longer- term work. Final report 15-6-18 21 What are the implications for the reliability of the multi-agency child protection system? Effective practice with children and their families requires sound professional judgement based on evidence and the practitioner's knowledge and experience. If professionals working with a family do not have a clear understanding of each other’s role and potential knowledge, then there is a risk that assessments will lack important information. This will in turn affect the quality of critical and analytical thinking that needs to take place and may influence the quality, effectiveness and timeliness of decision making. 15 Early help means providing support as soon as a problem emerges, at any point in a child’s life, from the foundation years through to the teenage years. Providing early help is more effective in promoting the welfare of children than reacting later.” (Working Together 2013) 16 Appreciative Inquiry (AI) is a change management approach that focuses on identifying what is working well, analysing why it is working well and then doing more of it. The basic tenet of AI is that an organization will grow in whichever direction that people in the organization focus their attention. If all the attention is focused on problems, then identifying problems and dealing with them is what the organization will do best. If all the attention is focused on strengths, however, then identifying strengths and building on those strengths is what the organization will do best. Finding 1: There is a perception from partner agencies in part of the county that Child Protection & Proceedings teams have a better understanding of the relevance of supported housing input for safeguarding than Assessment and Intervention services, undermining joint working in early intervention. One of the key aspects to effective interventions with families is the quality of partnership working relationships between different professionals. If the understanding of each other’s roles is not clear for those working at the early help15 stage, then opportunities for review and assessment of a child needs can be missed or delayed potentially leaving some of them at risk of significant harm. Considerations for the Board and partner agencies • Do the reasons given for this fully explain the issue? • What lies behind this? • Is it likely to apply to all the teams in the county? • Do other agencies in the county divide their services between assessment and longer-term work? • How does the Board think that the adoption of ‘Appreciative Inquiry16’ will change practice? Final report 15-6-18 22 Finding 2 Do hospital professionals standardly take a medical and social history only to inform their treatment of the immediate presenting illness/injury rather than also assessing whether the health history raises safeguarding issues? Professional norms & culture around multi-agency working in assessment and longer-term work. Description Child neglect can be multifaceted and enduring, and as such may be difficult to pick up from one single incident. It may involve a broader set of circumstances which can only be pieced together through the accumulation of evidence. Though neglect can affect any child, its impact particularly applies to infants and very young children who, among all the age groups, are at the highest risk of death and/or mental and physical damage. Whilst the immediate focus on the presenting illness/accident is essential it is also necessary for there to be adequate consideration of the impact of the home conditions on the health and general development of children. How did the issue manifest in this case? Even before the birth of Baby KK, there were known concerns about the poor home conditions and the parents’ ability to fully acknowledge the impact this could have on their children. From the antenatal period, this knowledge was shared with hospital staff and information relating to safeguarding was completed in a specific section of Baby KK’s medical records. During the baby’s lifetime Baby KK was seen and/or admitted to the local hospital on several occasions in addition to being seen for follow up appointments. The baby presented with a range of health problems including gastroenteritis, bronchiolitis, and an arm injury. Although these illnesses are not in themselves uncommon for babies to have, especially over the winter months and gastroenteritis can cause nappy rash and be associated with urinary tract infection, it appeared that other contributory factors were not explored in depth. One example was when Baby KK was taken to hospital with gastroenteritis. When the child was admitted to hospital it was not documented that a possible cause was the lack of cleanliness and hygiene at home. Professionals in the community at that time were reporting observations of feeding bottles with mould and the bottle steriliser being found still in the cupboard. At the time staff in the hospital were unaware of these concerns despite SW2 approaching the hospital to ask if there could be a link. Similarly, following an acute episode of bronchiolitis in the November, the causes of subsequent presentations to hospital with breathing difficulties were not explored beyond the immediate medical cause despite both parents and professionals suggesting that the poor home conditions may have been a factor. Final report 15-6-18 23 A final example is that when Baby KK presented at Accident & Emergency with an arm injury. Even though there was a child protection plan because of neglectful parenting, the injury and the parent’s explanation were accepted, and the other known risk factors were not considered. If this had happened, then he would have been referred to be seen by the paediatrician. How do we know it is an underlying issue and not something unique to this case? (what other evidence is there?) The case group reported that this is common practice and can be evidenced in different departments. Often the time-pressure on services results in reduced consultation times, therefore clinicians do not have the time to read about previous attendances, especially if they relate to another specialist or the information stored with the safeguarding section. Often history taking is focused on asking the parents to update and provide additional information. The case group discussed with the review team there being “a culture of specialisms” in the health field with safeguarding being viewed as a specialist service. The danger of this approach for safeguarding is that clinicians identify their safeguarding responsibility as being purely to pass on information and not recognise their wider safeguarding role. They consider their function to be to refer to a specialist i.e. the safeguarding team rather than continuing to be involved and providing guidance and support to social workers in determining whether health problems are indicators of safeguarding concerns. How common and widespread is this pattern? This review concerned a child that was seen at the Hospital in the county and all the research was undertaken with professionals working in or with that hospital. However, practice that was undertaken was routine and similar to that in other hospitals and there is no reason to think that the underlying practice would be different in other hospitals across the county or probably the rest of England. What are the implications for the reliability of the multi-agency child protection system? All professionals working with children have a duty to safeguard and promote the welfare of children and contribute to the multi-agency safeguarding process. If health professionals do not adequately consider the impact that environmental conditions and neglectful parenting may have on a child’s well-being then, opportunities to intervene on behalf of children are missed. Final report 15-6-18 24 This review has identified that, in relation to acute presentations, there is may be a tendency to focus on the presenting illness/injury and not to consider other explanations and check records even when there are known safeguarding concerns. This potentially places some children at risk if all aspects of neglectful parenting are not fully explored. This is particularly true for acute short admissions (less than 24 hours) as hospital records may not be easily accessible. Considerations for the Board and partner agencies • Is this a known problem to the Board? • Does the Board think that this finding would apply to other hospitals in the county? • Is it known whether children with a known condition get a more consistent service and are better protected? • Would a single electronic record improve identification of safeguarding concerns? Finding 2 Do hospital professionals standardly take a medical and social history only to inform their treatment of the immediate presenting illness/injury rather than also assessing whether the health history raises safeguarding issues? Final report 15-6-18 25 Finding 3 Are general practitioners in the county reluctant to refer directly to Children’s Social Care, preferring to consult with fellow health professionals? Professional norms & culture around multi-agency working in assessment and longer-term work. Description General practitioners (GPs) and primary healthcare teams are best placed to spot the early signs of child abuse and neglect. They have an overview of issues affecting individual members of a family which, in combination, may impact on a child’s welfare. They are also in a position to co-ordinate the work of different agencies supporting children and families. The RCGP/NSPCC Safeguarding Children Toolkit for General Practice identifies the following role for GPs in safeguarding and protecting children from abuse and neglect: • ‘The majority of children and their families in the UK are registered with a GP and general practice remains the first point of contact for most health problems. • GPs and their practice teams have a key role not only in providing high-quality services for all children but also in detecting families at risk, supporting victims of maltreatment and providing on-going care and assessment while contributing to case conferences and care plans. • Identification of child abuse has been likened to putting together a complex multi- dimensional jig-saw. General Practitioners and their Teams, who hold knowledge of family circumstances and can interpret multiple observations accurately recorded over time, may be the only professionals holding vital pieces necessary to complete the picture. • It is important to acknowledge when there may be barriers to recognition of risk and taking action on child maltreatment and to overcome them. Child maltreatment is a costly societal and public health issue but is preventable and should not be tolerated’. 17 How did the issue manifest in this case? On the day that Baby KK was seen by the GP for the 8-week developmental check, Sibling was noted to be bleeding from the mouth, on examination the child was reported to have a torn frenulum18. There was no clear account of how this injury occurred. This caused the GP some concern, combined with the fact that both children were dressed inappropriately for the weather. Although the GP was concerned enough to discuss with a colleague who was the safeguarding lead GP for the practice he did not contact CSC and instead decided to discuss the case with the health visitor. At this point the GP was unaware of the initial 17 Safeguarding Children and Young People: The RCGP/NSPCC Safeguarding Children Toolkit for General Practice - http://www.rcgp.org.uk/clinical-and-research/toolkits/the-rcgp-nspcc-safeguarding-children-toolkit-for- general-practice.aspx 18 Frenulum is a small fold or ridge of tissue which supports or checks the motion of the part to which it is attached, in particular a fold of skin beneath the tongue, or between the lip and the gum. Final report 15-6-18 19 DfES/DH Research Project The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children May 2006 – October 2008 26 child protection conference held three months previously or that the outcome was that there should be child in need plans for the two children. The family only registered with this GP in September 2015 and although CSC have a record that the minutes of the ICPC were sent to the GP they were not found in the children’s records and the Surgery have no record of that ICPC taking place or the minutes received. When interviewed for the review the GP with lead for safeguarding in the practice also reported that she did not routinely read conference minutes and therefore was not always aware of the current safeguarding concerns relating to children registered with their surgery. She suggested that this was usual practice for most GPs. Although the GP and health visitor discussed the injury and general appearance of the children, the focus of the conversation was on ensuring the family were receiving support. The opportunity to highlight the incident as a safeguarding one was not addressed by either professional. It is difficult to understand why when the GP learnt of the ongoing safeguarding concerns for the children and that they were the subject of child in need plans, the responsibility to contact CSC was not recognised. How do we know it is an underlying issue and not something unique to this case? On talking with case group members, previous examples were given where a GP had contacted CSC for advice on a case and the response they had received had dissuaded them from making contact with CSC in another incident. They said they felt more comfortable discussing concerns with a fellow health professional especially one who had a lead in safeguarding. Research has identified that a GP often will consult a fellow GP or other health professionals for further discussion rather than refer to CSC in the first instance (Hilary Tompsett et al 2009).19 In part this may be because GPs view themselves as supportive as opposed to challenging and want to keep their relationship with the patients. Members of the review team wondered if GPs could lack confidence in dealing with child protection concerns and feel that other professionals had a greater knowledge base and expertise than GPs. The nature of general practice is that the GP needs to know "a bit about a lot", as generalists they may struggle to feel that they are experts in that area. One suggestion is that GPs are generally very aware of their safeguarding responsibilities, but may need guiding through the process, particularly if they have not had recent child protection involvement in a case. Interestingly the perception held by many professionals that GP’s are the hub for all the health information is not one that is shared by many GP’s who expressed concern that people thought that the allocated GP would hold all the information about any registered patient. Final report 15-6-18 20 DfES/DH Research Project The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children May 2006 – October 2008 27 How common and widespread is this pattern? Research conducted by Hilary Tompsett et al in 200920 found that half of the GPs consulted expressed a preference for seeking early advice and support from a paediatrician or other health colleague, rather than children’s social care services. In addition, two thirds of GPs rated the health visitor as highly significant to refer to, where there was concern for a child. GPs on the whole would prefer a model of referral that allows more stages of consideration, discussion and consultation before ‘raising concerns’. It has not been possible to determine how many children could be involved as data on how many children with child protection plans are held at each GP practice is not known. The arrangements described at this GP practice may also not be representative of other GP practice therefore further research may be needed to determine the extent of this problem. What are the implications for the reliability of the multi-agency child protection system? The majority of children and their families in the UK are registered with a GP and general practice remains the first point of contact for most health problems. GPs and their practice teams have a key role not only in providing high-quality services for all children but also in detecting families at risk, supporting victims of maltreatment and providing on-going care and assessment while contributing to case conferences and care plans. If GP’s do not share safeguarding concerns relating to a child they are treating then the opportunity to intervene and share information with CSC will be missed, potentially leaving children at risk of harm. Finding 3: Are general practitioners in the county reluctant to refer directly to Children’s Social Care, preferring to consult with fellow health professionals? Considerations for the Board and partner agencies • Is this a known problem to the Board? • Is it known how often GPs refer to CSC? • What is known about why GPs may be inhibited from referring? • How is the LSCB assured that GP’s recognise their roles in safeguarding and are confident in making referrals to CSC when required? • How is the LSCB assured that when child protection conference minutes are circulated that they are routinely reviewed and considered by GPs? • Are the present arrangements for liaison between GP practices and health visitors the best way of safeguarding children with specific health care needs? • Do GPs receive relevant information in a timely manner? • Should there be data collected indicating how many children with child protection plans are held at individual GP practices? Final report 15-6-18 28 Finding 4 Does the fluctuating nature of neglect and the inconsistent ability of parents to maintain improvement undermine professionals’ ability to see and respond to neglectful parenting? Professional norms & culture around multi-agency working in assessment and longer-term work. Working Together 2015 defines Neglect as: 21 The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs Neglect is notoriously difficult to define, partly because it is cumulative and difficult to measure. In addition, neglectful parenting can fluctuate and often the underlying impact on children in the long term is not analysed. There is a tendency to focus on physical symptoms which are easier to evidence. Often professionals find it harder to agree something as neglect when it is not seen as a deliberate act. One of the difficulties in identifying children who are being neglected is that there is no set standard about what is ‘acceptable care’. This makes it very difficult for professionals to evidence when care falls below an acceptable standard and makes the decisions about when the quality of care is so low as to warrant decisive action more difficult. How did the issue manifest in this case? During the 10-month period that CSC worked with the parents both social workers considered the detrimental impact to health that the poor living conditions could be having on the health and wellbeing of both children, but especially in relation to Baby KK. Whilst both social workers had concerns, they did not have the expertise to evidence that the neglect contributed to the health problems experienced by Baby KK. When they appropriately sought the backing of medical staff to support their observations that the poor home conditions could be causing an adverse effect on the children the response they were given was that they could not prove a definite link to enable them to take protective action. When Baby KK was admitted with gastro enteritis SW1 asked the hospital what they thought the cause could be and could it have been due to the poor unhygienic home 21 Working Together to Safeguarding Children 2015 HMG Final report 15-6-18 29 conditions? The hospital’s response was that they felt that the parents were probably not to blame and that Baby KK probably had a propensity to stomach disorders which are not uncommon in premature babies. SW2 contacted the hospital after Baby KK had been seen for breathing difficulties to explore further if the home conditions were a contributory factor to his health problems, especially as the parents were clear that it was the mould causing Baby KK’s ill health. The hospital responded by saying that yes, it could be a result of home conditions, but it could also be because of a range of other medical reasons. Although in the community there was a wealth of evidence of extremely poor home living conditions, it is apparent that hospital staff did not understand the extent of the actual living conditions for these children and the term “poor living conditions” a common umbrella term used did not convey the true nature of the problem. Additionally, due to his prematurity and known medical history it was understandable that these factors were given more importance and the impact of the home environment was lost. Overall, the lack of substantive, consistent evidence of neglectful parenting causing significant harm to the children influenced the decision not to make the children subject to a child protection plan at the first ICPC. How do we know it is an underlying issue and not something unique to this case? Neglect is a multi-faceted issue, which can include dimensions such as emotional, supervisory and medical neglect, as well as neglect of physical care (Horwath, 2007).22 In order to understand whether neglect is occurring, therefore, a range of factors must be considered including emotional and developmental needs as well as the immediate need for an adequate diet, warmth and safety. This case has suggested the focus on trying to improve the living conditions, and lack of evidence to link home conditions with physical health or development at times meant that two young children remained living in a neglectful environment. Discussions with the review team indicated that when there appears to be a physical effect on a child of the parents’ actions or inactions (i.e. a failure to gain weight) it is easier to evidence neglect leading to safeguarding action. Action was immediately taken by both the health visitor and the social worker. This was discussed with case group members who confirmed that in the absence of clear detriment to the child as a result of parents’ actions it was hard to clearly identify that their behaviour was intentionally neglectful parenting. Review of the ‘Neglect Strategy’ is underway and has already identified a varying capacity to sustain improvement with families. Audits of neglect in the county have also identified that this as an area of difficulty. Discussions within the review team confirmed that this was likely to be repeated in other circumstances, and that it was in part why the medical assessment of a child was 22 Horwath, J (2007) Child Neglect: Identification and Assessment, Basingstoke, Hampshire: Palgrave Macmillan Final report 15-6-18 30 deemed to be such an important facet of the child protection investigation, as it provided the opportunity for concrete evidence. Research has also shown that the cases that are most likely to catch the attention of the frontline practitioner are those that present the clearest evidence of harm. Research on biases in human reasoning finds that recall is stronger for very vivid or emotive material, such as visible injuries to children. How common and widespread is this pattern? There were 26,761 children in the UK on child protection registers or the subject of child protection plans under a category that included neglect on 31 March 2016 (or 31 July 2016 in Scotland). This equates to 46% of all the children on child protection registers or the subject of child protection plans according to the NSPCC (NSPCC, 2016). In the county data collected over a seven-month period in 2017 indicates that 65% of children with child protection plans have neglect as the primary criteria and a further 27% have it as a secondary criterion. National research regarding neglect has highlighted that it presents a significant challenge to professionals: ‘Numerous factors have been identified as potential obstacles to effective action. Firstly, professionals may have concerns about neglect, but they may lack the knowledge to be aware of the potential extent of its impact. Secondly, resource constraints influence professional behaviour and what practitioners perceive can be achieved when they have concerns about neglect. Thirdly, a number of additional ‘mindsets’ hamper professional confidence and action’.23 This research explored the observable risk factors that could be identified in neglectful families and suggested that ‘Systematic assessment of these factors and the interrelationships between them, using a conceptual framework such as Glaser’s tiers of concern should lead to more timely action and fewer missed opportunities’. 24 This review was conducted in one area of the county however discussions with the review team and findings from County-wide audits would suggest that this finding is applicable across the whole LSCB. What are the implications for the reliability of the multi-agency child protection system? For children to be effectively protected professionals need to be confident in their understanding of all aspects of neglectful parenting including the impact of poor home environments and understand the long-term effects on children and babies if intervention and change does not occur in a timely way. 23 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report November 2014 , Marian Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lushey & Harriet Ward – Childhood Wellbeing Research Centre 24 ibid Final report 15-6-18 31 Finding 4: Does the fluctuating nature of neglect and the inconsistent ability of parents to maintain improvement undermine professionals’ ability to see and respond to neglectful parenting? Identifying and assessing child neglect can be difficult, and evidencing progress over time – or lack of it – can be even trickier. Yet this is crucial for making the right decision about a child’s welfare. This review has identified that without hard evidence professional struggle to ensure the long-term effects on young children and risks are recognised. Considerations for the Board and partner agencies • What does the Board know about this problem? • What are the barriers to professionals being able to identify and respond to neglect? • What does the Board know about how well the ‘Neglect Strategy’ recognises this challenge for staff? • What does the Board know about how well the tools available to professionals across agencies help in identifying risk factors for neglect? • Do professionals across agencies in the county apply consistent and comparable standards in determining the risks presented by the environment that families live in? • Has a focus on obtaining the views of the child meant that other assessment tools are less used? Final report 15-6-18 32 Finding 5 Seeing the task of hospital clinicians as to “assess, treat, discharge, and where necessary refer on to specialist services” works for most children but means there may be limited involvement of hospital professionals in on-going safeguarding work even when a child is being admitted repeatedly to hospital, undermining multi-agency safeguarding work to protect children. Professional norms & culture around multi-agency working in assessment and longer-term work. Description Healthcare professionals are in a key position to be able to identify vulnerability within families and act upon concerns when it is thought that an infant, child or young person may need ‘early help’ or be ‘at risk of harm’. To do this successfully, it is essential that each individual service recognises its own responsibility in identifying concerns, sharing information and taking action where necessary. Within all services staff who come into contact with children and young people have a responsibility to safeguard and promote their welfare and should know what to do if they have concerns about safeguarding issues, including child protection. In England, all NHS trusts, foundation trusts, and public, voluntary sector, independent sector, social enterprises, and primary care organisations providing health services, must have a named doctor, named nurse, and named midwife. 25 Hospitals by their very nature operate in a different way to community services. Within a hospital, safeguarding is viewed as a specialism led by the ‘named professionals’ with every staff member being trained and aware of their safeguarding responsibilities to refer appropriately to the safeguarding specialists. The practice of referring to a specialist is common practice in hospital and so the expectation that safeguarding work is led by the ‘named professionals’ and not the clinician who is treating the child is the norm and a partnership is maintained between the safeguarding team and the clinician in order to get the best outcome. The safeguarding team provide a consistent overview and supervision and inform changing medical and nursing teams. How did the issue manifest in this case? On several occasions throughout his life Baby KK was seen and admitted to the local hospital. From before the birth there had been safeguarding concerns around neglect that had been shared with the hospital. CSC communicated on a number of occasions with hospital staff, initially through the named midwife then the named nurse but not usually directly with the doctors who treated Baby KK, the exception being on one occasion when the baby attended with an arm injury. 25 Safeguarding Children and Young people: roles and competences for health care staff INTERCOLLEGIATE DOCUMENT March 2014 Published by the Royal College of Paediatrics and Child Health 2014 on behalf of the contributing organisations. https://www.rcn.org.uk/nursing/survey-of-designated-nurses-for-safeguarding-c... Final report 15-6-18 33 At one point the social worker wanted to explore if the repeated breathing problems experienced by Baby KK could be due to the poor home environment. She raised these issues with the named nurse who liaised with the paediatrician involved in the case. The response was appropriate and explored different possibilities i.e. that poor home conditions were ‘one of a number of factors that could be relevant’. The paediatrician responded to the question but may have had a different view if he had spoken directly with the social worker who could have provided detailed information about the home conditions. Overall the focus of safeguarding responsibility within Hospital1 was on sharing information about any concerns that had been observed but not analysing and exploring if there was a link between the known poor home environment and limited parenting capability with the presenting medical symptoms. On another occasion Baby KK was ready for discharge following a Paediatric Intensive Care Unit admission with bronchiolitis. Although hospital staff knew the condition of the home was poor and had agreed to delay the discharge, a discharge planning meeting was not held. However, discharge ‘discussions’ occurred, and hospital staff liaised with the social worker and they agreed that the baby could be safely discharged. The hospital staff were satisfied that CSC had organised a “big package of care” although there was no record of the care being provided. The accepted norm that hospitals generally do not play a part in ongoing safeguarding work was also accepted by CSC who did not approach the hospital to be actively part of the safeguarding process for Baby KK and no hospital staff, including the named nurse, were invited to the core group meeting that was held two days before discharge. A discharge planning meeting could have been incorporated into the core group meeting. How do we know it is an underlying issue and not something unique to this case? This case has suggested that because hospital staff were not an integrated part of the safeguarding work being undertaken in the community, the opportunity to protect children at an earlier stage was delayed. By the very nature of how hospitals operate, patients are not usually seen by the same staff when presenting for a variety of health illnesses or accidents. The reason for presentation will indicate which department will treat them and unless they are under the care of a specific consultant then generally each admission is treated as a one off with the expectation that the patient will not need to return. This makes it difficult then to identify a single person who can be part of the safeguarding process for a patient over a period of time. Attending conferences and being a core group member is part of the safeguarding responsibilities of hospital staff and they do attend if invited and are able to do so. If they cannot attend they will send a report. Baby KK had an allocated consultant as a result of his Neonatal Intensive Care Unit admission and was offered outpatient follow-up and ongoing care. However, this was not known by the social work staff, and despite a number of contacts being made with the hospital, it was never suggested that the hospital was available to attend such meetings. Final report 15-6-18 34 This review has identified that this approach of delegating safeguarding to specialist professionals who are not directly seeing the patient may lead to a dilution of the information being discussed. It also may lead to hospital professionals seeing their main responsibility for safeguarding children, already known to CSC, as being to share information about specific concerns rather than analysing or exploring the child and family presentations in relation to known safeguarding risks which in this case were around the home environment and poor parenting. How common and widespread is this pattern? This review concerned a baby seen at a county hospital and all of the research was undertaken with professionals working in or with that hospital. That being said, the practice that was undertaken was routine and similar to that in other hospitals and there is no reason to think that the underlying practice would be different in other hospitals across the county or probably the rest of England. All hospitals are required to have named professionals who are their organisations specialist in child protection and often are the key people who act on the behalf of health professional in overseeing and managing safeguarding work. Data relating to the number of children with child protection plans and child in need plans who are treated at hospital in the county is not collected. However, it is known that Hospital1 shared information with CSC on 189 occasions during September 2016 to September 2017, this cohort would include children with child protection plans, child in need plans and looked after children. What are the implications for the reliability of the multi-agency child protection system? Effective safeguarding relies on professionals working closely together. If professionals only see their role as being to assess, treat, discharge, and where necessary refer on to specialist services then there is a danger they will only focus on the presenting problem and miss the wider picture which could identify child protection risk factors. With the ‘New Deal and Working Time Regulations26’ for junior doctors there is increased changeover of doctors. There is also a danger that this leaves hospital professionals taking a passive role and not being proactive in safeguarding children. If health professionals just address medical problems and do not work closely in partnership with social workers, especially where there is neglectful parenting, there is a danger that children will be cared for by inadequate parents for longer than is necessary. 26 www.bma.org.uk/advice/employment/contracts/junior-doctor-contract Final report 15-6-18 35 Finding 5: Seeing the task of hospital clinicians as to “assess, treat, discharge, and where necessary refer on to specialist services” works for most children but means there may be limited involvement of hospital professionals in on-going safeguarding work even when a child is being admitted repeatedly to hospital, undermining multi-agency safeguarding work to protect children. All agencies who have any contact with children or work with parents and carers for children have safeguarding responsibilities. Effective safeguarding systems are those where all professionals know about how to protect children and there are good partnership arrangements that enable joint collaboration. This review has identified that a potential flaw in the multi-agency system is the extent to which frontline hospital professionals are fully engaged with safeguarding work. This is because they see this as the responsibility of a specialist safeguarding team and do not fully understand their ongoing role in safeguarding work. Considerations for the Board and partner agencies • Does the Board think that this finding would apply to other hospitals in the county? • Are there any examples where there is greater involvement of frontline professionals in safeguarding work in the community? • What does the Board think would assist professionals to consider wider factors when working with children were there could be child protection concerns? • What does the Board know about the frequency and effectiveness of discharge planning meetings? • Is the board confident that discharge planning meetings are routinely held in all situations? Final report 15-6-18 36 Finding 6 Does the nature of chronic neglect mean that evidencing that deteriorating conditions is increasing harm, make it hard for the current threshold in care proceedings to be met, risking leaving children for over-long periods in substandard care? Patterns in human–tool operation. Description When social workers are concerned about the welfare of a child, they may be thinking about taking the case to court so that they can ask the court to make orders to protect the child. In most cases the Public Law Outline27 requires the social services department to arrange a meeting with the parent(s) to see if it is possible to reach agreement about what needs to happen to protect the child from harm, so that court proceedings can be avoided. The hope is that the parents will come to the meeting with a solicitor. The solicitor will be able to help the parents to negotiate an agreement with the social services department to try to avoid the need to go to court. This formal meeting is often known as a “pre-proceedings meeting” or “PLO meeting”. In some cases, the social workers may feel that the risk of harm to a child is so great, or the case is so urgent, that the case should go straight to court. In these cases, no meeting takes place at all and the discussions about whether care is good enough take place in a court environment. How did the issue manifest in this case? CSC commenced legal proceedings in January 2016, and it was not until the 2nd of March that the FSW and SW visited the family at home to deliver the letters of intent. Although mother got a solicitor immediately, father did not. The PLO meeting with mother and CSC took place on the 15th of March but it could not go ahead for father as he still did not have a solicitor of his own. It was not clear if this delay was because father was being difficult and wanted to delay the process or just that he did not see the need for having a solicitor. However, SW2 was so concerned that father would not contact a solicitor without firm encouragement that she visited on the 20th March and did not leave until father had contacted one. The PLO meeting was arranged and held on the 27th of April. The threshold for initiating the PLO was deemed to be met in early January therefore it took almost four months for the initial process to be achieved during which time Baby KK and Sibling were experiencing neglectful parenting that in the views of professionals constituted significant harm. It was also evident that during this time the home conditions were deteriorating, and the pressure experienced by the parents was leading to disagreements between them with verbal arguments, possible domestic violence and possible physical abuse of Baby KK. 27 'The Practice Direction Guide to Case Management in Public Law Proceedings' [2008] 2 FLR 668, more commonly known as the 'Public Law Outline' or 'PLO' has been revised with effect from 6 April 2010. The revised PLO has three main features: elaboration of the 'Timetable for the Child' principle, reducing the burden of documents required at issue of proceedings, and streamlining the PLO forms. Final report 15-6-18 37 How do we know it is an underlying issue and not something unique to this case? (what other evidence is there?) Conversations with case group members indicated a degree of frustration with the time taken to achieve the threshold for care proceedings with some families. There was a lack of understanding of how the process worked but a feeling that there was better intervention when there was immediate progression to court intervention because of risk of physical injury. Review team and case group members agreed that the legal processes worked well if a child had made a disclosure and there was clear evidence of significant harm but felt that they did not work well with neglect cases where the incidents were cumulative. ‘The PLO brings important benefits in terms of clarifying expectations of parties to proceedings and setting aims. However, one of the PLO's main aims, reducing delays in proceedings, is not being met, and is unlikely to be met without holistic investment in the family justice system. Merely tackling burdensome paperwork will not be enough to truncate the long timescales of care and supervision proceedings because there are problems which need to be tackled that run much deeper into the family justice system: problems such as delays in the appointment of guardians, underfunding, and ineffective inter-agency co-operation’. (Familylawweek.co.uk) Research about pre‐care proceedings has identified that while pre‐care proceedings are valued by social workers, their managers, and parents and sometimes they can enable enough change in a family for a proportion of children to remain with their parent(s), however, the process may delay decisions for children who eventually have to enter care28. How common and widespread is this pattern? As of 31st March 2017, there were 870 looked after children in the area however the majority of these children would probably not be subject to a legal order. Nationally the number of children looked after under a care order has increased by a third, from 7,550 children in 2016 to 10,130 in 2017. 31% of all children starting to be looked after were looked after under a care order in 2017, up from 23% in 201629. It has not been possible to access data detailing the numbers of care proceedings in the area with breakdown of how many children become the subject of care orders and how many are resolved by children remaining with parents because this data is not currently collected. The Local Authority is considering whether this data should be collected in the future. 28 Masson, Judith M. and Bader, Kay and Dickens, Jonathan and Young, Julie, The Pre-Proceedings Process for Families on the Edge of Care Proceedings: Summary Report (April 3, 2013). Available at SSRN: https://ssrn.com/abstract=2281153 or http://dx.doi.org/10.2139/ssrn.2281153 29 Source: SSDA903 https://www.gov.uk/government/statistics/children-looked-after-in-england-including-adoption- 2016-to-2017 Final report 15-6-18 38 What are the implications for the reliability of the multi-agency child protection system? By focusing on obtaining evidence as part of the PLO process, a lack of evidence should not be assumed to be positive. The way the PLO process works and the thresholds for intervention operating in the county courts has the potential to leave children, especially those at risk of neglect, in substandard care for long periods. Finding 6: Does the nature of chronic neglect mean that evidencing that deteriorating conditions is increasing harm, make it hard for the current threshold in care proceedings to be met, risking leaving children for over- long periods in substandard care? This case has identified that where there is chronic neglect and it is hard to evidence immediate risk of significant harm, the time that it takes to meet the current threshold for care proceedings risks leaving children in risky situations for long periods. The current legal arrangements do not easily include other agencies meaning that professionals may not be aware of the reasons for the apparent lack of intervention. Parents may also contribute to delay by not co-operating with the PLO processes such as accessing legal advice. The effect of this may lead to there being significant time before intervention to remove children from risky environments. Considerations for the Board and partner agencies • Are the current legal processes effective at protecting children when in a neglectful situation? • What does the Board know about the timeliness of the current legal process? • What is the understanding of agencies outside of CSC of the current legal processes including PLO? • How involved are agencies in contributing to planning for children once PLO is initiated? Final report 15-6-18 39 Finding 7 Is there a culture in the county whereby constructive challenge is interpreted as personal and organisational criticism, fostering defensiveness between agencies and reducing the likelihood that escalation of safeguarding concerns happens when needed? Patterns in human–management system operation. Description In order for children to be protected, professionals need to work well together and part of a healthy working relationship is the ability to discuss and constructively challenge each other. Without challenge and analysis, risks may not be fully understood and outcomes for children may not be in their best interests. This case has suggested that when challenged staff from different agencies can take the criticism personally and become defensive, this in turn can lead to staff avoiding challenge such as escalating concerns. How did the issue manifest in this case? Following Baby KK’s attendance at the Accident & Emergency department with an arm injury reportedly caused by the baby’s arm becoming trapped in the cot, SW2 was not comfortable with the diagnosis made by the doctor that this was accidental injury. Based on the social worker’s background knowledge of this child, namely that the child spent much time in a car seat and had never been seen in the cot by a professional, the story of the baby being in a cot appeared unusual. The social worker rightly questioned the presentation with the A&E registrar, but the registrar was clear that the stories of both parents matched, there was no delay in presentation and that the injury matched the suspected mechanism. The doctor acknowledged that the baby was unkempt and possibly overweight and was aware that CSC were working with the family. SW2 did not challenge the registrar as to why he had not referred Baby KK to a paediatrician in line with the procedure for injuries in babies under one year of age, especially when they are subject to a Child Protection plan because she was not aware of this protocol. Still uneasy with the decision of the registrar SW2 discussed the injury with her manager. The matter however was left there and there was no consideration of escalating their concerns and asking for a review of the case by either the named doctor in the hospital or the Designated Doctor for the county who could have reviewed the case notes. How do we know it is an underlying issue and not something unique to this case? The Review Team and Case Group reported that many staff including managers were not ready or confident to escalate issues when there is difference of opinion. People were too polite to challenge each other but were left uncomfortable with the outcomes. Staff have witnessed constructive challenge being interpreted as personal criticism, which leads to defensiveness. This defensiveness can occur at all levels within organisations. Final report 15-6-18 40 A previous SCR of Child X carried out in the LSCB found: “Sometimes staff feel that ‘challenge’ is too confrontational, rather than seeing it to be simply requiring good answers” Alan Bedford 2013. The most recent Ofsted inspection process identified that although the LSCB was able to challenge practice ‘it was often issue-specific and reliant on the individual authority of the independent chair, rather than as part of a consistent exercise of the board’s role as critical friend’. It also praised the child protection conference dissent group as ‘an effective venue for challenging decision making and planning at conferences to ensure that children have plans that meet their assessed needs and risks’ however this body has now been disbanded. The report concluded that the board’s ‘influence on key partnership agencies is not as strong as it could or should be’. How common and widespread is this pattern? This review was conducted in one part of the county however Review team members did not think that this was an issue that was specific to the area but was representative of practice throughout the county. There has been significant work done on developing the levels of need document since the Ofsted inspection and it is thought that the work associated with this may have enabled professionals to have greater confidence in the escalation processes however this has not yet been evidence through practice. Since the initiation of the MASH system there have been examples in practice where decisions have been challenged however there are currently no systematic records kept of challenges. Similarly, although the Section 11 audit30 requires agencies to evidence that staff are aware of escalation processes there is no requirement for agencies to keep records about numbers of challenges or their outcomes. What are the implications for the reliability of the multi-agency child protection system? If opportunities for challenge are missed due to a professional’s previous experience this is a chance to re-evaluate a situation that is lost and allows a perpetuation of potentially flawed ‘fixed’ thinking. This can lead to the professionals missing critical and significant information about the nature of relationships within a household, as well as the nature of the care being provided to the children. 30 The LSCB assesses the effectiveness of local safeguarding arrangements in various ways, including Section 11 safeguarding self-assessments. This is where all local agencies and organisations who provide services to children and young people are asked to self-assess the extent to which they meet the safeguarding requirements and standards as set out in Section 11 of the Children Act 2004. The LSCB has formally adapted and developed the Section 11 Audit Tool and Guidance based on Board priorities. Final report 15-6-18 41 Finding 7: Is there a culture in the county whereby constructive challenge is interpreted as personal and organisational criticism, fostering defensiveness between agencies and reducing the likelihood that escalation of safeguarding concerns happens when needed? Critical challenge between professionals should be regarded as something that is both healthy and productive in developing a strong and healthy safeguarding system. If there is defensive thinking and mutual self-protection there is the possibility that children will be left at risk. Considerations for the Board and partner agencies • What knowledge does the Board have of this issue? • How has the introduction of ‘Signs of Safety31’ and ‘Appreciative Inquiry32’ changed the culture in the county? • How does the Board and its member agencies consider the degree to which ‘challenge’ is encouraged as an important part of professional work, and valued as something in the interests of children? • How does the Board know if escalation policies are sufficiently understood and applied in cases where there is professional disagreement? • How can the Board evidence that there is sufficient training around escalation policies and that it has changed practice? • What does the Board know about the barriers to professional challenges to each other, particularly around decisions made at child protection conferences? 31 The Signs of Safety model is a tool intended to help practitioners with risk assessment and safety planning in child protection cases. Its purpose is to enable practitioners across different disciplines to work collaboratively and in partnership with families and children. https://www.nspcc.org.uk/services-and-resources/.../signs-of-safety- model-england 32 Appreciative Inquiry (AI) is a change management approach that focuses on identifying what is working well, analysing why it is working well and then doing more of it. The basic tenet of AI is that an organization will grow in whichever direction that people in the organization focus their attention. If all the attention is focused on problems, then identifying problems and dealing with them is what the organization will do best. If all the attention is focused on strengths, however, then identifying strengths and building on those strengths is what the organization will do best. Final report 15-6-18 42 Finding 8 The routine method of communication used in hospital settings – namely verbal instructions - does not accommodate limitations to parental capacity to understand the information being given. Professional norms & culture around multi- agency working in assessment and longer-term work. Treating sick babies and children is dependent on a collaborative approach between professionals and parents. Often the day to day care for a sick child will be the responsibility of the parent who will need to maintain the health regimes initiated by staff in the hospital setting when the child returns to live in the community. Generally, hospital staff show parents how to do the treatment and then watch them as they do it to check they understand the process. This advice is often supported by the parents being given leaflets that explain in more detail the advice given. How did the issue manifest in this case? Hospital staff had contact with the family throughout Baby KK’s life. Most professionals in the community working with the family were aware that the mother had some learning difficulties and were careful to check her understanding and SW2, in particular, was using visual aids to assist in this process. It is unclear however how much awareness there was by hospital staff of mother’s limitations. Following the near fatal episode of Bronchiolitis in December, Baby KK was prescribed an inhaler. Although routine instruction was given to the parents there is no evidence that the hospital staff provided any additional guidance or assessed the mother’s capacity to understand and use the inhaler. There are no records of what advice was given but normal practice is that when a child is prescribed inhalers in hospital staff teach parents inhaler techniques and review these at every admission. This is conducted routinely and is only documented if there were concerns about the technique. Mother has reported to the lead reviewer that when Baby KK was first prescribed an inhaler, she was shown once how to use it and she described this as not being very helpful. Baby KK was seen at the hospital and admitted with breathing difficulties on several occasions yet there is no record that staff checked to see if parents had understood how, why and when they should use the inhaler. Mother reported that it was “really hard to use the inhaler, Baby KK would cry so much that she wasn’t sure that her baby could take much in because [the child] was crying too much”. It was not until the April that Baby KK was admitted with mother to the hospital to specifically address training on how to administer inhalers which was five months after they had first been prescribed. Final report 15-6-18 43 Mother has dyslexia33 which meant that she struggled to understand medical terminology and said that doctors routinely used long words which she did not understand. She described being told that Baby KK had bronchiolitis and having to look up the word on the internet to find out what it meant. Mother reported that whilst some nurses supported her by explaining the meaning of some of the words used by the doctors this did not happen all the time. There was no attempt to communicate in a different way such as by using pictorial aids as a way of instruction, a method SW2 had adopted. How do we know it is an underlying issue and not something unique to this case? Hospital staff like many other health professionals tend to approach teaching and informing patients/parent using instructive methods often supported by leaflets which works well for many individuals, but not all. It can be a challenge for staff to know what exactly a client has understood if they do not themselves indicate that they have not fully understood something. Professionals in the case group who were not hospital staff confirmed that it is not unknown for their clients to be unclear about what they have been told in hospital even though it is reported that processes have been explained to them. It was also reported that on occasion patients nod in agreement even if they haven’t understood what is being said to them. It is not uncommon for people with dyslexia to adopt strategies to manage the effects of their condition, making it harder for professionals to realise that if they have a difficulty. Research has identified that ‘40-80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion is correctly recalled; furthermore, almost half of the information that is remembered is incorrect’. There were three explanations for patients forgetting information ‘first, factors related to the clinician, such as use of difficult medical terminology; second, the mode of information (e.g. spoken versus written); and, third, factors related to the patient, such as low education or specific expectations’34. This research concluded that ‘Memory for medical information is often poor and inaccurate, ... Patients tend to focus on diagnosis-related information and fail to register instructions on treatment. Simple and specific instructions are better recalled than general statements. Patients can be helped to remember medical information by use of explicit categorization techniques. In addition, spoken information should be supported with written or visual material. Visual communication aids are especially effective in low- literacy patients’. 33 Dyslexia is a common learning difficulty that can cause problems with reading, writing and spelling. It's a "specific learning difficulty", which means it causes problems with certain abilities used for learning, such as reading and writing. Unlike a learning disability, intelligence isn't affected. 34 Patients' memory for medical information, Roy P C Kessels, PhD, Journal of the Royal Society of Medicine, Royal Society of Medicine Press, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC539473/ Final report 15-6-18 44 How common and widespread is this pattern? It is estimated that up to 1 in every 10 to 20 people in the UK has some degree of dyslexia35 however the issues raised would apply to any individual with literacy difficulties or problems with cognitive functioning. This review concerned a child that was seen at the Hospital and all the research was undertaken with professionals working in or with that hospital. However, practice that was undertaken was routine and similar to that in other hospitals and there is no reason to think that the underlying practice would be different in other hospitals across the county or probably the rest of England. What are the implications for the reliability of the multi-agency child protection system? If parents are to safely provide ongoing health treatments in the community to their children, there must be confidence that they understand how to administer such support. To achieve this understanding, staff in hospitals need to be enabled to provide guidance and support to parents in a way that is customised to the specific needs of the parents. Without this there is the potential for parents to misunderstand or ignore guidance about the provision of treatment to their children having an adverse impact on their health and possibly causing direct harm to them. Specifically, if the parents of babies and children with health problems are not given sufficient support in understanding how to manage their conditions well in the community they will keep returning to hospital which is an inefficient use of resources. 35 Source NHS Choices Final report 15-6-18 45 The current systems in Hospitals for advising parents about diagnosis and treatment of their children are not sufficiently customised to accommodate parents with literacy problems or other learning difficulties. If health interventions for babies that rely on parental delivery are to be effective, there needs to be reliable mechanisms to check that the parents understand what it is they need to do, when they need to do it and why. Without this, some failures are inevitable. Considerations for the Board and partner agencies Is this a known problem to the Board? Does the Board think that this finding would apply to other hospitals in the county? What are the barriers to health professionals in enabling them to communicate in more effective ways for patients with learning difficulties? Is there enough/the right health support in the community for families with known learning difficulties who have children requiring medical treatment such as inhalers? Finding 8: The routine method of communication used in hospital settings – namely verbal instructions - does not accommodate limitations to parental capacity to understand the information being given. Final report 15-6-18 46 Appendix 1 – Methodology 1. This SCR has used the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high-risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2015 revision of Working Together to Safeguard Children (2015) now requires all SCRs to adopt a systems methodology. 2 The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3 Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4 The basic principles – the ‘methodological heart’ – of the Learning Together model are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, and in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5 Typology of underlying patterns To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises Final report 15-6-18 47 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category. 6 Anatomy of a finding For each finding, the report is structured to present a clear account of: - • How the issue manifests itself in the particular case? • In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case? • What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? • How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. Illustrated below. Final report 15-6-18 48 7 Structure of the Review There were three main groups who worked together to complete the review: - 7.1 The review team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent lead reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints and changes in structure. The review team members also have responsibility for supporting and enabling members of their agency to take part in the case review. Review Team Members Fiona Johnson, SCIE Independent Lead reviewer June Hopkins SCIE Independent Lead reviewer LSCB Partnership & Support Manager County wide Deputy Designated Nurse Safeguarding Children County wide designated GP for safeguarding children Named Nurse for Safeguarding Children, Community Health Service Provider Service Coordinator, Child Protection Conferences Children and Families Principal Social Worker Detective Chief Inspector Public Protection Local Head of Housing Advice at Borough council Safeguarding Advisor Safeguarding & Health Team Early Help & Family Services 7.2 The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 17 case group professionals, and up to 19 professionals were invited to attend the case group meetings which discussed the practice in this case and agreed the findings. 7.3 Review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The review team form the ‘engine’ of the process, working in collaboration with case group members who are involved singly in conversations, and then in multi-agency ‘Follow- on’ meetings. The report will be received by the Serious Case Review Sub-group and the GSCB Executive who will have oversight of the final report and response plan. The sequence of events in this review is shown below: Final report 15-6-18 49 Date Event 05/04/17 Introductory meeting for the Review Team at this meeting the Governance group was identified as required and formed 08/05/17 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of. 24/05/17 – 26/05/17 Three days’ conversations with members of the Case Group (individual sessions of about 1.5 hours with each member of the Case Group; normally conducted by two members of the Review Team) 12/06/17 First Review Team analysis meeting 27/06/17 Second and third Review Team analysis meeting 14/07/17 First Follow-on meeting (Review Team and Case Group) In this meeting, the group works together on • identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case • appraising the practice in these KPEs • considering what was affecting the work/workers at the time (the ‘view from the tunnel’) 05/09/17 Fourth Review Team analysis meeting 28/09/17 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group were provided with a draft report which sets out the emerging underlying patterns and findings and were asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 13/10/17 Fifth Review Team meeting – to consider the draft final report Final review team meeting - to consider final draft report 18/10/17 SCR Sub-Group meeting – to consider the draft final report 13/11/17 LSCB meeting – to consider the draft final report Final report, fit for publication, to be submitted to Department for Education (DfE) 7.5 Scope and terms of reference Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored. Final report 15-6-18 50 7.6 Sources of data 7.6.1 Data from practitioners • Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team. • Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed. 7.6.2 View from the Tunnel and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ which enabled us as reviewers to capture the optimum learning from the case. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time. 7.6.3 Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in this SCR. Everyone has contributed very fully in the process. Individual practitioners all have participated responsively in conversations, which have recalled their role in this story, and in group discussions which have at times been very difficult and challenging. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network and has allowed us to capture the learning which is presented in this report. 7.6.4 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: Children’s Services records Midwifery records Hospital records Police records Community Health Records/ GP records 7.6.5 Data from family, friends and community As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. Final report 15-6-18 51 Appendix 2 Glossary A&E CIN CP CSC Accident and Emergency department of hospital. Child In Need Child Protection Children’s Social Care LSCB CSC GP HMIC Local Safeguarding Children Board Children’s Social Care General Practitioner Her Majesty’s Inspectorate of Constabulary. Independently assesses the effectiveness and efficiency of police forces – in the public interest. LSCB Local Safeguarding Children Board MARF MASH NHS NSPCC Ofsted Multi Agency Referral Form Multi Agency Safeguarding Hub. The Multi-Agency Safeguarding Hub (MASH) is a partnership between The County Council, The Constabulary, and health agencies working together to safeguard children, young people and vulnerable adults. National Health Service National Society for the Prevention of Cruelty to Children Office for Standards in Education, Children’s Services and Skills. They inspect and regulate services that care for children and young people, and services providing education and skills for learners of all ages. SCR Serious case review Single Assessment SCIE Single Assessment process is the assessment process used in children’s social care which replaced initial and core assessments Social Care Institute for Excellence. The Social Care Institute for Excellence (SCIE) improves the lives of Final report 15-6-18 52 people who use care services by sharing knowledge about what works. They are a leading improvement support agency and an independent charity working with adults’, families’ and children's care and support services across the UK. Strategy meeting / discussion A strategy discussion is held when there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. This may be following a referral and initial assessment or at any time during an assessment where a child is receiving support services if concerns about significant harm to the child emerge. The purpose of the strategy discussion is to enable the Children’s Services’ department, Police and other relevant agencies (e.g. health services, schools) to share information, make decisions about initiating or continuing enquiries under s. 47 of the Children Act 1989, what inquiries will be made and by whom, whether there is a need for action to immediately safeguard the child, and what information about the strategy discussion will be provided to the family. Decisions will be made regarding the provision of any medical treatment, how to handle inquiries in the light of any criminal investigation and whether other children affected are in need or at risk. TM Team manager Final report 15-6-18 53 Bibliography Barnett, O., Miller-Perrin, C., Dale, R.D., Family Violence across the Lifespan: An Introduction, Sage Publications, 2010 Marion Brandon et al Analysing child deaths and serious injury through abuse and neglect: what can we learn? 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NC51196 | Serious incident involving a 4-year-old child who was admitted to hospital in June 2016 after ingesting a potentially lethal dose of a sibling's epilepsy medication. Child I taken to hospital by ambulance having been found unresponsive by Father. Blood tests showed high levels of epilepsy medication. Incident treated as non-accidental. Police unable to prosecute due to insufficient evidence. A strategy meeting was held and Child I's siblings were placed in foster care. Family were well known to services. Mother and Father had presented as homeless prior to becoming parents. There had been multiple reports of domestic abuse and possible physical abuse of Child I's siblings. This led to Section 47 enquiries but concerns were not substantiated. Ethnicity and nationality unknown. Learning points include: thorough risk assessments should be undertaken when a partner has left a domestically abusive relationship but children are with the perpetrator; it is important to be aware of the pressures and difficulties faced by young parents; and all professionals who can offer insights into a family should be invited to meetings examining levels of need and risk for children and families. Uses the SILP methodology. Recommendations include: promote awareness of the Escalation Policy; GPs should consider social issues in a child's life that may affect the ability of the parent/carer to maintain a medication regime when prescribing children medication; and the LSCB to seek assurance from Children's Social Care that issues highlighted are being addresses in a timely manner, particularly the application of Child in Need procedures.
| Title: Serious case review: SCR I17: review report. LSCB: Reading Local Safeguarding Children Board Author: Kevin Ball Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review SCR I17 REVIEW REPORT Lead Reviewer: Kevin Ball Considered by Reading LSCB: 23rd January 2019 This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with Reading Safeguarding Children Board prior to publication. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. OFFICIAL SENSITIVE1Contents Item Page Introduction 3 Process for conducting the review 3 Family Structure 4 Relevant background information prior to the time-frame under review 4 Other relevant background information during the time-frame under review 5 Key Episodes -Key episode 1: October 2015 – March 2016-Key episode 2: April 2016 – June 2016-Key episode 3: June 20167 – 9 Findings & analysis -The quality of practice & systems in regard to the sibling’s epilepsy-What was known about the parental history, vulnerability & risk factors inthis case? What consideration was given to the impact of these on thechildren?-The quality & effectiveness of any assessment, planning & intervention-The quality & effectiveness of information sharing and use in this case-The use of dissent, professional disagreement and escalation9 – 25 10 12 14 23 24 Good practice 24 Conclusion 25 OFFICIAL SENSITIVE2Recommendations 26 1. Introduction1.1. Reading Local Safeguarding Children Board (LSCB) decided to undertake a Serious Case Review into the case of a child, aged four years, who was admitted into hospital in June 2016 having ingested a potentially lethal dose of a sibling’s epilepsy medication. For the purpose of this review the child shall be known as Child I. Child I, and siblings, had a long history of agency involvement and the children were considered under Child in Need1 procedures in 2016. The Police were unable to make a prosecution due to there being insufficient evidence to prove how the child came to ingest the medication. However, the Family Court fact finding process in April 2017 concluded that an adult deliberately administered the medication and that they delayed seeking professional medical help. 2. Process for conducting the review2.1. Reading LSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Reading to safeguard children2. 2.2. Reading LSCB agreed that this SCR would be undertaken using the SILP3 methodology, which engages frontline staff and their managers in reviewing cases and conforms to the expectations as set out in statutory guidance4. The review was conducted by Kevin Ball, who wrote this report, and Nicki Pettitt. Both are independent safeguarding consultants, experienced chairs and authors of SCRs, and SILP associate reviewers. Both are fully independent of Reading LSCB and its partner agencies. 1 Child in Need Plan - Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs. 2 The review has therefore: i) Identified improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice; and ii) Clearly identified what lessons have been learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result. Details of this are contained in single agency action plans as well as the over-arching LSCB action plan. 3 SILP – Significant Incident Learning Process. 4 Working Together 2015 (under which this SCR was commissioned) expects that SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. OFFICIAL SENSITIVE32.3. Agency reports were completed providing agencies with the opportunity to consider and analyse their practice and any systemic issues5. They provide details of the learning from the case within their agency but also allowed agencies the opportunity to reflect on actions and make recommendations for improving their own practice. Following these reports being submitted practitioners, managers and agency safeguarding leads came together for a multi-agency workshop. All agency reports were shared in advance and the perspectives and opinions of all those involved at the time were discussed at the event. This group then reconvened to examine and debate the first draft of the SCR report. 2.4. It was agreed that the time-frame under review would be from 01/03/2014 in order to capture any relevant information about the initial diagnosis of the sibling’s epilepsy and medication through to June 2016 just after Child I’s admission to hospital having ingested the epilepsy drugs. Relevant information prior to these dates was also considered, particularly involvement with Child I’s parents. 2.5. The contribution of family members is an important part of the SILP model of review. The Lead Reviewer, via the LSCB, made attempts to meet with Child I’s Mother and Father. Due to Mother’s circumstances it was only possible to have a telephone discussion; which was very helpful. It proved impossible to track down Child I’s Father’s whereabouts and therefore it has not been possible to gain his contribution. Where relevant, and helpful, Mother’s contributions have been integrated in to the report. 3. Family StructureThe relevant family members in this review are: Family member To be known as: Subject child Child I Sibling 1 to Child I Sibling 1 Sibling 2 to Child I Sibling 2 Father to subject child Father Mother to subject child Mother Father’s partner Father’s Partner Mother’s partner Mother’s Partner 4. Relevant background information prior to the time-frame under review4.1. In November 2009 both Mother and Father (prior to becoming parents) presented themselves to the local Housing Advice centre reporting being homeless as they had been evicted from the 5 Agencies that have contributed to this review are: -Reading Borough Council Children’s Social Care- Royal Berkshire NHS Foundation Trust-Thames Valley Police- Nursery-Berkshire West Clinical Commissioning Group- Berkshire Healthcare Foundation NHS Trust-Reading Borough Council Housing Management Service- Berkshire Women’s Aid-Oxford University Hospitals NHS Foundation TrustOFFICIAL SENSITIVE4paternal grandmother’s house due to a violent incident. Father, having been in the care of a neighbouring Local Authority for approximately two years was judged as a relevant child6 and therefore needed to seek advice about his situation. Issues with housing continued, again in 2011 but also during the time frame under review. 4.2. In September 2011 concerns were identified about domestic abuse between Child I’s Mother and Father. At this time Sibling 1 was six months old. No vulnerabilities had been documented by the Midwifery Service during Mother’s pregnancy with Sibling 1. 4.3. In July 2012, an extended family member made a referral to Children’s Social Care describing Sibling 1 as having bruising on the arms and legs, and that Father had squeezed and threatened the child. Section 477 enquiries were made however the concerns were not substantiated. There is no record of a child protection medical taking place. At this time, Sibling 1 was 15 months old and Sibling 2 was two months old. During Mother’s pregnancy with Sibling 2 the main concern reported to the Midwifery Service by Mother was housing; domestic abuse was not mentioned. Given the housing issues Mother was supported by specialist midwives. 4.4. During the pregnancy with Child I Mother did not raise any concerns and no vulnerabilities were recorded. At this point Mother was living with Father. 4.5. Health Visiting records from March and December 2013 indicate that Mother could be difficult to get hold of, and opportunistic visits were often more successful than scheduled appointments. During one appointment the Health Visitor did ask questions about domestic abuse between Mother and Father; despite the Health Visitor being aware of previous incidents, Mother stated that there were no problems, and the Health Visitor described ‘… a stable and loving environment … and the parents had resolved their differences and appeared to be getting on well …’8. 4.6. In February 2014, shortly after Child I was born, both Siblings 1 & 2 were admitted within two days of one another, via ambulance, to Royal Berkshire Hospital with febrile convulsions. The Ambulance Service, on attending the family home, were concerned that the children in the home were dirty and unkempt, with a poor and unclean living environment. This information was 6 Relevant child: A ‘relevant child’ is a child who is not being looked after by any local authority, but was, before last ceasing to be looked after, an eligible child, and is aged 16 or 17. It is the duty of each local authority to take reasonable steps to keep in touch with a relevant child for whom it is the responsible authority, whether he is within their area or not to appoint a personal adviser for each relevant child. An ‘eligible child’ is one aged 16 or 17, who has been looked after by a local authority for a period (13 weeks), or periods amounting in all to that period, which began after he/she reached 14 years of age and ended after he/she reached the age of 16. It is the duty of the local authority looking after an eligible child to advise, assist and befriend him/her with a view to promoting his/her welfare when they have ceased to look after him/her. For each eligible child, the local authority shall carry out an assessment of his/her needs with a view to determining what advice, assistance and support it would be appropriate for them to provide while they are still looking after him, and after they cease to look after him/her, and shall then prepare a pathway plan for him/her, Children Act 1989 & Children (Leaving Care) Act 2000. 7 Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare. 8 Berkshire Healthcare Foundation NHS Trust, report to Review. OFFICIAL SENSITIVE5passed to the Hospital who, in turn, passed this to the MASH9. The condition of the family home was not judged to be linked to the febrile convulsions although vulnerabilities were recognised and this was passed to Children’s Social Care. This onward referral was not taken any further as it was judged by Children’s Social Care that a threshold for further assessment or intervention was not met. During this period of hospital admission Father is reported as being verbally aggressive to hospital staff but also another patient’s parents. 5. Other relevant background information during the time-frame under review5.1. In March 2014 Sibling 2 was prescribed medication for epilepsy. There were no current risk factors to justify the Health Visiting Service offering any greater level of support beyond that of a universal level of service10. 5.2. The Health Visiting Service conducted a home visit which resulted in a referral to the MASH due to Father becoming aggressive and threatening when the Health Visitor challenged Mother about picking Child I up by the wrists. As consent to make a referral was not sought from the parents by the Health Visitor, and as the aggression was targeted at professionals rather than the children, the outcome of this referral was that it would not be taken any further. Whilst this decision was challenged by the Health Visiting Service it did not result in further action. 5.3. In August and September 2014 the Police were involved on five occasions due to an incident with neighbours, an allegation from Mother that Father was domestically abusive and a heavy cannabis user, reports about domestic incidents, concerns about the children and parental cannabis use. One of these incidents involved a report that Father had attempted to strangle Mother. This was not the first disclosure of this nature. These incidents were automatically notified to Berkshire Women’s Aid, the Health Visiting Service and Children’s Social Care. 5.4. On three occasions the nursery recorded incidents involving Sibling 1. On one occasion she had singed hair (stating that she had fallen in the oven), on another a cut finger (stating that Sibling 2 had cut her with a knife), and on a third, a mark on her arm (stating this was from climbing out of a window). These incidents were discussed internally by staff, but also with Mother. The explanations given seemed plausible, as were the assurances by Mother that she would be more vigilant. 5.5. In the later part of 2014 there were three further Police attendances due to domestic incidents. Risk assessments11 were completed however only information about one incident was passed to Children’s Social Care. Information was also passed to Berkshire Women’s Aid to make contact. Concerns that emerged were an unclean house, Mother stating that Father was 9 MASH: Multi Agency Safeguarding Hub which is able to undertake an initial assessment and conduct agency checks to determine the best course of action. 10 The Healthy Child Programme: Pregnancy and the first 5 years of life, Department for Health, focuses on a universal preventative service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. Different tiers of service are available dependent on need. The universal level of service is the lowest level of intervention and support offered. 11 DOM5 – Domestic abuse risk assessment form. OFFICIAL SENSITIVE6aggressive and threatening, and Father alleging that Mother was not taking her anti-depressants. The Health Visitor remained involved and increased her input in February 2015 to Universal Partnership Plus12. She had spoken to the MASH following a domestic incident in October 2014 and had stated that, on that occasion, she had no safeguarding concerns. Sibling 2’s epilepsy was being managed via reviews with the hospital paediatric epilepsy clinic and the GP, who was responsible for prescribing medicines. 5.6. Risk factors were noted by the Health Visitor following Child I’s nine-month developmental check in December 2014. These included domestic abuse and the parent’s heavy smoking. Child I was assessed as within developmental milestones except for communication and gross motor skills which were judged as borderline. Further visits did not raise any concern for the children, and in July 2015 the Health Visitor was advised by Mother that she was feeling depressed as she and Child I’s Father had ended their relationship and he was living with his new girlfriend in the house next door. 6. Key Episodes6.1. In wishing to conduct a proportionate review of this case and identify learning for the multi-agency partnership, it is important to remain mindful of the local context. Reading Borough Council was inspected by Ofsted13 in May 2016 and a number of findings were made in respect of the quality of service to children and families. The time-frame under review precedes this inspection, yet contains relevant background information. With the benefit of hindsight, this information provides us with useful insights and as such, is outlined above. However, there are specific periods of intervention with the children and family that are judged to be of greater significance, and which are more recent. They are key from a multi-agency practice perspective rather than to the history of the child. Given the findings of the Ofsted inspection, this Review has therefore focused on these, whilst acknowledging the more historical features of the case, as a way of identifying learning and promoting improvements. This Review has identified three key episodes that warrant closer examination. These are; -Key episode 1: October 2015 – March 2016-Key episode 2: April 2016 – June 2016-Key episode 3: June 2016Key episode 1: October 2015 – March 2016 6.2. In October, November and December 2015 there were four reported domestic incidents; the children were not present during three of these incidents but were present for the fourth, which occurred in early December. This final incident resulted in a conviction of criminal damage. On all 12 See footnote 10; Universal partnership plus is an increased level of visiting and support. 13 Reading Ofsted inspection report, 2016 OFFICIAL SENSITIVE7four of these occasions the domestic abuse assessment form score was rated as medium risk14; an increase from standard as used on previous occasions. As the children were present during the fourth incident, Children’s Social Care were informed and a notification sent to Berkshire Women’s Aid from the Police. The outcome of the information exchange between the Police and Children’s Social Care was that the case was closed and no further action taken by Children’s Social Care; records indicate that this was due to the fact that Father had visited Mother’s property (and the home in which the children were living) rather than him actually living there. 6.3. Towards the end of December, there were another three domestic incidents, in addition to the ones outlined above, requiring Police attendance; the children were confirmed to be present during two of the incidents and Children’s Social Care were informed of these by the Police. During one of the incidents Father had removed Sibling 1 from the home. Again, all three incidents were rated as medium risk and on two occasions Berkshire Women’s Aid were informed by the Police. The outcome of the information exchange was that Children’s Social Care agreed, at the end of December, that a Child & Family Assessment15 was appropriate for the following reasons; the increasing number of domestic incidents, health concerns, threats, home conditions, possible emotional harm, Mother’s mental health and parenting capacity, the drug use and the risk of neglect. This assessment commenced in January 2016, 16 days after the decision had been made. At this stage all three children were now living with Father and his new partner. 6.4. However, prior to the Child & Family Assessment being started the Police were called to three domestic incidents involving the Father and his new partner in a different house on consecutive days; one of these included an incident where Father had tried to ‘throttle’ his new partner. These were categorised as medium risk (one being re-categorised from standard to medium) and Children’s Social Care were informed of two, as the children were present. During this time, the Health Visiting Service received domestic abuse reports, as outlined above, and contacted Children’s Social Care to discuss their involvement. At this time Father’s Partner is reported to have stated that she did not want to be in the relationship and did not want to be mother to his children. 6.5. At the beginning of March, the Police were called to a further domestic abuse incident at Father’s house. Risk was assessed as medium and information was sent to Berkshire Women’s Aid and Children’s Social Care. Records appear to indicate neither the Hospital nor Health Visiting Service were contacted as part of any initial assessment exercise by Children’s Social Care. The Child & Family Assessment was closed in mid-March following management oversight as no concerns were found. Just prior to the closure of the case, the Police attended a domestic incident between the Father and his Partner. For the second time a risk assessment was declined 14 Medium risk: there are identifiable indicators of risk of serious harm. The offender has the potential to cause harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse, *Serious harm is defined as risk which is life-threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible, Thames Valley Police guidance. 15 Child & Family assessment is undertaken under section 17 of the Children Act 1989, where a child may be considered to be in need of support and assistance. OFFICIAL SENSITIVE8by the Father’s Partner however it was categorised as medium and Children’s Social Care were informed. Key episode 2: April 2016 – June 2016 6.6. Later in April, Father’s Partner called the Police reporting a domestic incident. Despite Father’s Partner not wanting a risk assessment the matter was still categorised; initially standard but then increased to medium as a result of a further review of the incident by the Police. The three children were not present during this episode. 6.7. Following this incident, the case was reviewed by Children’s Social Care who decided to re-look at the situation given the presenting issues. This re-assessment did not result in any action being taken. At this time, Father’s Partner had also reported that she was nine weeks pregnant. It was known that Father’s Partner had experienced a difficult and neglectful childhood herself. 6.8. In May a further domestic incident occurred between Father’s Partner and Father, during which Father is reported to have threatened to ‘… get someone to rape her 12 years old sister …’. Children’s Social Care were informed of this and conducted a visit the same day. The Father’s aggressive shouting in front of the children was observed. 6.9. At the beginning of June a Professionals Meeting was convened by a Social Worker. This was attended by a Family Worker, a School representative and a Nursery representative. No concerns were raised by anyone. Key episode 3: June 2016 6.10. In mid-June Child I, aged two years and five months, was taken by ambulance to the Royal Berkshire Hospital having been found unresponsive by Father at 09.30 hrs. 6.11. Whilst Child I was being stabilised tests were being completed to ascertain the cause of the collapse. At approximately 13.00 hrs blood tests revealed high levels of epilepsy drugs in Child I’s system; which had the potential to cause respiratory arrest. At this point the medical team considered this as a non-accidental incident and Children’s Social Care were contacted by the Hospital at 16.15 hrs. 6.12. At 16.40 hrs Children’s Social Care contacted the Police requesting a Strategy Meeting16 for the following day due to Child I’s circumstances on admission. A further call from the Berkshire Emergency Duty Service (EDS) was logged at 19.15 hrs with a similar request. Following enquires by the Police with the EDS it was established that Sibling 1 & 2 were with Father’s Partner. The following day, the Strategy Meeting took place however it was not established until 18.55 hrs that Siblings 1 & 2 were in fact with the paternal grandmother. The day after the Strategy Meeting, a 16 Strategy Meeting is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare. OFFICIAL SENSITIVE9Legal Planning17 meeting took place and there was a joint assessment of the Siblings. The next day Mother, Father and Father’s Partner were spoken with by the Police, prompting the Siblings to be accommodated under section 20 of the Children Act 198918 by the local authority. Three days after the precipitating incident, both Siblings were placed in foster care. 7. Findings & analysis1. This section offers findings and analysis about the quality and effectiveness of the multi-agencysafeguarding response to Child I, and siblings. It draws on systems thinking concepts19 as a way ofmaking sense of some aspects of how this case was managed, whilst also offering learning pointsfor improving practice.2. This case is subject to review due to the potentially life-threatening ingestion by Child I ofepilepsy drugs. The Family Court made findings about this being deliberately administered. TheCourt also found that that either the Mother, Father or Father’s Partner were negligent in that theyfailed to properly supervise Child I, or siblings, allowing access to the drug.3. As a result of undertaking this Review, and therefore with the benefit of hindsight, the moststriking finding is one that highlights an absence of known risk factors relating to the misuse, ormismanagement, of prescribed medication by the adults in this family. Oversight by theprofessional health system of the management of epilepsy was acceptable, and the prescribingof drugs for this condition from a GP perspective was also acceptable and would not have raisedany concern.4. The Review has highlighted a number of other risk factors which undoubtedly compromised thesafety and welfare of all three children, however it has not been possible to identify anysubstantive links between these and the deliberate administration of epilepsy drugs to Child I. Ithas portrayed a picture of a relatively chaotic family experience for all the children. This, in itself, isa learning point for those working closely with children and families where there are other knownand quantifiable risks highlighting the need to ‘think the unthinkable’ and be open minded aboutsources, motivations and predictability of harm to children.7.1. The quality of practice & systems in regard to the sibling’s epilepsy 7.1.1. Given the other history, and behaviours of the adults, this Review has sought to examine whether the inappropriate use of prescribed drugs was a factor that was missed by those 17 Legal Planning meeting provides an opportunity to discuss evidence and determine whether a threshold is met to initiate legal proceedings (immediate or planned) as a way of safeguarding, and promoting, the welfare of a child. It is convened by the local authority and follows guidance, as set out in the Public Law Outline: Guide to Case Management in Public Law Proceedings. 18 Section 20, Children Act 1989: the provision of accommodation for a child by the local authority, who is deemed in need (even though a person who has parental responsibility for that child is able to do so) if the local authority considers that to do so would safeguard or promote the child’s welfare. 19 i) Systems thinking for safety: Ten Principles – A White paper, Eurocontrol, 2014 ii) A systems approach to policy evaluation, Caffrey, L., & Munro, E., The London School of Economics and Political Science, 2017, iii) Systems approaches to managing change: A Practical Guide, The Open University, 2010. OFFICIAL SENSITIVE10professionals involved with the children and family. On that basis, the following areas have been examined; a) Diagnosis: This Review has found no evidence to indicate the original diagnosis of Sibling 2having epilepsy was incorrect. The Royal Berkshire NHS Foundation Trust Hospital has reflected onthe initial management of Sibling 2 when brought in with seizures in 2014. Whilst there could havebeen some improvements in the initial management this did not impact of the care of the child.Improvements have been implemented as a result of this finding.b) Prescribing: Review and analysis of the prescriptions issued in respect of epilepsy medication forSibling 2 reveal that approximately 50% more medicines were provided than were required,between March and December 2014. Some caution is needed in drawing an automatic negativeconclusion from this finding; firstly, the fact that other adult members of the close family were alsoprescribed with the same medication and it is not knowable whether there was any sharing ofmedicines, and secondly; there was an increase in dosage in December by the PaediatricConsultant. The over-ordering of the medication was not highlighted as an issue at that point. As apoint of learning, on any occasion that a clinician adjusts the dosage or formulation it alsoprovides an opportunity for the prescribing practitioner to undertake a review of pattern of usage.This would apply especially so in families where there are known vulnerability factors. Mother wasable to recall that she was careful about the dosage given, and that she was aware of theimplications of giving an over-dose because a member of her extended family had beenadmitted to hospital once because of this very issue. Discussion with the GP Practice Manager hashighlighted that there is often a leeway given to the seeking and issuing of repeat prescriptions toallow for life e.g. spillage, holidays, etc. The over-collection of prescriptions is rarely seen as anissue of concern, where-as the failure to collect would be flagged as a worry. With an outcomebias in mind (i.e. Child I being over-dosed), caution is needed in drawing a conclusion that theover-prescribing across a 10-month period equates to a deficit in practice, systems and processesgiven the tolerances described. It is impossible to conclude that the over-prescribingautomatically meant over-administration.c) Dispensing: Due to the number of pharmacies in the Reading area it has not been possible, orproportionate, to examine this area. Mother recalled using three different pharmacies, and it isnot known which ones Father used.d)Advice and support: All prescribed medicines have information and safety leafletsaccompanying them. This includes advice about the dosage as well as storage guidelines. Safetyadvice was, and is, not always explicitly documented by the Epilepsy Nurse. Mother describedfeeling certain in her knowledge of the drug.e) Storage of medication: The Health Visiting Service acknowledge that safe storage of medicinesis not always discussed, and was not in this case. General home safety is part of a Health Visitorsassessment and in this case, nothing suggested that the home environment was unsafe. There isevidence in the Social Work assessment that Sibling 2’s epilepsy was discussed, with informationhighlighting that the Father was considered to be the more reliable parent in giving Sibling 2 thedrug. Beyond that, there is little mention of it being explored or being considered an issue. Thestorage of the drug was examined following the critical incident and Father’s Partner indicatedOFFICIAL SENSITIVE11that it was kept in a locked cupboard however on checking this was not the case, with it being in a bag of children’s clothes which was in reach of the children. Mother described that whilst living with her, the medicines were stored in a lockable cupboard. f) Administration of medication: The administration of Sibling 2’s epilepsy medicine was reliant on Mother, Father and Father’s Partner. In the case of children taking prescribed drugs there is an assumption that a competent and responsible adult supervises and supports the administration. As Sibling 2 was being regularly reviewed by the Hospital, it is reasonable to assume that the medicines were being administered appropriately since diagnosis. There is no evidence to suggest this was not the case and to an extent there has to be an element of trust between medical practitioners and parents - trusting that parents will do the right thing in giving prescribed medication to their children. Mother described feeling confident in her handling of the medicines. It is worth noting that Sibling 2 ceased taking epilepsy drugs approximately one year after the critical incident, and no longer has seizures. g) Review: There is no evidence to indicate that the ongoing management of the condition was inappropriate by professionals. Sibling 2 was reviewed by a Consultant Paediatrician and an Epilepsy Nurse, and whenever there was a failed appointment the GP was informed with further appointments being arranged. 7.1.2. Hair strand tests on Child I indicate drug ingestion from April 2016 onwards. It is impossible to know whether it was administered before this time period. It would be speculative to form views about whether the drug was given when the children lived with the Mother and Father, just the Mother, or whether it began when Father started living with his new partner. 7.1.3. When placing the above findings in context of other known information about how this family functioned and behaved, it magnifies the importance of the case needing to be assessed in a thorough and holistic way when concerns began to escalate in October 2015. With the benefit of hindsight, the gaps and deficits in the quality and effectiveness of assessments and intervention become more pronounced (outlined below). Matching an assessment of need, abuse or harm alongside an assessment of the three adult’s understanding of the management and administration of medication would have been an option worth considering, however it is evident that Children’s Social Care did not consider the inclusion of medicines management in any assessment work. Again, with the benefit of outcome bias it is impossible to know whether the critical incident could have been predicted or prevented. Epilepsy is a life-threatening condition and requires potent drugs to manage it. Research20, although relating to opiate based drugs, highlights the need to think the unthinkable and that some parents may give their children drugs that are prescribed for an adult. Learning point: When working with children in families where prescribed drugs are used on a regular basis it is important to ask questions about medicine management. This should include an assessment of how these drugs are prescribed, what advice and support is given, and how the drugs are stored and administered. This should apply to prescribed drugs for both adults and 20 Medications in drug treatment: tackling the risks to children, Adfam, 2014. OFFICIAL SENSITIVE12children. It may then be appropriate to cross reference the information gathered with professionals involved in the prescription and review of those drugs e.g. GPs and hospitals. Learning point: When working with children, whose parents may have poor mental health, limited abilities and learning difficulties (diagnosed or not) it will be important to assess competence and practical understanding about using prescribed drugs, especially when concerns about neglect, children’s safety and welfare have been raised. 7.2. What was known about the parental history, vulnerability & risk factors in this case? What consideration was given to the impact of these on the children? 7.2.1. Both the Mother’s and Father’s background is relevant from a child protection and safeguarding perspective. Relevant information includes; • Both Mother and Father experienced housing, or homelessness issues, at around 17/18 years of age; strongly indicative of extended family disharmony prior to them becoming parents themselves. • As children themselves, Father, and his Partner, had been in local authority care. Children who have experienced episodes of being in the care of a local authority are more likely to have had adverse childhood experiences, and to have experienced abuse or neglect. In turn, they are also more likely to have experienced less secure and less stable relationships. There is a body of research evidence that supports the view that such experiences may go on to compromise their own parenting capacity and abilities21. • Father’s Partner explicitly stating that she did not want to be the mother to Father’s three children. • The use of cannabis, anger management problems, attempts at strangulation, domestic incidents and intimidation of professionals. Some of the domestic incidents reached a threshold which resulted in criminal charges being made, and convictions. • A previous referral in 2012 to Children’s Social Care, from a family member, reporting bruising to Sibling 1 allegedly caused by Father. At the time, Sibling 1 was 15 months old and Sibling 2 was two months old. Although not substantiated it does highlight possible concerns about parenting capacity, control and anger management, especially for someone in a household with very young children. • The use of opportunistic visits to the Mother as likely to be more successful than scheduled appointments; this does reflect a degree of dysfunction and chaos by the Mother. • Mother’s mental health; her depression and inconsistent use of medication to treat this. • When admitted to hospital in 2014 with febrile convulsions concerns were noted that the home was dirty and unkempt, with a poor and unclean living environment. Again, this is reflective of parents that were likely to be struggling to manage. 21 Does the past predict the future? Reder, P., in Studies in the Assessment of Parenting, Reder, P., Duncan, S., & Lucey, C., Routledge, 2007. OFFICIAL SENSITIVE137.2.2. Research22 highlights that the above factors are common in other case reviews conducted and do impact on parent’s capacity to keep their own children safe. Of specific note are; young parenthood, accommodation difficulties, the cumulative risk of harm, particularly mental health, domestic incidents and criminal behaviour. All of these factors featured in this case and were known about by agencies at the time of their involvement with the parents and children. Research23 also highlights that the use of strangulation (known about on at least two occasions with different partners) is significant as a feature of a coercively controlling relationship, but also a strong potential risk indicator of homicide. Research24 also tells us of the difficulties victims of domestic abuse face when attempting to leave an abusive relationship; reminding us that it is a significant, and often bold step to take. Mother described attempts to leave but that she was threatened by Father, either physically, or emotionally with not seeing her children again. Learning point: Recent attempts of strangulation in current intimate partner relationships should always be taken seriously, risk assessed and safety planning discussed. Any agency can refer what they consider to be a ‘high risk’ situation to the Police. Research supports the finding that women who experience attempted strangulation are on the edge of being a victim of homicide. Learning point: In situations where it is known that a partner has left a domestically abusive relationship but left children behind with the known perpetrator it will be appropriate to conduct a thorough assessment of risk to the children. Attempts to end, or the ending of a relationship, may signal an elevation of risk. 7.2.3. The features outlined above are suggestive of individuals, who in themselves, are somewhat vulnerable. When these pre-disposing vulnerabilities are compounded by situational factors, such as becoming a parent and having multiple, and often competing demands, it does increase the likelihood of both individuals being more easily stressed and challenged by the care needs of their children. 7.2.4. The protection of Mother, or Father’s Partner, from Father was considered in isolation of needing, in parallel, think how to reduce the Father’s coercive and abusive behaviours. Father clearly had a role in providing care to his children, yet understanding his background and considering the likelihood of him going on to commit further abuse and harm was absent. Learning point: The role of men in a household can often be overlooked even though they may be a cause of concern. The care and protection of children is often perceived to be the role of the mother in the household25. Engaging men, as fathers, in the assessment process is an important aspect of assessing risk to children. 22 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, University of Warwick & University of East Anglia, May 2016. 23 i) Domestic Homicide Reviews: Key findings from analysis of domestic homicide reviews, December 2016, Home Office, and ii) Non-fatal strangulation is an important risk factor for homicide of women, 2007, Glass, N., Nancy Glass, Laughon, K., Campbell, J., Wolf Chair, A., Block, C.R., Hanson, G., Sharps, P., & Taliaferro, E., Journal of Emergency Medicine. 24 Safe lives: about domestic abuse 25 NSPCC briefing: Hidden men: learning from case reviews, April 2015. OFFICIAL SENSITIVE147.2.5. Records and discussions, as part of this Review, support a finding that the Health Visiting Service recognised the above pre-disposing vulnerabilities and risks. This is evidenced by i) the increase in service offer from Universal to Universal Plus; ii) the frequency of visiting but also the acknowledgement that opportunistic appointments usually had a greater success that scheduled meetings; iii) the Health Visitors efforts to remind Mother to attend appointments; and iv) referrals being made to the MASH. It is therefore reasonable to conclude that the Health Visiting Service was aware of the impact of the background vulnerabilities for Siblings 1& 2, and Child I. 7.2.6. The Housing Needs & Management Service were not aware of Mother’s vulnerabilities, as she had not disclosed them in 2009. Later contact in 2013 did not reveal any change to the original assessment of Mother having no support needs or vulnerabilities. The Housing Needs & Management Service was aware of Father’s background, as this was disclosed by him when he first presented as homeless although he declared that substance misuse was not an issue. 7.2.7. Children’s Social Care were aware of both the Mother and Father’s backgrounds; however, this Review has found that there was little consideration of how these might have had an impact on Siblings 1 & 2, and Child I. The steady accumulation of concerns, particularly domestic incidents did not prompt Children’s Social Care to review the history, or create a chronological account which would highlight how the levels of risk to the children might be increasing. Incidents were dealt with in isolation. Learning point: Young parents can often experience additional pressures and difficulties, especially when they are unsupported. It is important to be alert to other factors, aside from the age of a young parent, which will further compromise parenting ability e.g. housing issues, mental health, and the quality of the relationship with the other parent. Learning point: Making the links between background information in a parent’s life and current parenting capacity is crucial to effective safeguarding practice; acting on this information when there are concerns is critical in order to prompt other agencies to become involved and promote targeted support and safety planning. 7.3. The quality & effectiveness of any assessment, planning & intervention. 7.3.1. Statutory guidance in place during the timeframe under review26 sets out expectations for the local authority, and relevant partner agencies for providing early help and the identification, assessment and response to those families that would benefit from early intervention as soon as a problem emerges. This offer of early help should sit within a continuum of services which will stretch through children needing support and assistance to children needing statutory intervention to safeguard and protect them from abuse or neglect. Regardless of which level of support is needed, assessment should be based on a holistic understanding of need – usually obtained via 26 Working together to safeguard children, 2015, HM Government. OFFICIAL SENSITIVE15contact with other agencies and professionals – be child focused, and include an appreciation of the child’s daily lived experience and their voice27. 7.3.2. In this case key episodes 1 & 2 highlight that there were two opportunities to formally assess and intervene with this family by Children’s Social Care under section 1728 of the Children Act 1989; however, there were also opportunities whereby the Police, Health Visiting Service and Housing Needs & Management Service had contact with either the children, the Mother, Father, or Father’s Partner. 7.3.3. Key episode 1 shows a steady increase in the frequency of the Police being called for domestic abuse related incidents. It is likely that there were other incidents where the Police were not contacted, and that domestic disharmony and dispute were common place in the family home at this time. The children cannot have been immune to this and the observations from the Health Visitor strongly suggests a level of accommodation29 to this behaviour; ‘…throughout the … incident Sibling 1 and 2 seemed unconcerned with the shouting and aggressiveness of the Father’s actions, Child I didn’t cry and it appeared that they were used to this behaviour … I have concerns that the Mother appeared unembarrassed and shrugged off the fact that I was leaving because of the Father’s threatening behaviour …’. Children can be victims of domestic abuse too, although will not necessarily be viewed as the primary, or obvious, victim. Although the children were not present for all of these reported, and attended, incidences it is important to remain mindful of the cumulative impact on the children of living in such an environment. Research30 confirms the harmful effects on children of witnessing and living with domestic abuse, aside from them potentially being injured during conflict ‘… effects include high rates of depression and anxiety, trauma and … behavioural problems …’. These can impact on educational attainment, forming relationships, self-esteem, and general health and wellbeing across the life-span. The perception of children being passive bystanders, or simply witnesses, to domestic abuse should therefore be challenged. Learning point: Children who live with domestic abuse are victims too. Consideration should always be given to understanding the child’s daily experience of living in such an environment and the potential for emotional harm. The contribution of the Police & Berkshire Women’s Aid to assessment, planning & intervention 27 The term ‘voice of the child’ is a colloquial term of setting an expectation that children are seen, spoken with and their views ascertained at every available opportunity. Children’s perceptions of events, behaviours and people are important to understand as this supports assessment, planning and intervention being child focused. 28 Section 17 – see footnote 1 & 18. 29 Children living with domestic violence: Towards a framework for assessment & intervention, Calder, M., 2006, Russell House. 30 Stanley, N., Cleaver, H., & Hart, D., The impact of domestic violence, parental mental health problems, substance misuse and learning disability on parenting capacity, in, The Child’s World, 2nd Edition, The comprehensive guide to assessing children in need, Edited by Horwath, J., Jessica Kingsley Publishers, 2010. OFFICIAL SENSITIVE167.3.4. During this period (October 2015 – March 2016) the Police attended 15 incidents, of which two were specifically classed as child protection incidents, three were classed as domestic abuse incidents between Mother and Father, and 10 were classed as domestic abuse incidents between Father and his Partner. Five of the domestic abuse incidents were categorised as standard risk by the Police but then re-graded as medium risk by an impartial Police Risk Assessor. No incidents were categorised as high risk; if they had of been, they would have been passed to the Police Domestic Abuse Investigation Unit but also MARAC31, and benefitted from greater scrutiny and oversight as a whole, rather than being considered in isolation. The use of strangulation as a method of control or causing fear or abuse must always be taken into account. Learning point: Seeking a fresh, and often impartial, perspective on an assessment of need or risk can be a positive and worthwhile step, for all agencies and professionals involved with a family; particularly when multiple referrals have been received on a case, but also when individual practitioners operate in busy organisations and have competing demands on their time. It reduces the likelihood of professional desensitisation and accommodation to issues that may have serious and lasting consequences. 7.3.5. The Police were asked to record the ‘voice of the child’ on each occasion however records reveal that due to the age of the children this was rarely achieved. This raises questions about how Police Officers can meaningfully capture the experiences of young children, or children whose verbal ability is limited. Training provided to the Police, since this incident, has sought to develop their approach to dealing with domestic abuse incidents and encourages officer to speak to children of all ages to ensure they have a voice. Learning point: Seeking verbal feedback from children is ideal whenever possible. When this is not possible it may indicate a need to involve other professionals who might be able to gain the children’s views, i.e. schools, nursery. 7.3.6. Importantly, the focus for the Police as a law enforcement agency will be offender and victim centred. Whilst their minds-eye will be alert to a crime being committed, during domestic abuse related call-outs their focus will be on the primary victim of the call out. In this case, it is therefore unsurprising that the views, and lived experience, of the children were not the Police’s greatest priority at the time of the call-out. From a system thinking perspective, this is an inevitable trade-off, which is caused as a result of the Police having a primary role and purpose, as defined in legislation. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs, such as these, help us understand system behaviour and system outcomes. The trade-off in this case for the Police during call-outs was their focus on the adult victim against spending time with the children to gain their contribution. Despite this occurring, the appropriate information about the children being in the house at the time was shared by the Police in a timely manner with the appropriate agency – 31 MARAC – Multi-Agency Risk Assessment Conference is multi-agency risk and information sharing forum led by the Police to manage high risk situations of domestic abuse. OFFICIAL SENSITIVE17Children’s Social Care. Positively, this does indicate a level of understanding by Officers that there was a likely impact on the children’s welfare. 7.3.7. The Police have, and continue to review, the way in which they assess and manage the risk posed by the domestic abuse offender and the risk to the victim. In this case, there was a clear increase in the number of call-outs – especially during the November and December periods – regarding Father being involved with either Mother or his new partner. An evaluation of any emerging patterns, and recognition that the Father was seemingly becoming a serial offender across more than one relationship, would have been beneficial at the time. The Police have recognised that this did not happen in the way they hoped it might at the time and two years on from this incident they have been able to report on improvements. There is also recognition that the concept of coercive control by Father towards Mother, was not considered at the time. 7.3.8. Since this time, the Police have introduced, or strengthened, measures in an attempt to reduce the likelihood of similar oversights recurring, but also improve their response. These measures include; i) a regular Domestic Abuse Repeat Incident meeting which looks at the top 10 repeat risk offenders across the region. This case would have met the criteria to be discussed at this forum, ii) there is now better oversight of domestic abuse incidents at the MASH on a daily basis, iii) the introduction of ENCOMPASS, which is a Police led process whereby domestic abuse incidents will trigger an e-mail to the relevant child’s school. This would not have had any impact in this case due to the age of the children, however it can provide a level of reassurance that Police attendances at disputes where there are school age children will share information with schools, who will be in a position to monitor the child’s welfare, iv) there are also plans to introduce a further strategy, MATAC32, which will work alongside MARAC as an initiative to target the most harmful perpetrators in a particular area. 7.3.9. Berkshire Women’s Aid has highlighted that during this timeframe under review they were commissioned to deliver a pilot project for medium risk victims. This was not focused on offering support but to offer basic safety planning, and onward referral for support of the victim if consenting. Despite referrals being sent by the Police, Mother did not respond to the contacts by Berkshire Women’s Aid due to the ongoing threats. At the point she did engage with them Mother’s relationship with Father had ended. Further offers to support Mother were declined however Mother has described that since the relationship ended with Father, she engaged with them. 7.3.10. Berkshire Women’s Aid also made numerous attempts to contact Father’s Partner having received the referral information from the Police, with the majority of attempts resulting in Father’s Partner not wanting any support. 7.3.11. The response by both Mother, and Father’s Partner does reflect an inherent tension for an organisation such as Berkshire Women’s Aid that is established to have an adult victim focus. In knowing that domestic abuse is taking place in a household where there are children living presents a dilemma for workers in having to apply a threshold. This threshold is whether the safety 32 MATAC – Multi-Agency Tasking & Coordination: a Police led initiative to tackling the most harmful and serial domestic abuse perpetrators. OFFICIAL SENSITIVE18and welfare of any children is sufficiently compromised by them not making an onward referral to other agencies i.e. Children’s Social Care. They are therefore required to balance risk; ensuring the safety of the adult victim if other agencies become involved in a victim’s life may increase the risk to all in the household. In this case, Berkshire Women’s Aid have reflected, with the benefit of hindsight, that the increasing number of referrals – particularly in relation to Father’s Partner in late 2015 and then 2016 warranted an escalation of their response. This could have happened by Berkshire Women’s Aid increasing their assessment of the risk level category to high, which would have prompted a referral to the MARAC, or by the use of more confident professional judgement which may have resulted in a discussion with Children’s Social Care. It is noteworthy that Mother had implemented her own safety planning by leaving the relationship with Father. This was however limiting as they continued to live as neighbours. Research supports the period around a woman leaving an abusive relationship as being particularly risky33. 7.3.12. Whilst recognising that children are victims of domestic abuse as well, the referral to MARAC can have the effect of removing any dilemma that some professionals may face in trying to juggle the safety and welfare of an adult versus children. Research34 supports the use of MARAC as a mechanism for sharing information but also risk. However, when there are children involved a referral to Children’s Social Care should also, always be considered. Factors which contributed to this not happening at this time by Berkshire Women’s Aid include; the standard of professional supervision of workers, less management capacity and therefore less oversight, and professional confidence in assessing and decision making. Learning point: Where there are significant concerns about domestic abuse between adults a referral to MARAC may be appropriate in order to raise the profile of the case, but also provoke a greater professional response; any professional can make this referral. This may be alongside a referral to Children’s Social Care if children are in the household. Learning point: Applying professional judgement to situations of risk and harm can be a complex task often informed by factors such as experience, values, personal circumstances, individual bias, work place culture and environmental pressures. Keeping a sense of purpose, and absolute focus on the safety and welfare of the child is critical to applying professional judgement. 7.3.13. Berkshire Women’s Aid are represented at the MASH and has been able to make improvements to their systems and structures in the time period following this incident. The contribution of the Housing Needs & Management Service to assessment, planning & intervention 7.3.14. The Housing Needs & Management Service have identified that in March 2016 a change in the tenancy agreement between Mother and Father was not thoroughly assessed. This lacked any contribution by other agencies or professionals that might have been working with the family 33 Research report: Risk Factors for Children in Situations of Family Violence in the Context of Separation and Divorce, Department of Justice: Government of Canada, accessed 14/11/18 34 Domestic Homicide Reviews: Key findings from analysis of domestic homicide reviews, December 2016, Home Office. OFFICIAL SENSITIVE19at the time, as well as the involvement of Mother. Also, Father reported that one of the children had a disability; this was not considered any further and taken at face value with no consideration about what this might mean for accommodation. Whilst the change of tenancy went ahead, and it secured a level of stability for the children in terms of them physically remaining in the same house the Housing Needs & Management Service acknowledge that they could have completed a more holistic, and family focused, assessment of the situation. 7.3.15. Since this incident the Service has made considerable improvements to assessment tools but also reporting systems and structures. Tools guide workers to undertake a more holistic assessment based on the requirements of the Homelessness Reduction Act 201735, and which require a Personalised Housing Plan. These Plans are to be shared with other professionals who are working with members of the household (with consent). In terms of risk to the children, housing does not appear to have been a critical factor. However, the proximity of Mother to Father and his new partner i.e. next door, was a contributing factor in that it increased the likelihood of continuing dispute and acrimony. So, whilst the silo assessment by the Housing Needs & Management Service lacked depth, the greater task for them should have been working with the other agencies involved with the family to understand contextual risks. They were not aware that the children were being assessed by Children’s Social Care in January or April 2016. The reasons for this will be examined below. The contribution of the Health Visiting Service to assessment, planning & intervention 7.3.16. Records and discussions confirm that the Health Visiting Service was cognisant of the background information and the situational risks for the children of living in a household where domestic abuse was the norm. As noted above, the Health Visitor recorded her concerns about the children’s apparent immunity to witnessing a domestic incident and appropriately made a referral to the MASH; however, the matter was closed as consent to do so, was not sought from the parents by the Health Visitor. For the Health Visitor to seek consent at the time of visiting, when Father was present, it would have been challenging – especially given the levels of aggression and previous intimidation encountered. Indeed, this experience has had a lasting influence on the accompanying student at the time, helping shape how other challenging home visits might be conducted in the future for this individual. It is therefore unsurprising that consent was not sought on the day. Learning point: Aggression and intimidation of professionals should always be taken seriously. Not only is there a danger of physical and psychological harm, but there is also the danger that such behaviour may be a deliberate ploy to divert the professional from assessing the risk to children. 35 This assessment must include assessing the circumstances that have caused someone to be homeless or threatened with homelessness, the applicants housing needs, what accommodation would be suitable for them, their household and anybody who might reasonably be expected to live with them and the support that would be necessary for the applicant and anybody who will be living with them, to have and to sustain suitable accommodation. When assessing the housing needs of an applicant we consider the individual members of the household and all relevant needs; this includes an assessment of the size and type of accommodation required, any requirements to meet the needs of a person who is disabled or has specific medical needs, and the location of housing that is required. This should then prompt a Personalised Housing Plan. OFFICIAL SENSITIVE20Such matters should always be reported, dealt with in a timely and robust manner and seek the involvement of the Police if necessary. 7.3.17. Despite the decision to close, and the matter then being escalated the decision to take no further action was upheld by the MASH Manager at the time. The Health Visiting Service has reflected on the unsuccessful efforts to escalate the matter. As learning from this, the Service plans to increase training to Health Visitors about how to effectively escalate, as well as issue refreshed guidance. 7.3.18. Consent to share information is never needed if there are concerns about the safety and welfare of a child36. The Health Visitor had legitimate and justified concerns. The Health Visitor’s action was appropriate; the response by the MASH was not appropriate. Positively, anecdotal feedback from Managers and practitioners contributing to this Review suggests that there has been considerable improvement since this incident about the MASH’s response to consent not being gained. Learning point: Government guidance busts the myth that consent is always needed to share personal information. It is not; ‘… you do not necessarily need the consent of the information subject to share their personal information. Wherever possible, you should seek consent and be open and honest with the individual from the outset as to why, what, how and with whom, their information will be shared. You should seek consent where an individual may not expect their information to be passed on. When you gain consent to share information, it must be explicit, and freely given. There may be some circumstances where it is not appropriate to seek consent, either because the individual cannot give consent, it is not reasonable to obtain consent, or because to gain consent would put a child or young person’s safety or well-being at risk. Where a decision to share information without consent is made, a record of what has been shared should be kept’. 7.3.19. The Health Visiting Service had no knowledge of the case being managed as a Child in Need, as this was never communicated to them by Children’s Social Care. As far as they were concerned the case had been closed when their attempts to gain support had failed. The reasons for this will be examined below. The contribution of Children’s Social Care to assessment, planning & intervention 7.3.20. As stated, there were two formal opportunities when Children’s Social Care became involved – January and April 2016. Both of these episodes were processed, and conducted, via Child in Need procedures. On both occasions the case was closed with no further action despite the re-opening of the case in April prompting another look at the issues. 7.3.21. Children’s Social Care has acknowledged deficits in their management of this case37, for both episodes ‘… the assessments undertaken did not fully consider the history of the case. There was optimism displayed when the children were in the Father’s care and short-term improvements 36 Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers, HM Government, March 2015 and updated July 2018. 37 Reading Children’s Social Care, report to Review. OFFICIAL SENSITIVE21were not considered alongside the violence that they were exposed to. This was particularly evident in respect of Sibling 1 who was starting to display challenging behaviour at both home and school …There was no analysis as to the root cause of … behaviours. The assessments undertaken are of limited use and failed to join together all of the information so a clear picture of the children’s lived experience was known. … There was no multi-agency meeting to share information … It appears no professional involved with Child I and siblings clearly understood the family’s circumstances … there was an emphasis on the here and now and with no professional fully considering the longer-term needs of these children … The level of support … was not adequate to protect the children … social work churn was significant and management oversight and supervision was … limited …’. In terms of managing the case via Child in Need guidance, ‘… CiN planning was not effective and there was not a multi-agency plan in place. There was no evidence of multi-agency CiN meetings taking place. On more than one occasion this case should have escalated into the child protection arena …’. 7.3.22. The lack of a meaningful chronology in this case was a contributing factor in Children’s Social Care failing to appreciate the level of risk, but also the daily experience of the children. The preparation of a chronology and using information gathered from multiple sources would have been a good place to begin assessing need. Identifying persisting patterns, rather than focusing on the presenting issue per se, would have supported more meaningful and focused intervention. Learning point: When concerns or worries begin to emerge, regardless of professional discipline, taking a step back to reflect on what might be happening will be time well spent. Having date ordered, up to date and good quality records about children and families will significantly help your reflections. Learning point: Gathering and analysing background information in the form of a chronology can be a useful tool in assessing and predicting future behaviours. The chronology may be specific and particular to your context e.g. not brought to appointments, domestic incidents, but the use of chronologies should be a consideration for all professionals involved in working with children and families38. 7.3.23. Children’s Social Care have recognised that there were at least six incidences when the situational risks to the children might have resulted in an escalation of their response, rather than an assessment and stepping down of intervention. These mostly relate to various domestic abuse incidents between June 2014 and February 2016. Mother described wishing she had received more help, as she was managing three children on her own and had very limited support from anyone else. 7.3.24. In recognising these significant deficits, there are clear themes emerging from this case review which are similarly reflected by the Ofsted findings from their inspection in 2016 which relate to whole system failures. Ofsted noted children were ‘… left at potential risk of significant harm for too long before action was taken. These failures were particularly prominent where children were affected by domestic violence … A breakdown in management oversight and too 38 Risk in child protection: Assessment challenges and frameworks for practice, Calder, M., with Archer, J., Jessica Kingsley, 2016. OFFICIAL SENSITIVE22many changes of managers, alongside the failure of professionals to recognise the level of risk posed to children, were all too evident in far too many cases …’. The incident which prompted this SCR to be commissioned took place at the time of the inspection; it is therefore not unreasonable to draw conclusions from the findings of this Review, and place them within the context of the Ofsted findings in the preceding months to the inspection. Whilst being alert to bias, it is possible to make sense of the findings from this Review knowing the challenges and pressures Children’s Social Care were facing at that time. From a system thinking perspective, demand and pressure, coupled with resources and constraints, will impact on efficiency and performance. With the Children’s Social Care system experiencing a high staff turnover and inconsistent management oversight, there is an inevitable consequence passed on to the service user; in this case, the children and families in receipt of services. The lack of a chronology may be viewed as another example of a trade-off being used at the time in order to manage demand; some aspects of practice had to give and chronologies were one. Trade-offs are an inevitable consequence of a system and process managed by people – especially balancing efficiency against thoroughness. For managers and those responsible for examining practice quality and performance, it is important to consider how busy front-line workers make trade-offs from their point of view and explore how they balance efficiency and thoroughness in light of the conditions and environment in which they operate. Remaining alert to the impact this has on children’s welfare and decision making is crucial. 7.3.25. The systems thinking concept that can accompany a trade-off is emergence. Emergence39 is a key property of complex systems – of which the multi-agency child protection system in one. The strength of a complex and self-organising system can often be tested against its ability to respond to emerging issues which cannot be controlled, predicted or easily managed. Emergence as a concept is therefore relevant as it allows us, often with the benefit of hindsight, to better examine system weaknesses – rather than purely concentrating on the efforts, or errors, of individual practitioners. Ofsted found embedded and anchored practice that had emerged due to demand and pressure. The impact in this case of taking the short-cut was inadequate assessments, and silo working arrangements. Research40 highlights this stating ‘… a danger that can arise in such situations is cultural normalisation and professional desensitisation. This maybe a very appropriate coping mechanism by professionals overwhelmed by the volume and complexity of their task, but can result in vulnerable children being left without adequate assessment of their needs’. Learning point: From a safeguarding system perspective, when the system struggles to manage the demand, there may be value to gaining an understanding about the likely trade-offs that will be used by workers and managers to cope e.g. not using chronologies to inform safety planning, not involving all relevant partner agencies, or not providing supervision. Agree which are acceptable, and which are not negotiable. Monitor, and remain alert to risks to children for when the safety net might fail. 39 Seel, R., Emergence in organisations, 2006. 40 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, University of Warwick & University of East Anglia, May 2016 OFFICIAL SENSITIVE23The multi-agency contribution to assessment, planning & intervention 7.3.26. The contributions and actions of agencies involved with Child I and siblings has been examined above from a single agency perspective thus far – in relation to key episodes 1 & 2. However, the cornerstone of contemporary child protection practice is the operation of a multi-agency safeguarding partnership. Statutory guidance41 states that ‘… no single professional can have a full picture of a child’s needs and circumstances and, if children and families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action…’. 7.3.27. As already stated, submissions by Children’s Social Care have revealed that there was no Child in Need plan in place, nor any evidence of Child in Need meetings taking place. This is supported by the findings across other agencies and professionals involved with the three children. The Health Visitor was not aware that the children were being ‘managed’ or ‘processed’ as a Child in Need case, nor were the Police, the GP or the Housing Needs & Management Service. This confirms a break-down – in the management of this particular case – on information sharing, but also recognition of the role other agencies and professionals could offer in supporting or safeguarding these children. As a result, there was no multi-agency assessment and no holistic plan which resulted in fragmented intervention. This was seen when a ‘professionals meeting’ was held in June 2016 at Sibling 1’s school. This meeting appears to have been convened following knowledge of a further domestic incident between Father and his Partner. It is unclear on what basis this meeting was being held i.e. Child in Need, and whether it was with or without the knowledge of Mother, Father and his Partner, or whether it was as a pre-cursor to an escalation of concern. Regardless, the record indicates that no concerns were expressed by anyone attending about any of the children (Family Worker, School and Nursery). Crucially, neither the Health Visitor nor the Police were invited. The case was subsequently closed. This example highlights the need to work with all other relevant professionals involved with a child, and family, so as to gain a holistic, current and accurate assessment of need and risk. Learning point: When holding a meeting to examine levels of need, and risk, for children and families it is important to be clear about the basis for the meeting and under which procedure the meeting is being held. It is also always worthwhile asking ‘… is there anyone that is not here today that knows the child/family and who can offer any insights?’. If other professionals were invited but could not attend, have they been able to offer their contribution, either via the phone, e-mail, or written report? If not, why not, and who will take responsibility for seeking any outstanding information? 7.4. The quality & effectiveness of information sharing and use in this case 7.4.1. Information sharing has been examined above in respect of parental history, and assessments and intervention from the perspective of the relevant agencies involved at the time. In some cases the timely and effective sharing of information was seen e.g. by the Police notifications to Children’s Social Care, but also examples of inadequate sharing have been noted e.g. Children’s Social Care informing and involving other agencies in Child in Need planning. 41 Working together to safeguard children, 2015, HM Government. OFFICIAL SENSITIVE247.4.2. Key episode 3 is significant in that, again, it highlights examples of good information sharing i.e. timely and necessary, but also practice that is less than optimal. 7.4.3. The response by the Ambulance Service was good, in that Father made the phone call at 09.30 hours and Child I was admitted to hospital 40 minutes later. The initial response by the emergency staff was also good in terms of history taking, assessment, and obtaining information from Father about the epilepsy drugs for Sibling 2. Child I was being stabilised whilst blood was being tested – including testing for epilepsy drugs. This assisted with diagnosis by 13.00 hours and treatment at an early stage. Once the blood tests confirmed the presence of the epilepsy drug, the Consultant was able to consider a differential diagnosis, and Children’s Social Care was contacted around 16.15 hrs. The above management reflects timely and effective use of information from a medical management angle, but also in considering what the most appropriate pathway would be, given the confirmation of the diagnosis. 7.4.4. Records then indicate delays creeping in. The Police were contacted at 16.40 hours on the day of admission by Children’s Social Care but noted they ‘…were not clear about what they want the Police to do other than to arrange a strategy discussion for the next day …’. A further call from Children’s Social Care is noted to have asked what the Police’s intentions were; clearly these two calls reflect some uncertainty about how to manage the situation. From a Children’s Services perspective, the reasons for these delays rest in the systemic issues identified by Ofsted noting ‘… widespread and serious failures in the assessment, planning and management of children in need of help and protection …’. From a Police perspective, at the time of the incident the Police Child Abuse Investigation Unit (CAIU) did not work late shifts so the matter went to CID to deal with, causing delays. The working arrangements in the Police CAIU have now changed. With the benefit of hindsight the Police have been able to see that limited background checks were completed at this time with information gathering and consideration about the two siblings not being as thorough as it could have been. This impacted on the initial quality of the police investigation undermining the potential for any witnesses to be interviewed at the earliest opportunity. Had the initial response been more coordinated it might have strengthened the Police investigation. As a result there was no specific medical, with a child protection focus, to see if Sibling 1 had traces of epilepsy drug in her system, or if Sibling 2 had the correct levels of drug in her system. An assumption was made that because they were with an extended family member, they were safe. The Strategy Meeting happened the day after the admission, and the joint assessment of the Siblings took place the day after this – almost two full days after Child I had been admitted. The day after this, all children were placed in the care of the local authority. 7.4.5. Sibling 2 attended Nursery, on two separate occasions with either singed hair (stating that she had fallen in the oven), a cut finger (stating that Sibling 2 had cut her with a knife), and a mark on her arm (stating this was from climbing out of a window). This information was not shared with Children’s Social Care or the Police as the Nursery were satisfied with the explanations given by Mother. The Nursery were confident in their handling of these incidents and it has been noted that the Nursery was judged as good by Ofsted in 2015 and outstanding in 2017. 7.5. The use of dissent, professional disagreement and escalation OFFICIAL SENSITIVE257.5.1. The use of escalation, as a result of professional disagreement is a feature in this Review on two separate occasions. The first incident, in February 2014, was where the Ambulance Service were concerned about the home conditions and the children’s appearance. Appropriately, this information was shared with the MASH however the matter was not taken any further. 7.5.2. Information from Children’s Social Care for this Review reveals that a decision was made by the MASH that a welfare visit was needed. The term ‘welfare visit’ is misleading as a visit conducted by a Social Worker, fundamentally, is an opportunity to conduct an assessment. However, the management decision of the Access to Assessment Team was that a welfare visit was not necessary which resulted in the referral being closed and no further action. There is no evidence to indicate that this decision was challenged or escalated. Whilst it might be possible to place this scenario in practice from over four years ago, Practitioners, and Managers have advised that this could, and does still happen occasionally. This highlights two issues; 7.5.3. Firstly, a continued mismatch in understanding about thresholds for conducting an initial, exploratory assessment to gain a view about the safety and welfare of children. This mismatch is located at the front-door of the safeguarding system – potentially having a significant impact of the initial evaluation of risk and safety planning. 7.5.4. Secondly, it highlights a flawed communication loop – again, at the front-door of the safeguarding system – in which practitioners and Managers may not have a completely shared understanding about the interaction and flow of work through the system. This dysfunction is then viewed by those outside of that dynamic as ‘… the referral was not accepted because the threshold was not met …’. If the original referrer had known that the referral was, in fact, not accepted because the Managers in the MASH and Access to Assessment disagreed about threshold, it may have prompted further discussion or escalation. From a system thinking perspective, there are two feedback loops at play in this situation; internally between the Managers, and then externally, back to the referrer. The driving factor should be ‘… is the safety and interests of the child paramount in the process …? Learning point: Effective communication between professionals – both within their own agency as well as across agencies – is important. Effective child centred communication can reinforce positive practice42. Ensuring communication is open and transparent with all relevant people, is one way to reduce the likelihood of unintended consequences, such as misunderstandings about outcomes and expectations. 7.5.5. The second incident when escalation was used concerned the referral by the Health Visitor, again in 2014. This was in relation to the Health Visitor not gaining consent to make the referral, and the case being closed despite the matter being escalated to the MASH Manager. This report has already discussed the matter of consent and highlighted that it is not necessary if there are concerns about the safety and welfare of a child. The Health Visiting Service has acknowledged that there is learning for them in terms of strengthening their understanding and confidence in using escalation. Despite the matter being closed down, there is always another avenue to take 42 The Munro Review of child protection Part one: A systems analysis, HM Government, 2010 & Systems Dynamics by Morecroft, J., in Systems approaches to managing change: A Practical Guide, Reynolds, M., & Holwell, S., The Open University, 2010. OFFICIAL SENSITIVE26in order to raise the profile of the concerns held. Using Named/Designated Safeguarding Nurses within health organisations provides a further opportunity and/or allowing a more strategic role to argue for the best interests of the child, rather than operational staff becoming embroiled in further exchanges. A professional disagreement & escalation protocol can; be an opportunity to reflect on decision making; encourage professional curiosity; be a way of avoiding professional disputes that put children at risk or obscure the focus on the child; allow a way of resolving the differences within and between agencies quickly and openly. On this occasion, this opportunity was not taken. Learning point: In working with high numbers of children and families, but also other professionals it is inevitable, but also healthy, that there will be professional disagreement at times. Consideration of whether decisions made are in the best interests of a child should be the driving principle. 8. Good practice8.1. The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered good and supports good outcomes for children. Good practice from a number of agencies and professionals has been acknowledged; this includes, •The consistency offered by the Health Visiting Service, supporting a better relationship withMother and a more informed view about levels of risk over time.•The Health Visitors attempts to escalate concerns, when initially informed the case wouldnot be opened for an assessment by Children’s Social Care. This demonstrated a childfocused intervention, but also a degree of tenacity.•The use of text messages by the Health Visitor to support Mother in taking the siblings toappointments.•Discussions between the Health Visitor and Mother about domestic abuse when opportunemoments arose without Father being present.•The family being discussed in the vulnerable families’ supervision and child protectionsupervision sessions by the Health Visiting Service.•The medical response to Child I when admitted to hospital unresponsive, being timely andearly consideration of a differential diagnosis.•Good liaison between the Health Visitor and the Nursery in order to access funding for anursery place for Siblings 1 & 2.•The impartial oversight provided by the Police Risk Assessor and increasing the risk categoryfrom standard to medium.•The timeliness of notifications about domestic incidents by the Police to Children’s SocialCare.9. Conclusion9.1. This Review has examined the circumstances in which Child I, and Siblings came into contact with a range of agencies over a four-year period. It has gathered documentary information from those agencies and organisations who had contact with Child I and siblings but also benefitted from the contributions of front-line practitioners and managers involved with those services. Mother was able to make a contribution; however, a limiting factor has been the absence of the Father’s contribution. OFFICIAL SENSITIVE279.2. The Review has highlighted a small number of features that can be described as good practice. It is important that these are used to strengthen the multi-agency safeguarding arrangements across the Reading area. 9.3. The Review has also identified a number of factors and areas where practice could have been more robust, or where a different course of action might have been considered. These include the use of case history to inform assessment and planning, the critical need to fully assess children’s experience of living with domestic abuse, and the important role that Children’s Social Care have in leading, coordinating and reviewing safety planning for children. These issues serve as reminders of the constant need to remain child focused but also alert to how organisational pressures can divert professionals away from keeping children safe. 9.4. The Review has identified a number of learning points throughout for agencies and professionals to consider and use to strengthen their practice. 9.5. The Review concludes with recommendations to the LSCB, which build on the recommendations and actions already identified by single agencies. 10. Recommendations10.1. A number of single agencies have identified learning during the process of researching their involvement in this case; as such they have completed action plans and are already working to make improvements to services. In a number of cases, actions have already been taken to reduce the likelihood of reoccurrence. The following additional recommendations are provided to ensure that Reading LSCB and its partner agencies are confident that any other areas are addressed and that the LSCB is able to monitor progress. 1. The LSCB to promote the learning from this review across all relevant partner agencies, andseek assurances that it has been disseminated and embedded.2. The LSCB to monitor implementation, and seek progress reports, on the implementationand embedding of actions from all single agency action plans,3. The LSCB to promote awareness of the recently revised (May 2017) Escalation Policy:Resolution of professional disagreements relating to safeguarding of children and youngpeople, across the children’s workforce.4. Where possible, when GPs and other clinicians are prescribing medications for a child(particularly those drugs that could be used as a sedative and/or where over-dose couldbe fatal) consideration should be given to social issues in the child’s life which may impacton the ability of the parent/carer to maintain a medication regime safely.5. The LSCB to seek assurance from Children’s Social Care that the issues highlighted in thisreport are being addressed in a robust and timely manner; particularly in relation to theapplication of Child in Need procedures, and including the use of history to informassessment and planning, the quality of assessments especially of those situations wherechildren are living with domestic abuse, the recognition of risk, the coordination andeffectiveness of multi-agency meetings to safeguard and protect children.OFFICIAL SENSITIVE28 |
NC047160 | Death of a 13-month-old girl of Somalian heritage in February 2013. Post mortem identified evidence of fractures, judged to be strongly indicative of a non-accidental injury. Parents were both convicted of neglect. Family were known to universal services only. Mother arrived in the UK seeking asylum whilst pregnant with Child S. Father and Child Ss siblings joined at a later date. All injuries to Child S occurred after the family were reunited. Issues identified include: professionals had only limited information about the familys history in Somalia; family moved regularly between local authorities making it harder for agencies to share information and provide them with consistent support; and mothers family were sometimes used to interpret for her rather than providing an independent interpreter. Recommendations include: a single system is needed in London to ensure health visiting services are notified by GPs when new children move into an area and an effective notification system is needed across London for informing universal health and childrens services when housing services move vulnerable families.
| Title: Serious case review: Child S. LSCB: Greenwich Safeguarding Children Board Author: Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Greenwich Safeguarding Children Board Serious Case Review Conducted Under Working Together to Safeguard Children 2013 Child S The Overview Report Lead Reviewer Amy Weir MA MBA CQSW December 12th 2015 Final Version 12th December 2015 2 | P a g e GREENWICH SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW RELATING TO Child S Date of birth: January 2012 Date of death: February 2013 Ethnic origin: Black African OVERVIEW REPORT CONTENTS PAGE Executive Summary 3 1. Introduction 4 2. Serious Case Review Process 5 3. Family Composition and Cultural Issues 10 4. The Facts - Background and Summary of Agency Involvement 11 5. Child S's Experience 12 6. Analysis of Practice and the Lessons Learnt 13 7. Conclusions and Terms of Reference 16 8. Recommendations for Greenwich Safeguarding Children Board 18 9. Recommendations for individual agencies 19 10. Learning from the review 19 Appendices Appendix A - Family and Significant others and Genogram Appendix B - Scope and Full Terms of Reference Appendix C. Membership of the Greenwich LSCB Serious Case Review Panel Appendix D - LSCB action plan and progress. Appendix F - List of References Final Version 12th December 2015 3 | P a g e Summary of the Findings of this SCR What happened in this case? This young child of a newly arrived family from a war-torn area suffered multiple fractures. Expert medical opinion found that physical abuse and the injuries contributed to her death. The family had only been in the UK since mid-2011. They were supported by other family members and used universal health services and appeared to seek medical advice until the child received these injuries. Prior to the death of this child, there had been no concerns about the care the child was given or her mother’s parenting. The family were not known to any targeted services. It is unlikely that the death of this child could have been predicted from the history as it was known or from the information which each agency had. The parents have been convicted of neglect for failing to access appropriate medical intervention for the child - under Sec 1 (1) Child and Young Person’s Act 1933 neglecting a child in a manner likely to cause him/her unnecessary suffering. The trial took place at the end of 2014 and the parents were sentenced in January 2015; father received a custodial sentence and mother was given a suspended custodial sentence. What might have reduced the risk of this child’s death? Some system issues for consideration have emerged from this review. There appear to have been some areas for improvement in the universal, early help system. It is important to note, however, that Child S’s injuries and physical abuse seem to date from only the last 2 months of life and after father and the other siblings were reunited with this child and her mother. High mobility / universal health service in several areas involved. In 18 months, the family moved on four occasions and lived in four different London Boroughs. It is clear from this review that there are several obstacles to ensuring that continuity of universal service provision is achieved for vulnerable families with young children across London. This family, which was mother alone with one child for most of this period, was potentially vulnerable as asylum seekers; the mother and child may have been vulnerable as they moved further from extended family members. Although mother registered with GPs, Child S did not consistently get the access needed to universal health care surveillance and support provided for under 5s through the health visiting service. Missed opportunity to identify and address needs of a family who sought asylum & was given leave to remain Mother was thought to be suffering from post-traumatic stress during her first few months in the UK– though she apparently did not want support for this. There may have been a better understanding of mother’s needs if interpretation services had been used all the time – particularly during her pregnancy and the early months of Child S’s life; her family were used to interpret on some occasions rather than seeking additional support for her. However, there are indications that mother was reluctant to seek help. There may be hidden vulnerabilities and risks as far as families who have recently sought asylum and have been granted leave to remain are concerned. The need in the current high demand on housing to move families to other areas away from the host Borough increases the likelihood that vulnerabilities may not be identified. Although this Serious Case Review was commissioned by Greenwich Safeguarding Children Board, the family had only been living in Greenwich for a few weeks prior to the child’s death. Therefore, the findings and recommendations are mainly for wider consideration beyond Greenwich across London and for the other areas in which the family lived. Final Version 12th December 2015 4 | P a g e 1. Introduction In order to ensure confidentiality and out of respect to family members, all names are anonymised throughout this report. 1.1 Background to this Review This Serious Case Review (SCR) was commissioned following the death of a 13 month old child referred to as Child S in this review. It considers the circumstances of the death and whether the services, which were received from a range of professionals across several different London local authority areas, responded appropriately to address the child’s needs. 1.2 Child S was born in January 2012. The child died aged thirteen months old in February 2013. Two days after Child S's death the initial post mortem identified that there was evidence of fractures. As a result of this, a specialist paediatric post mortem was undertaken. This revealed that there were severe multiple fractures of different ages which were judged to be strongly indicative of non-accidental injury. These factors led to the decision on 6th March 2013 by the Greenwich Safeguarding Children Board (GSCB) Chair to undertake a serious case review. 1.3 Child S was the youngest child of the S family. Child S was born in January 2012 and was reportedly in good health but died unexpectedly in February 2013. The immediate cause of death according to the post mortem was inhalation of stomach contents; multiple healing and recent bone fractures caused by a “forceful event” (ribs, long bones and scapula) were also found. The pathologist dated the child’s injuries to two main time periods – two to four days and two to four weeks prior to death. All of these injuries occurred after father and siblings came to the UK in December 2012. 1.4 At the time of her death in February 2013, Child S was in the care of mother and father and she was living with them and four other siblings. 1.5 Summary of Circumstances Leading to the Review 1.5.1 A Review was regarded as necessary because of the unexplained fractures which were identified during the post mortem. The family were for the most part only known to universal health services in the various London Boroughs where they had lived. No particular concerns about the parenting of Child S or the child’s siblings had apparently been identified. However, the death is believed to have resulted from physical abuse and the parents were arrested in relation to the child’s death, were charged and were subsequently found guilty Final Version 12th December 2015 5 | P a g e of child neglect at the end of November 2014; they were sentenced in January 2015. For these reasons, it was decided by the Greenwich Safeguarding Children Board in 2013 that this case met the criteria for undertaking a Serious Case Review - as set out in Working Together 2013. 2. Serious Case Review Process 2.1 The Statutory Basis for Conducting this Serious Case Review This Serious Case Review (SCR) was formally commissioned on 6th March 2013 when the Independent Chair of the Greenwich Safeguarding Children Board endorsed the recommendation from the Serious Case Review Panel that a review should be carried out. Ofsted and the Department for Education were notified of Child S's death and that the decision to conduct a SCR had been made. The decision was based on the criteria from Working Together to Safeguard Children 2013 which identify the factors which should be taken into account when deciding whether a SCR should be undertaken. 2.2 Terms of Reference 2.2.1 The full terms of reference are appended to this overview report. The Individual Management Review authors were asked to consider the issues listed in Working Together as well as the particular issues set out in the terms of reference. SCR Criteria from Working Together to Safeguard Children 2013 The statutory guidance requires LSCBs to undertake an SCR when the criteria are met (regulation 5 of the LSCB guidance 2006). Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs are to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either Final Version 12th December 2015 6 | P a g e (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In addition the guidance requires that SCRs address the following: providing a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence advising the Greenwich Safeguarding Children Board, relevant local authorities and other agencies on lessons to be learned. agreeing with GSCB partners and other relevant agencies what action they need to take in light of the SCR findings. be written in plain English and in a way that can be easily understood by professionals and the public alike; and be suitable for publication without needing to be amended or redacted. Key Issues to consider in the SCR - Specific issues which have been identified as requiring particular analysis in this case are: There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care department. Given this, the SCR focused on the role of universal services: did professionals have an understanding of the family history prior to their asylum application? should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK, had sought asylum and had been granted leave to remain? were the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)? are there specific issues around ethnicity, language or religion? whether and what sort of vulnerability assessment might have been undertaken consider the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBK&C) and the host local authorities? was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012? were there any organisational difficulties being experienced within or between agencies? Final Version 12th December 2015 7 | P a g e 2.2.2 The Time Period for this Serious Case Review is from May 2011 – when the mother arrived in the UK – to the outcome of Child S’s post mortem in February 2013. This review considers all the information which has been ascertained from that period. 2.2.3 Other Review processes The Coroner decided not to hold an inquest in relation to Child S's death. There was a criminal trial which concluded in January 2015. The minutes and papers from the Greenwich Rapid Response Meeting held on 6th February 2013 have also been shared and considered in the review. As part of the review process, Child S's parents were contacted to inform them that a review had been taking place. This contact was initiated following the ending of the trial. Mother was written to but there was no response from her. It has not been possible to contact father who is serving a custodial sentence as his whereabouts have not been received from the Prison Service. Every effort has been made to make contact with the parents up until the final date of publication as there are many questions remaining about what happened in the family. It is still planned to share and discuss the findings of this review with the parents. 2.3 Timing of the Review There has been no delay in the decision making in the arrangements for undertaking this review. The independent SCR Panel Chair, the Overview Author and the Individual Management Reviews were commissioned promptly. The review was completed in a timely way. There was some delay in finalising the overview report. The criminal trial did not conclude till January 2015. It only became known in mid-2015 that the Coroner had decided not to hold an inquest. 2.4 The Serious Case Review Panel and Overview Report - independence and process 2.4.1 The SCR Panel Chair and the Lead Reviewer are appropriately independent, qualified and experienced professionals. 2.4.3 The overview report has been written from the evidence set out in the Individual Management Reviews and agency statements as well as from document reading and from further conversations with IMR authors to Final Version 12th December 2015 8 | P a g e clarify the details and findings. The author has also considered whether there are any relevant research findings to apply to the case. 2.4.4 The membership of the Serious Case Review Panel is set out in Appendix C. 2.4.5 The Serious Case Review Panel met on four occasions prior to the first presentation of the Overview Report to the LSCB. The Independent Chair encouraged adherence to timescales, and the general management of the Serious Case Review Panel meetings and the process was efficient and effective to ensure maximum learning from the Review. The Independent Chair was provided with professional business management and administrative support. The Serious Case Review Panel provided the Lead Reviewer with good advice and constructive comments about this Report and they effectively challenged each of the Individual Management Reviews. The Panel was proactive in identifying points of concern as well as areas for learning which have been incorporated into this overview report. 2.5 Individual Management Reviews The family have lived in four local authorities across London; the following organisations have been identified as ‘participating organisations’ which had important information to contribute to the review. NHS Greenwich Clinical Commissioning Group submitted an overarching Individual Management review based on submitted IMR’s from health services (GP, Health Visitor and Midwifery) in Greenwich, Wandsworth, Hackney and Kensington and Chelsea. NHS West London Clinical Commissioning Group NHS City and Hackney Clinical Commissioning Group NHS Kingston Clinical Commissioning Group NHS Wandsworth Clinical Commissioning Group Kingston Hospital Royal Borough of Kensington and Chelsea (RBKC) Housing Needs Services Metropolitan Police Service Royal Borough of Greenwich Children’s Services 2.5.1 In accordance with Working Together 2013, Individual Management Review authors were advised of the need to look openly and critically at individual and organisational practice. They were asked to judge whether the case indicated that improvements to practice could and should be made, and if so, to identify how those changes will be brought about. (Working Together to Safeguard Children 2013). The Individual Management Final Version 12th December 2015 9 | P a g e Review Report authors were briefed as to their responsibilities by the Independent Chair and Overview Report Author at the beginning of the process. The LSCB Manager also supported the authors and she was available throughout the process to give advice. 2.5.2 All those who conducted the Individual Management Reviews were identified by the Serious Case Review Panel and the Independent Author, as being either completely independent of the area, or senior personnel within each agency who were completely independent of any direct involvement or line management responsibilities concerning the case. 2.5.3 The Serious Case Review Panel decided that the following agencies and organisations would be asked to contribute to the Review. Individual Management Reviews were provided by: Homerton University Hospital NHS Foundation Trust Kingston Hospital NHS Foundation Trust Primary Care in City and Hackney – the Nightingale Practice NHS Greenwich Clinical Commissioning Group Royal Borough of Kensington and Chelsea Housing Needs Service Statements of Information by: Royal Greenwich Children’s Services Oxleas NHS Foundation Trust St George’s NHS Health Care Trust (Community Division) Metropolitan Police London Probation Service London Ambulance Service UKBA 2.6 The Voice of the Young Person, Family and Significant Others 2.6.1 Throughout the course of this review, all those involved have kept the circumstances and interests of Child S in mind. Child S has been the central focus of all the enquiries made. 2.6.2 As stated above, the criminal proceedings against Child S’s parents concluded in January 2015. Mother has been written to but there has been no response. Father is still serving a prison sentence. The parents had Final Version 12th December 2015 10 | P a g e previously been informed that a review was being undertaken. They will be contacted when the report is published so that the findings of the review can be shared with them. 2.6.3 It is clear from the evidence of medical experts in this case for the court proceedings that Child S had suffered considerable pain and discomfort following the more than 70 fractures inflicted upon her – on at least 2 occasions. The fractures have been dated as having occurred at two to four days and two to four prior to her death. It was stated that she would have been very distressed and in a lot of pain. It is of serious concern that her parents apparently did not seek medical help for her when she would clearly have been in considerable pain. 2.6.4 Evidence given in the trial has been that mother had told a friend she was concerned about the pain Child S was experiencing; she told her friend that she was worried and wanted to take the child to see the GP. On one occasion, the mother took the child to see the GP but she did not mention the child’s arm injury but only mentioned chest problems. In her own statement, mother told Police that father prevented her from taking the child to see the GP and she was frightened to challenge him about this. Father has made no statement about what happened to Child S. 3.0 Family History and Cultural Issues 3.1 Details of the family composition and of significant others are set out in the appendices to this report. All names have been anonymised. 3.2 The family originate from Somalia. All members of the family are Black African Somalis. The family composition includes the parents and four living siblings; Child S, the subject of this review died in February 2013; the family reported that another child of the family had died in Somalia. The mother moved to the United Kingdom in May 2011 leaving her four children in Somalia and she made an application for asylum. At that point, she was in the early stages of pregnancy. It is reported that the family were issued with a ‘reunion’ visa and her husband and children joined her in December 2012. 3.3 The family were placed in the Royal Borough of Greenwich on the 7th December 2012 by the Royal Borough of Kensington and Chelsea (RBKC) which had accepted the family as homeless. Prior to the move to Greenwich, the mother had lived in Hackney in accommodation provided by RBKC, and had lived in Wandsworth and Kensington and Chelsea with relatives and extended family members. She had also lived for some of the time with extended family members. Final Version 12th December 2015 11 | P a g e 3.4 The panel has considered the lifestyle, culture and identity of Child S and her birth family. There is comparatively little information about this family since they have only been living in the UK for a short time. They observe the Muslim faith. Their main language is Somali. 3.5 Mother and father both had some contact with the Somali Parents’ Network after they moved to Greenwich. The Network supported the parents with advice about how to meet their cultural needs locally and about financial support and access to schools for the older children. As part of this review, the author of this report met with a representative of the network to gain an understanding of what its involvement had been. 4. Background and summary of agency involvement 4.1 The family – were in contact with universal health services in each of the London Boroughs that they lived in. There was no contact with Children’s Social Care services in any of the London boroughs that the family lived in. 4.2 When she claimed asylum from UKBA on arrival in the UK in May 2011, Child S’s mother went to live with her sister in Wandsworth. Child S’s mother used her sister’s papers to travel to the UK and her sister received a custodial sentence for this immigration offence. 4.3 Child’s S’s mother registered for maternity services at 11 weeks of pregnancy. From the symptoms she described, it was suspected that she was suffering from post-traumatic stress. The UKBA was informed by the St George’s Healthcare Trust in September 2011 that mother showed some symptoms of trauma and depression and that she was feeling anxious whilst the future remained uncertain. An interpreter was used so that her needs could be assessed and the health visitor, as part of her support, gave her advice about her asylum claim and about benefits. Mother said that she had good family support and the health visitor had no significant concerns about her well-being. 4.4 Child S was born In January 2012 while mother was still living with her sister’s family. She appears to have coped well with the new baby and was well supported by health staff. She was reported to be missing her husband and other children but was able to speak to them by telephone. 4.5 In August 2012, Child S’s mother approached the RBKC Housing Needs Service for housing under the homelessness legislation. The mother and child S were given temporary accommodation in a flat in Hackney in September 2012. In October 2012, RBKC accepted responsibility for securing suitable accommodation for the household including father and the four other children if or when they should come to the UK. Mother had Final Version 12th December 2015 12 | P a g e advised that she had applied for the rest of her family to re-join her under a family re-union visa. RBKC Housing did not identify any other specific support needs other than that the family needed accommodation. 4.6 Mother registered herself and Child S with a GP in Hackney in November 2012. However, they were not known to the health visiting service as the information from the GP practice did not inform the health visiting service that this young child was registered with the practice and living in the local area. Child S was never examined or seen by the GP during the stay in Hackney. 4.7 In December 2012, the father and the other four children arrived in the UK. They approached RBKC for larger accommodation and they were allocated alternative four-bedroomed accommodation in Greenwich. 4.8 The family registered with a GP in Greenwich in December 2012. However, although mother tried to register Child S with the GP this was not actioned and Child S remained registered with the GP in Hackney. 4.9 Child S died in February 2013. The father reported that the Child had had breathing difficulties and he rang 999. The child was found to be unresponsive. A specialist post mortem subsequently showed that Child S had healing fractures, multiple fractures with high energy fractures on the collar bone. The parents were interviewed, arrested, are currently on bail having been charged under Sec 1 (1) Child and Young Person’s Act 1933 relating to neglecting a child in a manner likely to cause her unnecessary suffering and the trial is set to begin on September 2nd 2014. 4.10 Timeline for the family 2011 -14 May 2011 Mother entered UK pregnant May 11 to July 12 Mother lived with her sister in Wandsworth Jan 12 Child S was born July to Nov 12 Mother lived with her sister in RBKC Nov to Dec 12 Mother moved to Hackney (placed by RKBC Council) Dec 5th 12 Father and other 4 children entered UK Dec 7th onwards Family moved to Greenwich (placed by RKBC Council) February 13 Death of Child S February 13 Both parents were arrested February 13 Four siblings taken into care and legal proceedings initiated and since completed. November 14 Trial of both parents. Found guilty of neglect. Final Version 12th December 2015 13 | P a g e 5. Child S’s Experience – January 2012 to February 2013 5.1 Throughout this review, there has been a strong emphasis on ensuring that Child S’s experience is appreciated. In his 2009 report Lord Laming stressed the importance of attending to and understanding the direct experience of children and young people and said: “Professionals can find it very difficult to take the time to assess the family environment through the eyes of a child or young person..... Staff across frontline services need appropriate support and training to ensure that as far as possible they put themselves in the place of the child or young person and consider first and foremost how the situation must feel for them.” 5.2 The Biennial Analysis of Serious Case Reviews 2005-07 (Marian Brandon et al) identified how children who had died were able “to slip from view”. The review stressed the importance of “seeing the world from the child’s point of view and understanding the risks of harm he or she faces”. It stressed that this depends on front line staff really focusing on the child. 5.3 Child S had several different addresses in just over a year. Child S’s mother had family support while she was living with her sister and brother-in-law. When they moved to Hackney, it is likely they would have been more isolated living at a considerable distance across London from the rest of the extended family. They were registered with a GP and therefore could access support from the practice. Overall most of the information we have about Child S’s mother suggests that she coped well with Child S and provide good care. 5.4 When father and the other children joined mother and Child S in December 2012, this must have been a very significant change for Child S. Her father and four siblings had had no contact with this child until then. 6. Analysis of Practice and the Lessons Learnt This overview report does not repeat the analysis included in all the Individual Management Reviews, but highlights those issues the SCR panel thought were most significant. It also adds additional analysis drawing on relevant research to consider what lessons can be learned. Several areas for improvement and lessons have been identified within the review process. 6.1 The analysis included in a number of the Individual Management Reviews and the Health Overview Report was helpful and of good quality. Final Version 12th December 2015 14 | P a g e 6.2 Mother had only been in the UK for less than two years when Child S died. Mother had relatives here and she decided that it would be better for her family to seek asylum in the UK with the help of her sister. The family had already experienced the trauma of one of their children having been killed in Somalia. There is very little other information about the family’s history and it was likely to have been very difficult for services to get to know them well as they were living in four different London Boroughs during the period. 6.3 However, the IMRs show that universal services – particularly in health and housing - addressed mother’s needs. She was well supported during her pregnancy and post the birth of Child S. The health visiting service before she moved to Hackney supported mother in her care of Child S. Mother was given advice about her asylum status and about the financial benefits she could receive. Interpretation services were used and it is clear that Child S’s mother was able to get appropriate responses to the needs she identified for herself and the family. On the face of it, there is no reason to believe that mother did not receive the help and support that she needed; help and support were offered and mother decided not to take up everything which was offered and that was her choice. 6.4 The high mobility of this family undoubtedly affected the way that services were delivered to the family. Although, arrangements and handovers across different areas appear to have worked well until Child S and mother moved to Hackney, Health care was still provided via the GP in Hackney. Unfortunately, there was no contact with a health visitor as that service did not know that Child S and her mother were now in Hackney. When they moved to Greenwich Child S remained registered with the Hackney GP through an administrative error so again the Greenwich health visiting service was not put in contact with her immediately. 6.5 At the time of Child S’s death, there was a system in place in London - NOTIFY - which was intended to ensure that information is shared about homeless families as set out below: NOTIFY is a web-based notification and information system, designed to improve homeless households' access to services. Its primary role is to notify relevant services of the placement or movement of homeless households placed in temporary accommodation by London boroughs under homelessness legislation. It will also produce comprehensive information on homelessness and temporary accommodation in London. The system uses information provided by London borough housing departments to notify housing, education, social care, and health services about homeless households placed in, moving between or leaving temporary accommodation. Information is contained in a database and updated weekly. The following link - http://www.notifylondon.gov.uk. – provides an outline of how the system was supposed to operate at the time these events occurred. Final Version 12th December 2015 15 | P a g e However, local intelligence suggests that despite the appearance that Notify has London-wide coverage, it appears that only about two-thirds of London Boroughs actually use it regularly and reliably. It also appears that neither universal health nor children’s services are linked in through authorised users as the Notify website would suggest. It cannot be relied upon that universal health or children’s services are linked in through authorised users as the Notify website would suggest. 6.6 The only agency which provided any overall linkage with the family through the geographical moves from West London to Hackney and then to Greenwich was RBKC Housing between November 2012 to the death of Child S in February 2013. RBKC Housing Needs used the Notify system both when the family was moved to Hackney and also when they moved to Greenwich. The housing provider appropriately provided accommodation for the family and responded quickly to those needs. For the RBKC Housing Needs Service, there were no particularly outstanding concerns about mother’s vulnerability and this family’s application was seen as similar to many others. Generally, as families are moved to different Boroughs by housing providers, there is no effective system where there are children in the family, to notify either health or children’s services that these families have moved in or out. In this case, RKBC did use the Notify system and took the appropriate action to inform Hackney and Greenwich Local Authorities of the family’s placement in the respective Boroughs. However, since the family was not known to Children’s Social Care and since no concerns had been identified about the care of Child S, neither Hackney or Greenwich children’s services would have had cause to assess the family. There would clearly be real advantages for all concerned and particularly for children if there was a clear and more effective notification system in place across London – particularly in relation to children under 5 years. 6.7 During the course of this review, London Councils decided to undertake a review of the Notify system; this commenced in March 2014 and the Chair of this SCR panel was directly involved. A report was published in December 2014. The report has made some recommendations for improvement but it is not clear that they fully address the issues raised in this review and some members of this SCR panel believe that it does not give sufficient regard to safeguarding. 6.8 Mother was able to register with GPs and to access basic medical care for herself and Child S when this was required. However, the gaps in communication across universal health provision resulted in Child S not receiving the full range of health promotion and surveillance which should have been in place as set out in the Healthy Child Programme (2009). If mother was under additional stress this would also have been assessed more comprehensively through the programme. The HCP is the early intervention and prevention public health programme that lies at the heart of our universal service for children and families. At a crucial stage of life, the HCP’s universal reach provides an invaluable Final Version 12th December 2015 16 | P a g e opportunity to identify families that are in need of additional support and children who are at risk of poor outcomes. DH Healthy Child Programme (2009) 6.9 There was a significant change within the family from December 2012 after father and the other four children re-joined mother and Child S. It is known now that Child S was being injured at home during the last two months of her life and that the child would have been suffering considerably having had multiple fractures inflicted. In addition, neither parent sought appropriate medical intervention for Child S after she was injured – even though it was clear to other family members that she was hurt when she cried and showed she was in pain. It appears that when she was picked up she cried and she struggled to crawl or move. Neither parent has accepted this picture of how impaired Child S was. 6.10 Mother took Child S to see the GP in mid-January 2013, just a few weeks before the death. The child was presented with an upper respiratory tract infection. Although mother originally stated that she told the GP about the child’s sore arm, the GP does not recall this and noted nothing about this. In a subsequent statement, mother admitted that she did not take the child to the GP about her sore arm. The GP was very clear in evidence in court about what she would have done if the arm had been mentioned. 6.11 Although mother eventually made a statement admitting that she was aware that Child S was in pain and needed medical treatment, she alleged that she was too frightened of father to take the child for medical attention. Father has said nothing about events except that Child S suddenly became unwell on the day that she died. 7. Conclusions 7.1 It is unlikely from all the information which has been gathered, that Child S’s death was either predictable or preventable. There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care Department. There had been no concerns about the well-being or safety of Child S at any point. 7.2 Mother seemed to be well able to care for Child S and there had been no concerns about her parenting of the child. Mother appeared to have followed health advice and ensured that Child S received appropriate immunisations. 7.3 However, after December 2012, there was a significant change in the family and it appears that, after that time, the care of Child S deteriorated and she was subjected to physical abuse causing multiple, severe Final Version 12th December 2015 17 | P a g e fractures. Although it is not clear which parent inflicted these injuries, it is as concerning that neither parent sought medical treatment for Child S to relieve the suffering which was being experienced. 7.4 Addressing the Terms of Reference Did professionals have an understanding of the family history prior to their asylum application? It is clear that there was only limited information about the family’s history in Somalia. This all came from mother’s self-report, via a family member or, on some occasions, through an interpreter as her English was limited. Professionals are described as having had some understanding of this background which seems to have enabled mother to be provided with the services they needed. However, there is mention in early health records that mother may have been suffering from post-traumatic stress, which had been identified on her arrival in the UK, but it is not clear that this was sufficiently identified or pursued as vulnerability. We do not know whether this condition persisted in mother but it is clear that professionals did not see her or her child as vulnerable. Should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK and seeking asylum and subsequently were granted leave to remain? The panel has found no evidence in the enquiries made which indicate that most of the needs of mother and this child were not addressed. However, some concerns have emerged about whether sufficient use was always made of interpreting services to ensure that mother’s wishes and feelings were fully ascertained. Mother also had family in the UK to support her so she was not totally isolated. It appears that when Child S was in her mother’s sole care, she flourished and was making good progress. Was the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)? Mother was living within her extended family for much of this period and was clearly able to access benefits, housing and health services. In the last few weeks before Child S’s death, the health visiting service was not in touch with or visiting the family. This might have provided additional support to the family but it is clear too that the family were in touch with the GP and the local Somali Family Network so there was some support available. Were there specific issues around ethnicity, language or religion? As far as language is concerned, mother has limited use of English. It is well evidenced that interpretation services were provided for her when she was in contact with most services and that, even when these were offered, she did not always take up what was available. There is no indication that there were any problems for services in responding appropriately to the family’s cultural or religious needs. What sort of vulnerability assessment might have been undertaken? The health services in contact with the family were seeking to respond to the needs presented by mother and to assess whether there were additional needs. The records show that a range of different responses were provided. There is evidence that she was reluctant to discuss what had happened in Somalia and that she preferred to depend on the support from her extended family. It is possible Final Version 12th December 2015 18 | P a g e therefore that it would have been difficult to elicit from mother more about her circumstances. The RBKC housing needs assessment did not identify any specialist needs and also there was awareness that she had family support. The Housing Needs Service would not make any specific assumptions about the vulnerability of someone who had previously sought asylum, as they would assess a household’s vulnerability on a case by case basis. If there had been any concerns about the mother’s parenting or the child’s welfare this would have been noted and considered. What was the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support? The family’s mobility is one of the most significant issues in this case. As set out above, there is a gap in current arrangements for ensuring that health and children’s services are notified when children move across London Boroughs. Although is also clear that RKBC is very diligent in using the Notify system when it is responsible for families. Were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBKC) and the host local authorities? There are some legislative provisions about the responsibility of housing authorities to share information when a family moves. The Housing Act 1996 requires local authority housing need services to notify each other when placing a homeless housing in temporary accommodation in another local authority area (s.208 of the Act). Further, the Homelessness Code of Guidance that accompanies the Housing Act states that when homeless household are placed in another borough, the placing housing needs service should take positive steps to ensure effective liaison and co-operation between the relevant service departments of both local authorities, including housing, social services, environmental health and education. The Homelessness Code of Guidance also states that local authorities should ensure that all babies and young children placed in temporary accommodation have the opportunity to receive health and developmental checks from health visitors and / or other primary care professionals. The Notify system was designed to fulfil the above requirements for information sharing. It is noted that RBKC Housing Needs used the Notify system correctly and according to its purpose. In common with many other London authorities, the London Borough of Greenwich did not use the Notify system. Evidence has emerged to indicate that the Notify system is not being used effectively and consistently across the whole of London. There would need to be a pan London policy change, if an effective system to ensure that health and children’s services were informed of the movements of families between areas, was to be put in place. In this case, it would have provided an additional mechanism beyond GP registration to inform other local services that Child S had moved into the area. Was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012? The only agencies which would have known immediately about father’s and the other children’s arrival in December 2012 were the UKBA and the RBKC Housing Needs Service. UKBA did not have any specified responsibility to consider the needs of the newly arrived other members of the family. Given the information available to RKBC, no specific needs could be identified concerning the newly arrived members of the family in Greenwich. If the Notify system was more regularly used then local health services and education services in Greenwich could have been alerted. Final Version 12th December 2015 19 | P a g e Were there any organisational difficulties being experienced within or between agencies? As stated above, this review has highlighted concerns about whether information about children is being adequately transferred when their families move across Borough boundaries and from one GP to another. The pick- up of information by health visiting services when families move and register with a new GP appears to be problematic. The application of “corporate caseloads” for health visiting which are not aligned to GP practice may also militate against efficient and speedy identification of new children in the area. 8. Recommendations for Greenwich Safeguarding Children Board In addition to the Individual Management Review recommendations, this Serious Case Review has highlighted a number of areas requiring attention. These are detailed in the Action Plan along with the specific actions required. These recommendations should be read in conjunction with the Action Plan which provides detail about methods of implementation and timescales. The Greenwich Safeguarding Children Board recommendations are set out below: There was limited involvement with this family by Greenwich services. Therefore, the recommendations listed below are for wider resolution on a wider London basis with GSCB needing to work with the London LSCB and other local LSCBS to progress them. 8.1 GSCB should link with the London LSCB and NHS England and the local CCG to raise awareness across London that a more consistent and single system is required to ensure health visiting services are notified by GPs that new children have moved in. 8.2 Following the London Councils’ Notify system review, the Chair of the GSCB SCR review group to take to the London LSCB and London Councils the continuing concerns raised in this review about how vulnerable families with children are moved around London by Local Authority Housing Services without an effective notification system for informing universal health or children’s services being made. 9. Recommendations for individual agencies The Individual Management Reviews provided in support of this Serious Case Review contain recommendations which have been considered and endorsed by the LSCB, which if robustly implemented, will enhance safeguarding arrangements across the partner agencies of this LSCB and the other LSCB areas concerned. The GSCB has been tracking and monitoring the completion of these actions. 10. Learning from the Review – next steps Final Version 12th December 2015 20 | P a g e The learning from this review is being taken forward within each agency and by the LSCB. Findings will be discussed with those staff who were directly involved. It is still hoped to share the review report with the parents but this may not be possible. There is a communications strategy and timetable in place for the publication of the Overview Report. The Chair is mindful of the need to proceed with sensitivity about this given the high visibility of this case in relation to the criminal proceedings. This is the final SCR report as at 12th December 2015. It had been planned to publish early in 2015 after the conclusion of the criminal trail and after the inquest. However the LSCB was not informed for many months about the Coroner’s decision not to hold an inquest and this resulted in the delay in publication. Amy Weir MA MBA CQSW Lead Reviewer Child S Serious Case Review Final Version 12th December 2015 21 | P a g e Recommendations to GSCB – Progress Report and Update Recommendation Action Planned Progress 1. GSCB should link with the London LSCB and NHS England and the local CCG to raise awareness across London that a more consistent and single system is required to ensure health visiting services are notified by GPs that new children have moved in. Panel Chair (JN) to write to NHS England and ask for issue to be raised with London LSCB. JN also to write directly to London LSCB to check out response. Completed. Completed. 2. Following the London Councils’ Notify system review, the Chair of the GSCB SCR review group to clarify the outcome of the Review. If necessary, take to the London LSCB and London Councils the continuing concerns raised in this review about how vulnerable families with children are moved around London by Local Authority Housing Services without an effective notification system for informing universal health or children’s services being made. Panel Chair (JN) to meet with lead for Notify. JN to join group reviewing Notify from 27/3/14 and to be completed by Sept 14. SCR Panel Chair to take forward further concerns re Notify review and its recommendations after end of review. Met in February 14. Completed. Review reported Dec 2014 – completed. To be completed in Sept 14. Final Version 12th December 2015 22 | P a g e Appendix A Family and Significant others Sibling 5, F Deceased Sibling 9, M Sibling 4, F Sibling 11, M Father 42 Sibling 3, F Child S Mother 34 Final Version 12th December 2015 23 | P a g e Appendix B GREENWICH SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW Terms of reference CHILD S Introduction: Background to the review Child S was born on the 01/01/2012 and was reportedly in good health but died unexpectedly on the 05/02/13. On 07/02/13 following an initial post mortem a pathologist reported that there was evidence of fractures and a specialist paediatric post mortem was undertaken which revealed severe multiple fractures which were judged to be strongly indicative of non-accidental injury. The family composition included parents and four living siblings (one child is reported to have died in Somalia). The family originate from Somalia. The mother moved to the United Kingdom in May 2011 when she made an application for asylum and at that point was in the early stages of pregnancy. It is reported that the family were issued with a ‘reunion’ visa and her husband and children joined her in December 2012. The family were placed in the Royal Borough of Greenwich on the 7th December 2012 by the Royal Borough of Kensington and Chelsea who had accepted the family as homeless. Prior to the move to Greenwich the Mother lived in Kensington and Chelsea, Wandsworth and Hackney some of the time living with extended family members. The family were in contact with universal health services in each of the London borough’s that they lived in. There was no significant contact with Children’s Social Care services in any of the London boroughs that the family lived in. Decision to initiate a Serious Case review An extraordinary meeting of the Greenwich Safeguarding Children Board Serious Case Review Work Group was held on the 19/02/13 to share information, consider the circumstances of the death and decide whether to initiate a Serious Case Review. The outcome was that the Chair of the SCR panel wrote to the Independent Chair of the GSCB on the 22/02/13 recommending that the criteria for a SCR were met. The Independent Chair of the GSCB considered the recommendation and decided on the 6/03/13 that a SCR should be undertaken. Ofsted and the Department of Education were informed of the decision to initiate a SCR. The GSCB Serious Case review panel met on the 14/03/13 to draft the terms of reference. Process of the Review The GSCB SCR work group agreed A SCR Panel would be formed to oversee the SCR process. The panel would be chaired by John Nawrockyi, Director of Adults and Older Peoples services. The Chair of the panel is independent and has had no involvement in the case. The SCR panel membership will include representatives from the Greenwich Safeguarding Children Board and those agencies that are contributing IMR’s. The SCR work group agreed that the SCR would take account of the systems model in reviewing agency contact with the family. Final Version 12th December 2015 24 | P a g e Working Together to Safeguard Children 2013 The statutory guidance requires LSCB’s to undertake an SCR when the criteria is met (regulation 5 of the LSCB guidance 2006). In addition the guidance requires that SCR’s address the following: provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence advising the Greenwich Safeguarding Children Board, relevant local authorities and other agencies on lessons to be learned. agreeing with GSCB partners and other relevant agencies what action they need to take in light of the SCR findings. be written in plain English and in a way that can be easily understood by professionals and the public alike; and be suitable for publication without needing to be amended or redacted. Key Issues to consider in the SCR There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care department. Given this the SCR will need to focus on the role of universal services; did professionals have an understanding of the family history prior to their asylum application? should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK and seeking asylum? were the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)? are there specific issues around ethnicity, language or religion? whether and what sort of vulnerability assessment might have been undertaken consider the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBK&C) and the host local authorities? was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012? were there any organisational difficulties being experienced within or between agencies? Lead Reviewer Amy Weir has been appointed as the Lead Reviewer for the SCR. She is an experienced social care professional who has also worked in child health services and has had considerable experience of Serious Case Reviews. Ms Weir is entirely independent of any Greenwich agency. Time Period to be covered The time period of the review will start in May 2011 when the mother arrived in the UK to the outcome of the post mortem on the 7th February 2013. Organisations participating in the Review Given that the family have lived in four local authorities across London the following organisations have been identified as ‘participating organisations’ NHS Greenwich Clinical Commissioning Group will submit an overarching Individual Management review based on submitted IMR’s from health services (GP, Health Visitor and Midwifery) in Greenwich, Wandsworth, Hackney and Kensington and Chelsea. NHS Clinical Commissioning Groups Collaborative (Central/West London/ Hammersmith/ Hounslow CCGs NHS City and Hackney Clinical Commissioning Group NHS Kingston Clinical Commissioning Group Final Version 12th December 2015 25 | P a g e NHS Wandsworth Clinical Commissioning Group Royal Borough of Kensington and Chelsea (Housing Services) Metropolitan Police Service Greenwich Children’s Services Each participating organisation will submit a chronology, in a consistent format, of their involvement with Child S. A chronology template will be provided to each organisation that is undertaking an Individual Management Review. In addition and given the issues of mobility the following organisations will be formally approached by the Independent Chair of the GSCB requesting any relevant background information that might inform the SCR. United Kingdom Border Agency Children’s Services in Wandsworth Children’s Services in Hackney Children’s Services in Kensington and Chelsea London Probation Service The Greenwich Somalian family network Involvement of family members Child S’s parents are subjects of a criminal investigation and any approach to the family will only occur in liaison with the Metropolitan Police and Crown Prosecution Service. The SCR panel agreed in principle that at an agreed point in the process the parents could be invited to meet with the Overview Report writer and a SCR panel member to give them the opportunity to contribute to the SCR. Parallel Investigations The case is the subject of a criminal investigation which is being led by the Metropolitan Police and the Coroner is also involved as there is likely to be an Inquest into the death of Child S but this will not occur until the outcome of the judicial process. The Chair of the Child Death Overview Panel is aware of the decision to initiate the SCR and the case will not be reviewed until all the relevant processes have been completed. Continuing liaison with the Police and Coroner will be necessary and will be co-ordinated by the SCR Panel. The timing of the full publication of the SCR will be determined by the criminal justice process. Interest from the Family, Public, Media The SCR Panel will manage contact with family, the public or media interest establishing a subgroup to progress the work if required. If the criminal investigation results in a trial a joint inter-agency media strategy will be agreed by the SCR panel. Independent Legal Advice There is no indication that this is required but this will be kept under review by the SCR Panel. Other Considerations In what way could the ‘systems methodology’ assist the dissemination of the learning from this Serious Case Review across the agencies in the London boroughs? These terms of reference will be reviewed by the SCR panel as the SCR is progressed. John Nawrockyi Director of Adults and Older People’s Services Chair of the SCR panel for Child S. Final Version 12th December 2015 26 | P a g e Appendix C. Membership of the London Borough of Greenwich Safeguarding Children Board Serious Case Review Panel Independent Panel Chair - John Nawrockyi Lead Reviewer (in attendance) – Amy Weir Police CAIT Greenwich CCG Kingston Clinical Commissioning Group Designated Nurse Wandsworth Clinical Commissioning Group/ Designated Nurse ‘Tri Borough’ LSCB Manager(Westminster, Kensington & Chelsea & Hammersmith & Fulham) Senior Quality & Reviewing Officer, Greenwich Children’s Services Housing Needs Manager - Royal Borough of Kensington & Chelsea Final Version 12th December 2015 27 | P a g e Appendix D - List of References Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010 Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12 New learning from serious case reviews: a two year report for 2009-2011 Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children - 2013 Lambeth Safeguarding Children Board Serious Case Review - Child H (2014) London Child Protection Procedures 2012 DH 2011 Health Visitor Implementation Plan: A Call to Action DH Healthy Child Programme 2009 London Councils – Information about operation and purpose of Notify - http://www.notifylondon.gov.uk/Final Version 12th December 2015 28 | P a g e Appendix E Pen description of SCR Panel Independent Chair John Nawrockyi has been the Director of Adult Social Services, and before that the Director of Social Services, adults and children, for Greenwich Council since 2004. Prior to that, he was the Director of Housing and Social Services for Southend Council. John's career in social care started in the voluntary sector, but he has worked in local government since 1974, covering all aspects of children's, adults' and older people's social services, both as front line worker and senior manager. He also had a one-year secondment into the NHS in 1999 to assist in the application for a local Primary Care Trust to be established. John is quite active for the Association of Directors of Adult Social Services. He is currently the co-Chair of the Disabilities Network and Secretary of the Workforce Network, and until the programme finished in 2009, was the ADASS Lead for Supporting People. Pen description of SCR Lead Reviewer For more than 30 years, Amy Weir has delivered, managed, inspected and advised organisations delivering children services - working for both local and central government. Since 2006, Amy has worked as an independent children’s services consultant. She has been employed by Ofsted as an inspector; she has been the independent chair of three Safeguarding Boards and chaired SCR panels and written overview reports. She has no connection with services for children in Greenwich or this case. GREENWICH SAFEGUARDING CHILDREN BOARD Child S SERIOUS CASE REVIEW SUMMARY FROM ACTION PLAN TO MEET RECOMMENDATIONS 1. The SCR identified that the most significant issue in this case was the family’s mobility. All of the recommendations for individual agencies related in some way to this issue. 2. The only action for the Greenwich Safeguarding Children Board was to work with the London LSCB, NHS England and the individual agencies to raise of awareness of the issues and to track and monitor the completion of the agreed actions. 3. Health: There were specific but similar actions identified across a number of different NHS Trusts, Community Health Services and Care Commissioning Groups These actions addressed the need to ensure that there is a robust and effective system in place between GP practices and Health Visiting services, pan London, so that all new registrations of families with children under 5 are notified to those services. Individual agencies have implemented local changes where needed which are now embedded in practice. The GSCB has been in contact with NHS England who has discussed this at a London wide level to ensure that learning has been disseminated across London and also nationally. 4. Housing: There was a review by a housing department of the Notify system. This is an on-line notification system intended to simplify information relating to families placed in other authorities by a housing department. Information from this review has informed a review led by London Councils of the Notify system and there is currently a draft pan London proposal that is being consulted on. 5. Learning Learning from this SCR has already been disseminated through the GSCB and other agencies directly involved with the SCR Following publication learning will be made more widely available across the multi-agency network 6. Conclusions: The action plan for individual agencies has been robustly monitored and reviewed by the GSCB All involved agencies have implemented the actions identified, embedded them in to practice and continue to monitor them Where actions related to London-wide or national bodies these have also been progressed. |
NC52345 | Death of a 5-month-old baby in March 2017. Child J was taken to hospital in the early hours of the morning by Mother, having been found unresponsive by Maternal Grandmother on Mother's bed where Mother and siblings were sleeping. Mother's urine proved positive for both cannabis and cocaine. Siblings were placed in foster care. Parents had unstable childhoods and a history of substance misuse. Mother's first child was removed from her care as a toddler due to neglect, and was subsequently adopted. Information came to light in court; Mother had been using crack cocaine approximately three times per week for the last five months. Uses the Significant Incident Learning Process (SILP) methodology. Family is mixed heritage. Learning includes: parents who have previously had difficult experiences of receiving services from children's social care are likely to be suspicious and reluctant to engage; where a pattern of avoidant behaviour begins to emerge, including reluctance to agree to assessment, this should be evaluated as a risk factor in its own right and escalated where appropriate; practitioners benefit from good support and challenge to deal effectively with resistant and avoidant parents. Recommendations include: ensure practitioners consistently use a probing and analytical approach to gathering and sharing information when a parent is suspected of substance misuse; ensure practitioners feel confident and well supported in dealing with suspicious, resistant and avoidant parents; ensure practitioners are competent in working with families where domestic abuse is a feature; ensure that practitioners are competent in understanding, describing and recording children's lived experience.
| Title: Serious case review: Child J. LSCB: Milton Keynes Safeguarding Board Author: Karen Perry Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW Child J Publication date: 3 July 2020 Lead Reviewer & Report Author: Karen Perry 2 CONTENTS 1. Introduction and process of the Serious Case Review page 3 2. Details of the family and case context page 4 3. Key Episodes page 5 4. Thematic analysis page 11 5. Good Practice page 21 6. Conclusions and summary of lessons learned page 23 7. Recommendations page 24 8. Appendix: Methodology page 25 3 INTRODUCTION AND PROCESS OF THE SERIOUS CASE REVIEW 1.1. This Serious Case Review (SCR) is in respect of a 5 month old baby who died suddenly in March 2017.1 Child J’s siblings were aged under 6 years at the time that he died. The inquest in 2019 recorded a narrative conclusion and the cause of death as ‘unascertained’. The local authority has made suitable arrangements to protect the siblings. 1.2. The areas of learning identified include the following; Assessment, planning and communication: • Assessments need to take historical information into account; previous assessments, including those regarding parents’ own childhood and/or their previous children, need to be summarised in sufficient detail and stored accessibly • The importance of professionals in contact with children and their families asking themselves “what is life like for this child” “is it good enough”; “what might their presentation and behaviour tell us about their experiences, wellbeing and emotional health”? Dealing with suspicious, aggressive and avoidant parental behaviour: • Parents who have previously had difficult experiences of receiving services from children’s social care are likely to be suspicious and reluctant to engage. Therefore practitioners need to recognise this and be creative and persistent in; building relationships; looking behind the behaviour; and spotting the moment to offer support and/or escalate concerns. • Where a pattern of avoidant parental behaviour begins to emerge this should be evaluated as a risk factor in its own right and escalated where appropriate. • Practitioners benefit from good support to deal effectively with resistant and avoidant parents. Good support should include reflective supervision, and training, supported by appropriate policies and procedures Substance Misuse: • Parents who misuse drugs can be very plausible; practitioners should remain sceptical about a parent’s statement that their drug use is historical until they are confident they fully understand the likely risks of relapse having taken into account the following factors: the circumstances in which the drug use started, how the person managed to stop, and their individual vulnerabilities for relapse • Practitioners always need to consider the potential impact on children of actual and potential 1 Working Together 2015 states a serious case review should be held for every case where abuse or neglect is known or suspected and either a child dies or is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. The Independent Chair of Milton Keynes Safeguarding Board (MKSB) agreed that the criteria for a Serious Case Review was met in this case. 4 substance misuse, including when parents are arrested on suspicion of involvement in drugs offences Domestic Abuse: • Practitioners need to be more aware how easy it is to underestimate the cumulative impact on both the victim and children when there have been a significant number of “low level incidents” of domestic abuse 1.3. This report will be published on the MKSB website. The MKSB will also ensure that learning is widely disseminated locally. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The footnotes should be read alongside the main text. They include the author’s comments as well as references to relevant research, legislation and guidance. 1.4. The SCR takes into account multi-agency involvement from the spring of 2015, (when the family arrived in Milton Keynes) until 4 weeks after Child J died in the spring of 2017. 1.5. The MKSB agreed to undertake this review using the Significant Incident Learning Process (SILP)2, a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time. Family members were also offered the opportunity to speak to the lead reviewer. Only Father agreed to this. 2. DETAILS OF THE FAMILY AND CASE CONTEXT 2.1. Child J has 3 older siblings who will be referred to in this report as Siblings 1, 2 and 3. The parents of the children are referred to as Mother and Father. Other family members will be referred to by their family relationship e.g. Maternal Grandmother. 2.2. Child J was part of a family of mixed heritage. Child J has been described by those who knew him as a placid, contented and alert baby who liked being cuddled, who looked well, and had age appropriate development. Every practitioner who met the family noted that he had a particularly strong bond with his mother. 2.3. The parents had lived in Milton Keynes when they were children. Both had unstable childhoods and a history of substance misuse. Mother’s first child was removed from her care as a toddler, due to neglect, and was subsequently adopted. 2.4. Mother and Father met when they first lived in Milton Keynes. During their relationship Father spent a lot of time in Mother’s household, but also maintained a separate address. The relationship during the period under review was characterised by instability, including domestic abuse, frequent house moves, and a period abroad. They lived in London prior to Mother being rehoused in Milton Keynes in 2015. Both parents had occasional periods of employment. Siblings 1 and 2 were enrolled in a nursery on arrival in Milton Keynes, to assist with childcare. Both parents presented as bright, articulate and very plausible. The children appeared to be loved, the siblings were engaging and 2 See appendix 1 5 boisterous3, and the family did not stand out in any particular way in the local community where they lived.4 3. KEY EPISODES Key Episode 1: April 2015-March 2016 - arrival of the family in Milton Keynes 3.1. In April 2015 a referral was received from a London borough social worker who had recently completed an assessment. This contained full details of historical concerns but concluded that “no safeguarding concerns were highlighted”. The social worker thought the children would benefit from monitoring by a health visitor. 3.2. Milton Keynes Children’s Social Care contacted Mother who seemed suspicious and refused support. The London assessment was briefly summarised on Children’s Social Care records and no further action taken. In June 2015 a Multi-Agency Referral Form (MARF) was also received from the London health visitor which included concerns about Sibling 2 having behaviour issues and speech delay. 3.3. The family registered with a GP in June. Sometime subsequently alerts were added to two Sibling’s records regarding concerns about Father’s mental health, possession of a weapon and taking drugs. Two alerts referring to the removal of a child due to neglect and drug use were added to Mother’s record. Father’s records were not linked to Mother or any of the children.5 3.4. Mother attended a new patient health check appointment. She told the practice nurse about her history of crack addiction. She requested some support with anxiety and depression, but failed to attend a follow up appointment a week later. This pattern was repeated when she made a similar request to the GP in August 2015 and at all subsequent times when Mother made a request for help with her mental health. 3.5. Before the health visitor had the opportunity to visit, she received two phone calls from the health representative in the Multi-Agency Safeguarding Hub (MASH). The first was to tell her that a health visitor from the London borough had been in touch, to pass on previous safeguarding concerns. The second was to suggest that the family be visited in pairs due to the suspicious and verbally aggressive reception received from Father when Children’s Centre staff made an introductory courtesy visit.6 The health visitor spoke to the London health visitor who confirmed the past history and recent difficulties with non-engagement with developmental reviews. Speaking with health visitors from previous authorities is routine practice as records sometimes take a long time to arrive, several months in this case. 3.6. Phone contact between health visitor and Mother resulted in a successful home visit when both parents and all 3 siblings were present. The parents were co-operative at this visit, giving details of their history. The health visitor detected, but apparently did not challenge, a strong smell of cannabis in the house. The family were clear that the children had not, and would not, be receiving 3 Their current behaviour when all together is sufficiently challenging for them to be in a placement with two full time carers. 4 An area of relative deprivation In Milton Keynes. 5 Since an audit in March 2017 arrangements have been put in place to ensure families are linked 6 The health worker in MASH does not recall advising to visit in pairs but this is what is recorded in the health visiting notes 6 immunisations due to their religious beliefs. These religious beliefs were in line with a broadly Judaeo-Christian viewpoint, with some mysticism type elements which Mother was aware could be “misinterpreted as madness”. 3.7. The health visitor made a number of routine follow up health referrals for the children. Father brought Sibling 2 to outpatients for a Physiotherapy appointment in September 2015 which had been outstanding in London. Advice was given regarding exercise and footwear. Sibling 2 was not brought for 2 follow-up appointments. A letter was sent to the GP and the parents saying Sibling 2 had been removed from the waiting list. This is in line with the Hospital Trust’s “Was not brought policy for children and young people” when there are no clinical or wellbeing concerns; the GP would consider re-referral if further concerns were raised. Children not being brought, especially to review appointments was typical for this family. 3.8. During Key Episode 1 the police dealt with 5 incidents reported by or about family members. Information was shared with Children’s Social Care about 3 incidents.7 Two involved arguments between family members/alleged violence by Father toward Mother. The third involved children being found alone in a messy house; Father returned and stated he had been outside the house, in the parking bay. 3.9. Co-incidentally, on the same day as one of the incidents reported to the police, police officers accompanied the mental health street triage team to make a home visit. Mother had reported being in distress about a historical incident after receiving some training at work. The home visit was made, despite Mother not wanting one, because she was unable to be contacted by phone. Mother agreed to a brief discussion on the doorstep and it was suggested that she contact her GP for a referral to Improving Access to Psychological Therapies (IAPT). Key Episode 2: March 2016- October 2016 Antenatal period until birth of Child J 3.10. Mother attended the GP practice and a booking in appointment with a Midwife when she was 7-8 weeks pregnant. Mother told the midwife about a history of depression; multiple house moves; the adoption of her first child and her use of crack cocaine in 2007-8. She reported she had stopped using cannabis several months ago and, when challenged by the midwife that she smelt strongly of cannabis, said this was due to visiting a friend who still smokes cannabis. She was referred for consultant care due to some potential health risks associated with her pregnancy. 3.11. The midwife gathered further information from Children’s Social Care and the health visitor and decided to offer additional support from the Red Team8 due to the historical concerns and domestic abuse incidents. Mother refused this support. Records show the Red Team midwife contacted 7 Domestic Abuse Stalking & Harassment (DASH) forms are reviewed by a sergeant before being passed to police risk assessors in the MASH who decide if information should be shared with Children’s Social Care. Direct referrals to Children’s Social Care can be made in situations judged as high risk by the attending officers, rather than passing their report through the triage. MASH policy is that if incident is graded “standard risk” and the family is known, but not open, then information will not be routinely shared. DASH gradings: STANDARD - Current evidence does not indicate likelihood of causing serious harm. MEDIUM - There are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse. HIGH - There are identifiable indicators of risk of serious harm. The potential event could happen at any time and the impact would be serious. 8 Vulnerable Families Midwives 7 Children’s Social Care in London who were unwilling to disclose details other than the fact of historical involvement without a written request. When this was sent health records show that further information was refused as the case was closed. The reason for this is unclear; the London borough has no record of any contact by the midwife. 3.12. During her pregnancy Mother reported feeling increased anxiety and accepted a referral by the midwife to IAPT. During a home visit the health visitor challenged Mother about the failure to take Sibling 1 to speech therapy and gained permission to contact the school. She also recorded that she could smell cannabis. 3.13. The first 3 incidents reported to the police in Key Episode 2 were not shared with Children’s Social Care. Mother’s pregnancy was known but not recorded by police at any incident prior to Child J’s birth.9 3.14. The first incident involved an altercation between 3 women at the house. The second incident was a call from Mother requesting a “violent man” be removed from her house. She was heard to ask the siblings “what did daddy do to mummy’s throat”. Mother would not confirm the name of the male when police officers attended. The police risk assessors in MASH did not review the report for 2 weeks due to backlogs of incidents caused by a staff shortage. 3.15. The third report was from school; that Father had reported an altercation with Mother. Officers spoke to Father who disagreed with the version passed onto the police. On the same day a third party reported Mother and Father arguing in the street with Siblings 1 and 2 present. Father told police this was about contact arrangements. The following day Mother phoned the MASH asking for support and raising concerns about Father making more allegations against her. Accordingly phone contact was made by MASH staff to challenge Father about inconsistent accounts and both parents about the need to work together in the interests of their children. 3.16. Between the 2nd and 3rd reports to the police, Father contacted the MASH alleging that Mother was using crack and Grandmother was a drug user who was always asking for money. Father told the author that he was (appropriately) asked what reasons he had to say Mother was using crack, he stated he said there were a lot of lighters in the house. If this exchange happened it is not recorded. The health visitor confirmed MASH concerns that they might not be getting a genuine picture of the family so, in order to decide an appropriate response to the referral, a social worker from the MASH made an unannounced home visit.10 The social worker thought he smelt cannabis; Mother said she “did not do drugs anymore”. The social worker concluded that the family were going through a difficult time due to the separation. He felt Mother would benefit from some support, which she declined. The social worker concluded a Child and Family Assessment would be appropriate if there were any further concerns. 9 Poor recording of pregnancy on DASH forms is being addressed by the police 10 The social worker saw all three children and spoke to the school/nursery but not the police. An Ofsted inspection conducted in Sept – Oct of 2016 https://reports.ofsted.gov.uk/local-authorities/milton-keynes criticised what they described as pre-assessment visits in response to concerns referred about a child’s welfare because these visits did not always result from a formal multi-agency strategy discussion with partners to determine whether the threshold was met to undertake child protection enquiries. Children’s social care managers at the learning event considered that this was not the same practice and described it as a pragmatic response to gather information to identify an appropriate outcome to a referral. 8 3.17. Soon afterwards Police officers attended the house in response to Mother alleging that a neighbour had threatened her and Father. The police officers were concerned about the disarray in the house and that the children had not had a recent meal. This information was shared with Children’s Social Care. 3.18. The final report to the police was from Maternal Grandmother alleging that Mother had phoned her in distress stating that Father had assaulted her. Mother denied this, and the report was not shared with Children’s Social Care. 3.19. Towards the end of Mother’s pregnancy the GP referred Sibling 2 back to Physiotherapy due to a reported history of falls. Shortly afterwards the health visitor received a telephone call indicating that Disabled Living Allowance (DLA) had been claimed for Sibling 2 by Mother. The health visitor made it clear to Mother that her observations did not support such a claim, but that she would make appointments for podiatry and physiotherapy to obtain a specialist opinion. 3.20. The assessment by the physiotherapist was very thorough due to the inconsistencies between her clinical observations and Mother’s reports of falls. Mother was reluctant to provide the routine social history that is protocol for an initial appointment. She was also unwilling to accept the physiotherapists recommended treatment of correct footwear and exercise and made a remark about it not mattering as they were going to move again anyway. Sibling 2 was not brought to a review appointment. The physiotherapist wrote to the GP about the failure to attend and her concerns, so that these could be shared if the family did move. 3.21. The nursery submitted a MARF to MASH about Sibling 2’s failure to return to school after the summer holidays; the parents had threatened to change schools to somewhere “less intrusive”.11 Concerns described included Sibling 2’s unkempt appearance, his aggressive behaviours at school to both peers and staff and Father’s concerns about Mother’s mental health. MASH spoke to Mother and Sibling 1’s school (to which Sibling 2 moved). A letter was sent to Mother providing information about Child and Family Practices (CFP). 3.22. Attendance at consultant appointments during the pregnancy was sufficiently poor for the midwife to escalate to a supervisor. The midwife had a discussion with Mother just prior to Child J’s birth. This resulted in Mother giving consent to the submission of a MARF so that she could have all the “accusations” cleared up. This resulted in the commencement of a Child and Family Assessment by a social worker which was concluded in December; the SW had a high workload and progress was hampered by difficulty making appointments with the parents. Key Episode 3: October 2016-March 2017, postnatal period until Child J’s death 3.23. When Child J was born, as the midwives on the ward knew a MARF had been done, and why, they contacted Children’s Social Care who confirmed that Mother and child could be discharged home. The midwifery service completed the usual postnatal visits. Mother initially refused a new birth contact from the health visiting team and made a complaint against the named health visitor.12 Both 11 The nursery where M had attended was the 3rd pre-school setting that the children had attended, reasons for previous changes are unknown, although the nursery at the school where Sibling 1 attended provided more hours 12 The complaint was ostensibly about information legitimately shared with the midwife about father being potentially aggressive, however the complaint was equally likely to be due to the health visitor’s refusal to support the application for DLA for Sibling 2 9 midwife and heath visitor gave her the standard advice about preventing Sudden Unexpected Death of Infants (SUDI) in relation to positioning of babies, not co-sleeping and avoiding babies overheating. 3.24. The parents were co-operative with the home visits made by the social worker, although Father made it clear he did not feel an assessment was necessary. The social worker observed nothing of concern in the home and the couple told her they were intending to move away from Milton Keynes soon. 3.25. As she felt “everyone is keeping an eye on her”, Mother was reluctant to come to the 6 week check until she was reminded that this is a service offered to all new mothers. Child J was never brought to baby clinic, despite a request from the health visitor for attendance on 2 specific dates. 3.26. At the beginning of December there was a serious fire at the house; Mother was advised to take Child J to the hospital as a precaution. Mother’s initial behaviour within the Accident & Emergency Department appeared appropriate. However, as time passed, her behaviour became increasingly bizarre and erratic, alternating between pacing and agitation to periods of calm and with no attempts to address her dishevelled appearance, as attendees in her circumstances would usually do. Accident & Accident staff thought her behaviour and bizarre comments, (eg. ghosts starting the fire and her phone typing on its own), could be indicative of a post-natal psychotic episode and made a referral to the Mental Health Services. Child J was admitted to the paediatric ward for further assessment and review; both parents were unhappy about this. Due to all the circumstances the consultant paediatrician made particularly thorough checks and notes. 3.27. A mental health practitioner attended promptly. Mother was calm and presented rationally during a thorough assessment, which included asking about drug use. Mother denied or down played her comments in hospital. She said relationship with Father was improving. She admitted using cannabis 7 weeks previously. There was no evidence of an acute mental health problem. 3.28. A number of agencies contacted MASH as a result of the fire. The social worker had recently finished her assessment which concluded that while she felt that parents had not been fully honest about their strained relationship and she was concerned about the number of referrals about the family, lateness to school could be due to the demands of having 4 children under 5 years old and that the school were managing the concerns about Sibling 1’s behaviour. The social worker used the Signs of Safety model13 to review her recommendation to cease involvement. She assisted the family to get temporarily re-housed and offered Child and Family Practice (CFP) for practical help. The parents declined this. 3.29. In January 2017 Mother told school she had contacted the police about Father threatening to report her to children’s services for being a “crackhead”. School completed a MARF; Mother alleged that Father was emotionally abusive, he had smacked Sibling 3, and that he was still living in the same house because he had no-where else to go. Father had also attended school, claiming Mother was angry and upset. The school correctly identified that this was a time where Mother might be persuaded to accept support from the local CFP. This support was agreed by MASH staff and accepted by Mother. 13 www.signsofsafety.net 10 3.30. During the early weeks of 2017 there were 3 reports to the police alleging domestic abuse of Mother by Father which were shared with Children’s Social Care.14 3.31. During January 2017 Mother was prescribed anti-depressants by the GP. When she did not respond to the GP’s attempt to arrange a follow-up appointment after a repeat prescription, the GP made the health visitor aware. 3.32. A Signs of Safety mapping meeting involving both parents was convened promptly by the CFP worker to plan the focus of the work. The subsequent Team Around the Family (TAF) meeting was cancelled by Mother.15 When professionals who had not got the message about the cancellation arrived at the house, both parents were present and there was a strong smell of cannabis. 3.33. Within a couple of months of involvement by the CFP, it had become clear that, despite attempts at providing a co-ordinated service, Mother was continuing not to accept offers of routine health checks and additional support. In addition, there were concerns about the on off relationship with Father, Mother making and then retracting allegations of domestic abuse, and the lack of understanding by both parents of the impact on the children of all the arguments, the going back and forth between properties and not attending school regularly. Accordingly a further TAF was planned to pull together all the information so that a referral could be made to Children’s Social Care; this didn’t happen because it was superseded by a child protection investigation due to Child J’s death. Key Episode 4: Child Protection investigation after Child J’s death 3.34. Child J was taken to the hospital in the early hours of the morning by Mother, having been found unresponsive by Maternal Grandmother on Mother’s bed16 where Mother and the other siblings were sleeping. A crack pipe was found in the house. 3.35. The appropriate Child Death procedures were followed including contacting the police and the council Emergency Duty Team. Later that day a strategy meeting17 involving appropriate key people was convened by Children’s Social Care. This included a record using the Signs of Safety approach. 3.36. A range of appropriate actions were agreed, which included the police finding the children, and considering using their Powers of Protection,18 interviewing parents and Maternal Grandmother, and taking forensic samples from the baby. Mother’s urine proved positive for both cannabis and cocaine. Maternal Grandmother refused to be interviewed by the police. A subsequent hair test for Father, used as evidence during the care proceedings, proved positive for cannabis. 3.37. The police exercised their Powers of Protection and the siblings were placed together in foster care. Due to concerns that Mother was of low mood and expressing suicidal thoughts while in custody, the police and mental health services ensured that Mother had an immediate mental health assessment. This concluded that, despite suffering from reactive depression, Mother was at low risk of suicide and low risk of harm to both herself and her children. 14 Two of these were made by Maternal Grandmother 15 A further TAC meeting involving school, health visitor and CFP worker was held a week later. 16 At the bottom of the bed. The house was very warm so no need for any covers. 17 As described in Working Together 2015, a strategy discussion/meeting is convened by children’s social care to decide whether or not to initiate enquiries under S47 of the Children Act 1989 –the local authority’s duty to investigate whether a child might have suffered or be at risk of significant harm 18 Section 46 Children Act 1989 11 3.38. The following day an application for an Emergency Protection Order (EPO)19 was made. Key new information came to light in court; that Mother had been using crack cocaine approximately 3 times per week for the last 5 months. 3.39. A social worker made a quick and thorough assessment, which ensured the continuance of the Care Proceedings. 4. THEMATIC ANALYSIS 4.1. The learning from this review was identified from information and opinions provided in the agency reports and at the learning event. The themes are: • Assessment, planning and communication • Substance misuse • Dealing with suspicious aggressive and avoidant parental behaviour • Domestic Abuse Assessment planning and communication: 4.2. NSPCC research20 identified 10 common pitfalls in assessment practice when children are living at home. Three of these are particularly helpful in analysing practice in this case. 4.3. The first pitfall is ‘Attention is focused on the most visible or pressing problems; case history and less obvious details are insufficiently explored’. Research repeatedly suggests the need to make time to read the case history. Chronologies and summaries can be helpful, but only if they are of adequate quality. 4.4. MASH staff told this review that electronic case records are reviewed every time a referral is made to MASH and previous contacts are routinely recorded on each new one. However the assessment from the London authority was not stored in the usual place and the summary of the referral from the London borough did not detail all of the relevant history. Most significantly the summary did not include Mother’s crack use; that a child had been removed from her care and adopted; and that Sibling 1 had previously been subject to a Child Protection Plan and a Child in Need Plan whilst in a south eastern authority. 4.5. Children’s social care participants at the learning event told this review that, because requests for archived records are not always dealt with in a timely manner, and key information can sometimes be time-consuming to extract from old paper files, archived children’s social care files on parents are not requested unless there is to be ongoing involvement with a family. This threshold was not reached until after Child J’s death. In addition, the existence of an archived record on Mother’s first child who was adopted was not obvious as this child was not detailed in family relationships nor visible in the summary. 19 Section 44 Children Act 1989 20 Broadhurst et al (2010) 10 common pitfalls in assessment practice and how to avoid them www.nspcc.org.uk/inform 12 4.6. Children’s social care participants attending the learning event told this review that social workers doing duty visits did not always have time to read the history in full. Information from the school and health visitor were taken into account, alongside the duty visit, in response to Father’s allegation that Mother was using crack. However the police were not included in the agency checks. This would not have revealed the strangulation allegation as it was still caught up in the backlog, but police may have shared information about the argument between the 3 women, when Mother called one a grass regarding the cannabis “factory”. 4.7. The social worker who conducted the Child and Family Assessment did not see the London assessment as it was not stored in the usual place on the electronic case recording system.21 The assessment done by the CFP worker built on the one done by the social worker. However she did not see the London assessment either, as her manager could not locate it for the same reasons the social worker didn’t.22 4.8. Information in the London assessment (2014-15) included information from historical records; that Maternal Grandmother had made a number of requests in Mother’s teenage years to have her received into care to protect her from drug dealers that were visiting the house; allegations that Mother and Maternal Grandmother smoked crack together and that this was funded by Mother being sexually exploited; and that allegations about domestic abuse had been a feature of parent’s relationship since the beginning. The assessment concluded that: whilst there was no evidence of the use of crack since her first child had been removed, Mother had continued to smoke cannabis, including when pregnant with Sibling 2; that she declined drug treatment at this point; that Father had been convicted in 2009 for cultivation of cannabis; and that the nursery that Sibling 1 attended had concerns about child and Father smelling of cannabis. 4.9. It is unlikely that knowledge of the history would have made a substantial difference at any particular point. However, given that it demonstrated that the concerns seen in Milton Keynes were long term and entrenched, it might have accelerated the point at which more intensive intervention occurred. 4.10. The CFP involvement provided co-ordinated activity based on assessment and use of joint visits and Team Around the Family (TAF) arrangements. By early March 2017 the agencies involved were clear that social work involvement was necessary to promote and safeguard the children’s welfare. No other agency apart from the school had considered using the Common Assessment Framework (CAF), which might have led sooner to TAF arrangements and/or the involvement of the CFP; some form of assessment is necessary to gain involvement of the CFP. TAF arrangements would have enabled better sharing of all the information known about the family and perhaps brought forward more intense involvement. 4.11. Participants at the learning event expressed a view that use of the CAF was helpful in evidencing what work had been done and any lack of change (especially when they included a chronology). However they also felt that use of the CAF in Milton Keynes had diminished.23 The barriers relevant to this case that they described included the need to gain consent from parents, (none of the 21 This has since been addressed 22 Children’s social care records can only be accessed by Managers in the CFPs 23 This is consistent with the findings of 2 local reports. The recent MKSB Thematic Learning Review (August 2017) which identified the lack of a simple framework to support a “see plan do review” cycle and the Early Help survey findings (2016) 13 practitioners felt they had a good enough relationship to get consent), and limited opportunities for practitioners working within acute settings to gather information about the whole family. 4.12. In terms of use of alternative tools, although “Signs of Safety” tools are most effective for enabling change when they are used jointly with parents24, practitioners are increasingly using these as a method of analysis. Participants at the Learning Event told us that use of the local neglect tool was not yet embedded, partly because practitioners found it hard to use.25 4.13. What no-one knew in detail26 before the death of Child J, was that Father had been in care himself as a teenager as the result of criminal behaviour. Father’s use of a different name meant a search of old records did not reveal his care history and he told the social worker conducting the C&F assessment that his parents “were always supportive”. Whilst this might partly account for the lack of probing about Father’s background on this occasion, it remains the case that, in all of the assessments, any history focuses on Mother’s childhood and parenting of her first child; there was limited enquiry about Father’s childhood or early adulthood. There was also no enquiry about Maternal Grandmother and her role within the family, despite Mother’s childhood history and one of the incidents reported by the police involving an argument when Maternal Grandmother was providing childcare. 4.14. The second pitfall is ‘Insufficient weight is given to information from family, friends and neighbours’. There were a number of allegations made to the police and/or Children’s Services; about domestic abuse (by Maternal Grandmother and Mother) or Mother’s crack use (by Father) respectively. Research27 suggests that allegations made by family friends and neighbours tend not to be taken as seriously as those reported by a professional, and can be seen as malicious, especially when there is ongoing conflict of some kind. In this case there were a number of significant challenges. The police records show there were many allegations and counter allegations between Father and Maternal Grandmother, and the point at which Father made allegations about Mother’s crack use was during one of their separations. In addition, several practitioners reported how difficult it was to know what to believe given that Mother and Father tended to retract allegations and denied domestic abuse, whoever reported it. Mother also consistently denied non historical use of crack. 4.15. As well as considering whether information is given in good or bad faith by family members, it is important to consider whether it might be accurate. It is possible both for good faith information to be inaccurate (mistaken for example) or, as in this case, bad faith information to be partially or completely accurate (for example real concerns reported following a falling out).28 Whilst Father’s allegations about Mother’s use of crack may have been in bad faith, they may also have been 24 Social workers use them this way, also hospital paediatric staff use the “3 colomns” with parents when discharging children with complex health conditions; what we are worried about (past harm, future danger, complicating factors); what is working well (existing strengths and existing safety); what needs to happen (family and child protection authority safety goals and next steps for future safety) 25 They also told the review about some face to face opportunities they use to share information, for example asking relevant professionals to the Multi-disciplinary meetings that are convened by GP practices 26 Father told some practitioners that he had been adopted but only told the school that he had been in care. 27 Broadhurst et al, 2009; Buckley, 1999 cited in Broadhurst et al (2010) 10 common pitfalls in assessment practice and how to avoid them www.nspcc.org.uk/inform page 16 28 Writing Analytical Assessments in Social Work, Chris Dyke. 2016. 14 accurate. However, in the absence of other tangible evidence of crack use, it was not possible to take any action. 4.16. The third pitfall is ‘Insufficient attention is paid to what children say, how they look and how they behave’. The children were all under 6 years old at the time of Child J’s death. The older two had delayed speech and staff who conducted assessments told this review they were reluctant to engage.29 This would have made it very difficult for practitioners to directly ascertain their wishes and feelings. 4.17. However, during the period covered by this review, the children were mentioned 19 times in police records as having been present at incidents. On most occasions when police officers attended after incidents, the children were seen and generally described as being happy with officers witnessing them playing.30 However in several of the calls to the police the children could be heard, distressed, in the background. This was not taken into account, as it was not recorded on the forms presented to police risk assessors in the MASH. There was also no mention of Mother’s pregnancy; Child J was not mentioned until after he had been born. 4.18. Sibling 1 was regularly aggressive to both peers and staff from admission to nursery aged 4 years, to the extent that Sibling 1 was excluded after biting a member of staff and put on a reduced timetable for transition to reception. Similar concerns began to emerge about Sibling 2. Their behaviour at school may therefore have been indicative of their experience at home and the impact of it. However this would have been difficult to identify for definite at the time as there was also evidence of the parents minimising and not consistently handling the children’s poor behaviour. 4.19. When children are less able to directly express their wishes and feelings, these need to be assessed through observation, including putting oneself in the shoes of the child to consider their lived experience. Whilst there was limited tangible evidence of neglect by the time of Child J’s death, more scrutiny of the children’s lived experience might have heightened concerns at an earlier point to prevent the kind of cumulative harm that would have caused more serious problems for the children as they got older.31 Managers suggested that emerging evidence of the effectiveness of recent work done locally on fabricated illness might be relevant. In particular, they said this was enabling practitioners to more explicitly consider and articulate the impact of family circumstances and parental behaviour on children when making referrals to the MASH. This appears to be assisting in demonstrating earlier that the threshold for involvement by children’s social care is met. 4.20. The health visitor does not appear to have been contacted until the very end of the Child and Family assessment, which was conducted over a 3 month period. Earlier contact could have enabled more observation of the younger children and potential for joint working. 29 The parents agreed to requests for the children to be seen alone; this could have been because they were confident that the children would not or could not disclose anything of concern 30 When they weren’t seen this is usually because of Mother’s refusal to engage 31 The terms ‘cumulative risk’ and ‘cumulative harm’ were first identified by Bromfield and Higgins in Australia in 2005 who defined cumulative harm as ‘the effects of patterns of circumstances and events in a child’s life which diminish their sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or layers of neglect.’ Bromfield, L., & Higgins, D. (2005). National comparison of child protection systems (Child Abuse Prevention Issues No. 22). 15 4.21. Communication between agencies was generally effective. Discussion at the learning event between MASH and hospital staff identified scope for raising awareness of how to access social workers in the MASH when hospital staff had serious concerns about children’s welfare or safety. This is being addressed. Summary of learning; assessment planning and communication 4.22. Where there has been significant involvement by children’s social care within the same local authority with previous children (eg child protection plan) or the parents in their own childhoods, previous assessments need to be promptly tracked down and taken into account. In addition, the process for storing assessments completed by children’s social care in other local authorities needs to be clear and well documented, so any assessment is easily located. 4.23. All summaries of assessments need to be sufficiently comprehensive to give the reader an adequate grasp of salient points. 4.24. There needs to be a relentless focus on the impact on children. Practitioners should ask themselves in every contact: “what is life like for this child”; “is it good enough”; “what might their presentation and behaviour tell us about their experiences, wellbeing and emotional health”? They should also consider which practitioner might be best placed to engage or observe individual children. 4.25. Multi-agency chronologies are undoubtedly helpful in identifying patterns of behaviour and extent of change. Analytical frameworks for example Signs of Safety 3 columns are useful to help practitioners order their thinking. The content of each of these needs to be used effectively to inform assessments and referrals. See recommendations A, B & C Dealing with suspicious, aggressive and avoidant parental behaviour: 4.26. The parents were highly suspicious of any agency involvement and very skilled at deflecting attention from matters into which they did not want too close enquiry. To a degree, both behaviours are understandable in the context of their previous involvement with statutory agencies in Milton Keynes in their childhoods32 and with Mother’s first born child. Whilst they were not always entirely happy with the involvement in previous local authorities, their reluctance to co-operate seems to have increased markedly once they returned to Milton Keynes. Their previous experience with agencies probably also enabled them to anticipate what practitioners might need to hear. 4.27. Parents’ suspicion most strongly expressed itself whenever they had first contact with agencies that they were not expecting to be aware of them, (for example the children’s centre), or when questions about their social history were asked, (for example by hospital paediatric staff). They were sometimes reassured when practitioners explained that this was a universal service or a standard protocol. 32 Father was abused by a person in a position of trust but not initially believed when he disclosed his abuse 16 4.28. A previous recommendation that a Child & Family assessment be done if further concerns were raised was not followed. Children’s social care practitioners at the learning event felt that this decision would have taken into account that the school had a student social worker about to start placement who Children’s Social Care practitioners believed would become involved. However, if this was the reason, the school was not aware of it at the time and the student SW never became involved. This was due to a judgement of school staff that other families had higher priority needs and that introducing a new person to a suspicious family was not appropriate. 4.29. Although Father told the author he did ask for help when the family came to Milton Keynes, there is no record of this. There is however, much evidence that both parents were generally reluctant to accept additional help of any kind. It is striking that one of the reasons given by practitioners for not completing CAFs was the assumption that consent would not be given. It is also significant that the time when Mother agreed to an assessment appears to have been motivated by a desire to avoid involvement rather than gain help. In addition when she did accept (practical) help from the CFP this was at a time of crisis, and with limited engagement; she was reluctant to sign the consent form and frequently cancelled appointments with the CFP worker. 4.30. A number of the letters sent to Mother/parents confirming the outcome of referrals included relevant information about services. Information about CFPs was provided 4 times. Suspicious and avoidant parents are more likely to respond to offers of help if they are made by someone with whom they have a relationship and/or in a crisis. Both circumstances applied when the CFP got involved in early 2017. 4.31. Both parents were also verbally aggressive and intimidating on occasion. Sometimes this appears to have been a deliberate tactic: for example making or threatening to make complaints; Mother’s behaviour with the physiotherapist; and Father’s at the hospital. When they felt significantly challenged about their parenting by professionals they would seek to escape, for example, by stating they were moving (imminently) to another area or by seeking to change schools. This latter response by parents is not uncommon – but did seem to be part of a pattern in this case. 4.32. Practitioners were able to keep themselves safe by sharing information about concerns33 and considering strategies to manage risks, for example invitations to clinic, joint visits etc. Emotional support is also important because feeling unsafe undermines the ability to act effectively. Practitioners generally felt they had good access to emotional support and supervision to discuss any concerns about their safety, although reflective supervision is harder to provide on demand. Good supervision is mindful of the difference between effective engagement and collusion. 4.33. Practitioners felt that the steps they took to manage aggressive behaviour in this case were proportional. However it is important to recognise that strategies for managing aggressive behaviour should be kept under review. Tactics like joint visiting can have an escalatory effect, and policies that exclude service users who are aggressive can result in intimidating behaviour being used as a tactic. 33 The exception was at the hospital where there were flags for the children’s welfare but not Father’s behaviour 17 4.34. Some practitioners at the learning event had had training on dealing with aggressive and avoidant parents. Practitioners were clear about the benefits of courses known to have been well received and enthusiastic about making them more widely available.34 4.35. Milton Keynes Safeguarding Board has a “hard to engage families” procedure35 which covers most of the issues above. The procedure specifically includes guidance on professionals’ meetings to share information and ownership of concerns. For families where children’s social care is not involved these can help identify that the potential risk of significant harm threshold has been met for referral. However convening such a meeting was not considered in this case, perhaps either because of a low awareness of the procedure, or a lack of recognition that such a meeting might have been helpful. Summary of learning: dealing with suspicious, aggressive and avoidant parental behaviour 4.36. Parents who have previously had difficult experiences of receiving services from children’s social care are likely to be suspicious and reluctant to engage. Because withdrawal by parents from services whenever they feel challenged increases the risk for children it is important to: consider the possible reasons behind difficult behaviour; make persistent attempts to build a relationship: use creative ways to engage parents and spot the moment to offer support and/or escalate concerns. 4.37. Where a pattern of avoidant behaviour begins to emerge, including reluctance to agree to assessment, this should be evaluated as a risk factor in its own right and escalated where appropriate.36 Practitioners could make better use of the MKSB “hard to engage families” procedure. Use of professionals’ meetings might assist in identifying whether and when the potential risk of significant harm threshold has been met for referral to children’s social care. 4.38. Practitioners benefit from good support and challenge to deal effectively with resistant and avoidant parents. See recommendation B & D Substance Misuse: 4.39. The NSPCC summary of those Serious Case Reviews between 2010 and 2013 which involved substance misuse37 identified learning which resonates for this case. They concluded that too much credence tended to be given to parents’ self-reporting of drug use that was not seen as excessive, coupled with reports of happy healthy children. They also suggest that assessment of risk needs to be ongoing. 7 of the 9 new or increasing risks had some relevance for this family. These were new partner (or previous partner coming back); involvement of extended family members in family life; missed appointments with any agency; domestic abuse or mental ill health problems; criminal 34 The two courses mentioned were a local one for children’s social care on dealing with difficult dangerous and evasive people and a nationally available one; http://www.sandstories.co.uk/ which also has a good focus on the child’s lived experience 35 http://mkscb.procedures.org.uk/ykpxz/assessing-need-and-providing-help/additional-practice-guidance/hard-to-engage-families 36 This was also a learning point from a previous Milton Keynes SCR (Child A published Jan 2016) 37https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/parents-misuse-substances/ 18 activity or anti-social behaviour incidents; stress (which may impact upon substance misuse habits); moving home. 4.40. A number of practitioners had suspicions about parental use of cannabis, which Mother admitted on occasions. However she was not willing to accept any treatment. Several practitioners looked for signs of drug use, including taking opportunities to look round the house. Some of those who visited the house also looked for evidence of cultivation of cannabis. The focus of attention by practitioners was more on Mother than Father, although it is important to note that Father also has a history of drugs offences and cannabis misuse. 4.41. There are a number of potential risks to children associated with parental cannabis use. These include inhalation of smoke (the school reported their clothing smelt of cannabis so they were likely to have been present on at least some occasions); impact of cost on family finances, possible contact with risky adults when purchased (or sold if cultivated); increased risks of co-sleeping for babies. However the potential impact of cannabis use on the children does not seem to have been explored in detail by any practitioner and the potential relevance missed entirely on occasion. For example when police visited the house to arrest Father for being the tenant of a warehouse where a “cannabis factory” was found, officers did not include this information in the referral they subsequently made to Children’s Social Care about the messy house. Nor did they make the connection when they became involved to deal with an argument between women where Mother had accused one of them of being a grass regarding the discovery of the “cannabis factory”. 4.42. No tangible evidence of crack use was ever found until after Child J died. After Child J’s death Mother admitted that she was using crack cocaine for a minimum of 5 months prior to his death. Previously she had always denied anything other than historical use of crack. Admitting to cannabis use could have been putting into practice “Half a truth is often a great lie”38 to deflect attention away from more probing enquires about the historical crack use. 4.43. It is accepted that, in the absence of clear evidence, a suspicious parent who is quick thinking, used to dealing with professional involvement, and adept at plausible explanations, will be hard to challenge about their substance misuse until and unless the intensity of involvement permits closer scrutiny, or a more confiding relationship. These conditions began to be in place once the CFP became involved. 4.44. Since Child J’s death it has become clear that Mother never received any treatment for use of crack cocaine. Her return to Milton Keynes increased her vulnerability to relapse by putting her back in close contact with Maternal Grandmother, who appears to have been complicit in her drug use as a teenager. The old adage about past behaviour being the best predictor of future behaviour is too simplistic because it does not take into account capacity to change. However there does seem to have been too much weight given to crack use not being likely to be a current or future risk because of the length of time since Mother admitted to last using it. 4.45. No-one has ever seen obvious physical signs of Mother’s crack use. It is known that she has continued to use crack cocaine since Child J’s death. Practitioner’s observations of her presentation since then suggest that the erratic and bizarre behaviour she displayed in the hospital are typical of how she has presented around those times. The effects of crack use can mimic psychotic symptoms 38 Benjamin Franklin 1758 19 and then cause depression. It is possible therefore that the symptoms of mental illness she complained of were at least partly associated with crack addiction. It is also possible that her long-term use of cannabis was at least partly a way of self-medicating to address feelings and/or depression caused or exacerbated by her abusive childhood. 4.46. Practitioners at the learning event considered that awareness of substance misuse was generally high in Milton Keynes and that the specialist service is very responsive, once people are willing to accept help. Summary of learning: substance misuse 4.47. Parents who misuse drugs can be very plausible,39 and agencies had different pieces of the jigsaw relating to suspicions of substance misuse which would have benefited from being analysed as a theme. A clear understanding about current, recent AND previous patterns of use assists practitioners to make better predictions of current and future use. 4.48. Practitioners should remain sceptical about drug use being historical until they are confident they understand: a) the circumstances in which it started, b) how the person managed to stop and c) their vulnerabilities for relapse 4.49. Practitioners need to be aware of the potential risks to children’s health and wellbeing associated with parental drug use, including when adults are arrested for drugs offences, and be able to describe and record the potential and actual impact clearly. See recommendation E Domestic Abuse: 4.50. During the period, assaults were alleged by Mother, Maternal Grandmother and Father. Mostly Father was the alleged perpetrator.40 No evidence of actual injuries was ever seen by any agency.41 The Home Office definition of domestic violence and abuse42 includes emotional and psychological abuse. Practitioners gave examples of how Father “pressed Mother’s buttons” by deliberately saying or doing things to make her angry. Mother was justifiably anxious that Father would make allegations about her. 39 This was also a learning point from a previous Milton Keynes SCR (Child A published Jan 2016) 40 Father told the author that he felt he was treated differently (worse) than a woman would be when he made allegations of abusive behaviour as a victim. 41 Mother has subsequently alleged that injuries were in places not easily visible (eg to her body and scalp) 42 The cross-government definition of domestic violence and abuse is: any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological; physical; sexual; financial; and emotional abuse. https://www.gov.uk/guidance/domestic-violence-and-abuse 20 4.51. It was common for Mother to withdraw/deny allegations. Whilst this is not unusual in relationships involving domestic abuse, it makes it more difficult for police to take any action to prevent further incidents unless there is corroborative evidence. This is especially so if difficult circumstances at the time they attend make it hard to identify and/or focus on challenging discrepancies based on what they already know. 4.52. The reasons for Mother not co-operating with the police are not known. However, for example, victims can withdraw allegations because reporting them has ensured their immediate safety, but following through would then increase the risk to themselves or their children. The signs of fear, and the reasons for it, may not always be obvious, and women may act in ways that appear inconsistent and harmful to their best interests.43 4.53. Research suggests that the cumulative seriousness and impact of multiple incidents of “low level” domestic abuse tends to be underestimated as each incident is usually seen in isolation.44 None of the incidents met the definition of anything more serious than the category of ‘standard’ when the DASH assessments were undertaken. This reduced the opportunity for multi-agency oversight of what was happening as standard categories of domestic abuse are not routinely referred to Children’s Social Care. Whilst several incidents were considered sufficiently serious to be referred,45 some weren’t. The sharing of 3 other alleged incidents might have triggered more active curiosity about what was going on in this family; the allegation about potential strangulation of Mother; the conflicting accounts of Father’s concerns passed on by the school and the concerns about Father’s behaviour at the hospital. 4.54. Midwives routinely ask women at booking whether they are experiencing domestic abuse, however some women will not disclose it. Domestic abuse reports are shared with health visitors and up loaded to GPs records, to which midwives have access. Participants at the learning event indicated that the system for police sharing information with the health visitor and passing it on to the midwives works effectively; as long as police attending incidents record that a woman is pregnant. 4.55. The number of incidents of reported domestic abuse, or neighbour disputes where the children were present, should have prompted some consideration of what it would feel like to live in such an environment. Research suggests46 that the impact of the stress, fear and anxiety associated with domestic abuse can be significant for unborn children and babies. Mother was not noted as pregnant on DASH forms and, when Child J was a baby, one entry describes him as “fine, not affected as only 3 months old”.47 Practitioners at the learning event expressed the view that awareness of domestic abuse was more consistently good amongst practitioners where exploring 43 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 Department for Education para 4.2.5 passim 44 Stark E (2012) “Re-presenting Battered Women; Coercive Control and the Defence of Liberty” in Violence against women: Complex Realities and New Issues in a Changing World . Les Presses de Universite du Quebec 45 Since July 2017 practice has been refined so that if any incident is shared ALL previous incidents will be routinely shared, irrespective of previous grading. 46 National Scientific Council on the Developing Child. (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper 3. Updated Edition. http://www.developingchild.harvard.edu AND National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. http://www.developingchild.net 47 This has been addressed by the police since 21 this was a standard part of their practice (for example Midwives) or who worked in localities where domestic abuse was prevalent. Summary of learning: domestic abuse 4.56. When there are a significant number of “low level incidents” of domestic abuse it is easy to underestimate the impact on both victim and children, and practitioners who deal with a lot of incidents of domestic abuse can become desensitised. In addition signs of fear and the reasons for them may not always be obvious to the onlooker. 4.57. Awareness of the impact of domestic abuse on unborn children and babies needs improving to be consistently good. This is especially so for practitioners where exploring domestic abuse is not a standard part of their practice, or who have limited contact with families where domestic abuse is prevalent. See recommendation F 5. GOOD PRACTICE 5.1 When undertaking a review, it is important to also consider any good practice undertaken on the case. A number of positive interventions were noted above and it is important to highlight them again here. They include: • Health visitor and social worker working in the London borough shared information proactively when the family moved • Health representative in MASH identified the family after the referral from London • TVP & Street Triage, who decided that the seriousness of the information warranted a home visit despite Mother not wanting one • School staff visited Sibling 1 in his home environment prior to his admission to nursery and identified that this was a family that might need extra support • The midwife and health visitor shared information with each other during antenatal and postnatal period • The GP referred key incidents for discussion in the Multi-Disciplinary Team • That health visitor expressed her disagreement that Sibling 2 met the criteria for DLA but also referred for a specialist opinion • When Mother complained the health visitor recognised that a change of health visitor might benefit the family; until then the named health visitor had been the same person • The newly qualified physiotherapist provided a thorough assessment of Sibling 2, was not intimidated by Mother’s behaviour, consulted the hospital safeguarding lead and passed on her concerns about the potential for “doctor shopping” • The Child and Family assessment completed by the social worker provided a balanced analysis which acknowledged past concerns and behaviour and current concerns and potential risks • The strong partnership between the school and the social worker • The support provided to the registrar by the sister in the Emergency Duty Department in response to Father’s aggressive behaviour • The escalation of concerns by the Emergency Duty registrar to the hospital safeguarding lead to ensure that Child J was admitted to hospital after the fire 22 • That the registrar and the nurse acted effectively to encourage Mother to stay for the mental health assessment and stayed hours beyond the end of their shift to ensure an effective response to Mother and Child J after the fire • The speed and thoroughness of the mental health assessment of Mother in response to a request from the Emergency Department • The paediatric staff on the ward systematically addressing and recording all the issues raised by their Emergency Duty colleagues • The school safeguarding lead successfully challenged the view that MKAct was a sufficient response to the family’s needs in January 2017 • The school safeguarding lead knew the children well and established a rapport with Mother that enabled a referral to CFP • The prompt advocacy by social worker and CFP with housing • The CFP assessment built on the Children and Families assessment conducted by the social worker. • CFP established a relationship with Mother in particular and provided a swift, intensive and tenacious response which included visiting Father in the town outside Milton Keynes where he and Sibling 3 had been temporarily re-housed • When the Health Visitor was informed that Mother was moving she went to the house to check • The application of learning from a previous local SCR involving drugs misuse; the importance of looking out for evidence of drugs use and seeing the bedrooms • The Team Around the Family worked well together, and recognised relatively quickly when it was necessary to escalate their concerns to Children’s Social Care. • When Mother did not respond to the GP’s attempt to arrange a follow-up appointment after a repeat prescription for anti-depressants the GP made the health visitor aware • The speed of the assessment and joint police and Children’s Services action to protect the siblings after Child J’s death. • Following the death of Child J the chaplaincy team provided hospital staff with an opportunity for a professional debrief; a safe space for staff to reflect on the impact that their involvement had on them personally • When the first foster placement was breaking down, Sibling 2 was allowed into school all day to give sufficient time for Children’s Social Care to find a suitable alternative local placement which kept the 3 siblings together and enabled the older two to continue to attend the same school. 23 6. CONCLUSIONS AND LESSONS LEARNED 6.1 In his 2003 inquiry report into the death of Victoria Climbie48, Lord Laming used the phrase "respectful uncertainty" to describe the attitude social workers (and indeed other practitioners) need when working in child protection: that they must be much more sceptical and mistrustful about what might be really happening behind closed doors. In this case a number of practitioners used the phrase “respectful disbelief” which is a particularly useful concept for working with people where there are issues of substance misuse, domestic abuse and avoidant behaviour. 6.2 Whilst more scepticism about what practitioners were being told might have been useful on occasion, the parents were skilled at deception and it is difficult to take action when there is limited tangible evidence. Even had more intense involvement commenced earlier, and been successful in finding out more about what life was like for the children, there still would have been no way of predicting Child J’s death. 6.3 Whilst there are a number of learning points from this review which will be useful to improve services for children and families in Milton Keynes, there was also considerable evidence of good practice in this case from all agencies. Examples included: attempts to build relationships with the parents, professional curiosity and tenacity, prompt responses and thorough assessments, information sharing, partnership working, and escalation. Accordingly a learning point from the most recent triennial review of Serious Case Reviews has considerable relevance; that ”the harms children suffered occurred not because of, but in spite of all the work that professionals were doing to support and protect them”.49 48 Lord Laming (2003) The Victoria Climbie Inquiry. The Stationery Office 49 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 Department for Education page 162 24 7. RECOMMENDATIONS The individual agency reports have made single agency recommendations. Milton Keynes Safeguarding Board has accepted these and will ensure their implementation is monitored. To address the multi-agency learning, this Serious Case Review identified the following recommendations for Milton Keynes Safeguarding Board (MKSB): A) That MKSB ensures that practitioners are competent in understanding, describing and recording children’s lived experience, and that they can effectively convey the impact of this on the child, especially when making referrals to Children’s Social Care. B) That the MKSB’s current work on Early Intervention, including the revision and use of the CAF, explicitly takes into account the learning from this review, in particular processes to support appropriate escalation to CFP and to Children’s Social Care services. C) That MKSB seeks assurance from Children’s Social Care that: I. The practice of making duty visits to assist in decision-making about the appropriate outcome of a referral regarding a child’s welfare has been reviewed in the light of the 2016 Ofsted inspection report50 and that any continuation of this practice is explicitly supported in the relevant procedures.51 II. Criteria has been agreed for when historical information should be retrieved from archives to inform assessments. D) That MKSB ensures practitioners consistently use a probing and analytical approach to gathering and sharing information when a parent is suspected of substance misuse: this should include the implications of past, present and potential future misuse, as well as the impact on children. E) That MKSB ensures practitioners feel confident and well supported in dealing with suspicious, resistant and avoidant parents. F) That MKSB ensures practitioners are competent in working with families where domestic abuse is a feature: in particular that they are fully aware of the impact of domestic abuse on babies, including before their birth; and consider the cumulative effects of “low level incidents” on both victims and children. 50 https://reports.ofsted.gov.uk/local-authorities/milton-keynes 51 “A – Z of Children and Families Policies and Procedures” 25 Appendix 1: Methodology and structure of report The MKSB agreed to undertake this review using the Significant Incident Learning Process (SILP) Principles of SILP: proportionality; learning from good practice; active engagement of practitioners involved at the time; engaging with families; systems methodology; avoidance of hindsight bias Stages of SILP; multi-agency agency chronology; agency reports which identified the single agency learning; two learning events held in November 2017 for practitioners and managers; comments and challenge to this overview report for practitioners and managers The Lead reviewer and author is Karen Perry, an experienced ex senior local authority manager of services for children who need protection and/or care. Karen is entirely independent of Milton Keynes SCB and its partner agencies. A description of what happened during the period within the scope of the review is split into “Key Episodes”. Key episodes are periods of intervention that are judged to be significant in terms of identifying learning through understanding the quality of the work undertaken with the children and their family. |
NC52436 | Death of a newborn infant in September 2020. Child E was born with no brain activity after a breeched labour and delay in the parents accessing medical care, with their life support being switched off the day after birth. Learning includes: professionals should understand that some parents with a long history of intervention may be resistant to professional involvement; there are limitations to child protection information sharing arrangements when it comes to missing people; information sharing on missing people requires joint data to be made available on risk factors to predict the likelihood of specific harmful outcomes. Recommendations include: safeguarding practitioners use joint supervision to reflect on progress made against intervention plans when there is limited engagement and risks remains unresolved; joint agreement and understanding of a missing person incident enables action to be taken, including the most appropriate use of police powers; practice should be led by continuous assessment of need for children and families, with assessment including therapeutic input and, when appropriate, joint intervention by children and adult's services; parents who have a history of repeated removals of babies, and a history of adverse childhood experiences (ACEs), require support and joint intervention from adult and children's services; local partnerships should explore how they can engage with providers of private baby scans to raise safeguarding standards.
| Title: Local child safeguarding practice review (LCSPR): Child ‘E’. LSCB: Camden Safeguarding Children Partnership Author: Wendy Thorogood Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 LOCAL CHILD SAFEGUARDING PRACTICE REVIEW (LCSPR) CHILD ‘E’ Author: Wendy Thorogood, Independent Nurse Consultant 2 CONTENTS 1. Introduction - Serious safeguarding incident ................................................................. 3 2. Brief case background .................................................................................................. 3 3. Scope for a Local Child Safeguarding Practice Review (LCSPR) ................................. 4 4. A brief chronological overview of Child E’s case ........................................................... 4 5. Focus of the Review ..................................................................................................... 6 6. Learning in action ...................................................................................................... 14 7. Recommendations ...................................................................................................... 16 8. References ................................................................................................................. 17 3 1. INTRODUCTION - SERIOUS SAFEGUARDING INCIDENT 1.1 Child E was born with no brain activity on 16th September 2020 at Borough B Royal Infirmary Maternity Unit, after a breeched labour and delay in the parents accessing medical care. Child E was put on life support immediately after the birth, and the life support was switched off on Thursday 17th September 2020 at approximately 15:00. Child E died 6 minutes later. 1.2 Child E’s parents are understood to have fled from London to Borough B having attempted to conceal the pregnancy because the unborn baby had been placed on a pre-birth Child Protection Plan. The Mother attempted to give birth in the Bed and Breakfast accommodation where the couple were staying in Borough B, however ended up calling an ambulance and attended hospital when mother was in distress. 1.3 When the parents arrived at the hospital, the Mother was examined and found to be in advanced labour. The parents concealed their identity and did not make it known to the hospital that there was a risk that baby was in breech so the hospital initially tried to proceed with a natural labour. The hospital quickly discovered that the baby was in breech and the labour was much higher risk. Child E was born via emergency C-section with no brain activity and was immediately connected to life support. Due to the parents’ irregular presentation of events, borough B hospital promptly worked with County B Police force colleagues and identified that the parents had given a false identity and determined their true names. 2. BRIEF CASE BACKGROUND 2.1 Child E was the fifth child born to the parents. Their oldest child was removed as a baby and is in long-term foster care. Their 3 younger children are Looked After by Borough A. 2.2 Mother and Father came to Borough A in 2018 whilst pregnant with their second child. Both parents are reported to have significant learning difficulties. Mother is estimated to have a learning age of a 9/10 year old and father is estimated to have the learning age of an 8/9 year old (as recorded in a Psychologist report undertaken in a previous set of care proceedings in 2019). Both parents are recorded within Borough A’s Children’s Safeguarding and Social Work records as not understanding any of the safeguarding concerns raised during proceedings and not having the capacity to learn the skills required to safely care for a young child due to the extent of their cognitive functioning. 2.3 Following a pre-birth assessment unborn Child E was made subject to a Child Protection Plan in April 2020 under the category of neglect. Due to COVID-19 most of the pre-birth Child Protection Plan during pregnancy was managed through telephone contact. 2.4 On the 3rd July 2020, parents left their residence in Borough A and took most of their belongings with them. In response, a national missing person alert was undertaken by Borough A’s Children’s Safeguarding and Social Work. Information was also updated on the Child Protection Information System (CP-IS) as per protocol, outlining the concerns of the allocated social worker. A photo of each parent was shared. 2.5 For the period of time they were absent from Borough A, they would not disclose their location. The allocated social worker and midwife maintained weekly telephone and text contact with them. Within this contact, parents were regularly advised to seek medical attention around Mother’s health and her potentially high-risk (breeched) pregnancy. 4 3. SCOPE FOR A LOCAL CHILD SAFEGUARDING PRACTICE REVIEW (LCSPR) 3.1 As set out in Working Together 2018, a Rapid Review took place in September 2020 with colleagues in Boroughs A and B. Emerging learning themes identified at the time were: How the multi-agency network shared concerns of ‘significant medical risk at birth’ for unborn missing cases. How the multi-agency network provided support to non-engaging parents with learning difficulties, especially if pregnancies are short periods apart and they have suffered multiple removals of their children. How a specialist service could help parents with learning difficulty/disability to understand the risks, work with services and offer support with the child protection system. A review of how CP-IS (Child Protection Information Sharing System) is used in England. It is new to NHS 111 but embedded regionally in London and not accessible to all Ambulance Services nationally. 3.2 Following the Rapid Review meeting the Borough A’s Statutory Safeguarding Partners recommended to the National Panel that the case provided an opportunity for local learning. 3.3 The National Panel supported the decision to carry out a cross-borough Local Child Safeguarding Practice Review (LCSPR). This commenced in November 2020. 3.4 An Independent Reviewer, Wendy Thorogood, who has a health background, experience in the themes covered in this case was appointed. 3.5 A chronology of key events was compiled across agencies in Boroughs A and B in December 2020. A well-attended practitioners’ learning event took place in January 2021 with open dialogue and collective reflection on practice. 3.6 An Action Learning - Emerging Themes report was presented to the LCSPR panel in February 2021. 3.7 On 4th February 2021, the HM Coroner (in Borough B) decided that the case would be taken to an Inquest. The Inquest was formally opened on the 10th February 2021 and directions were given on reports, statements and timelines. This report has been requested to be shared with the Coroner in May 2021. 4. A BRIEF CHRONOLOGICAL OVERVIEW OF CHILD E’S CASE: 4.1 Child E’s parents are Catholic, white Irish and related by a grandfather. Both have reportedly had a history of childhood abuse and intervention from services as children. 4.2 Concerns about contraception were raised by some professionals. The Mother informed the reviewer that she was not averse to using contraception, despite her cultural or religious beliefs, but she was resolute in her desire to have a baby and keep it. It is important to note that during this review it has been confirmed that she is pregnant again. This is important information going forward to ensure the right support. Learning Point: There was a gap of eight or so years between the first child and second pregnancy and presenting in Borough A. It might be appropriate to review what intervention if any took place in their previous Borough/ Country of residence that prevented a pregnancy at that time, with the intention of exploring if it would affect current thinking and engagement and intervention. 5 4.3 The pregnancy under review was reported to the GP at around 4 weeks and referrals were made to Borough A’s Children’s Safeguarding and Social Work because of previous safeguarding concerns. This was therefore not a late presentation or concealment of the pregnancy, but Social Care assessments and intervention were triggered immediately. 4.4 In June 2020) the Mother attended an ultrasound scan which determined that the baby was in breech position (28 weeks). There were no concerns at that point as babies continue to move and it was felt that there was a chance the baby would turn before the birth. 4.5 The parents have a history of aggressive disruptive behaviour, which included neighbourhood disturbances involving the Police. This information was shared with Borough A’s Children’s Safeguarding and Social Work are via the parents, and was not formally reported by Borough A Police, this information should have formally been part of the ongoing pre-birth child protection conference planning. 4.6 Child E’s parents went missing prior to the birth, however they did maintain contact with their allocated social worker and midwife in Borough A, although they did not disclose their location. 4.7 It is now understood that Child E’s parents fled from Borough A to Borough B, although they were indicating they were going to another borough, arguably to avoid intervention at birth. This is a repeated pattern of behaviour. During the 2nd pregnancy they had presented in Borough A whilst the first child was in kinship care in another borough. Example of good practice: Unborn Child E had been placed on a pre-birth Child Protection Plan and information was promptly shared with Countries/Boroughs where the family had a connection. 4.8 There was a high level of activity once the parents were identified as missing. They kept communication open with the social worker and midwife, mainly via text messages. Both professionals encouraged the parents to inform them of their whereabouts and urged them to seek medical help by presenting at any hospital. They also reminded the parents of the risks involved in a breech presentation and delivery. The parents reported to the Healthcare Safety Investigation Branch (HSIB) after the death of Child E, that they had paid for a private scan and that the baby ‘was okay’ and that the baby was ‘still in a breach position’. 4.9 A missing person’s alert was sent out nationally via the NHS route. Information was updated on the Child Protection Information System (CP-IS) network as per protocol. 4.10 The parents gave false names and past-history when calling for an ambulance. This was key, as it led to a delay in identifying them on the CP-IS system. 4.11 The Mother reported to the Independent Reviewer that she was unaware she was in active labour, although this was her 4th pregnancy, with one being a previous breech presentation. On admission to hospital the Mother was 10 cm dilated, indicating advanced labour. Meconium1 was visible on admission. Both parents failed to report to staff that the Child E at the last scan was in a breech position. 4.12 Child E was born with no brain activity following an emergency caesarean procedure. She died the following day in the presence of both parents. 1 Meconium presenting in the fluid surrounding the baby means the baby is suffering from stress and the mother is in active labour. Intervention by medical staff is vital to continuously electronically monitor baby’s heart beat and the effects of contractions on the unborn baby. External cephalic version (ECV) – turning a breech baby in the uterus ECV is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. ECV should be carried out by a doctor or a midwife trained in ECV in a hospital where the mother can have an emergency caesarean section if needed. Around 50% of breech babies can be turned using ECV, allowing a vaginal birth. But if the mother is at term/overdue, as in this case, and her waters have broken and she is having contractions, research suggests it is too late for an ECV. https://www.nhs.uk/pregnancy/labour-and-birth/what-happens/if-your-baby-is-breech/ 6 5. FOCUS OF THE REVIEW 5.1 This LCSPR examined the work undertaken one year prior to the serious incident, and the period immediately after the incident to consider key episodes from historic records in order to triangulate information. 5.2 Key areas explored: Impact of COVID-19 during the time scale of the intervention. Case work and intervention How the multi-agency network shares concerns of ‘significant medical risk at birth’ for missing person cases The cycle of pregnancy and removal of babies How the multi-agency network provides support to non-engaging parents with learning difficulties The risks of private scans Areas of good practice and areas of learning have been highlighted. 5.3 The Review heard from professionals involved about their experiences of working with Child E’s family at the time, and about any issues which were affecting them or their agency which may have impacted their work. The Review took place online with the support of a workbook provided so professionals would have the opportunity to reflect personally on their involvement. The questions included in the workbook were: What worked well and what challenges were there? What influenced the actions or hindered them? Systems issues? Why did things happen or did not happen? Was this case unique or is it similar to others? If, on reflection of your work, you have learned how you, agencies or systems could or should have done something differently – let us know. Have we identified the right lessons from this case? 5.4 IMPACT OF COVID-19 ON RISK ASSESSMENT AND HOME VISITING DUE TO NON-ENGAGEMENT 5.4.1 All practitioners were in agreement over the unprecedented challenges to support and safeguard Child E’s family due to the COVID-19 restrictions in 2020. This was not a family that professionals could easily engage with virtually. The only technology they would use was a phone and they preferred to text and speak not video call. 5.4.2 They disengaged with many appointments; For example, they refused to attend hospital unless both could be present, which was difficult due to COVID-19 restrictions. However, we heard from staff that special measures were in place to accommodate their needs and to ensure engagement by allowing the partner to be present at all appointments, and by doubling up the appointments to include scans at the clinical assessments. 5.4.3 From the discussions with all staff, the Independent Reviewer does not believe COVID-19 to be the barrier to the care and assessments offered, more that the parents chose to disengage and used COVID -19 as an excuse. 7 5.4.4 The parents, under the restrictions of COVID-19, were able to abscond. Furthermore, additional benefits and a maternity grant received during the restrictions enabled the purchase of bus tickets, as reported by the parents. Example of good practice 2: Borough A’s Children’s Safeguarding and Social Work and Health colleagues fully understood the importance of keeping up contact during COVID-19 and no evidence has been found to suggest that any element of care offered was missed because of the restrictions. Borough A’s Social Work team and Health went out of their way to safeguard Child E, with additional attention to detail including having an Emergency Protection Order outlined in readiness for the delivery. 5.4.5 The parents were unrestrained in contacting staff frequently if they wanted something, sometimes creating a hectic environment. This could be viewed as them setting their own terms of engagement and intervention. It is important for professionals to be aware of this and communicate with families accordingly. 5.4.6 In order to do so the professional needs to set clear boundaries (firm ground). Professionals should endeavour to present intervention more as a learning culture than a compliance culture, enabling the professional to use their expertise to assess needs wherever possible with the cooperation and understanding of the family, ensuring they receive the appropriate help without dictation or pronouncements. It seems likely in this case that, because of their learning difficulties, that Health and Social Work tried every way possible to engage with the family, and there is evidence that this was taken advantage of by the parents. 5.4.7 There were joint meetings between the midwife and social workers for when supervised contact visits with their older children were arranged. However, the parents often did not attend (DNA) although great persistence was demonstrated by the midwives and social worker to keep the contact going, leading to additional investment and time to accommodate their needs. 5.4.8 During the period of this review, it was clear all professionals had tried hard to engage with the parents. However, there are outstanding medical tests such as historic genetic screening which still needs to be completed. The parents avoidance of all pre-birth conferences reflects the resistance to intervention from services which led to a lack of measurable progress and risks remained. 5.4.9 The parents struggled to attend key appointments, would overstate co-operation and compliance, and often seemed to minimise professionals’ concerns. The parents were focused on being able to prepare for the baby by providing equipment and funding. Seemingly believing that was what was being asked of them and thus, in their view, overcoming the barrier that had led to their last child being removed, without fully understanding the risks being presented. They presented as aggressive and threatening when challenged, making unjustified claims of progress being made and actions carried out. In the view of the Independent Reviewer, the parents not attending the child protection case conferences indicated a refusal to address key issues, minimising the 2 Government policy and the literature research on children’s services all emphasise the importance of agencies working together and the value of partnership structures. Consistent evidence indicates that parents and children are best served if the support on offer is joined up and well-coordinated’. It would be appropriate to recognise that although services may be provided in one setting, there is still a risk of services not being joined up, because of different agencies (and competing interests/perspectives) involved. (Warren, 2010). 8 importance of intervention, whilst focussing on other issues that have little relevance or benefit for the unborn Child E. Arguably, they appeared to show no understanding of the reasons for past children being removed from their care, with an element of selective disengagement. Learning point: Professionals should understand that some parents with a long history of intervention may be resistant to the involvement of professionals, rather than resistant to change in itself, particularly where they feel professionals are exercising power over them. This is a key learning point for all involved to reflect on and consider what might be done differently. 5.4.10 Recorded evidence showed the professional relationship with parents was designed to ensure the parents felt respected and avoided judgmental language or assumptions about their behaviours or motivation. The Independent Reviewer found recorded evidence of such conversations within the records which is an example of respectful practice. 5.4.11 The couple are related by a grandfather 3 and appear totally interdependent on each other and have few friends or close family to support them or that they would trust. In these circumstances there is an inherent risk of genetic complications, although the clinical significance is uncertain in Child E’s post mortem and would require further testing of the parents. Genetic screening remains an unaddressed intervention which has been requested by medical professionals historically and is key for any future children to be informed of any possible risks to growth and development. 5.4.12 The parents were openly hostile and aggressive at times. At the practitioner event, learning in action was witnessed, strategies were discussed on how to overcome this and how to a re-evaluate risk and better engage with the parents. Example of good practice: A good example was shared in relation to the Father’s behaviour at the bedside of Child E and the interaction with the Doctor, who had the ability to set boundaries with the Father, diffusing his escalating anger and leading to cooperation in a stressful situation. 5.5 CASE WORK AND INTERVENTION 5.5.1 The role of children’s safeguarding social work service: The children’s social worker was proactive and available to the parents and was often contacted many times a day. The social workers’ ongoing dedication and commitment was exemplary, along with her historic knowledge of the case, she was a key connection between other professionals. Example of good casework and use of supervision: This case had been subjected to independent audit and was graded as an example of outstanding practice with good understanding of risk assessment. The records reflect the importance of good supervision and reflection in a case where parents are desperate to keep their baby, yet do not have the understanding or capacity 3 Key fact: Consanguinity refers to relationships between blood relatives e.g. first cousins, which is common in a number of different cultures. Families from all communities can be affected by genetic disorders therefore tests need to be performed and any risks identified. 9 to provide for the child's basic care needs consistently. This case was time consuming and frustrating leaving all staff involved emotionally drained. Independent supervisor’s comments: “SW has worked tirelessly on this case, and the content of the file is evidence of the hard work and commitment put into the challenge of maintaining a supportive relationship with the parents whilst holding onto the focus of prioritising the needs and safety of this unborn baby”. 5.5.2 Role of Health and Adult Social Care services: In November 2018, the parents were referred by Borough A’s Children’s Safeguarding and Social Work for an assessment for eligibility for services from Borough A Learning Disability Service (LDS), the specialist, integrated adult learning disability team. The parents were assessed by two clinical managers from LDS who judged them not to have a ‘global learning disability’. Measuring IQs is difficult and therefore eligibility is based on adaptive functioning as well as IQ. Both parents showed good communication skills at the initial contact assessment, including life skills, and demonstrated a high level of adaptive functioning 5.5.3 Throughout Borough A’s Children’s Safeguarding and Social Work assessments and reports, the parents were referred to as having learning ‘disabilities’. Learning ‘disability’ is a much higher level of impairment than having learning ‘difficulties’ and the generic use of the term could have influenced how professionals worked with this family. 5.5.4 During the care proceedings for Child E’s siblings, the parents were identified by a court appointed psychologist as having a learning disability/global developmental delay. The purpose of this report was to determine the parents’ ability to care for their children by assessing their behavioural functioning and capacity for change. Namely, to adjust and think through how their judgements and actions affected their children’s safety and welfare. They were not able to demonstrate the ability to sufficiently meet the needs of their children, nor prioritise them over their relationship with each other. The parents had limited awareness of their impact on others. It is evident in the case records that any decision about capacity to parent was determined by both information about any ‘disability’ as well as testing their functioning as parents. 5.5.5 What is perceptible is that the parents were not impaired to organise and run their lives as adults. Borough A’s Adult Social Care struggled to engage with the family who could not understand their role in their case. At this point clearer guidance from Borough A’s Children’s Safeguarding and Social Work to Adult Social Care could have helped, including joint work to facilitate a shared understanding of the families’ needs. These parents had a number of vulnerabilities. Adult Social Care’s telephone calls to the parents were reported by them as unhelpful. The parents were not able to understand what the “Adult Service could do for them”. It appears the parents had a fixed agenda about with whom they would engage with and they did not see themselves as in need of additional services. 5.5.6 Arguably, Borough A Learning Disability Service were constrained by how their service is commissioned. The service which is required for this family is not currently available. This would require a bespoke therapeutic package of care and specialist intervention. Adults who have suffered childhood abuse rarely get the service they require, yet lifelong impacts of abuse are well documented and supported by research. The outcome frequently manifests itself in poor physical health with a consequential impact on Social Care time and budgets. 5.5.7 A point of discussion was how social care assessments could provide a person-centred joint Children and Adult Social Care support package, which promotes continuity of care and communication with partner agencies. The assessment carried out was not a true reflection of this family’s needs and capability to change because Adult Social Care were not fully aware of the past risks. There should have been closer working between Borough’s Adult Social Care and Children’s Safeguarding and Social Work services to understand their needs considering the emotional impact of their childhood including life skills and ability. 10 5.6 THE CYCLE OF PREGNANCY AND REMOVAL OF BABIES: 5.6.1 This case reflects the perpetuating emotional cycle of getting pregnant, giving birth and having the baby removed. Professionals rarely have access to a robust intervention for the consequences of having a baby removed at birth, which is a traumatic experience for both parents and baby. 5.6.2 It is clear these parents have had long-term involvement with child protection services. They had personal experience of the system as disadvantaged children and built up extensive knowledge which could include mistrust of interventions, seeing this as a negative experience rather than a service that is designed to promote change. 5.6.3 They first became parents at a young age, with few positive resources to bring to parenthood. Historic family abuse and court involvement, which is typically adversarial, can compound parents’ difficulties, exacerbate mental health problems and prompt a return to coping strategies such as misuse of drugs and alcohol, and aggression towards authorities, undermining recovery. Professionals struggled with this in this case. 5.6.4 Although there is a clear consensus that children must be protected from harm, there is a strong moral and economic argument for continued work with parents beyond the conclusion of court proceedings to prevent repeat family court appearances and removal of additional infants. This involves relationship based longer-term professional help. 4 5.6.5 Integrated commissioning for proactive intervention for such families is therefore required and should be developed. The cost for each child going through the system is between £140,000 -£250,0005. 5.6.6 Integrated commissioning may be an effective way to achieve successful transitional care for adults who are without diagnosable health conditions or meeting the thresholds for Adult Social Care. They arguably require a service offering intervention and support to improve life chances and choices. However, this innovative relational approach to commissioning requires a local partnership recognition of common values, vision and joint ownership between relevant stakeholders. 5.6.7 Professionals worked hard to address the parent’s challenging behaviours and lack of engagement. Working with resistance and denial were common features and reflected in supervision. Arguably, understanding the resistance at a deeper level may have resulted in better understanding of the fear, stigma, shame and ambivalence the parents presented with as vulnerable adults with unaddressed needs. Joint working with Adult Social Care is required to be strengthened and commissioned so therapeutic services are available in order to deliver change. 5.6.8 The services provided did not meet the parents’ complex needs to effect a holistic change. Were the parent’s expectations constrained by the services available? This remains an area which is unaddressed nationally for adults who require support and intervention but will not reach the threshold as vulnerable adults. Once a child is removed focus shifts to the child in care, leaving a gap in services for the parents who may require therapeutic intervention. 4 “Regarding the high rates of removals at birth that we have uncovered in this study (60% of all repeat cases), we urgently need to establish best and humane practice in these difficult circumstances to ensure professionals work in partnership with mothers as far as possible and that clear pre-birth plans are in place at a timely point. We need to see agencies routinely seeing pregnancy as an important window for change – pre-birth help needs to start much earlier.” https://www.nuffieldfjo.org.uk/app/nuffield/files-module/local/documents/Executive%20summary_Born%20into%20care%20literature%20review_December%202019.pdf Arguably, there is no statutory obligation to offer any support when a child is removed: while a mother’s/father’s multiple needs may result in child protection concerns, Cathy Ashley, Chief Executive of the Family Rights Group charity, says that “on their own, the parent’s need doesn’t meet adults’ services threshold for intervention and support”. This is something for all partners to consider within your locality when you are faced with this situation of such cases to break the cycle. 5 https://dera.ioe.ac.uk/2710/1/Microsoft_Word_-_PLR0910078Blazey_Persson.pdf. 11 5.7 HOW THE MULTI-AGENCY NETWORK SHARES CONCERNS OF ‘SIGNIFICANT MEDICAL RISK AT BIRTH’ FOR MISSING PERSON CASES Definition of ‘missing’: “Anyone whose whereabouts cannot be established will be considered as missing until located, and their well-being or otherwise confirmed. All reports of missing people sit within a continuum of risk from ‘no apparent risk (absent)’ through to high-risk cases that require immediate, intensive action”. (Home Office 2002 and OASys 2006). 5.7.1 There was a historic flight risk. This was a family with historic poor engagement including absconding to avoid social work intervention. 5.7.2 There was recorded evidence that the parents intended to go to another borough to have Child E and therefore a contingency plan was put in place. Professionals’ concerns were due to the family history and risks to the unborn baby. Initial cross-borough discussions took place early and all relevant partners were involved and consulted without delay, including an Emergency Protection Order application in readiness. 5.7.3 Borough A’s Children’s Safeguarding and Social Work sent out the national missing alert to Health in a timely fashion, once the parents were identified as missing. This included using the CP-IS system to update current information, reflecting the April 2020 review of the policy. The CP-IS[2] system is not fully embedded with all Health partners and in this case the ambulance service did not have access to CP-IS. Borough B confirmed that their process is to review CP-IS alerts for every A&E attendance along with unscheduled maternity attendances. Although, the information provided on CP-IS is not detailed, it alerts Health professionals if a family have an open social work case and provides useful contact details. Health alerts concerning missing families still varies across England therefore all areas should regularly review their Missing Policy to ensure the system is up to date. 5.7.4 There were initial concerns raised about the practicalities of the missing person process but no errors were identified in the system or the reporting. The service was reviewed nationally in April 2020, giving clear local guidance, however the system cannot function effectively where false identification is used, as was the case with these parents. The hospital receiving the emergency call used the CP-IS system and were able to challenge and determine their true identity and hence their links with Borough A’s Children’s Safeguarding and Social Work. 5.7.5 The fact that during COVID restrictions, the parents were able to access both additional benefits and the maternity grant, and thus abscond, illustrates the benefit of a closer collaboration with the Department for Work and Pensions (DWP) who now have a dedicated safeguarding team. It would have been an effective and efficient way of identifying where the parents had settled. 5.7.6 Borough A Police were involved in strategy meetings around this case from 5 months into the pregnancy. At that stage there were no additional significant concerns regarding health risks, the main concern focusing on non-engagement. To enable officers to undertake a thorough assessment of the case it would have been necessary to disclose the historic medical risks to justify a review by the Police of personal data. Even then, it is apparently unlikely that the family would have reached a threshold to trigger additional powers such as finances and mobile phone investigations. The family would have not been able to be detained by the Police, even if they were located, although there could have been a notification to the local Social Care and health services. 5.7.7 Nearing the birth of Child E there was a lot of activity and contact with the family mainly between the midwife and social worker, however the family refused to disclose their whereabouts. Borough A Police disagreed with the term “missing” in its purest form as contact was being made via the phone. It was at this point it would have been prudent for the professionals involved to follow the formal [2] https://digital.nhs.uk/services/child-protection-information-sharing-project 12 steps, such as the Escalation Policy, to ensure the Mothers and unborn child's welfare and safety remained paramount. 5.7.8 Effective partnership working is vital in order to ensure that positive outcomes for children and families are central to all assessment, planning and intervention. This includes the need to consider differing views and experiences which evidence the value of exchanging ideas and developing critical thinking in regards to how best to achieve improved outcomes. 5.7.9 Staff are very used to the term ‘missing’ for children, though not so much for adults. The category of missing is critical to the clarification of roles and immediate action. Police are the lead agency for the investigation of missing children, although arguably this is less clear for adults. Every year an estimated 200,000 people go missing in the UK. In some cases, missing adults may have made a choice to leave and ‘start their lives over again’, but the vast majority of missing people, children and adults, are vulnerable and need protection and support. 5.7.10 The use of police powers would have assisted in identifying their whereabouts, triggering support and advice to the family and formally linking with local services for intervention and further assessment. 5.7.11 Prompt application of Borough A’s Escalation Policy would have ensured strategic leadership oversight and could have supported and triggered a police led investigation. 5.7.12 It is common for the Police’s strategic lead for missing persons to have a senior role in leading the Forces’ response to dealing with vulnerable people. Senior leaders are responsible for building and developing partnerships together with other statutory and non-statutory partners. 5.7.13 Reducing the harm to those who go missing, including through a tailored, risk-based response, ensuring agencies work together to find and close cases as quickly as possible at a local and national level. Learning Point - An indicator of harm There is always a reason for a person to go missing. Understanding the circumstances will allow the police and other relevant authorities to tackle any potential causes of harm and identify intervention and safeguarding measures that can stop or minimise further episodes. Going missing may be a symptom that something is wrong in a person’s life. This can often be described in terms of push and pull factors that push people away or pull them towards something, e.g., being pushed away by abuse or financial problems, or being pulled towards exploitation. 5.7.14 In July 2018, the All-Party Parliamentary Group for Runaway and Missing Children and Adults carried out an Inquiry into safeguarding missing adults who have mental health issues. Recommendations from the subsequent report included the need for better multi-agency working, with a significant role for the Health and Social Care sectors in the response to missing adults. The report identified that this multi-agency approach could improve all stages of a missing investigation: risk assessments, response at the point of return, ongoing support and prevention. 5.7.15 People go missing because of a myriad of reasons and no one episode is the same. The only common factor across all missing episodes is that people are at increased risk of harm and may need support. We can only do what is right for missing people by working in a truly multi-agency way. There needs to be clearer criteria for describing a missing person as vulnerable. 5.7.16 It was clear in this case it was to avoid removal of the unborn baby which has been a repeated pattern of behaviour and will continue until the family receive the right intervention and help required. 13 Learning point CP-IS has its limitations as do the local arrangements for sharing information on missing people. Risk assessment is broadly thought of as clinical or actuarial assessment. Best practice requires joint data to be made available on the power of individual risk factors – or combinations of risk factors – to predict the likelihood of specific harmful outcomes. Attempts at developing such measures are very much in their infancy and still require improvement nationally. Information sharing between trusts can still be hit and miss. Joint risks need to be jointly owned and recorded more accurately. Nationally, at present, harm is inconsistently recorded in a missing person report, whether suspect or victim. Repeated missing episodes elevates risk, which can place the police in a complex situation within the constraints of the Human Rights Act and bearing in mind that “all people have the right to a private life”. Arguably, it is best practice to seek medical intervention for a birth of a baby. Nevertheless, it is not law. In this case, if the family had been found earlier, they could have linked with local Social Care and Health for intervention. 5.8 HOW THE MULTI-AGENCY NETWORK PROVIDES SUPPORT TO NON-ENGAGING PARENTS WITH LEARNING DIFFICULTIES/ DISABILITIES 5.8.1 Services nearly always have room for improvement. This review was commissioned because of the desire to explore ever-evolving reflections to support developing successful strategies for encouraging participation or deciding on interventions where non-engagement is a serious risk to the child’s safety and welfare. Example of good practice: This report identified that professionals had anticipated problems ahead of this review, with good use of arrangements in place to facilitate parents’ participation, such as joint parental access to the clinical appointments. 5.8.2 Staff were aware of issues such as low literacy levels, however the suggestion of learning disabilities rather than difficulties set a pathway that was not a true reflection of this family’s needs. This assessment should have reflected a better understanding of need when considering this family’s complexities, resulting in a service requiring therapeutic input and joint intervention by both Children and Adult Services with the aim of improving life chances. 5.8.3 Parental reactions to intervention by the removal of a baby from possible harm is both, emotionally and physically complex, leading to fear and mistrust and possibly a general hostility towards authority based on previous poor contacts with agencies. This couple are extremely complex and require a therapeutic service that needs to be bespoke to ensure it will meet their needs. 5.8.4 There is ample research into a repetitive cycle of birth and repeated removal of babies due to the potential for neglect and abuse. Parents who have a history of adverse childhood experiences (ACEs) require support and joint intervention from Adult and Children’s Services including all partners. 5.9 THE RISK OF PRIVATE SCANS 5.9.1 More than 200 outlets across the UK now sell ultrasound scans, with hundreds of thousands being carried out each year. The Royal College of Radiography have long debated the risks with supporting evidence of women not being told about serious conditions and abnormalities. 14 5.9.2 If it was the case that the parents accessed private scans, this interaction could have identified where they were and should have raised safeguarding concerns if they were linked in to wider partnerships. This service has no links to the NHS and remains unregulated. Businesses that provide this service normally have a disclaimer indicating that it is not a medical scan but one that offers ‘reassurance’, although it can miss or fail to refer serious problems to the parents and the NHS. This is an area that has been identified in other reviews and the associated risks should be nationally debated. The fact that these parents state they had a scan indicates a level of critical thinking and a level of capacity as they wanted to monitor the baby’s health away from the NHS, and this should have informed the assessments. 5.9.3 The Care Quality Commission says there is good quality care in the industry but it has a "growing concern". 5.9.4 Private baby scanning studios offer a variety of services, however they are unregulated and do not comply with any professional duty of care or responsibility or the identification of safeguarding concerns. Whilst this is something that requires national debate, it is also an opportunity to explore what is on offer in your local area and gain engagement into your local partnership. 5.9.5 This family told informed professionals that they had paid for a scan and there were considered to be no issues with the baby’s development. The business providing the service would have no understanding of the social concerns or risks to the unborn baby. 6. LEARNING IN ACTION - AREAS CONSIDERED: 6.1 Within the reflective practitioner’s event, learning in action was witnessed, leading to positive challenge between the different police forces. The debate that followed led to the police reviewing the actions taken and an immediate change to practice. There are no legal orders available until the baby is born although Child Protection Plans do provide powers to work within the law to enable services to work together to keep an unborn child safe from harm. Whilst Child E was unborn, the only way to locate the family was through the parents. This is an opportunity to think about how to work with vulnerable parents who go missing and agree a threshold to activate missing persons’ enquiries. 6.2 There could have been joint supervision for Borough A or a ‘stop and think’ 6 or local area’s equivalent meeting to reflect on risks and concerns and revisit any outstanding actions. 6.3 Where joint supervision across organisations is commonplace for staff, they report they have the opportunity to jointly assess activity and progress, or lack thereof, particularly in challenging cases in a safe environment. This way all partners report they have a stronger working relationship, breaking down the risk of silo working. The blend of services’ reflections bring a different view leading to a shared perspective. 6.4 Finding the family earlier could have been beneficial in order to identify if Child E had been born. It would not be about criminalising the parents but rather putting safety planning in place. 6 Stop and think meetings (or borough equivalent) are an effective means of bringing together all professionals involved in a case to reflect on progress so far and the impact of intervention, whilst, considering all risk and threats. Without good evidence, do not be over-optimistic about progress. Share information with other professionals regularly and check on their view of progress made to challenge your assumptions, hypothesise about possible underlying issues that parents may not want to face, consider evidence carefully and reflect on the quality of parental engagement and motivation to change when progress is not being achieved. This would ensure all professionals are fully aware of case developments. This form of joint case supervision and case review would be seen as best practice, and should be ongoing in a complex and perplexing case and written into local policy. 15 6.5 At the point of the Mother being missing and overdue a strategy meeting in Borough A (with Children’s Safeguarding and Social Work, Police and Health) was held to ensure all partners were aware of the risks involved, principally an unassisted delivery in breech position. A missing alert/report was opened at this stage. Professionals need to balance the parents’ rights in relation to privacy (HRA 1998) and police powers to trace them if reported missing in specific circumstances. 6.6 At the commencement of the strategy meetings, depending on the risk assessment, consideration should be given for police to initiate a missing person’s enquiry at the most appropriate time so the use of their powers and resources can be most effective. 6.7 Through the course of the strategy meetings it would be useful if the topic of ‘When to report the person missing’ is continually reviewed so that the most appropriate use of powers and resources can be utilised. 16 7. RECOMMENDATIONS 7.1 JOINT SUPERVISION - Safeguarding practitioners need to able to review the impact of their involvement when there is limited engagement and the risk remains unresolved. Joint supervision can be way of achieving reflection on progress made against the plan of intervention in the best interest of the child and the family. 7.2 TIMING OF MISSING PERSON ENQUIRIES - A joint agreement and understanding of a missing person incident enables a decision on action to be taken including the most appropriate use of police powers. An investigative approach that is cyclical rather than linear will enable the police service to work effectively with other agencies. Multi-agency processes should be based on a problem-solving approach and if necessary, the appropriate use of an Escalation Policy, to enable strategic oversight and appropriate, responsive decisions to be made. 7.3 JOINT ASSESSMENTS AND INTERVENTION - Labels should not be a barrier to intervention. Practice should be led by continuous assessment of need for children and families. The assessment should include therapeutic input, consultative conversations and, where appropriate joint intervention by both Children and Adult Services with the aim of improving life chances. 7.4 SUPPORT FOR PARENTS WITH REPEATED REMOVALS- Parents who have a history of repeated removals and adverse childhood experiences (ACE) require support and joint intervention from Adult and Children’s Services. This requires all partners to develop a deeper understanding to prevent this persistent cycle of birth and removal causing emotional and physical harm to the parents. Professionals need to consider a jointly commissioned bespoke care package which provides specialist, social and therapeutic intervention as appropriate 7. 7.5 PRIVATE BABY SCANS - Private baby scans are unregulated and do not comply with professional duty of care or responsibility or the identification of safeguarding concerns. Local partnerships should explore how they can engage with them to raise safeguarding standards. 7 https://www.pause.org.uk/independent-department-for-education-evaluation/ Learning Point: Positive Choices service run by Suffolk council work with parents have had one child removed within the last two years and have expressed a wish for support, and for their lives to be different service for parents in their own right is a example of good practice: https://www.suffolk.gov.uk/children-families-and-learning/keeping-children-safe/positive-choices-service/ 17 8. REFERENCES 1. An exploration of the experience of co-dependency through interpretative phenomenological analysis. A thesis submitted for the degree of Doctor of Philosophy By Ingrid G. F. I. Bacon College of Health and Life Sciences Brunel University August 2014 2. Babies Removed at Birth: What Professionals Can Learn From ‘Women Like Me’ Wendy Marsh Jen Leamon First published: 27 February 2019 3. NSPCC 2018 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/children-in-care/statistics/ cited June 2018 4. Conti, G, Morris, S., Melnychuk, M., & Pizzo, E. (2017) the economic cost of child maltreatment in the UK: a preliminary study. London: NSPCC 5. Department of Children and Families, July 2016. Keep on caring. Supporting Young People from Care to Independence. www.gov.uk/government/publications 6. refer to FACTS – Looked-after Children’s outcomes- www.firststaruk.org 7. NSPCC 2018 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/children-in-care/statistics/ cited June 2018 8. Kelly, E., Lees T., Sibieta, L. & Waters, T. 2018 Public Spending on Children in England: 2000 to 2020. Institute for Fiscal Studies. Children’s Commissioner June 2018 9. Harrison, N. (2017) MOVING ON UP: Pathways of care leavers and care-experienced students into and through higher education. University of West of England, Bristol |
NC52264 | Sexual abuse, sexual exploitation and rape of an adolescent girl over many years. Lauren was placed in foster care under an emergency protection order when she was 17-years-old. Learning includes: the importance of an effective professional response to the sexual abuse and exploitation of children; the importance of recognising the specific needs of disabled children and young people and responding appropriately; recognising, assessing and responding to adolescent neglect; understanding relational and developmental trauma; dealing with professional disputes and differences of opinion in ways that put the child and young person at the centre. Recommendations include: sexual exploitation itself should be addressed directly instead of just focussing on addressing family difficulties or programmes designed to educate young people; ensure that there is a process in place whereby all children who are subject to a child in need or child protection plan because of sexual exploitation have a disruption plan in place which would be incorporated into these wider plans; professionals need to support young people and address their fears and reluctance, alongside recognising their capacity; consider how best to address victim blaming language; focus on restorative practice principles that foster and enhance partnership working and a culture where respectful professional challenge is productive and welcomed as the voice of a 'critical friend'.
| Title: Lauren: serious case review. LSCB: Gloucestershire Safeguarding Children Executive Author: Jane Wiffin Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 56 Lauren Serious Case Review Jane Wiffin July 2020 Page 2 of 56 1. Introduction Reason for the Review 1.1 This Serious Case Review1 is about Lauren2 who is now aged 18. When she was 17, she came into foster care through an Emergency Protection Order (EPO3). The trigger event for the EPO was Lauren (aged 17) being sexually exploited and harassed on-line by an adult male who had asked her to meet him where he would give her money and alcohol to engage in sexual activity. There had been a long history of Lauren being sexually abused, raped and exploited by predatory men. Lauren had expressed a wish to die on social media and there were concerns about her father being able to protect her. An Emergency Protection Order was sought and granted; Lauren was placed in foster care. 1.2 A children’s guardian4 was allocated for the follow up hearing to extend the EPO; she reviewed the chronology provided by Gloucestershire Children’s Social Care (GCSC) about their involvement with Lauren and her family dating back to February 2016, when Lauren was 14. This contained information about 149 significant events, including allegations of sexual assault, sexual exploitation and rape. Lauren had been provided with services under a child in need plan for a year and was subject to child protection plans under the category of neglect for 2 years. During this time, she was assessed as having significant learning disabilities, poor health, emotional distress and a Mental Capacity Assessment in early 2018 had found that she did not have the capacity to consent to sexual activity. From January 2018 onwards there were a number of Legal Planning meetings to consider whether the threshold for issuing legal proceedings had been met; these were beset by delay, drift and incident led practice. At the beginning of 2019 there were escalating concerns about the extent of the sexual abuse and sexual exploitation that Lauren experienced and growing evidence that her father and sister had facilitated her meeting inappropriate adults. Lauren was nearly 18 when the EPO was taken, and so proceedings continued under 1 A serious case review (SCR0 was the process undertaken after a child died or was seriously injured and abuse or neglect was thought to be involved. Its purpose was to look at lessons learnt to help prevent similar incidents from happening in the future. The arrangement for undertaking reviews of critical incidents relating to children and young people has changed and serious case reviews are no longer undertaken. They have been replaced by child safeguarding practice reviews; CSPR. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf 2 An anonymised name 3 An Emergency Protection Order (EPO) enables a child to be removed from where s/he is, or to be kept where s/he is, if this is necessary to provide immediate short-term protection. Under Section 44 of the Children Act 1989, the local authority (or any person) can apply to the family court for an Emergency Protection Order where: The court is satisfied that there is reasonable cause to believe that the child is likely to suffer Significant Harm if s/he is Not removed to accommodation provided by the applicant; 4 A Children’s Guardians is qualified and experienced social work who is appointed by the court to represent the rights and interests of children in care proceedings. Their role is to consider what is best for the child at all times during a case Page 3 of 56 the auspices of the court of protection. She remains protected and living away from home. 1.3 The Independent Chair of Gloucestershire Local Safeguarding Children Board agreed that Lauren had experienced significant harm, despite extensive safeguarding activity, and therefore the criteria for an SCR had been met. Process of the Review 1.4 The approach to this review is consistent with the principles and approach set out in Working Together 2015i. An independent overview author (Jane Wiffin) was commissioned to lead the review and write this overview report. A multi-agency panel was convened to oversee the SCR, contribute to the analysis and provide critical feedback on the report. Each agency involved with Lauren and her family were asked to complete individual chronologies, an appraisal of their agency’s response and to make single agency recommendations to address any practice concerns or to promote effective practice. These documents were discussed at meetings of the multi-agency panel and further amendments made as a result. The author used these documents and some original records as the basis of her understanding of the professional response to Lauren. Each agency interviewed its own staff and an event was held to bring all those who had worked with Lauren and her family together to contribute to the analysis and lessons to be learned. Their contribution was invaluable and the author and panel would like to thank them for what was a difficult task. The author is responsible for the completion of this report. Lauren and her family 1.5 Lauren and her family are white/British. She has one sister who is 3 years older than her; Jem5. Both girls were brought up by their mother and father in complex circumstances (see section 2). When Lauren was 11 and Jem 14, their mother took them to live in another local authority area. They remained there for 9 months, but moved back to Gloucestershire to live with their father where they remained with him until Lauren was removed from his care in 2019; he had a partner, who did not play a parental role in Lauren’s life. Lauren and Jem continued to visit their mother and they were in regular contact. Lauren has a paternal grandmother who lived close to her and who she saw regularly. There is no information about any other extended family. A family group conference was held in 2016, but no extended family attended. This is the only evidence that the role of the extended family was explored. 5 An anonymised name Page 4 of 56 Lauren’s Involvement 1.6 Lauren has been settling into foster care whilst this review was ongoing. This was an unsettling time for her and although she is doing very well, it was felt that to meet another new adult, the author, would be unsettling and impact on her placement stability. Her social worker has spoken to her about her feelings about the last few years and has shared these with the author. This information is woven into the fabric of the report. Family Involvement 1.7 Given that Lauren could not be spoken to directly, and this report is about her, it did not seem right, given the complex circumstances, to speak to either parent or the sister. There also remain issues about Lauren’s future to be resolved which take priority. Page 5 of 56 2. Background History Lauren’s Early Life: a brief summary 2.1 Lauren has had contact with many different specialist services throughout her childhood due to issues of neglect caused by her parents own difficulties. The poor physical and emotional care provided to Lauren resulted in global developmental delay and specific concerns about her impaired gross motor skills. Lauren was slow to walk, with professionals attributing this to being strapped into a pushchair for long periods of time. This also led to lifelong mobility issues which required regular hospital attendance. These early developmental impairments would remain as areas of health and education concerns which impacted on her throughout her childhood. 2.2 When Lauren was aged 3 and Jem aged 5 the nursery/school they attended had worries about Jem’s knowledge of sexual matters which they assessed as inappropriate for her age. They made a referral to GCSC and assessments and support were provided. 2.3 Over the next four years there were a number of referrals from different agencies to GCSC, an early help assessment (called a Common Assessment Framework6) was completed and support provided; this early help plan progressed into a Child in Need (CiN) plan7 because of increasing concerns about safety and well-being. The lack of progress of the CiN plan led to Lauren (aged 7) and Jem (aged 10) becoming subject to Child Protection (CP) plans8 for neglect for a period of 6 months; a pattern that would be replicated later in their lives. Although there remained concerns about parental conflict and ongoing neglect, the CP plan was discontinued and support again provided through a CiN plan for a further period of 9 months. This ceased and Lauren and Jem attended school, but were not in contact with any specialist support services. 2.4 When Lauren was 10 and Jem 13 their mother withdrew them from school to home educate them. The school were concerned and an assessment completed; this concluded that mother should ensure that Lauren and Jem returned to school immediately. Mother then moved to another local authority area taking the girls with her and contact with Gloucestershire services ceased. The girls remained out of school for the next 9 months. 6 The Common Assessment Framework (CAF) was the process to identify children who have additional needs, assess needs and strengths and to provide them with a co-ordinated, multi-agency support plan to meet those needs. Every Child Matters and The Children Act 2004 7 Children in need are defined in law as children who are aged under 18 and: need local authority services to achieve or maintain a reasonable standard of health or development. need local authority services to prevent significant or further harm to health or development. are disabled. A CIN Plan is drawn up following a Single Assessment which identifies the child as having complex needs and where a coordinated response is needed in order that the child's needs can be met. 8 A child protection plan is drawn up at the initial child protection conference. It says what support and monitoring will be put in place when a child is considered to be at risk of significant harm because they have suffered, or are likely to suffer physical abuse, emotional abuse or sexual abuse or neglected. Page 6 of 56 2.5 Mother then told the girls’ father she could not cope because of Lauren and Jem’s behavioural problems and they returned to live in Gloucestershire with him in 2013. There was initial contact with GCSC and the Police with the focus being on how to manage appropriate contact with mother. Lauren and Jem started to attend school in the final term of the year; Lauren in year 7 and Jem year 10. They would both remain at this school for the rest of their school career; leaving at age 16. They seemed to settle in, though Lauren was subject to bullying; this appears to have been caused by pupil attitudes to her difficulties with walking caused by earlier neglect. She was noted to have a learning disability and was provided with special educational needs support. At this stage there was no clear outline of her specific learning needs or the extent of her cognitive difficulties. 2.6 At the beginning of year 8, when Lauren was aged 11 and Jem aged 14, the school were concerned about their low attendance and poor emotional wellbeing said to be caused by contact with their mother. Support was provided by the Families First Team9 for the next 6 months. The school remained concerned about Lauren, reporting that she was displaying heightened anxiety and stress due to complex and fractious family relationships. The school made their first referral to GCSC. A single assessment10 was completed which focussed on mother and both girls contact with her. Concerns about Lauren self-harming were highlighted, but no proposal for how this might be addressed. GCSC decided there was no role for them and work continued with Families First Team to provide support to father about how to ensure Lauren and Jem had safe and appropriate contact with mother. Jem was referred to Children and Adolescent Mental Health Services (CAMHS11 - previously known as CYPS in Gloucestershire) at this point by her GP because of concerns about her low mood and self-harm. This referral was not accepted. 9 Families First is a family support service provided by the local authority which aims to help families within a 6-12-week review cycle in order to make and sustain improvements. They use a ‘whole family approach’ which involves identifying the things that are impacting on the family environment and using the family’s strengths to build stronger family units. 10 A Child and Family (C&F) Assessment addresses the most important aspects of the needs of a child / young person, and the capacity of his or her parents or care givers to respond appropriately to these needs within the wider family and community context. The conclusion of the assessment should provide analysis of the findings leading to a clear understanding of need that will facilitate care planning and inform service provision. C&F Assessments should contain input from other professionals. 11 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are the NHS services that assesses and treat young people with emotional, behavioural or mental health difficulties. Page 7 of 56 3. Chronology of professional involvement: November 2015 to March 2019 This review is about the significant sexual exploitation, sexual assault and sexual abuse of Lauren by predatory men who were aged from teenagers to much older men. The chronology will not provide much detail about this ongoing sexual abuse because this is private to Lauren. It is important to say that the level of the sexual abuse and exploitation was serious, causing significant harm, was exacerbated by her known medical needs, and was frequent. The language used in the records by many professionals during this time was that Lauren was making active choices, putting herself at risk, actively sexualised and at times seeking out the abusers. This language does not accurately reflect the level of exploitation and grooming that she experienced by predatory males, the lack of protection or guidance from her father who appears to have encouraged Lauren, or the realities of her cognitive capacity to make informed choice. Therefore, the language has been changed by the author in the summary chronology that follows to make it clear that it is the responsibility of the predatory men who cajoled, groomed and exploited Lauren and this will be discussed in the findings that follow the chronology. There were many professionals and services involved with Lauren over the 3 years and 3 months under review. This means it is impossible to outline all contacts and actions by those professionals; the chronology focusses on significant events and episodes. What is clear is that many professionals worked very hard on Lauren’s behalf and were very worried about her safety and well-being. Early Concerns: November 2015 Lauren is aged 14 3.1 The initial scoping for this SCR set the period from March 2016; there were earlier concerns about sexual exploitation and it seemed important to start at this point. 3.2 In November 2015 pupils reported concerns to school staff about posts on Facebook indicating sexual exploitation and likely sexual activity relating to Lauren aged then 14. This was reported to GCSC. There was no response and school escalated their concerns to the Gloucestershire Safeguarding Children Board office (GSCB). A strategy meeting12 was held on 2nd December and possibly there was a follow up meeting on the 8th December. Given these allegations related to a child of 14 years old it would have been expected that a single assessment or Child Protection 12 This is a meeting or discussion which takes place between Children’s Services, the Police and possibly other child care agencies at the beginning of child protection enquiries. The purpose of the discussion is to decide whether and how the child protection enquiries should be carried out; and whether any immediate steps need to be taken to keep the child safe while the child protection investigation is underway, for example, if someone should be asked not to have contact with the child for the time being. Page 8 of 56 inquiry13 would have been initiated. This should have included talking to Lauren about if anything harmful had happened to her. The decision was that the work with Families First Family Support Worker (FSW) would continue. 3.3 In February 2016 the school were concerned about reports that Lauren was being uncharacteristically aggressive and when this was discussed with her, Lauren reported to her teaching assistant that her father was rarely at home and left Jem to look after her with her new boyfriend about whom there were concerns that he posed a sexual threat to children. Lauren was 14 and Jem 16. Lauren said she had witnessed sexual activity and sexual discussion between her father and his girlfriend and Jem and her boyfriend. Lauren also reported that her father had threatened to physically beat her because of what she had seen. This information was shared with the Families First FSW and it was agreed this would be shared with GCSC. 3.4 Over the next few weeks further information of concern emerged. Lauren was sent sexually explicit photos. She had attended a party at her mother’s where there was excessive alcohol use; Jem reported that Lauren was seen in the company of a man in his mid-twenties and she was concerned. There was confusion about what action was being taken. The Police were involved and school contacted GCSC. It was agreed that a strategy meeting would be convened and this took place 6 weeks after the original concerns and at this meeting it was agreed that child protection inquiries would be undertaken. 3.5 Two days after the strategy meeting Lauren told school that she had been raped whilst visiting her mother for a Halloween party in 2015; this was in the context of a party where everyone including Lauren was consuming large amounts of alcohol. A Police inquiry was started and this did not conclude until October 2018. Child Protection inquiries were already underway and no further strategy meeting was convened regarding the allegation of rape. Lauren was seen by her GP who made a referral to the Sexual Assault and Referral Centre (SARC14) for sexual health support; Lauren was provided with an Independent Sexual Violence Advisor (ISVA15) outreach worker to support her through the Police investigation and potential trial and to be a single point of contact for Lauren. 13 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. 14 Sexual assault referral centres (SARC) provide medical, practical and emotional support. They have specially trained doctors, nurses and support workers. 15 Independent Sexual Violence Advisors (ISVAs) are trained to provide emotional and practical support to survivors of rape, sexual abuse and sexual assault. Their main role is to support around the criminal justice process, but they are independent from the Police and are not legal advisors. Page 9 of 56 Child in need process: April 2016 to April 2017. 3.6 There were ongoing concerns about sexual exploitation and Lauren talked to the school nurse about her worries. The GCSC single assessment was completed at the end of April and this highlighted: that Lauren was at significant risk of sexual exploitation and online grooming; the language from this point onwards was always about the likely risk, yet if people took seriously her allegations of rape she had already been significantly harmed and was at risk of more sexual harm. This does not come across clearly throughout the whole period of the review; there were concerns about the suitability of Jem’s boyfriend because he was convicted of sexual offences against children, and Jem’s risk of sexual exploitation; concern about Lauren’s self-harm and her struggle to regulate her emotions; concerns about father’s emotional unavailability, commitment to parenting and his ability to protect Lauren and Jem. The issues about poor sexual boundaries in the home do not appear to have been discussed within the assessment, nor the implications for keeping Lauren or Jem safe from sexual harm. There is no sense that Lauren’s learning disability was considered or the implications of this for the type of support she would need. The alleged rape was referred to as “non-consensual sex” and there was no plan of support included. The emphasis was on Lauren learning to keep herself safe and avoiding taking risks; essentially putting her safety on her own shoulders. 3.7 The conclusion of the single assessment was that Lauren and Jem would be supported through a CiN plan and that an Initial Child Protection Conference (ICPC16) might be convened in the future. This decision was inconsistent with the evidence of significant harm. The assessment does not draw on the knowledge or concerns of other professionals involved with Lauren at this point: School were worried about Lauren’s safety and well-being as well as her engagement with learning; they extended the Special Educational Needs (SEN) support that she was provided with and asked that an Education, Health and Care Plan (EHCP17) be started. As part of this a cognitive assessment from a clinical psychologist had been commissioned; 16 This is a meeting which takes place between social workers, other professionals and family members when a child is considered to be at risk of significant harm because they have suffered physical abuse, emotional abuse, sexual abuse or neglected. The conference meets to discuss the risk to the child and decide whether the child needs a child protection plan to protect him or her from harm in the future. 17 This is a statutory document. An EHC plan details the education, health and care support that is to be provided to a child or young person who has a Special Educational Need or a Disability (SEND). It is drawn up by the local authority after an EHC needs assessment of the child or young person, in consultation with relevant partner agencies, parents and the child or young person themselves Page 10 of 56 The GP was concerned about Lauren’s emotional well-being and made referral to CAMHS. Lauren was offered an appointment and assessed as having no mental health concerns so no services required; a referral to Youth Support Team (YST) was proposed The School Nurse had completed a family needs assessment and was concerned about Lauren’s mobility issues and made a referral to the physiotherapy team; Lauren had a malformation of her hip. The School Nurse continued to offer support through the School Nurse drop in which Lauren attended regularly; the School Nurse was concerned about issues of neglect and particularly ongoing head lice infestation which were untreated and Lauren’s rotten teeth; Community Paediatrician 2 continued to see Lauren and had organised further tests regarding her physical wellbeing and physical circumstances; The SARC were supporting Lauren and her sexual health and well-being; The Police were investigating the recent allegation of rape and Lauren was provided with support regarding the criminal proceedings by an ISVA outreach worker; Families First/FSW1 were still offering support but they were concerned about father’s poor engagement. 3.8 A draft CiN18 plan was included in the completed single assessment which focussed on the risk of sexual exploitation for both girls, the need to consider whether father could protect Lauren and Jem, action to address hygiene and health needs including the lack of dental care and action to address Lauren’s’ deteriorating behaviour. This draft plan was not formulated into an actual CiN plan by the new social worker (SW2) and in reality, there was no plan or coordinated support for the next 12 months. The first CiN meeting took place at the end of April 2016. There was no CIN plan or goals and minutes were not taken. There was a delay in Social Worker (SW)2 visiting Lauren and the family and no action seems to have been taken until the end of the summer holidays. Lauren and her father talked about feeling unsupported by their SW. 3.9 At the end of June 2016 the cognitive assessment of Lauren was completed after Lauren had not been brought to a number of appointments. The clinical psychologist (who had assessed Lauren as a younger child) found she had very low-level basic literacy and numeracy skills, considerable difficulties with reasoning, problem solving, working memory and the ability to hold onto information. This assessment 18 When a single assessment finds that a child is not at risk but is in need of social work services, a child in need plan involving other agencies involved with the family should be developed and agreed with the child's parents at a child in need planning meeting. The plan should set out what is working well within the family as well as any concerns, and be clear about which agencies will provide which services to the child and family. The plan should describe clear outcomes for the child and what is expected of the parents and how the plan will be reviewed. Page 11 of 56 informed a plan of action at school; it was shared with other professionals and should have informed the child in need process and all other agencies working with Lauren. This did not happen, and the individual support provided over the subsequent years did not always take account of Lauren’s cognitive capacity; the work of the FSW and the youth worker being an exception. 3.10 In July 2016 school were aware of the summer holidays starting and expressed concern to GCSC that there had been little action to address the risks to Lauren, that she continued to be subject to sexual exploitation, was struggling to contain her emotions characterised by difficult and aggressive behaviour and was barely in school. SW2 replied and said that she had not been able to meet with the family as there had been no one at home on a number of occasions, that Families First were still involved, another family support worker had been allocated and it had been agreed by the GCSC managers that there was no need for ongoing social work support. SW 2 said that there was to be a CiN meeting19 planned for two days later, but this did not take place, and was rescheduled to September. 3.11 School discussed this with the ISVA who made a safeguarding referral to GCSC; this was not responded to. The school nurse also sought information about the date of the next child in need meeting and what action was being taken to keep Lauren safe over the holidays; it was agreed that a joint visit between the social worker and school nurse would take place over the summer. School continued to share their concerns, requested a strategy meeting and this was agreed by GCSC; it did not take place. SW 2 and the School Nurse visited Lauren over the summer, but there is no case record of this within GCSC. SW2 made a referral to Youth Support Team and the young carers’ project. 3.12 The CiN meeting planned for mid-September took place. There was still no CiN plan and the minutes consisted of four bullet points in GCSC case records. Soon after this meeting, father told school that he could no longer cope with Lauren’s difficult behaviour and aggression and she had gone to live with her mother. All agencies were informed. Lauren returned to father’s home at the end of September. Lauren’s GP made a further referral to CAMHS and consultation was provided by CAMHS to the school and SW2 regarding Lauren’s behaviour. Father had shifted the focus from his parenting to Lauren having problems with her behaviour. This was not challenged. The Youth Support Worker (YSW) (1) started seeing Lauren individually; Lauren said she would like to focus on self-harm, healthy relationships and support regarding the sexual abuse she had experienced. The GCSC single assessment was updated at the end of September. Much of the information was taken from the previous assessment and there was no analysis of the current circumstances for 19 This is a regular meeting attended by all involved professionals, the family and child to discuss the progress of the child in need plan. Page 12 of 56 Lauren and no CiN plan formulated. This assessment was approved by the team manager for SW2. 3.13 During October 2016 there were increasing concerns about Lauren being targeted by predatory males for sexual exploitation on line, Lauren was sexually assaulted and a Police investigation started. Lauren also then reported that she and a friend were provided with tobacco and drugs including cocaine in exchange for sexual activity. These incidents were reported to the Police, but Lauren said she did not want to be interviewed or make a complaint. This should have been addressed sensitively by SW2. 3.14 At this time Lauren, who was now aged 15, told professionals that she had a boyfriend with whom she was involved in a sexual relationship; SW2 took her for contraceptive advice. There was an unquestioning acceptance of the concept of boyfriends over time (because Lauren described them as such) rather than a predatory male, without scrutiny or analysis, except by community paediatrician 2. A professionals’ meeting was held, described by some agencies as a strategy meeting, to discuss ongoing concerns about sexual exploitation. There are no recorded decisions about next steps emerging from this meeting. There was also a child in need meeting; there was still no formal plan and the minutes consisted of brief notes. 3.15 In October 2016 SW2 made a referral to the diversion from care team20 because it was believed that father was not coping with Lauren’s behaviour and angry outbursts. The aim of this work was to support the whole family and to prevent family breakdown. The second allocated Family Support Worker (FSW2) noticed immediately that Lauren had significant learning needs; she didn’t understand time, whether an event was a week ago, or 3 days ago or a month ago. She could not understand money, and she didn’t know how to wash her hair or what to use to wash herself with. There were incidents of poor home safety, with Lauren having set fire to her hair which FSW 2 addressed in the short term. FSW2 focussed on improving these self-care skills; but there was no discussion about this lack of skills being connected to historic and likely ongoing neglect. FSW2 also offered father support through attendance at a parenting class, which he declined. He described himself as a “reluctant parent”, a phrase that was used in many contexts and reports, but without an analysis of the meaning or implications for Lauren and Jem. FSW2 was concerned that father showed little concern about the sexual exploitation of Lauren. 20 This was a specialist family support service intended to prevent family breakdown, caused largely by parenting difficulties in the context of adolescence. Page 13 of 56 3.16 In November the GP completed Lauren’s learning disabilities review21. It is unclear the extent to which this was shared/discussed with other professionals and it did not influence the CiN process. 3.17 SW2 was unable to attend the CiN meeting in mid-November. Professionals expressed significant concerns about Lauren’s lack of protection from sexual abuse and exploitation, her poor school attendance and ongoing evidence of her poor emotional and physical wellbeing. The clinical psychologist agreed to contact GCSC to share these concerns; the school also contacted the GSCB. The Police were also contacted by health services (unspecified which health agency this was) regarding Lauren and sexual exploitation. It was agreed that the senior practitioner and Police officer from the specialist Child Sexual Exploitation (CSE) team would become involved. SW2 deputy team manager (DTM) asked for a strategy meeting to be convened; this did not happen. The Police also chased the need for this meeting without success. 3.18 At the beginning of December 2016, school sought information from GCSC about why the agreed strategy meeting had not taken place without any reply. At this time father reported to the Police that Lauren had gone missing with unknown adult males. She was recorded as a missing person. Over the next week Lauren disclosed rape and sexual exploitation/assault by a number of men. A Police investigation started and a strategy meeting was held. This meeting was attended by FSW/SW2 and the Police. There were no representatives from health or education invited. It was agreed at this meeting that Child Protection inquiries22 would be started and completed within a week and legal advice would be sought by GCSC. The subsequent strategy meeting discussed Lauren’s cognitive difficulties, but no plan of action was agreed and the implications for the Police inquires and interviews were not addressed. Lauren’s poor attendance at school was discussed and a possible referral to hospital education was considered. 3.19 The Police deleted applications on Lauren’s phone. Lauren was reluctant to be interviewed about the rape and assault, but eventually agreed. At this Achieving Best Evidence (ABE23) interview she made a number of further disclosures about sexual 21 Adults and young people (aged over 14) with a learning disability are offered annual health checks by the GP. This is because of concerns that this group of adults/YP often have poor physical and mental health. https://www.nhs.uk/conditions/learning-disabilities/annual-health-checks/ 22 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. 23 The ABE is a structured interview led by the Police, but also involving social workers to gather evidence for use in the investigation and criminal proceedings. In addition, any information gained during interview may also be used to inform enquiries regarding significant harm and any subsequent actions to safeguard and promote the child’s welfare and in some cases, the welfare of other children. Page 14 of 56 abuse and exploitation by a number of men. Further Police investigations were started, but Lauren was not facilitated to attend follow up interviews and father ultimately reported that she did not want to pursue any further Police action; there does not appear to have been any work done to consider the reasons for Lauren’s reluctance and what support could be provided. There also does not seem to have been any work to get father to support her. There were concerns about father’s ability to keep Lauren safe and father was asked to allow Lauren to come into care on a voluntary basis24. He refused. The Police considered proceeding without a victim complaint, but because of evidential gaps this was not possible and no further Police action was taken. 3.20 The Child Protection inquiries agreed at the most recent strategy meeting were completed towards the end of December 2016 and acknowledged that Lauren was at risk of significant harm (but not having experienced significant harm); it was proposed that an initial child protection conference was not necessary and that a risk management plan was in place. There is little evidence regarding this plan. 2017: Lauren aged 15 3.21 At the beginning of January 2017, the school sought an update of progress from GCSC. SW2 replied that the Family Support Worker had seen Lauren and the family over the Christmas holidays and all seemed well. School were unhappy with the lack of progress and contacted GSCB. They were advised to share their concerns with senior managers at GCSC and this led to the Assistant Director for safeguarding providing managerial oversight; she asked that a strategy meeting be convened, a risk assessment completed and the required electronic recording brought up to date. These actions were shared with the school by the Head of Service (HOS) for safeguarding at GCSC who also asked for some information about Lauren’s cognitive abilities. This information was provided, along with Lauren’s EHCP. The HOS sought legal advice and there was a plan to hold a Legal Planning Meeting (LPM25); this did not happen. 3.22 At the beginning of January Lauren attended the sexual health clinic (SARC). She was worried about her health and there were some complex health issues identified which were exacerbated by the sexual abuse she was experiencing. At this appointment Lauren provided a worrying picture of extensive sexual exploitation 24 Section 20 of the Children Act 1989 sets out how a Local Authority can provide care/accommodation for a child within their area if that child is in need of it. Anyone with parental responsibility can voluntarily allow the Local Authority to place their child with an alternative carer under section 20 of the Children Act 1989. 25 When social workers decide that the parent’s care of their child is not improving enough to protect the child from significant harm, they will call a legal planning meeting. This meeting is for social workers and the local authority’s lawyers to decide whether it is in the child’s best interests for the parent(s) to be given a further period of support to improve their parenting, or to find someone else in the child’s wider family to care for the child, or for the child to be removed from their parent’s care straight away. Page 15 of 56 and sexual abuse by adult men causing her significant physical and emotional harm. This was shared with SW2 and other professionals. Lauren also shared similar information with the FSW2, youth worker and SW2. 3.23 On 18th January the Police officer from the CSE team sent an email to the Youth Support Team (YST) to say that although there were many professionals involved with Lauren, little progress had been made. The Police officer asked that the CSE outreach worker from the youth support team start work with Lauren and the Youth Support Worker who had seen Lauren for 6 individual sessions over the previous 10 weeks was replaced. The rationale for this change is not clear and occurred at a time when it was also planned that SW2 would be replaced by SW3. There were at least 5 professionals providing Lauren with direct individual support, and many others seeing her regularly in the context of her educational and health needs. There was no discussion about the impact of so many different professionals working with Lauren, the requirement for her to build new and changing relationships and the impact of this given her cognitive and emotional difficulties. It also remains unclear the purpose of the different interventions, many of which seem to duplicate the work of others. 3.24 A strategy meeting was held on the 19th January. SW2 did not attend and SW2’s manager chaired via conference call. Lauren’s learning needs were discussed in detail, but it remains unclear how this influenced the plan of action. It was agreed father would be asked to allow Lauren to come into care on a voluntary basis; which he refused. It was agreed that the child protection inquiries should continue, though they had been completed in December. It is unclear why this confusion existed. 3.25 After the strategy meeting school contacted the GCSC Assistant Director for Safeguarding to express concerns that the risks to Lauren had not been fully considered. The assistant team manager for SW2 replied, suggesting the focus required was on getting Lauren back to school. There was further discussion over the next few days about a referral to hospital education and this was made by Community Paediatrician 2 at the beginning of February 2017. 3.26 Lauren continued to attend a number of health appointments supported by her CSE youth worker; father did not attend. There remained concerns about her sexual and physical health, some unexplained physical anomalies and her walking/gait. These were all being appropriately investigated and addressed by health professionals. 3.27 On the 27th January a new social worker (SW3) from the specialist CSE team was allocated. She was tasked with completing a new assessment and convening a child in need meeting. GCSC had decided to wait for the completion of the single assessment before considering the need for an initial child protection case conference; causing further delay. Page 16 of 56 3.28 On the 21st February there was a CiN meeting. There was good multi-agency attendance and mother, father and Lauren also attended. It was reported that Lauren and her father did not want her to come into voluntary care, but father assured professionals that Lauren would be supervised as often as possible. There were concerns that some of the men harassing Lauren sexually lived in the flats around them. It was agreed that work would be undertaken with Lauren to say “No”. Further evidence of the emphasis being on Lauren to be responsible for the harm she was experiencing. It was suggested that teaching her to say “no” was the only way of keeping her safe in the long term. There was no discussion of what action needed to be taken regarding Lauren’s fear of the men in the flats where she lived. 3.29 A few days after the CiN meeting, there was a discussion by GCSC with their legal team. It appears a full history was not provided and the conclusion was that Lauren was at risk of harm from adults outside the home and therefore Police action was necessary but no care proceedings26 would be possible. It was agreed that an Initial Child Protection Conference should be convened, but this did not happen. 3.30 Over the subsequent weeks professionals had concerns that Lauren looked unkempt, and had untreated head lice. She was observed to be hungry when she went out with the CSE outreach worker and she attended A&E after a fall and reported not to have eaten or drunk anything for 48 hours. She made further disclosures of sexual assault, rape and sexual harassment by many adult males. Lauren attended an ABE interview and disclosed a number of sexual assaults; these were investigated by the Police but could not be pursued due to evidential issues. 3.31 The GP made another referral to CAMHS because of Lauren’s ongoing health problems which were thought to be likely caused by emotional difficulties. This was referral was not accepted. The GP also made contact with Community Paediatrician 2 and SW3 to express concerns. 3.32 The GCSC single assessment was completed mid-March 2017. This focussed on Lauren’s health needs, issues of her understanding of consent and her cognitive capacity, without any conclusion being formed. Father’s parenting was seen in a positive light. The assessment recommended that an initial child protection case conference be convened. 3.33 The ICPC was held at the beginning of April 2017. Lauren was made subject to a Child Protection plan for sexual abuse. She was supported to attend the conference by an independent advocate. Father met with the chair of the conference, but left before the conference started. There is no information available about his views. The concerns discussed were that Lauren was unsafe in her community because she was 26 Care proceedings is the name for the court process when Children’s Services go to court because they are concerned that a child is not safe. In care proceedings, Children’s Services can ask the court to make an order to protect the child, Page 17 of 56 well known to perpetrators. There was no action agreed to address this. There were also concerns about her not being in school, and that father was not able to keep Lauren safe and protected from sexual predators. The plan focussed on asking father to attend all meetings, to understand the need to supervise Lauren and a family group conference to be convened; the purpose of this remains unclear. 3.34 At the end of April 2017 Lauren’s EHCP was reviewed. This outlined the current level of support she was provided with in school, her poor attendance, her complex health needs and emotional fragility alongside her sexual abuse and exploitation. The plan was for her to attend college in September 2017. 3.35 In mid-May Lauren reported to FSW2 a sexual assault by an adult male she knew who she had been encouraged to meet to smoke marijuana. She was physically and sexually harmed. This was not reported to the Police and no action was taken. There should have been a strategy meeting, discussion about any criminal action and also to consider any health needs. 3.36 At the beginning of June 2017, Lauren was assessed by a Speech and Language (SALT) therapist which was initiated by the CSE youth worker. This assessment reiterated that Lauren had significant difficulties in understanding anything other than very simple language; she could not understand the word “safe”, could only explain very simple events and had poor memory recall. This SALT assessment was shared with the FSW2 and SW2. The CSE outreach worker began adapting her materials for working with Lauren with advice from the SALT team, but would cease working with Lauren at this time due to unforeseen circumstances. 3.37 There were continued incidents of sexual assault and abuse of Lauren and she was supported to attend the SARC for health screening. There was a core group at the beginning of June 2017 where it was noted by SW3 that some progress had been made. The incident of sexual assault in May was discussed and there is no evidence that the lack of any action regarding this by GCSC was challenged. 3.38 In mid-June 2017 Lauren made a disclosure of rape to SW3. This was reported to the Police. An ABE interview was organised, but Lauren said she did not want to attend or go for a medical examination. Her father also said she did not want to engage and due to lack of evidence there was no action possible. Once again it is unclear how much work was completed to understand Lauren’s reluctance and to get father to encourage the need for investigative action. 3.39 The first Review Child Protection Conference (RCPC) took place at the end of June. Lauren attended with an advocate; father did not attend. Father’s lack of engagement was discussed. The need for a transition plan27 for Lauren given that she 27 If a child, young person or their carer is likely to have support needs when they turn 18, the local authority must assess them. There should be no gap in services. In England, when the transition between children’s and adults’ Page 18 of 56 was moving into adulthood was discussed but no plan agreed. Professionals agreed that Lauren remained at significant risk of harm and the CP plan remained in place. It was noted that father had not engaged fully with the plan and the chair of the conference concluded that “if the high level of support continues to fail to protect Lauren from sexual harm by predators, and father is unwilling to agree to actions and/or is unable to keep Lauren safe the GCSC are to seek legal advice about possible care proceedings. Given the circumstances and father’s lack of engagement this was an appropriate plan. 3.40 Lauren was now aged 16. A new social worker was allocated, SW4. FSW2 remained as part of the team, along with a group of health professionals and the specialist CSE team continued to have oversight of Lauren’s circumstances, but were not directly involved with the CP Plan. 3.41 Over the summer of 2017 Lauren had many appointments for her physical and sexual health. She continued to report being harassed sexually via her phone and there was a further reported incident of sexual assault that was not reported to the Police. 3.42 In September 2017 Lauren started to attend college and sought support from the pastoral support worker to delete social media applications and the telephone numbers of men who she did not know. In the first few months of college Lauren’s attendance was 100% and she engaged well in activities provided. 3.43 In October 2017 Lauren told her GP that she had been raped. This was reported to the Police and she was provided with emotional and medical support. The Police started an investigation but there was conflicting information and Lauren then reported that she had consented to sexual activity with the two named suspects; as she was now 16 this meant no further Police action could be taken. Once again there was no action agreed to explore with Lauren about why she felt unable to follow through with an allegation of rape, professionals, including the Police, seemed too ready to accept that she had willingly engaged with sexual activity. Given her cognitive abilities, the long history of her being sexually exploited and sexually abused and her vulnerabilities this needed further exploration. There was a lack of reflection here of how hard it is for anyone to follow through with an allegation of rape, let alone someone in Lauren’s circumstances. 3.44 At the end of October 2017 Lauren saw a Consultant Paediatrician 2 who told her about the outcome of the tests for her physical health and also discussed some findings which related to her cognitive abilities. The paediatrician made a referral to services takes place, a local authority must continue to provide the individual with any children’s services they were receiving throughout the assessment process. This will continue until adult care and support is in place to take over. Page 19 of 56 the learning disability team at CAMHS, which was reviewed, but was judged not to meet their criteria for a service and the Consultant Paediatrician was advised to make a referral to youth services. 3.45 At the end of November 2017, the second RCPC was held. Lauren remained subject to a child protection plan for sexual abuse given recent sexual assaults and exploitation. Father and Lauren did not attend the conference, and the chair again questioned father’s commitment to the child protection plan; she asked that a Legal Panning Meeting (LPM) be held before the Christmas holiday. The plan going forward was SW4 would provide father with a list of expectations regarding ensuring Lauren was safe and to check her mobile phone. Father was also encouraged to take breaks from caring for Lauren; it is unclear what this meant but there is a sense of professional sympathy for a father parenting alone. There was to be a further referral to Children and Young People with Disabilities team (DCYPS). There was no mention of a referral to adult services and addressing the transition arrangements for Lauren. 3.46 Two weeks later a Strategy meeting was held which confirmed the need for a Legal Planning Meeting. Action was not taken until after the Christmas holidays and was only prompted by audit activity. 2018: Lauren 15 3.47 In early January, Lauren’s circumstances were reviewed because of an audit of cases undertaken in December 2017 as part of the Ofsted28 monitoring visit to GCSC in January. The manager and Head of Service (HOS) responsible for overseeing Lauren’s plan were alerted to delay and drift in this despite evidence of significant sexual and emotional harm. Senior managers and the Chair of the LSCB were alerted to the concerns. The head of service raised concerns about Lauren’s cognitive capacity and ability to give consent to sexual activity. This was the first time this had been considered as an issue and the educational psychology assessment which took place in 2016 was used to guide thinking about Lauren. The HOS also raised questions about Lauren’s complex health needs and the impact of sexual assault and abuse; another important issue, which was known about but not addressed. This head of service sought advice from the GCSC legal team and was told that the criteria for emergency action (an Emergency Protection Order EPO) had not been met and that a formal LPM was required. The manager was advised of the need for an expert cognitive functioning assessment of Lauren; this was commissioned. 3.48 In January the CSE team senior practitioner and a CSE Police officer visited Lauren and her father. They discussed recent concerns about the exchange of sexually explicit images. Lauren confirmed that images had been shared and a person was 28 Ofsted is the Office for Standards in Education, Children’s Services and Skills. They inspect services for children and young people. Page 20 of 56 arrested and questioned. There was insufficient evidence of criminal activity and therefore no criminal action could be taken. At this meeting Lauren reported being coerced and cajoled to meet many adult males, and that her father was not trying to stop this. The senior practitioner from the CSE expressed significant concern about the risks to Lauren and the lack of ability of father to keep Lauren safe from harm. This was discussed with SW4. 3.49 The next day SW4 and Team Manager 1 visited; they asked father again if he would give consent for Lauren to come into foster care voluntarily and father and Lauren said they did not want this to happen. Father was informed of the forthcoming legal meeting and was advised to consult a solicitor. 3.50 The Director for Safeguarding reported progress back to senior managers and the independent chair of the GSCB. She said that legal advice had been sought and although there were insufficient grounds for an EPO, the GCSC would compile evidence to seek a care order in the next week. This did not happen; it seems because in the short-term father’s engagement (undefined) with professionals had improved. Team Manager 1 was spoken to about the lack of effective planning and consideration of Lauren’s needs in the context of a child centred approach. He agreed that there had been some drift and would take action to address this. He would remain the team manager responsible overseeing Lauren’s circumstances for the next 15 months. 3.51 In the second week of January a new social worker was allocated to work with Lauren and her father (social worker 5). On the 17th January Team Manager 1 sought further legal advice and was informed again that the grounds for an EPO had not been met and he was advised to hold a formal LPM and to make an onward referral to adult services; this was important in the context of thinking about transition arrangements, but did not happen. It is not clear why as this had been discussed some six months earlier at the Child Protection Case Conference. 3.52 The LPM took place on the 23rd January 2018 and was attended by both children’s services and adult services lawyers. It was agreed that Lauren was at risk of significant harm (the records provided to the review focus on the future, rather than that Lauren had already experienced harm); a pre-proceedings meeting29 was planned for 14th February which father and mother would be invited to. A psychological assessment was commissioned with a primary focus on whether Lauren would be able to understand and engage with any care proceedings that were undertaken. There was also a specific question about what work or strategies would help to keep Lauren safe from predatory males. It was also agreed that a 29 Children's Services send a letter before proceedings to parents before a pre-proceedings meeting. This meeting is an opportunity for parents to discuss with Children's Services what they want parents to do to care safely for their child and to avoid a child being removed from their care. Parents will normally be given a further 6 weeks after the meeting to make necessary changes to keep their child safe. Page 21 of 56 mental capacity assessment would be undertaken and a referral to adult services. This referral did not happen. 3.53 On the 25th January SW5 & SW6 completed a mental capacity assessment30 which found that Lauren did not have the capacity to consent to sexual activities, did not understand that she was at risk of sexual health risks, pain caused by the sexual activity exacerbating her complex health issues or any physical or emotional danger. This was important information which needed to be discussed in a multi-agency context with all agencies that were supporting Lauren and trying to keep her safe; this did not happen. It was agreed that SW5 would organise a best interest meeting31 and an advocate would be appointed for Lauren. Lauren now had a mentor supporting her organised through college and a CSE youth worker (3) had been asked to provide Lauren with support. 3.54 The LPM took place on the 14th February. Only father attended; mother was invited but did not attend. The current concerns about Lauren being sexually abused and exploited were discussed. Father was asked to ensure Lauren was supervised, to monitor her phone use, to attend meetings and to agree to a capacity and cognitive assessment. It was agreed that the cognitive assessment of Lauren would be commissioned and a further LPM would be held in 5 weeks. 3.55 A best interests meeting was held on 27th February. The focus was on Lauren’s lack of mental capacity to consent to sexual activity. There was discussion about what further Police action could be taken against a number of individuals as a consequence of this. Subsequently the Police were able to serve a warning notice to one individual to prevent further exploitation. It is not clear what other professionals were expected to do as a result of the mental capacity assessment. There is less clarity about what other agencies needed to do as a consequence of Lauren’s lack of capacity in this area. From this point on the language used in records continued to suggest that Lauren was “putting herself at risk of harm” and was somehow making her own decision regarding the risk of sexual and physical harm; this was never an appropriate response, but after the mental capacity assessment was evidentially not true. 3.56 On the 28th February a joint risk assessment was completed by SW5 and CSE youth worker 3. This assessment brought together much of the history of concerns regarding sexual harm and exploitation, alongside Lauren’s poor physical health. Lauren’s views were recorded and although she said she understood professional concerns, she felt that she could not be stopped doing what she was doing; this was 30 Under the Mental Capacity Act (MCA) 2005, professionals need to assess capacity where a person is unable to make a particular decision at a particular time because their mind or brain is affected by illness of disability. 31 A Best Interest meeting should be held where an adult (16+) lacks mental capacity to make a decision for themselves and needs others to make those decisions on their behalf. Page 22 of 56 not contextualised alongside her lack of mental capacity. Father’s views are not included, despite there being a space for them to be; it is not clear whether his views were sought. The plan was for Lauren to have a simple phone, for father to report her missing and all professionals to carefully consider how to communicate with Lauren. This was an important plan going forward, but there was little analysis of what caused the significant level of abuse and exploitation of Lauren by others, what role father had played in the past and present and there was too much focus on Lauren as an agent of change, as opposed to those who were abusing her and the role her parents needed to play. 3.57 At the beginning of March 2018 there were further concerns about Lauren being cajoled into exchanging sexually explicit photos and this was investigated by the police. Lauren did not want to hand over her phone for evidential purposes and so no further action was possible. It is unclear how much any one talked to her about this. Professionals were also concerned that Lauren now had 2 phones which is not in line with the expectations of father outlined in the risk assessment recently completed. There is no evidence that father’s role in this was challenged or addressed. 3.58 Consultant Paediatrician 2 wrote to CAMHS challenging their decision not to accept the referral regarding Lauren. CAMHS agreed to offer an appointment; she was not brought to an appointment in early March and a second appointment two weeks later was also not attended. Grandmother and father had telephoned to report Lauren’s ill health as a reason. As a result, CAMHS asked their complex cases team to consider her circumstances and this happened in April 2018. 3.59 On the 14th March the review LPM was held and SW5 reported that father was engaging with the CP plan and progress was being made. It is unclear why this feedback was provided. Lauren remained largely unsupervised, and father was not monitoring her phone and suggested he did not understand the need to do so. 3.60 At the end of March 2018, the cognitive and capacity assessment was received by GCSC legal team. The assessments conclusion was that Lauren did not lack the capacity to understand pre-proceedings or to participate in court proceedings if that was necessary. Lauren was found to have a learning disability and in line with the two previous assessments of her cognitive ability, she was found to have poor language abilities, did not understand many common words, poor memory and she was not able to read material or understand documents. Her cognitive abilities were noted to be at the developmental level of a 7-year-old. In terms of the specific question about strategies for keeping Lauren safe from harm, the advice was “when Lauren is intimidated and cajoled into non-consensual sexual activity’ she needs to contact mentors and her family to support her (rather like alcoholics have supporters to contact when they need a drink)”. This advice suggested that Lauren understood Page 23 of 56 what was happening to her and did not hold the grooming behaviour of predatory adult men responsible for the harm Lauren had already experienced. The report also said that Lauren would be kept safe by the love of her family. This despite there being evidence in the report of a long history of neglect and Lauren telling the psychologist that there was no one who loved her. 3.61 On the 5th April 2018 the third RCPC was held with a new CP chair. Lauren and her father attended. Lauren remained subject to a CP plan for sexual abuse, but professionals agreed that progress had been made, the current protection plan was working and father was now more engaged. This was in stark contrast to the previous conference, held 5 months earlier, which had recommended legal action. The LPM had taken place just 6 weeks before this conference and the confidence of professionals appears to have been based on the period since then. During that time there had been ongoing concerns about Lauren being sexually abused and exploited, lack of attendance at appointments for Lauren and discrepancies regarding phones. 3.62 On 12th April Jem reported concerns about Lauren receiving explicit images; the Police investigated, but could not identify any suspects. They deleted the account from Lauren’s phone. 3.63 On the 24th April Lauren came into college with evidence that she had self-harmed. Her injuries were treated, she was provided with support and SW5 informed. Lauren was encouraged by college to see her GP and she went the same day. Lauren told the GP that she was very low in mood and feeling that some professionals were not listening to her. The GP said he would speak to SW5 about these concerns and ask her to take them seriously; he also proposed that Lauren download a self-harm support application to her phone. The GP contacted CAMHS for an urgent appointment and also contacted SW5. CSE youth worker 3 discussed these worries with Lauren who said that she felt that professionals were stopping her from doing what she wanted to do. Lauren shared over time with these professionals that she craved love and attention; to be liked and much of the online activity fulfilled that need for her. 3.64 At the beginning of May 2018 SW5 was due to meet with Lauren, but she was not at home and SW5 reported her missing to the Police. Lauren returned home without Police action being needed. Lauren later told college staff that she had met with an adult male and had been cajoled into sexual activity. The college made a referral to Gloucestershire Rape and Sexual Abuse Centre (GRASAC) for support from an independent sexual violence advisor (ISVA). This was responded to 8 weeks later; the decision was that they did not have the capacity to support Lauren and also, she had not engaged with a previous offer of help. 3.65 On the 25th May the 13th core group took place. SW5 felt that progress continued to be made; she said there were now less concern about sexual exploitation and abuse Page 24 of 56 and father was working with the plan. Two days later SW5 reported concerns to the police about sexually exploitative messages being sent to Lauren. The police investigated, but it was not possible to identify the suspect; father was asked to remove Lauren’s smartphone - an action from some months earlier which was not complied with. 3.66 On the 13th June 2018 the CAMHS practitioner from the complex case team visited Lauren at college and an assessment of her mental health needs started. 3.67 On 26th June Lauren saw Consultant Paediatrician 2 with CSE youth worker 3 who had supported her to write some questions beforehand regarding her different complex health needs. Consultant Paediatrician 2 answered all of Lauren’s questions in easy to understand language and CSE youth worker 3 had brought visual cards of a thumbs up or down so Lauren could indicate understanding. This was followed up by an easy to read letter with answers to all of Lauren’s questions. This was good child focussed practice. 3.68 SW5 was away on extended leave in June/July and CSE youth worker 3 and college mentor and staff were Lauren’s main sources of support. The CSE youth worker liaised with the Police about the progress of various investigations related to explicit images being shared; Lauren refused to provide the Police with her phone. The CSE youth worker helped Lauren delete social media applications and messages. 3.69 The CAMHS assessment was completed and it was agreed a referral to the adult community learning disability team would be made to support Lauren into adulthood and to have her needs addressed. The CAMHS practitioner continued to see Lauren, to attend meetings and contribute to professional thinking about Lauren’s circumstances. 3.70 SW5 returned from her extended leave in the last week of July in time to attend the core group held on the 27th July. At this meeting the ongoing concerns about the number and explicit nature of the messages that Lauren received from unknown predatory males on line was discussed. It was agreed the CSE youth worker would continue to support these being deleted and managing the social media accounts. It was acknowledged father had not enforced the requirement for Lauren to have a simple phone and the CAMHS practitioner expressed the view that Lauren remained at considerable risk of sexual exploitation and that father was unable to protect her. SW5 reported that there was no evidence that Lauren had been recently sexually assaulted (referred to as going out to meet men) but this was incorrect as she had made a recent allegation of sexual assault which father had said did not take place. 3.71 At the end of August 2018 SW5 discussed the progress of the child protection plan with her manager in supervision. She reported good progress, that father had engaged with professionals (no outcomes discussed) and that the incidents of sexual Page 25 of 56 exploitation and abuse had reduced; it is unclear against which criteria she was judging this. The manager proposed ending the pre-proceedings process and sought permission from the head of service. 3.72 Legal advice was sought and it was agreed that the pre-proceedings process was not needed and father was informed. Lauren would remain subject to a CP plan and once again it was suggested that a referral to adult services needed to be made given that Lauren was now 17. This had been discussed some 9 months earlier. 3.73 On the 20th September SW5 met with Lauren for the last time before she left the team. Lauren talked about being coerced into sexual activity with 2 men and how unhappy she was about this. SW5 discussed this with her manager a week later. SW5 considered that Lauren was at significant risk of sexual exploitation, that father was unable to keep her safe and had not confiscated/changed her phone when necessary. It was agreed there was a need to share concerns with senior managers and to liaise with adult services to plan and co-ordinate Lauren’s transition and support into adulthood. This was an action from January which had not been completed and remained as an incomplete action for the following few months. SW6 was allocated to work with Lauren briefly. 3.74 The 4th RCPC took place at the beginning of October 2018. This was chaired by the chair of the first two conferences; providing much needed continuity and knowledge of Lauren’s circumstances. The CP plan was reviewed and most of the actions had not been completed. The college said they had become increasingly more concerned about Lauren and there was evidence of ongoing sexual exploitation. It was reported that adult services would not engage with the CP plan, but as evidenced by SW5’s recent supervision, it seems likely they had not been approached. The conclusion from the chair of the conference was that father had not been able to keep Lauren safe. The chair asked that an urgent meeting be convened between the head of safeguarding, legal services and the vulnerable adults’ team to decide on next steps to safeguard Lauren. This was an appropriate proposal, but did not happen. 3.75 A strategy meeting was convened 9 days after the RCPCC and focused on the risks posed to Lauren of 2 adult males who were known to be perpetrators of the sexual exploitation of other young people locally. A further complex strategy meeting was held and the Police were able to issue disruption notices to 3 men regarding Lauren’s lack of capacity to consent to sexual activity. 3.76 A new social worker was allocated (SW7) with the same team manager overseeing the work. SW7 was immediately concerned about the extent of sexual abuse and exploitation that Lauren had experienced and her father’s lack of cooperation and inability to act protectively. She noted that father had refused to limit Lauren’s access to a smart phone and had purchased an Apple iWatch for her so she could continue to receive and send messages. SW7 organised a core group meeting for the Page 26 of 56 13th November 2018. At this meeting professionals shared significant concerns about Lauren’s use of social media and being sexually exploited by many predatory males. It was agreed that legal advice would be sought. An LPM was held on 14th November and the legal advice was that no order under the Children Act 1989 could be sought because Lauren was nearly 18 and advice needed to be sought from the adult services legal team. SW7 started to ensure that Lauren was discussed at weekly complex strategy meetings where known perpetrators of sexual exploitation were mapped. 3.77 On the 15th November Lauren said she had been raped; it is not clear who she told, but this was investigated by the Police and led to no further action due to a lack of evidence and the suspect providing an alibi. CSE youth worker 3 organised for Lauren to seek sexual health advice and whilst there Lauren reported further incidents of coercion to engage with sexual activity with a number of adult males. The sexual health centre and CSE youth worker talked to Lauren about the abusive nature of this. 3.78 On the 29th November Lauren came into college with superficial wounds to her legs and she said she had stabbed herself with scissors. She went to see the GP and said that a boy had told her to kill herself. The GP noted that Lauren looked unkempt and tearful and suggested she come back for a follow up discussion in 2 weeks’ time. 3.79 On the 5th December a further LPM took place attended by head of service and the head of service for disabled children. The advice given was the same as at the previous meeting, and the need for the adults’ social care legal team to be involved was reiterated. 2019 3.80 On the 9th January the Head of Service for Safeguarding sent an email to the children’s legal team challenging their decision not to start care proceedings and querying the involvement of the adult services legal team. The reply reiterated the previous advice and confirmed that a referral had been made to the principle lawyer in the adult legal team. 3.81 The 5th RCPC was held on 11th January and chaired by the same chair. Lauren attended, and an advocate read out her views. Father did not attend; he had made it clear that he considered the meetings a waste of time and would not work with any professional. It was reported that father had opposed professional advice about Lauren’s phone and use of social media. Professionals agreed that little progress had been made in 2 years and that a referral to the vulnerable adult’s team was required. There was a follow up meeting two weeks later which reiterated the same concerns. A representative from adult services was present and the only decision recorded in the information available to this review was that action would be taken Page 27 of 56 through the court of protection32. The CAMHS practitioner made a referral to the community learning disability team; he had previously been advised that Lauren would not meet the criteria for support. 3.81 On 18th January adult’s legal services allocated a solicitor who made contact with SW7. There was some email correspondence, but no immediate action and 6 days later a new solicitor was allocated. There was further discussion, but a legal meeting would not be held for another 6 weeks. There was no explanation for this ongoing delay and no challenge of it. 3.82 Over the next few weeks Lauren told professionals that father had brought her a new smart phone and her use of social media increased; she was contacted by many adult men and asked to exchange explicit photographs. She also told professionals about being persuaded by a number of men to take part in sexual activity. She reported that her father and sister asked about these encounters, and accepted they were taking place. Lauren reported that her father knew the perpetrators by sight, was aware of their plans and did nothing to stop the abuse; in fact, Lauren said he would be prepared to take her to meet men. Lauren also reported that father had hidden a smart phone, in case professionals removed her phone. This information was shared with the Police by SW7, but led to no further action.SW7 shared the names of sexually exploitative men with the CSE Police team, and asked that disruption notices were served. Some were, but SW7 was told on 13th February that “they could not serve disruption notices on everyone she has sex with”. SW7 was also told that Lauren could not be interviewed successfully because of her learning disability. 3.83 On the 25th February Lauren was supported by the CAMHS practitioner and pastoral support from college to attend an assessment with the Adult Community Learning Disability team (CLDT). Afterwards she told CSE youth worker 3 that she did not want adult social care support and nor did her father; Lauren said father had told her to avoid any contact with them. The CLDT concluded that Lauren had no underlying mental health issues and therefore they could not offer her services. They did comment that Lauren seemed very vulnerable and at high risk of sexual abuse and exploitation. They felt that she would likely need trauma services in the future when her circumstances were more settled and she was safe from harm. 3.84 CSE youth worker 3 went to see Lauren on 1st March 2019 to take her to the planned core group meeting. Lauren said that she had recorded the names of men who had persuaded her to engage in sexual activity recently in her notebook and father had ripped the pages out. Lauren was tearful, said that she wanted someone to look 32 The Court of Protection in English law is a superior court of record created under the Mental Capacity Act 2005. It has jurisdiction over the property, financial affairs and personal welfare of people who lack mental capacity to make decisions for themselves. Page 28 of 56 after her properly and that her father did not care about her or what she did. She asked if she could come into foster care voluntarily. This was discussed with the HOS by SW7. SW7 sought foster placements but could not get through to Lauren. SW7 spoke to Lauren late in the afternoon and Lauren said she had gone out with Jem who had left her alone with a man who had sexually assaulted her. Lauren said that she would wait until she was 18 to leave. Father and Lauren’s sister Jem could be heard being very aggressive and said Lauren was safe. 3.85 SW7 contacted the Police to ask if they could use Police protection powers to remove Lauren given, she had been sexually assaulted on four occasions that week. They said the risks had not changed and so no action could be taken. The name of the man who had sexually assaulted/raped Lauren was shared with the Police, but no disruption notice was served. It has later become known that this man had his children removed by GCSC. 3.86 On the 8th March Lauren reported to youth worker 3 that her father had dropped her in town for the day. She was persuaded by a man to meet him and he sexually assaulted her. Lauren said that father knew that this was likely to happen but did nothing to address this. The incident and the name of the man was shared with the CSE Police team, but no disruption notice or any other action was taken. 3.87 On 14th March SW7 and her team manager visited Lauren. Lauren said that her father did not want them to come into the flat, but she could speak to them on the landing. When spoken to Lauren said that no one was keeping her safe. At this point father came out; he ignored SW7 and the team manager and told Lauren to get ready to go to the local social club with him. This was a place Lauren had talked about where she had been approached by predatory men and had been sexually abused and exploited. She had made father aware of this on many occasions. SW7 and the team manager left. 3.88 The next day CSE YW3 saw a post on social media from Lauren saying “I am feeling broken. I am not worth it to be in this world. I should be dead”. CSE YW3 visited immediately. Lauren said that she was being harassed by a man from the midlands who was sending explicit photographs and asking her to do the same. He had proposed that they meet at a hotel, where he would give her alcohol and money in exchange for sexual activity. This information was shared with the Police and SW7. SW7 sought legal advice and an Emergency Protection Order was sought and granted; Lauren was taken into foster care. She has remained living away from home and protection sought for her through the court of protection. Page 29 of 56 4. Analysis and key themes 4.1 The purpose of any Serious Case Review is to explore the strengths and weaknesses of the local and national safeguarding system and to consider action required to address gaps and promote effective practice. The intention is to understand how well a child’s needs for safety and care were met and what might have been influencing the professional response at the time. There are 6 key concerns arising from a review of Lauren’s circumstances and these form the finding that follow: Finding 1: The importance of an effective professional response to the sexual abuse and exploitation of children (those under 18) Finding 2: The importance of recognising the specific needs of disabled children and young people and responding appropriately. Finding 3: Recognising, assessing and responding to adolescent neglect Finding 4: Understanding Relational and Developmental Trauma; the importance of professional recognition that this causes increased vulnerability to children and negative impact on children’s lives Finding 5: Dealing with professional disputes and differences of opinion in ways that put the child and young person at the centre. Finding 6: The operation of routine support and safeguarding processes for Lauren Finding 1: The importance of an effective professional response to the sexual abuse and exploitation of children (those under 18) Child Sexual Exploitation (CSE) is a form of Child Sexual Abuse (CSA). It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child Sexual Exploitation does not always involve physical contact; it can also occur through the use of technology. It can involve children and young people of all ages and genders from all social and ethnic backgrounds. Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening Page 30 of 56 4.2 The first key finding ls about the professionals’ response to sexual abuse and sexual exploitation. The sexual abuse, sexual exploitation and sexual violence involving children and young people are a significant and serious issue which is known to impact negatively on all aspects of a child or young person’s development, with serious long-term physical, emotional, social, educational and mental health consequences. There were several issues related to the response of professionals to the sexual abuse and exploitation of Lauren in 7 key areas: Early action; Language; Understanding sexual exploitation as significant harm; The importance of a holistic and planned approach; Investigating crimes and disruption; Disclosures as help seeking behaviour; Case holding of CSE cases by the CSE specialist team. The Importance of early and prompt action to address the exploitation of children and young people 4.3 It is essential that children and young people affected by sexual abuse and exploitation are effectively safeguarded and that action is taken early to prevent patterns of offending behaviour developing and becoming entrenched without action from outside agencies; this can leave children and young people feeling like their circumstances are spiralling out of control without any immediate solution. This is what happened to Lauren. 4.4 Lauren experienced sexual abuse, sexual violence and sexual exploitation by many different predatory men over at least a 3-year period. There were concerns in November 2015 about Lauren being targeted online by predatory males to sexually exploit her when she was 14. The school she attended were appropriately concerned and made a referral to GCSC. This was not initially responded to, but after school escalating this lack of action, a strategy meeting was held. 4.5 This strategy meeting decided that no action was necessary and that the existing family support work would continue; despite there being no evidence that any part of the family was engaging with it. There was a lack of specific action agreed to explore what was happening to Lauren, which adults were involved in her exploitation and what action was necessary to address this. Although this was the first incident of concern, there had been a long history of neglect and this was an important early opportunity to undertake an assessment and address the concerns about the adult male behaviour. 4.6 In February 2016 the school noticed that Lauren was exhibiting signs of emotional distress (expressed as aggressive behaviour) and when this was discussed with her, Page 31 of 56 she provided a picture of a chaotic home life with her father where there were clear problems with sexual boundaries and a lack of care, attention and supervision. Lauren also described visiting her mother’s home at weekends where parties were held and Lauren said she drank alcohol excessively; Lauren’s sister told school that an older man (29) was hanging around and she was concerned this man might be sexually assaulting Lauren. School continued to be notified of sexually explicit content on Lauren’s social media accounts. 4.7 Once again, school made a referral. There was considerable delay in action being taken. There was a strategy meeting and an assessment by GCSC which led to Lauren being subject to child in need processes. There is no evidence that this focussed on the behaviours and activities of the many men who were targeting Lauren. Early action could have sought to prevent the growing number of adult men being in contact with Lauren and address the pattern of offending behaviour and Lauren’s response to it. Lauren was clear that the experiences were scary and harmful, but that she also craved attention. This meant that men were able to take advantage of her. At this point it was also not known that her cognitive difficulties impacted on her ability to always predict the risk she might be in. The language used about sexual abuse and exploitation 4.8 National Guidanceii makes it clear that the victims of sexual abuse and sexual exploitation should never be held responsible for the harm they have experienced. Many high profile SCRsiii iv have highlighted the tendency of professionals to use language which unintentionally implies that the child or young person are in some way responsible for what had happened to them, either through their own actions, such as “engaging in risky behaviour” or “dressing sexually inappropriately” or through their existing vulnerabilities such as learning disabilities, poor mental health, previous experience of neglect. This has led to children and young people feeling they are to blame for what has happened to them, and this often echoes the language of abusers. This may prevent a child or young person from disclosing their abuse, through fear of being blamed by professionals. When victim-blaming language is used amongst professionals, in meetings and in reports there is a risk of normalising and minimising the child’s experience. 4.9 It is clear that all the professionals who had contact with Lauren were very concerned about her and the harm she was experiencing. There were lots of ways, however, in which language was used which implied that she was making a choice to link with predatory adults, or simply choosing to go and meet them This was to confuse the choice to meet, with the need for attention and the action of the various men who took advantage of the meeting to sexually assault Lauren. There were comments in records that “she was dressed in an overly sexualised way” as if this contributed to the harm she experienced. The issue of coercion and control was Page 32 of 56 never clearly enough articulated and Lauren was described as “going off with men”, “meeting men”, “engaging in sexual activity”. There were implications that she lied and that this “was very much Lauren”. This was completely inappropriate and is discussed in the findings that follow. 4.10 It is of concern that the psychological assessment commissioned as part of the possible care proceedings in January 2018 referred to Lauren’s “promiscuous behaviour”. This report was read by many of those involved, but this phraseology was not challenged. 4.11 In March 2018 it became clear through a Mental Capacity Assessment (MCA) that Lauren could not consent to sexual activity. Despite this professional records still suggest that she was choosing to go and meet with men for sexual activity and using the language of “engagement with sexual activity”. This was not possible for her. She was choosing to get attention not abuse. 4.12 From the end of 2018 until when Lauren came into care there were escalating concerns about the level of abuse, rape and assault she was experiencing. At this point it was very clear that she could not consent and was being exploited. The Police members of the CSE team told SW7 that they could not issue disruption notices to “all the men she (Lauren) had sex with” and said that “She is not doing herself any favours with her pictures on Facebook.” These were inappropriate comments that needed robustly challenging. 4.13 It is imperative that appropriate terminology is used when discussing children and young people who have been exploited, or are at risk of exploitation. Language should reflect the presence of coercion and the lack of control young people have in abusive or exploitative situations, and must recognise the severity of the impact exploitation has on the child or young person. Understanding sexual exploitation as significant harm 4.14 It is the responsibility of children’s services departments, in partnership with other agencies to establish whether a child or young person in their area is at risk of, or suffering significant harm. “Harm” is the “ill treatment or the impairment of the health or development of the child”. Significance is determined by “comparing a child’s health and development with what might be reasonably expected of a similar child”v. Although there are no set criteria for determining whether or not harm is “significant” a decision is made based on assessment and professional judgement using the available evidence. If a child is found either to have suffered significant harm or being at risk of significant harm an initial child protection conference should be convened in order that the risks to the child can be considered in a multi-agency context. The criteria here are not the behaviour or attitude of the adults/parents in a child’s life but the harm to them and how attributable it is to the care they have Page 33 of 56 experienced/will experience. A confusion that was evident regarding decision making for Lauren. 4.15 There was considerable evidence from the start of the review period and across it that Lauren had experienced significant harm on a number of occasions. Decision making regarding this was slow and characterised by drift and delay. There was a strong focus on likelihood of significant harm, that the harm was somehow in the future, and a lack of acknowledgement that the harm had happened and was continuing to happen. A firmer response was required. Lauren was raped in March 2016 by a predatory male known to Lauren’s mother. He made contact with Lauren seemingly at a party held by mother, in which Lauren was very drunk. There had been concerns about poor parental supervision and a lack of sexual boundaries at home. A strategy meeting was held, child protection inquiries undertaken, but the conclusion was that a child in need plan would be implemented; the caveat was that an ICPC would not be held if father made the required changes to his parenting. Lauren had experienced significant harm. The evidence was the actions of the adults; sexual assault by men, poor care and supervision by both parents. The impact was clear; she was self-harming and was struggling to emotionally regulate herself characterised by angry outburst and aggression at school and home. The decision should have been for an ICPC to be held. 4.16 There was considerable drift with the CiN plan from GCSC which was challenged by other agencies. The significant harm was not addressed. This was caused by the pressures on GCSC at this time, problems with assessment processes but also some attitudes to Lauren. She continued to be seen as making poor choices, and engaging in meeting men. Her father was characterised as struggling with her behaviour, rather than being a parent who provided no emotional care (he told professionals he was a reluctant parent) or putting boundaries in place for an adolescent (he spent much of the time away from home with his girlfriend). The perceived struggle of father to manage Lauren’s difficult behaviour as opposed to recognising the corrosive impact of trauma led to a referral to the diversion from care team with a focus on helping father deal with Lauren’s behaviour, rather than a focus on the harm she was experiencing. 4.17 In April 2017 Lauren became subject to a CP plan when the significant harm she was experiencing was recognised by GCSC; all other agencies had been pushing for child protection action from March 2016. There was an escalation caused by Lauren’s circumstances being reviewed in an audit completed by GCSC. Legal advice was sought and GCSC were advised to hold a legal planning meeting. This was an opportunity for GCSC to consider whether the threshold for legal proceedings had been met and what action was needed to be taken by both parents. The threshold criteria for care proceedings is that a child is experiencing significant harm and the Page 34 of 56 harm is connected to the quality of parental care being provided. This clearly was the case here. 4.18 Few expectations were placed on father in the pre-proceedings plan, and none were placed on mother, despite Lauren continuing to visit and there being previous evidence of poor boundaries being provided by mother enabling predatory males taking advantage of Lauren. The pre-proceedings process lasted for a six-month period within which Lauren continued to be harmed and father and mother do not appear to have been required to take any action or evidence any change to ensure she was safe. This was a further opportunity to recognise the significant harm that Lauren was experiencing daily and take authoritative action to address it. Father was asked on a number of occasions to allow Lauren to come into local authority care under a voluntary agreement. He refused; this is not surprising given that it is clear that he did not recognise or acknowledge his role in keeping Lauren safe. This left father as the decision maker for Lauren’s safety. Something that was inappropriate. 4.19 Ultimately evidence emerged that father asked Lauren about her experiences of sex, facilitated access to a smart phone, treated the perpetrators who abused her as acquaintances and drove her to meet adult predatory males. It is of concern that this was not enough evidence to take action for an emergency order and no Police action has been taken to address the behaviour of father and should be a matter of review. 4.20 GSCB have published a number of SCRs that indicate that there is a lack of recognition within GCSC about significant harm and the actions needed to address it. Lauren’s circumstances highlight that this remains an issue of concern. Addressing sexual abuse and exploitation: the importance of a holistic plan and approach 4.21 The serious harm that sexual abuse and sexual exploitation causes to children and young people’s emotional and physical health is clear and requires swift and multi-faceted interventions based on good quality assessment. However, addressing sexual abuse and sexual exploitation is complex and just like any safeguarding concern requires a coordinated multi-agency response which addresses the holistic needs of a child or young person and their family. Addressing sexual exploitationvi requires a multi-facetted response including: ensuring that crimes are effectively investigated and those responsible brought to justice, and that where possible perpetrators coercive and controlling behaviour is disrupted through a disruption plan; Addressing the individual circumstances of a child or young person, across their educational needs, emotional needs, physical health needs and addressing the impact of trauma; Working with a young person on issues of safety. This requires safety planning and making sense of coercion, control and grooming and helping children and Page 35 of 56 young people to make sense of this for themselves. Research suggests that although educating children and young people about healthy relationships and the process of grooming is helpful, this approach does not increase safety because it is not the behaviour of the child or young person that causes the abuse. There is a danger that a focus on education about healthy relationships suggests that the child or young person can keep themselves safe by their own efforts and may imply the abuse is the child or young person’s responsibility. Addressing any co-existing vulnerabilities such as other kinds of abuse and neglect and working with parents to enhance safety of the child young person and to provide emotional support. 4.22 Lauren was recognised as a child who was being sexually exploited from November 2015. The first support offered was through the family support service, Families First. This response did not directly address threat to Lauren posed by predatory men and instead focussed on her behaviour and support to father to manage this. The issues of sexual exploitation were focussed on individual support to Lauren and Jem to recognise abuse. This was not enough. 4.23 Concerns then escalated with Lauren making disclosures of rape and sexual assault; this harm to her led to a single assessment being completed by GCSC. This assessment did not address the concerns about sexual exploitation or propose any action. Lauren became subject to a child in need plan. This was never really formulated, but it did not address sexual exploitation or that Lauren had been raped aged 14. This pattern was to continue. There were further reassessments and CiN meetings, but no CiN plan and no focus on sexual exploitation, Lauren’s wellbeing, her emotional needs or her health needs as a result of the sexual abuse, addressing perpetrator behaviour or how father and mother could keep her safe. 4.24 There were many agencies involved. School were focussed on education, addressing Lauren’s learning needs, but also her emotional health and wellbeing. There were two FSWs involved, one from Families First and the other from the diversion from care team; both were trying to address family relationships and father was offered attendance at a parenting programme which he rejected. The FSW was also helping Lauren build self-care skills which were very underdeveloped. The GP and Paediatrician addressed Lauren’s physical health needs and tried to get her some support for her self harm and low feelings. The school nurse provided support. The Police were investigating the crimes Lauren reported. The ISVA was supporting Lauren regarding criminal processes and the youth worker was doing work with Lauren about safe relationships and keeping safe. This was a lot of support which was not coordinated into one plan focussed on the core issue of sexual abuse/exploitation and the impact on all aspects of Lauren’s life. Page 36 of 56 4.25 Each agency carried out its own plan of action, without this being connected to the child in need process. This led to some duplication of activity. There was a lack of overall objectives; there was no clarity about what the package of professional involvement was hoping to achieve for Lauren. The work of the Police happened in almost total isolation. This was despite Lauren sharing information about sexual crimes committed against her. She gave names, talked about locations and places she was frightened of. This information was shared across the professional network, but there was no mapping of this information until October 2018 and no discussion about the need for disruption activity as part of the CiN plan. 4.26 When Lauren said she was reluctant to attend Police interviews, there seems to have been little discussion about how this might be addressed. There was also no discussion about the impact of her learning needs on her ability to take part in police interviews/ABE processes. This is not to say that all professionals did not try and be part of a wider plan. They showed huge commitment to do so; an overarching plan bringing all of the services together did not exist. 4.27 From April 2017 for a period of 2 years Lauren was subject to a CP plan for sexual abuse. There were regular child protection case conferences and many core groups over this period of time. The package of services and involvement of agencies remained much the same as under the CiN process. The lack of coordination remained, and there does not appear to have been clear objectives to be achieved or an outline of what needed to be changed or how to address the sexual abuse and exploitation Lauren was experiencing. 4.28 At a number of stages of Lauren’s journey through services the CSE assessment tool was used. It remains unclear how this influenced the professional response or how it was helpful in keeping her safe. 4.29 Child Sexual Abuse and Exploitation is complex; it is often difficult to create change and keep children and young people safe. What is required is a holistic multi-agency coordinated plan. This did not happen sufficiently for Lauren. It is also important that all professionals consider the balance across the work between the focus on the victim of sexual exploitation and the support they might need, action to ensure that parents do all they can to protect, nurture and support a child or young person and action to address the criminal behaviours of perpetrators and action to disrupt offending. Victims of sexual crimes and exploitation need to know that professionals will put equal energy into preventing CSE happening, protecting and supporting victims and pursuing and disrupting offenders. If the focus of support is on the child alone there is a danger that this will imply that it is the victim’s fault, they were abused and they are alone in making it stop. The balance was not always right for Lauren. Page 37 of 56 The investigation of crimes. 4.30 Over a three-year period, Lauren made at least 23 allegations of sexual assault which were shared with the Police; 10 of these allegations were about rape. Only 1 resulted in a prosecution and this took over 2 years. There is evidence that the Police investigated these allegations, and experienced difficulties with evidence. Lauren was often described as being unwilling to attend Police or ABE interviews and her father also often said they did not want to pursue any inquiries. There was insufficient multi-agency discussion regarding what to do about this and little exploration of what this was about. This review does not know why Lauren felt unable to attend interviews; whether she was frightened or embarrassed or not supported by father. This should have been a focus of the child in need process, the many strategies meetings/discussions that took place and also the CP conferences that were convened. This would have helped the investigation process over time. 4.31 There is some evidence that the CSE Police team had fixed views about both the reliability of Lauren’s testimony, blaming her for what happened to her and that she was an unreliable witness. This left her without a sense that she deserved justice. 4.32 Lauren also had a learning disability. The details of this were provided through an assessment in June 2016 where it was found she had problems with memory, very low-level basic literacy and numeracy skills, considerable difficulties with reasoning, problem solving and the ability to hold onto information. There were further assessments in June 2017 and March 2018. All came to the same conclusion that Lauren was operating at a cognitive level at a chronological age of 8yrs and could not learn from her negative experiences. 4.33 It is not therefore surprising that Lauren gave contradictory information. This was not helped by father and her sister also undermining her version of events on a number of occasions. The ABE guidancevii requires those conducting the interview to consider the child and young person’s needs before an interview takes place, including family background, any special needs, the child’s cognitive, memory and linguistic abilities; current emotional state and relationships with family members. 4.34 The chronologies and Independent Management Reports (IMR) provided by the Police and GCSC provide no information about who conducted the ABE interviews, and how much planning took place to make Lauren more comfortable (included in the ABE guidance) and to address both her learning needs and the impact of the traumatic events she experienced. Although these two agencies are primarily responsible for undertaking ABE interviews, other agencies who know a child well can check to see what preparations have been made and how they can help. There is no evidence that this was discussed in any of the many multi-agency meetings that took place. Page 38 of 56 Disruption activity 4.35 There was discussion of activity to disrupt the behaviour of possible predatory males by the Police, but this was inconsistent and there were concerns expressed by professionals in late 2018 that more could have been done regarding child abduction warning noticesviii when it was found Lauren could not consent to sexual activity. When this was shared with the Police the view was expressed “that they could not serve disruption notices on all the people she had sex with”; this was completely inappropriate and unacceptable practice33. It has emerged that one of the adult men who exploited Lauren had his children removed from his care and that there were emerging issues regarding sexual boundaries. This is why addressing the sexually abusive and exploitative behaviour of men is important; there is rarely one victim. 4.36 There could overall have been more discussion across the multiagency network in partnership with the Police to consider what could be done. Research highlights the importance of a disruption plan to reassure victims that everyone is taking their disclosures of harm seriously. Children and Young Peoples disclosures: help seeking behaviour 4.37 Following on from the criminal action taken to address Lauren’s disclosures of sexual abuse, assault and exploitation it is important to consider how these disclosures were dealt with. Whenever children or young people make disclosures or tell professionals that something is happening for them, they are being harmed or are worried about something they are developing and maturing their help seeking behaviour. Like any other developmental skill, children need to learn how to seek help from others. Children and young people who have been abused and neglected have the development of their help seeking behaviour interrupted. They may live in households where they are threatened not to tell professionals anything or to seek help, and they may also experience blame from those looking after them signalling that the abuse or harm was their fault. They may also find that they tell professionals their concerns, and the help seeking either does not work, because nothing happens, or makes things worse because those who are harming them are alerted and there is further abuse as a consequence. 4.38 Lauren made many allegations that she had been harmed to professionals. This did not lead to action in most cases against those who had harmed her. The previous 33 At that time the males in contact with Lauren were not all identified and in fact it was not possible to identify them all, as a result it was not possible to issue disruption notices to all of them. Lauren continued to use social media and post images of herself in which she could be perceived as an adult/over 18, this made the perusal of online offending extremely difficult as it was not possible to prove that males who then engaged with her, knew she was a child, she was therefore inadvertently exposing herself to risk. Many professionals spoke to Lauren about this in an effort to manage the risk and educate her about online safety. Page 39 of 56 section has highlighted the importance of a disruption plan and this could have provided reassurance that action was being taken. The criminal processes for the rape in March 2016 took 2 years. This bothered Lauren. More could have been done to reassure her that the Police were taking the issue seriously. It is not clear how the lack of criminal action in her other disclosures was discussed with her. There was some sense that this was her fault because she would not attend interviews, or share her phone with the Police. What was needed was a more sophisticated understanding of what was going on for a child who had been abused, neglected and harmed and who could not call on her parents for advice and support. 4.39 Professionals need to promote help seeking behaviour in children and young people and enable them to seek help; not leave the responsibility with the child. They need to recognise and address barriers and ensure an ACTION, CONSEQUENCES, REPAIR approach. That is professionals are clear what action is being taken by whom, with what outcome, and when. If there are no formal outcomes possible, the message should not be “this agency cannot do anything because there is not enough evidence” but a focus on what can be done; what action can be taken, however small. Children and young people need to know it was worth telling someone. Children and young people need to have what happened to them acknowledged as wrong and harmful, even if there is no formal outcome possible. Finally, children and young people need some form of repair; their parents, carers and important adults saying sorry about what has happened. In the early disclosures of abuse, this did not happen for Lauren. Her help seeking was not promoted. The role of the CSE team 4.40 This review had as a specific term of reference a question about whether the specialist CSE multi-agency team should be case holders for children and young people who are being significantly sexually exploited and harmed by predatory males. The Independent Management Reports ( IMR) provided by agencies draw no firm conclusions about this. The picture for Lauren is confusing. At times she was provided with a social worker from the district teams and at other times the CSE team were the key worker. This led to a number of changes of professionals working with her and did not seem to improve the response to her safety. 4.41 This review cannot draw a firm conclusion; it can highlight that this decision needs to be based on the assessed needs of the child or young person. Where there are high levels of co-existing vulnerabilities, as with Lauren, she needed a social worker who was addressing the underlying issues of neglect and potential emotional abuse. She also needed the CSE team to be addressing disruption of perpetrators behaviour, taking forward Police investigations, thinking about the link between the Police and the child in need/child protection plan. What is always needed is clarity of role and task to address the holistic needs of a child or young person. That was missing here. Page 40 of 56 A recent Gloucestershire SCR draws the conclusion that there should be a clear lead professional to ensure multi agency involvement is properly coordinated and that the child or young person has a single point of contact. This would have been helpful for Lauren and her family. 4.42 This review has highlighted weaknesses in the multi-agency response to the child sexual exploitation and sexual abuse in Gloucestershire despite considerable guidance and training being available and a specialist team in place. Recommendation 1: The Gloucestershire Local Safeguarding Children Executive (GSCE) needs to ensure that action is taken to address: 1. Where early help plans are deemed an appropriate response to the early signs of sexual exploitation. That the sexual exploitation itself is addressed directly and not just focussed on addressing family difficulties or programmes designed to educate young people. 2. Ensure that there is a process in place whereby all children who are subject to a CiN plan or CP plan because of sexual exploitation have a disruption plan in place which would be incorporated into these wider plans. 3. In cases of sexual exploitation nationally there are well documented concerns about the engagement of vulnerable, traumatised and abused young people in action to address their abuse. The causes for this are well known and should not be automatically focussed on a failure in the young person. Professionals need to be supporting young people, addressing their fears and reluctance, alongside recognising their capacity. This should be a routine part of the early help/child in need/child protection planning and discussion process. 4. There were considerable concerns that the vast majority of professionals working with Lauren struggled to avoid victim blaming language which implied choice and control. Some professionals went further and actively implied “promiscuity”. All seemed to lose sight that she was a child with a learning disability who was being exploited. This remains a national and local issue which the GSCB will need to consider how best this can be addressed, The Children’s Society and other agencies have produced guidance about language. This is not a solution because this is about attitudinal change, but might be a helpful starting point34. Finding 2: The importance of recognising the specific needs of disabled children and young people and responding appropriately. 34 https://www.csepoliceandprevention.org.uk/sites/default/files/Guidance%20App%20Language%20Toolkit.pdf Page 41 of 56 A person has a disability if he or she has a physical or mental impairment and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. Equalities Act 2010 4.43 This finding focusses on whether agencies and professionals identified Lauren as a disabled child with extensive learning needs and the extent to which this influenced their response to her in a child centred way. The UN convention on the rights of persons with disabilities and the Equalities Act 2010 make clear the importance of disabled children having their identity as a disabled person recognised, their needs met, their capacities enhanced and reasonable adjustments made to ensure that they get the same benefits from services as any other child or young person. 4.44 Lauren had a learning disability from early childhood. These early cognitive difficulties may well have been exacerbated by the neglect she experienced as a young child. When Lauren started at school in 2013 in Gloucestershire, having been home educated in another county, there was a recognition that she had learning needs and she was provided with specialist educational needs support. In 2016 there were concerns about her coping mechanisms and appropriately the school instigated the Education, Health and Care Plan (EHCP) process. This included a psychological assessment, and from this a clear outline of Lauren’s cognitive abilities and challenges emerged. She was found to be considerably behind her peers, had poor problem-solving skills, impaired memory and struggled to understand words and concepts. The school put in place a programme of support and a modified timetable based on this assessment. 4.45 GCSC undertook a single assessment of Lauren and her family in April 2016. This described that Lauren was functioning at “around age 6-7” without any analysis of what this might mean for the CiN plan or professional involvement with her. There was no CiN plan and so this was not addressed. There were a number of re-assessments within the CiN process which did not address Lauren’ cognitive style and there was no plan. 4.46 In October 2016 the family support worker (diversion from care team) discussed her concerns about Lauren’s cognitive capacities with the youth worker. As a result of this they agreed to modify their approach and there is evidence that information was provided to Lauren using appropriate communication and visual imagery. This was good practice. 4.47 These two workers were not included in the many strategy meetings held, and so their knowledge of Lauren’s learning style built up through working closely with her, was not part of the discussions. There is evidence that Lauren’s cognitive abilities were discussed, but it is unclear the extent to which this influenced the broader plans to keep her safe and ABE interviews. There is no evidence regarding what planning or reasonable adjustments were made. Page 42 of 56 4.48 It was also good practice that the youth worker commissioned a speech and language assessment in June 2017. This informed the work of this agency, was shared with others, but there is no evidence that it influenced all the work with Lauren. 4.49 Lauren had many health issues. Her GP saw her for her annual learning disability health check, but this appears to have been separate from the CiN processes and CP plans. 4.50 Lauren was provided with an advocate to help her express her needs in the CP conferences that started in April 2017. It is unclear the extent to which this work made use of the existing cognitive assessments to ensure that this process was understandable to Lauren. Lauren also attended a number of conferences, and it remains unclear what action was taken to ensure that the language used in the conference was understandable; it seems unlikely that she was provided with an easy read version of any of the conference reports. 4.51 Consultant Paediatrician 2 saw Lauren regularly with either the youth worker or the family support worker. He adapted his language to ensure that Lauren understood and he followed this up with a letter after appointments in language that was understandable. He organised for the youth worker to spend time with Lauren preparing questions she had about her health needs and used these to provide Lauren with clear health information that she wanted to know about. In this meeting the youth worker prepared a “thumbs up” and “thumbs down” so Lauren could indicate what she did and did not understand. This was effective child centred practice which took account of Lauren’s disabilities and individual circumstances. It was a good example of giving her some control in circumstances where she had little control in other areas of her life. 4.52 In January 2018 there was a practice audit of the service response to Lauren. This raised significant concerns about drift and delay, and the lack of action to safeguard Lauren. The head of service recognised that account needed to be taken of Lauren’s learning disabilities. This was effective practice and led to a mental capacity assessment and a further cognitive assessment. The Mental Capacity Assessment (MCA) found that Lauren did not have the capacity to consent to sexual activity. This led to appropriate disruption action by the Police, but did not change the professional narrative of Lauren making a choice to meet men. This knowledge was not integrated into the plan, and ultimately for a while professional evaluated the risks to Lauren having lessened from this point onwards. This was evident in the discussions between SW7 and her manager in August 2018 and review case conference that took place in September 2018. The MCA should have highlighted that she was at increased risk and more dependent on advice and support at home. Page 43 of 56 4.53 A further cognitive assessment was undertaken in March 2018. This was focussed on Lauren’s capacity to engage with possible care proceedings, but also confirmed the significant level of her learning disabilities. This report both acknowledged these disabilities, lack of capacity to consent to sexual activity and suggested that she would need to be taught to say “no”; a complete contradiction which was not picked up by those receiving the report. 4.54 The CAMHS worker received this report in September 2018; he made sure that it was shared appropriately and that this outline of Lauren’s cognitive needs should inform the assessment being undertaken by the adult learning disability team. This was appropriate. 4.55 There was a mixed picture across this review of the extent to which professionals understood Lauren’s learning disabilities, respected that they were part of her individual identity and made adjustments to ensure that she had a chance of understanding and taking part in all the different services and professional working with her. In many agencies records it was just recorded that Lauren had a “mental age of 8 to 10 years” without any further analysis or action. There were good individual responses from some professionals, which was likely undermined overall by the lack of a coordinated approach. Lauren worked with many different professionals and there were many changes over the 3 years; this would have been very confusing for her. 4.56 Lauren was also an adolescent with learning disabilities who was heading into adulthood. A consideration of what help she needed to make that transition successfully was required; alongside this she was a vulnerable child and was to be a vulnerable adult. Some thought was also needed regarding this transition as a disabled person. There were discussions in January 2018 regarding this (when she was 16) but there was continued drift and delay and this was only actioned when she was nearly 18. Lauren’s learning disability and the action necessary to promote her well being got lost in all the other concerns that professionals had. There are two key issues to address here: The ability of non-specialist safeguarding and welfare professionals (including the Police) ability to recognise the needs of a child or young person with a learning disability, think about what this means for the child or young person, and implications for the work to be completed with that young person. It is not good enough to record that a child “has a mental age of 7”. This is both disrespectful to the child or young person and is outside of the requirements of both the Equalities Act 201035 and the Disability Discrimination Act 199536. 35 https://www.gov.uk/guidance/equality-act-2010-guidance 36 https://www.legislation.gov.uk/ukpga/1995/50/contents Page 44 of 56 There was insufficient Transition planning for Lauren Recommendation 2: The GSCE should ask core agencies involved with Lauren to undertake an Equalities Impact screening of their current service offer to assess the extent to which it effectively addresses the needs of learning-disabled children and young people not known to specialist services. Recommendation 3: The GSCE may wish to develop guidance regarding best practice in working in a child centred way with children and young people with learning disabilities who receive services from non-specialist agencies. Recommendation 4: The transition planning from children to adult social care services was not effective. It is not clear if this was just an issue for Lauren or there are wider concerns about transition planning. The GSCE should seek further information to evaluate what action needs to be taken in this area. Finding 3: Recognising, assessing and responding to adolescent neglect Adolescent neglect is defined as “persistent and pervasive failure by a parent or parent figure to meet an adolescents physical, emotional, educational, medical and safety needs; causing harm to their health and development and increasing their vulnerability to all forms of exploitation, increasing possible engagement with risky behaviours such as substance misuse, sexually harmful behaviours, anti-social behaviour, crime and increasing the likelihood of poor mental health and wellbeing. It may be deliberate or not”37 4.57 Adolescence is a time of great emotional, physical and cognitive change. Adolescents need appropriate parenting and research suggests where neglect is ongoing during this time the outcomes are connected with poor mental health, criminality, self-harm and vulnerability to exploitation amongst a range of other negative outcomes. There was considerable evidence of historical neglect of Lauren and her sister which was across their whole childhood and of neglect into adolescence. Where there has been this cumulative level of emotional and physical neglect children go into adolescence without the frameworks or emotional structures to enable them to manage the demands of this developmental stage. This is not their fault and these structures need rebuilding. This analysis did not form a part of the ongoing child in need or child protection plans. 4.58 There are six key questions to be considered when assessing and addressing neglect and indeed these questions are the basis of the existing GSCB neglect toolkit: 1. Persistence 2. Type of neglect including: 37 Page 45 of 56 o Physical o Emotional o Educational o Medical o Supervisory o Is it global: concerns in all developmental areas? 3. Impact and lived experience of the child; what does the neglect mean for them 4. Causal factors 5. Omission or commission 6. Other abuse that the neglect is enabling Each question provides a picture of the neglect, how pervasive it is and what action in each area is needed. Persistence and evidence of cumulative harm 4.59 Lauren and her sister had experienced neglect which was cumulative and pervasive throughout their childhood. This was known by most agencies and was covered extensively in the assessment completed in April 2016 by GCSC. This historical neglect was recognised, but there was little analysis of what this meant for Lauren’s overall well-being and her transitioning into adolescence. Some of her physical health needs were caused by historical neglect; certainly, some of her emotional health outcomes such as self-harm, anger and need to be liked and wanted would be connected to this long-term experience of neglect. Her cognitive skills would also likely have been impacted. The impact of this early neglect would have left her unprepared for the transition into adolescence and impacted on her ability to cope and be resilient in the face of the demands of this new developmental stage. Yet the narrative was on her as an individual, not a child who had not been cared for. Type of neglect Physical care: 4.60 The Family Support Worker noticed that Lauren had few personal care skills, and spent time teaching her those. There was no discussion of why she did not have these skills; what had been the gaps in parenting. The School Nurse and GP noted that Lauren looked unkempt and there were times when she had untreated headlice. There were times when Lauren shared with professionals that she was hungry, and although this was addressed the meaning of it was not explored and not connected to this being parental neglect. The FSW witnessed Lauren setting fire to her hair whilst trying to cook and not knowing what to do, Education: Page 46 of 56 4.61 In 2016 Lauren started to withdraw from education, and it is unclear the extent the role father played in this. It is unclear the extent to which father engaged in school feedback sessions, though he did attend meetings. Health: 4.62 Father did attend health appointments, but for much of the years 2016 to 2019 a range of support workers attended appointments with Lauren and facilitated her attendance. Father suggested this was more appropriate because she was a young woman, but meant he did not have to demonstrate commitment to making sure she attended. The FSW did find hundreds of unopened health appointment letters in the family home. Emotional care: 4.63 Father was clear that he was a reluctant parent and refused to attend any parenting programmes. It is quite hard to get a picture of the emotional relationship between father and Lauren because this is not provided in records. Lauren did tell the psychologist in 2018 that no one loved her and she consistently told professionals that sending explicit pictures and meeting men was because she wanted to be loved and liked; there was no analysis of how this connected to her experiences of parental emotional care. It was clear that he was focussed on his own relationships and either left Lauren in the care of her sister and her partner or on her own; a very lonely existence for her. Supervision: 4.64 Father provided little supervision. He was often not at home, and Lauren believed that he did not care who she was with. Mother also provided little supervision which was a critical issue for Lauren. A detailed understanding of these five areas was required. Impact of neglect 4.65 It is also important to consider what impact parental neglect is having on a child or young person. There are real dangers that the impact of neglect in adolescence becomes focussed on the child or young person and they then are seen as the problem. There was a very clear impact of the neglect that Lauren experienced. She struggled to regulate her emotions and was described as being angry and aggressive. In 2016 when she had been raped, and was being left alone by father and rejected by mother, the analysis was on what was seen as her problematic behaviour. This led to the diversion from care team to be involved. The analysis was that teenage behaviour could cause family breakdown. Rather than adolescent neglect was having an impact and that was what was needed to be addressed. It was accepted that father refused to attend parenting classes, whilst continuing to sight Lauren as the Page 47 of 56 problem. Over time many professionals became concerned about incidents of self-harm and depression. Referrals were made to CAMHS and Lauren was consistently found not to have any form of mental disorder. The analysis needed to have been on the corrosive impact of the emotional neglect she was experiencing and what would be helpful to address this. Causal factors 4.66 If the neglect of children and young people are to be addressed, there needs to be a clear analyse of why it is occurring; what is causing it. In historical terms there was evidence of mother’s poor mental health and alcohol misuse, alongside father’s domestic abuse. In the period 2015 to 2019 there was no focus on the neglect, and therefore no analysis of why father was neglecting Lauren’s needs. Without this analysis there was no plan to create change. Omission or Commission 4.67 Professionals need to think about whether the neglect of a child is an act of omission or commission. Neglect is often assumed to be an act of omission with parents /caregivers struggling to provide effective care because of their own impoverished and deprived circumstances. This is very often the case and this knowledge provides a pathway to appropriate support and intervention. However, for some parents or caregivers neglect is an act of omission; they take no responsibility for the quality of care they provide and are often hostile or dismissive to advice or interventions. The lack of responsibility on the part of parents often tips into blame. Children and young people are held responsible for the poor-quality care they receive, with parents citing their young people as too difficult or too damaged to care for and this attitude has a powerful impact on young people’s lives. Father did suggest that Lauren was too difficult to manage and that he could not cope with her behaviour. He refused help to address this. This is a cognitive catch 22 for children and young people. The neglect they experience causes a negative impact, and this is then cited by a parent as the reason why they cannot parent well. Children and young people do not get the care they need, and then are held responsible for that lack of care. Children and young people can be referred to as damaged rather than living in damaging circumstances. Language here matters. This has extremely negative consequences on their wellbeing and future outcomes and needs to be addressed. There was evidence that father knew of the sexual abuse that Lauren experienced and did not intervene. This needed clearer challenge. What other kinds of abuse was the neglect enabling? 4.68 Research has shown that there is a strong connection between child and adolescent neglect and sexual abuse and exploitation. This is a complex relationship which requires assessment and analysis of an individual child and their family Page 48 of 56 circumstances. This did not happen for Lauren but more thought and discussion could have been had about the poor emotional care she received in her adolescent years, her assertions that no one loved or cared for her, and those that groomed her seemed to be paying her the attention she needed. 4.69 Adolescent neglect was an important issue here which was not articulated or assessed. It is a complex area of work which requires professionals to be skilled and trained, with the appropriate tools and frameworks. This review of Lauren’s circumstances concurs with the conclusion of the recently published SCR Liam by Gloucestershire LSCB. The multi-agency partnership response to adolescent neglect needs to be strengthened to ensure practitioners are competent and confident in identification of adolescent neglect and working with all aspects and types of neglect including assessment of parenting capacity, motivation to change, sustainability of any improvements. Impact on child and young person and parental/care attitude to the parenting task Recommendation 5: The GSCE needs to assure itself that the planned refocus on the GSCB Neglect Strategy, procedures, single agency training and multi-agency training programme results in demonstrable improved outcomes for children living in neglectful circumstances. Finding 4: Understanding Relational and Developmental Trauma; the importance of professional recognition that this causes increased vulnerability to children and negative impact on children’s lives “The impact of early neglect and trauma can cross every area of children’s lives, negatively affecting their capacity to…develop a moral sense…and make close, trusting relationships.” 4.70 This finding focusses on the professional understanding of the impact of developmental and relational trauma on Lauren and her circumstances specifically, but also other children and young people locally. Lauren experienced trauma in childhood in a number of ways. She lived in a household where father was domestically abusive to mother. She was taken out of school, and moved home, away from friends and family. She was raped and sexually assaulted on many occasions. With father seemingly uncaring about the impact for her and with some evidence that he might have played some part in introducing her to men. She experienced developmental and relational trauma. This was not part of the thinking about her circumstances and connects clearly to the issue of blame in neglect. 4.71 There is significant evidence regarding the negative long-term developmental effect of abuse and neglect of children by their primary caregivers or family members. This relational trauma, which takes place in the context of family relationships, is fundamentally different from single incident trauma where experienced by children Page 49 of 56 who were previously coping and developing appropriately. Children’s early relationships and interactions with adults are essential to provide the organising framework and representational models for children’s future relationships. Their developing sense of the world, sense of self, personality is grounded and moulded through these foundational relationships. Through these relationships children come to understand and make sense of their own inner worlds, how other people act and react in social encounters. Essentially, the quality of these early relationships is key to guiding a child’s identity, expectations of self and others, their self-esteem and self-concept. 4.72 Children who have experienced parenting relationships and an emotional milieu characterised by fear, anger, hostility, pain, intrusiveness withdrawal and disengagement learn to see others either as a threat or a source of alternative comfort. Children are left without a template for positive and appropriate social and emotional interactions. Contact becomes a source of stress and anxiety. In order to survive, children have to develop survival skills and powerful defence mechanisms to protect themselves from further pain and loss. Their ability to assess safety and danger becomes skewed, and they often have difficulties understanding other peoples’ feelings behaviours and intentions. The legacy for these children is that they are often fragile, wary, anxious, depressed, angry, emotionally vulnerable and struggling to make healthy relationships. 4.73 This makes developmental transitions more difficult. Adolescence is a time of considerable biological, psychological and social change and consequently the transition from childhood to adolescent can be difficultix. Adolescents who have experienced early trauma and abuse and whose family and social circumstances are complex have not always been equipped with the skills and emotional repertoire to manage this transition and can thus find it more difficultx. 4.74 These difficulties are not always then perceived as a result of those early experiences or current family difficulties, but as a problem with, and of, the adolescent. Researchxi and SCRsxii have highlighted that because adolescence is a time of independence that when adolescents become known to services there is a tendency for professionals to evaluate their difficulties in isolation and they can become seen as “troublesome” rather than “troubled by their circumstances” and there can be a lack of understanding that behaviours and responses to the world are a manifestation of trauma, not a manifestation of adolescence or individual problems. 4.75 There was considerable evidence of how the relational and developmental trauma impacted on Lauren. She demonstrated anger and aggression at home and at school. She self-harmed and she went into situations where she knew there was some level of risk that an individual would take advantage and assault her. Professionals needed to see Lauren’s responses as a manifestation of trauma and severe neglect. If this is Page 50 of 56 not acknowledged, there is a danger that children and young people see themselves as the problem that needs fixing through attendance at CSE education sessions, or support through CAMHS, or helping parents to manage their difficult behaviour. This analysis might have been complex for Lauren to understand, but the message that this is not about “what is wrong with you” but about “what has happened to you” might have been helpful in building her resilience and addressing her sense that she was not loveable. She had just not been loved. This message is important to all professionals working with adolescents: they need a good understanding of relational and developmental trauma as a frame of reference to understand children’s lives. Recommendation 6: Multi-agency partners of the Gloucestershire Local Safeguarding Children Board (GSCB) have already made a commitment to a trauma informed and restorative approach to practice, informed by the learning from ACEs. The findings from this review of Lauren’s circumstances needs to inform the ongoing development of a trauma informed approach and the GSCE should satisfy themselves that this would make a difference to the service response to young people like Lauren. Finding 5: Dealing with professional disputes and differences of opinion in ways that out the child and young person at the centre. 4.76 It is inevitable that there will be professional disputes and differences of opinion given the complexity of safeguarding. What is important that these difference or disputes are addressed in a child focussed way. Research and serious case reviews have highlighted that differences of opinion and professional disputes are not always handled effectively to the detriment of a child or young person. 4.77 The school Lauren attended raised early concerns about her from 2015 until she left the school in 2017. They expressed clearly their unhappiness with decision making by GCSC and the drift and delay in the action being taken. They particularly felt that Lauren should have been subject to child protection processes from March 2016, and this view was shared by other agencies. The school sought advice from the GSCB and their concerns were successfully taken up by senior managers. The psychologist and ISVA also made clear their concerns. This led eventually to Lauren becoming subject to a child protection plan for neglect. This demonstrated that safeguarding partners across the safeguarding partnership have an awareness of the existing escalation process and their ability to focus on the needs of a child. 4.78 In December 2017 senior managers in GCSC became aware through an audit of Lauren’s circumstances that there had been drift and delay in planning for her and this was raised with the responsible managers. This also led to further action and a legal planning meeting. It is of concern that once this initial scrutiny was gone, Page 51 of 56 concerns about how well Lauren was being safeguarded diminished. It took a new social worker and child protection chair in late 2018 to raise the lack of progress. 4.79 There is some evidence that these escalations were taken personally by the individual social workers and team managers involved. It is always hard for a professional to be told that their analysis and approach is not addressing the needs of a child. The escalation process and the normality of these differences occurring in complex cases should help to see this not as individual criticism but making change in the best interests of the child. It appears that these feelings of personal criticism by individuals and their managers meant that their views became more entrenched, and that they did not accept this new analysis. This is certainly clear in the period after the audit. Legal planning processes were initiated, but after a six-month period they were halted. There was little evidence that Lauren’s circumstances had changed, that she was any safer or that father had taken any steps to improve his response. 4.80 This highlights the need to address personal feelings of criticism in the context of the escalation process and for there to be a complex case meeting to discuss a new analysis. The escalation process has not worked if the differences of professionals’ analysis have not changed. The process may have changed, but the view of what is happening for the child has remained the same. This happened here. 4.81 Work has already been undertaken regarding the GSCB escalation policy which has been simplified and training provided to all agencies including schools and Senior Managers in GCSC. However, this review concurs with the view of the recently published SCR by GSCB about Liam38 which suggests that more needs to be done to promote the role of escalation in partnership working together with respect and mutual understanding of others’ roles and responsibilities and understanding of the limitations in practice. There should be a focus on restorative practice principles that foster and enhance partnership working and a culture where respectful professional challenge is productive and welcomed. Recommendation 7: The GSCE to undertake work to promote the role of escalation in partnership working in the context of respect and mutual understanding of others’ roles and responsibilities. There should be a focus on restorative practice principles that foster and enhance partnership working and a culture where respectful professional challenge is productive and welcomed as the voice of a ‘critical friend’. Finding 6: The operation of routine support and safeguarding processes for Lauren 4.82 The terms of reference for the IMRs produced as part of this review asked specific questions about decision making, assessments and child protection plans. It is clear 38 https://www.gscb.org.uk/media/2098723/scr-0319-liam-final-20200430.pdf Page 52 of 56 that these did not work well for Lauren. The routine child welfare and protection processes were ineffective. 4.83 There were a number of overall assessments undertaken over a three-and-a-half-year period. These were either under the auspices of the child in need framework or child protection. They consistently lacked robustness, analysis and a focus on CSE or neglect - the two key issues that were important for Lauren. At times the assessments were cut and posted from previous versions and were not child centred. The voice of Lauren and Jem was not clear, and Lauren’s learning disability not analysed. The focus should have been on father and mother’s responsibility for providing care and protection. The assessments were also an opportunity to consider Lauren’s reluctance to engage with the Police and disruption of the perpetrators of sexual exploitation activities. The primary statutory responsibility for undertaking these assessments lies with GCSC and concerns about the quality of assessments was a message from the last full inspection of children’s services and addressing the quality of assessments is part of their improvement plan. The multi-agency group also has a part to play. These assessments should be shared with all agencies working with a child. If these assessments do not address the core issues this needs to be challenged. Agencies could have challenged the quality of the assessments as they related to Lauren. 4.84 Lauren was a Child in Need for a period of one year. This is an important process with the Children Act 1989 making it clear that the health and development of this group of children will continue to be impaired without a clear CiN plan; which addresses the key concerns; provides services which address those concerns; sets goals and which is reviewed to ensure progress or address the lack of it. The first single assessment within the period under review was undertaken in April 2016. There was a plan of action outlined as part of the conclusion of the assessment, which was not made into a CiN plan. This meant there was never a CiN plan formulated for Lauren and her family. There were regular CiN reviews, but they were used to feedback what had happened in the period since the last meeting. These meetings did not have an overview or consider the cumulative harm. There was no reviewing process, because there was no plan. These meetings were well attended and included all those concerned about Lauren and one meeting enabled the multi-agency group to pull together a comprehensive picture of concerns in November 2016. This still did not lead to a formal CiN plan. 4.85 It is of course clear that it was inappropriate for Lauren to be considered in need of support, rather than in need of protection, but nevertheless an appropriate CiN plan with goals, intended outcomes and services targeted at concerns could have contributed effectively to supporting Lauren. It is the primary statutory responsibility of GCSC to develop an appropriate child in need process and there is clear guidance locally regarding this. Poor child in need processes have been a concern in a number Page 53 of 56 of Gloucestershire SCRs and were also highlighted as an issue in the last full Ofsted Inspection. This is part of the current improvement plan. It is also important that all agencies that are part of a CiN plan advocate on behalf of children, by noticing the lack of a plan, with appropriate services and goals, and do something about this. This did not happen for Lauren. 4.86 There were many strategy meetings/discussions held over the three and a half years reviewed. There were times they should have been held and were not. They lacked health input, given the concerns about sexual abuse and exploitation and they were not always child focussed. Lauren’s learning disability, for example, was discussed, but no plans were made to take account of this in keeping Lauren safe. Each strategy meeting was viewed in isolation; there was no sense that anyone involved highlighted that this was the 4th/5th/6th 7th strategy meeting (and so on) and therefore considered what that meant both about the effectiveness of current planning or the safety of Lauren. These meetings are intended to come up with a plan to keep a child safe. There was too little discussion about how criminal procedures dovetailed with CiN/CP processes, how those criminal procedures could be maximised by addressing Lauren’s inability to take part, and father’s lack of responsibility to ensure that all was done in this area. These meetings did not also serve to discuss disruption tactics until October 2018. Again, strategy meetings form part of the improvement plan for GCSC. They also need to be part of a review process for the Police to see how their work can be incorporated into the child welfare processes. 4.87 Lauren was subject to a CP plan for two years. It is not clear what this plan was hoping to achieve. The service response was remarkably similar to those delivered under the CiN process. Lauren continued to be targeted and abused, but there was a lack of analysis of the grooming and predatory behaviour of the men who were assaulting her, a lack of acknowledgement of neglect generally, and emotional neglect and abuse specifically and mistaken sense that Lauren could be either taught to “say no” or “not meet me” or be supervised at home and have her phone removed. This was not the right plan. This should have been noticed by managers, the chair of the conferences and the multi-agency group and challenged. There were times when concerns were expressed about the quality of the CP plan and the lack of progress of its limited goals, but this did not lead to any real change. The primary statutory responsibility for the quality of child protection meetings and plans lies with GCSC and creating change around these processes is included in the improvement plan. It is also the responsibility of all agencies to notice when child protection processes are not being effective for a child and take action to address this. This is to be an advocate for a child and in this case an advocate for Lauren, 4.88 There was a lack of urgency in the responses to Lauren’s needs from the children and adult legal team, which replicated the delay in taking timely and authoritative action Page 54 of 56 across the previous three years of involvement. This lack of urgency needs to be addressed. The legal teams were provided with verbal information from social workers and their managers to help them to provide effective legal advice. They should have been provided with a chronology and an analysis of all concerns. For Lauren this meant the legal team did not understand the seriousness of her circumstances, the extent of the harm she was experiencing, caused by the lack of safety from father. The legal team in turn provided advice that the legal threshold had not been met to take action to safeguard Lauren. This caused frustration to the social workers and their managers; yet the advice was accepted without challenge or an escalation of concerns. Those managers and social workers could simply have gone back to the legal team and explained that they may not have made clear the seriousness of the concerns regarding Lauren and been prepared to provide more information and analysis in writing. There is current work underway to address this in GCSC. 4.89 The failings of routine safeguarding and support practices with children’s services had a profound impact on the lack of safety and prevention of harm to Lauren. There were times when multi-agency partners did recognise that these routine processes, which are the responsibility of children’s services, were not happening as they should do and there was appropriate challenge. There were though times when agencies did not notice the lack of effectiveness of assessment, planning, meeting and review processes. The basics do matter. It is the responsibility of children’s services to deliver these, and for multi-agency partners to support them to do so and to notice when things go wrong, These failures to provide the basics of the safeguarding system to Lauren and her family need to be seen in the context of the Ofsted Inspection39 published in June 2017 which highlighted many of the issues present in Lauren’s case. There is an improvement plan in place which speaks to the concern in this finding. Recommendation 8: The GSCE will need to be assured that the current improvement plan for Children’s services delivers change that will make a difference to children like Lauren and this this work is being done alongside multi-agency partners as critical friends. 39 https://files.ofsted.gov.uk/v1/file/50004377 Page 55 of 56 5. Conclusion 5.1 Lauren was a child of 14, with a learning disability which often went unrecognised; she was severely sexually abused, exploited and assaulted over a three-year period. It is important to recognise that the considerable sexual, physical and emotional harm that Lauren experienced was caused by a large number of predatory males and it is important that this is both recognised and acknowledged; something that was not consistently the case for Lauren at the time. 5.2 Lauren could also reasonably have expected to be cared for, nurtured and protected by her parents and wider family. There is considerable evidence that this was not the case by her parents; there is little information available about the wider family and their relationships with Lauren. She experienced early neglect from both her parents with long term impact on her emotional and physical well-being. There is also clear evidence of the ongoing neglect of her adolescent needs, particularly for safety, love and advice. Her father did not keep her safe from sexual abuse and did not comply with advice from agencies which might have helped. 5.3 Safeguarding children is also the responsibility of public authorities and it is clear that the safeguarding systems and processes in Gloucestershire failed to keep Lauren safe from harm over a three-year period. The reasons for this are complex and are not associated with the actions of any one individual or agency alone. There is much evidence that many of the professionals involved with Lauren worked hard to provide support and endeavoured to find ways to protect her. It is never one factor that leads to the failure to ensure the safety of a child. For Lauren there were weaknesses in the multi-agency responses to child sexual exploitation, including disruption and particularly worrying victim blaming attitudes that got in the way of ensuring she understood that she was not responsible for the severe sexual abuse and assault she experienced. Her learning disabilities were not understood and this exacerbated these problems alongside the impact of her experiences of neglect and trauma. Alongside these complex factors which interacted negatively and cumulatively over time, the basics of the child in need and child protection system were not in place. 5.4 There is no simple solution to the complexity of child sexual abuse and exploitation, but a focus on the perpetrators of this abuse, their persistence and grooming of those who are vulnerable in our society is necessary, and a recognition that this is an issue that needs addressing early on. Waiting for the harm to happen, and then trying to address an already entrenched pattern of predatory male behaviour does not work. Blaming the victim does not work. Lauren was not responsible for the considerable harm she experienced, and this review and others like them are an opportunity to reflect on how to improve the response to child sexual abuse and child sexual exploitation. Page 56 of 56 References ihttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/591903/CSE_Guidance_Core_Document_13.02.2017.pdf https://bristolsafeguarding.org/media/1213/brooke-overview.pdf https://bbcdevwebfiles.blob.core.windows.net/webfiles/Files/SCR-into-CSE-in-Oxfordshire-FINAL-FOR-WEBSITE_(2).pdf DfE (2018) Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children: London https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf Sara Scott, Di McNeish, Silvie Bovarnick and Jenny Pearce (2019) What works in responding to child sexual exploitation. DMSS https://www.dmss.co.uk/pdfs/what-works-in-cse.pdf https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/794554/6.5120_Child_exploitation_disruption_toolkit.pdf DOH (2000) Framework for the Assessment of Children in Need and their Families http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf Raws, P. (2016) Troubled Teens: A study of the links between parenting and adolescent neglect: The Children’s Society https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/troubled-teens-a-study-of-the-links-between-parenting-and RIP (2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence NSPCC (2014) Teenagers: learning from case reviews: Summary of risk factors and learning for improved practice around working with adolescents: https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/teenagers/ |
NC52434 | Review of three cases involving adolescent self-harm, including a young person who attempted suicide in 2021. Themes include: professional fears around challenging conversations with young people on self-harm being rooted in a fear of making situations worse; if foster carers are equipped and supported when taking on a young person who self-harms; issues around risk management plans and working collaboratively to find the best support for a young person; issues of working across boundaries, including young people being registered for services in a different borough and in relation to child and adolescent mental health service (CAMHS) provision; if therapeutic interventions are focused enough on the impact of adverse childhood experiences; lack of knowledge or experience in discussing gender identity with young people. Recommendations include: review working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health; adolescents are able to have agency over their own risk management plans; training on gender identity and what this means for young people; support parents struggling with self-harming behaviour; support the training of foster carers in understanding self-harm and risk management; the young person and their parent/carer have continued access to a CAMHS clinician regardless of where they are living; agree a mechanism for managing risk across agencies; ensure gender identity is a key strand of equality action planning across all agencies.
| Title: Thematic child safeguarding practice review – child and adolescent mental health (Young Person H and others). LSCB: Ealing Safeguarding Children Partnership Author: Ealing Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Thematic Child Safeguarding Practice Review – Child and Adolescent Mental Health (Young Person H and others) Introduction This review was conducted to consider three cases involving adolescent self-harm, occurring in close time proximity to each other; alongside young people involved in the Partnership reporting the daily struggles of young people with their mental health. This led us to the view that reviewing the cases would promote further improvement and learning. Only one of the cases met the criteria for a Rapid Review as defined in the Guidance, however, a Rapid Review was convened in a second case that, while not meeting the criteria, provoked a high level of professional anxiety regarding the ability to manage risk. This Review was conducted in accordance with the requirements set out in Working Together 2018 and is written with the intention of publication. Process In completing this Review, a number of key elements were employed to understand the experience of the three young people with services and to reflect on the challenges relating to adolescent mental health for practitioners and for young people. This included the following: 1. Individual agency reports to inform of services’ involvement 2. An event with practitioners to explore the issues raised and to consider issues around risk and professional anxiety that such cases bring 3. A number of events with young people to discuss mental health services and to determine their perspective on the services provided. These events were coordinated by the Youth Service and supported by the Young Ealing Safeguarding group. The reason for the Child Safeguarding Practice Review (CSPR) Learning Event: In 2021, information was received by children’s social care that a young person was found in their room by a fellow resident choking / having breathing difficulties having consumed unknown substances. They had several cuts and scratches to their body, both new and older; their body was covered in black paint or ink, as was their room. They left a ‘suicide’ note A panel of senior multi agency professionals was convened to consider the criteria for a CSPR in Working Together to Safeguard Children 2018. It was at this panel that two other 2 young people were discussed as each had common features. In addition, all presented professionals with high levels of anxiety around managing risk. It was decided to conduct a single local Child Safeguarding Practice Review and learning event regarding all three young people to identify learning and to improve arrangements to safeguard and promote the welfare of children. One of those young people was also subject of a separate Rapid Review. The three young people: • Young person A was born in the UK in 2004, their mother and father being from different middle Eastern countries. Young person A was born female but in November 2020 stated that they identified as non-binary and wanted to be referred to as ‘they’ or ‘their’. They also changed the name they wished to be known by. They has been looked after by the local authority since August 2016. • Young person B was born abroad in 2004. They were a few days old when they came to be cared for by their adoptive parents, the adoptive parents knowing a friend of the birth mother. The adoption was later formalised. The family moved to the UK in 2016. In September 2019 the young person first came to the attention of Children’s Social Care when they became looked after by the local authority, subsequently returning briefly to the care of their adoptive parents, before returning to the care of the local authority. • Young person C was born in the UK in 2005, their ethnicity is white. Young person C was born female but over the summer of 2021 they stated that they now identify as non-binary and wish to be known by another name. They have four siblings; their mother has a disability resulting in communication challenges. They have an Education, Health and Care Plan and are on roll at a school for young people who require social and emotional support. Legal framework and methodology for the review The ESCP’s statutory and relevant agency partners agreed to conduct a local CSPR with a thematic element to include three young people with common features. • It was agreed for a collective Child Safeguarding Practice Review (CSPR) learning event with all the professionals involved to be led by John Churchill, Acting Assistant Director from Children’s Social Care, Thomas Webster, Named Nurse Safeguarding Children and Young People from Health and Sheila Lock, Independent Chair and scrutineer of the Local Safeguarding Children Partnership. • A large quantity of multi-agency information was gathered in the initial stages of the review to support the practitioners’ learning event. The learning event was to identify learning to improve arrangements to safeguard and promote the welfare of children. • The practitioners learning event took place virtually in December 2021, attended by 42 professionals from 15 organisations. 3 • Young people undertook sessions under the leadership of the YES group Common features of cases for consideration These notes are a summary of the information drawn from the submissions of partner reports and from the commentary and the direct contributions of those attending the learning exchange events. It is clear that in all three cases there are common features of the cases that merit discission • They all involved adolescents • They were all born female • There were challenges around identity, particularly sexual identity • Sexual abuse had been reported in the past and had gone largely unaddressed • All displayed significant episodes of self-harm which was escalating • All were - or had been - in the care of the LA • All cases presented considerable concern to professionals regarding the ability to effectively plan and contain risk Key themes of the review practitioners learning event It is clear in the analysis of the learning reports supplied by agencies that all three young people presented issues in relation to their home circumstances that necessitated them coming in the care of the Local Authority. Self-harm and challenging behaviour were central to increased parental concern regarding their ability to keep their child safe from the risk of serious injury or death. Managing such risk and working to reduce it, are significant challenges for professionals also, and in each of the three cases professionals reported feeling anxiety that they could not mitigate out the risk for these young people. Underpinning this fear was a sense of an expectation that children being cared for by the state would be ‘safer’ and that, as professionals, in serious self-harm cases, this could not be a given. The review recognised that even the most detailed plan with strategies to ensure supervision could not prevent instances occurring. The young people went to considerable and determined lengths to cause injury to themselves. At the root of professional concern was a real sense that ultimately in the event of injury or death, they would be held responsible, despite best efforts. There were a number of key areas that emerged in the discussion and the chat around these cases. These issues triangulate with the discussions held amongst young people around self-harm and adolescent mental health These are set out with a short narrative below: a. The understanding of adolescent behaviour and risk taking The discussions with professionals and young people focused on the need to understand the development of adolescent brains, and the appetite for increased risk taking, alongside the development of behaviour to self-regulate that risk. There 4 was a view that the challenging behaviour of adolescents creates challenges for professionals, and, as a consequence, adolescents feel unheard and not seen. Risk means often the behaviours aren’t explored or discussed. For professionals the fear around the challenging conversation about self-harm is rooted in a deep fear of making the situation worse. For young people, not talking about such issues deepens a sense of not being cared about or listened to. The reality is – if someone is self-harming and is risking life changing injury or death, what worse can happen? b. Holding case risk This is an area of considerable exploration and discussion. There was a recognition of anxiety for professionals in relation to escalating self-harm and the unspoken fear that a child /young person might die from escalating activity. The culture of ‘blame’ was explored and recognised as a factor. The inability to mitigate or fix risk was discussed and acknowledged, alongside the challenge of how we accurately record such risk. In such cases professionals are left with a position of recognising that it is impossible to mitigate 100% of risk in such cases, and that this is something that alongside our professional responsibilities we must live with. c. Planning and managing risk In the discussions and using the written submissions, the issues around holding case risk, planning and assessment were explored and acknowledged. A number of issues and areas of challenge and potential improvements were noted, including: • Any significant change /incident should trigger more effective multi-agency planning and collaboration to share understanding of the presenting issue • Before changing a plan significantly, i.e., a placement, are we asking: what has changed to make this a viable proposition? Or are we being driven by available resources rather that the needs of the young person? • Are we effectively managing risk through strategy discussions when the risk is an allegation of a new kind of abuse on an open long-standing case? It was concluded that reflecting on these issues in our planning framework was important, reminding professionals of the need to collaborate and share decision making in high-risk cases. d. What does care look like for this group There was considerable discussion to consider the ‘ask’ we are making of foster carers in these situations: do we prepare, equip, and support them sufficiently with the reality of the risk they are taking on with a young person who self-harms? The responsiveness of our local approach to a crisis and potential breakdown in foster care was considered, alongside a discussion about who is the client in these cases. Is it the young person? Or is it those trying to support the young person? Or is it both? 5 e. Collaboration in risk management was discussed There was a view that in not planning effectively around risk management plans we don’t communicate and distribute risk across the system; this in turn means we are not working collaboratively to find the best support for the young person. It also means the risk sits disproportionately with one agency. f. Cross boundary working The complexities of regional arrangements, particularly in health were explored. The issue of working across boundaries was discussed, in particular, the challenges of being registered for services in a different borough to the residing borough, or in relation to the provision of CAMHS. The Integrated Care System and ensuing changes prompted a conversation regarding the protocols that should operate to ensure no one falls under the radar. g. Appropriate therapeutic intervention There was a discussion around therapeutic intervention and the assessment of the model to be deployed and its focus. Is it focused enough on the impact for young people with adverse childhood experience(s) was a critical and live question. The suggestion was that, too often, the impact of history on current mental state goes largely unexplored and that we could do more to ensure that this is recognised as being an underlying factor in current behaviours. h. Understanding health and health passports The discussion focused on whether health professionals did enough to ensure that mental health was given parity with physical health in the health passport. It was felt young people could be given more accessible tools, including the app to help ensure they were the drivers of information held about them. In addition, using technology to encourage young people to check in on feelings and moods was considered as an opportunity to open up greater dialogue. i. The complex nature of young people who self-harm and risk The multitude of professionals involved, illustrated by attendance at the learning events, was a feature that impacts on communication and planning, and that was recognised, particularly as some services are not borough-based. Ensuring one point of contact for young people was considered something that professionals should explore more effectively, recognising that this should be determined by young people and based on trust. The use of advocacy and the concept of care navigators were explored in trying to ensure the voice of young people was at the forefront. j. The challenge of parenting a child with mental health difficulties In many ways this is linked to the earlier points about responsiveness and supporting the right people to offer care. It was recognised, though, that managing anxiety and risk and its challenges, as articulated by professionals, is the same challenge parents face. They often have little by way of skills and experience, and feel significant anxiety when a child 6 starts to self-harm. Supporting those parents through training, information, advice, buddying and peer support, alongside engaging them fully and acknowledging their concern was felt to be important. The issue of respite was also a feature of the discussion - short break schemes akin to services for children with a disability. k. Gender identity There was an acknowledgement of the lack of knowledge, skill or experience in discussing this with young people and of the key part it plays in adding to young people’s sense of belonging and identity. Professionals highlighted the complexity of gender identity and the ability of professionals to keep abreast of this as part of the agency approach to equality and diversity. While recognising this is part of the piece around challenging conversations, it is also a key strand of equality training. Professionals considered that they want to operate in a climate of respect and inclusivity and that without exploring the issues for themselves safely they harbour a fear of getting it wrong. Young people were of the view that they have something to bring to the table in raising awareness and training professionals on these issues, based on their experience. l. The ability of the system to be responsive and to share and manage risk at an operational /strategic level The professionals group considered the concept of a dynamic risk register / risk panel to keep a multi-agency response to these young people high on the agenda. Professionals felt that such an approach would promote greater ownership and awareness, create more proactive responses and improve risk oversight. Key themes to consider in next steps A comprehensive action plan in response to this learning will be attached, but in the spirit of co-production, this will be produced following further collaboration with those commissioning services as well as with practitioners and will include collaboration with young people. a. Upskilling our workforce • Confidence to have difficult conversations, knowing sometimes that will reduce risk and does not increase it • Making sure IROs bring challenge to allegations that haven’t been pursued, particularly around CSA • Focused learning on gender identity – using lived experience of young people where possible • Making sure equality planning considers learning regarding gender identity • Developing professional curiosity and asking the right things • Understanding collective role as corporate parents 7 b. Recording of unmitigated risks • Reminding professionals not all risk can be managed away and those areas that cause ongoing concern should be captured c. Developing our collective responsibilities • Planning • Assessment • Listening to each other with respect • Validation of all contributions being important d. Reinforcing the voice of young people • Ensuring young people know their plan • Giving young people agency over their own plan • Providing a rationale to young people when it is not possible to safely act on their wishes Conclusions from the review practitioners learning event There were a number of conclusions and reflections from consideration of these three cases. Attendance at the events and including young people’s views suggest that this was experienced as a useful and worthwhile approach. a) The common features of the self-harm cases • All three were born female • All three highlighted issues around gender identity • All three have alleged being sexually abused • All three became looked after by the local authority b) We should not focus on introducing new things, but instead strengthen the process and policies we have, but perhaps remind people of the points above c) If we do have new things, we should limit them to be effective to include • A focus on upskilling people to have difficult conversations /talk about difficult issues • A focus on professional curiosity • Building skills and knowledge around gender and identity • Supporting professionals to recognise that you cannot mitigate against 100% of risk 8 Recommendations A number of key recommendations emerge from this work and should be considered further by the Ealing Safeguarding Children Partnership: Recommendation 1 - Understanding and managing the risk • Reviewing working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health • Dynamic risk management as Corporate Parent, including social work team and foster carers Recommendation 2 - Improving our engagement and plans for young people • Having the young person at the centre of the plan – adolescents are able to have agency over their own plans. • IROs to challenge practice to ensure young people are owning their own plans • Shared ownership of the plan to ensure all involved know and support this plan • Specific training to be provided on gender identity and what this means for our young people Recommendation 3 – Improving Engagement and plans with parents and carers • Supporting parents struggling with self-harming behaviour so that care is not always seen as the solution to managing risk • Supporting the training of foster carers in understanding self-harm and risk management Recommendation 4 - Strategic • Young person and their parent or carer to have continued access to a CAMHS clinician regardless of where they are living as part of the corporate parent offer • Agree working practices to ensure the location of young person’s GP is not a hindrance to continuity of CAMHS access • Agree a mechanism for managing risk across agencies, through exploration of a Dynamic Risk register • The partnership must ensure that gender identity is a key strand of equality action planning across all agencies and that it is a feature of workforce training 9 Post-script – case study During the course of this Review, professionals have continued to work with the three young people involved. In respect of one young person, they moved home over three months ago and there has been no hospital admittance during that time; and there has been no self-harming. There is support provided in the home, although this has reduced. The young person has been able to return to mainstream school and receive support from CAMHS. There are challenges, but there are some very good days too. The young person has been able to develop friendships at school and enjoy the normality of school life as well as being able to go shopping with friends. The young person’s relationship with the parent they live with is also improving helped by time they spend together walking. (25.3.22) |
NC52232 | Serious injuries to two unrelated children, Child Q aged 4-years-old and Child R aged 7-weeks-old, whilst in their parents' care in December 2020. In both these cases there was some professional disagreement about whether the injuries sustained were non-accidental, with paediatricians believing that the injuries in both cases were likely to be non-accidental. The families involved in these cases were both known to children's social care prior to the children's injuries. Professionals made several referrals to children's social care but these often did not meet the threshold for statutory intervention. Both cases featured recent and historic domestic abuse and historic safeguarding concerns. Mothers had experienced adverse childhood experiences and mental health problems. Disguised compliance and a lack of professional curiosity were also features in these cases, as well as issues around hidden men. Child Q was of a mixed background and Child R was mixed Black and White ethnicity. Learning includes: there was a lack of clarity about the men involved in the children's lives; domestic abuse didn't appear to have been considered by professionals; and there was disagreement between medical and children's social care professionals about the cause of the injuries. Recommendations include: decision making at strategy meetings should include all appropriate agencies; the children's workforce should feel confident recognising potential non-accidental injuries; and the development of a practitioner forum should be considered, where medical and social care staff can gain an understanding of each other's roles.
| Title: Local child safeguarding practice review report: Children: Q and R: date of significant incidents: December 2020. LSCB: Dudley Safeguarding People Partnership Author: Su Vincent Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 LOCAL CHILD SAFEGUADING PRACTICE REVIEW REPORT Children: Q and R Date of significant incidents December 2020 Review author: Su Vincent, Designated Nurse Safeguarding Children, Dudley CCG. 2 Contents 1. Framework of the review: ...................................................................................................... 3 2. Scope ...................................................................................................................................... 3 3. Summary of Facts ................................................................................................................... 3 4. Other relevant facts ............................................................................................................... 4 5. Analysis .................................................................................................................................. 4 6. Terms of reference ................................................................................................................. 9 7. Identified learning .................................................................................................................. 9 8. Conclusions and Recommendations .................................................................................... 10 3 1. Framework of the review: 1.1 Working Together to Safeguard Children 2018 contains the statutory guidance for undertaking Child Safeguarding Practice Reviews (CSPRs) when a serious child safeguarding cases has been reported. These are cases in which: • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed 1.2 Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. 1.3 Issues might appear to be the same in some child safeguarding cases but reasons for actions and behaviours may be different and so there may be different learning to be gained from similar cases. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families. 1.4 Some cases may not meet the definition of a ‘serious child safeguarding case’, but nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near miss’ events. Safeguarding partners may choose to undertake a local child safeguarding practice review or another form of review in these or other circumstances. 1.5 Two cases were referred into the DSPP Learning and Improvement sub group in September 2020 for consideration to potentially undertake an identified learning review. Following the Rapid Review Meeting (RRM) for both cases, similar themes were identified in both cases. The Rapid Review panel initially considered undertaking a thematic review of both cases but the National Panel recognised that much of the work had already been completed and learning had already identified. Therefore this local report has been completed using the findings of the RRM and identified learning from both cases. Terms of reference for the review were identified at the RRM. The RRM highlighted recurrent themes in the safeguarding and promotion of the welfare of children and some concerns around the way that two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. 2. Scope It was agreed that the scoping period would begin from the beginning of 2018 to the date of the critical incidents. Any pertinent information outside of the identified scoping period would also be included. 3. Summary of Facts Case 1 Child Q Identity Relationship to Child Age Ethnic Origin Child Q Subject child 4 Mixed-other mixed background Adult A Mother 22 Not recorded Adult B Father 21 Not recorded 4 Case 2 Child R Identity Relationship to Child Age Ethnic Origin Child R Subject child 7 weeks Mixed-Black and White Adult C Mother 23 White and Black Caribbean Adult D Father 21 White and Black Caribbean Child 2 Sibling 3 White and Black Caribbean Child 3 Sibling 8 White and Black Caribbean Child Q sustained a serious leg fracture whilst in the care of her Father. She articulated to the paediatrician that her father threw her onto a piece of furniture and broke her leg. The father has admitted to causing the injury but states that it was in play. The case is subject to an ongoing police investigation. Following the injury, father did not seek medical attention for the child who would have been in significant pain. The injury was identified by mother when father return Child Q back to her care the following day. The injury required surgical intervention and subsequent physiotherapy. At this time father cannot have contact with Child Q. Child R. Parents have two children. Child R and a 3 year old. There is also an older sibling residing with maternal grandparents under a Child Assessment Order (CAO) as mother was very young when she had the baby. There was a positive assessment undertaken by Children’s Social Care (CSC) during the pregnancy with her second child. There were no further contacts or referrals to CSC until the time of the critical incident. A referral was made from Russell’s Hall Hospital in September 2020 stating that Child R had attended A&E with his parents and had a boggy swelling on his head. An X-ray confirmed a fracture to the skull. There was also several bruises noted around the child’s eyes and leg. The explanation was that the child had accidentally fallen from a height of approximately 40 to 50 cm whilst father was changing his nappy. A child protection medical identified no internal injuries. Following the incident, father picked up the child who cried. He did not identify any obvious injuries and the child settled. Father called mother to inform her (mother was out taking Child 2 to nursery with paternal grandmother). Mother and father met up at the hospital. A CP medical was undertaken by hospital following the identification of the skull fracture and referral to CSC. An initial strategy discussion took place out of hours by EDT and included the involvement of a paediatrician. However there was a degree of disagreement around whether the mechanism described by father was consistent with the injury. A second strategy meeting was arranged for due to the professional disagreement regarding the mechanism of the injury and a joint S47 investigation was later agreed. 4. Other relevant facts No other relevant facts were identified 5. Analysis The serious harm criteria was discussed at length by the panel. Serious harm includes (but is not limited to) serious and/or long-term impairment of a child's mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical 5 health. This is not an exhaustive list. When making decisions, judgment should be exercised in cases where the impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred (WT 2018). The burden of proof in child abuse cases is different to that of the criminal courts. In a criminal case the standard is “beyond all reasonable doubt” in order to secure a conviction. In cases of suspected child abuse the standard of “balance of probabilities” is applied. In a recent case (Re BR Proof of Facts), Mr Justice Peter Jackson stated that in cases of child abuse: “The standard of proof is the balance of probabilities: Is it more likely than not that the event occurred? Neither the seriousness of the allegation, nor the seriousness of the consequences, nor the inherent probabilities alters this.” Whilst both children suffered significant injuries, medical opinion concluded that both should recover from the injuries with no long term physical or mental impairment. It was helpful to have the attendance of a senior paediatrician at the panel to discuss the mechanism and potential impact of both injuries. Paediatric opinion was that both injuries were more likely to have had a non-accidental cause. In both cases there appeared to be some professional disagreement around whether the injuries sustained by the children were compatible with the explanations offered by the parents. In the case of Child Q, the paediatrician was very clear at the strategy meeting that they felt that the explanation given by father would not have resulted in such a significant injury. There was evidence at the meeting that some professionals appeared to find it difficult to “think the unthinkable” and were somewhat complicit with the parental explanation. The decision in the case of Child R was subsequently challenged using the multi-agency escalation process which led to a S47 investigation being commenced. There were also a number of other themes that were common to both cases. These include Domestic abuse Both cases featured recent and historic domestic abuse. In both cases several domestic abuse notifications had been received. One case had been discussed at MARAC but both of the victims (mothers to the children in both cases), were reluctant to disclose the extent of the abuse, declined support and minimised the level of abuse within their relationships. In one case the mother stated to the GP that “although her partner was abusive, he was company”. This was considered to be quite typical of victims of domestic abuse who are often controlled to the point of acceptance (IRIS 2020). Domestic abuse has been identified as one of the adverse childhood experiences (ACEs) that has long lasting impact on the health and wellbeing of children. Children can experience both short and long term cognitive, behavioural and emotional effects as a result of witnessing domestic abuse. Each child will respond differently to trauma with some demonstrating resilience and not exhibiting any negative effects. However many children may also feel angry, guilty, insecure, alone, frightened, powerless or confused. They may have ambivalent feelings towards both the abuser and the non-abusing parent. Children’s responses to the trauma of witnessing domestic abuse may vary according to a multitude of factors including, but not limited to, age, race, sex and stage of development. It is equally important to remember that these responses may also be caused by something other than witnessing domestic abuse (NSPCC 2019). 6 In August 2020, Women’s Aid released the report: A Perfect Storm – The impact of the Covid-19 pandemic on domestic abuse survivors and the services supporting them. The report highlights that the covid pandemic and subsequent lockdown has had a negative impact on victims of domestic abuse. Two-thirds of survivors identifying as currently experiencing abuse stated that their abuser had started using lockdown restrictions or the Covid-19 virus and its consequences as part of the abuse. Lockdown restrictions and the fear of spreading the Covid-19 virus made it more difficult for women to seek support or leave their abuser during lockdown. Over three quarters of survivors of those living with an abuser said they felt they could not leave or get away because of the pandemic. (Women’s Aid Survivor Survey 2020). Children have also been impacted during the pandemic. Half of the survivors with children who were currently experiencing domestic abuse disclosed that their children had witnessed more abuse towards them, and over one third said their abuser had shown an increase in abusive behaviour directed towards their children. (Women’s Aid Survivor Survey 2020). Both of the cases involved injuries to children during the pandemic and both families were known to have had a history of domestic abuse. Historic safeguarding concerns and CSC involvement There had been historic safeguarding concerns in both cases. The mother of Child Q had been in care since the age of 4 and her stay put carers had raised concerns regarding her maturity and ability to care for her child. Her lifestyle was described as chaotic and the home conditions raised concerns. The child subsequently became subject of an Early Help plan in which mother was successfully supported to improve her parenting skills. In the case of Child R, mother had had a child placed with maternal grandmother as she was only 14 when she became pregnant. This child remains with her grandmother. A number of referrals to Children’s Social Care had been made by professionals in both cases but often did not meet the threshold for statutory intervention. At the Rapid Review meeting it became clear that not all agencies were in receipt of all of information required to inform their decision making and to undertake a holistic assessment of the family and child and to understand the child’s lived experience. There appeared to have been evidence of start over syndrome in both cases with historic concerns not always informing risk analysis and holistic assessment. Both mother’s had experienced ACEs in their formative years which is known to often impact on parent’s ability to safely parent their children. Maternal mental health issue In both cases, the mothers of the children had suffered from mental health issues. Both had previously been referred to CAMHS, and both suffered from depression and anxiety. Mental health assessments carried out seem to suggest that their mental wellbeing had been impacted by their experiences as children. The impact of ACEs on children going into adulthood is well documented and predict poor adult outcomes. Exposure to ACEs quadruples the risk of sexual risk-taking, mental health problems and problematic alcohol use and debilitating diseases. Over the past 20 years, ACE studies consistently confirm that the greater the number of ACEs experienced before the age of 18, the greater the chance of poor adult outcomes (Early Intervention Foundation 2020). 7 Decision making for ICPC It is important that all professionals working with children and families understand the concept of significant harm and also what constitutes abuse and neglect in order that they may engage with the strategy meeting and offer a professional opinion. They should be able to gather and analyse information as part of an assessment of the child’s needs. The West Midlands Multi Agency Safeguarding procedures identify that strategy meetings should be multi-agency as far as possible and should involve all key professionals known to, or involved with, the child and family. Local authority children’s social care, health and the police should always attend. Where the child is in hospital, the appropriate clinician should also be included. The strategy meeting/discussion should: • Decide whether, or how, section 47 enquiries should be pursued and produce a plan for carrying out the enquiries • Agree an interim multi-agency plan to adequately safeguard the child or children during the period between the strategy meeting/discussion and the first conference. The decision to proceed (or not) to ICPC in these cases appears to have been made unilaterally by CSC following the strategy discussion. There was little evidence of multi-agency decision making at the time and this was acknowledged in the scoping document provided by CSC for both cases. Disguised compliance Disguised and non-compliance was a feature in both cases. Cancelling appointments, DNA’s, not answering calls from professionals, not registering with GP featured in the scoping documentation regarding both children. Disguised compliance involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement (NSPCC 2019). Parents and carers may minimise concerns raised by practitioners or deny that there are any risks facing children. They may develop good relationships with some professionals whilst criticising or ignoring others which can divert attention away from parents’ own behaviours. Parents and carers displaying disguised compliance may manipulate professionals and situations to avoid engagement or intervention and some parents and carers may say the right things or engage ‘just enough’ to satisfy practitioners. This appears to be the case with both of these families. The mother of Child Q declined any support from domestic abuse services, police and both mothers engaged only intermittently with mental health support. Published case reviews highlight the importance of practitioners being able to recognise disguised compliance, establishing the facts and gathering evidence about what is actually happening in a child’s life. Professional curiosity Professional curiosity refers to “seeing past the obvious” and is a combination of looking, listening, asking direct questions, checking out and reflecting on information received. It involves not taking a single source of information and accepting it at face value and testing out professional assumptions about different types of families. Effective professional curiosity results in triangulating information from different sources to gain a better understanding of family functioning and the lived experience of the child which, 8 in turn, helps to make predictions about what is likely to happen in the future. In these cases it was clear that a number of professionals accepted what parents were saying. At the strategy meeting for Child R, some professionals accepted the father’s explanation for the injury despite a differing medical opinion. Studies demonstrate that often practitioners do not like to “think the unthinkable” and sometimes attempt to “fit” the injury to the explanation rather than to review the whole picture and review the case holistically. This suggests a ‘bias’ towards an optimistic interpretation of medical advice. It would appear that sometimes if paediatricians cannot definitively identify an injury as non-accidental, then an accidental cause if often accepted. An SCIE analysis of SCR reports found several examples in which agencies such as social care and the police wrongly interpreted medical advice about cause of injury as being definitive, when in fact it was only one of a range of possibilities. For example, advice that an injury could be consistent with the parental explanation being interpreted as meaning that the injury did have an accidental cause. The analysis within the SCR reports for these cases highlights a number of reasons for wrong interpretation of advice from health professionals, including: • a general over-reliance on medical opinion to determine risk, rather than the weighing up of a range of types of evidence • a ‘clash’ between social care and police pursuit of categorical explanations from medical professionals with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. Professionals also accepted the fact that both mothers reported that they had separated from their partners following incidences of domestic abuse despite evidence to the contrary, as both women had become pregnant following the alleged separations. Hidden men Men play a very important role in children’s lives and have a great influence on the children they care for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers / female carers. Both of these cases highlighted the issue of hidden men. It was difficult to determine which men were involved in the care of the children, which men were being referred to within the agency records and if father was actually biological father or mother’s partner. It was also unclear if the perpetrators of the domestic abuse directed to the children’s mother were fathers to the children or mother’s ex/current partner. Professionals involved with men who are fathers (such as substance misuse workers, mental health and probation officers) tend not to share information about potential risks with other professionals supporting the children and partners of those men. This may be because they are unaware the men have contact with their children. Consequently, practitioners depend entirely on parents to share this information, which they may or may not do. From the NSPCC Serious Case review analysis undertaken in 2015, two categories of ‘hidden’ men emerged: •Men who posed a risk to the child which resulted in them suffering harm •Men, for example, estranged fathers who were capable of protecting and nurturing the child but were overlooked by professionals. 9 Professionals sometimes rely too much on mothers to tell them about men involved in their children’s lives. If mothers are putting their own needs first, they may not be honest about the risk these men pose to their children. Professionals do not always talk enough to other people involved in a child’s life, such as the mother’s estranged partner(s), siblings, extended family and friends. This can result in them missing crucial information and failing to spot inconsistencies in the mother’s account. Professionals can be reluctant to judge the decisions parents make about their personal and sexual relationships. However this is to ignore the risks that might be posed to children by men who are in short-term, casual relationships with the mothers (NSPCC 2015). 6. Terms of reference Address the case specific terms of reference. • The scoping period will be from the beginning of 2018 to the date of the critical incidents. Any pertinent information outside of the identified scoping period would also be included • To identify the role played by the fathers of both children • To review the multi-agency decision making process when agreeing to proceed to ICPC • Did practitioners use professional curiosity when presented with evidence of neglect/abuse? • Did practitioners recognise and act on disguised compliance from both families? • Was the impact of maternal mental health issues on both mother’s parenting ability recognised by practitioners? • Were all involved practitioners aware of the history of domestic abuse? 7. Identified learning • There was a lack of clarity around the males involved in the lives of the children • The decision to proceed (or not) to Initial Child Protection Conference appears to have been made unilaterally by CSC • Practitioners often have difficulties managing cases in which they face hostility and aggression from families • Despite mother being seen with injuries, domestic abuse did not appear to have been considered or queried • There was clearly some professional disagreement between medical and CSC practitioners regarding the causes of the injuries. 10 8. Conclusions and Recommendations Both children sustained significant injuries which may or may not have long term effects on their health and development. Each of the families demonstrated a number of risk factors for abuse including maternal mental health issues and a history of domestic abuse, both of which can impact on parent’s abilities to safely care for their children. The decision to proceed to ICPC appears to have been made unilaterally and does not reflect the opinions of others attending the strategy meeting. In the spirit of partnership working, this needs to be addressed to ensure that equal gravitas is given to all agency judgements and opinions. The mother’s partner was very intimidating and sometimes threatening towards professionals involved in the case and it would appear that professionals sometimes struggle to deal with hostile family members and this may impact on their decision making and management of cases. Recommendations to include single agency and any multi agency 1. The DSPP should ensure that decision making at strategy meetings includes all appropriate agencies 2. That the children’s workforce feel confident and competent to recognise potential NAI in children 3. That the DSPP should consider the development of a practitioner forum to include medical and social care staff so that there is mutual understanding of each other’s roles when managing cases of potential NAI 4. That the learning from this case is shared across the partnership |
NC52206 | Serious injury to a 4-month-old baby consistent with shaking and an impact to the head in November 2015, resulting in permanent impairment. Mother was convicted of child cruelty to the baby and their sibling in March 2020. Both baby and older sibling were taken into care and adopted. Family were known to multiple agencies, including Children's social care. Concerns that neither parent seemed to have bonded with the baby. Parental history of: refusal to accept support or engage with services; social care interventions; teenage pregnancies; adverse childhood experiences; violence and crime (father), mental health issues (mother). Ethnicity or nationality of the baby is not stated. Lessons: if families do not want or refuse early help it, concerns should be escalated; intervention pathways need to be clear; new birth visitors should have all the information before the first visit; need to remain focused on all family members and their needs; information should be linked, shared proportionately and well-recorded; assessments should identify risks and vulnerabilities; referrals should be seen in context; engage with fathers. Blended approach based on Root Cause Analysis. Recommendations include: improved provision and organisation of early help services including how new birth visits are carried out; develop operational guidance to enable triggers where there are multiple referrals/contacts including using chronologies; fast decision-making when there is an open case and another referral is made.
| Title: Serious case review: BSCB 2015-16/03. LSCB: Birmingham Safeguarding Children Partnership Author: Anne Aukett Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review BSCB 2015-16/03Independent Lead Reviewer: Dr Anne Aukett Publication date: 18th November 2020 2 Contents Page 1. Introduction 3 2. Reasons for an SCR 4 3. Terms of Reference 5 4. Methodology 6 5. Family Involvement 8 6. Summary of Family Circumstances 9 7. Summary of Key Events 12 8. Key Issues arising from Review and Author’s Analysis of them 17 9. Conclusions, Key Learning Points and Comments 36 10. Recommendations to Address the Key Learning Points 44 11. Embedding the Learning from this Case 46 12. References 47 Appendix 1 Abbreviations Appendix 2 Agencies who participated in the SCR process by submitting an Information Summary Report and Chronology 3 1. Introduction 1.1 This report concerns the serious injury of a 4-month-old baby. Although the baby survived the injury, they will have permanent impairment as a result. The baby had head injuries that were non-accidental and were likely to have been caused by a single event of inappropriate forceful handling. The injuries were consistent with shaking and an impact to the head. The baby was also found to have an older rib fracture. The baby was the second child of two young parents - themselves children. During the process of the investigation the older sibling was found to have old injuries (rib fractures). Initially both parents were arrested; however the mother was later charged and pleaded guilty to causing the injuries to both children. In March 2020 the mother was sentenced to 12 months imprisonment for the first charge of child cruelty in respect of the baby, and a further six months for the second charge of child cruelty in relation to the sibling. Both sentences are to run concurrently and are suspended for 18 months. Both children were adopted in May 2019 where they have settled very well. 1.2 This does not appear to be a case of deliberate mistreatment or abuse but of the inability of a very young parent to cope. 1.3 There had been considerable involvement of agencies with the parents, their families and the two young children prior to the incident. 1.4 The Serious Case Review Sub-Group of the Birmingham Safeguarding Children Board (BSCB) discussed the case on 18th December 2015 and recommended to the Independent Chair of the BSCB that the criteria for a serious case review was met. The Independent Chair, after due consideration and peer review, agreed and decided on 27th March 2016 to commission this Serious Case Review. 1.5 This case fits the national profile of non-fatal physical abuse in that the baby was under a year old, the incident took place within the family, and the perpetrator was the mother. The baby had never had a Child Protection Plan but was known to Children’s Social Care. 1.6 These two children suffered harm in spite of all the work professionals were doing to support and protect them. Rather than looking at whether serious harm was predictable or preventable we need to look at the opportunities that arose for prevention and protection and the underlying systems and processes that might get in the way of, or support, such work. What could have been done differently? 1.7 At one of the meetings during this review it was said that as the “Threshold for Care” would not have been met (before the injury), how could it have been prevented? Surely there are more ways to protect children? 1.8 This case highlights learning in managing individual cases, working together as professionals and agency structures, processes and cultures. 4 1.9 In reviewing this case the author is mindful of the massive amount of organisational change in all agencies before, during and after the events described. Therefore, where changes have been put in place that would mean that practice now would be different, to those referred to within the review. 2. Reasons for a Serious Case Review 2.1 Statement of Working Together Criteria for an SCR 2.1.1 Regulation 5 of the Local Safeguarding Children Board’s Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) Abuse or neglect of a child is known or suspected; and (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (1) 2.2 Process of Decision Making 2.2.1 When considering the case on the information known at that time the Serious Case Review Sub-Group noted that there was a range of issues in relation to the family. The children’s parents were both teenagers with two children under the age of one, each having health concerns. Both parents were known to Children’s Social Care and had had intensive interventions in their own right. There was an unreported rib fracture in the sibling, and concerns about domestic abuse as well as the injuries indicative of shaking. There were a significant number of agencies involved with the family. The last assessment completed was in June 2015. 2.2.2 The recommendation from the Serious Case Review Sub-Group was to undertake a serious case review as the sibling had sustained serious non-accidental injuries and there were concerns about how agencies had worked together. 2.2.3 The Independent Chair agreed with the Serious Case Review Sub-Group. The injuries the baby had sustained were likely to result in sustained serious and permanent impairment of health or development. It was clear that agencies had been involved and risk factors identified but that the available information indicated that they had not necessarily worked collectively together to ensure the two children were effectively and fully safeguarded. 5 2.2.4 The Independent Chair peer reviewed the case and the peer reviewer agreed that the grounds for a serious case review were met. 3. Terms of Reference 3.1 Aim 3.1.1 The focus of the Serious Case Review is on the quality of professional practice and the way in which frontline practitioners worked as professionals within their own agencies and together to best identify the needs of the family, plan to meet those needs and progress those plans. 3.2 Process 3.2.1 This was to be a simple and proportionate review given that care proceedings were also underway, and that there was an outstanding criminal investigation that had not yet concluded. 3.2.2 A Lead Reviewer was identified and commissioned to lead the work. 3.2.3 The Serious Case Review was to use a blended methodological approach, led by the Lead Reviewer reporting to the Serious Case Review Sub-Group. 3.2.4 Both parents and their immediate family members were to be involved. 3.3 Time Period: 1st January 2015 – 18th November 2015 3.3.1 The review began at the point of the confirmation of mother’s pregnancy with the baby and concluded at the point of the admission of both children into foster care. 3.3.2 Some events prior to this were considered as they were important to subsequent events. 3.4 Key Issues 3.4.1 The Lead Reviewer was asked to utilise the methodology above and explore in depth: • The nature of the family’s needs, lifestyle and their ability to meet their own and their children’s needs themselves; • The needs of both the baby and the sibling, and the impact of those on both children’s lives; • The vulnerabilities inherent in two young parents caring for two children under one-year-old, both with health needs, and how well these were 6 identified, recognised and responded to by professionals in contact with the family; • The quality of interagency information-sharing, joint assessments of need, joint planning and joint interventions to support the family; • The quality of referrals, assessments and casework by Children’s Social Care in relation to both children during the period under review; • The theoretical casework models utilised, and the research evidence used by practitioners to inform decision making; • The journey the family experienced in terms of their contact with professionals over the period under review, and why things happened the way they did; • Those key incidents during that journey where positive learning can be identified and used to improve multi-agency and single agency practice in similar situations; • The impact of repeat short interventions on the family’s relationship with professionals; and • Any other key matters arising from the involvement of the family and the practitioner events. The Serious Case Review Report was also to consider relevant research as part of its analysis. 3.5 What was out of scope 3.5.1 The review was not to: • Consider in detail the baby’s birth family or previous agency contact with them unless it was directly pertinent to the terms of reference (e.g. the factors that gave grounds for care proceedings); • Consider events prior to the pregnancy and birth of the baby; • Consider the extended family network and agency contact with them except and unless it was pertinent to decision making. 4. Methodology 4.1 Independent Lead Reviewer 4.1.1 Dr Anne Aukett is a retired Consultant Community Paediatrician. She trained in Birmingham and held posts in the West Midlands, Sheffield and The Gambia. Much of her work was in safeguarding children. During her career she was a Named and Designated Doctor and Clinical Lead for Safeguarding at the Strategic Health Authority. She was the Vice Chair of Birmingham Safeguarding Children Board and Chair of the Serious Case Review Sub-Group. She was the author of six serious case reviews prior to the requirement for independence. Leadership posts 7 included Clinical Director and Medical Director. Since retirement five years ago she has taken on commissioned work including serious case reviews. 4.2 Panel Head of Service Safeguarding Children - Birmingham Community Healthcare Trust Detective Chief Inspector – West Midlands Police Childcare Quality and Sufficiency Manager – Early Years, Childcare and Children Centres Service Head of Service East - Directorate for People, Birmingham City Council Head of Safeguarding - Birmingham Women's NHS Foundation Trust Principal Officer Child Protection – Directorate for People, Birmingham City Council Neither the author nor the panel had any involvement in the case. 4.3 Participating Agencies 4.3.1 See Appendix 2 4.4 Methodology used. 4.4.1 A blended methodological approach was used based on Root Cause Analysis. (2) • Key incident chronologies and agency reviews were completed by each agency in contact with the family. • An initial learning event was held involving all the frontline practitioners and managers in contact with the family. At the event practitioners and managers were open and honest and some insight was gained into why things happened the way they did. It was salutary that some practitioners said that they had learned things about the family at the event that they had not known before. • Immediate learning and actions required were identified from the reports and at the event, some of which had/have already been implemented. • A second learning event involving middle and senior managers was held to look at the learning derived from the review and how this could be applied to the wider system especially in the light of changes since the events under review. This was also a helpful meeting given the pace of change. Managers were able to share where there are still difficulties in multi-agency working and where partners can help to address them. 8 • A final report with learning points and suggested recommendations. 5. Family Involvement 5.1 There is an expectation that families will be involved in case reviews. Working Together 2015(1) includes the following guidance: “Families, including surviving children should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.” 5.2 In this case the children were too young to speak for themselves but how they might have felt is considered. 5.3 Family perspectives can add valuable insights and support learning for future protective services but there are inherent tensions in the process.(3) The reality of such participation in this area is under researched and practice varies across the UK. However, it is acknowledged that families may have information about hitherto unknown aspects of a child’s life. On the other hand, families may have little understanding of the risks facing the child. 5.4 In this case it was felt that meeting with the family was an essential component of the review and would allow the family to have a voice in the process, contribute to the learning and raise, at an early stage, any concerns or issues that they felt they would like addressed as part of the review. 5.5 At the point the report was written, due to the ongoing criminal investigation, it was not possible to meet with relevant family members. However, subsequent to the conclusion of the criminal proceedings both parents were contacted. The mother has declined to contribute to the review process. The father has not responded. 5.6 During the Family Court proceedings mother admitted to causing the injuries to both children. 5.7 Mother has said that she felt guilty because she was not able to cope and that she did not want anyone thinking she had hurt the children. She did not want to think she had caused the injuries and had never meant to hurt them. She was finding it difficult to deal with the fact that she had hurt her children just like her father hurt her. The difference being that he meant to hurt her, but she never meant to hurt them, but they still got hurt and she has to live with that and feels very bad. 5.8 Father has said very little other than denying that he had anything to do with the injuries. 9 6. Summary of Family Circumstances This provides the “Context” as described in the model outlined below. At the time of the events under review the following was known about the family circumstances. It is to be noted that this family consisted of four “children”. 6.1 Mother 6.1.1 Mother was a very young vulnerable mother. She was 16 when this baby was born and 15 when the baby’s sibling was born. There was only eight months between the two births. 6.1.2 Mother herself had a troubled childhood and has disclosed that her parents regularly physically abused her as a child. 6.1.3 She has borderline/below average intellectual ability and it has subsequently been stated that she has a cognitive reading age of about 10 years. She attended primary and secondary school, but didn’t finish year 10 as she was pregnant. Attendance had been 83% up to that point. She returned to take one GCSE in Year 11 and obtained a grade C. She had behaviour problems at school – abuse to staff, truanting and being defiant. 6.1.4 She has three teenage siblings and a younger half sibling. There was significant police and social care involvement with her family with child protection concerns including domestic violence, poor living conditions, drug and alcohol abuse, unexplained burns to a sibling and anti-social behaviour. She was never in Local Authority care but was required to live with her maternal grandparents for a short period of time when she was 13. 6.1.5 Mother left her family home in July 2014 during her pregnancy with the sibling. Initially she went to live with her maternal grandparents together with her older sibling, but later moved in with her boyfriend and his family. Apparently in October 2014 (after her first baby was born) mother herself made a disclosure to Children’s Social Care regarding her own mother. This related to domestic violence and drug abuse. The youngest three children were made subjects of a Child Protection Plan (neglect). Mother was also assessed at that time, but her case was closed as she was said to be in a stable relationship with the father of her child. It was thought that she was supported by the father’s family. 6.1.6 As a teenage mother she was recruited to the Family Nurse Partnership (FNP) Programme (4) but left having disengaged. Following her arrest for the injuries to her baby, mother presented to her GP querying whether she had post-natal depression. She was started on anti-depressants. It was not felt she had any significant mental disorder but that this was a mild depressive episode and a fairly normal response to the situation. 10 6.2 Father 6.2.1 Father was 16 when the older sibling was born and 17 when this baby was born. 6.2.2 Father too had had a troubled childhood. He had been the subject of two Child Protection Plans, one in respect of inappropriate chastisement of himself and his siblings and one relating to his father taking inappropriate photos of a sibling. There were concerns about poor home conditions and presentation of the children. There have been many police contacts with his family. The majority of these incidents relate to neighbour disputes and anti-social behaviour. His mother left home suddenly in 2008/9 following a domestic violence incident when he was 11/12 years old. His father had a new partner (step-grandmother). 6.2.3 Academically he was said to be an able child with the potential to achieve, but during secondary school he had problematic behaviour including disruption, being argumentative and aggression. His behaviour was seen as anti-social and put him at risk of offending. This was mainly due to neighbour disputes. The Youth Offending service was involved, and he engaged with short-term work. His family was seen to be supportive at that time. 6.2.4 In July 2014 following a Section 47 enquiry he and the other children in his family were subject to Child in Need Plans. 6.2.5 Father has been linked to numerous incidents of violence towards others and property (not family members). These have not resulted in a conviction. In February 2015 he is alleged to have assaulted his stepmother’s ex-partner with a baseball bat. In July 2015 he was the victim of a minor assault. 6.2.6 Father briefly left the family home on 27th September 2015 but had returned by 7th October 2015. During this time, he fell off a bike and sprained his wrist. 6.2.7 He was in work (apprenticeship). 6.3 Sibling 6.3.1 The baby’s older sibling was only a year old at the time of the serious injury. This was the parents’ first child who was born at 38 weeks. It would appear that mother was initially pleased to be pregnant with this child, but when she was involved with the FNP worker she seemed to have little attachment to the new-born baby and was disappointed by the sex of the child. 6.3.2 The sibling had had their routine child immunisations and had had other minor health problems for which they were appropriately taken to the GP. They had an Atrial Septal Defect (ASD) which was identified by the GP at the age of 2-months-old. This is a small hole in the heart which usually causes no problems in childhood but requires six-monthly reviews by the hospital. The sibling was otherwise healthy and was meeting their developmental milestones. 11 6.3.3 The sibling presented as a smiling inquisitive child and was reported to have good interaction with the mother. It was later said that the child could present with challenging behaviour such as screaming and slapping and that they were a poor sleeper. 6.3.4 The sibling had a severe nappy rash at the time of the incident. 6.4 The Baby 6.4.1 The baby and subject of this review was the second child. The birth was not planned. The baby was born at 28 weeks gestation and spent 2 months on the Neonatal Unit (NNU). At the time of discharge the baby was 36 weeks gestation. The baby was ventilated on the NNU and had chronic lung disease as a result of immature lungs which required oxygen at home. On discharge from hospital the baby was tube-fed but by the time of the incident was taking bottles, albeit sometimes with difficulty. 6.4.2 The baby had a Patent Ductus Arteriosus (PDA). This is an extra small channel near the heart common in premature babies, which usually closes in time on its own. The baby was on no treatment for this. Scans whilst on the NNU showed some brain haemorrhages associated with the baby’s prematurity. These were without clinical significance. 6.4.3 The evidence seems to be that mother and indeed father did not bond with the baby. 6.5 Home Circumstances 6.5.1 Both parents were living with the paternal grandparents from early in the pregnancy with the first child (June/July 2014). Mother appeared to receive a great deal of support from step-grandmother. 6.5.2 Mother, father and their first baby moved into their current address on 9th March 2015. This was following a homeless application due to overcrowding at the paternal grandparents’ home. They seem to have been proactive in requesting repairs to the property, but there was a report of a burglary on 29th March 2015. 6.5.3 In the house at various times there was also a dog, a bird, and a snake. After the move to their own home mother appears to have continued to have considerable support from step-grandmother and spent part of most days in that household. 6.5.4 Father seems to have had little to do with the care of the children especially during the day when he was either at work or out with his friends. 12 7. Summary of Key Events 7.1 Events prior to the timeframe of the Review 7.1.1 These are included as they are important to the subsequent decision-making in the case. 7.1.2 During her pregnancy with the older sibling mother was enrolled in the Family Nurse Partnership Programme. The FNP worker worked with mother in the summer of 2014. On 15th July 2014 the FNP worker raised a number of concerns with the family’s social worker (parenting capacity, attachment and bonding, ability to parent, ability to respond to child’s changing needs, overcrowding, limited support from maternal family, domestic violence, mother having been brought up in a cycle of deprivation). This was a social worker who was carrying out an assessment of mother’s family following a referral regarding domestic violence. Mother at that time was moving between her own home and that of her boyfriend (father). 7.1.3 The social worker told the FNP worker that he could not open an assessment on the unborn child and gave the number for Information and Support Service (IASS) in order for the FNP worker to make a referral. The social worker also said that he would make sure the information she had given him was recorded on mother’s assessment. On 16th July 2014 the FNP worker phoned Children’s Social Care and a referral form was sent electronically. There is no trace of this referral on any of the Children’s Social Care systems; however, the FNP Nurse received an automated response that it had been received and was to be dealt with by the social worker already working with the family. The case was never opened, and no further action taken. The social worker did not record the concerns on mother’s assessment and indeed recorded that there were no concerns regarding the pregnancy having contacted the GP surgery. That assessment was closed on 21st July 2014 with no further action. 7.1.4 As a result of the FNP worker making this referral mother disengaged from FNP. Mother told the FNP worker she did not want her as her worker. She was unhappy about her making the referral. She did not want the FNP Nurse “meddling in her life”. She refused input from both this worker and the Programme. The FNP worker was involved for approximately three months. It is not clear when she stopped visiting but the health visitor received a handover on 7th November 2014. 7.1.5 On 4th September 2014, when the community midwife made a referral regarding the unborn child (sibling) she mentioned mother had declined FNP support. Mother apparently consented to this referral. No action seems to have been taken. 7.1.6 This first child was born in October 2014. 13 7.1.7 In October 2014 Mother made a disclosure to Children’s Social Care relating to her own mother and as a result of this all her siblings were made subjects of a Child Protection Plan. No further action was taken in regard to mother as she was no longer in the family home and was seen to be supported by father’s family. 7.1.8 On 23rd October 2014 the community midwife did her final post-natal visit. She noted that the home environment was unclean with a strong smell of animal urine. There was underwear on the floor in the hall with human faeces. The baby was discharged into the health visitor’s care and the midwife documented that she would contact the health visitor. 7.2 Events leading up to the injury within timeframe of review 7.2.1 On 12th January 2015 mother’s pregnancy was confirmed by her GP. The sibling was then three months old. 7.2.2 Mother attended her first antenatal appointment with the community midwife on 2nd February 2015 when she was accompanied by step-grandmother. The following day (3rd February) a homeless application was made. As both mother and father were under 18 a referral form was sent to Children’s Social Care. Although clearly recorded by Housing with a copy of the form no trace of this can be found within Children’s Social Care. 7.2.3 The first key event occurred on 6th February 2016 when mother’s sibling disclosed to the school nurse that mother was experiencing domestic violence and was pregnant. The school nurse made a verbal and written referral to MASH regarding this allegation. She also phoned the health visitor. On the following Monday a Strategy Meeting was held at MASH involving the police, social care and health. An ‘amber’ rating was given, and a decision made for a single agency assessment. A social worker was not allocated until 17 days later and a home visit not done until 16th March, more than five weeks after the referral. 7.2.4 In the interim, on 9th March the family had moved to their own home. 7.2.5 The assessment was completed and closed on 10th April 2015 with mother referred to a children’s centre two months after the referral. This key event is discussed in more detail later. 7.2.6 As the family had moved, a new health visitor was allocated on 13th May 2015 although the old one remained involved up to the point of handover. The new health visitor visited on 26th May 2015. Mother declined children’s centre support or a family support worker. The issue of what to do when support is clearly needed but declined is considered later. 7.2.7 On 17th June 2015 mother went into labour at 28 weeks gestation. The baby was born and admitted to the NNU. The sibling was eight months old. 14 7.2.8 Mother went home two days later. 7.2.9 The midwifery service contacted MASH to check if the family were known as part of the lateral checks for the baby and were told that mother had been previously known and the last assessment had been completed on 3rd June 2015 (the author remains unclear what this related to). They also contacted the health visitor and on the same day received information from the health visitor who advised FNP were involved (inaccurate). No concerns were noted. The new family health visitor contacted the NNU on 24th June 2015 with more accurate background information and a “discharge-planning booklet” was commenced on the NNU. Mother was discharged from the midwifery service on 29th June 2015. 7.2.10 On 20th July 2015, the new birth worker visited the home. The baby was still in hospital and the worker had no information about the family. The “assessment” completed relates to the sibling. She contacted the health visitor. This is discussed later. 7.2.11 The baby remained on the NNU for two months. The baby had the usual medical problems of a premature baby and remained oxygen-dependent. Mother visited most days and learnt to care for the baby. There is little recorded about father’s visits. 7.2.12 At the first visit of a new HV (previous one had left) on 30th July 2015 mother disclosed that she was struggling to cope with visiting the hospital and caring for the sibling and on 4th August 2015 after another visit the health visitor phoned the NNU about home conditions and was told that a discharge planning meeting would be held. The NNU contacted Children’s Social Care for information but were told the baby was not known. 7.2.13 The baby was discharged home on 13th August 2015 on tube feeds and oxygen. No discharge planning meeting was held. The baby was 36 weeks gestation. This key event is discussed later. 7.2.14 The Neonatal Outreach Team visited regularly starting on the day after discharge. The health visitor did the New Birth visit on the 17th August 2015 and mother and baby had a post-natal check at the GP on the 20th August 2015. 7.2.15 Over the following four weeks the baby was admitted three times to the Paediatric Unit (24th August, 9th September and 14th September 2015). On each occasion the baby was discharged within 24 hours. 7.2.16 On Friday 25th September 2015 the health visitor visited. This was another key event and was a follow-up visit to one on the 22nd when the sibling had a severe nappy rash. The health visitor offered to complete a Family Common Assessment Framework (FCAF) but mother refused. Following advice from the Trust Safeguarding Team the health visitor made a phone referral to MASH followed up by a Multi-Agency Referral Form (MARF). The essence of this referral was that 15 mother was not seeking appropriate medical advice to treat the nappy rash and was not being straightforward with professionals. 7.2.17 Father left the family home on the 27th September 2015. 7.2.18 The following Tuesday (29th) the health visitor went again to the home. She found mother tearful. Father had left. The sibling had a bruise on the forehead. Mother felt she couldn’t cope alone and was now accepting of family support. The health visitor didn’t pass this new information onto MASH but completed an FCAF with mother and referred to the local children’s centre for family support. A multi-agency professional discussion between Children’s Social Care and the police was not held at MASH until the 6th October. It was agreed that the case should be allocated to an Assessment and Short-Term Intervention (ASTI) worker and a family/single assessment commenced. This was now 11 days after the referral. The case was allocated on 10th October 2015 (two weeks post referral) and he made an unannounced home visit on the 14th. This sequence of events is discussed later. 7.2.19 The health visitor phoned mother on the 1st October and visited again on the 7th and 13th. Father had returned. The sibling’s nappy rash was not improving, and mother had not consulted the GP as advised. She stated she had an appointment that day but when three days later the health visitor checked with the surgery she was told the child and family had not been seen since August. The health visitor then phoned and e-mailed the social worker team manager expressing concern about the family and learned that the social worker had already visited and had also been told that the sibling had been taken to the GP for treatment. It was decided that a joint home visit should be done, and this was scheduled for 20th October 2015 7.2.20 In the meanwhile, a FSW was allocated on 12th October and had made several failed attempts to contact mother and had drawn up a draft Family Support Plan. She had also spoken to the health visitor. It was decided that the FSW should visit after the planned social worker/health visitor visit on the 20th. 7.2.21 On the evening of 17th October, the baby was admitted to hospital with serious injuries. 7.3 Events after the admission to hospital with the serious injury 7.3.1 The baby was admitted to hospital after a 999 call. The baby had difficulty breathing and was treated overnight on the High Dependency Unit. The initial focus was on providing urgent medical care. Seizures were noted in the early hours of the morning and a CT scan later that day showed an extensive subdural haemorrhage. Following discussion with the Children’s Hospital, non-accidental injury was suspected. This was discussed with mother and the nursing staff made a safeguarding referral to the Emergency Duty Team (EDT) at approximately 8pm 16 on the 18th October. Concerns were expressed about the safety of the sibling at home with father overnight. The social worker provided information about past Children’s Social Care involvement. The referral was followed up the following morning (Monday) when a MARF form was sent to MASH. 7.3.2 The social worker spoke to the medical staff later that day and confirmed that the sibling was with father and paternal grandparents. 7.3.3 The following day the Safeguarding Nurse from Heart of England Foundation Trust phoned the social worker who stated that a professionals’ meeting or strategy meeting would be held depending on the results of the medical investigations and that he would meet with the parents. Later that day the social worker met with the safeguarding nurse and informed her that the paternal grandparents had current involvement with Children’s Social Care. She queried the placement of the sibling with them and whether a strategy discussion should be held and the police informed. The social worker said he intended to do that. 7.3.4 On the 21st October the Named Doctor reviewed the x-rays and an old rib fracture was seen. A skeletal survey was done, and a skull fracture seen. The ophthalmologist examined the baby and found retinal haemorrhages. There were several phone calls between the safeguarding nurse and the social worker’s team manager relaying the information about the medical findings. Concern was again expressed about the sibling and a strategy meeting requested. The police were informed and a strategy meeting scheduled for the 22nd October 2015. At some time during the day the social worker visited the ward when mother, father and sibling were there. At the end of the afternoon nursing staff were still worried about the safety of the sibling and also how they should supervise the parents with the baby on the ward. These concerns were eventually expressed to EDT who suggested the ward staff should persuade mum to go home and that a “safe and well” check would be done regarding the sibling. 7.3.5 The doctor explained the situation to mother who, after phoning father, went home. It was apparent that the sibling was with father at home. The doctor informed the police who found the sibling at home with father when they visited the family home with a social worker. They were both taken to the paternal grandparents’ house. The police and social worker were happy with this arrangement. 7.3.6 On the 22nd October a strategy meeting was held. Both children were placed in Police Protection and Section 47 enquiries started. Parents were arrested and interviewed. Later that day the sibling was placed in foster care. This was four days after concerns had been expressed about the sibling’s safety. 7.3.7 The following day during a discussion about the children going into care, mother told the social worker that she had shaken the baby. 17 7.3.8 On 29th October old rib fractures were found on the skeletal survey of the sibling. 7.3.9 On 18th November Interim Care Orders (ICO) were obtained on the baby and the sibling and on discharge from hospital on 30th November the baby too went into foster care. 7.4 What has happened since 7.4.1 Mother went to the GP on 26th October 2015 expressing concern that she may have postnatal depression. This led to the GP referring her to the Mental Health Trust Single Point of Access. The referral was screened on the same day by a community psychiatric nurse who forwarded it to the Community Mental Health Team who subsequently saw her. On the advice of her GP mother also self-referred to Birmingham Healthy Minds. 7.4.2 The parents separated in November 2015. Mother has said that father “kicked her out”. She has gone back to her mother’s home. 7.4.3 Father is said to have a new relationship with a 16-year-old girl who is now also pregnant. 7.4.4 There has been a parenting assessment done in which mother engaged and did well. Father did not engage. He has asked to be reassessed with his new partner. 7.4.5 The foster carer had expressed concerns about both children: developmental delay in the baby and worries about poor interaction, developmental delay and poor weight gain in the sibling. These symptoms in the sibling may well relate to poor attachment given the child’s experiences in the first year of life. 7.4.6 The baby has been followed up by the neurosurgeon. The baby has developmental delay and hemiplegia as a consequence of the head injury. 8. Key Issues arising from the Review and Author’s Analysis of them 8.1 In reviewing this case the author is mindful of the recent report and triennial analysis of Serious Case Reviews (5) where it is stated: “We therefore suggest an approach that steers away from whether a death or serious harm could have been predicted or prevented to acknowledging that there is always room for learning and improvement in our systems.” 8.2 Also the Wood report (6) where it is stated, “The main purpose of an enquiry into an event is to improve the systems we provide to protect children” and “If we want to achieve a safer system to protect children, we must create an environment in which better skilled practitioners can practice and get on with the work of protecting children.” 18 8.3 The Triennial Review report suggests a model “Pathways to harm, prevention and protection”, which is outlined in diagram form below: Pathways to harm, prevention and protection From: Sidebotham, Brandon et al. (May 2016) (5) 8.4 This postulates that by looking at cases within a framework that looks for opportunities for prevention/protection within this concept of pathways to harm, there is a shift away from individual blame to opportunities for improvement within the system for safeguarding children. 8.5 The focus of this Serious Case Review is on the quality of professional practice and the way in which frontline practitioners worked as professionals within their own agencies and together to best identify the needs of the family, planned to meet those needs and progress those plans. Therefore, the key issues will be about preventative and protective actions by agencies and the systems and processes to support them. However, the context of the children’s and the parent’ characteristics, predisposing vulnerabilities and risks will also be discussed as will protective actions that were taken by the family. 8.6 The essence of this case revolves around a struggling young parent, not an intentionally wicked or cruel one. This fits with a national pattern where 44% of maltreatment-related deaths were not intentional (5), and the local picture as reflected in the recent review of Serious Case Reviews. (17) Therefore, in looking at professional practice we are not so much looking at whether professionals identified signs of harm but whether they recognised that mother was struggling to cope and what they did about it. 19 8.7 The nature of the family’s needs, lifestyle and their ability to meet their own and their children’s needs themselves 8.7.1 In the pathways model this relates to predisposing risk. 8.7.2 There were four children in this family: both mother and father were children themselves. There is a large body of evidence on adverse outcomes associated with teenage pregnancy. Neither parent had positive parenting models and would have had difficulties in putting their children’s needs above their own. There is a general consensus that child maltreatment, particularly physical abuse, may lead to an intergenerational transmission of negative or abusive parenting behaviours. More recently emphasis has been placed on a maternal history of emotional neglect being associated with poor parental outcome. (7) Mother’s own childhood, up to the point she left her home, was characterised by physical abuse, domestic violence, drug and alcohol abuse and neglect. On moving to father’s home, she moved to another household where violence and anti-social behaviour were commonplace. 8.7.3 Father’s childhood was also troubled with concerns about neglect, inappropriate chastisement and possible sexual abuse. Neither parent had a positive experience of intervention by statutory agencies, particularly Children’s Social Care, who throughout their childhoods appear to have intervened for short periods with no real change in the children’s circumstances. 8.7.4 Apart from these adverse childhood experiences there were other areas of predisposing risk. There was a history of criminality (father) and domestic violence. Whether mother had an underlying mental health problem is unclear. She presented to the GP post the event feeling depressed and she has since revealed that she was exhausted, stressed and cried most days. 8.7.5 Even experienced/mature parents would have had difficulties coping with a premature baby and their needs and there also seems to be evidence that neither parent really bonded with this child. There was certainly maternal ambivalence to this pregnancy and possibly to the previous one when mother expressed disappointment at the sex of her first child. These feelings may well have continued. 8.7.6 It would appear that father had little to do with the care of the children. He was out most of the day at work and once home often went out with his friends leaving mother to cope alone. Whilst the baby was on the NNU he visited rarely. In this he demonstrates his immaturity. 8.7.7 It would appear that mother gained considerable support from the paternal step-grandmother. Whilst living in the same household this would have been practical and hands-on, but once out of this household the support would have been more distant. Mother and the sibling certainly spent time at the paternal grandparents’ 20 house, but this became more difficult once the baby was born and came home. Mother seemed to have accessed some support and advice by phone, but she was isolated having moved to a new area away from what little support she had. 8.7.8 The house move was positive in that it moved the family from an overcrowded and possibly unsafe environment. It did however disrupt any positive social networks and certainly disrupted mother’s antenatal care and health care for the sibling as mother failed to register with a new GP until 19th August, 5 months after the move and well after the birth of the baby. This house move added to the family’s vulnerability. 8.7.9 There was therefore evidence of cumulative and interrelated risk of harm to these children. All of the above information was available to agencies at the time and this is considered further below. 8.8 The needs of both children and the impact of those on both children’s lives 8.8.1 In the pathways model this relates to predisposing vulnerability. 8.8.2 The sibling was only one year old at the time of the incident. It would appear that this child had little in the way of health needs. The heart defect would not have impacted on their life at all and it appears they were taken appropriately to the GP for minor childhood ailments as well as for their immunisations. The sibling was only eight months old when the baby was born. Developmentally the sibling was said to be within normal limits. At this age the sibling would have started to crawl and be inquisitive. The sibling was a poor sleeper and it has since been stated that they would wake up two or three times a night. The sibling would be in need of play and stimulation. It was observed by the health visitor that there were few toys in the house. The health visitor also noted that mother was “short” with the sibling and had to be reminded that they were still very young and needed a lot of care and attention themselves. It was noted that mother did not appear to fully understand these needs. However, it is also observed that the sibling was mostly appropriately dressed and that they had good interactions with mother. Little is observed about the sibling’s interactions with father. 8.8.3 From the sibling’s point of view the birth of the baby would have had considerable impact as initially they would have had to be cared for by others whilst the mother spent time on the NNU, and later once the baby was home mother’s attention would have to be divided between the two, of which the baby required a great deal. The sibling’s challenging behaviour (screaming and slapping) may have been their only way of expressing that the mother was ignoring them. The sibling’s untreated nappy rash would also have been very uncomfortable. This also indicated that the sibling’s physical needs were of lower priority to mother than those of the baby. 8.8.4 The baby had considerable needs. 21 8.8.5 “Babies and young children are inherently vulnerable and dependent, and features which mark them out as especially fragile place them at higher risk of abuse and neglect. Low birth weight babies and those requiring special care…potentially pose challenges to their parents over and above the considerable demands of any new born infant.” (5) 8.8.6 The pregnancy with this baby had not been planned and neither parent really bonded with the baby. Once home the baby required oxygen all the time which would have meant it was difficult for mother to take the baby out of the house. The baby was initially tube fed. Mother and father had been taught to do this. Once fed by bottle the baby remained quite a difficult feeder and frequently vomited. As a premature baby they required frequent regular feeds, which necessitated a night feed. Mother was understandably anxious about the baby and this led to three admissions back to hospital. 8.8.7 It was of concern that mother did not always follow the advice given about the care of the children particularly in terms of getting medical attention for the sibling’s nappy rash, but in hindsight it can be seen how difficult this may have been for her with no help from father and a very needy baby. She later admitted how much she was struggling to cope with the children. Her own experiences are likely to have meant that although she could cope with their physical needs, she lacked the empathy to deal with their emotional needs. 8.9 The vulnerabilities inherent for two young parents with two children under one year, both with health needs, and how well these were identified, recognised and responded to by professionals in contact with the family 8.9.1 This relates to both preventative and protective actions by agencies in the above model. 8.9.2 Lord Laming in his 2003 report (8) says “Cases involving vulnerable children do not come with convenient labels attached” but in this case they were pretty obvious. 8.9.3 There was evidence of so-called “cumulative risk of harm” but research indicates that most children living in vulnerable or risky environments are unlikely to be abused. Equally it is difficult, often impossible, for professionals to protect children if their parents are not open and honest with them. Mother did not engage fully with professionals and father not at all. 8.9.4 “There is cumulative risk of harm when different parental and environmental risk factors are present in combination or over periods of time…adverse experiences in the parents own childhoods, a history of violent crime…When presented with any of these risk factors, practitioners should explore whether there may be other cumulative risks of harm to the child, as well as any protective factors.” (5) 22 8.9.5 In working with the families with these risk factors it is often Universal Services that play an important role. Children at the threshold of intervention may be at particular risk. (5) The actions of these services are considered here and the actions of CSC in section 8.11 below. 8.9.6 All agencies failed to engage with father. He never attended antenatal appointments and so the midwives never saw him. The health visitor never saw him either and did not seem to explore his relationship with mother and what role he had in the lives of the children. She and others accepted at face value mother’s assertion that the allegation of domestic violence was malicious and didn’t seem to explore why he had left the family home and indeed why he had returned. Also not explored were the consequences of the mother’s strained relationship with father or the support mother received from his family. The neonatal unit staff also had opportunities to enquire about father. He rarely visited the baby, but when he did so there is little indication that he was engaged in any meaningful way. This lack of effort to find out about the men in children’s lives has featured in other serious case reviews. 8.9.7 There is a difficult balance to be struck here in that enquiry about him from mother could have put more pressure on her. Direct contact with him would have been difficult as he was out of the home during the day and most of the professionals work mainly 9-5 Monday to Friday. Having said that, more efforts could have been made by utilising end of day visits and telephone calls. Some social workers do work late and at weekends. The FNP Programme does try to engage young fathers as well as mothers. Although he was registered on the children’s centre system this was only as the father of the children and it is unclear what, if any, services could have been offered to him. 8.9.8 “Although families are usually a supportive and protective element in a child’s life, for some the wider family context can instead present additional risks.” (5) 8.9.9 Mother repeatedly stated to professionals that the extended (paternal) family were supportive, indeed this is given as a reason for not engaging in the offered Family Support Services. This support from the paternal family was therefore assumed. Evidence gathering or further assessment did not test the assumptions. There was over optimism about this given the history of that family. 8.9.10 The FNP worker whilst working with mother did identify vulnerabilities both in mother’s attitude to her unborn child and the risks in both households. Unfortunately, although she appears to have acted on these concerns this was not followed through and led to mother’s disengagement with this service, which would probably have been the most appropriate intervention to support her. During the first pregnancy the Midwifery Service had similar concerns and responded by making a referral to Children’s Social Care. The support from the extended family was again given as a reason for no further action regarding the 23 unborn child. The recognition by these professionals of these vulnerabilities are cited, although out of scope, as it is clear that there were concerns about mother’s ability to parent from mid-2014 onwards, but nothing was logged about this until February 2015. 8.9.11 When mother’s pregnancy with the baby was confirmed there was no record as to whether there were questions asked by GP or Midwife as to how mother, who was still a child herself, would cope with two babies under the age of one. The midwife did not ask the usual question about domestic violence, as the paternal step-grandmother was present. She did however refer to the Teenage Pregnancy Midwifery Service even though mother had declined this service. The GP did not enquire further at the postnatal check either. This is highlighted in the report from the Clinical Commissioning Group. 8.9.12 It is not clear whether the issue of mother’s mental health was explored at all. The health visitor should have enquired routinely using the Whooley Questions (12) but this was not recorded although it is recorded that she responded to enquiries about how she was managing with “fine”. She gave similar answers with the previous baby. The GP did not enquire about her mental health. 8.9.13 The Health Visiting Service did offer an enhanced service Universal Plus. This is offered to families with additional and complex needs. The health visitor visited on a regular basis and was persistent in offering further Early Help through FCAF and Family Support Services. When these services were declined frequent contacts and support were maintained. 8.9.14 The school nurse in her referral to MASH in February 2015 recognised the vulnerabilities of both mother and child and responded appropriately (see 8.5 below). However the main focus of the subsequent assessment was on the sibling and not on mother’s own needs as a child herself. 8.9.15 When the baby was born the midwives were aware of the social concerns highlighted in the pregnancy, but this did not feature in their handover to the NNU. When mother requested to go home, they did recognise the vulnerabilities of the mother with two young babies and contacted the Maternity Safeguarding Team. They erroneously thought that FNP was still involved and were informed by MASH that there was no current Children’s Social Care intervention. They also contacted the health visitor and this prompted her to phone the NNU and share the information she had. The NNU documentation lists quite a comprehensive list of vulnerabilities. Although a discharge planning booklet was commenced the identification of the factors did not lead to an enhanced assessment regarding the additional support the parents would need, and no discharge planning meeting was held (see later). 8.9.16 Whilst on the Unit the staff clearly monitored mother’s visits and observed her interaction with the baby. They were generally positive about her provision of 24 care for the baby although there were some indications of her difficulty in managing to visit and care for the sibling. At the point of discharge mother was deemed to be competent in the physical care of the baby but there was no evidence that they considered the family as a whole, the young age of the parents, their own experiences of childhood, the emotional impact of caring for the baby and another child or parental access to support. This is acknowledged in the Heart of England Foundation Trust’s own report. Further support was however given by the Neonatal Community Outreach Team who visited regularly. 8.9.17 Following the birth of the baby there was a New Birth visit by a new birth worker from the children’s centre. The worker did not know anything about the baby who was still in hospital. The visit instead focused on his older sibling and did not record any concerns. Mother was told of support groups available at the centre. The new birth worker did contact the health visitor on her return from the visit as she was concerned that both parents were very young and had two babies under the age of one. This raises questions about the current process of new birth visits and is discussed later as well as in the report from the Early Years Service. 8.9.18 The only other professional involved was a housing officer who interviewed the parents when they requested rehousing from the parental parents’ home. A referral was made to Children’s Social Care due to the age of the parents as well as the fact that mother was expecting her second child. Although it is commendable that the officer recognised the vulnerabilities this referral does not seem to have been acted upon and it was not followed up. 8.10 The quality of interagency information sharing, joint assessments of need, joint planning and joint interventions to support the family 8.10.1 This relates to the systems and processes to support prevention/protection in the above model. 8.10.2 “Effective communication requires practitioner skills and a culture that promotes information sharing as well as clear systems and guidance that enables information to be critically appraised and used to guide decision making and planning. Information received must be triangulated and verified and child protection agencies must provide prompt feedback to referrers and others participating in safeguarding.” (5) 8.10.3 The importance of information sharing features in nearly all Serious Case Reviews. 8.10.4 There are instances of poor information sharing throughout this case both within and between agencies. This applies not only to recorded information sharing but also to the lack of informal professional conversations. 25 8.10.5 To look at this chronologically: • During mother’s pregnancy with the sibling the FNP worker shared important information with the social worker. This was not recorded on mother’s assessment and so was not available to the next worker who assessed mother. There was no mechanism to record this on the unborn child either and so it was not available when she first came to the notice of Children’s Social Care in February 2015. • There were four children in this family. There seemed to be no linkage between them so that when an enquiry was made on one of them information known about the others was not shared. When the school nurse made a referral about domestic violence this was recorded on the sibling’s file not mother’s, although she was a child herself. When an enquiry was made to MASH about the baby, they were told the baby was “not known” although mother, father and the sibling were. • Consent seems to be a huge barrier to information sharing in MASH, particularly if a case does not meet the threshold. • The community midwife did not pass information on to the health visitor. Although this is agreed practice, the midwife was newly qualified and the service was under pressure at that time. There are systems and processes in place to ensure this should happen. • The Midwifery Service did not pass information on to the NNU. • The new birth worker had no information about the family when she visited. This would seem to be the norm. It is said that with approximately 120 new births per month and three workers there is not enough time to make contact with health visitors prior to the visit. Staff often have difficulty knowing who the health visitor is, although there is apparently a health visitor directory on the Birmingham Community Healthcare website. New birth workers do not have access to the Children’s Social Care IT recording system Carefirst. • There was no feedback on referrals (see later 8.11) • Strategy meetings in MASH were delayed. • The GP seems to have been totally “out of the loop” with no discussions held within the practice about this vulnerable family. Although the health visitor did communicate with the GP this does not seem to have generated any discussion. This may be because the regular meetings (six-weekly) that are held in GP surgeries about vulnerable families are with the “linked health visitor”. This was a Solihull GP and the family health visitor was from Birmingham. There may therefore be a cross border issue. • There was no NNU discharge planning meeting. At the time of this case the threshold to hold a discharge planning meeting was that Children’s Social Care knew the family or that an FCAF was being initiated. There was no current involvement. The family’s vulnerability warranted an FCAF but mother had refused. This is highlighted in the Heart of England Foundation Trust’s report 26 and subsequent actions to address this are considered later. This is also an issue in another current Serious Case Review. • When the baby had three admissions in quick succession this was another opportunity for a professional discussion. • The health visitor did not inform the Neonatal Community Outreach Team (NCOT) that she had referred to MASH. This was probably because the referral was made quite late on a Friday. • New information the health visitor had about mother’s inability to cope was not conveyed to MASH. This may have been because the health visitor was accustomed to delay in the system and felt she should refer directly to family support herself to save time. • Information was not triangulated. Mother’s words were taken at face value especially in relation to the allegation of domestic violence. The health visitor did do this in contacting the GP to check whether mother had taken the sibling or not but when the social worker visited and mother repeated the same information, he accepted it. • Several opportunities existed for professional conversations. A Team Around the Family (TAF) meeting could have been held. • The hospital’s communication with Children’s Social Care did not convey the level of concern they had about the safety of the sibling nor did Children’s Social Care appreciate that it was not necessary to await the result of medical tests before acting. Dealing with such “medical uncertainty” has been a feature of other Serious Case Reviews. 8.10.6 There were some examples of good practice in information sharing and joint work: • When the school nurse made the referral about mother and alleged domestic violence she also informed the health visitor who was able to explore this further with mother. She also informed the GP. • There was good handover of information from the FNP nurse to the health visitor and from one health visitor to another. • At the first strategy meeting (6th February 2015) all three agencies were present and information was obtained from the health visitor by phone. The police had a great deal of information about father and his family, which they shared. • There was good joint work and liaison between the NCOT and the health visitor. • There was a joint visit by the social worker and health visitor planned. This was to be followed up by a visit from the family support worker. Unfortunately, the baby was injured before this took place. 8.10.7 Other than these there is little evidence of any joint assessment, planning or intervention. 27 8.11 The quality of referrals, assessments and casework by Children’s Social Care in relation to both children during the period under review 8.11.1 This relates to Protective Actions by statutory agencies in the above model. 8.11.2 Referrals need to be clearly identified as referrals and document risks and concerns. 8.11.3 There were a number of referrals to Children’s Social Care: • The referral made by the FNP Nurse in July 2014. Although she did send a Multi-Agency Referral Form electronically this seems to have been treated as “information only” and no assessment opened on the unborn child (sibling) this was just pre-MASH. The form identifies many risks and vulnerabilities. • The referral made by the midwife in September 2014 to which mother apparently consented. This referral does not outline the risks and vulnerabilities and indeed states that mother is well supported. It is not surprising that no further action was taken. • The referral by Housing in February 2015. This referral seems to have been “lost”. It is assumed it was made on the basis of the “Southwark Judgment”.(9) • The referral by the school nurse in February 2015 after mother’s sister had alleged domestic violence being perpetrated by father. The case was only opened on the sibling and not on mother who was herself a child. • The referral by the health visitor on 25th September 2015 did not convey the level of her concern. And she did not follow this up with the further information she received on 29th September that father had left, and mother couldn’t cope. • The hospital referral on 18th October 2015 which was received following the injury to the baby did not immediately proceed along a “red” MASH pathway, as the case was already open to Children’s Social Care. 8.11.4 The need for redesign of the MARF form is discussed in Section 9. 8.11.5 For some of these referrals there was no feedback to the referrer. This should be standard practice. There is however a duty of the referrer to follow up the outcome as this will inform their future work with the family. A system is in place to inform referrers at the point of decision making in MASH. 8.11.6 Assessments contribute to decision-making and action to protect children. They also provide a picture of the child, family functioning and information about them that can be used in future work with the family. Too often, as in this case, assessment is seen as a one-off event often relying on a single visit. 8.11.7 They need to be timely and comprehensive and although Children’s Social Care is the lead agency, they should include information from other professionals working with the family. There should not be overreliance on what is said and 28 there should be critical analysis of the information gathered. Lateral checks or information from other agencies should be followed through. The focus should not be just on a single issue but also on other relevant issues. A manager should not sign off an assessment before all identified risks are addressed. 8.11.8 If concerns are not substantiated the family may still have on-going needs and there may still be risks to the child. There needs to be a mechanism to address these. 8.11.9 The importance of robust assessments is emphasised in the triennial review. (5) “To be effective, assessments must incorporate both information gathering and appropriate appraisal of that information to understand risk and formulate appropriate plans.” 8.11.10 In this case there were a number of opportunities for assessment. Two assessments were done. Of these only one was completed before the serious injury. 8.11.11 The first of these was following the referral of the school nurse on 6th February 2015 regarding an allegation from mother’s sibling that mother was experiencing domestic violence. Mother was pregnant with her second baby. A timely strategy meeting was held at MASH and it was agreed that a single agency assessment should be undertaken. There was then a delay of 17 days before the case was allocated. The expectation is that a case should be allocated within 24 hours. Even if there was a backlog the case should have been allocated within 2-3 days. The allocated worker did not contact the referrer at all and there was no contact with mother’s sibling who had made the allegation. A home visit to mother was not made for a further two weeks. It was by then five weeks after referral. By any standards this is not timely. 8.11.12 The manager’s instructions were: • To read all the historical information • Contact mother • Explore extended family support • Lateral checks with other professionals • Speak to father • Assess home environment • Ensure a suitable risk assessment is completed 8.11.13 When the visit was undertaken mother was alone in the house with the sibling. Father was not there and there was no was contact with him afterwards. Mother stated that this was a malicious and fictitious act by her sibling. She stated she knew the effect of domestic violence on children having experienced it herself. Everything was fine. The social worker accepted this. 29 8.11.14 As far as lateral checks are concerned it is assumed that the detailed information provided by the police would have been available to the social worker. It is not clear whether or not the worker read all the historical information available but if she did there doesn’t appear to be any critical appraisal of that information in relation to risk and vulnerability. It is stated that “Health have raised no safeguarding concerns in relation to (the sibling).” This seems odd in that the health visitor was in possession of considerable worrying information passed on to her by the FNP nurse and the school nurse had made the referral in the first place. The GP was not contacted nor is there any record of a contact with mother’s midwife. Mother had a pregnancy outreach worker and although the social worker mentions this there is no recorded contact with her. 8.11.15 There is no recorded contact with the extended family and the historical information if read would have raised considerable concerns. 8.11.16 We can assume the home environment was assessed. The visit took place in the new family home. 8.11.17 As far as risk assessment is concerned, the tools used are listed as interviews, observations and lateral checks with health. 8.11.18 The protective factors are listed as: • New home • Child happy • Mother has good understanding of DV and its impact • No evidence of domestic violence • Good support from paternal family • No concerns raised by other agencies • No concerns by the police 8.11.19 The risk factors are listed as: • Young parent known to Children’s Social Care • Father known to the police • Allegation of domestic violence • Isolation 8.11.20 This risk assessment is at best extremely superficial and shows no insight into the vulnerabilities and risks in this family. The majority of the protective factors are not protective at all e.g. “child happy” and the list of risk factors shows no indication of any analysis of the available information. 8.11.21 What is even more surprising is that three weeks later the manager signed off this assessment when hardly any of her original instructions had been followed. 30 No further action was taken except that mother was to access support from the Children’s Centre. There is no indication that this was followed up. 8.11.22 This referral and assessment was not recorded on mother’s Carefirst records but on that of her older child, even though mother herself was still a child and the referral had been made about her. 8.11.23 By any standards this was a poor quality assessment. It was both superficial and inaccurate. 8.11.24 The referrer was not informed of the outcome of the assessment. 8.11.25 The second assessment was not completed until after the serious injury. The health visitor made the original referral with concerns regarding both children. She felt that the parents needed support, that mum lacked the maturity to understand the needs of the children and had not been honest in relation to whether she had sought advice regarding health needs. There was considerable delay in allocation of the case (12 days) and the reason for this delay is not clear. It could be argued that the nature of the information did not warrant an urgent response. The team manager requested that a family support worker should undertake a visit with the social worker to consider the support required. Although this assumes that the outcome of the assessment would be family support this is a reasonable assumption given the nature of the referral. The expectation was that the assessment would be completed in 10 days. This doesn’t indicate that the manager felt this would go further than an offer of family support and therefore “set the tone” for the assessment. 8.11.26 The social worker did what he regarded as an initial visit four days later and took mother’s words at face value that she had sought advice about the nappy rash. He felt there were no immediate concerns especially as mother said she would welcome support and was open about her relationship problems. No risk analysis was done at this stage and he had no understanding of the case history when he did this first unannounced visit. He contacted the family support team the following day and the health visitor contacted him two days later. Joint visits were arranged. This plan for joint working was a good one but the baby was admitted in the meantime. 8.11.27 This changed the whole nature of this assessment. The events over the next few days are detailed above. This is covered in the analysis contained in the Children’s Social Care report and I would agree with them that the decision to undertake Section 47 investigations should have been taken when the hospital first referred on the 18th October expressing concerns that the injuries may have been caused non-accidentally. There should have been consideration at that point of the safety of the sibling. In the event they did not commence until four days later. This delay seems to have been partly because there was already an allocated worker and it did not therefore follow the “red” MASH process. It is 31 recognised by Children’s Social Care that there are still delays in Strategy discussions in cases that are “open”, and they are liaising with the police as to how to improve the response in these situations 8.11.28 The police and a social worker did a so-called “safe and well” check on the evening of 21st October. This was precipitated by the hospital’s increased concern for the safety of the sibling expressed throughout that day but not done until late in the evening. The sibling was left in the care of the father and paternal grandparents. It is doubtful that the workers concerned had any of the information known about that family but as it was by then late and the sibling was already asleep it was perhaps not unreasonable to leave them there especially as a strategy meeting was planned for the following day. Concern has been expressed in another Serious Case Review about these checks, which are often done by uniformed officers and only provide a snapshot at that moment in time. As there was a social worker present, they would normally have taken the lead with the police only intervening if to them the sibling was obviously not safe. 8.11.29 The remaining casework by Children’s Social Care was carried out after the sibling had been taken into care. Mother and father were interviewed and at this interview mother admitted she had shaken the baby. The social worker responded appropriately to this. The authorising manager lists the elements of the assessment, which includes assessment of paternal family 8.11.30 The assessment subsequently completed appears to be thorough covering all the relevant issues. 8.12 The theoretical casework models utilised, and the research evidence used by practitioners to inform decision-making 8.12.1 This relates to systems and processes to support prevention/protection in the above model. 8.12.2 “Professionals need training and support in analysis and decision making and appropriate supportive tools need to be developed.” (5) 8.12.3 Most agency reports cite “Right Service, Right Time” (10) as the model they are using and both the Community Trust and the Hospital state that this was used to inform decision making in relation to the referrals they made. This model was not known by the GP practice as they fall within Solihull CCG although they were familiar with a similar model used in Solihull but had not had a reason to utilise it in this case. 8.12.4 The Mental Health Trust whose only involvement was “after the event” refer to the “Think Family” approach (11) and health visitors also use the “Whooley Questions” (12) to assess maternal mental health although it is not clear they were used in this case. 32 8.12.5 The hospital used the “Strengthening Families” (13) model to support safeguarding supervision and analysis with staff following the baby’s admission with injuries. Clinical decision-making was supported by PEWS, the Paediatric Early Warning Scores. (14) Almost every hospital in the UK uses this. 8.12.6 In Maternity Services, the green booking notes and accompanying guidance provide a framework for practitioners and will help decision-making. 8.12.7 Health visitors use a variety of tools depending on what level of service is being offered but Right Service, Right Time is the main one used for decision making in safeguarding. 8.12.8 The new birth worker used the “Pre-Assessment checklist” which is part of the FCAF paperwork. This clearly failed to identify the vulnerabilities of this family so was no aid to decision making. The CAF provides a theoretical framework for Early Help and both TAF and Team Around the Child (TAC) meetings could have been utilised but were not as mother failed to give her consent until a very late stage. 8.12.9 The theoretical model, which has been used for the longest time and provides the basis for many others, is the Framework for Assessment for Children in Need. (15) More recently has been the introduction of the “Signs of Safety” approach (16) but this was not in use at the time of this case. The one assessment done by Children’s Social Care uses the paperwork being used at the time and cites the tools used as interviews, observations and lateral checks with Health. It is therefore impossible to know what theoretical models the worker drew on and what informed their approach. It seems doubtful that they were “evidence informed”. The so-called Risk Assessment was based on the person’s own perspective. 8.12.10 Practitioner decision-making will ultimately depend on what they think. But what they think is coloured by learning, supervision, asking for advice, empathy, experience and confidence to challenge amongst other things. 8.13 The journey the family experienced in terms of their contact with professionals over the period under review and why things happened the way they did 8.13.1 This relates to the whole pathway. 8.13.2 The family’s journey is outlined in Section 7 and took place in the wider social, physical and cultural environment in which they lived. This changed over time, as did the vulnerabilities of the children and the risks posed to them by their parents and others. The harmful actions causing the injuries and omissions e.g. the untreated nappy rash were the end point of their journey. The contact with professionals and why things happened in the way they did has been explored as far as is possible in the sections above and below. There were opportunities to explore further with mother what life was like for her, particularly during the 33 baby’s stay on the neonatal unit and subsequent admissions but when this was attempted, she always asserted that father’s family would support her, and staff accepted this without exploring further. 8.14 Those key incidents during that journey where positive learning can be identified and used to improve multi-agency and single agency practice in similar situations 8.14.1 This relates to the whole pathway and in particular to identifying opportunities for prevention and protection. 8.14.2 Key incidents or events are indicated in Section 7. Many issues are raised in the course of a review, which, in some ways, is an audit of practice using the case as the “sample”. Issues will be identified which although important to recognise and act upon are not necessarily pertinent to the outcome of this case. Some will be particular to this case. Others will clearly be generalised to wider practice and not particular to just this case. These are the issues that generate the learning points that are outlined in Section 9. 8.14.3 There are some issues that agencies have already recognised, and actions have been put in place to address them. 8.14.4 The GP practice missed two opportunities to enquire from mother how she was coping. The first when she attended the GP to confirm this pregnancy and the second when she attended with the baby for her postnatal check. The GP practice in Solihull has now implemented holistic postnatal assessments to assist in the recognition and response to early identification of needs. This learning should be shared with other practices. 8.14.5 The Mental Health Trust have identified that the Think Family approach was not applied when mum attended after the incident and that there was a lack of multi-agency liaison between internal and external partner agencies. Two recommendations are made to address these areas. 8.14.6 The Birmingham Community Healthcare Trust have recognised that the house move was a trigger point for increased vulnerability and that this could have provoked the health visitor to explore this further with mother. There is no certainty however that mother would have agreed to further support at this point. The Birmingham Community Healthcare Trust is to continue to maintain a practice focus on Early Help in responding to neglect to improve workforce understanding and support for families and children. 8.14.7 The Heart of England Foundation Trust recognised that the Teenage Pregnancy Midwifery Service could have provided support to this mother. Mother had refused this. There were capacity issues in this service, but these have been recognised and recruitment is underway. They have also noted that mother was placed on a “low risk” midwifery-led pathway as she was not under 16 at the 34 time. The policy has since been amended to include mothers under 17. There is no indication that this would have provided further opportunities for protection or prevention. They identified that there was a missed opportunity when baby was transferred to the NNU. The specialist midwife looking after the baby did not discuss their concerns with the NNU staff, but in the event the health visitor gave them the information a few days later and this was recorded on the appropriate documentation. However no specific action was taken, and the family were not discussed with the Safeguarding Team. No discharge-planning meeting was held. This would have been an opportunity for prevention. This has now been recognised and the NNU Team now have weekly meetings where babies who have social and safeguarding issues are discussed and there is closer liaison with the Safeguarding Team. There have been increased resources to enable this. 8.14.8 There was certainly delay in action to protect the sibling once the baby was admitted to hospital with non-accidental injuries and this considered above. (8.11) 8.15 The impact of repeat short interventions on the family’s relationship with professionals 8.15.1 This will affect protective actions by parents in the above pathway. 8.15.2 “There is a need for a shift in emphasis from incident or episodic service provision to a culture of long term and continuous support.” (5) 8.15.3 The history of repeated short interventions in mother’s life would have led her to the view that Children’s Social Care were of no help. Her experience during childhood was that they intervened when not needed and did not intervene when they were. This led to mistrust of those services and a lack of trust in professionals. This was probably reinforced by father and his family who themselves had been in receipt of repeated short interventions. 8.15.4 Effective safeguarding of children relies on good collaborative working between professionals and families. This requires longer-term relationships and trust. Equally it requires professional curiosity and challenge. 8.15.5 The only service to have a regular input was the Health Visiting Service but even this was interrupted by changes of worker. In spite of this they did establish a relationship with mother that enabled her to talk about her childhood. This would seem to indicate that if mother did establish a relationship with a professional, she would trust them. 8.15.6 Mother and baby spent lengthy periods engaged with the hospital services. Access to the same professional is difficult to achieve in these circumstances and a significant number were involved. This would have militated against establishment of relationships, but some conversations did take place, which touched on her troubled background. 35 8.15.7 Both Children’s Social Care interventions consisted of one home visit with no follow up. This would just have reinforced mother’s view that “they come, they go, they do nothing.” She was able to reassure both workers that she was ok and could cope. 8.15.8 It is surprising that mother disengaged from FNP. These events are outside the timescale of this review, but this service is long term and would have seemed ideally suited to this mother. It would seem that she felt acceptance of support from outside the family was an admission of defeat on her part and there must have been an underlying worry that her children would be removed. 8.16 Other key matters arising from the involvement of the family and practitioner events 8.16.1 As yet there has been no family involvement. 8.16.2 Three matters arose at the practitioner and managers’ events: 8.16.3 The role of the pregnancy outreach worker. It was thought this was a school-based professional. Information has subsequently been obtained from Birmingham City Council’s Education School Age Parent Coordinator. 8.16.4 Contact with the social worker was made in December 2014 (Author unclear which social worker this was) who stated that school was working and supporting mother in returning to school and that the service was not required. Mother had apparently indicated that she did not want the team’s service. In February 2015 the school notified the service that mother was pregnant for a second time. The worker then worked closely with the school to ensure appropriate support was offered. This included: • Improving school/home liaison • Maternity school uniform supplied by school • Exam dates and times provided • Revision resources provided by school for exams • Transport funded • Details of Careers Service to ensure post-16 options explored There is no indication that this worker was in contact with any of the other professionals involved. 8.16.5 The Birmingham Safeguarding Children Board’s ‘Never Shake a Baby’ campaign. The ‘Never Shake a Baby’ campaign was a direct result of the tragic death of a baby and the subsequent Serious Case Review. The campaign formed part of a wider range of ‘Safer Parenting Guidance’, providing advice on the correct sleeping position for a baby, how to bath a child and never shake a baby. All three sets of guidance were incorporated in three NHS leaflets, which were disseminated across the city targeted at parents through GP surgeries, 36 libraries, health centres and children’s centres during 2012. Unfortunately, the NHS campaign evaluation lacked sufficient detail to assess tangible outcomes. 8.16.6 The dangers of shaking a baby have also featured in other Serious Case Reviews: a 4-year-old old shaken and battered in 2009/10 and a baby aged 22 months who was shaken and thrown 2011/12. 8.16.7 The BSCB’s ‘Safer Sleeping’ campaign commenced 1st April 2016 and had a far more rigorous evaluation process in place to measure outcomes, with the findings scheduled to be presented to the Executive Group 22nd November 2016. 8.16.8 The campaign was built around health visitors at the 28-week antenatal visits where all mothers are provided with a ‘Safer Sleeping’ resource pack. The resource pack includes guidance on safe handling. The health visitors repeat this advice at the new birth visit and this reaches those who, for whatever reason, have not had the 28-week visit. The 2012 leaflets are part of the resource pack. It was stated that the midwife gives advice to the mother at discharge and that the teenage pregnancy midwife looks with parents more specifically at handling. There is also information in the ‘Red Book’. The NNU staff and Neonatal Community Outreach Team were not aware of the campaign. As pre-term babies are particularly vulnerable and mothers may miss the 28-week visit, if their baby is already on the NNU, it seems particularly important that the packs are available on the NNU. 8.16.9 It was clearly evident at both the practitioner and manager events that the pace of change at the moment is immense and that practitioners in all agencies are finding it difficult to keep up with the changes. This produces a potential disconnect between the strategic policy makers and the front line. 8.17 Consideration should also be given to the racial, cultural, linguistic and religious background to this case and any impact that may have had on decision making by professionals 8.17.1 There is no indication that this had any impact on the decision making in this case. 9. Conclusions, Key Learning Points and Comments 9.1 Of the 50 cases of non-fatal physical abuse looked at by the Triennial Review, three-quarters were under a year old and all the incidents took place within the family. The majority had never had a Child Protection Plan, but three-quarters were known to Children’s Social Care. The perpetrator, where this was identified, was more likely to be the mother, domestic abuse was a characteristic and there was evidence of neglect in almost half of cases. This case therefore fits the national profile of non-fatal physical abuse. 37 9.2 The review in its conclusion states that “If we are going to further reduce serious and fatal maltreatment, we need to identify family risk and vulnerability and look for opportunities for prevention and protection”. It goes on to say that there will be such opportunities even when you can’t predict which children will be harmed or die and that professionals should do their best in the way they know works best. 9.3 These two children suffered harm in spite of all the work professionals were doing to support and protect them, particularly the health visitor and the Neonatal Community Outreach Team. Rather than looking at whether serious harm was predictable or preventable we need to look at the opportunities that arose for prevention and protection and the underlying systems and processes that might get in the way of or support such work. What could have been done differently? 9.4 At one of the meetings during this review it was said that as the “threshold for care” would not have been met (before the injury) how could it have been prevented? Surely there are more ways to protect children? The recent review of Serious Case Reviews in Birmingham (17) states that cultural changes and social work/professional tools should emphasise needs and support over threshold concerns. 9.5 This case highlights learning in managing individual cases, working together as professionals and agency structures, processes and cultures. 9.6 There seem to be six general areas that generate learning. Since the events of this case there have been major changes and there are more to come. Therefore, where changes have been put in place that would mean that practice would have been different, these are referred to. The impact of changes needs to be evaluated. The pace of change is alluded to above. 9.7 The provision of Early Help 9.7.1 The importance of Early Help as described by Allen (18), Field (19) and Munro (20) is accepted by all agencies, and this family from any perspective was ‘crying out for it’. Both mother’s and father’s childhood experiences meant that they were likely to have difficulties in effective parenting themselves, they were very young, and they had two very young children, one with significant needs. There were many risk factors and an absence of protective ones. 9.7.2 The Family Nurse Partnership (4) is a voluntary, preventative programme for vulnerable, young, first-time mothers. It is evidence-based and the worker stays involved for two years after the birth of the child. It would also have engaged father and looked at positive relationships. The FNP Nurse has the capacity to complete intensive work with young parents. This would have been the ideal intervention. Mother disengaged from this and this non-engagement in offered 38 support formed the pattern from then on and professionals accepted mother’s assurances that she would seek help if she needed it. 9.7.3 The crucial question therefore is what to do if parents who clearly need ‘early help’ don’t want it or refuse it? There needs to be a clear easy pathway to help and support and parents need their ‘hands held’ to access it. This can be reinforced at contacts that ‘happen anyway’ such as the New Birth Visit, GP visits etc. Practitioners can talk to and engage the help of other agencies in working out who the best person is to engage the family. They also need to explore why families are refusing help. 9.7.4 If families do not engage professionals, they need support to escalate if the vulnerabilities and risks warrant it as they did in this case, rather than give up. This in turn requires confident, tenacious practitioners with good supervision and practice support. The Signs of Safety approach may help this and could have explored with mother the sort of support she needed and would accept. It would have given her the opportunity to say, “I can’t do this”. Parents respond better when they understand what we are worrying about and the impact on their children. The FCAF was meant to be the framework but there is a view that this is not robust enough and consent remains an issue. Other mechanisms include the TAF and the TAC. 9.7.5 There seem to be two separate family support teams with different modes of access. These workers have the same name but different roles and provide a different level of intervention. If a professional was to be informed that a Family Support Worker was involved, they may assume a higher level of intervention than the reality if it was a “Family Centre FSW” rather than a “Local Authority FSW”. 9.8 The pathway needs to be clearer 9.8.1 Consideration also needs to be given to what sort of interventions would have prevented the harm to these children. In addition to FNP there are other parenting programmes such as Incredible Years and Triple P. Childcare that could have been offered for the sibling whilst the baby was in hospital and after the baby came home. Home Start would have been another option. There is no guarantee that mother would have accepted any of these. Changes in Practice 9.8.2 “Signs of Safety” has not been adopted per se as a model but some of the tools from it are being used as part of Relationship Based Practice. However only social work staff have had any training in this approach. Other agencies have not been engaged in this. If this is to be the model a common language and understanding is needed across agencies and this will require some coordination. 39 9.8.3 Children’s Social Care has initiated changes in supervision and practice support but the impact of this is yet to be evaluated. Similarly, with Health Visiting. 9.8.4 The FNP programme has been decommissioned. The reasons for this are unclear but apparently based on a report published in the Lancet (21) looking at short term outcomes such as smoking cessation and admission to hospital. The research did not look at long-term benefits particularly those relating to safeguarding. As a response to this the Community Trust have developed a Vulnerable Parents Pathway. Whether this will replicate the therapeutic relationship that was the basis of FNP is still to be seen. 9.8.5 FCAF is no longer used and instead there is to be a new Early Help Assessment tool. 9.8.6 Right Service, Right Time is to be re-launched in November 2016. 9.8.7 See also below regarding Consent 9.9 New Birth Visits and how they are carried out 9.9.1 It is essential that the worker who does these visits has full access to all the information about the family before they do the visit. Currently they only have a list of new births without any other information. Access to Children’s Social Care information via Carefirst and contact with the health visitor seem to be prerequisites. It also seems dangerous for the workers that they “go in cold”. There is no “single view of the child” that is easily accessible. The paperwork used for these visits (pre-CAF Checklist) does not lend itself to showing a true picture of a family’s needs and should be reviewed and revised. It is understood that there may be changes to this service, but the learning is still pertinent. There is currently duplication with both Children’s Centre Staff and health visitors doing New Birth Visits often within days of each other. There are also differences across different settings and no links between them. Changes in practice 9.9.2 The Local Authority, who now commissions Health Visiting Services as well as Children’s Centres and other more specialist early years provision currently provided by both the Local Authority and the Voluntary Sector, has drawn up a new integrated service specification. This was out to tender with a start date for the new service set for September 2017. It is understood that there would be collaborative bids to deliver this service but that in the future it is likely that there will only be one “New Birth Visit” and that the health visitor will do this. The budget for this new integrated service is likely to be less than that of the current parts. 9.9.3 The pre-CAF checklist is to be replaced by an Early Help Assessment tool. 40 9.9.4 The data warehouse (Sentinel) could conceivably provide a link of information between Children’s Social Care and Children’s centre staff but at the moment this seems unlikely 9.10 Remaining focused on the child and family 9.10.1 There were four children in this family all with their own needs and vulnerabilities. This was not always apparent in the work with this family where the focus was often on one only. Father was never engaged by anyone and his lack of visibility should have been a warning sign in itself. Mother was viewed in her role as mother and not as the subject of concern, for instance in the response to the domestic violence referral, and the needs of the sibling seem to have been mainly overwhelmed by those of the baby. 9.10.2 There was no linkage of information so that when enquiries were made about one, information that was held on the file of another was not linked. Records should have been opened for all four children including the two who were parents with cross-linking of information. It is apparently standard practice in some Authorities that there are separate social workers for young parents who are children themselves. The parents’ own childhood experiences and the likely effect on their ability to parent would then have been highlighted. 9.10.3 Losing focus on the whole family is also highlighted in other Serious Case Reviews. (17) Changes in practice 9.10.4 Since July 2016 Children’s Social Care have been recording all contacts made to the service. This will mean that there will be a record of all referrals made even if the decision has been made that the threshold for statutory intervention has not been met. The system will record contacts as well as referrals and assessments. Guidance for Pre-Birth assessment was subsequently updated, and Early Help assessments now take a whole family approach. 9.11 Information Sharing 9.11.1 This was an issue at both a formal and informal level and features in nearly all Serious Case Reviews both national (5) and local (17) It is covered in 8.10 above. Lack of professional conversations led to a situation where each incident was treated separately without taking into account the whole history and context. 41 9.11.2 The main Learning Points from this are: • Within MASH, consent is a huge barrier to the sharing of information on a family if the threshold of referral is not met. Hence pieces of information are not put together that could together mean that the threshold for intervention would be met. • The TAF/TAC meetings were apparently not being used to their fullest extent. Even without consent families could be discussed and a joint plan made that would support the involved practitioner in their work with the family and in managing risk and uncertainty. It would have been a forum where all of the information on risks and vulnerabilities could have been put together • Discussions within GP practices about vulnerable families need to be embedded. This may have been hampered in this case by cross border issues. There will always be these issues and there is an expectation that practitioners should recognise the problem and resolve it by practitioner-to-practitioner conversations. GPs already have a list of health visitors and their catchment areas. • The criteria for holding multi-agency hospital discharge planning meetings should be reviewed especially for the neonatal units. • The information access for family support teams in children’s centres should be reviewed. Changes in practice 9.11.3 MASH has changed. (see below) 9.11.4 There have been considerable discussions about consent and a very useful paper compiled for the EHSP Conference in June 2016 on Consent, Information Sharing and Thresholds. This should address some of the current uncertainties of practitioners and ensure that information shared is proportionate and well recorded. 9.11.5 TAF meetings have ceased and have now been replaced by the “Early Help Panel”. Practitioners could take cases here anonymously to get advice and guidance and the “Early Help Desk” could collate information. TAC meetings will continue as currently, with the focus on children with Special Educational Needs. There is some evidence that the Early Help Panels are not being utilised to their full extent. There needs to be enough flexibility in the system to allow professional conversations to take place 9.11.6 Within this NNU the discharge planning process has changed and there is now a Discharge Planning Nurse in post. There is a new Discharge Planning booklet to be introduced within the next few months. This will be based on Strengthening 42 Families (13) and aims to recognise vulnerable families early and put a plan in place prior to discharge. 9.11.7 The CQC inspection was critical of interaction between health visitors and midwives. An inter-agency group was set up to take forward the CQC recommendations. 9.12 Quality of assessments in Children’s Social Care 9.12.1 This is covered in detail above in 8.11 above. It is understood that the framework for these assessments has changed since the case under review. However whatever forms are used the quality of assessment and casework will still be reliant on the individual and their manager’s ability to analyse and challenge. Changing paperwork and forms does not necessarily change practice and although checks and balances can be built-in it will always be a “judgement call”. 9.12.2 The focus should be on fully identifying risks and vulnerabilities as well as positive factors. It seems obvious to point out that all risks identified both by the referrer and the social worker should be addressed (or there should be a monitored plan to address them) before an assessment is signed off and closed by a manager. 9.12.3 In this case there were also issues of speed of decision-making allocation and completion. Systems have now changed, and it is unlikely these delays would occur now. Changes in Practice 9.12.4 A new assessment proforma has been introduced for Section 17 and Section 47 Family Assessments in May 2016 and a new “Early Help Assessment” is being developed. Both of these will provide further guidance for social workers and managers. 9.12.5 Practice evaluation has now been introduced within Children’s Social Care. This consists of two evaluations. The learning from them is fed back to the practitioner and their manager. 9.12.6 A Practice Evaluation Bulletin has been introduced. Circulated quarterly it has already included some of the learning points from this Serious Case Review. 9.12.7 The expected speed of decision-making has changed. For all cases coming to the front door a decision should be made that day. A family support worker and a manager should be allocated that day. If the case is referred from CASS to Children’s Social Care a decision should be made within 24 hours whether to 43 proceed to a Section 17 assessment in which case the child should be seen within 3 days, or a Section 47 where there should be a same day response. 9.12.8 It is acknowledged that there are still issues at the front door. A Front Door Reference Group reports to the Board (via Quality and Assurance). This should monitor the quality and progress of decision-making. There is also an audit of the Front Door within MASH daily. 9.13 The operation of MASH 9.13.1 It is understood that the operation of MASH changed during the period under review and that it has changed at least once since. There is a view that MASH is vulnerable especially in terms of resources and that the MARF form needs revision. This should reflect the need to record context, risks and vulnerabilities as well as harmful actions/omissions by parents/carers. It may need adaptation if the “Signs of Safety” approach is embedded in practice particularly of Health and Children’s Social Care. In this case there was delay in holding Strategy meetings and not all partners were present. It is assumed that this was a resource issue. The front door decision seems to be made without background information and in this case a change in circumstances meant the case was escalated, as the case was already open to Children’s Social Care. This issue of response when new concerns are raised about open cases is recognised both by referrers and Children’s Social Care. 9.13.2 The referrals made for this family were all seen in isolation and therefore even when there had been a number within quite a short timescale this did not trigger further action. Changes in practice 9.13.3 The MARF has been replaced. Since the beginning of October 2016 there is now a “Request for Support Form” which incorporates some of the aspects and tools within the “Signs of Safety” approach. It includes sections on “What is going well?” “What are your concerns?” and “What needs to happen next?” 9.13.4 MASH has changed. From 4th September 2016 there is now CASS (Children’s Advice and Support Service). MASH will only be used for Section 17 and Section 47 enquiries. The pathway through the front door has changed and all enquiries including requests for information will go to the Early Help Desk. There will no longer be the option of “No Further Action”; there will always be an Early Help offer. 44 9.13.5 The changes made in July 2016 whereby all contacts with Children’s Social Care are recorded should assist workers within CASS/MASH to consider previous referrals made to the service. 10. Recommendations to Address the Key Learning Points These are suggestions only and open to amendment. They will be considered by the Serious Case Sub-Group who will identify the key action required to embed the learning from this case for endorsement by the Executive Board. 10.1 The provision of Early Help and what to do when parents refuse it 10.1.1 Mindful of the changes already made over the past year the following recommendations were made in November 2016: Recommendation 1 The Learning and Development Sub-Group of BSCB together with the Workforce Development Workstream of the Early Help and Safeguarding Partnership consider how to disseminate to all frontline practitioners the changes in the pathway to Early Help. This to encompass: • The re-launch of Right Service Right Time • Referral process for Early Help and how to make good referrals • CASS and MASH • Signs of Safety • Consent guidelines • The use and functioning of the Early Help Panels and Desk • Effective use of the Early Help Assessment tool Recommendation 2 The Local Authority and CCG commissioners consider the effect of the decommissioning of FNP and how they will evaluate any replacement programme. Recommendation 3 BSCB through its Quality, Impact and Outcomes Sub-Group evaluate the effect of changes to supervision and practice support. Recommendation 4 The utilisation and functioning of the Early Help Panels to be monitored and evaluated. In particular the ease of access and whether or not they are creating a further barrier to professional conversations. 45 Recommendation 5 The Early Help and Safeguarding Partnership should consider renaming the two teams of “Family Support Workers” to better reflect the differing roles of these two teams of workers. 10.2 New Birth Visits and how they are carried out It is recognised that these will change in less than a year. In the meantime: Recommendation 6 The means of access to background information about families for family support workers from the health visitor, Children’s Social Care and other children’s centres to be resolved by the Early Years Childcare and Children’s Centres Service with the help of partners. 10.3 Remaining focussed on the child and family This is an issue for supervision and practice support and therefore no further recommendation is made other than that in Recommendation 3 above. 10.4 Information Sharing The issues regarding Consent and are covered in Recommendation 1 above. The use of TAF now Early Help Panels is covered in Recommendation 4 above. Information access for family support teams is covered in Recommendation 6 above. Recommendation 7 As part of the Sustainable Transformation Plans, the Birmingham Midwifery Partnership should ensure that the improvements in discharge planning for babies being discharged from Neonatal Units are implemented across the city and also consider whether any other parenting support should be available for this particularly vulnerable group of babies and their families. 10.5 Quality of assessments in Children’s Social Care It is recognised that many changes have been made over the last year, therefore no recommendation is made in relation to this. However, BSCB needs to have an assurance that these changes do improve the quality and timeliness of assessments. 10.6 The operation of MASH Many changes have been made in the last year, some of which address the learning from this case. BSCB needs to be assured that these changes simplify rather than complicate the access to help and support for families and that all workers understand the changes. This is covered in Recommendation 1 above. 46 Recommendation 8 CASS/MASH to develop operational guidance to enable “triggers” where there are multiple referrals/contacts and use of chronologies. Recommendation 9 A specific recommendation around fast decision making when cases are already open to Children’s Social Care and another referral is made. 11. Embedding the Learning from this Case 11.1 Serious Cases Sub-Group has overseen implementation of the emerging learning during the review process. Whilst the SCR involved ten agencies, only four of those agencies identified areas for improvement in their own safeguarding arrangements. All ten learning points have been fully implemented. 11.2 The final SCR reports makes nine multi-agency recommendations. These recommendations have helped shape and inform the development of multi-agency safeguarding arrangements within Birmingham. Serious Cases Sub-group have monitored the timely implementation of these recommendations and all are now complete. 47 12. References 1) Working Together to safeguard Children. HM Government. March 2015 2) Root Cause Analysis: A Tool for Total Quality Management. Wilson P, Dell LD, Anderson GF. 1993 ASQ Quality Press p 8-17. 3) Rights, Responsibilities and Pragmatic Practice: Family Participation in Case Reviews. Morris et al. Child Abuse Review 24. 198-209 2015 4) The Family Nurse partnership programme. DOH. Information Leaflet July 2012 (first published Dec 2010) 5) Pathways to harm-pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. May 2016. Sidebotham P, Brandon M. et al 6) The Wood Report. Review of role and functions of LSCBs. March 2016 DFE 0031-2016 7) The Relationship between Maternal Childhood Emotional Abuse/Neglect and Parenting Outcomes: A systematic Review. Hughes M, Cossar J. Child Abuse review Vol. 25 31-45 2016 8) The Victoria Climbie Inquiry. Lord Laming. January 2003. HMSO 9) Responding to Youth Homelessness following G v LB Southwark judgement. Shelter.org.uk/childrensservice 10) Right Service, Right Time. BSCB. March 2015 11) SCIE (2011) Guide 30: Think Child, think parent, think family: a guide to parental mental health and child welfare. London SCIE 12) NICE Clinical Guideline 192. Antenatal and Postnatal Mental health. London NICE 2014 13) Centre for the Study of Social Policy. Strengthening families www.cssp.org. 14) PEWS. A severity of illness score to predict urgent medical need in hospitalised children. Duncan H, Hutchison J, Parshuram CS. Journal of Critical Care Vol. 21 271-278 2006 15) Framework for the Assessment of Children in Need and their Families. DOH<DEE<Home OFFICE HMSO 2000 48 16) ‘Signs of Safety’ Practice at the Health and Children’s Social care Interface. Stanley T. and Mills R. Practice Social work in Action, DOI; 10.1080/09503153.2013.867942. Jan 2014 17) A Review of Birmingham safeguarding Children’s Board’s Serious Case Reviews and Learning Lessons reviews 2009-2014. Gibson M, Chesterman M, and White S. University Of Birmingham. 2016 18) Early Intervention: The Next Steps Graham Allen MP.HM Government 2011 19) The Foundation Years; preventing poor children becoming poor adults. Frank Field. HM Government 2010 20) The Munro Review of Child Protection. Interim report; The Childs Journey. Prof. Eileen Munro 2011 21) The effectiveness of a nurse led intensive home visitation programme for first time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Robling M, Bekkers MJ et al The Lancet Vol. 387 146-155 Jan 20 49 Appendix 1 Abbreviations ASD Atrial Septal Defect ASTI Assessment and Short-Term Intervention BCHC Birmingham Community Healthcare NHS Trust CAF Common Assessment Framework FCAF Family Common Assessment Framework CASS Children’s Advice and Support Service CCG Clinical Commissioning Group CSC Children’s Social Care CQC Care Quality Commission EDT Emergency Duty Team EHSP Early Help and Safeguarding Partnership FNP Family Nurse Practitioner FSW Family Support Worker GP General Practitioner HV Health Visitor IASS Information and Support Service MARF Multi Agency Referral Form MASH Multi Agency Safeguarding Hub NCOT Neonatal Community Outreach Team NNU Neonatal Unit PDA Patent Ductus Arteriosus SCR Serious Case Review SW Social Worker TAF Team Around the Family TAC Team Around the Child 50 Appendix 2 Agencies who participated in the SCR process by submitting an Information Summary Report and Chronology: Birmingham Children’s Hospital Birmingham Community Health Care Birmingham & Solihull Mental Health Foundation Trust Birmingham Children’s Social Care Birmingham Early Years Heart of England NHS Foundation Trust Sandwell and West Birmingham Hospitals Solihull Clinical Commissioning Group West Midlands Ambulance Service West Midlands Police Nil Returns: Birmingham & Solihull Women’s Aid Birmingham Women’s Hospital Change Grow Live Community Rehabilitation Company Family Action National Probation Service NSPCC Royal Orthopaedic Hospital Sandwell and West Birmingham Clinical Commissioning Group |
NC52318 | Multiple injuries to an infant girl in May 2019. Amelia's mother was later charged for child cruelty. Learning includes: the local safeguarding children partnership to consider further promotion of its practitioner-based toolkits to support working with unidentified adults and adopting a family approach; children's services and the local NHS Trust to share the toolkits again with frontline staff, and ensure the toolkits are included in training; future audits of multi-agency practice to review agency record keeping, ensuring that records are clear regarding what information has been shared by service users, and what information has been passed to other agencies for further action; the need to develop information for partner agencies on the use of agreed escalation routes; seek assurance that the voice or perspective of the child is included in case files and safety plans. Recommendations are embedded in the learning points.
| Title: Learning review report: Amelia. LSCB: Hampshire Safeguarding Children Partnership Author: Hampshire Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Learning Review Report Amelia Amelia lived with her mother and older half-brother. As an unborn baby, Amelia and her brother were previously subject to Child Protection and Child in Need Planning due to concerns related to domestic abuse, poor home conditions and neglect. The children’s Child in Need Plan ended three months prior to Amelia’s birth in October and no issues or concerns were raised by any agencies working with the family. However, there were incidents of Amelia not being brought to routine health appointments, and one minor incident of Amelia’s father harassing her mother’s previous partner but neither raised safeguarding concerns nor required onward referral to Children’s Services. The relationship between Amelia’s mother and father had ended before her birth. The relationship between Amelia’s mother and her previous partner had resumed prior to Amelia’s birth. In the following January they separated but both remained living in the family home. A male family member was also living in the home at this time and was reported to be sleeping on the sofa and helping with jobs in the home. Following the separation of Amelia’s mother and her previous partner, concerns were raised regarding verbal arguments and escalating aggressive behaviour between the adults in the presence of both children. A referral was made into the Multi-Agency Safeguarding Hub and the Police were requested to visit the family home. During this visit, Amelia’s brother disclosed that his mother’s previous partner had previously hit him on the face which had left a red mark. This was witnessed by Amelia’s mother and both children were placed on a Child in Need Plan. From January to March, the previous partner of Amelia’s mother was thought to be providing the majority of care to both children until he moved out. Amelia’s mother was reported to be in a new relationship, following her previous partner moving out of the family home. Amelia’s mother was engaging with professionals as part of the Child in Need Plan. In late March, during a routine health visitor appointment, Amelia’s mother reported low mood and that she was pregnant, and her new partner was the father. A scheduled Child in Need Review meeting took place in April, and this was extended to include the unborn baby. In late May 2019, Amelia was presented to the Emergency Department with an arm injury. Following further examination, Amelia was found to have multiple injuries. No explanation was given by the adults for the injuries. Amelia’s injuries were considered to be non-accidental, and a Section 47 investigation was commenced. Amelia’s mother was latterly charged for child cruelty. The supporting investigation highlighted that the adult family member who had been living in the family home had continued to reside at the home in exchange for him undertaking most of the care for Amelia and her older brother. Learning Point One: HSCP has previously published and promoted online practitioner-based toolkits to support working with unidentified adults and adopting a family approach. HSCP to consider the re-promotion of these and other toolkits as part of its work to improve communication with agencies. Hampshire Children’s Services and Southern Health Foundation Trust to re-share both toolkits directly with front line staff and ensure both are included in training for newly recruited staff and trainees. Children’s Services to continue with their existing work under their transformation programme to seek internal assurance on the implementation of agreed tools and policies. Learning Point Two: HSCP to include a reference in future audits of multi-agency practice to review agency record keeping and ensure that records are clear what information has been shared by service users, and what information has been passed to other agencies for further action. Learning Point Three: The understanding and use of agreed escalation routes have featured in other learning reviews and audits of practice undertaken by HSCP. HSCP to: - Develop a short briefing guide that partner agencies can share with staff in staff training and briefing sessions. - Include information on escalation in either of the 2020 rounds of Regional Practitioner Briefings - Request that all external trainers reference the agreed escalation protocol in all HSCP training. Learning Point Four: As part of existing audits of practice and peer review programmes, HSCP to continue to seek assurance that the voice or perspective of the child is included in case files and safety plans. Learning Point Five: HSCP to share the learning from this case with all its external trainers to inform its ongoing multi-agency training programme. HSCP to share the learning of this case in its next round of Learning Lessons sessions. HSCP to publish this case in both the ‘Understanding Unidentified Adults’ and ‘Adopting a Family Approach’ toolkits. Publication Date: 29 March 2022 |
NC52478 | Death of 12-week-old boy from severe abusive head trauma; mother's partner was found guilty of Stephen's murder and of causing earlier injuries. Learning is embedded in recommendations. Recommendations include: assurance as to the way in which agencies record and update the details of family/household members; consider whether a change in intimate partner during pregnancy be added as a risk factor; ensure that services commissioned to support offenders' rehabilitation activity requirements (RAR) are provided with relevant information about the nature of the offending, risk management, and the expected outcome of their involvement; assurance that concerns, and referrals, are not processed based on a hierarchy of referrer (giving less weight to concerns from neighbours or family members), and that the response is proportionate to the reported lived experiences of children and others potentially at risk within the household; provide assurance that children are both seen, and spoken to, within the expected protocol and timescales of a child and family assessment; those with parental responsibility who are not resident in the family home should be made aware of agency involvement and enabled to contribute to the assessment; and that health partners report on progress in the embedding of improvements in growth monitoring of infants, with evidence of impact through quality assurance of practice.
| Title: Child safeguarding practice review overview report in respect of ‘Stephen’. LSCB: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Author: Catherine Powell Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Overview Report in respect of ‘Stephen’ AUTHOR: CATHERINE POWELL CHILD SAFEGUARDING CONSULTANT DATE: 12TH APRIL 2022 1 Acknowledgements As lead reviewer and author of this report, I would like to acknowledge the help and support of the Child Safeguarding Practice Review panel, the independent scrutineer, the Chair of the Child Safeguarding Practice Review sub-group, and staff from the Independent Safeguarding Partnership Service. I am indebted to those who completed a chronology of their agency’s involvement with Stephen and his family members, and those who contributed to this report through the virtual practitioner conversations. The challenges of delivering services during the Covid-19 pandemic, alongside contributing to a review of this nature, are acknowledged. I would also like to thank Stephen’s father, and the father of Stephen’s half-siblings, who shared valuable insights regarding the importance of practitioner understanding of the role of men in the family and household, and in ensuring fathers’ involvement in the lives of their children. Governance I declare that I have found no conflict of interest in completing this review, and that I am independent to Cambridgeshire and Peterborough Safeguarding Adults and Children Partnership Board and partner agencies. The report has been commissioned by, and written for the Board, and overseen by a multi-agency child safeguarding practice review panel of local senior managers and practitioners from the following agencies: • Cambridgeshire Constabulary • Cambridgeshire Children’s Social Care • Cambridgeshire and Peterborough Clinical Commissioning Group • Cambridgeshire and Peterborough NHS Foundation Trust • Cambridgeshire Community Services NHS Trust • North West Anglia NHS Foundation Trust • Cambridgeshire and Peterborough Independent Domestic Violence Advisory Service • Cambridgeshire Education Directorate Additional support has been provided by the Lead of the Integrated Front Door and Assessment Service (Children’s Social Care), the National Probation Service and the CRC Deputy Director and Head of Cambridgeshire Local Delivery Unit (BeNCH). In preparing this report for publication, the details of the child and their family, as well as the individuals providing care to them, have been anonymised in accordance with statutory guidance and best practice. Catherine Powell Child Safeguarding Consultant 17th March 2022 2 Executive Summary A local child safeguarding practice review (CSPR) was commissioned following the death of a 12-week-old male infant, Stephen, who had suffered serious abusive head trauma. Post-mortem, evidence was found of historical injuries, including fractures, reflecting physical abuse over time. Mother’s partner (who was not Stephen’s biological father) has been found guilty of his murder and of causing the earlier injuries. An important finding of the review is a recognised change in family dynamics when this individual, a known perpetrator of domestic violence, joined the household. Stephen had older half-siblings. At the time of his death, children’s social care services were completing a child and family assessment. This followed police call outs and referrals from neighbours and others concerned about the welfare of the children and their mother. The sequence of events leading up to Stephen’s death are complex, and a range of agencies were involved, or had information about mother’s partner, not all of which was shared in a timely way. Some inaccuracies in recording were made that had an impact on the perceived level of risk within the family. In addition to the involvement of police and children’s social care, services were also provided by primary care (GP), maternity, health visiting, education (including pre-school), housing, probation, and MIND mental health support. Professional dialogue between involved practitioners and agencies was found to be somewhat limited. Such communication may be critical in adding context, clarity and expertise to data provided through a trawl of records. The review was overseen by a multi-agency CSPR panel. Panel meetings and consultation with practitioners and managers was managed via virtual means due to Covid-19 restrictions. The progress and improvements in child safeguarding practice that were shared is testament to reflection and learning that has already taken place locally. This review highlights, and builds on, these developments. Four ‘practice episodes’ are identified. These expose cross-cutting themes that contribute to the learning and recommendations and reiterate the enduring message from other reviews for the need for authoritative child-centred practice. The first practice episode reflects the importance of establishing and recording paternity, and of ‘professional curiosity’ and enquiry regarding the background, role and status of men in the household; the second relates to the checks and balances in managing the multi-agency response to domestic abuse and the need for agencies to share information regarding concerns about children in the household in a timely way; the third highlights systemic issues in recording infant weight and in recognising signs of Stephens ‘faltering growth’; the fourth practice episode recognises a pattern of ‘parental resistance’ to engagement with practitioners, with a concomitant need for authoritative practice. As reflected in the literature, the review acknowledges the ‘unpredictability’ of death and serious harm in child safeguarding practice. It also notes the risks to children who may be ‘on the boundary’ of the child protection system. In this case, the risk to Stephen and his half-siblings was recognised, but the risk was balanced by protective factors and an approach that sought to work collaboratively with the family. The review finds that the initial responses to concerns of domestic abuse and the welfare of the children (i.e., the offer of early help) were not sufficiently robust. This is because the known risks at this time included 3 mother’s pregnancy, the involvement of family and neighbours in raising concerns, the young age of the siblings, and the, then, new partner’s history and criminal convictions as a perpetrator of serious domestic abuse. The multi-agency safeguarding hub (MASH) partners’ response also lacked robustness in interrogation of the partner’s background, and in the provision of an indicative response in the application of the Domestic Violence Risk Identification Matrix (DV-RIM) framework. The offer of early help was not taken up by the family. Had a statutory child and family assessment been commenced at an earlier stage, this would have enhanced multi-agency working, provided key insight into the daily lived experiences of the children, and a clearer view of whether Stephen and his siblings were ‘children in need’ or ‘children in need of protection.’ Critically, there would have also been a timely opportunity to support the family in addressing the known risk from the partner, including the application of the domestic violence disclosure scheme. Recommendation One: The Board seeks assurance as to the way in which agencies record and update the details of family/household members. This may include completion of a genogram (or equivalent record of family make-up) and recording of current address/addresses. The recommendation applies to those providing services to children and to adults who are parents/carers. Such services should be required to demonstrate compliance with their wider responsibilities in child safeguarding. Consideration should also be given as to whether a change in intimate partner during pregnancy be added as a risk factor to section two of the pre-birth protocol in its next revision. Recommendation Two: The Board requires the National Probation Service to ensure that services commissioned to support offenders’ rehabilitation activity requirements (RAR) are provided with relevant information about the nature of the offending, risk management, and the expected outcome of their involvement. Information sharing includes the evaluation of progress in achieving the goals of the RAR. Recommendation Three: The Board seeks assurance that concerns, and referrals, are not processed based on a hierarchy of referrer (giving less weight to concerns from neighbours or family members). The response should be proportionate to the reported lived experiences of children and others potentially at risk within the household. Recommendation Four: The Board requires Cambridgeshire Constabulary to provide assurance that stated improvements to internal system checks ensure correct allocation, grading and sharing of DASH/F101 notifications with other agencies are in place, with evidence of impact. Partnership agencies should also seek to progress and support improvements in the management of domestic abuse notifications to ensure the identification and prioritisation of high-risk cases. Recommendation Five: The Board requires Children’s Social Care to provide assurance that children are both seen, and spoken to, within the expected protocol and timescales of a child and family assessment. Those with parental responsibility who are not resident in the family home should be made aware of agency involvement and enabled to contribute to the assessment. 4 Recommendation Six: The Board requires health partners to report on progress in the embedding of improvements in growth monitoring of infants, with evidence of impact through quality assurance of practice. Recommendation Seven: The Board undertakes quality assurance activity to assure members that the work it has undertaken to enhance practitioners’ understanding of authoritative practice has been embedded and resulted in a positive impact on practice. 5 Contents 1.0 Introduction and Background 6 2.0 Narrative Chronology: Stephen’s story 8 3.0 Key practice episodes 15 4.0 Discussion 21 5.0 Progress and improvements 24 6.0 Learning points and recommendations 25 References 28 Appendix One: Terms of reference 30 Appendix Two: Guided discussion points for practitioner conversations 31 6 1.0 Introduction and background 1.1 This report sets out the findings of an independently led local child safeguarding practice review (CSPR) commissioned by the Cambridgeshire and Peterborough Safeguarding Adults and Children Partnership Board (‘the Board’). The review concerns Stephen, a White British baby boy, who died in hospital at the age of twelve weeks, having sustained serious abusive head trauma. 1.2 Clinical investigations and post-mortem examination revealed the presence of multiple rib and other fractures, some of which were in the stages of healing. This reflected physical abuse over time. Stephen’s mother’s male partner (who was not Stephen’s biological father) has been found guilty of his murder, and of causing the earlier injuries to him. The purpose of this review is to learn from the case and to identify improvements that may be made in provisions for safeguarding and promoting the welfare of children. 1.3 Stephen was the baby brother to half-siblings, who attended pre-school/primary school. At the time of his emergency admission to hospital, children’s social care services were completing a child and family assessment1. The decision to undertake the assessment followed police call outs and referrals from neighbours and others concerned about mother and her partner’s ‘constant arguing and screaming’ and the ‘children crying’. The concerns, which arose over a period of several months, dated from the time that mother’s partner became part of the family and ‘things changed’ for the children in the household. 1.4 Mother’s partner had a significant history of a pattern of abusive behaviour towards intimate partners and ex-partners and criminal convictions resulting from his controlling, coercive and violent behaviour. His victims appear to have been vulnerable women, with children (including unborn children) who were also placed at risk. The children of one previous partner had been subject to child protection planning because of his presence in the family. An assessment by a responsible officer was that this man posed a medium risk to known women and children. 1.5 Stephen’s mother seemingly began the relationship with the partner when she was already pregnant with Stephen. At that time, he was completing a period of probation and was receiving services from a community rehabilitation company [BeNCH]. As part of his rehabilitation activity requirements, he was directed to attend a local MIND wellbeing service for one-to-one mental health support and access to an emotional control [anger management] programme. From the outset of the relationship, this individual portrayed himself to professionals and others as being ‘dad’ to Stephen. Mother concurred with this. 1.6 When mother’s partner joined the household, he was being treated by the GP for depression and anxiety. He had been assessed as not being fit for work because of these conditions. This meant not being able to undertake unpaid work in the context of his community sentence. Substance misuse was disclosed to the GP at his appointments. Despite assertions to others, including his responsible officer and MIND worker, that he was ‘bi-polar’, clinical colleagues contributing to the review found no evidence in the medical records of a formal diagnosis or treatment for this psychiatric disorder. He had, however, 1 S.17, Children Act 1989 (A Child and Family Assessment is also known as a Single Assessment.) 7 been diagnosed with attention deficit hyperactive disorder (ADHD), for which he received medication. 1.7 When the statutory assessment process began, a police disclosure relating to the partner’s criminal history was shared with children’s social care. Links were also made with other social care records concerning his history of domestic abuse. The risks that this partner presented had been previously shared with agencies at five multi-agency risk assessment conferences (MARAC). In short, the arrival of this partner, and his status and presence in the household, changed the dynamics, put the children and their mother at risk of significant harm, and ended with the tragic death of Stephen. 1.8 The broader family context indicates adversities in the lives of the mother and her partner, including during their own childhoods. In addition to evolving concerns about domestic abuse, other known ‘risk factors’ for child maltreatment were somewhat evident in the family. These include mental health, substance misuse and financial difficulties. Despite these factors, positive parental care of Stephen was observed and recorded by universal services. Crucially, there had been no historical safeguarding issues identified in the care of the older siblings; mother was seen to be a good parent. 1.9 The time-period for the review is from mother’s booking for maternity services for her pregnancy with Stephen, until his emergency admission to hospital. The reviewer requested detailed chronologies of practitioner involvement with the family during that time and, where relevant, agencies also provided additional background information. This information was considered alongside the ‘agency returns’ that contributed to the earlier rapid review undertaken in line with national guidance (HM Government, 2018a). 1.10 Whilst consideration of the practice of lead statutory agencies is critical to the CSPR, it is important to note at the outset that Stephen’s untimely death occurred in the context of service provision from other agencies with a role in safeguarding and promoting the welfare of children i.e., primary care (GP services), maternity services, health visiting services, education (including pre-school), housing services, the community rehabilitation company and MIND. 1.11 The complexity of the child protection system and the circumstances in which practitioners work together is recognised in statutory guidance. This local child safeguarding practice review takes a systemic approach to learn from Stephen’s case and to identify improvements that can be made in policy, provision, and practice to help to prevent similar incidents in the future. The improvements and recommendations may be of wider national interest. The terms of reference for the review can be found in Appendix One. 1.12 Consultation with front line practitioners is long since recognised to be an essential requirement of systems methodology (Association of Chief Police Officers and Crown Prosecution Service, 2014). Panel were advised that any such consultation wait until the criminal trial had been completed, as several involved practitioners were to be called as witness. This contributed to an unavoidable delay in completion of the review. 1.13 The Covid-19 pandemic precluded face-to-face practitioner events strongly favoured in undertaking a review of this nature. Following consultation with other independent 8 reviewers, and directions from the local CSPR panel, a series of eight virtual2 ‘practitioner conversations’, lasting 90 minutes and supported by panel members, were held. A total of 24 participants from key involved agencies took part. The aim was to enable free-flowing conversation, with guided discussion points circulated in advance. A copy of these can be found in Appendix Two. 1.14 The progress and improvements in local child safeguarding practice that were shared in the meetings is testament to the reflection and learning that has already taken place locally. This review highlights, and builds on, these developments. As such, practitioners, and their managers, are co-creators of the learning and will be key facilitators of the continuing improvement journey. 1.15 Stephen’s mother was made aware of the commissioning of the CSPR and had expressed a desire to contribute. Various favourable text-based messages were shared with the author, but ultimately telephone calls went unanswered. A key worker has been identified to provide mother with feedback on the progress and findings of the review. However, the fact that her views could not be ascertained, nor a face-to-face meeting arranged (due to the pandemic), are regrettable and an important omission in the report. 1.16 Contact was made with Stephen’s father and with the father to his half-siblings. Both men shared valuable insights regarding the importance of practitioner understanding of the role of men in the family and household, and in ensuring fathers’ involvement in the lives of their children. It is Stephen’s father’s wish that the learning from this review will help to prevent further infant deaths in the future. 2.0 Narrative Chronology: Stephen’s story 2.1 Baby Stephen was born at term, by normal delivery, following what appears to have been a straightforward pregnancy. His birth weight was just below average for a term male infant. Mother’s partner and maternal grandmother were present for the birth. Despite not being his biological father, Stephen was given the partner’s surname. His death, at the age of twelve weeks, occurred in the context of the known risk (as above) that this partner presented to the family. 2.2 When mother booked for her maternity care at 12 weeks of pregnancy, she initially provided the name of a different male partner as the father. This was subsequently changed on the hand-held maternity notes to reflect her new relationship. This change is believed to have been made around the 28th week of pregnancy. It was normal practice, at that time, for expectant mothers to complete biographical information on these records. Paternity has since been established through genetic testing. 2.3 In the 25th week of pregnancy, mother’s partner, who was subject to a probation order, reported to his responsible officer (community rehabilitation company) that he was in a new relationship (with Stephen’s mother). A note was made on his records of the need to find out more about this relationship when the officer next saw him. A week later, despite 2 Via MS Teams 9 the pregnancy, the presence of mother’s other young children in the household, and a record that he had recently shared news of ‘his baby’ (and subsequently the due date) with a MIND worker, the responsible officer was told by mother’s partner that there were no children involved. 2.4 Approximately six weeks prior to Stephen’s birth, police were called by a neighbour, who reported hearing mother and her children screaming. Mother’s partner initially resisted engaging with police, reporting that he had ‘a problem with the authorities’. Mother was noted as being pregnant. Police officers entered the premises and found the children were refusing to go to bed, and that a new puppy in the household had heightened tensions. Mother described the incident as being a verbal argument and that the couple ‘had been arguing a lot lately’. 2.5 A DASH assessment3 was completed and attending officers, who had checked police systems for the partner’s previous history, identified the risk as medium. A police domestic violence notification (known locally as the F101) was sent to the children’s school, children’s social care and health partners (GP, maternity, and health visiting services). Consent was sought from mother for her information to be shared. 2.6 The neighbour was spoken to by police officers. They reported that the noise and arguments had escalated since mother’s partner had moved in, and that the household was ‘much different to the atmosphere that they had been used to’. 2.7 School were aware that mother’s partner had previously been a perpetrator of serious domestic violence, as he had had an earlier relationship with another parent of children at the school. Those children had been subject to child protection planning because of his abusive behaviours. The designated safeguarding lead (DSL) asked staff to be vigilant in monitoring Stephen’s half-siblings. They also spoke to mother about the concerns who said that the neighbours were ‘being malicious’. 2.8 Four days after the initial call out, police were called to the home of a member of mother’s extended family and their partner, who reported that mother and her partner had made threats against them and caused criminal damage to their property. They also expressed concerns about mother’s children. Police declared a public order offence, but this was deemed as not being in the public interest to pursue. Practitioners have described a dysfunctional relationship between mother and this family member. 2.9 The next day, children’s social care, who had contact with the extended family member due to the service’s involvement with their own children, noted the relative’s reported concerns as follows; that mother’s partner was slapping the children, that he was threatening to kill [the family member] and was a perpetrator of domestic abuse in his current, as well as previous relationships. 2.10 A multi-agency safeguarding hub (MASH) enquiry followed. This found that mother had told school she was happy with her partner and the children were ‘fine’, although the eldest had told a teacher that he ‘didn’t like it’ when mother’s partner shouted. A DV-RIM4 3 Domestic Abuse, Stalking, Harassment and Honour Based Violence Assessment Tool 4 Barnardo’s Domestic Violence Risk Identification Matrix 10 was completed to assess the risk to the children and this was judged to be at scale one (moderate level of risk to children). 2.11 The outcome from the MASH enquiry was to recommend ‘early help’ support. A worker tried, but failed, to contact the family to offer this service. As a result of no contact, the case was closed as ‘no further action’ (NFA). Later that week, the police DASH assessment completed following the call out noted above (2.4) reached other agencies, including children’s social care. The ‘medium risk’ identified by the DASH did not change the outcome of NFA. 2.12 The health visitor undertook an antenatal visit at home as per the Healthy Child Programme. At this point she had received the police notification, but not the completed DASH form. The health visitor got in touch with MASH who mentioned two referrals had been made but did not disclose the details. The health visitor had a conversation with mother about the anonymous referral to children’s social care, obtained her consent to share information, and followed up the visit with a call-back to the MASH team. 2.13 Mother, who was nearly 36 weeks pregnant at this point had attended an antenatal appointment with the midwife earlier that day. The midwife discussed the concerns with mother who said this was a ‘malicious’ report, probably from [relative] as they were ‘always falling out’. 2.14 Shortly afterwards there was a further (second) call out by the police service in response to a neighbour’s concern about fighting between mother and her partner, and the wellbeing of the children in the household. Mother was reported to be accusing her partner of having an affair due to her pregnancy. As part of their domestic violence action plan, police added a marker to the address to identify a medium risk of domestic abuse to mother and children. Just over three weeks later, Stephen was born. 2.15 When Stephen was a week old, a neighbour made an anonymous referral (via housing) to children’s social care. The neighbour was concerned about the children being physically abused, neglected, and left unsupervised. They also reported shouting and aggression from mother’s partner towards the children. MASH report that their attempts to contact mother by phone and email failed. As the concerns were noted to be ‘similar to’ those received previously, a letter was sent offering support through the early help process, with NFA by children’s social care. 2.16 Prior to undertaking the ‘new birth visit’, when Stephen was 13 days of age, the health visitor contacted children’s social care for an update. She was informed that they had made numerous attempts to contact mother, that she was not responding to their calls, and they were wanting to put a family support worker in place. As they had been unable to make contact, they had not been able to gain permission to share information. The health visitor was advised to make another referral if there were concerns at the new birth visit. 2.17 The health visitor was also contacted by the midwife, who expressed concerns about Stephen’s half-siblings being left with the extended family member and partner mentioned above (see 2.7). This is because this couple were deemed to be unsuitable carers, due to child safeguarding issues that had led to the removal of their own children. 11 2.18 The health visitor undertook the new birth visit in line with the expectations of the Healthy Child Programme. The midwife had earlier recorded a small weight gain. This placed Stephen on the 25th centile (his birth weight was between the 25th and 50th centile). 2.19 Stephen’s maternal grandmother was also present for this visit. Mother reported that ‘father’ and the other children were with the relative and partner, as above. The health visitor challenged this because of the carers’ own history. Grandmother was reported to have been angry with the health visitor for raising this challenge, but subsequently joined mother in acknowledging the concerns. 2.20 The health visitor reminded mother about multi-agency working and professional communication. Mother assured the health visitor that she would email children’s social care back in response to their request for her to contact them. The health visitor arranged to visit the family at home in a week. 2.21 A week later the health visitor weighed Stephen. This reflected a normal weight gain for an infant of his age over the seven days, albeit with him remaining on the 25th centile. A positive report of Stephen ‘looking well, beautifully and appropriately attired in clothing fit for the season’ was made. A warm and reciprocal relationship with his mother was also recorded. 2.22 ‘Dad’ [mother’s partner] was reported to have stayed in the kitchen but was ‘polite and welcoming’ to the health visitor. The heath visitor asked mother if she had contacted children’s social care; the reply was that she had now received a letter from them stating that there would be no further action. On enquiring, mother reported to the health visitor that she was not in a controlling relationship. 2.23 In mid-September, when Stephen was just over four weeks of age, police were called four times during a Saturday night (between midnight and 04:15). Initially this was to respond to reports of mother being attacked in the street and calling for help, and then again as the arguments continued as the couple returned home. The police report that mother’s partner was ‘very anti-police and aggressive, before walking off’. 2.24 Mother, who had been physically injured, refused to complete the DASH paperwork and said that her partner sometimes ‘has problems with his mental health and was bi-polar’. The children were said to be with [family member]. Police visited the family member’s address, and all four children were seen, and noted to be ‘alive and well’. A standard risk police notification was completed. 2.25 In the morning, neighbours contacted children’s social care emergency duty team and the police with their continued concerns about mother and her partner ‘constantly arguing and screaming and the children crying’. At this juncture social care report that they ‘now have’ criminal records on mother’s partner, and other social care records. A further DV-RIM assessment was undertaken, and this was graded as scale three (serious level of risk to children). The outcome was for the family to be allocated from MASH to the assessment team for a child and family assessment. 2.26 Information was sought from the health visitor and the school. The health visiting information was provided by a duty health visitor who reported the positive findings from the named health visitor’s recent visit as recorded on the records. The school reported good 12 attendance and ‘immaculate presentation’ of the children. They also noted that the eldest sibling talked about [the sibling] and their mother ‘being slapped’ by mother’s partner. 2.27 The named [i.e., family’s] health visitor was made aware by her colleague that a child and family assessment was being commenced by children’s social care because of further domestic abuse concerns, the young age of the baby and ‘dad’s’ previous history of domestic violence. The health visitor informed me that she did not receive a police notification of the protracted incident, the details of which were not disclosed by the MASH team. 2.28 School, however, do report receiving a copy of a police domestic abuse notification the following day. The deputy designated safeguarding lead spoke to mother who said that this was a ‘small row’ with no physical contact. School followed this up with contact with MASH who advised that the case had been opened for a child and family assessment. 2.29 When the social worker visited to commence the assessment, mother, supported by grandmother, refused to give permission for the practitioner to speak to the children alone. Mother and her partner reportedly downplayed the concerns. Partner was described by the social worker as ‘acting in a controlling manner’. 2.30 A housing officer also visited the home to discuss anti-social behaviour. They observed a baseball bat over the front door. When asked about this, mother replied ‘it’s just what [partner] does.’ The housing officer had linked mother and her partner to an address where a known drug dealer was shouting for mother’s partner to come out, as he owed money to them. 2.31 The social worker sought agreement from the team manager to approach the siblings’ father for permission to speak to the children alone, effectively over-riding mother’s wishes. Mother did give permission for her medical records, and those of her children, to be released to children’s social care. The GP practice was aware that mother’s partner was part of the household but did not release his medical information at this time, as his consent had not yet been given to do so. Mother’s partner was recorded by children’s social care as being the biological father of Stephen. 2.32 The social care chronology notes that nearly three weeks after the agreement for the child and family assessment, further details on mother’s partner’s criminal history of domestic violence and abuse towards a previous partner were received from the police. 2.33 When Stephen was seven and a half weeks of age, the health visitor undertook a home visit to carry out an assessment of Stephen. His weight was noted in the e-records to be 37.5kgs. This was assumed by the chronology author to be a decimal point error, and a reading of 3.75kgs was suggested. This recording is disregarded for the purpose of the review, as the health visitor’s written record has been sourced. 2.34 The police have provided a copy of pages from the ‘red book’ (parent-held child health record) which is now in their possession. This records the weight as being 4.32 kgs at the home visit. The head circumference at this time was recorded as 37.5cms and this is seemingly what was erroneously entered on the weight chart. Whilst an increase on the previously known weight, a weight of 4.32 kgs placed Stephen just under the 9th centile at this time. 13 2.35 The health visitor noted that Stephen’s growth and development were ‘appropriate’, with Stephen ‘fixing and following, smiling, and turning to familiar voices’. The HV addressed ‘dad’s’ rough handling of Stephen when undressing him for weighing, but also noted ‘parents’ appropriate interaction, warmth, and sensitivity to his needs. Mother told the health visitor that her previous partner had subjected her to domestic abuse and that the children ‘had not seen their father in months’. 2.36 The school became aware that the children were again spending time with unsuitable carers (as above), and informed children’s social care. They also reported that one of the siblings had arrived at school very cold, dressed in a soaking wet coat. The headteacher spoke to mother about this and asked staff to monitor the children as the incident had been out of character as the children were ‘always well-presented and well-equipped ordinarily’. 2.37 The social worker undertook a further home visit to discuss the concerns from school and housing. Mother was distressed that the older siblings’ father was being involved and agreed for the children to be seen, and spoken to, at school. The social worker discussed domestic abuse and mother was recommended to do a Clare’s Law disclosure5. Mother said that her partner suffered from bi-polar disorder. He had been asleep in another room but came in and signed the consent form for his medical records to be accessed. 2.38 Stephen attended the GP practice for his first immunisations; ‘both parents’ were noted to have accompanied him. A small blister had been seen on his upper lip, which had ‘burst’; this was deemed to have been a ‘sucking blister’ and the assessment was overseen by the practice safeguarding team, who were aware of the s.17 assessment. 2.39 When Stephen was nine weeks old, he was apparently weighed at the Child Health Clinic. This weight/visit to the clinic is not recorded in the red book; but had been noted on the chronology as being 3.75 kgs in the clinic record. This would have reflected a loss and placed his weight as being just below the 0.4 centile. It is possible that this recording was also made in error. 2.40 A few days after the clinic visit Stephen was seen for a routine six to eight-week GP check (he was just over nine weeks of age at this time). His physical examination was reported to have been normal and there were ‘no [parental] concerns’. The medical records note that he was not weighed or measured at this check ‘as this had been done by the health visitor two weeks previously’, and the weight was recorded by the GP as 9lbs 8oz (4.32kgs) as per the entry in the red book at that time. The GP noted the weight and head circumference as being on the 9th centile. 2.41 Mother also saw the GP for her postnatal check. She discussed having ‘lots of stressors’ as neighbours had referred the family to children’s social care services. However, she also told the GP that she was ‘not worried as she thinks there are no problems’, but that it was playing on her mind. She added that she ‘feels guilty’ about the effect of the referral on her children. The GP diagnosed depression and issued a prescription. When asked about relationships at home, mother described her partner as ‘supportive’. 5 Clare’s Law is the Domestic Violence Disclosure Scheme that enables any member of the public to ask the police if their partner poses a risk to them. It also enables a close friend or family member to make enquires. 14 2.42 The social worker saw the siblings alone in school, as agreed by mother, and noted that the eldest looked ‘absolutely terrified and close to tears’. This contact took place some six weeks after the assessment commenced. The social worker believed that the children may have been warned not to talk to them. They also recorded that none of the children seemed anxious when asked about, or discussing, mother’s partner. 2.43 The pre-school manager (safeguarding lead) disclosed to the social worker that the youngest sibling ‘does come out with comments about mummy crying and people shouting out of the blue when she is playing’. This information was seemingly not discussed with mother or written on the child’s pre-school safeguarding file.6 2.44 The following day (which was the same day that Stephen was admitted to hospital), the pre-school manager commenced a log of concerns, as follows; that the youngest sibling had been upset on the last four times they attended pre-school, that they were taking longer to settle in than previously, that they had been wearing the same outfit for three to four weeks and was unclean. This was noted as a change, as this child was usually well presented. A plan was made to inform the social worker. 2.45 The other children were recorded to be late for school that morning; this was also seen to be unusual as their punctuality and attendance were normally good. 2.46 That afternoon, Stephen was taken by ambulance to hospital, fatally injured. There is evidence from the GP records (which include a transcript of mother’s call to the practice) that there was a delay in his mother and her partner seeking medical help. It was noted that mother collected the other children from school (early) before calling an ambulance, despite the presence of her partner in the household, and the urgency of the situation being made clear by the GP. Stephen’s siblings 2.47 Stephen is the child at the centre of the child safeguarding practice review. However, it is pertinent to make some additional reference to the lived experiences of his older half-siblings. Prior to the arrival of mother’s partner in the household, it appears that no serious concerns about the family had been raised by those who knew them; either as service providers, or as members of the local community. School reported well-mannered, well-presented, and polite children, with parents who engaged well with the school. 2.48 Neighbours’ growing anxiety about the siblings, and changes in the children’s presentation and behaviour at school after mother’s partner joined the household have been noted above. Although outside of the timeline of the review, the author of the education chronology added the voice of these children through reported disclosures made to education staff following their baby brother’s hospitalisation and subsequent death. 2.49 One sibling told school staff that they were told by mother and partner ‘not to trust the social’, and that their mother had told them ‘not to tell the truth, or the social would take [them] away’. They also shared that mother’s partner told them that school would not do anything if they told them what was happening at home, adding that school was ‘s***’. 6 This is being addressed by the Early Years Lead for the County following action taken by the education chronology author. 15 2.50 Stephen’s siblings additionally provided a vivid description of mother’s partner’s verbal aggression towards their baby brother, and of his violence towards their mother, to them, their pet dog, and of causing harm to himself. Some six weeks after Stephen was hospitalised and the children moved to a safe place, the youngest sibling was continuing to express anxiety that the person they had begun to call ‘dad’, was going to ‘come and get me’. 3.0 Key practice episodes 3.1 The child safeguarding practice review process enables the bringing together of information (from a range of sources and perspectives) to aid in an understanding what happened and why, to learn from the case, and to apply the learning to improve outcomes for children in the future. Identification of key practice episodes informs the learning. In this case, the key practice episodes identified include establishing and recording paternity, responding to reports of domestic abuse and concerns about the children, Stephen’s pattern of faltering growth and the evidence of parental resistance to engagement with practitioners. 3.2 Although ‘episodes’ are identified, these are often linked and expose some cross-cutting themes that contribute to the learning and the recommendations for improving the child safeguarding system that follow. This also reflects the enduring messages from other reviews, for the need for authoritative child-centred practice (Brandon et al., 2020). Establishing and recording paternity 3.3 The review has identified that from the outset of the relationship between Stephen’s mother and her new partner, this individual was presented to agencies and practitioners as being the putative father of Stephen. The original name (of the biological father) provided by mother at her booking appointment, was documented in maternity records, but altered on the hand-held maternity notes. Once born, Stephen was given mother’s partner’s surname, and an embedded belief that he was the biological father prevailed. 3.4 The fact that mother’s partner was presenting as, and was believed to be, Stephen’s father is a significant finding. Research on child homicide references the ‘clear danger’ that may be presented by a non-biological carer (Wilczynski, 1997). A change of partner in pregnancy is a pivotal event. Such changes should engender professional curiosity about the role and status of men in the household. 3.5 The community midwife did not meet Stephen’s biological father in person at any appointments, including the home booking. She recalls meeting mother’s partner subsequently but had no reason to suspect that this was a different male partner. Maternity colleagues informed me that changes were often made by clients on the hand-held notes, most typically changes of contact numbers. The change of partner’s name was not noted until the case became subject to review. 3.6 Stephen’s biological father was seemingly not part of his life; nor, it is understood, was he able to see him prior to his death. The estranged father of his half siblings was not informed of emergent concerns about his children or involved in the assessment process. A 16 clearer understanding of men in the family and household by all involved agencies may not only have better protected Stephen, but also offered an opportunity to explore the potential role of his father (and the father to his siblings) in the children’s care, welfare, and protection, particularly at the point of statutory assessment. As Brandon et al. (2020) note: ‘Lack of professional curiosity or interest in fathers and partners not only leaves women and children vulnerable it can also leave fathers feeling alienated, forgotten and their role in bringing up their children dismissed.’ (p.69) 3.7 An opportunity to explore paternity, and potential risks, occurred when mother’s partner disclosed to his MIND worker that ‘he was going to be a dad soon’, later sharing the due date of ‘his’ baby. This disclosure was made around the time he reported the new relationship with Stephen’s mother to his responsible officer at the community rehabilitation company, albeit disclosing that there were ‘no children involved’, and not sharing the news of the pregnancy. 3.8 Mother’s partner’s attendance for MIND mental health support reflected a rehabilitation activity requirement (RAR) in the context of his period of probation. The service informed me that after self-referral, he attended an initial assessment and two subsequent individual sessions. He was recorded as missing other appointments, and this resulted in his discharge from the service. It also negated his eligibility for the borderline personality disorder (BPD) peer support group that he was planning to attend7. 3.9 Despite the RAR, the MIND worker and responsible officer did not liaise directly with each other. The MIND service was aware mother’s partner was on probation. They understood (from the partner) that this was for criminal damage to canal side property. The service was unaware he had been judged as presenting a medium risk to known women and children. This raises a potential concern for the safety of female workers, as well as impacting on the service’s safeguarding responsibilities. 3.10 Mother’s partner’s probation ended approximately one month prior to the first police call out, and two months prior to Stephen’s birth. A responsible officer, supported by their manager (a senior probation officer), confirmed he had progressed satisfactorily through his period of probation. This was evidenced by his self-reporting, compliance and engagement with the service, and the fact that there were no further/alleged offences or police call outs during this time. The CRC were not aware that he had only partially engaged with the MIND service. 3.11 As acknowledged by the CRC, best practice is to complete a formal termination review at the end of a sentence, with the responsible officer recording whether they consider the service-user’s risk of re-offending and risk of harm have reduced, increased, or remained the same. This would normally triangulate feedback from other agencies. Had there been communication between CRC and MIND this may have prompted a discussion about the pregnancy and new relationship and a call to children’s social care before the period of probation ended. This would have also highlighted the fact that rehabilitation activity requirements had not been fulfilled. 7 Partner’s claim to suffer from BPD, similarly to his claim to be ‘bi-polar’, has not been clinically diagnosed. 17 3.12 The use of a genogram [family tree] or other means of recording family and household make-up can help to establish the presence of children (including unborn children) and to record putative paternity. This should inform initial assessments, as well as an ongoing understanding of the dynamics of relationships within families, and the identification and management of risk presented by a new boyfriend/father figure. However, the risks presented by deliberate attempts to deceive are acknowledged. The recommendation to record family and household make-up applies to all agencies who have safeguarding roles and responsibilities, including those whose primary client is the adult/parent in the family. The response to domestic abuse and concerns about the children 3.13 The change in family dynamics when mother’s partner joined the household is one of the most important findings of this review. This change was perhaps best described by concerned neighbours, to an extent by a family member, and later by the siblings’ school. The building of the chronology exposes the events, the risks, and the opportunities to improve the response to domestic abuse and concerns about the children. 3.14 The police officer who attended the first call out for domestic abuse, recorded as a verbal argument, was described by senior officers as exercising good judgement in completing a DASH assessment, as well as an F101 notification. The DASH assessment, which was circulated to agencies, gave the risk of domestic abuse as ‘medium’ and shared mother’s partner’s history of 15 previous police call outs involving an ex-partner and noted he had ‘previous convictions for assault.’ 3.15 The ‘flow chart’ used to manage the DASH process states that where risk is judged to be medium, police records for the victim and perpetrator are searched for any child protection or domestic abuse history. The research, carried out by civilian staff, was not [at the time] shared with partner agencies. A system-check to review the circumstances and risk assessment was in place. The review of any domestic abuse history ascertains if the parties have been heard at previous MARACs. (As noted earlier, mother’s partner, through perpetration of violence in a previous relationship, had been discussed at MARAC on five occasions.) 3.16 A few days following the first known incident, police again attended the family home after a neighbour reported ‘fighting between the occupants.’ Mother was accusing her partner of having an affair, due to her pregnancy (with Stephen). The police put a domestic violence action plan in place (DVAP). This meant that there was a marker flag on the family’s address to identify the vulnerability of mother and her children, and to name mother’s partner as the perpetrator. The marker is normally associated with high-risk cases. 3.17 Further concerns about domestic abuse and the welfare of the children were raised by an extended family member. A MASH enquiry was undertaken. Children’s social care had linked mother’s partner with another family who had had previous engagement with the service. However, the checks, and balances, in managing the agency response to domestic abuse and concerns about the children did not result in further protective action being taken at this time (for example, to raise the threshold from ‘early help’ to a potential for statutory 18 intervention8, to raise the risk of domestic abuse to ‘high’, and/or to consider re-referral to MARAC). 3.18 The review thus finds that the initial responses to concerns of domestic abuse and the welfare of the children (i.e., the offer of early help) were not sufficiently robust. This is because the known risks at this time included mother’s pregnancy, the involvement of family and neighbours in raising concerns, the young age of the siblings, and the, then, new partner’s history and criminal convictions as a perpetrator of serious domestic abuse. Further concerns from neighbours raised shortly after Stephen’s birth (see 2.15) did not change the agency response from the ‘early help offer’, despite the additional stressor of a new baby in the family. Whilst continued attempts were made to contact mother, including sending a letter, the case was ‘NFA’ (no further action). 3.19 The multi-agency safeguarding hub (MASH) partners’ response lacked robustness in interrogation of the partner’s background, and in the provision of an indicative response in the application of the Domestic Violence Risk Identification Matrix (DV-RIM) framework. This finding must be seen in the context of a need to process and manage a high volume of police notifications and DASH assessments, with limited resources. Critically, the decisions were not challenged by other services party to the information on the initial police notification and DASH and working with the family at this time. 3.20 When Stephen was four weeks of age, four episodes of domestic violence were reported over the course of one night (see 2.23-2.25 above). Police attending the initial episode may not have been aware of the DVAP, as the events were taking place in a public setting and not at the marked home address. However, officers subsequently attended the address. The view of the police panel member is that although Stephen’s mother refused to engage in a DASH, officers should have raised a ‘medium risk’ DASH because there had been three incidents attended by police within 90 days. 3.21 School were sent a standard police notification9 of the overnight incident, which stated this was a ‘verbal argument’ (albeit physical injuries to mother were subsequently noted). The health visitor was made aware that there had been ‘a further domestic abuse incident’ (but not the details) through a call from a MASH worker to the duty health visitor. This is the point at which children’s social care commenced the statutory child and family assessment. Stephen’s pattern of faltering growth 3.22 The family were not known to children’s social care prior to mother’s partner’s arrival in the household. Parental relationships with school and health services had been largely positive. Practitioners from universal services (education and health) had witnessed mother’s care of her other children, who were seen to be well-presented, with good punctuality and attendance at school. 8 Effective Support for Children and Families Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2018) 9 This is due to the grading of the incidents as per ‘Operation Encompass’; only school receive a notification for standard risk. 19 3.23 Stephen’s mother and her partner engaged with antenatal and post-birth home visits from maternity and health visiting services. When Stephen was just over three weeks old the health visitor noted a warm and reciprocal relationship with his mother, and that he was ‘looking well, beautifully and appropriately attired in clothing fit for the season’. Mother and her partner also took Stephen to the baby clinic to be weighed, he received his first course of immunisations, and was taken to the GP for a ‘six-week’ developmental review. 3.24 Integrating such findings reflects the expectation that child safeguarding practice balances protective factors with emergent risk before invoking procedures that may entail compulsory intervention in family life. This was evident in this case. However, there is the ever-present risk that positive findings may contribute to professional optimism that all is well. 3.25 Of potential significance, is the fact that mother booked late for her maternity care, reporting that she had done a positive pregnancy test six weeks previously. The booking was completed by a midwife at home, in the 13th week of pregnancy. Mother then attended all her scheduled maternity appointments. Late booking may be an indication of risk to the mother and/or the unborn child (National Institute for Health and Care Excellence, 2010). Current guidance from the NHS is that booking should normally take place before 10 weeks of pregnancy10. 3.26 The chronology reflects the ongoing contacts with universal health service practitioners. Here, it was concerning to find evidence that Stephen’s reported weights were indicative of a pattern of faltering growth. This is demonstrated by the references in section two (above) to the drops in the centiles in the first nine weeks of his life. 3.27 When Stephen was seen by the GP, aged nine weeks, for the ‘six-to eight-week’ developmental check, he was not weighed or measured. The stated reason for this was that his weight and his head circumference ‘had been done by the HV two weeks previously’. At this point, the welfare of Stephen (pre-birth and post-birth) and his half-siblings had been discussed at the in-house practice safeguarding meetings on four occasions and an alert [icon] added to the records. The practice was aware that a social worker was undertaking a child and family assessment. 3.28 In the context of an otherwise normal physical examination, no concerns about Stephen’s growth or development were identified by the GP or raised as a concern by mother. This appointment was the last time Stephen was seen by a health professional prior to his emergency admission to hospital 10 days later. Stephen’s pattern of faltering growth was not identified at this appointment, or in the earlier contacts with health professionals. This is important because, in the absence of an organic cause, his slowness in gaining weight/weight loss may have reflected the presence of physical injuries or neglect. 3.29 A recent paper by Laurent-Vannier et al., (2020) highlights a common retrospective finding of ‘sentinel injuries’ in infants who later sustained abusive head trauma. The paper acknowledges that most of these babies were seen by health professionals during this time, Your first midwife appointment - NHS (www.nhs.uk) (accessed 3/01/21) 20 but that such injuries were generally not identified. Whilst we now know that Stephen had already suffered non-accidental bone fractures at the time of his routine health appointments, identification of these covert injuries would have required specialist x-rays (a skeletal survey) undertaken as part of a child protection medical. The emergent pattern of faltering growth raises the question of whether there was a window of opportunity for a referral to a paediatrician in the context of known safeguarding concerns, including domestic violence and abuse. Parental resistance to engagement with practitioners 3.30 Early in mother’s new relationship with her partner, there were emergent indicators of ‘parental resistance’ to engagement with practitioners (Tuck, 2013). This was borne out in non, partial, or disguised compliance, and in deflecting or minimising practitioners’ concerns. This behaviour is best seen and judged cumulatively as a pattern, rather than by individual events. It is entirely possible that these behaviours relate to a controlling, coercive and violent relationship, but the evolving evidence reflects an increasingly risky situation for the children and their mother. 3.31 Parental resistance is seen throughout the timeline for the review. Mother’s partner had poor compliance with his ADHD medication regime (as demonstrated from a GP review of his prescriptions). He failed to engage fully with his RAR during his period of probation. When he joined the household, he was reported to absent himself from professional visits and described as being ‘resistant’, but also recorded as being both ‘polite and welcoming’. When police attended the call outs for suspected domestic violence, ‘he had a problem with the authorities’ before being ‘very anti-police and aggressive’ and walking away. When the social worker commenced the child and family assessment, mother’s partner was described as ‘confrontational’ and ‘controlling’. 3.32 Mother chose not to accept the early help offer, despite ‘numerous attempts’ to contact her by phone and email. This early indicator of parental resistance may have reflected her vulnerability (and that of her children) from the outset of her new relationship. As Brandon et al. (2020) note, overwhelmed parents may not have the emotional capacity or material resources to be able to take up the services offered. 11 Her behaviour was also evasive at times; for example, refusing to complete a DASH assessment after the protracted overnight domestic abuse incidents. On several occasions she excused her partner’s behaviour as being due to him having ‘problems with his mental health’ and being ‘bi-polar’ to detract from the presenting risk (N.B. such an excuse does not lessen the risk or impact for a victim or their children). 3.33 The police call outs were described to other agencies as being ‘due to neighbours being malicious’ and of it ‘being a small row’. Mother had told the school that she was happy with her new relationship. When asked by a housing officer why there was a baseball bat by the door, mother’s apparent response was ‘it’s just what he [partner] does.’ Reflecting the findings of another local review, (‘Child K’), this was a mother who was able to reassure professionals that all was well (Cambridgeshire Safeguarding Children Board, 2015). 11 Whilst the refusal is of note, families are not compelled to accept this intervention. 21 3.34 When the child and family assessment commenced, mother refused to give permission for Stephen’s siblings to be spoken to alone and became distressed when the social worker mentioned asking the children’s father for permission to do so. It is notable that maternal grandmother was seen to collude with her daughter when challenged; and then conceding to the professional view. Whilst there was subsequently an agreement for the children to be seen by the social worker at school, they were noted to look ‘absolutely terrified and close to tears’ prompting the practitioner to hypothesise that they had been warned not to talk to them. The children’s later disclosures confirm this seems to be so. 3.35 The children were seen at the social worker’s initial home visit and described as ‘chaotic but well-presented.’ Children’s social care reported that the delay in speaking to the children alone was in part due to the issue of gaining parental consent, with a half-term school holiday adding to this delay. This meant that the assessment was not completed in the expected timescales. Normal practice is to speak to the children, alone, within five days of the commencement of the assessment. 3.36 The conversation mother had with a GP at her postnatal check is illuminating. Here the involvement of children’s social care was shared with the GP in the context of anxiety and depression. Having put the blame on neighbours’ reporting, mother indicated that she was ‘not worried as she thinks there are no problems’, that she ‘felt guilty’ about the impact of social care’s involvement on the children, and that her partner was ‘supportive’. 3.37 Mother’s response to the GP has been discussed with practitioners from primary care. An important consideration is that mother’s relative’s children had recently been subject to proceedings and been removed. However, there was agreement that the disclosure may have presented an opportunity for an authoritative discussion on mother’s own safety and that of the risks to her children in the context of the statutory assessment and known risk from domestic abuse (Department of Health and Social Care, 2017). 3.38 This was also an opportunity for the practitioner to suggest to the mother that the input of children’s social care be viewed as a positive for the protection and welfare of her children, rather than being punitive. This finding has resonance with Brandon et al.’s (2020) suggestion that opportunities for protective actions by statutory agencies are curtailed by a perception that assessment equates with blame and creates a barrier to collaborative working. 4.0 Discussion 4.1 In their first annual report, the Child Safeguarding Review Panel (2020) note the ‘shocking’ (p.27) level of violence that has led to deaths of, and serious injuries to, infants under the age of one year. This has led to the commissioning of a national review that focuses on the motivation and behaviour of male perpetrators of this form of abuse. 4.2 Mother’s partner, who was not Stephen’s father, had a significant history of a pattern of abusive behaviour towards intimate partners and ex-partners, and criminal convictions resulting from his controlling, coercive and violent behaviour. His previous victims appear to have been vulnerable women, with children (including unborn children) who were also 22 placed at risk. As recognised by concerned neighbours, when mother’s partner became part of the family, ‘things changed’ in the household. 4.3 The tragic death of Stephen adds to the toll of cases that reflect the level of violence noted by the Child Safeguarding Review Panel. We now know that this baby had suffered serious injuries before the catastrophic head injury that ultimately killed him. Stephen’s death has had a devastating impact on his family and has caused great sorrow to those who provided care during mother’s pregnancy and in the short weeks of his life. 4.4 The review has highlighted key practice episodes in this case that lead to specific recommendations for the Cambridgeshire and Peterborough Safeguarding Children Partnership. There is evidence of embedding improvements in practice locally, reflecting learning from this case, as well as from other reviews and developments (see below). The Board will be seeking assurance that these improvements are secure and having impact. 4.5 Opportunities for further learning and improvement to support robust, evidence-based, authoritative practice and inter-agency working are recognised through the process of child safeguarding practice review. This includes sharing good practice in this case. 4.6 Examples of good practice include the opportunities taken by health professionals to ‘ask the question’ regarding domestic abuse; the school’s designated safeguarding lead’s direction for vigilance in observing the well-being of the siblings; the recognition by the social worker of mother’s partner’s ‘controlling’ and ‘confrontational’ behaviour; and the urgency of the need for Stephen to be taken to hospital, as clearly articulated by the GP. There is also evidence of managerial oversight and supervision of safeguarding practice within health and social care services. 4.7 Authoritative practice is reflected in the actions of the health visitor on receipt of the police notification, and subsequent DASH assessment, following the first call out. This practitioner liaised with children’s social care before and after undertaking a planned antenatal visit, where a frank and open discussion was held with mother about the concerns. Consent for information-sharing was also sought and given. This practice should be commended and modelled elsewhere. 4.8 In line with good practice, the risk analyses undertaken in response to the first known episode of domestic abuse balanced risk and protective factors. The protective factors included the health visitor’s observation of the house being ‘warm and clean’ and another child being ‘well-presented’. The initial school reports were also positive. The absence of historical safeguarding concerns within the family is an important finding. 4.9 The fact that ‘things changed’ when mother’s partner joined the family is key. The response to neighbours’ escalating concerns about the children was not sufficiently robust, reflecting previous findings from a national study that ‘insufficient weight is given to concerns raised by neighbours’ (Brandon et al., 2020:70) and the ‘hierarchy of referrer’ described in a more recent review (Shropshire Safeguarding Partnership, 2021). Agencies appear to have accepted mother’s explanation of neighbours’ reports being ‘malicious’, that the arguments were verbal, and that her partner was supportive. 23 4.10 Had a statutory child and family assessment been commenced at an earlier stage (and/or there had been consideration of the application of the multi-agency pre-birth protocol) this would have enhanced multi-agency working, provided key insight into the daily lived experiences of the children, and a clearer view of whether Stephen and his siblings were ‘children in need’ or ‘children in need of protection.’ Critically, this would have provided a timely opportunity to support the family in addressing the known risk from the partner, including the application of the domestic violence disclosure scheme. 4.11 The reviewer heard evidence to suggest limitations in professional dialogue and sharing of concerns between involved practitioners and agencies. This includes exchanges between statutory partners in the MASH. Other examples include communication between the CRC and MIND; children’s social care and health partners; and the timeliness of pre-school reporting and recording of concerns. Such communication may be critical in adding context, clarity and expertise to data provided through a trawl of records (referred to in the chronology as ‘agency checks’). As recognised in government guidance: ‘Professional judgement is the most essential aspect of multi-agency work which could be put at risk if organisations rely too heavily on IT systems.’ (HM Government, 2018b:14). 4.12 Chronology authors, panel members and practitioners have considered whether, at the point of transfer to the assessment team, it may have been more appropriate to consider a s.47 child protection enquiry, rather than a s.17 child and family assessment. Making a definitive judgement on this is challenging, with potential hindsight bias an important confounding factor. 4.13 As the Child Safeguarding Review Panel (2020) acknowledge, when there are child safeguarding concerns there is ‘unpredictability’ (p.6) of deaths and serious harm. Most families with multiple risk factors do not harm their children; and some children are harmed in families with no known risk factors. However, the risks to children who may be ‘on the boundary’ of the child protection system are also recognised (Brandon et al., 2020:14). The decision to undertake a child and family assessment was in keeping with the outcome of the second DV-RIM assessment. 4.14 The serious risk to the children was thus recognised, but the risk was balanced by protective factors and an approach to work collaboratively with the family. Furthermore, mother’s partner was understood to be Stephen’s father, a full disclosure of his criminal background had not yet been shared, indications from health services were that baby Stephen was essentially ‘doing well’, and school reports on his siblings’ well-being were initially largely positive. 4.15 However, as the period of assessment progressed there were, as recognised by the social worker, continuing indicators of ‘parental resistance’, and the subsequent delay in speaking to the siblings alone. ‘Further details’ on mother’s partner’s criminal record (see 2.32) were shared by the police12. When the social worker visited the school, pre-school staff expressed some serious concerns about the youngest sibling. These factors may have led practitioners to consider ‘step-up’ to s.47, but it was at this point that Stephen was 12 Arguably these could have been elicited through the MASH enquiry – see 3.20. 24 grievously injured, and events intervened. Agencies subsequently took appropriate actions to safeguard and protect the welfare of his siblings. 5.0 Progress and improvements 5.1 Discussions with CSPR panel members, practitioners and managers has highlighted evidence of learning and improvements in practice locally, reflecting learning from this case, as well as from other reviews and local developments. This section provides a summary of key improvements within the system. 5.2 Maternity staff are now more able to be made aware of changes to partner/putative father details through a new maternity e-records systems as changes to this information can only be made by the midwife (the system is known as K2 Athena/My pregnancy). The system for managing copies of DASH assessments and police notifications has been improved within maternity services, and this means that community midwives, as well as hospital-based staff, have more timely awareness of women who may be at risk from domestic abuse. 5.3 Domestic abuse, safeguarding and child sexual exploitation are current strategic priorities for the Cambridgeshire Constabulary. The service report they were ‘confident that they were now in a better place’ regarding response to domestic abuse incidents and ensuring the welfare of victims and children in the household. Leadership is provided through the ‘protecting vulnerable people’ department, and a domestic abuse delivery group seeks to enhance service delivery across the organisation. 5.4 There are plans for a ‘vulnerability focus desk’ in the two geographical divisions. These will enhance the support and supervision of frontline practice as part of ongoing developments. Supervisory oversight of all cases, including those deemed to require no further action, is now in place. Officers are equipped with an App, ‘We Protect’, to assist in their duties. 5.5 The designated paediatrician for child safeguarding has introduced improvements in clinical practice for infant growth monitoring. This follows the learning and practitioner reflection from Stephen’s case, as well as the case of ‘Jack’ (Cambridgeshire and Peterborough Safeguarding Children Partnership Board, 2020). The improvements include a review of the systems used to record, share, and evaluate children’s measurements within the parent-held, clinic and GP electronic health records. 5.6 There has been investment in new equipment, and access to a smartphone App. The App is essentially an ‘aide memoir’ that uses data from the Royal College of Paediatrics and Child Health (UK/WHO) to improve accuracy of recording measurements and helps to guard against accidental errors. Consideration is also being given to the use of the Ardens 6–8-week baby-check template in primary care.13 5.7 Children’s social care services have revised and aligned their systems and processes across Cambridgeshire and Peterborough. This means that the current 13 6-8 Week Baby Review: Ardens Healthcare Informatics (accessed 5/03/21) 25 framework for undertaking child and family assessments places a greater emphasis on multi-agency planning at the outset of an assessment, and clarification of the contribution of agencies and professional expertise in the process. 5.8 The safeguarding children partnerships board provides multi-agency safeguarding training for all professionals who work with children and families across both Peterborough and Cambridgeshire. A current programme of work is in place to support professional learning and improvement in ‘working with parents who are difficult to engage’. This includes professional briefings following CSPRs (where there is evidence of parental disguised compliance or confrontational behaviour) and training for practitioners in helping to support families through strategies for positive change. 6.0 Learning points and recommendations: 6.1 The fact that mother’s partner was presenting as, and was believed to be, Stephen’s father is a significant finding of this child safeguarding practice review. His arrival, status, and presence in the household, changed the dynamics, put the children and their mother at risk of significant harm, and ended with the tragic death of Stephen. A change of partner in pregnancy is a pivotal event. Such changes should engender professional curiosity and enquiry regarding the background, role, and status of men in the household. 6.2 In their review of serious cases featuring domestic abuse, the NSPCC (2020) highlight the importance of the verification of information about the composition of a household. Practitioners should keep this information up to date. Respectful enquiry and the completion of a genogram (or equivalent record of the family structure and relationships) address this finding. A recommendation is made: Recommendation One: The Board seeks assurance as to the way in which agencies record and update the details of family/household members. This may include completion of a genogram (or equivalent record of family make-up) and recording of current address/addresses. The recommendation applies to those providing services to children and to adults who are parents/carers. Such services should be required to demonstrate compliance with their wider responsibilities in child safeguarding. Consideration should also be given as to whether a change in intimate partner during pregnancy be added as a risk factor to section two of the pre-birth protocol in its next revision. 6.3 The review found that the MIND worker and responsible officer did not liaise directly with each other. The MIND service was aware mother’s partner was on probation, but not the nature of the offence. The fact of mother’s pregnancy was reported to the MIND worker, but this information was not shared with the community rehabilitation company. Mother’s partner’s rehabilitation activity requirements were not met. Recommendation two: The Board requires the National Probation Service to ensure that services commissioned to support offenders’ rehabilitation activity requirements (RAR) are provided with relevant information about the nature of the offending, risk management, and 26 the expected outcome of their involvement. Information sharing includes the evaluation of progress in achieving the goals of the RAR. 6.4 The checks and balances in managing the agency response to domestic abuse and neighbours’ growing concerns about the children did not result in timely protective action being taken. This includes the timely sharing of information from police partners. Two recommendations are made: Recommendation Three: The Board seeks assurance that concerns and referrals are not processed based on a hierarchy of referrer (giving less weight to concerns from neighbours or family members). The response should be proportionate to the reported lived experiences of children and others potentially at risk within the household. Recommendation Four: The Board requires Cambridgeshire Constabulary to provide assurance that stated improvements to internal system checks ensure correct allocation, grading and sharing of DASH/F101 notifications with other agencies are in place, with evidence of impact. Partnership agencies should also seek to progress and support improvements in the management of domestic abuse notifications to ensure the identification and prioritisation of high-risk cases. 6.5 Children’s social care reported that the delay in speaking to the children alone was in part due to the issue of gaining parental consent to do so, with a half-term school holiday adding to this delay. This meant that the assessment was not completed in the expected timescales. Normal practice is to speak to the children, alone, within five days of the commencement of the assessment. A recommendation is made: Recommendation Five: The Board requires Children’s Social Care to provide assurance that children are both seen, and spoken to, within the expected protocol and timescales of a child and family assessment. Those with parental responsibility who are not resident in the family home should be made aware of agency involvement and enabled to contribute to the assessment. 6.6 Stephen’s pattern of faltering growth was not identified as a concern by health professionals. In response to this finding (and learning from another local review) a programme of improvements in growth monitoring of infants has already been instigated. A recommendation is made: Recommendation Six: The Board requires health partners to report on progress in the embedding of improvements in growth monitoring of infants, with evidence of impact through quality assurance of practice. 6.7 The review found evidence of ‘parental resistance’ to engagement with practitioners. This was evidenced in non, partial, or disguised compliance, and in deflecting or minimising practitioners’ concerns. A recommendation is made: 27 Recommendation Seven: The Board undertakes quality assurance activity to assure members that the work it has undertaken to enhance practitioners understanding of authoritative practice has been embedded and resulted in a positive impact on practice. 28 References Association of Chief Police Officers, Crown Prosecution Service (2014) Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews: A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Boards National Policing Homicide Working Group. Brandon, M., Sidebotham, P. Belderson, P., Cleaver, H., Dickens, J, Garstang, J., Harris, J., Sorensen, P., Wate, R. (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report London: DfE. Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2020) Serious Case Review into the care of Jack (Author: Jane Scammell). Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2019) Cambridgeshire and Peterborough Pre-birth Protocol New Children Board Procedures | Cambridgeshire and Peterborough Safeguarding Partnership Board (safeguardingcambspeterborough.org.uk) Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2018) Effective Support for Children and Families in Peterborough and Cambridgeshire Cambridgeshire County Council (2015) Child and Family Single Assessment Framework (accessed via online safeguarding children procedures, op. cit.) Cambridgeshire Safeguarding Children Board (2015) Serious Case Review into the care of Child K (Author: Jane Scammell). Confidential Enquiry into Maternal and Child Health (2007) Saving mothers' lives: reviewing maternal deaths to make motherhood safer – 2003–2005. London: Confidential Enquiry into Maternal and Child Health. Department for Education (2019) Child Safeguarding Practice Review Panel: Practice Guidance London: DfE. Department of Health and Social Care (2017) Domestic Abuse: a resource for health professionals https://www.gov.uk/government/publications/domestic-abuse-a-resource-for-health-professionals (accessed 15/11/20) HM Government (2018a) Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children London: DfE. HM Government (2018b) Information sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers London: DfE. Laurent-Vannier, A., Bernard, J.Y., Chevignard, M. (2020) High Frequency of Previous Abuse and Missed Diagnoses Prior to Abusive Head Trauma: A Consecutive Case Series of 100 Forensic Examinations Child Abuse Review 29:231-241. 29 National Institute for Health and Care Excellence (2010) Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors; Clinical guideline [CG110] London: NICE. NSPCC (2020) Domestic abuse: learning from case reviews Summary of key issues and learning for improved practice around domestic abuse London: NSPCC Knowledge and Awareness Service. Shropshire Safeguarding Partnership (2021) Serious Case Review: The G children SSP. The Child Safeguarding Review Panel (2020) Annual Report 2018-2019 London: DfE. Tuck, V. (2013) Resistant Parents and Child Protection: Knowledge Base, Pointers for Practice and Implications for Policy Child Abuse Review 22:1, 5-19. Wilczynski, A. (1997) Child Homicide London: Greenwich Medical Media. Supporting documents Cambridgeshire and Peterborough Safeguarding Adults and Children Partnership Board (2020) Multi-agency Safeguarding Arrangements for Cambridgeshire and Peterborough Multi-agency Safeguarding Arrangements (safeguardingcambspeterborough.org.uk) (accessed 12/07/20) Cambridgeshire Constabulary DASH form v1.11 updated 8th November 2020. Cambridgeshire, Peterborough and South Lincolnshire MIND Safeguarding Adult Policy 2020. K2 Athena™ - Electronic and Personal Maternity Health Record Complete Electronic Maternity Health Record | K2 Athena<span class="trademark">™</span> (k2ms.com) (accessed 20/01/21) MASH enquiry form (draft) dated 27th November 2020. 30 Appendix One: Terms of Reference 1. How were risk and protective factors identified, assessed, and managed within the family? 2. What actions were taken by practitioners and agencies to ensure that concerns were shared appropriately, and within the available frameworks, to attempt to mitigate any risk? 3. How did practitioners and agencies that had contact with the family, work together to safeguard the children? 4. How well did practitioners and agencies understand the role and relationships of men within the household? 5. Can you identify any areas you consider to be good practice? 6. Does learning and improvement from this case resonate with other pertinent local (and national) reviews? 7. What recommended improvements can be made by local partners in safeguarding children policy, procedures, and practice in relation to this case? 31 Appendix Two: Guided discussion points for practitioner conversations Safeguarding in agency/organisation Broad discussion on how safeguarding and promoting the welfare of children works in your organisation, and with other local organisations/agencies. What is working well? Less well? Are you aware of any changes in practice or policy in the last year or so? (including pre-Covid-19)? How are families/individuals helped to access your service? What might prevent them from doing so? How is your role in safeguarding supported? Supervision? Management oversight? Learning opportunities? Case Tell me about your role & contact with family, length of time, frequency of contact, which family/household members. How would you describe your relationship with the family/household members? What was your understanding of the structure of the household when you started working with the family? How was this evidenced? (e.g. genogram/family tree). Were you aware of any changes to the family/household structure during your contact/service provision? What were the aims of any assessments that you were undertaking? How did this inform/link to planned outcomes for the children/adults in the household? What did progress/success look like at the time? What helped/prevented you achieving this? Were there any points at which you felt a different approach may be needed to ensure the children and their mother were safe and well? Did you speak to anyone else about this? (If so who/which agency). Given your knowledge of the DA incidents (from the police notifications), how did this impact on your contact with the family? Was there any signposting to sources of help (e.g. IDVA) What do you think the learning from this case might be; for your practice/for your agency/for the ways in which agencies work together in your locality? Are you aware of any changes that have already been made as a result of this case? Is there anything else that you would like to add? Thanks. Support post-meeting. Next steps. |
NC52299 | Significant brain injury to a 1-year-old girl in late 2017. Abusive head trauma was suspected as the possible cause of injury; a family court judgement found the injuries to be non-accidental. Learning includes: promotion of local guidance on concealed and denied pregnancies to increase awareness of the reasons why a woman may conceal or deny a pregnancy; in cases where it is has not been possible to provide guidance and support in the antenatal period, or when a newborn baby requires a prolonged stay in hospital, there must be a formal arrangement between health partners regarding the provision of advice and support to parents; the local partnership should include failure to thrive as an area of neglect for consideration, especially in 0-1-year-old babies; ensure guidance is available to promote understanding of failure to thrive when concerns are identified in relation to the weight and growth of infants; the development of a procedure to support staff in responding to unexplained injuries in immobile babies and children; practitioners need to be professionally curious about families' cultural and religious context when undertaking assessments and when planning interventions and support, whilst retaining focus on children; when there are language barriers, involving interpreters is important to ensure parents fully understand services being delivered and expectations. No recommendations, but advises action in response to the learning points.
| Title: Serious case review: overview report: Anna. LSCB: Children’s Safeguarding Assurance Partnership Blackburn with Darwen Blackpool Lancashire Author: Amanda Clarke Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report: Anna Author: Amanda Clarke Date: 1st April 2022 Page 2 of 24 Contents 1. The reason for the Serious Case Review ...................................................... 3 2. The children and their family ............................................................................ 3 3. Legal framework and methodology for the review .................................. 4 4. Overview of what happened, key circumstances and background ..... 5 5. Key themes of the review .................................................................................. 7 6. Conclusion/what needs to happen .............................................................. 15 7. References ............................................................................................................ 18 8. Appendix A – Framework & Methodology ................................................ 19 9. Appendix B – Terms of Reference ................................................................ 21 Page 3 of 24 1. The reason for the Serious Case Review 1.1 In late 2017 a serious injury occurred to Anna. When aged one year, Anna’s mother said Anna was loosely strapped into a highchair. Anna was said to have then stood up, falling out of the chair onto the floor where she lay unresponsive. Mother attended a walk-in centre with the child and was transferred to hospital. A significant brain injury was diagnosed with abusive head trauma suspected as being a possible cause. 1.2 A serious case review (SCR)1 referral was made to the local Safeguarding Children Board (now Safeguarding Children Partnership). It was concluded that the criteria for a SCR was met. An independent author (to be known as Author) was commissioned to work with a multi-agency panel of local senior professionals (the Panel) to identify any learning from the circumstances to improve arrangements to safeguard and promote the welfare of children. 2. The children and their family 2.1 Anna and her siblings as detailed below no longer reside with their parents. The names used in the overview report will be used to protect the true identity of the children. Mother and Father were from the Baltic States, Eastern Europe but all four children were born in the UK. Name to be used in the review Age at significant incident (late 2017) Anna 1 year Siblings Ava 1 year Sophie 2 years Thomas 3 years Mother (to all four children) Mid 20s Father (to all four children) 30 years 1 Serious case reviews are now known as child safeguarding practice reviews, Working Together 2018 Page 4 of 24 3. Legal framework and methodology for the review See Appendix A for information. 3.1 After consideration of criteria in Working Together to Safeguard Children 2015 (the guidance in use at the time) and after Panel members had been identified the first meeting of the Panel and Author took place in June 2018. 3.2 The Author, is an independent safeguarding advisor with no connections to the local area or any of the organisations involved in the review. Her career history includes working as an investigator within police public protection and conducting inspections and audits for the NSPCC. She currently chairs a Safeguarding Adults Board and a Safeguarding Children Partnership in the north of England. She also provides safeguarding advice and support for a Diocese in the Midlands. She has authored several case reviews and domestic homicide reviews. 3.3 At the time of the first Panel meeting a criminal investigation and family court proceedings were ongoing. These formal processes continued for a substantial period of time delaying the opportunity to hold a practitioners’ event for professionals who had offered support to the family leading to the significant incident. Meeting the parents as part of the review was not possible in the early stages due to them both being part of the criminal investigation A Panel meeting was held in February 2019 to discuss emerging learning themes from the review and any action required as it was clear the SCR would not be completed in expected timescales. Further delay was caused by the impact of the Covid 19 pandemic. The Panel reconvened in spring 2021, meeting virtually due to Covid 19 restrictions. It was decided that holding a practitioner event after such delay was inappropriate. Similarly, a Panel decision was made not to try to involve the parents of the children to contribute to the process, as information available showed they had moved on with their own lives. All four children were still too young to participate in the review. 3.4 The Panel therefore re-examined the journey of the children and family, identifying key learning themes to be highlighted in an overview report and demonstrating the current position for the local area in terms of safeguarding, almost four years after the significant incident. The decision to proceed in this way was considered proportionate under the circumstances. 3.5 The terms of reference for the review were developed at the first panel meeting and are attached at Appendix B. The timeframe for the review was agreed as January 2016 to December Page 5 of 24 2017; the start and end dates were when significant episodes occurred in the lives of the children, but Panel members and the Author were clear that other relevant incidents relating to the children and family occurring prior to the timeframe must also be considered. Non recent events in the lives of families are often significant and can impact upon and shape what occurs in the future. 4. Overview of what happened, key circumstances and background 4.1 The parents (to be known as Mother and Father) were not British and had been in the UK for part of their adult lives. Father had been known to UK services as a possible domestic abuse perpetrator in a different relationship in 2011 and 2012. In 2014, prior to the review timeframe Mother was late booking the pregnancy of the first child, Thomas, being 21 weeks pregnant when booking occurred. When Thomas was a baby an assault incident took place in his (Thomas’) presence. The assault was on Father, by a group of men in the family home. Mother was believed to be two months pregnant with Sophie at the time. A Section 47 investigation took place in early 2016 (the start of the review timeframe) regarding minor injuries to both Thomas and Sophie with parents not seeking appropriate medical attention. An assessment resulted in no further action. In autumn 2016 Mother attended hospital reporting pain to her legs. During treatment it transpired she was in labour with twins but said she was unaware of the pregnancy. Initially she did not want her partner, Father to be told about the babies. Whilst Mother was giving birth Father was unaware, at home with their other two young children. The twins, Anna and Ava required care in the neo natal unit. A referral was made to children’s social care due to the circumstances of a possible concealed pregnancy. After two days Mother informed Father about the babies and he was described as “shocked but not angry”. The twins remained in hospital, with visiting by Mother and Father described as limited, said to be due in part to having two other young children and little family support. Discharge was being discussed in late 2016 just prior to a domestic abuse incident taking place, with Father assaulting Mother. A section 47 investigation led to an initial case conference where all four children were placed on child protection plans for emotional abuse. During the assessment period Anna and Ava were discharged home, and their parents appeared reconciled. Page 6 of 24 Through early 2017 poor weight gain was noted for the twins and at times a lack of basic hygiene. A further domestic abuse incident by Father on Mother was reported to the police which the children witnessed. Mother informed the core group that she and Father had separated and within days she had retracted the domestic abuse allegation. A period in hospital followed for the twins for them to be monitored for their lack of weight gain. Signs of physical neglect were queried particularly regarding hygiene. At a discharge planning meeting at the end of the hospital admission it was reported that no underlying medical condition had been identified which would cause poor or slow weight gain. A legal gateway meeting took place and a further hospital admission for the twins. At discharge again there “was no medical indication for faltering weight”. A review child protection conference had concluded that all four children should remain on child protection plans (category of neglect) in the care of Mother. Within days of discharge unexplained bruising was noted to Ava’s eyes. The health visitor referred to the on-call paediatrician as per the local policy (at the time) for bruising in a non mobile infant. A short period in foster care was arranged before the children were returned to Mother; the origin of the bruising was not known but not considered to be caused non accidentally Father was trying to contact Mother around this time but his actions were reported to the police. Independent domestic violence advocate (IDVA) feedback was that Mother was accepting support. Pre proceedings had commenced and in early summer 2017 growth pattern/ weight was still an issue for the twins. This was noted as improved after a month and a step down from pre proceedings was discussed at a core group. All children remained on child protection plans when reviewed mid summer 2017. In autumn 2017 Ava sustained a serious injury to her lip requiring stitches. The cause was given by Mother as accidental but Mother’s delayed response to the injury was challenged. Some positive progress however had been noted regarding Mothers parenting leading to an end of pre proceedings. The children remained on a child protection plan. At this point it was noted that Father’s whereabouts were unknown. Page 7 of 24 In late 2017, two weeks after the review conference, the incident occurred resulting in Anna’s serious head injury. Mother gave an accidental explanation for the incident but abusive head trauma and a possible delay in seeking treatment was suspected. 4.2 In June 2021 a decision was made that there would be no criminal proceedings relating to Anna’s injuries and the police investigation was closed. The family court judgement was that the injuries were found to be non-accidental. All four children have been adopted and at the time of writing the report Anna was said to be doing well, making good progress. As a result of the significant incident she has a permanent brain shunt and is registered as partially sighted. She also has long term impact upon her mobility. 5. Key themes of the review 5.1 When the Panel reconvened in 2021, key themes from the review timeframe were identified as follows: • Concealed and denied pregnancy • Interface between community and acute health professionals regarding advice and support given to new parents • Failure to thrive as a form of neglect • Response to minor injuries in children • Managing language and cultural differences (i) Concealed and denied pregnancy Mother said she did not know she was pregnant with the twins despite having had two previous pregnancies and births. On contact with clinicians immediately prior to the pregnancy being detected neither Mother nor health professionals seemed to have realised that Mother was having a baby, let alone twins. Anna and Ava were thought to have been born at around 30 weeks therefore Mother had not reached full term. She may not have ‘appeared pregnant’. However, the circumstances for Mother when first at hospital and her response immediately after the birth, not wanting Father informed and asking to relinquish the twins, prompted the hospital referral of a possible concealed or denied pregnancy. This was appropriate. Page 8 of 24 The local safeguarding children partnership has updated a document titled Concealed and Denied Pregnancy Guidance, February 2021. Despite this guidance not being in place at the time of the births a timely referral was made from hospital. Other aspects covered by the protocol were not relevant as there was limited opportunity for professionals to suspect Mother was pregnant and take appropriate action in advance of the births. The outcome of an assessment after the referral to children’s social care was that the pregnancy was assessed as not concealed and a decision was made to take no further action. The Panel felt this outcome was questionable due to the previous support needs of the family and the additional pressure that caring for premature twins might bring, alongside already having two other young children. Assessments should examine the whole journey of a family and in this case there were additional indicators of risk and need leading up to the births impacted by possible cultural challenges faced by Mother and Father. This will be explored later. The arrangements within children’s social care have since changed locally. The initial child and family assessments at the time of the review were being completed by a private company, which the local authority had commissioned. This arrangement ended in 2017 and all referrals since then meeting threshold for assessment are undertaken by children’s social care within the local authority. Learning point 1 Regardless of the unusual circumstances of the case and whether the twins’ pregnancy was concealed the re- promotion of the Concealed and Denied Pregnancy Guidance may be useful, particularly to increase awareness of the reasons why a woman may conceal or deny a pregnancy, which include childhood trauma, domestic abuse, shame/fear of cultural expectations. (ii) Interface between community and acute health professionals regarding advice and support given to new parents Abusive head trauma was a suspected cause for the injury to Anna in late 2017. Often referred to as ‘shaken baby syndrome’ abusive head trauma can cause catastrophic injuries or death. The condition occurs most commonly in children younger than two years of age with an estimated Page 9 of 24 prevalence of 1: 3000 in babies younger than six months2. The persistent incidence of abusive head trauma in the UK is 20 to 24 per 100,000 children3. Many local safeguarding children partnerships (previously known as boards) have introduced education programmes for parents and carers of babies, and for professionals supporting them, to raise awareness about appropriate responses to crying babies, which is when abusive head trauma can often occur. ICON4 an evidence based, multi-agency programmes is now in use across the safeguarding children partnership area where the incident occurred. In 2016 key safety messages including responding to crying babies and safe handling were provided by professionals to expectant mothers and some fathers when pregnancies were known and women were receiving routine ante natal care. However due to Mother’s pregnancy being unknown and undisclosed she would not have received her pre-birth visit from a health visitor where such messages would have been shared. Post birth the twins remained in hospital for the first three months of their lives which meant on discharge they were outside of the timeframe for midwifery support once home. The community midwife did visit Mother at home in the days after the birth but there is no record of key messages being reinforced to Mother regarding crying and safe handling of babies. The Children and Family Wellbeing Service (CFWS) had been involved with the family when the older two siblings had been born in 2014 and 2015. Records show Mother attended two Bump, Birth and Beyond sessions in 2014 where key messages are delivered and both parents attended three baby clinic sessions in 2015. Their understanding and impact of receiving the information delivered for Sophie and Thomas, and retention of the advice for when the twins were born is unknown. Hospital recording for the twins showed the visits by Mother and Father were mostly short and irregular whilst it was understood there were challenges due to them having two other very young children and limited family support. Notes indicated that the twins would not be discharged until the parents had received training and were competent in understanding oxygen equipment/bathing babies and caring for them for longer periods of time. Prior to their discharge 2 CORE-INFO Head and spinal injuries in children, NSPCC and Cardiff University, May 2014 3 Abusive Head Trauma: The Case for Prevention- Dr Suzanne Smith PhD, Winston Churchill Memorial Trust Travel Fellowship, 2016 4 ICON: I-infant crying is normal and will stop, C- comfort methods can soothe and the crying will stop, O- ok to walk away if the baby is safe and the crying will stop, N- never shake or hurt a baby ICON is co-ordinated and supported by a national steering group based in Hampshire, iconcope.org Page 10 of 24 records did show that Mother received the required education as above but information specifically relating to safe handling of babies (similar to the ICON programme) is not recorded as provided. The health visitor who attended the discharge planning meeting took over the support for Anna and Ava (and Mother) once they were at home age approx. three months. There is no record that specific safety messages relating to abusive head trauma were provided. Learning point 2 In cases where it is has not been possible to provide guidance and support in the antenatal period and/ or if a newborn baby requires a prolonged stay in hospital there must be a formal arrangement between health partners in acute, community and primary care settings regarding the provision of advice and support to parents. Furthermore, it should be an expectation that when advice such as in the ICON programme has been given, a clear record must be entered in the child’s notes. Other professionals, for example support workers, social workers who may be involved with families who have not received information as routine should also continue to take opportunities to reinforce key messages. (iii) Failure to thrive as a form of neglect Throughout the timeline there was evidence of the twins’ failure to thrive particularly in relation to their weight. Once discharged home at around 3 months old they returned to hospital for two planned admissions in the spring of 2017 to monitor and investigate their weight loss for which no medical reason was found. When they were under the care of the hospital they gained weight. When they returned home they lost weight. Records also noted Mother being advised after the twins were observed being prop- fed (where a bottle is ‘propped up’ /positioned not requiring a baby to be held whilst being fed)5. Teats were also found to have been widened/ cut on feeding bottles (which may provide a faster flow). In relation to the two planned periods in hospital a doctor reported no underlying medical condition which would cause poor or slow weight gain. However, the same doctor reported the children were thriving which was challenged by the health visitor. It was positive that professional discussion took place around why the twins may not be thriving, despite a cause not being found. 5 Bottle feeding advice: never leave a baby alone to feed with a propped-up bottle as the may choke on the milk. www.nhs.uk Page 11 of 24 There may have been an element of over optimism in Mother’s parenting capacity under the circumstances. Mother, once the twins were brought home at three months was a single parent, with limited family support. She had been unprepared for the birth of the two babies and was already a parent to two other very young children (toddlers). She was a survivor of domestic abuse and records indicate she may have been suffering from mental health issues herself. Her experiences in her earlier life were not fully known as she only entered the UK as a young adult. Despite a package of support being put in place the pressures Mother faced cannot be underestimated. Over a third of 538 cases examined by the Child Safeguarding Practice Review Panel in 2018 to 2019 were identified as having a practice theme of ‘optimistic thinking6’. Observations shared about Mother in core groups and other professional forums did not demonstrate significant concern for Mother or her capability as a parent of four very young children. As a consequence the level of concern for the children’s wellbeing, apart from them remaining on child protection plans, was not identified or voiced by all professionals involved. Other ongoing issues, for example minor injuries sustained by the children throughout the timeframe (to be explored later) had little impact on the assessment of Mother and whether she was coping and whether the children were safe. Furthermore, records showed evidence of other possible signs of neglect for the twins on more than one occasion regarding their cleanliness and presentation. This was noted but does not seem to have been taken as an indicator of continuing neglect. The definition for neglect includes the phrase “persistent and severe failure to meet a child’s needs”. This does not mean circumstances and the environment have to get progressively worse; the threshold for neglect can be met by the concerns not getting substantially better despite, as in this case, continued professional intervention. The long term impact of neglect on children should not be disregarded. Overall, there was little positive progress made for all four children during the period that they were subject to child protection plans for neglect. It was encouraging that the home conditions were never reported as a significant concern. In addition to a child’s home setting being assessed, the wider aspects of neglect and differing impacts on particular children do not seem considered, for example the age of the children involved and any additional needs. 6 Annual report 2018-2019, Child Safeguarding Practice Review Panel Page 12 of 24 In April 2019 the local safeguarding children board (as it was known then) launched a refreshed multi-agency strategy to assist practitioners in tackling neglect more robustly. Also developed was a reference guide to the indicators of neglect and a neglect toolkit, created by Action for Children. The toolkit contains factors that may contribute to neglect many of which were relevant to Anna’s family. There are helpful prompts and examples regarding different areas of a child’s care. However, there is limited information in the current strategy to support practitioners in identifying a baby’s failure to thrive as a form of possible neglect. NICE guidance regarding faltering growth7 was published in September 2017 (when the twins were almost one) and NICE faltering growth quality standards8 have since been published, in 2020. At the time of publication of this report (spring 2022) a review of the neglect strategy is underway. This has found a need for greater consistency in the identification and assessment of neglect, as a result of which the local authority has purchased a licence for the Graded Care Profile 29 neglect assessment tool. This involves a significant commitment to training partnership staff which will be delivered over the course of the next 12 months. A revised neglect strategy is also envisaged to be published during this period. Learning point 3 It would be beneficial for the local Partnership to include failure to thrive as an area of neglect for consideration especially in 0 to 1 year old babies. The Partnership should ensure guidance is available to enable clear understanding of non-organic failure to thrive, including thresholds and referral pathways, when concerns are identified in relation to the weight and growth of infants. (iv) Response to minor injuries in children Throughout the review timeframe and before, there were several minor injuries noted to all four children and a significant injury to both Ava (the mouth injury) and Anna (the abusive head trauma). Minor injuries to the children included bruising, bite marks and scratches. When injuries were noted or reported initial action taken including by the nursery and the health visitor was usually 7 National Institute for Health and Social Care Excellence (NICE) – Faltering growth: recognition and management of faltering growth in children, NICE guideline (NG75) 27 September 2017. 8 National Institute for Health and Social Care Excellence (NICE) – Faltering growth, quality standard (QS197), 28 August 2020. 9 Graded Care Profile 2 (GCP2) is an assessment tool which helps practitioners take a strengths based approach to measure the quality of care a child is receiving, learning.nspcc.org.uk Page 13 of 24 appropriate. The health visitor used guidance regarding bruising to pre mobile babies and the nursery kept detailed notes. Records do indicate a delay in presentation and request for support by Mother for some injuries, including the two separate serious incidents involving the twins. All four children were on child protection plans for neglect when most of the injuries (minor or serious) occurred, but injuries were still managed mostly in isolation and did not lead to further investigation about Mother’s ability to keep them safe. The vulnerabilities of babies in particular should never be underestimated. In the NSPCC Learning Brief of the Child Safeguarding Practice Review Panel’s Annual Report 2018 to 201910 over a quarter of rapid reviews undertaken involved the death or serious harm of a child under 1 due to non accidental injury The local area’s neglect tool (mentioned early) which was launched after the timeframe for this review contains information about care and safety including for babies. For Ava and her siblings there was insufficient professional curiosity regarding the number of injuries across the four children who were all on child protection plans. When collated with other indicators of neglect for the family and the challenges which Mother herself faced the concerns for the children increased and should have been re-assessed. A serious case review11 in the local area completed in 2017 reinforced the need for practitioners to be professionally inquisitive with families. “It is crucial to ascertain whether explanations of injuries (however minor) are plausible. It is also important for professionals to view minor injuries collectively with other information about a child which together could give cause for greater concern”. The local area, as part of its multi agency arrangements does not currently have a procedure relating specifically to assessing unexplained injuries in immobile babies and children. Learning point 4 The local area should consider the development and launch of a procedure for use across the partnership to support staff in responding well to unexplained injuries in immobile babies and children. 10 27 % of rapid reviews, NSPCC Casper Briefing on the CSPR Panel Annual report 2018 – 2019, March 2020 11 SCR Child LB, learning brief published 2017 Page 14 of 24 (v) Managing language and cultural differences Both Mother and Father were not British and were thought to have entered the UK whilst adults12. All four children were born in the local Partnership area in the UK. The multi agency chronology is conflicted regarding the language capabilities of Mother. Some agencies noted a “language barrier” for Mother whilst other records show she was assessed as “speaking good” or “ok English” but that she sometimes “has difficulty communicating”. Father’s language skills and understanding are not well reflected in any agency records. English was described as “not the first language” for the older two children albeit they were very young themselves (not school age) and seemed to understand English. There is limited evidence of use of interpreters with Mother who was the main carer of all four children. Given the complex circumstances from the unexpected birth of the twins to their lack of consistent weight gain it was imperative that Mother fully understood the expectations regarding her family and the ongoing safeguarding processes, including at one point pre proceedings. A briefing issued by the NSPCC13 highlights learning for practitioners which is relevant to this case. The learning includes awareness of language issues, recording the first language and use of professional interpreters. As said earlier neither parent was from the UK in terms of their background. Little seems to be known regarding their upbringing. A separate NSPCC briefing14 states “professionals sometimes lack the knowledge and confidence to work with families from different cultures (and religions). A lack of understanding of the cultural context of families can lead to professionals overlooking situations that may put family members at risk; whilst the desire to be culturally-sensitive can result in professionals accepting lower standards of care”. In the Child Safeguarding Practice Review Panel third national review (September 2021)15 practitioners are encouraged to try “to seek to understand every individual within the context of their own histories, backgrounds and culture” not just simply record ethnicity and cultural background. 12 There were approximately 92000 Latvian nationals residing in the United Kingdom in 2020, an increase from the 29000 Latvian nationals residing in the United Kingdom in 2008. The highest number of Latvian nationals residing in the United Kingdom was in 2017 with 117 thousand nationals, www.statista.com The population of the UK at mid-year 2020 was estimated to be 67.1 million, www.ons.gov.uk 13 NSPCC Learning from case reviews briefing - People whose first language is not English, March 2014 14 NSPCC - Culture and faith: learning from case reviews, June 2014 15 The Myth of Invisible Men - Safeguarding children under 1 from non-accidental injury caused by male carers, Child Safeguarding Practice Review Panel, September 2021 Page 15 of 24 Learning point 5 Practitioners need to be professionally curious about families’ cultural and religious context when undertaking assessments, planning interventions and support, whilst retaining focus on children. Involving interpreters is important to ensure there is full understanding of the service being delivered and expectations, with records completed to demonstrate language and understanding has been properly explored. Good practice It is clear many professionals and services worked hard to support the children and their parents. Good practice is highlighted when practitioners or a team or department are considered to have excelled ‘over and above’ what is expected of them and their service. An episode during the timeframe which was agreed by the Panel as being good practice was the support provided by hospital staff after the domestic abuse incident just prior to the twins being discharged from hospital. This included emergency accommodation being offered for the older children and Mother. 6. Conclusion/what needs to happen Anna suffered life changing injuries after an incident in her home in late 2017. At the time she was subject to a child protection plan for neglect, as were her three siblings. The injuries occurred just after her first birthday; it is known that children around this age are extremely vulnerable16 17. Cumulative concerns existed for the family including a traumatic and unusual start to life for Anna and her twin followed by low weight gain and failure to thrive on discharge from hospital. There was recurring domestic abuse on Mother by Father, possible parental mental health issues and several minor injuries recorded for all four children during the review timeframe and before. Mother’s response to her children’s needs and to offers of support understandably fluctuated as for much of the period under review she had sole responsibility for four very young children, with little or no family support. Both Mother and Father were from a different country; understanding 16 Children under 1 are the most likely age group to die through abuse or neglect - Child deaths by abuse and neglect, NSPCC Statistics briefing, September 2020 17 Children under 1 have been consistently a high proportion of subjects of serious incident reports and serious case reviews- Child Safeguarding Practice Review Panel annual report, 2018-19 Page 16 of 24 of their culture and previous experiences was not fully explored or assessed and language capabilities not formally documented. An element of optimism appears to have existed for what Mother could achieve by herself as a parent, even with intervention, with limited progress made on the child protection plans. At times, there was a lack of professional curiosity and challenge regarding Father’s involvement with the family and associated risks, including the impact of the children living in an abusive environment. Father at one point was said to have returned to his home country but this was later found not to be the case. Unfortunately, the review process was delayed due to criminal and other court processes with further delay due to the Covid 19 pandemic. The Panel and Author have revisited the circumstances keeping in mind that many changes have occurred within the local area’s Safeguarding Children Partnership since the incident with Anna was referred. The original terms of reference from 2017 were re-examined and key learning themes identified. Reviewing practice, whenever this occurs, will always provide an opportunity to reflect on ways in which services can be developed and further enhanced. As a result of the significant incident(s) which occurred in the lives of Anna and her siblings, learning points have been agreed by the Panel based on analysis and findings from the case. These are repeated below for consideration and action by the local Safeguarding Children Partnership. Learning points 1. The re- promotion of the Concealed and Denied Pregnancy Guidance may be useful, particularly to increase awareness of the reasons why a woman may conceal or deny a pregnancy, which include childhood trauma, domestic abuse, shame/fear of cultural expectations. 2. In cases where it is has not been possible to provide guidance and support in the antenatal period and/ or if a newborn baby requires a prolonged stay in hospital there must be a formal arrangement between health partners in acute, community and primary care settings regarding the provision of advice and support to parents. Furthermore, it should be an expectation that when advice such as in the ICON programme has been given, a clear record must be entered in the child’s notes. Other professionals, for example support workers, social workers who may be involved with families who have not received Page 17 of 24 information as routine should also continue to take opportunities to reinforce key messages. 3. It would be beneficial for the local Partnership to include failure to thrive as an area of neglect for consideration especially in 0 to 1 year old babies. The Partnership should ensure guidance is available to enable clear understanding of non-organic failure to thrive, including thresholds and referral pathways, when concerns are identified in relation to the weight and growth of infants. 4. The local area should consider the development and launch of a procedure for use across the partnership to support staff in responding well to unexplained injuries in immobile babies and children. 5. Practitioners need to be professionally curious about families’ cultural and religious context when undertaking assessments, planning interventions and support, whilst retaining focus on children. Involving interpreters is important to ensure there is full understanding of the service being delivered and expectations, with records completed to demonstrate language and understanding has been properly explored. Page 18 of 24 7. References • Working Together to Safeguard Children 2018 • Working Together to Safeguard Children 2015 • Concealed and Denied Pregnancy Guidance (Local Safeguarding Children Partnership), February 2021 • CORE-INFO Head and spinal injuries in children, NSPCC and Cardiff University, May 2014 • Abusive Head Trauma: The Case for Prevention- Dr Suzanne Smith PhD, Winston Churchill Memorial Trust Travel Fellowship, 2016 • ICON, iconcope.org • Bottle feeding advice, www.nhs.uk • Child Safeguarding Practice Review Panel Annual Report 2018 - 2019 • National Institute for Health and Social Care Excellence (NICE) – Faltering growth: recognition and management of faltering growth in children, NICE guideline (NG75) 27 September 2017 • National Institute for Health and Social Care Excellence (NICE) – Faltering growth, quality standard (QS197), 28 August 2020 • Graded Care Profile 2 - learning.nspcc.org • NSPCC Casper Briefing on the CSPR Panel Annual report 2018 – 2019, March 2020 • SCR Child LB, learning brief published 2017 • www.statista.com • NSPCC Learning from case reviews briefing - People whose first language is not English, March 2014 • NSPCC - Culture and faith: learning from case reviews, June 2014 • The Myth of Invisible Men - Safeguarding children under 1 from non-accidental injury caused by male carers, Child Safeguarding Practice Review Panel, September 2021 • Child deaths by abuse and neglect, NSPCC Statistics briefing, September 2020 Page 19 of 24 8. Appendix A – Framework & Methodology A serious case review was commissioned by Local Safeguarding Children Board, following agreement at the Serious Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2015), which was the version of Working Together relevant at that time. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely: 5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCB must commission an SCR. Methodology The methodology used initially was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead, it is an effective learning tool for local safeguarding children boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken Page 20 of 24 of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not necessarily mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of safeguarding boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the boards may identify additional learning issues or actions of strategic importance. These may be included in the final review report or in an action plan as appropriate. Due to delays in parallel processes and the Covid 19 pandemic the review methodology was amended; the final stages of the review were completed as explained in the body of the report above. Organisation Role Independent Lead Reviewer Panel Chair Deputy Designated Nurse for Safeguarding Children Children's Social Care Quality and Review Manager Children and Family Wellbeing Service Locality Manager Early Years Early education Safeguarding Officer Lancashire Care foundation trust Specialist Safeguarding Practitioner Lancashire Constabulary Review Officer Southport and Ormskirk Hospital NHS Trust Named Nurse Safeguarding Children NHS Chorley and South Ribble CCG, NHS Greater Preston CCG and NHS West Lancashire CCG Deputy Designated Lead Nurse Safeguarding Children Lancashire Safeguarding Business Unit Business Co-ordinator Lancashire Safeguarding Business Unit Business Support Officer Page 21 of 24 9. Appendix B – Terms of Reference Introduction This Review is being commissioned by the Chair of Lancashire Local Safeguarding Children Board (LSCB) in accordance with the learning and improvement framework for LSCBs described in Working Together to Safeguard Children guidance (HM Government 2015). The Serious Case Review will be undertaken using methodology based on the Welsh Child Practice Review Model in accordance with Protecting Children in Wales: Guidance for Arrangements for Multi-agency Child Practice Reviews (Welsh Government 2012). A multi-agency panel established by Lancashire LSCB will conduct the review and report progress to the Board through its Chair. Membership will include an independent Lead Reviewer and representatives from key agencies with involvement. Timeframe for the review The review will cover the timeframe of 16/01/2016 to 19/12/2018. Any significant incident relevant to the case but prior to the start date of the timeframe may be included in the analysis completed by each agency. Subject(s) of the review XXX– DOB: 2016 XXX – DOB: 2016 Significant others XXXX - Sibling of xxx XXXX - Sibling of xxx Mother of xxx Father of xxx The purpose of the review is to: • Determine whether decisions and actions in the case comply with the policy and procedures of named services and the LSCB; • Examine the effectiveness of information sharing, case handovers/transfers and working relationships between agencies and within agencies; Page 22 of 24 • Determine the extent to which decisions and actions were focussed on the subject children; • Examine inter-agency working and service provision, including quality of assessments, for the child/children and the parenting capacity of all possible carers within the family; • Explore the consideration and use of early help processes, and whether this was effective; • Explore responses to the concealed/ denied pregnancy and whether assessments relating to the circumstances were robust; • Examine the interface between community and acute health provision regarding advice provided to parents/carers of new born babies; • Examine to what extent safe handling advice and support was provided to the carers; • Establish whether all injuries, including minor injuries, sustained by the children were responded to appropriately by parents and professionals; • Determine the impact of possible parental mental ill health within the family and whether appropriate services were considered to assist the mental wellbeing of the parents; • Examine responses to, and the management of, children not being brought to appointments, and non-engagement with services by family members; • Explore responses to concerns relating to the children’s failure to thrive and neglect, including whether existing policy/guidance is effective; • Explore whether all risk factors within the family were properly considered and were responses appropriate; • Determine the extent to which professionals identified domestic abuse, what actions were taken to support the family and was this appropriate to the circumstances; • Scrutinise the child protection plans and connected processes regarding all children within the family to ensure actions and outcomes were relevant, clear and child focussed; • Explore that language, culture and other aspects relating to diversity were appropriately considered in all service provision to the family; Page 23 of 24 • Examine the involvement of other significant family members in the life of the children, and family/community support provided to the subject family; • Establish any learning from the case about the way in which local professionals and agencies work together to safeguard children; • Identify any learning for the LSCB to consider in order that an action plan can be developed to support and improve systems and practice, where necessary. Tasks specific to the review panel: 1. To set the time frame for the review, see above; 2. Agencies that have been involved with the child/children and family will provide information of significant contacts by preparing an agency timeline with a focus on the purpose and scope of the review, see above; 3. Other agencies/services may be asked to provide a timeline following review of the information provided; 4. Agency timelines will include an analysis of relevant context, issues or events, and an indication of any conclusions reached. Information about action already undertaken or recommendations for future improvements in systems or practice may be included if appropriate. A case summary may include any relevant additional background information from significant events outside the timeframe for the review; 5. Agency timelines will be merged to create a composite timeline and used by the Panel to undertake an initial analysis of the case and form hypotheses of themes; 6. A full and accurate genogram of the subject family will be prepared for the panel and to assist the learning event; 7. The Panel, through the Chair and Lead Reviewer will seek contributions to the review from appropriate family members and provide feedback to the relevant family members at the conclusion of the review process; 8. The Panel will plan with the Lead Reviewer a learning event for practitioners to include identifying attendees and the arrangements for preparing and supporting them prior to the learning event and feedback following the event; Page 24 of 24 9. The learning event will explore hypotheses, draw out themes, good practice and key learning from the case including any areas for the LSCB to consider for the development or improvement to systems or practice; 10. The Panel will receive and consider the draft SCR report prepared by the Lead Reviewer, to ensure that the terms of reference for the review have been met, initial hypotheses addressed and any additional learning is identified and included in the final report; 11. The Panel will agree conclusions from the review and learning considerations for the LSCB and make arrangements with the Lead reviewer for presentation to the LSCB for consideration and agreement; 12. The Panel will plan arrangements for feedback to the family and the practitioners in attendance at the learning event and share the contents of the report following the conclusion of the review, and before publication; 13. The Panel will take account of any criminal investigations or proceedings related to the case; 14. The Chair of the LSCB will be responsible for making all public comment and responses to media interest concerning the review until the process is completed. It is anticipated that there will be no public disclosure of information other than the SCR report for publication. |
NC52192 | Life-changing head injury of an 11-week-old boy in September 2016. Parents were subsequently charged in connection to injuries. Over the first few visits from health visitors after Baby F was born, Mother reported low mood, relationship tensions and issues bonding with the baby. She was receiving workplace counselling and the health visitor offered the maternal early childhood sustained home-visiting (MECSH) programme. Both Mother and Father were diagnosed with post-natal depression. Baby F was seen at hospital twice prior to his life-changing injuries. On the second occasion, he was not seen by a senior doctor and was discharged with advice to Father. On the day of Baby F's life-changing injuries, Mother reported that Father had accidentally banged Baby F's head to workplace counsellor. The counsellor discussed this with a supervisor but no further action was taken. Baby F was taken to hospital where he was found to have life-threatening head injuries, intra-cranial haemorrhage and rib fracture. Baby F is of African/European heritage. Uses Partnership Learning Review model. Findings include: it is important to seek engagement with both parents to assess their mental health; supervisors need to be vigilant to ensure the most vulnerable families are discussed at supervision; and when parents have their own needs, there is a risk that focus on the child will be lost. Identifies considerations including: guidance on the detection and management of unusual medical presentations in non-mobile babies should be applied consistently by all agencies and counsellors should follow guidelines on safeguarding children.
| Title: Serious case review: Baby F. LSCB: Plymouth Safeguarding Children Board Author: Karen Tudor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW Report author: Karen Tudor August 2017 BABY F Baby CONTENTS PAGE INTRODUCTION Events leading to this Serious Case Review Conducting a Serious Case Review The Process of the Review Parallel Investigations/Enquiries Method Family Involvement Anonymity 1 1 1 2 2 2 2 3 3 KEY EVENTS 4 LEARNING THEMES 5 IDENTIFICATION AND RESPONSE TO POST-NATAL DEPRESSION Identification Response to Post-Natal Depression Keeping a Focus on the Baby Invisible Fathers The Importance of Supervision The Family’s Contact with GPs Diagnosing Post-Natal Depression in Fathers 6 6 7 9 10 10 11 12 12 UNUSUAL MEDICAL PRESENTATIONS IN NON-MOBLE BABIES AND CHILDREN Sentinel Injuries First Presentation Second Presentation Effective Communication Discharge Summaries 14 15 15 16 20 20 KNOWLEDGE AND UNDERSTANDING OF THE CHILD PROTECTION PROCEDURES AND THRESHOLDS FOR REFERRAL 22 ADULT SERVICES WORKING WITH PARENTS AND THEIR REPSONSES TO SAFEGUARDING CONCERNS 23 SUMMARY OF LEARNING 25 CONSIDERATIONS FOR THE PSCB 27 APPENDICES 28 1 INTRODUCTION Events leading to this Serious Case Review 1. This Serious Case Review (SCR) concerns an 11 week old baby, known as Baby F, who in September 2016 suffered a life-changing head injury. Baby F was admitted to hospital, medically examined and in addition to the head injury, was found to have a number of rib fractures and a healing rib fracture. His parents were arrested and charged in connection with the injuries; a trial is listed to take place in 2018. 2. Baby F was born in the summer of 2016, he is the first child of both his parents, they were living together and report they had been in a relationship for about two years. Baby F’s parents are a well educated, professional couple, both of whom have a complex childhood history and neither of whom had any local family support. 3. There were indications, from the beginning of Baby F’s life, that his parents struggled with the demands of a new baby and both parents were diagnosed with post-natal depression and were being treated by their respective GPs. Baby F’s mother had also been referred for counselling. On two occasions, prior to the head injury, Baby F was taken to the local hospital with unusual medical presentations which were not considered significant at the time. 4. After the diagnosis of the head injury, Baby F spent a number of weeks in hospital before being placed with foster carers. His injuries are life changing, for example at the age of ten months, his development appeared to be that of a baby aged two to three months. Conducting a Serious Case Review 5. When abuse or neglect of a child is known or suspected and either the child has died or been seriously harmed and there is cause for concern as to the way in which services have worked together to safeguard the child, the Local Safeguarding Children Board (LSCB) has to consider whether a Serious Case Review should be carried out. 6. The Plymouth Safeguarding Children Board (PSCB) under Regulation 5 of the Local Safeguarding Children Boards Regulations, 2006, decided the criteria were met for a SCR. The recommendation was confirmed by the Chair of the PSCB and notification of the decision was made to the Department for Education. 7. The purpose of the Review as defined by Working Together is: To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children 2 Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result As a consequence, improve interagency working and better safeguard and promote the welfare of children1 The Process of the Review 8. An Independent Reviewer was commissioned and the process overseen by a Serious Case Review Group, this is a sub group of the Local Safeguarding Board comprised of senior managers and clinicians none of whom had had direct involvement with the case; this group set out the terms of reference and agreed the review would cover the period leading up to Baby F’s birth (the pregnancy) until the date the injuries were diagnosed, a period of just over a year. (See Appendix for a list of SCR Group members) Parallel Investigations/Enquiries 9. Because of the criminal proceedings, the SCR was conducted in accordance with the guidance “Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews.”2 This guidance suggests a framework for the sharing and exchange of relevant information generated by Serious Case Reviews and a criminal prosecution to prevent one adversely affecting the other. Working within this framework enabled the Safeguarding Board to ensure there was no unnecessary delay in concluding the SCR because of the criminal proceedings and identify any learning as soon as possible after the events. Method 10. The Review must be conducted in line with government guidance, Working Together to Safeguard Children, 2015. In view of the move towards using systemic models and practitioner involvement to promote learning, the Board decided to use a review model known as a Partnership Learning Review. Involving practitioners, the baby’s family and working with the Serious Case Review Group, the Review addresses the question of who did what and why and identifies Themes for Learning. The methodology also recognises that people work in complex organisations where a range of factors can impact on the nature of the work and where relevant, these are reflected in the analysis. 1 Working Together to Safeguard Children, 2015 2 Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews, A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Boards, May 2014 3 11. A chronology of events was requested from the agencies who had worked with the family, and, because it was not advisable in light of the criminal investigation to hold meetings of practitioners, those who had worked with the family were invited to meet the Independent Reviewer individually or in single agency groups. The findings are reflected in the Learning Points and Considerations for the Safeguarding Board. (See Appendix for a list of agencies involved.) 12. As part of the analysis, the Independent Reviewer was asked by the SCR Group to consider the following questions The degree to which parental mental and emotional health influenced the multi-agency service response To what extent were the ethnicity and educational status of the parents taken into account in the assessment and identification of risk and to inform professional decision making and subsequent action The assessment of risk during key contacts The understanding and application of threshold Family Involvement 13. After discussion with the Crown Prosecution Service, in order to ensure evidence for criminal proceedings was not compromised, the mother and father of Baby F were invited to contribute to the Review in writing. They were contacted by the Independent Reviewer and asked their views on the services they had received; the parents declined the request to participate in the Review. Anonymity 14. For the purposes of publication of the report, details of the family history and current circumstances are kept to a minimum. The names of individuals have been anonymised, family members are: Baby F – Subject of Review, born in July 2016, Baby F is of African/European heritage Ms M – Baby’s F’s mother, aged in her early 20’s Mr F – Baby F’s father, aged in his late 20’s 4 KEY EVENTS Early 2016 Booking with midwife, Ms M says she has mental health problems and history of anxiety and depression, a history of “family problems.” Health Visiting team informed about Ms M’s history of low mood and depression. Summer 2016 Member of Ms M’s extended family very ill, Ms M described as “very stressed.” Summer 2016 Baby F born by emergency Caesarean Section, birth weight 2.5kgs/ 5.8lbs Ms M initially anxious, not wanting to be alone with Baby F but later calms and “eager to go home.” Baby aged 3 days Handover from Midwifery to Health Visiting Service for ongoing support in line with usual practice. Ms M placed on enhanced HV visiting programme, for weekly visits. Baby aged 10 days Health Visitor home visit – baby weighed, slight weight loss, within normal limits for a newborn baby. Ms M expressing some anxiety, advised to see GP if worsens, observed gently handling and emotional warmth from Mr F. Baby aged 2 weeks Ms M has first appointment with work place counselling service. Baby aged 4 weeks Ms M sees GP about anxiety and depression and is having counselling from work place service. Baby F is offered a place at a local nursery. Baby aged 5 weeks Parents call ambulance, Baby F, aged 5 weeks, admitted to hospital overnight, “unwell, crying and blood in mouth/vomit” Health Visitor and GP notified after discharge. Baby aged 5-6 weeks Baby F sleeping downstairs with Mr F as Ms M not waking for him during the night. Health Visitor notes Ms M reporting anxiety worsening and tensions within her relationship with Mr F. Ms M discussed anxiety with GP, to self-refer for additional counselling. Baby aged 6-8 weeks Ms M has three appointments with the work place counsellor, her anxiety continues. Baby aged 8 weeks Ms M sees GP and is diagnosed with post-natal depression. Baby aged 8 weeks Baby F seen at hospital, “small bilateral conjunctival haemorrhages, grumpy and not settled” discharged with “advice.” Baby aged 8 weeks Baby F attends nursery, Mr F tells Health Visitor he is feeling low. Baby aged 9 weeks Mr F has telephone consultation with his GP and reports he has symptoms of post-natal depression, thoughts of harming Baby F and of self-harm but reassures GP he is in control and won’t act on his 5 feelings, is prescribed medication and referred for counselling. Mr F is assessed by the counselling service during a telephone call; he is offered an appointment after the period of this review. Baby aged 9 weeks Baby F attends nursery, has small mark on cheek, staff report it could be pigmentation or small bruise, discussed by nursery staff, no action taken. Baby aged 10 weeks Ms M tells the counselling service that Mr F had banged the baby’s head; Counsellor took advice from supervisor, reassured by Ms M’s demeanour, no action taken. Baby aged 11 weeks Mr F telephones GP and is advised to bring baby to surgery immediately, Baby F has swelling on head, allegedly from hitting head on work surface during a feed, ambulance takes Baby F to hospital where he is found to have life threatening head injuries, an intra-cranial haemorrhage and rib fractures and an older rib fracture. Autumn 2016 Child Protection Investigation initiated followed by Care Proceedings. The criminal investigation was ongoing at the time of writing; a trial was expected to take place in 2018. LEARNING THEMES 15. From the documentation provided and meetings with the practitioners involved with the family, the following learning themes emerged: Identification and Response to Post-Natal Depression Response to unusual medical presentations in pre-mobile babies Knowledge and Understanding of the Child Protection Procedures and Thresholds for Referral Adult Services Working with Parents and their Responses to Safeguarding Concerns about Children 6 IDENTIFICATION AND RESPONSE TO POST-NATAL DEPRESSION Identification 16. Post natal depression is a well recognised condition which is said to affect an estimated 13% of women following childbirth. Research shows that it can have an enduring effect on both the mother's health and their child's development; for example there is a substantial body of research showing consistent associations between maternal post-natal depression and an increased risk of cognitive, emotional, and behavioural problems in children.3 17. Symptoms of post-natal depression include persistent feelings of sadness and low mood, lack of energy and feeling tired all time, difficulty bonding with the new baby and can include frightening thoughts for example about hurting the baby. 18. Factors associated with post-natal depression include a parent’s history of mental health problems, particularly depression in earlier in life, having no support from family or close family, a poor partner relationship and recent stressful life events such as bereavement4. 19. Ms M described herself as having most of these symptoms and the associated factors, which meant her presentation was seen as typical by the health professionals working with her. 20. What is less well documented, or generally understood, is the concept of post-natal depression in fathers. Believed to affect 5%-10% fathers, it is most commonly considered to be a risk for men when the baby is 3 - 6 months old;5 the factors associated with post-natal depression in fathers are similar to those of mothers, although research indicates that stress in the parents relationship is of greater significance for men; also the effects on the child may be particularly potent when the depression occurs very early in the child's life.6 21. In this case both parents were diagnosed with post-natal depression. For Mr F, the diagnosis of post-natal depression was much more unusual in that the majority of health staff who knew this family had either never heard of post-natal depression in fathers or never come across it before. 3 Postnatal depression : the impact for women and children and interventions to enhance the mother-infant relationship, 01 June 2011 - Publisher: National Childbirth Trust 4 NHS, Post-natal Depression, 2016 5 Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health, Janice H. Goodman Journal of Advanced Nursing Volume 45, Issue 1, pages 26–35, January 2004 6 Paternal depression an examination of its links with child and family functioning in the post natal period, Paul G Ramchandani et al, Journal of Psychiatry, June 2011. The effects of early paternal depression on children’s development, Richard J Fletcher, Emily Feeman, Craig Garfield and Graham Vimpani, Med J Aust 2011; 195 (11): 685-689. Fathers and Post-natal Depression, The fatherhood Institute Research Summary, August 2010. 7 Response to Post-Natal Depression 22. Regarding Baby F’s mother, the sequence of events leading up to Baby F’s birth was not perceived by the health workers as anything out of the ordinary. 23. Ms M had attended her ante-natal appointments with midwifery, information about her history was discussed and a brief assessment carried out to determine if Ms M had any particular issues with her pregnancy or in her family life which would have led to signposting to community services, for example the local Children’s Centre, or an enhanced or specialist service from midwifery. Although Ms M reported some anxiety and issues from her childhood, these did not indicate to those working with Ms M that there was a need for any additional work. There was nothing in Ms M’s contact with the midwives which made her stand out. 24. Baby F was born by Caesarean section at the beginning of July following a short labour. He was a small baby but his weight was within normal limits. For the first ten days following his discharge from hospital, midwives visited Ms M and nothing unusual was noted. The Health Visiting Service later noted the baby had a Mongolian Blue Spot but the documentation did not say where, what size or describe the appearance.7 25. On day ten, in line with usual practice, midwifery handed over responsibility for Baby F to the Health Visiting Service. Lack of capacity meant that there had been no ante-natal visit from Health Visiting; although a visit is considered best practice it is not uncommon and, as no particular concerns about Ms M had been identified, was not significant in the context of this Review. 26. Health Visiting became aware of some of Ms M’s feelings and anxiety from the beginning of their contact. Over the first couple of visits Ms M reported : An unplanned pregnancy Low mood Relationship tensions 7 Mongolian Blue Spot is a type of birthmark that is present at birth or appears soon afterwards. They are very common in children of African, Middle Eastern, Mediterranean or Asian background. It is important to document them to prevent them being mis-diagnosed as bruising. Learning Point: Fathers can experience post-natal depression, the signs and symptoms are similar to those of mothers and the potential effects on children are equally serious. 8 Difficulty with sleeping Anxiety over bonding with the baby Problems with breast feeding the baby Not waking for the baby at night Lack of family support. 27. Ms M also shared with the Health Visiting service that she had had some difficulties and disruption in her childhood. These factors were indicators that Ms M was at risk of post-natal depression and in line with good practice; the Health Visitor used assessment tools, the Whooley Questions, and a Moods and Feelings Assessment to gain further information. 28. Health Visitors report that in general, their response to an assessment is primarily limited to “signposting” to services within the community and advised Ms M to self-refer to the Health Services’ Counselling Programme. (The Health Visitor didn’t know at this point that Ms M was attending work place counselling) This was despite Health Visitors reporting to this review that the waiting time for the counselling service is over a year “so there’s not much point in referring.” 29. The Health Visiting service also offered Ms M the MESCH service. The Maternal Early Childhood Sustained Home-visiting (MECSH) programme is an evidenced based, structured programme of intervention for vulnerable mothers which encompasses primary health care and can include more specialist services as required. In this case the MESCH programme was to include weekly visits for six weeks followed by fortnightly visits until the baby was 12 weeks old. 30. The planned weekly visits did not take place, partly because of staff holidays and partly because the Health Visitor did not prioritise this case, of a possible 7 visits only 3 took place; the case was not seen as high risk by the Health Visitor and therefore no “cover” was requested during her absence. Had more visits taken place it is possible that a more in depth understanding of the family might have been achieved. 31. The Service Specification for Health Visiting which sets out the standards expected indicates that a further Moods and Feelings assessment should take place after four visits in order to assess any change, this did not happen in this case; neither is there any evidence that Ms M was offered help with breast feeding. Keeping a Focus on the Baby 32. The challenge of working with families when the parents have their own needs is always the risk of losing focus on the needs of the baby. When a mother has post-natal depression the 9 guidance makes many references to the effectiveness of a supportive partner, with two parents diagnosed with depression the potential impact on a baby’s care is likely to be greater. 33. The focus of intervention with the family over the 12 weeks before Baby F’s injuries were diagnosed was support for his parents. There is very little information in the records about the baby, his development and the nature of parental attachment. Baby F was only weighed by the Health Visitor twice in the 12 week period, partly because it is more practical and more usual for a baby to be taken to a local clinic for weighing. In this case the baby wasn’t taken to the clinic and although he was a small baby, there were no obvious concerns about his weight. Had the baby been undressed and weighed at home this would have created an opportunity to observe the parents handling of the baby and observation of his physical well-being including signs of injury. 34. The Health Visiting Service works to full capacity and decisions have to be made about prioritising resources, visiting frequency and direct contact with babies and children. The learning here is that the Health Needs Assessment which highlighted a number of risk factors from both parents, including post-natal depression, appears to have had little impact on the quality of intervention. Although there is information about both parent’s well-being, Ms M’s not waking at night, problems with breast feeding and lack of family support, there is limited information about the impact of the parent’s needs on the day to day care of the baby. Learning Point: Assessing mothers is good practice, but the assessment has limited value if it does not inform a plan and intervention and if progress is not regularly reviewed. When parents have needs of their own there is a risk that focus on the child will be lost; weighing and observation of a baby provides a valuable opportunity to be alert to a baby’s progress and any indications of concern. 10 Invisible Fathers 35. The Health Visiting Service’s own review of this case indicates that Mr F was largely “invisible” to the service and the Health Visitors reported this is not unusual as fathers are often absent during visits. Yet in this case Mr F was observed to be carrying out much of the care of the baby, sleeping in the same room as Baby F as Ms M wasn’t waking for him, feeding baby F and telling Health Visitors about his own feelings and low mood. Interestingly it was also Mr F who took Baby F to hospital on the two occasions he was seen there and who took him to nursery on several occasions. 36. Information on how to respond to post-natal depression in mothers commonly refers to the need for a supportive partner. Apart from one reference to his handing the baby sensitively, there was no assessment by the Health Visiting Service of Mr F’s own “moods or feelings” and how this might impact on his parenting capacity or ability to be the supportive partner. Mr F was diagnosed with post-natal depression a few days after Ms M, when Baby F was 8 weeks old. 37. Although it started well, the overall quality of work carried out by the Health Visiting Service appears to have been superficial. The recognition of potentially significant factors known to affect parenting and increase risk appears to have had little impact on the work undertaken with this family. The Importance of Supervision 38. The Health Visiting Service has a clear and comprehensive supervision policy which says that all safeguarding cases must be brought to supervision and any other cases, which may not be Learning Points: It is important to seek active engagement with both parents with a view to assessing their mental health and ability to be a supportive partner. This is especially important if either or both parents are diagnosed with post-natal depression. Opportunities to speak with parents alone, particularly when one has a mental health problem, are invaluable in contributing to the assessment of the impact of parental health on the care of a baby. 11 regarded as safeguarding but may be complex, can also be discussed. The Health Visitor in this case was relatively inexperienced and did not consider this case as one which needed to be discussed in supervision. 39. The Health Visiting Service has reviewed their practice and concluded this case should have been brought to supervision. The service is reviewing its supervision policy to emphasise the importance of recognising the complexities of any parental mental health issues and with particular attention to how MESCH cases should be overseen. Consideration for the PSCB The PSCB should seek assurance that the individual agency learning from this case and other learning which has emerged as part of the review, has been formally identified and addressed by the relevant agency. The Family’s Contact with GPs 40. Ms M had four contacts with the GP practice in the period between Baby F’s birth and his head injury; staff at the practice, were aware of Ms M’s anxiety and she was formally diagnosed with post-natal depression at the beginning of September, about two weeks before the baby’s head injury. At the same time as the depression diagnosis, the GP had tried to contact the Health Visitor to discuss Ms M’s mental health, problems with availability meant they weren’t able to speak to one another and the GP’s receptionist passed on a message to the Health Visitor which led to a “listening visit” from the Health Visitor. 8 41. The contact the surgery had with Ms M gave them no reason to consider that Baby F was at risk of harm. 8 Listening Visits: An Evaluation of the Effectiveness and Acceptability of a Home-based Depression Treatment, Segre et al, Psychotherapy Research Journal, Nov 2010 Learning Points: Knowing which cases to bring to supervision is an important skill. For less experienced staff, supervisors need to be vigilant to ensure the most vulnerable families are discussed, and assessments and interventions are carried out as planned. 12 Diagnosing Post-Natal Depression in Fathers 42. Mr F was registered at a different practice from Baby F and Ms M and it was Mr F’s GP who confirmed his diagnosis of post-natal depression. This was an unusual event for the GP who had not come across post-natal depression in fathers before. The consultation took place on the telephone as there were no appointments available that day; this is common practice in the area and is an essential part of coping with demand, but meant the GP did not see Mr F. Also notable was that Mr F came across as a well educated, thoughtful man who had researched the symptoms of post-natal depression and appeared to be looking to the GP for confirmation of his diagnosis and for treatment. 43. The GP was robust in her questioning, asking the same questions of Mr F as Ms M’s GP had asked of her, about thoughts of harming the baby, about thoughts of self-harm and exploring what might prevent such actions. Although Mr F acknowledged he had had thoughts of both, he reassured the GP that he was confident he would not act on his feelings. The GP also asked about Ms M and was told she too was suffering with post-natal depression. 44. The GP was reassured by Mr F’s responses and agreed to prescribe an anti-depressant medication, the GP also discussed counselling and Mr F said he had already self-referred. Unable to make the first counselling appointment offered, he was offered a later appointment which was due to take place just after Baby F’s head injury occurred. Was this is a missed Opportunity? 45. The response to Mr F appears to have been appropriate. On reflection, the GP was reassured by Mr F’s knowledge, confidence, his measured responses to the questions asked and that he was being pro-active and said he wanted to be supportive to his partner and family. 46. Had the consultation been with a mother with post-natal depression, the GP reports that this might have been more probing and might possibly have arranged a follow up appointment to see the parent and baby together; the father’s GP was disadvantaged because the baby was registered at a different practice and the GP didn’t have access to the baby’s records which would have provided extra information about the baby including information about the previous hospital visits. Although this might not have made a difference to the outcome of the consultation, it would have provided a bigger picture of family life. 47. The lost opportunity here was not sharing the information from this consultation with another agency. The GP, on reflection, takes the view that it is unlikely that Children’s Social Care would see this as meeting the threshold for action (although the GP also thinks Mr F would have agreed to a referral) but has concluded that a conversation with Baby F’s Health Visitor would have been appropriate. 13 48. The information about Mr F’s mental health may not have met the threshold for intervention from Children’s Social Care; it is also unlikely that even if a conversation with another agency had taken place at this time, the outcome for Baby F would have been different. The GP’s information about Mr F was only a part of the jigsaw which had not yet been put together however, the need for effective information sharing remains a vital part of safeguarding practice. Learning Points: When both parents are diagnosed with post-natal depression the potential impact on the care of a vulnerable baby is potentially greater; it is important to keep the child in mind when deciding what action to take. When a health professional has information relevant to the care of a vulnerable baby, consideration must be given about how this can be shared and with whom. This will contribute to the development of a holistic picture of family functioning and any risk to children. All agencies need to be alert to the risk that articulate, well informed and confident parents can be falsely reassuring in their self-reporting. 14 UNUSUAL MEDICAL PRESENTATIONS IN NON-MOBLE BABIES AND CHILDREN 49. Sidebotham et al in their paper, Pathways to Harm, Pathways to Protection state: “The high number of serious case reviews conducted with regard to babies under one year of age reflects the intrinsic vulnerability of the youngest babies who are dependent on the parents for care and survival.” 9 50. Injuries in babies and infants who are not crawling, cruising or walking (non-mobile) are rare and there is a wealth of research about their significance as potential indicators of child abuse. For example, the NICE guideline “When to Suspect Child Maltreatment”10 uses the terms “injuries and presentations” and prompts health practitioners to consider the possibility of maltreatment in forming a diagnosis, or as part of differential diagnosis.11 51. The Guidance states: “If an alerting feature or considering child maltreatment prompts a healthcare professional to suspect child maltreatment they should refer the child or young person to children's social care, following Local Safeguarding Children Board procedures.” 52. For all agencies working with children and families, the Plymouth Safeguarding Children Board practice guidance can be found as part of the South West Area Child Protection Procedures, 12 the “Bruising and Injuries in Non-mobile Children Protocol.”13 The procedures are clear that: “due to the significant risk of abusive injury ALL non mobile babies with an injury or bruising should be considered as a potential indictor of abuse unless evidenced otherwise by health professionals.” [sic] It also says “all injuries, however minor, are a cause for concern;” “all bruising on non mobile babies must prompt a referral to social care.” 53. In addition to the Child Protection Procedures, Safeguarding Boards often have specific guidance for practitioners about injuries and medical presentations in non-mobile children. (The term non-mobile is used in order to include older children who may be non-mobile because of disability) The Plymouth Safeguarding Children Board’s guidance “Bruising on pre- 9 Sidebotham et al, Pathways to Harm, Pathways to Protection, a triennial analysis of Serious Case Reviews 2011 to 2014, May 2016 10 See: http://guidance.nice.org.uk/CG89 11 A differential diagnosis is considering which of several possibilities might be producing the symptoms 12 South West Child Protection Procedures, 2017 13 Plymouth Safeguarding Children Board Guidance Document Bruising on pre-mobile babies, Guidance on the detection and management on bruising in pre-mobile babies, 2014 15 mobile babies, Guidance on the detection and management on bruising in pre-mobile babies.... Babies don’t bruise, break or bleed” can be found on their website. The guidance sets out what action is to be taken if a pre-mobile baby found to have a bruise. Sentinel Injuries 54. Studies about child deaths from non-accidental injuries show that these children often have a history of minor injuries prior to a very serious injury or death. Often this recognition comes later, with the findings of a severe or catastrophic non-accidental injury. In one study these injuries were present in 25% of children subsequently diagnosed as abused.14 These minor injuries in babies are described as sentinel events or sentinel injuries. They are defined as minor inflicted injuries/physical signs that are presented to physicians before the recognition that the child has been abused. 55. In this case Baby F was seen twice at the Emergency Department of the local hospital, once when he was 5 weeks old and then again when he was 9 weeks old. Baby F was not bruised but he did have unusual presentations which were seen before his catastrophic head injury. First Presentation 56. At the first hospital visit in August 2016, Baby F was noted to have a range of symptoms including his father reporting that the baby had been bleeding in his mouth; this was seen by the doctor as blood in sick on the baby’s bib. The other symptoms the baby presented with included having been hot, unsettled and irritable; it was these symptoms which led the examining doctor in the Emergency Department to consider sepsis as a possible diagnosis; consequently Baby F was promptly transferred to the paediatric department and admitted for tests to exclude this potentially life threatening illness. 57. In the course of needing to assess and treat a potentially very serious illness, the presence of the blood in the mouth was overlooked. A note was made on the baby’s record but this information was not considered significant by the doctors who examined the baby. In the context of possible sepsis, the bleeding appeared trivial and there was no exploration of the possible cause. 58. Bleeding from any orifice in an infant is very rare and in the absence of an underlying medical cause, can be an indicator of abuse.15 Oro-nasal bleeding (bleeding from the mouth and /or nose) without an obvious medical cause is listed as a “red flag” presentation, and the hospital has issued a care pathway to be followed by medical practitioners, the “Management of a 14 Sheets LK et al Paediatrics 2013: 131(4) 15 McIntosh N, Mok JY, Margerison A Epidemiology of oro-nasal haemorrhage in the first 2 years of life: implications for Child Protection. Paediatrics 2007; 120(5):1074-8 16 Child under 12 months referred with Bleeding from Nose or Mouth.”16 The pathway indicates possible diagnoses and says that consideration should be given to the possibility of Child Protection concerns. 59. The protocol was not followed in this case. Had Baby’s F’s presentations been “red flagged” the hospital’s safeguarding team would have been advised, the facts noted and proper consideration given to the possibility of risk of harm and if any further action was required. 60. However it is interesting to note that the blood on the bib was included in the discharge summary sent from the paediatric department to the GP practice and the Health Visiting Service. The information was added to the Health Visiting record 10 days later, the delay said to be caused by resource issues. There is no evidence that the Health Visitor saw the information or discussed the hospital visit with the parents. The information was not included in the chronology of the Baby’s GP practice; the GPs appear to have been unaware of the incident. (See section on Effective Communication) Second Presentation 61. The second visit to the Emergency Department took place four weeks later, when Baby F was 9 weeks old, and also involved an unusual presentation. 62. Mr F took Baby F to the Emergency Department reporting that the baby had recently been immunised and was upset and irritable. Also noted on his record was the presence of “red spots” in the baby’s eyes. These were described differently in various hospital records and in subsequent conversations with medical practitioners as part of this review, as “haemorrhagic spots on the eyes,” “red spots on his eyes” “blood spots on the eyes” and by Baby F’s GP, who saw the Baby 2 days after the hospital visit, as ”sub-conjunctival haemorrhages.” 63. Sub-conjunctival haemorrhages are caused when the blood vessels on the surface of the eye are broken and, like bleeding in the mouth, whilst common in adults, are rare in babies. Where it does occur there is sometimes a clear link with another health problem, for example whooping cough; if there is no obvious explanation, sub-conjunctival haemorrhages can be an indicator of child abuse. 64. An example from the literature states: “sub-conjunctival haemorrhages in infants and children can be a finding after non-accidental trauma. We describe 14 children with sub-conjunctival haemorrhages on 16 Taken from: Epidemiology of oro-nasal haemorrhaging and suffocation in infants admitted to hospital in Scotland over 10 years. Arch Disease in Childhood, 2010 17 physical examination who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, sub-conjunctival haemorrhage may be related to abuse. Non-accidental trauma should be on the differential diagnosis of sub-conjunctival haemorrhage in children, and consultation with a child abuse paediatrics specialist should be considered.”17 65. In this case, Baby F was seen and examined by a junior doctor who concentrated on the fact of the recent immunisations and quickly reached the view there was nothing of particular concern. In a similar way to the first presentation, it was the mention, by Mr F, of the possible reaction to the immunisation which distracted the doctor who examined Baby F away from considering the possible significance of the “spots on the eyes.” 66. Any child who is seen in the Emergency Department has to be “signed off” by a senior doctor before they can be discharged. In this case the “signing off” involved the junior doctor giving a brief verbal report to the senior doctor. It is not unusual in this busy emergency department, that a child is not actually seen by the senior doctor signing off and Baby F was not seen. The junior doctor was not available to be interviewed as part of this review, but is said to have reported the baby as having a reaction to his immunisations with a recommendation that he be discharged home and his father given advice about management. The “haemorrhagic spots on the eyes” were reported to have been mentioned, but the senior doctor did not think about the possible significance and therefore no consideration was given to whether any further action or referral to paediatrics was necessary. 67. It would appear that the reasons for the oversight were: The use of the term “spots on the eyes” which does not accurately describe the presentation The concentration on the recent immunisations and the view that the symptoms Baby F was exhibiting related to that, leading to the information which did not fit a hypothesis being disregarded The volume of work at this busy emergency department which means babies are not routinely seen by senior doctors as part of the signing off process 68. These findings resonate with the learning summarised in the NSPCC’s publication, “Paediatrics and accident and emergency: learning from case reviews” which says “Within medical teams there can be poor communication and escalation of concerns. Some Reviews uncovered evidence of doctors over-estimating how well they had briefed doctors coming on duty18.” 15 Sub-conjunctival Haemorrhages in Infants and Children: A Sign of Non accidental Trauma, Paediatric emergency care 29(2):222-6 · February 2013, Catherine A Deridder et al 18 Paediatrics and accident and emergency :learning from case reviews, Summary of risk factors and learning for improved practice for the health sector, NSPCC, May 2015 18 69. Also relevant is that the senior doctor was not aware that Baby F had been seen in the emergency department four weeks earlier. The medical practitioners at the Emergency Department reported that “99% of the time no notes are available, you have to rely on what parents tell you.” This understanding is not accurate as patient notes are available to be viewed on the computer system and administrative staff make a note on a child’s record of the number of previous attendances. 70. Another factor which was considered by staff to have hindered recognition was a change of name. The first time Baby F attended the emergency department he was booked in under his mother’s family name, on the second occasion he was using his father’s family name. This is not unusual for new-born babies however all patients have a unique NHS number which avoids the risk of relying purely on names. This case highlights the need to both seek out patient records and to be attentive to NHS numbers as well as patient names. 71. Had the senior doctor known about the earlier hospital visit, this would have provided another opportunity for consideration of the risk factors. 72. Sub-conjunctival haemorrhage has recently been reinstated on the hospital protocol as a “red flag” injury which should be referred to the safeguarding team. The minimising of the potential relevance of Baby F’s “spots on the eyes” meant an important opportunity was lost both for proper consideration, diagnosis and “red flagging” and later by leaving the information off the discharge summary, there was no opportunity for a second opinion or follow up once the baby was back in the community. 19 Consideration for the PSCB 73. Although “bruising” was not a feature of Baby F’s presentation at hospital, the studies on injuries and presentations in non-mobile babies and children demonstrate that the principles behind the protocol apply to all injuries including bleeding and other unusual medical presentations. The phrase on the website, “babies don’t bruise or bleed” could usefully be developed into a more comprehensive protocol which makes specific reference to other types of injuries and presentations. See for example, Western Bay Safeguarding Children Board, Multi-Agency Policy for Minor Injuries in Babies, 2015, which specifically mentions oro-nasal bleeding and sub-conjunctival haemorrhaging and Bristol Safeguarding Children Board, Multi-Agency Guidance for Injuries in NON-MOBILE Babies, 2015. 74. The challenge for the PSCB is not new, in 2010 the death of a four week old baby, known as Child E, led the Board to commission a Serious Case Review. Although this child died seven years ago, it is notable that there are some issues which impacted on that case which remain unresolved; namely the impact of a mother and father being registered at different GPs and the guidance in relation to unusual presentations, in that case a “red mark.” 75. The report points out: “the need for GPs to be aware of the significance of information they hold in respect of parenting capacity and in this case sharing of information was affected by the parents Learning Points: All practitioners need to be mindful about the importance of using clear and accurate language, particularly when describing unusual presentations which are open to interpretation. Practitioners should ensure they consider all of a child’s symptoms and signs when formulating the differential diagnosis at presentation in order to avoid downplaying or ignoring those commonly seen in unwell children but which may be indicative of abuse. The presence of a number of apparently minor injuries to a baby can be considered Sentinel Injuries and may be an indication that the child is at risk of harm. Knowing if and when a baby has attended the Emergency Department is important in alerting health professionals to the potential significance of apparently minor injuries. Information systems must be accessible and fit for purpose. 20 being registered at different practices. Developing effective information sharing pathways in such circumstances is therefore crucial ...” SCR, Child E, 2010 The PSCB should satisfy itself that their guidance on the detection and management of bruising, injuries and unusual medical presentations in non-mobile babies and children is clear and comprehensive and that is it understood and able to be applied consistently by all agencies. Effective Communication 76. There are a number of examples from this review where communication was not effective. The previous section of the report describes the need for accurate language when describing presentations; this is particularly important when examining babies. 77. In addition to communication within organisations, there were a number of occasions in this case where poor communication between agencies impacted on practice. 78. Although Baby F’s unusual presentations at the Emergency Department did not trigger a safeguarding alert, had the information been properly communicated to the GP and Health Visiting Service, this would have created an opportunity for a second opinion on the nature of the medical presentations and also to consider the implications within a broader knowledge of the family. Health Visitors are particularly well placed to have an overview of the issues affecting different family members. Discharge Summaries 79. When a baby is seen in hospital, discharge summaries are sent to the GP and Health Visiting Service. If the baby is seen by a paediatrician, as was the case in baby F’s first admission, the discharge summary is typically a three page document detailing the presenting symptoms, treatment carried out and any follow up required. If the baby is seen in the emergency department and doesn’t need to see a paediatrician, as in the second hospital visit, the discharge summary is shorter and uses tick box computer generated menus with a space for the doctor to add a note for the GP if necessary. 80. After the first hospital visit the “blood coming out of the baby’s mouth (in his sick)” was included in the discharge summary but the summary was not seen by either the GP or health visiting service. This meant that a potentially valuable opportunity for a second consideration of the bleeding was lost. 81. The reason the information was not seen lies within the systems for receiving information and ensuring it is seen by the relevant people. For the Health Visiting Service, at the time of these events, information was placed on the Baby’s file as an administrative action, for the Health 21 Visitor to know it was there, required checking the file before every visit. This didn’t happen in this case. This cumbersome process has since been changed and now all communications are passed to the lead Health Visitor who is required to note a response to the information, pro-actively passing it on to the allocated Health Visitor when appropriate. 82. A similar system is in place for the GPs where information from the hospital is placed on the patient file, it is reviewed by a duty GP who assesses the significance and decides if any action is required. In this case the information about the bleeding was either not seen, or not seen as significant, and the GPs remained unaware of it. 83. After Baby F’s second hospital visit the discharge summary did not mention the “haemorrhagic spots in the eyes” and therefore the Health Visitors were not aware of it and there is no mention in their records that it was observed by the Health Visitor. 84. However Baby F’s GP was aware of the presentation because Mr F took the baby to the surgery a few days after the hospital admission and discussed it with the GP. The GP records note that Baby F had “small bilateral sub-conjunctival haemorrhaging.” The GP was alert to the possibility that this may have been caused by a non-accidental injury and was robust in questioning Mr F about the presentation. The GP examined Baby F, weighed him and saw nothing which caused alarm; the GP was re-assured by Mr F reporting that the baby had been seen by doctors at the Emergency Department who, Mr F said, had been satisfied that the bleeding was caused by the baby “straining.” (to evacuate his bowels) This was not mentioned in any of the hospital records but after a lengthy consultation, the GP was satisfied that no further action was necessary. The GP assumed that the ED has acted robustly and would have been aware of the possible implications of sub-conjunctival haemorrhaging in a baby. Checking back with the Emergency Department would have created the possibility of further consideration about whether any action needed to be taken. Learning Point: Sub-conjunctival haemorrhaging in babies can be an indicator of child abuse. Relying on parents self-reporting runs the risk of being falsely re-assured. For all agencies it is important to remember that parents can be misleading when giving an account of injuries and professionals need to retain an open mind and use their own professional judgement in deciding whether or not to take action. 22 KNOWLEDGE AND UNDERSTANDING OF THE CHILD PROTECTION PROCEDURES AND THRESHOLDS FOR REFERRAL 85. The expectation of the Plymouth Safeguarding Children Board is that all agencies who worked with this family, adults or children’s services, would be familiar with the South West Child Protection Procedures. As part of learning and disseminating knowledge of the procedures, staff from all the agencies are invited and expected to attend basic Child Protection training. All the agencies are expected to be able to access a Safeguarding Advisor who is expected to have a detailed understanding of the procedures and the principles which underpin them. 86. There were two occasions during the period of this review where the Child Protection procedures should have been followed but were not. 87. A few days before Baby F was admitted to hospital with his head injury, he was observed by nursery staff to have a small mark on his cheek which may, or may not, have been a bruise. The mark was described by staff during the process of this review as being about 1 × ½ cm and showed as a slight discoloration of the baby’s skin. Because of the colour of the Baby F’s skin, it was difficult for the staff to decide if this was a bruise or a skin pigmentation. The staff group looking after Baby F briefly discussed the mark but reached no decision and no action was taken. 88. The staff should have referred their concern to their manager, who as Safeguarding Advisor, would have taken the decision whether or not to refer to Children’s Social Care. It is impossible to know whether a referral at this stage would have changed the outcome for Baby F in any way as the mark may not have been a bruise. However, in response to this case, the nursery have carried out an internal review and all staff have been reminded about the protocol for action to be taken if bruising on a non-mobile baby is observed or suspected. The nursery has also reviewed their recording practice in order to ensure all pre-existing birth marks are noted. This case has been a stark reminder to nursery staff that some children are subjected to child abuse and they report that they are more sensitised to the possibility and more observant of the babies in their care. Learning Point: It can be difficult to distinguish between bruising and skin pigmentation on babies, any marks on pre-mobile babies which have not been previously documented, should be discussed with the agency’s safeguarding lead and the Child Protection Procedures followed. 23 ADULT SERVICES WORKING WITH PARENTS AND THEIR RESPONSES TO SAFEGUARDING CONCERNS 89. It is not uncommon in Serious Case Reviews for comments to be made about the need for services for adults to be mindful about the implications of parental behaviours and/or mental health on children. In this case, during July, August and September, Ms M was receiving counselling provided by a work place service. 90. In that setting it was unusual for counsellor’s clients to be parents; the counsellor was not very experienced and had no knowledge of Child Protection, the South West Child Protection Procedures or how to respond if there were any concerns about a child. 91. The agency concerned, despite being a significant and well established part of the local education system, sometimes working with parents and sometimes working with older children (16+) did not have a Child Protection policy, the counselling department had no knowledge or understanding of the Child Protection Procedures and the agency did not have a named Safeguarding Advisor. All of this meant they were ill equipped to manage concerns about possible risk or harm to children. 92. It became obvious at the start of Ms M’s therapy that, as well as her current problems, Ms M had some complex historical issues relating to her own childhood. The counselling agency acknowledges that in hindsight, this case should have been allocated to a more experienced worker. 93. As the sessions continued Ms M appears to have freely shared information about her home life and the stresses of parenting. To her credit, the counsellor sought advice from a senior colleague who suggested some lines of enquiry about Ms M’s safety and encouraged the counsellor to liaise with Ms M’s GP and Health Visitor in order to make sure she was getting their support. In the event, this never happened and the counsellor left it to Ms M to pursue this action herself. 94. Earlier on the same day that Baby F was admitted to hospital with his head injury, Ms M had a counselling session; she told the counsellor that Baby F’s father had accidentally banged the baby’s head on a cupboard. The counsellor discussed the matter with a senior colleague who asked about the counsellor’s view of the risk to Baby F. The supervisor appeared to have been re-assured by the counsellor’s response; this was thoughtful and considered and included reference to Ms M’s improved demeanour and response to an assessment tool which indicted she was feeling less anxious than previously. As a result no further action was taken. 24 95. The counsellor and/or the supervisor should have taken immediate advice from a safeguarding advisor who should have referred the matter to Children’s Social Care without delay. 96. To their credit the agency concerned has recognised the shortfalls in their Child Protection Practice and have devised a detailed action plan to address the deficits. The plan includes actions for individuals, for example training, and for the agency the recruitment of a Safeguarding Advisor. The agency is also seeking to develop links with the Safeguarding Board. Consideration for the PSCB The PSCB should assure itself that associate counsellors working for the counselling service in this case are familiar with and follow BACP guidelines with regard to safeguarding children. Learning Point: All agencies have a responsibility for safeguarding children. Agencies working with adults who are parents must always keep the child in mind and be clear about the limits of confidentiality and when there is a need to take action. 25 SUMMARY OF LEARNING 1. Identification and Response to Post-Natal Depression a) Fathers can experience post-natal depression, the signs and symptoms are similar to those of mothers and the potential effects on children are equally serious. b) Assessing mothers is good practice, but the assessment has limited value if it does not inform a plan and intervention and if progress is not regularly reviewed. c) When parents have needs of their own there is a risk that focus on the child will be lost; weighing and observation of a baby provides a valuable opportunity to be alert to a baby’s progress and any indications of concern. d) It is important to seek active engagement with both parents with a view to assessing their mental health and ability to be a supportive partner. This is especially important if either or both parents are diagnosed with post-natal depression. e) Knowing which cases to bring to supervision is an important skill. For less experienced staff, supervisors need to be vigilant to ensure the most vulnerable families are discussed, and assessments and interventions are carried out as planned. f) When both parents are diagnosed with post-natal depression the impact on the care of a vulnerable baby is potentially greater; it is important to keep the child in mind when deciding what action to take. g) When a health professional has information relevant to the care of a vulnerable baby, consideration must be given about how this can be shared and with whom. This will contribute to the development of a holistic picture of family functioning and any risk to children. h) All agencies need to be alert to the risk that articulate, well informed and confident parents can be falsely reassuring when self-reporting. 2. Response to Unusual Medical Presentations in Pre-Mobile Babies a) All practitioners need to be mindful about the importance of using clear and accurate language, particularly when describing unusual presentations which are open to interpretation. 26 b) Practitioners should ensure they consider all a child’s symptoms and signs when formulating the differential diagnosis at presentation in order to avoid downplaying or ignoring those commonly seen in unwell children but which may be indicative of abuse. c) The presence of a number of apparently minor injuries to a baby can be considered Sentinel Injuries and may be an indication that the child is at risk of harm. d) Knowing if and when a baby has attended the Emergency Department is important in alerting health professionals to the potential significance of apparently minor injuries. Information systems must be accessible and fit for purpose. e) Sub-conjunctival haemorrhaging in babies can be an indicator of child abuse. Relying on parents self-reporting runs the risk of being falsely re-assured. For all agencies it is important to remember that parents can be misleading when giving an account of injuries and professionals need to retain an open mind and use their own professional judgement in deciding whether or not to take action. f) Knowledge and Understanding of the Child Protection Procedures and Thresholds for Referral 3. Knowledge and Understanding of the Child Protection Procedures and Thresholds for Referral a) It can be difficult to distinguish between bruising and skin pigmentation on babies, any marks on pre-mobile babies, which have not been previously explained and documented, should be discussed with the agency’s safeguarding lead and the Child Protection Procedures followed. 4. Adult Services working with Parents and their Responses to Safeguarding Concerns a) All agencies have a responsibility for safeguarding children. Agencies working with adults who are parents must always keep the child in mind and be clear about the limits of confidentiality and when there is a need to take action. 27 CONSIDERATIONS FOR THE PSCB a) The PSCB should seek assurance that the individual agency learning from this case and other learning which has emerged as part of the review, has been formally identified and addressed by the relevant agency. b) The PSCB should satisfy itself that their guidance on the detection and management of bruising, injuries and unusual medical presentations in non-mobile babies and children is clear and comprehensive and that it is understood and able to be applied consistently by all agencies. c) The PSCB should assure itself that associate counsellors working for the counselling service in this case are familiar with and follow BACP guidelines with regard safeguarding children. 28 APPENDICES A. List of Practitioners involved with Baby F and his Family Health Visiting General Practitioners Counselling Service Midwifery Emergency Department and Paediatric Department, local hospital Nursery B. Members of the Serious Case Review Group DCI, Public Protection Unit, Devon & Cornwall Police, Chairman Head of Safeguarding (Children and Adults), NEW Devon CCG Joint Acting Principal Educational Psychologist, Plymouth City Council Head of Safeguarding, Children, Young People and Families, Plymouth City Council Designated Doctor, Safeguarding Children, NEW Devon CCG |
NC52276 | Chronic neglect of four siblings over several years. In 2019, two of the siblings aged 1.5-years-old and 2.5-years-old were reported to have been injected with heroin, which was confirmed by a child protection medical examination. Learning focuses on the following themes: understanding the lived experiences of each child and impact of the behaviour and lifestyle of the parents and carers; responding to neglect; processes around child protection, public law outline (PLO) and placements; adult services' work with parents and incorporating a Think Family approach; multi-agency working and communication; and desensitisation and professional culture. Recommendations include: examine the current position relating to neglect in the local area; ensure that that PLO processes are being conducted in a timely way and any delays and risks are addressed immediately; ensure a partnership approach in supporting families involved in PLO proceedings and related matters; provide training to the multi-agency workforce on working with families significantly affected by substance misuse; promote the use of the resolving professional disagreements protocol and the role of the child protection conference chair as a point of reference for any professional who is concerned about the progress of a child protection plan; provide opportunities within training for professionals to focus on desensitisation and the impact this may have on the children and families receiving support.
| Title: Child safeguarding practice review: overview report: Ava, Lucas, Harper and Chloe. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Amanda Clarke Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Overview Report Ava, Lucas, Harper and Chloe Author: Amanda Clarke Date: 21st July 2021 Publication Date: 5th October 2021 2 Contents 1. The reason for the Child Safeguarding Practice Review.................................................... page 3 2. The children and their family…………………………………………………........................................ page 3 3. Legal framework and methodology for the review………………………………………………………. page 4 4. Overview of what happened, key circumstances and background………………………………. page 5 5. Key themes of the review……………………………………………………………………………………………. page 7 5 (i) Understanding the experiences of each child and impact of their parents/carers’ lifestyle and behaviour upon them ……………………………………………………………………………………………………. page 9 5 (ii) Responding to neglect……………………………………………………………………………………………… page 11 5 (iii) Processes – Child Protection/ Public Law Outline (PLO)/ Placements……………………… page 15 5 (iv) Adult services’ work with parents and incorporating a “Think Family” approach……. page 21 5 (v) Multi-agency working and communication………………………………………………………………. page 24 5 (vi) De-sensitisation and professional culture………………………………………………………………… page 28 6. Conclusion/ what needs to happen………………………………………………………………………………. page 29 7. Recommendations………………………………………………………………………………………………………… page 30 8. References……………………………………………………………………………………………………………………. page 32 9. Appendices……………………………………………………………………………………………………………………. page 33 3 1. The reason for the Child Safeguarding Practice Review 1.1 In late 2019 information was received by children’s social care that two young children had “been injected with heroin to make them sleep”. There were two older siblings also living within the same family. Child protection medical examinations took place of the two youngest children and subsequently results indicated a positive opiate test for both children. A rapid review meeting concluded that the serious harm threshold had been met due to the suspected chronic neglect that all four children had experienced for a long period resulting in child protection plans and a public law outline1 (PLO) process. It was decided that a Local Child Safeguarding Practice Review of the case was necessary to identify learning to improve arrangements to safeguard and promote the welfare of children. 2. The children and their family 2.1 The children at the centre of this child safeguarding practice review remain living in the north of the country. They no longer reside with their parents. The names below will be used to protect the true identity of the children. Name to be used in the review Age at significant incident (late 2019) Chloe 1.5 year Harper 2.5 years Lucas 9 years Ava 16 years Mother 34 years Father (of Chloe and Harper/ stepfather to Ava and Lucas) 37 years Maternal grandmother 51 years 1 The Public Law Outline (PLO) sets out the duties that local authorities have when taking a case to court 4 3. Legal framework and methodology for the review See appendix A for information. 3.1 After consideration of criteria in Working Together to Safeguard Children 2018 a panel of senior multi agency professionals was convened but the first meeting of the Panel had to be delayed from March to June 2020 due to the Covid 19 pandemic. At this time an Independent Author had been commissioned. See appendix B for membership of the Panel. Due to unforeseen circumstances the Author was replaced and a different Independent Author was required to continue work on the review. That Author, Amanda Clarke, met with the Panel in November 2020. 3.2 Amanda Clarke is an independent safeguarding advisor with no connections to the local area or any of the organisations involved in the review. Her career history includes working as an investigator within police public protection, and inspection and audit for the NSPCC. She currently chairs a Safeguarding Adults Board and a Safeguarding Children Partnership. She also provides safeguarding advice and support for a Diocese in the Midlands. She has authored several case reviews and domestic homicide reviews. 3.3 The Panel with the Author, due to time elapsed and working restriction relating to the Covid 19 pandemic, made the decision to refocus the delayed review on a shorter period leading up to the significant incident in late 2019. This decision was considered proportionate under the circumstances. Therefore, the main timeframe of the review was identified as September 2018 to December 2019. 3.4 It was agreed that the experience of the children and family and service delivery during the timeframe would be explored relating to key learning themes which the Author and Panel had highlighted from the large quantity of multi agency information gathered in the initial stages of the review. The key themes, listed below and the timeframe were the focus of a practitioners’ meeting held to inform the review enabling professionals with direct involvement with members of the family to contribute. 3.5 Panel members and the Author were clear that other significant episodes relating to the children and family which occurred prior to the timeframe would also be considered and discussed by the Panel and by practitioners. It was agreed that non recent events in the lives of families are often significant and can impact upon and shape what occurs in the future. 3.6 The practitioners meeting took place virtually in January 2021 and was attended by 13 professionals. 5 3.7 The involvement of children and families in reviews, and in this review particularly, was acknowledged by the Author and Panel as very important. The Author spoke by telephone to the parents, to be known as Mother and Father, and their views are included where relevant throughout the report. Extensive efforts were made to engage the eldest two children. Lucas eventually provided brief written feedback via his foster carer but Ava understandably did not want to revisit her experiences. She did however give permission for any feedback given by her to professionals and recorded during the course of the timeframe, and immediately after, to be used. 3.8 It was the intention of the Author and Panel as much as possible to complete the review with the children always at the centre of every key theme explored, to ensure the children’s experience and perspective was not lost. All thoughts and comments from the children are reflected in the report in blue italics to ensure they are clearly visible. 3.9 Due to the review taking place during the Covid 19 pandemic all work was conducted virtually. 4. Overview of what happened, key circumstances and background 4.1 The four children had been subject to a child protection plan under the category of neglect since October 2018. The neglect of the children, which included at different times all six identified aspects of neglect2 was underpinned by domestic abuse, parental mental health, substance and alcohol use, and offending behaviour. 4.2 In November 2019 an older child (not within the family but who has the same father as the two youngest children Chloe and Harper), alleged that Father had been injecting both children with heroin to get them to sleep. Safeguarding medicals were undertaken for Chloe and Harper. Positive opiate tests were eventually returned for both children, although there was no evidence of an injection site at the safeguarding examinations. However, when one of the children attended nursery three days later a potential injection bruise to the thigh was seen. 4.3 As a result of the reported information care proceedings commenced for all four children and they were removed from the care of Mother and Father. 2 Aspects of neglect- medical, nutritional, emotional, educational, physical and lack of supervision/guidance: all subsumed under the term ‘failure to meet a child’s basic physical and/or psychological (and/ or emotional) needs,’ The Local Area’s Neglect Strategy 2019 6 4.4 Concerns for the family are in agency records from 2006 (when the family appeared to move to the area where the review is hosted). The family were known to numerous services up to the significant incident in late 2019. Issues within the family included neglect, domestic abuse, parental mental health and substance abuse. The children spent periods in the care of their maternal grandmother, although she was known to have her own mental health and substance misuse problems. She also had care of a child (now a young adult). Both maternal grandmother and that child were identified as in need of local family support services but the suitability of maternal grandmother to provide care for her grandchildren was never formally assessed. 4.5 During Mother’s pregnancy with Chloe (born in 2018) there were concerns about Mother’s drug use and all children were referred to children’s social care by the specialist midwife when Mother was 30 weeks pregnant. The baby was born with neo-natal abstinence syndrome (NAS)3 and there were concerns about Mother’s ability to care for the baby, including un-safe sleep concerns. An initial child protection conference held after the birth focussed mainly on un-safe sleep issues, rather than considering the whole spectrum of neglect. A decision was reached to place the new baby on a child protection plan and her elder three siblings on child in need plans. Despite evidence of the parents’ ongoing substance use a decision was made to end the child protection plan 10 weeks later. 4.6 In September 2018 (the start of the review timeframe), a violent domestic abuse incident was reported involving both Mother and Father. Both parents sustained serious injuries and were noted by attending police officers to be under the influence. Weapons were also recovered from the home address. There was no evidence that any of the children were physically present, although the eldest child Ava was aware of what had happened. 4.7 In the following days there were more concerns about Father including him attending Lucas’ school significantly under the influence. Within days Father made a serious suicide attempt at home and after this incident the children again went to stay with maternal grandmother. However, concerns were raised about her ability to provide basic care for her grandchildren and about her own mental health. These concerns resulted in the children returning to the parents, although Ava refused to go back and elected to live with an aunt. 3 NAS is a constellation of symptoms occurring in a baby as a result of withdrawal from physically addictive substances taken by the mother 7 4.8 Ava subsequently disclosed that she was aware of her stepdad’s (Father’s) suicide attempt and had witnessed Mother overdosing as a result. Ava said she had been unable to sleep due to fearing that she would wake up to find both parents dead and have to care for her siblings. 4.9 As a consequence of the events occurring from September 2018 all four children were made subject to a child protection plan on the grounds of neglect. 4.10 The children remained subject to child protection plans throughout 2019. During that year there were ongoing concerns about both parent’s alcohol and substance use, mental health and criminality (both were subject to probation supervision and Father spent a period of time in 2019 in prison). It was suspected that both parents prioritised their substance use over the care of their children, both in terms of their availability to provide care and emotional warmth, and in their use of financial resources, which resulted in times when the children did not have adequate food or warmth. 4.11 There was significant multi-agency involvement with the family (21 professionals attended the ICPC) many who had continuing concerns. The case progressed to Public Law Outline pre-proceedings in March 2019, but the children mostly remained in the parents’ care until the significant incident in late 2019 leading to the review. 5. Key themes of the review 5.1 Under the central theme of voice and focus on the children and their lived experiences the key themes which will be examined within the review are as follows: • Understanding the lived experiences of each child and impact of parents’/carers’ behaviour and lifestyle upon them • Responding to neglect • Processes – Child protection/ PLO/ placements • Adult services’ work with parents and incorporating a Think Family approach • Multi-agency working and communication • De-sensitisation and professional culture 5.2 The four children in this case will remain at the centre of the review and all analysis of services provided will be presented, where possible, with the perspective and experience of the children in mind. 5.3 There is limited evidence whilst the children remained living within the family, with the parents or with maternal grandmother, that they were regularly asked about their wishes and feelings. For the younger children Chloe and Harper this is understandable due to their ages. 8 However, Ava and Lucas were well able to provide an opinion about their daily lives but this opportunity for them to share their thoughts was not consistently provided to them, despite them being in contact quite frequently with different professionals. Examples of the views of Ava when asked about her situation are below (taken from agency records and used with the permission of Ava): On a child protection visit to Ava at her aunt’s address, she is clear about mother keeping her off school to care for her siblings. She spoke of her Mother’s ongoing heroin use and that she would “rather go into care than return home”. Ava disclosed that Father has been talking about hanging himself in front of Mother, and Ava had witnessed her Mum overdosing. When the family had a sudden move to a new address- Ava states she has been to the address and “it is a hovel” and “social workers should take her brother and sisters into care”. 5.4 Other thoughts of Ava regarding her parents’ behaviour and her having to care for her siblings were reflected earlier. 5.5 Prior to the significant domestic abuse incident records show Lucas as late for school and he told staff it was because he was looking after his siblings. Some weeks before Lucas had said that Mum (Mother) doesn’t get up in the mornings and Ava takes him to school/gets him ready. 5.6 Many reviews have referenced the importance of focussing on children and listening to their voices. In several cases this does not happen as frequently as it should particularly when children remain living in possible neglectful conditions as happened with this family. Ava was at an age where she could articulate exactly what life was like for her and her siblings, as the quotes above demonstrate, but this focus on the children to gather thoughts and feelings did not occur as often as it should. Professionals allocated to the case from children’s social care through the time frame often changed and there was little opportunity for trusting relationships to be built with children’s social care workers. As a contrast, the allocated Families in Need (FIN)4 support worker did remain consistent. 4 As part of FIN- Family Support Workers were allocated to undertake specific pieces of work within Child Protection Plans and several Family Support Worker staff were co-located within the Children Social Care Teams. This changed in late summer 2019 to ensure the allocated social worker developed a relationship with the families and took the lead role in supporting the children subject of CP Plans (and their families). 9 5.7 It is also important to recognise that some children communicate through their behaviour, rather than speech. Those working with them should endeavour to analyse the behaviour to inform overall assessment of the child’s situation and their needs. 5.8 Professionals in the area can access a Safeguarding Partnership 7 minute briefing titled Voice of the Child (2019) which highlights the importance for every professional ‘to put ourselves in that child’s shoes and think ‘what is life like for this child right now?’ The Partnership may wish to revisit this resource and explore ways of refreshing and re-promoting the key messages. 5.9 In the latest analysis of national case reviews5 it was noted ‘the complexity of some families’ situations and the large volumes of information held can get in the way of identifying the risks faced by children. Practitioners need to be aware of this and to constantly come back to seeking to understand the lived experience of the child’. 5.10 In the case of the four children this was certainly the position in terms of the amount of information which existed about service involvement throughout the children’s lives. Despite that, there was little evidence of questioning relating simply to ‘what it is like to live as a child in this family,’ which is discussed further below. (i) Understanding the experiences of each child and impact of their parents/carers lifestyle and behaviour upon them 5.11 The ‘child’s voice' does not only refer to what children say directly, but to many other aspects of their presentation. The lived experience of the child includes what a child sees, hears, thinks and experiences on a daily basis, all of which can impact on their personal development and welfare whether that be physically or emotionally. 5.12 Professionals needed to look deeply into the lives of each child in the family and ask the question ‘what is it like as a child living every day within this family setting?’ There was some evidence in the timeline of individual professionals trying to act for the children on identifying the harmful environment in which they lived. However, a coordinated multi agency and timely response was required and this did not happen. 5.13 Mother and Father both had a long history of parental mental ill health, substance misuse and domestic abuse, previously referred to in other reviews as the ‘toxic trio’, although Mother 5 Complexity and Challenge: a triennial analysis of SCRs 2014-2017 (March 2020) Marian Brandon, Peter Sidebotham et al 10 herself denies any abuse from Father saying abuse only occurred from other partners. Criminality was also a feature in their lives as were other adverse childhood experiences. The daily lifestyle of Mother and Father impacted considerably on the children. Caring responsibilities were often shifted to the older children (particularly Ava), all children witnessed (or experienced the aftermath) of harmful events involving the adults, normal family routines were not in place and there was a general absence of emotional stability. 5.14 When discussing the case at the practitioner’s meeting, including looking back on some of the specific experiences of the children, the participants could clearly see the unacceptable environment in which the children had been living. However, the cumulative harm with which they lived had not always been apparent at the time of services being involved as professionals responded to each crisis point in isolation. The ways in which professionals reacted and shared their collective concerns did not lead to substantial positive action for the children. Several times after incidents of concern the children were taken to stay with Maternal Grandmother, who had her own support needs. This was only a marginally better and safer option for the children’s care and there is little evidence that the older children were asked if this was where they wanted to be. Short term placements and other processes are explored below. 5.15 The lifestyle of Mother and Father in this case was described as ‘mostly chaotic’ and affected by their own personal needs. This overshadowed the needs of the children and professional responses to concerns within the family often became focussed on issues relating to the adults, such as their substance misuse and mental health. At the practitioners’ meeting there was a suggestion that some professionals may have held the view ‘if the parents could be helped this would in turn help the children’. However, positive outcomes for the children were mostly not evident even after extensive efforts at supporting Mother and Father. There were some attempts to explore the children’s experience by professionals who were involved with Mother and Father for predominantly adult facing work. This is positive especially as this was not the core business of the practitioners involved, for example the probation officer working for the Community Rehabilitation Company. 5.16 Scrutiny of the child protection plans for the children showed an approximate equal split between actions focused on the parents and actions focused on the children. This was clarified as possibly due to the previous model of working for the local area. The previous model was described as more risk focused, which explains why there may have been more focus in actions on parents and carers. 5.17 Adult focus generally will be examined in more detail later. The new model of working will also be discussed. 11 5.18 The work conducted to fully understand the lived experience of all the children by lead professionals whilst the children remained at home was impacted by sickness and changes in personnel. There were substantial gaps in contact with the children and adults in the family by children’s social care. The Families in Need service (explained earlier) did undertake visits to the family which included seeing the children but it is unclear if significant liaison took place between families in need workers and children’s social care over what was being observed. It was positive to note that several case notes were entered by FIN practitioners. Both FIN and children’s social care use the same recording system but case discussion between involved practitioners should still have occurred. 5.19 A review6 from the same local area in 2021, and many other reviews, highlight the importance of building and maintaining trusting partnerships with families. This is crucial when parents or carers have unstable emotional health or face other challenges. A trusting relationship is more likely to be developed when workers are involved long term especially in complex cases. Stability and routine was lacking in most areas of the children’s lives therefore a permanent worker for the case may have enabled trust to be established and as a consequence a greater understanding of the children’s experiences within the family. Frequent changes in worker allocation should be minimised, whenever possible. 5.20 The position regarding staff sickness which impacted on the children’s social care response to the family was explained in detail to the Panel. During the timeframe of the review and when the children were on child protection plans two social workers allocated to the case and a manager were on sick leave for long periods. FIN family support workers continued involvement with the family during these times and children’s statutory child protection visits were undertaken by temporary agency staff. It is acknowledged that not all visits were recorded by the temporary staff on the children’s social care records. 5.21 Staffing changes and shortages across children’s social care and in other agencies were discussed at length with the Panel. There was acknowledgement that this was a local and national issue. The current position regarding staffing locally is discussed later. 5.22 On speaking to Mother and Father separately the Author heard they were confused and disappointed by the changes in workers allocated to the family. This also created an element of suspicion for them as to the reasoning behind some staff changes. Mother did speak positively about 6 Serious case review - Child CD, published February 2021 12 one social worker who she said she “got to know a bit better and who listened”. This was a practitioner involved before the start of the review timeframe. 5.23 Reference to a child’s behaviour being an indication of trauma they may have experienced was evident in observations made since the children were brought into care. Harper’s behaviour included her demonstrating a high- pitched scream regularly and for long periods, taking food and hiding food to gorge eat and presenting as frightened that food would be taken away. Chloe’s behaviour was described as similar to Harper’s with an additional extreme fear of water and bath times in particular. (ii) Responding to neglect 5.24 Neglect of the children was evident throughout the review timeframe, and before. It was clear from what Ava said when she did get chance to speak to professionals, that neglect was a factor in all of their lives. 5.25 The child protection plans applied to all four children after the September 2018 incidents were under the category of neglect which is positive that the cumulative risks for all children were acknowledged. 5.26 Professionals involved with the family over the first half of the timeframe did not see or report circumstances often traditionally seen as the first indicator in a family affected by neglect. The home conditions were not generally described as poor, apart from some safety issues and repairs which were required. The older children, Lucas and Ava who were seen quite regularly at school at that time were not described as neglected in their appearance. 5.27 Indicators of neglect for the children were linked more to emotional factors which included experience of living with domestic abuse, parental mental health issues and substance misuse, and the uncertainty and fear which will be continually present for children living in those settings. Lucas in his written feedback for the review said he didn’t like feeling scared (when living at home) and he didn’t like it when his mum (Mother) and Ava argued. 5.28 In addition, Lucas was noted to be often tired at school and Ava had caring responsibilities especially for Chloe and Harper, and at times for her parents. There had also been concerns from birth and before regarding the parents’ care of the younger children. A substantial quantity information was available in agency records for the period prior to the identified review timeframe relating to Chloe and Harper. 13 5.29 Neglect continues to be the main type of maltreatment recorded in official data on safeguarding and often, as in this case, it can lead to serious harm. In the Serious Case Review Analysis (2014-2017) referenced earlier, it was stated “neglect based cases are systemically difficult as sometimes there is not a 'single' index incident to focus the review upon” compared to physical abuse and sexual abuse cases. Neglect, as in this case impacts directly on children’s lives every day. 5.30 Responses to neglect can often focus on young children in the knowledge that neglect during a child’s early years will often lead to poor outcomes for those children as they grow up. Younger children are more vulnerable by reason of their age with no ability to look after themselves. This was evidenced when the youngest child (Chloe) was placed on a child protection plan at birth but the older children were seen as child in need level. Unusually, Harper who was still just an older baby at that time was also categorised as child in need. Whilst the decision was questionable for the older children, Ava and Lucas, the rationale for Harper as a baby herself not being seen by professionals as at similar risk to her younger baby sister is unexplained, apart from an apparent focus on the un-safe sleep concerns for Chloe as a newborn baby. Child protection processes are discussed later. 5.31 Adolescents living in situations of neglect may be particularly vulnerable to having their needs, and the risks they face, overlooked. For Ava, the more usual adolescent concerns now more identifiable to professionals such as going missing and being exploited were not known to be a key risk for her at that time. The emotional harm, which she was regularly experiencing at home was a significant risk, including to her transition to young adulthood, but this often went unnoticed possibly due in part to being less obvious than other concerns. 5.32 It is important to recognise that in the Ofsted 2018 inspection of the Council area’s children’s social care services, findings for the area meant that ‘many children were not having their needs responded to in the right way or at the right time’. Ofsted reported that ‘as a result, some children live in situations of chronic neglect for long periods of time. Their situations do not always improve and, for many, they deteriorate, resulting in poor outcomes and increased risk. For some children, the impact is serious, with children suffering additional harm that affects their health and development’. 5.33 The timeframe under review was the same period when Ofsted inspected local services and the children in this case did continue to live with neglect until the significant incident later in 2019 led to their removal. In the two months leading to the alleged injection of Harper and Chloe records show professionals noted several indicators of neglect, all whilst the children were on child protection plans for neglect. These included Ava’s school attendance declining and having no money 14 for the bus to school, Lucas upset at school but not saying why, Lucas requiring urgent dental extractions, Harper and Chloe looking “grubby with wet soggy nappies” and the parents reporting no money for nappies and food. In addition, the house was noted as cold and the parents admitted to using drugs at home. Both parents also experienced mental health crisis points during this time. 5.34 There was no evidence whilst conditions and circumstances deteriorated that neglect assessment tools were used to help identify the escalating risks. 5.35 In response to the Ofsted findings, and specifically relating to neglect, the local area has undertaken considerable work which is detailed in the area’s Neglect Strategy Implementation Plan. 5.36 The neglect strategy for the area was agreed in autumn 2019 and launched by the Safeguarding Children Partnership in March 2020. Within the strategy is a section which summarises the main impacts of neglect at each stage of a child’s development7 . 5.37 Action taken on the implementation plan includes training and awareness sessions delivered for ‘Recognising and Overcoming Child Neglect’, together with ongoing ‘Graded Care Profile 2’ (GCP2) training and Refresher training for GCP2. This is the agreed neglect assessment tool for the area. 5.38 Furthermore, specific training regarding identifying the six forms of neglect, the impact on children’s daily lived experience and responses was provided to 249 Children’s Services’ practitioners from February to September 2020. Further data was provided of training attendance from January 2020 to February 2021 with a total of 130 training sessions taking place within children’s services, totalling almost 2000 attendees. Much of the training related to practice issues relevant to this review including neglect, restorative practice, assessing brothers and sisters, outcome based planning, using analysis and critical thinking, and safety planning. As in many areas the training has continued to be delivered on a virtual basis during the Covid-19 national restrictions throughout 2020 and 2021. 5.39 Partner agencies have been supported regarding their identification and response to neglect and the expectations of each agency at different levels of the continuum of need, which includes the use of multi-agency assessment tools. It was suggested at the practitioners’ meeting the use of assessment tools which help to enable consistent identification of neglect continues to be area for development within the area. 7 Neglect strategy 27.09.2019/ includes Jan Horwath Child Neglect- Identification and assessment, 2007 15 5.40 The training data is positive in terms of uptake and as expected all activity on the neglect strategy implementation plan is subject to regular review which includes audit activity to scrutinise responses. The Principal Social Worker undertook a series of baseline neglect audits during late 2020 and has provided reflective feedback to involved practitioners. There is a plan for audit of five cases a month on an ongoing basis with feedback to both involved children’s services’ practitioners and multi-agency partners and with involvement with the individual family. The Author was told reports are provided to senior leaders and shared at a monthly Neglect Champion Group, consisting of service managers across children’s services. The themes of lessons learned from via these audits are now also being shared within the Safeguarding Children Partnership. 5.41 Another local review for the same area published in spring 2021 has a focus on the neglect of three children8. Action relating to the concerns about neglect for these three children was provided by the same local agencies as for Ava, Lucas, Harper and Chloe. Neglect in the other case for the three children may have been more obvious in terms of their living conditions and presentation but similarities are evident in the responses by professionals in terms of action taken and the ‘naming of neglect’ as a concern in its own right. 5.42 A recommendation was made that when the Local Safeguarding Children Partnership disseminates the learning from the R, N and A children review, “the opportunity is taken to highlight the response to neglect in (that) case and further embed the Council Area’s Neglect Strategy and the use of Graded Profile 2”. 5.43 Findings for the review of Ava, Lucas, Harper and Chloe would reinforce the need for the recommendation detailed above in the R, N and A children review. 5.44 Performance data regarding child protection processes shared with the Panel indicated that identification and responses to neglect was now more effective in the local area. However, there may be a need for more information around evidencing the positive impact of early help processes relating to neglect and its early identification. 5.4.1 Recommendation 1 The Children’s Safeguarding Assurance Partnership should examine the current position relating to neglect in the local area including analysis of data across the continuum of need, examination of audit findings and other relevant performance information to reaffirm the Partnership’s responsibility and priority to respond more effectively to children and families believed to be 8 Local CSPR- Ryan, Nathan and Amelia, May 2021 16 affected by neglect, including specific attention to the position for young carers and the delivery of the early help offer across the local area. (iii) Processes – Child Protection/ Public Law Outline (PLO)/ Placements 5.45 The decision was made by the Panel that the processes relating to child protection conferences, Public Law Outline and short term placements would be the focus of the review as these were the key process related elements of the case with most relevance to what had happened for the children. 5.46 The children were subjects of child protection processes for the majority of the review time frame leading to the significant incident in late 2019. All were placed on child protection plans in autumn 2018. 5.47 A revised model for child protection conferences, in accordance with the area’s principles from the new model of working, was introduced in early 2020. Professionals in conferences are expected to work with families to help them understand the concerns that they have. Joint plans are developed to build on existing strengths and support parents make the changes that are needed to keep their children safe. A new partners' report to conferences has been launched which enables professionals to structure their information in the same way that it will be presented in the conference. The new model for child protection conferences is enhanced by a revised children and family assessment tool, a child protection plan outline template, and a core group recording template. 5.48 The revised core group meeting template ensures all core group members are recorded. Therefore as in this case where absence of allocated social workers impacted on some core groups, in the future in the eventuality of the allocated social worker being off work unwell, their manager and another social worker would be able to identify key core group members as active involvements in a child’s plan. 5.49 Examination of records associated with the child protection plans of the four children from late 2018 show core groups were mostly held regularly with multi disciplinary engagement but on three occasions were not attended by a social worker. It was said at that time there was a high turnover and change amongst conference chairs in the area which made it difficult to escalate issues from core groups such as non attendance or concerns relating to lack of progress. The current experience at core groups, as outlined above, was described as improved by some attendees at the review’s practitioners’ meeting. 17 5.50 According to some participants at the practitioners’ meeting held in January 2021 the new model for child protection conferencing was working well but had been impacted to an extent by Covid 19 restrictions and virtual working arrangements. At the time of the review it was said the use of advocates was being embedded to assist children’s involvement but wasn’t able to be utilised in this case. 5.51 Voice of the child was included in the first conference during the review timeframe. It was reported that Lucas said he has been scared when his mother was shouting at his sister. He said that he had been late for school because he has been looking after his baby sisters. Information was also shared that he was upset when his mother has said things and he had been increasingly saying he has stomach-ache and is feeling unwell. He has been weepy and upset in school. The views of Ava were also represented. 5.52 There was limited input from the children in the review conference in January 2019. Lucas was not wanting to speak to the social worker. Ava was “wanting to stay at her aunt’s” (where she had been living). 5.53 At the second review conference in July 2019 the notes state no children had completed the conference pack. It was recorded Ava had given brief feedback that she is happy to be back home but wants to be left alone. Ava had returned home from staying with her aunt at this point. Lucas had said he is happy in his new home and likes playing football – he is glad that his dad is back (Father had been in prison). 5.54 It is positive that the parents attended and contributed to all three conferences (except the second review conference when Mother attended alone). In feedback to the Author both parents separately shared the view that there seemed confusion in meetings between the different fathers of the children as all three fathers coincidentally had the same first name. Mother was open about being a survivor of domestic abuse by one of the men but said professionals complicated that male with her current partner (Father) who she claimed had not been abusive towards her. Father gave the same account. 5.55 After the first review conference a further assessment was completed in February 2019. The assessment explored the needs of the children and the impact of parental substance use upon them, recommending the possible issuing of legal proceedings. 18 5.56 A care planning meeting took place in early March with the decision that the children were to remain with the parents. Agreement for Public Law Outline process (PLO)9 followed soon after with an initial PLO meeting held mid April 2019 where the schedule of expectations was signed by Mother. A review PLO meeting was held in early July 2019 but apart from Father signing the schedule of expectations in August 2019 after release from prison no further activity occurred relating to the legal process until the urgent care proceeding in early December 2019. PLO should not go on longer than 16 weeks. 5.57 In the Ofsted inspection of the local children’s social care services (2018) an area of improvement was the oversight of pre-proceedings work and placement- with- parent practice to address drift and delay. In response, a review of cases where families were subject to PLO processes was undertaken to address concerns about risk, drift and management oversight. 5.58 In the summer 2019 a newly appointed senior leadership in children’s services established management oversight panels, one of which tracked children subject of PLO pre-proceedings. The weekly panel chaired by the assistant director reviews all children subject of pre proceedings with the allocated team manager and service manager, to ensure any drift is identified at the earliest opportunity, tracked and addressed. A revised PLO procedure and associated documentation was launched in October 2020. 5.59 Recently published Best practice guidance: Support for and work with families prior to court proceedings March 2021, Public Law Working Group suggests that “the purpose of the PLO pre proceedings process is to be a genuine opportunity to work closely with families by offering help and support to address their recognised needs in a bid to negate the need to issue care proceedings”. Whilst there was little evidence that such work took place with the family in this case improved management of pre proceedings in the local area is said to be now in place. It should be an aspiration that the wishes and feelings of children who are subject to pre proceedings will be prioritised as an integral part of the process in order that thoughts about their own future can be properly considered. 5.60 Discussion at the practitioners’ meeting regarding PLO processes indicated there was some lack of understanding and awareness of the general process and requirements. Despite PLO being local authority driven it was suggested it would be useful for a short briefing to be developed to explain the purpose and function of PLO pre-proceedings to wider partners in order that there is a 9 The Public Law Outline (PLO) sets out the duties that local authorities have when taking a case to court 19 better understanding of a process which sadly becomes integral to many safeguarding cases in which partners are involved. 5.61 Recommendation 2 The Director of Children’s Services in the local area should provide assurance to the Children’s Safeguarding Assurance Partnership that PLO processes are being conducted in a timely way and any delays and risks are addressed immediately. 5.62 Recommendation 3 The Children’s Safeguarding Assurance Partnership should consider opportunities to ensure a partnership approach is the aspiration in supporting families involved in PLO proceedings and related matters, including raising the awareness of professionals about the process, timescales and responsibilities. 5.63 On several occasions in the review time frame and at times in the past the children were often placed in Maternal Grandmother’s care for short periods of time including overnight stays. The reasons were mainly due to crisis points for the parents when the children needed to be accommodated elsewhere. 5.64 Maternal Grandmother (MGM) was never formally assessed as a suitable carer to look after Chloe, Harper, Lucas and Ava. Whilst there is no suggestion of harm being caused to the children by MGM there is information to indicate that she faced challenges of her own in terms of her own mental wellbeing and alleged use of illegal substances. Information gathered as part of the review highlighted safety and space issues at MGM’s address where the children went to stay, particularly regarding sleep settings for the youngest two children. Additionally, the relationship between MGM, Mother (MGM’s daughter) and Father was often volatile leading to the children being removed from MGM’s care by the parents unannounced despite a short term placement having been agreed. 5.65 The impact of the MGM placement on the children’s emotional wellbeing in terms of the lack of stability and at times them witnessing hostile behaviour between adults over whether they should stay there would have been detrimental. Ava had disclosed after the domestic abuse incident in autumn 2018 witnessing Mother and MGM arguing over Mother’s refusal to allow Chloe and Harper to stay with MGM whilst agreeing that Ava and Lucas could go. 5.66 It is important to note that during the review’s timeframe all four children were mostly on child protection plans for neglect when attempts were ongoing to resolve the complications of 20 where they should stay after a crisis episode had occurred. The emotional impact of the uncertainty will have added to the trauma which all of the children were known to have experienced. 5.67 Records showed concerns were expressed by MGM herself regarding her capacity to care for all the children together due to her own physical and mental health. Other history known to services about MGM’s capacity to parent and additional support she might need was never properly explored. 5.68 Circumstances which arise when children need emergency short term accommodation are a challenge to manage, often occurring out of hours and in stressful situations. However, a priority should remain that the safety and welfare of the children involved is the most important consideration. From records available for the timeframe of the review there is limited evidence that MGM was assessed as being able to provide appropriate temporary care for the children. Furthermore, apart from provision of some basic equipment to help MGM look after her grandchildren in her own home there is little note of what other support she herself was offered whilst undertaking the role of family carer. 5.69 It was noted that when children's social care is required to find a short term placement it is rare for them to enquire into the health records of the person being considered as the short term placement carer. Police held information and intelligence is often known about the carer but relevant health issues are mostly unchecked, as in this case. 5.70 In the local area’s Social Work and Safeguarding Service Procedures Manual there is a chapter on Family and Friends Care (3.4). The local authority does have a general duty to assess all arrangements where children are living with their wider family or friends’ network where it appears that services may be necessary to safeguard or promote the welfare of a Child in Need (which was the position for Ava, Lucas, Harper and Chloe who were all on child protection plans so met the threshold of need). 5.71 Within the chapter, also referenced is the Initial Family and Friends Care Assessment: A good practice guide developed by Family Rights Group in partnership with an expert working group, February 201710. 10 The guide is a response to the lack of any minimum standards as to how such assessments, commonly called viability assessments, are conducted. Viability assessment are often used by local authorities to decide whether a family member or friend might be a potentially realistic option to raise a child who cannot live safely with their parents. 21 5.72 In the local area the foster service now has a connected carers team. This team undertake the full connected carer assessment11 and has a process in place to track and monitor all progressions of assessments being undertaken. The assessment tool has been revised and is a comprehensive report, including a police national computer check and questions about the health of the family member (the proposed carer). In emergency situations an initial viability assessment considers the suitability of a family member. 5.73 In many areas the need for short term placements to be arranged quickly may be a recurring issue. However, the urgent task of finding children somewhere to stay should not lose sight of the need to ensure the placement is assessed as safe, is in a child’s best interests, and for children old enough to communicate an opinion on their care to be consulted. 5.74 The Panel discussed opportunities for contingency planning for children in terms of involving families and children in discussions in advance regarding their preference for a short term placement should an emergency need arise. The Author was told that work is already underway in the local area to update genograms for families and develop safety plans which are accessible to emergency duty team staff. This was not considered as setting up families to fail by expecting a crisis to occur but being prepared to respond to any emergency, including a sudden illness. 5.75 Recommendation 4 The Children’s Safeguarding Assurance Partnership should require a multi agency audit to be undertaken of the content and quality of genograms and safety plans for families to ensure relevant information is on record with appropriate assessments completed to inform decisions for emergency short term placements. (iv) Adult services’ work with parents and incorporating a “Think Family” approach 5.76 From the wealth of information available for the timeframe of the review, and for significant events before, the involvement of predominantly adult facing services with the family was considerable. 5.77 Professionals from a range of different adult services were regularly seeing Mother and Father. Police involvement was usually at times of crisis with officers taking appropriate action. 11 Regulation 24 of the Care Planning, Placement and Case Review (England) Regulations 2010, effective from April 2011, relates to immediate placements of children with relatives and friends not previously approved as foster carers. 22 Services working with the parents longer term included the substance misuse team and probation (the community rehabilitation company). Domestic abuse support services did try to offer support to Mother after the incident at the beginning of the timeframe. 5.78 Both parents also accessed support for their own health needs including from the GP and mental health services. 5.79 Involved professionals from some of these services were able to contribute to the practitioners’ meeting. 5.80 The overriding sense from the adult facing professionals was that there was an understanding of the need to be aware of the children of Mother and Father when working with them as adults. This was evident in conversations which took place in the practitioners’ meeting. Professionals had differing levels of awareness and experience of safeguarding children requirements but all appeared aware of the importance of trying to respond to any concerns presented during their work with the parents. 5.81 A challenge raised was high workload which is a common issue within all organisations. Adult workers, an example being drug support services were managing very large caseloads meaning core business in seeing adults allocated to their case list was a priority. Any additional work, for example regarding children, generated as a result of supporting adults was followed up but there was very little free work time to devote to such tasks. When problems occurred in trying to call to update multi agency colleagues by phone to share information, frustration was a feature due to time pressures. Multi agency working and communication is discussed below. 5.82 The engagement of adult facing services in the child protection processes ongoing through most of the timeframe was generally good. Professionals attended conferences and core groups which demonstrates the commitment and focus from adult workers involved in this case to the safeguarding of the four children. Records show many professionals including adult focused workers did try to raise concerns about the children at core groups. 5.83 Specific good practice to highlight from records was the involvement of the CRC probation officer who undertook several home visits enabling her to observe and record relevant information about the children in conjunction with her work with the parent. There was evidence of numerous calls between the CRC officer and other involved multi agency partners when the position for the children as well as the adults was discussed. 23 5.84 The substance misuse support worker also demonstrated positive wider thinking in terms of the children by noting on a home visit that “the house was cold and that Ava was upstairs looking after the younger children”. 5.85 The adults in the case did sometimes fail to attend appointments but they also did seek out services for themselves. At GP appointments and with other professionals Mother in particular, appeared to be open about her own challenges, for example her drug use, including how and when she was using. The impact of this on the children through the timeframe was sometimes but not always considered. The GP did make a referral to children’s social care in spring 2019 after Mother admitted using heroin. The CRC practitioner also tried to share conversations between CRC and Mother when Mother admitted to regular drug use at home. See below reference to communication. 5.86 A lack of detailed knowledge of illegal drugs, their impact and other drug related awareness linked to safeguarding children (and adults) was highlighted in the practitioners’ meeting by some attendees. There was an assumption it seemed that all professionals, when working in a locality where drug use was thought to be common, had a sound knowledge of drug related information to inform their own work but this was not the case, apart from for specialist workers. An example was given that most GPs would not have additional specialist knowledge relating to illegal substances and its impact on children. Whilst many GP practices now have safeguarding leads the wider awareness of specific drug related issues was generally not available. 5.87 Addiction, as in this case, is often likely to impact on a parent’s capacity to prioritise the children’s needs and general family functioning. Furthermore, addiction can impact on the adult’s risk taking behaviours, such as drug seeking behaviour and sometimes criminal activity to ensure their addiction is fed. 5.88 An opportunity for learning more about drugs, addiction and other safeguarding related issues in a multi agency forum would be a useful exercise to equip more professionals working across children and adult services with more confidence and awareness to respond more effectively to families where drug use is a serious concern. The Author was told that similar training had occurred in the past but capacity to facilitate the training on top had become a challenge. 5.89 Recommendation 5 Public Health on considering the findings of the review should revisit the public health substance misuse service commissioning arrangements to re-implement the provision of training by the provider to the multi-agency workforce to ensure a broader confidence and knowledge base exists 24 across the partnership for professionals working with families significantly affected by substance misuse. 5.90 Regarding neglect as the main area of concern for the children in this review, within the report from the Ofsted joint targeted area inspection programme July 2018, Growing up neglected: a multi-agency response to older children there is a reference relevant to all four children in the case, not just the older two: 5.91 “For services to be effective in identifying the neglect of (older) children, there needs to be a whole-system approach. This includes adult services that work with parents where professionals are well placed to identify risks parents may pose to children because of adult mental ill-health, substance misuse or offending behaviour”. For Ava, Lucas, Harper and Chloe many professionals were in that place to see risks as a result of their work with the parents. What they do with concerns about children identified through their work with adults is a key point; systems for obtaining professional advice, sharing information and making referrals should be as simple as possible to ensure risks are shared and not lost. 5.92 There should also be wide promotion of escalation processes should the appropriate response not be received when information has been shared between services. This will ensure professional challenge is recorded and hopefully resolved. 5.93 The ability of adult facing workers to identify children’s safeguarding issues (and vice versa) does to an extent depend on how well individual practitioners understand the need to look wider than their specific area of work. ‘Safeguarding is everyone’s business’ has been a well- used slogan across safeguarding strategic partnerships for a number of years but should perhaps now evolve into ‘Safeguarding everyone is everyone’s business’. 5.94 A more joined up approach to safeguarding is the aspiration of many local safeguarding children partnerships and safeguarding adult boards. In the local area there is collaboration in terms of there being one business unit for the children’s partnership and the three safeguarding adult boards and progress is being made for a more all age approach, an example being for contextual safeguarding. 5.95 The action plan implementation group in response to the 2018 Ofsted inspection of local children’s social care services includes membership of adult facing services and health providers who cover the whole age range. Therefore, service provision from an adult perspective and how this links and supports children’s safeguarding should be considered. 25 (v) Multi-agency working and communication 5.96 There was positive multi agency engagement in the case as evidenced in analysis of available records and in the information shared for the timeframe of the review. As highlighted earlier, professionals representing all agencies involved in the case attended the strategy meeting, child protection conferences and reviews, and core groups. 5.97 A challenge in complex cases with numerous professionals involved is the amount of people that families are requested to see and respond to. This must feel more difficult for children when many different people are attending their home. Both Ava and Lucas in being asked to participate in the review said they did not want to talk to another person about what had happened. Ava and Lucas throughout the timeframe saw numerous professionals from several agencies and at times were expected to answer questions from people who they possibly saw as strangers. The professionals with long term involvement with the older children were from school, which is common in most cases. Fortunately, school staff were an integral part to the child protection processes which occurred throughout 2018 to 2019. Lucas in his feedback via the foster carer for the review said the school advisor gave him the best help. 5.98 The younger two children may not have been of an age to articulate their thoughts but seeing numerous different adults in their home, would be challenging for any small child and especially for a child who had had the additional experience of living at times in an unstable and volatile environment. 5.99 Joint visits were not a regular occurrence despite being suggested as a possible route into the family, for example discussion took place between the IDVA and social worker but a visit dd not take place. School designated safeguarding leads did visit jointly with the educational welfare team. School staff also attended with a FIN practitioner to follow up on school absence. 5.100 Sometimes Mother and Father were not responsive to visits or appointments. They reported themselves that they “did not take kindly to most professionals”. In families when professional relationships are sometimes strained practitioners should try to be creative in planning opportunities to visit, joining up with other disciplines where possible. The younger children were being seen by health visitors as routine which could have been a chance to try to link visits if properly explained to the family. It was noted at the strategy meeting in autumn 2018 that Mother had a good relationship with her then health visitor, which was seen as unusual for Mother who rarely engaged positively, possibly due to years of her own adverse experiences. Circumstances such as that, however uncommon, should be used to try to develop other sound working relationships. 26 5.101 The most challenging relationship described by both Mother and Father was with children’s social care which is not unusual or unexpected in cases where involvement has been longstanding and complex. There was a complete lack of trust from the parents with children’s social care staff, not helped by the turnover and sickness of practitioners involved with the case. 5.102 It is not evident from the review timeline how often temporary agency workers covered the statutory responsibilities for the children as the visits and core groups undertaken by agency staff do not appear to have been fully recorded. Core groups and recent developments were discussed earlier. 5.103 Regarding management oversight of the case the team manager was very new in the social care team manager role. The strengthening and supporting families (SSF) service which at the time had responsibility for children supported by longer term child in need plans, child protection plans, PLO and care proceedings had management vacancies at all levels. The SSF service during the timescale reviewed was predominantly overseen by one service manager, which would have been a challenging context for any individual to manage. Recruitment to all roles within the SSF service, including for experienced social workers was said to be a difficult at the time. 5.104 Significant attempts have been undertaken to recruit to roles within the specific area of children’s services with targeted recruitment under regular review. Attractive benefits have been agreed for new staff which include pioneering new ways of working. 5.105 Additional leadership roles in SSF were appointed to by late summer 2020 and core responsibilities for the SSF have been adjusted12. The staff sickness rate has significantly improved, all of which has positively impacted on performance especially regarding statutory visit timeliness and core groups being undertaken in accordance with expected practice standards. These were issues at times for the case under review. 5.106 The new model of working in the local area (mentioned above) states “understanding how children and families want us to work with them is fundamental to forming effective working relationships and supporting families to keep children safe”. 13 The opportunity for children and 12 During 2019 the SSF service had responsibility for supporting children via Child In Need Plans, Child Protection Plans, Pre-Proceedings PLO and Care Proceedings. A decision was made to move the responsibility for supporting children during care proceedings to the Supporting Our Children Service (SOC). In April ‘20 all children who had care proceedings commenced became allocated to the SOC Service at the Initial Hearing, with the SSF service remaining responsible for completing all the children’s Care Proceedings which had commenced prior to this date. 13 This uses the ‘Heads, Hearts, Hands’ model of social pedagogy and is not based on the needs of agencies and practitioners. 27 families to feedback on their experience of the new model of working is featured in the implementation plan. 5.107 Partner agencies are said to have agreed that the new local model of working should underpin how children are worked with at all levels of need. This includes the changes to formal processes mentioned earlier to support the model, including how child protection conferences and plans are facilitated. At the practitioners’ meeting for the review some frontline professionals outside of children’s social care had limited knowledge of the new model, by its name or by their recent experience. Others were encouraged by their experience of the model’s different way of working and impact on child protection conferences in particular. 5.108 It was confirmed a multi agency implementation group has helped with communication about changes and expectations across the whole partnership therefore any gaps in awareness of the new model should be small. 5.109 A video and other promotional material about the model is available and in use across the local area. 5.110 Regarding multi agency communication between professionals, conversations did take place between partners about the children and adults within the immediate family, and about MGM. Examples include the contacts between the substance misuse service with the CRC. FIN staff did try to communicate with involved partners but they did not hold social work responsibility for the children. 5.111 Some professionals reported difficulties in communicating with children’s social care, including speaking to the named worker by phone or email. Contacts went unreturned. Mother and Father both said children’s social care rarely responded to their calls. 5.112 Other challenges in multi agency communication were reported when partners were trying to report new concerns for the children, for example Lucas’ school reporting Father in attendance at school whilst appearing drunk and when the GP referred Mother admitting to using heroin. Partners said they were unclear if concerns had been received and what action had been taken. There is evidence to show that these concerns were on record. 5.113 When the information about the significant incident (the allegation about the younger children being injected) was shared in late 2019 the initial information was received by the business support service for the SSF service. This was due to the children being allocated to the SSF service at this time. The business support staff member emailed the message to the social worker allocated for the children not knowing the social worker was on sick leave, hence the delay in the concern being 28 addressed. The email was not copied to the social worker’s team manager or a duty social worker for the team. 5.114 A review was undertaken regarding the incident and a new process has been put in place by the SSF service manager and lead for the business service. When telephone calls are received by business support service resulting in email messages being sent to a social worker, an email is also copied to their team manager. Additionally, when a member of staff reports going off sick from work, the IT service is contacted to put an ‘out of office’ reply on their email account. This ensures that people emailing a particular social worker are aware the social worker will not be accessing the email and there will be no response from the worker. 5.115 An essential question to remember for all professionals supporting families, however large or small their part may be in the multi agency response, is what is life like for the children living in these circumstances? This focus should be a question that professionals from different disciplines regularly ask themselves and each other when trying to support families including whenever multi agency communication opportunities take place or when communication is difficult. This did not always happen in the case of Ava, Lucas, Harper and Chloe. 5.116 Multi-agency supervision for complex families, such as in this case would enable all professionals working with a family to come together to discuss the risks, roles and responsibilities and the lived experience of children including what the children may have said or what their behaviour demonstrates. It would also provide an opportunity for respectful challenge to occur as necessary relating to the support being offered to families and any drift occurring across services. In short, such a process must be expected to improve multi agency working and communication. 5.117 The Author was told this type of partnership supervision is part of the local area’s child protection standards pathway, but the criteria currently is when a child’s protection plan has been in place for 12 months. 5.118 Recommendation 6 The Children's Safeguarding Assurance Partnership should promote the use of the Resolving Professional Disagreements protocol and the role of the child protection conference chair as a point of reference for any professional who is concerned about the progress of a child protection plan. 29 (vi) De-sensitisation and professional culture 5.119 The existence of neglect within the family and in particular for the children is clear, throughout the entire review timeframe. The local area is known for its deprivation with several families living with poverty14. Previous research has identified that some professionals working with families living in areas of high deprivation come to accept lower standards (Brandon et al, 2014 / Jack and Gill 2003). 5.120 Professionals become ‘accustomed to working in areas with large numbers of children and high deprivation. As a result, there may be a normalisation and desensitisation to the warning signs of neglect’, Complexity and challenge: a triennial analysis of SCRs 2014-2017, Marian Brandon, Peter Sidebotham et al March 2020. “Poverty blindness” may occur where professionals are working in these types of areas. 5.121 However, in this case the associated desensitisation to warning signs such as poor hygiene and poor home conditions may have run concurrently with desensitisation to substance misuse and its impact on families, lack of emotional warmth and a general stability for children. Professionals may regularly see families living in these environments and facing similar challenges but that should not become the expectation which then becomes the norm. 5.122 The focus on children and their life experience must remain at the core of all work with families. Professionals should challenge themselves and each other with the question would this be good enough for my own child? Lower standards and aspirations for some children should not be seen as acceptable. 5.123 Recommendation 7 The Children’s Safeguarding Assurance Partnership must ensure that all multi agency training programmes reference the need for professionals to be alert to desensitisation when working routinely with high levels of need, providing opportunities within training for professionals to focus on desensitisation and the impact this may have on the children and families receiving support. 5.124 The timeframe of this review was a period when considerable pressure existed for the local children’s services department in terms of performance which unsurprisingly impacted to some degree across the whole partnership. Whether this had a direct impact on professional culture, and consequentially, services provided to families is not known. The sense of hope and commitment for 14 Over a quarter of children under 16 were known to be living in poverty in 2016 30 a joined up professional culture amongst the attendees at the practitioners meeting for the review, and within the Panel was clear. The new model of working fully implemented and embedded across the whole partnership area should encourage a shared professional culture which in turn should be better for children and families needing support. 5.125 Complexity and challenge, March 2020 states “the professional culture within an individual organisation and its wider partnership was repeatedly noted as a significant influence on making a difference and delivering impact from reviews (such as this) and their recommendations”. 5.126 Working together in partnership and recognising shared responsibilities will be more effective when there is a shared understanding of roles, professional culture and expectations. The local safeguarding adults board and safeguarding children partnership should continue their endeavours in linking work streams and priorities where possible to encourage a stronger commitment to wider safeguarding. 5.127 Towards the conclusion of the review regarding these four children the local council area received positive findings of a final assessment of children’s social care. The judgement should hopefully bring some stability to those working within the department and those working in partnership, which should translate positively into the services delivered to children and families in the area. A focused visit took place in February 2021 with developments continuing to be addressed. 6. Conclusion/ What needs to happen 6.1 Examination of what happened in the lives of the four children and their family has highlighted the environment of significant neglect in which they lived. The brief feedback available from the children, helps to show what life was like for them and that for much of the time they were, as Lucas said scared and confused. 6.2 Despite some individual professionals recognising the unacceptable lived experience for the children the multi disciplinary processes which occurred did not routinely help to ensure that the children’s situation improved. The children did not always remain the key focus when decisions were being made and when services were delivered. The complex and cumulative nature of neglect for these children was a constant challenge for professionals and organisational circumstances locally at the time meant that some responses were not effective and delays occurred. 6.3 On speaking to the parents, the Author sensed a desire from them both to parent well, but there was a lack of ability to do so due to their own conflicting needs and how they felt about the 31 support they were offered. The new model of working within the area is based on relational practice which should help to improve how families are supported. 6.4 This review examined key themes and areas of practice impacting on the lives the children based on their experiences during a specific timeframe. Recommendations have been made for the Children’s Safeguarding Assurance Partnership to consider as a result of analysis of what happened in the case. 6.5 By trying to keep the children at the centre of the review, child focus and the child’s voice was the thread running through all lines of enquiry. However, constant reference to the voice of the children being gathered, has highlighted the question about what difference is made when this happens (“so what?”) Even when we listen to children and observe their lived experience it is what professionals do individually and as a collective with the concerns that have been spoken about or observed. If opportunities are not taken to act on what is seen or heard taking note of what is happening in the lives of children will be just that. Extensive records, as in this case, will become larger but proactive responses and positive outcomes must also be the aim. 6.6 The Children’s Safeguarding Assurance Partnership must ensure wide circulation of the findings of this review to ensure all professionals and agencies have an opportunity to reflect on the experiences of the children and what needs to change as a result. 7. Recommendations 7.1 The Children’s Safeguarding Assurance Partnership should examine the current position relating to neglect in the local area including analysis of data across the continuum of need, examination of audit findings and other relevant performance information to reaffirm the Partnership’s responsibility and priority to respond more effectively to children and families believed to be affected by neglect, including specific attention to the position for young carers and the delivery of the early help offer across the local area. 7.2 The Director of Children’s Services in the local area should provide assurance to the Children’s Safeguarding Assurance Partnership that PLO processes are being conducted in a timely way and any delays and risks are addressed immediately. 7.3 The Children’s Safeguarding Assurance Partnership should consider opportunities to ensure a partnership approach is the aspiration in supporting families involved in PLO proceedings and 32 related matters, including raising the awareness of professionals about the process, timescales and responsibilities. 7.4 The Children’s Safeguarding Assurance Partnership should require a multi agency audit to be undertaken of the content and quality of genograms and safety plans for families to ensure relevant information is on record with appropriate assessments completed to inform decisions for emergency short term placements. 7.5 Public Health on considering the findings of the review should revisit the public health substance misuse service commissioning arrangements to re-implement the provision of training by the provider to the multi-agency workforce to ensure a broader confidence and knowledge base exists across the partnership for professionals working with families significantly affected by substance misuse. 7.6 The Children's Safeguarding Assurance Partnership should promote the use of the Resolving Professional Disagreements protocol and the role of the child protection conference chair as a point of reference for any professional who is concerned about the progress of a child protection plan. 7.7 The Children’s Safeguarding Assurance Partnership must ensure that all multi agency training programmes reference the need for professionals to be alert to desensitisation when working routinely with high levels of need, providing opportunities within training for professionals to focus on desensitisation and the impact this may have on the children and families receiving support. 33 8. References • Working Together to Safeguard Children, July 2018 • The Local Area’s Neglect Strategy 2019 • Local Safeguarding Partnership 7 minute briefing - Voice of the Child (2019) • Complexity and Challenge: a triennial analysis of SCRs 2014-2017, Marian Brandon, Peter Sidebotham et al, March 2020 • Local Serious Case Review- Child CD, February 2021 • Ofsted inspection of the Council area’s children’s social care services, 2018 • Child Neglect- Identification and assessment, Jan Horwath, 2007 • The Local Area’s Neglect Strategy Implementation Plan, 2019 • Local Child Safeguarding Practice Review- Children Ryan, Nathan and Amelia, May 2021 • Best practice guidance: Support for and work with families prior to court proceedings, Public Law Working Group, March 2021 • The Local Area’s Social Work and Safeguarding Service Procedures Manual, Chapter 3.4 • Initial Family and Friends Care Assessment: A good practice guide developed by Family Rights Group in partnership with an expert working group, February 2017 • Growing up neglected: a multi-agency response to older children, Ofsted joint targeted area inspection programme July 2018 34 9. Appendix A 9.1 Purpose of child safeguarding practice reviews, Working Together 2018 9.1.1 The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policy makers. 9.1.2 Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose. 9.1.3 Serious child safeguarding cases are those in which: • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed. 9.1.4 Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health. This is not an exhaustive list. When making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred. 9.1.5 16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) states: Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if – (a) the child dies or is seriously harmed in the local authority’s area, or (b) while normally resident in the local authority’s area, the child dies or is seriously harmed outside England. 9.1.6 Safeguarding partners must make arrangements to identify serious child safeguarding cases which raise issues of importance in relation to the area and commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken. 9.1.7 When a serious incident becomes known to the safeguarding partners, they must consider whether the case meets the criteria for a local review. 9.1.8 The criteria which the local safeguarding partners must take into account include whether the case: 35 • highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified • highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children • highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children • is one which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate. Safeguarding partners should also have regard to the following circumstances: • where the safeguarding partners have cause for concern about the actions of a single agency • where there has been no agency involvement and this gives the safeguarding partners cause for concern • where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around • where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings. 36 10.0 Appendix B 10.1 Panel Membership Head of Cluster (Chair) National Probation Service Safeguarding Practitioner Clinical Commissioning Group Named GP for Safeguarding Clinical Commissioning Group Head of Safeguarding and Principal Social Worker Local Authority Children’s Services Schools’ Safeguarding Advisor Local Authority Early Years Service Manager Local Authority Review Officer Police Deputy Head of Safeguarding Acute Hospital Trust/ 0 – 19 community health provider Safeguarding Practitioner Acute Hospital Trust/ 0 – 19 community health provider Deputy Director Community Rehabilitation Company Safeguarding Manager Adult substance misuse service provider Service Manager NSPCC |
NC52713 | Thematic review focusing on two families where adults had significant vulnerabilities, including a history of abuse and neglect in their own childhoods, previous relationships where domestic abuse featured, mental health issues and substance misuse. Learning includes: systems must enable the impact of a parent's vulnerabilities and associated risks to be understood by all professionals working with the family; professionals require support when trying to work with resistant and hard to engage families who do not acknowledge professional concerns and refuse to 'own' a child protection plan; when the concerns or allegations do not meet the threshold for criminal charges, formal multi-agency consideration should be given to why this is and to the potential need to safeguard the child and/or their siblings; professionals need to understand the ongoing and reoccurring nature of domestic abuse and parental mental health issues to fully appreciate the impact on children; there is cumulative risk of harm to a child when parental and environmental risk factors are present in combination or over periods of time; as children approach adulthood, those who are known to be vulnerable, particularly those that are on a child protection or child in need plan, require on-going and focused multi-agency support with a clear plan; and COVID-19 had an impact on the families and the professional response. Recommendation is embedded in the learning.
| Title: Local child safeguarding practice review: thematic review. LSCB: East Sussex Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. V8 Sept 2022 1 Local Child Safeguarding Practice Review Thematic Review September 2022 V8 Sept 2022 2 Contents 1. Introduction page 2 2. Process page 2 3. Learning page 3 4. Recommendations page 15 1 Introduction 1.1 The East Sussex Safeguarding Children Partnership (ESSCP) agreed to undertake a Child Safeguarding Practice Review (CSPR) by considering two cases where serious incidents occurred1 following long-term concerns about domestic abuse, alongside other child safeguarding issues. 1.2 Family A. Where a young adult stabbed his mother’s partner following a domestic abuse incident between the couple. A younger sibling was at home at the time. The family were known to partner agencies due to concerns about long-term domestic abuse, parental mental health issues, violence, and substance misuse. 1.3 Family B. Where the mother’s partner attacked the children’s mother with a hammer. A 13-year-old child, one of two living at home, sustained an injury during the assault and the perpetrator tried to hang himself in the home. The family were known to partner agencies due to long term domestic abuse, parental mental health issues and neglect. An older child who is in care had made allegations of historic sexual abuse from the mother’s partner. 1.4 It was agreed that both cases should be considered in this review due to similarities. In both families the adults had significant vulnerabilities, including a history of abuse and neglect in their own childhoods, previous relationships where domestic abuse featured, mental health issues and substance misuse. Both families had older children who were estranged from them or no longer in their care. All the children were the subject of child protection plans. The serious nature of the incidents also resonated with decision makers as they both involved domestic abuse. 1.5 Learning has been identified from considering the professional involvement with both families in the following areas: • Knowing and considering a parent’s history and vulnerabilities • Working with hard to engage families who refuse to cooperate with child protection planning • Recognising the lack of an ongoing police response to an issue does not mean that a child is not at risk • The impact on children of reoccurring domestic abuse and parental mental health issues • Vulnerable children approaching adulthood • The impact of COVID-19 2 The Process 2.1 An independent lead reviewer was commissioned2 to work alongside local professionals to undertake the review. Information provided to the Rapid Review meetings was considered and 1 Both incidents occurred in 2021. The delay in completing the CSPR was due to the limited capacity of partner agencies due to other reviews and the on-going impact of COVID19. At the time of publication there are no on-going parallel proceedings. 2 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer and is entirely independent of the ESSCP. V8 Sept 2022 3 additional information was requested from individual agencies via chronologies which included the identification of single agency learning and any improvement actions that were required. 2.2 Professionals involved at the time were involved in group discussions about the cases and the wider system. Due to the on-going response to Covid-19, practitioner participation sessions were held in January 2022 using video technology. 2.3 The lead reviewer made many attempts to meet with both families, including Child A1, to identify any learning from their perspective. This was not successful. 3 Family composition3 3.1 The family members will be referred to in the report as follows: Family A Mother A Mother’s partner to be referred to as Stepfather A Child A1 - although they were aged 18 at the time of the incident, the majority of involvement was while they were a child. They went to a special school and have a history of mental health issues and substance misuse Child A2 – age 12 (all ages are at the time of the serious incident) Child A3 – 4 months old An older sibling who no longer lives at home will also be referred to Family B Mother B Mother’s partner to be referred to as Stepfather B Child B1 – age 13 Child B2 – age 11. This child has significant learning difficulties An older sibling who no longer lives at home will also be referred to 4 Learning from the review 4.1 When considering the information gained from the Rapid Review meetings, the detailed agency reflective chronologies and discussion with those involved at the time, the learning identified is as follows: Learning point 1: Systems must enable the impact of a parent’s vulnerabilities and associated risks to be understood by all professionals working with the family, who need to ensure that all available background and current information is accessed and considered when making plans for children. 4.2 Both cases were complex with multiple adult vulnerabilities that presented risks to the children over a considerable period of time. All of the adults had significant histories that were knowable to professionals involved with the children, even though in both cases there was resistance by the adults to engaging with services and a refusal to discuss their childhood and life experiences in any detail. Parents/carers who have had adverse childhood experiences and suffer with vulnerabilities due to their mental health, domestically abusive relationships, and substance4 or alcohol abuse, are more likely to have children who require a safeguarding response, and those involved with the 3Both families are white British and no specific learning regarding the professional response to their culture was identified during the review. 4 The term ‘substance misuse’ in this report is used to refer to illicit drugs, unless prescribed medication is specifically stated. V8 Sept 2022 4 families were aware that there were likely to be complex parental histories and vulnerabilities that had a significant impact on their children. 4.3 Mother A had been in domestically abusive relationships previously, resulting in CSC involvement. Her relationship with Stepfather A was abusive and in 2018 he received a custodial sentence for an assault, with Mother A not supporting the prosecution. She suffers with both mental and physical health concerns and was on medication, including strong painkillers, sleeping tablets and anti-depressants. There was no evidence she was using any non-prescribed drugs during her pregnancy with Child A3 but it is now known that she had been misusing heroin, along with her partner, prior to the serious incident and that the wider family were aware of this issue but did not share it with any professional. 4.4 Stepfather A grew up in a family where domestic abuse and alcohol misuse featured. He was well known to uniformed police officers in the area and had an extensive criminal record for violence and drug related offenses, including time in custody. Child A3 was his first child but he had previous relationships where domestic abuse featured. The family home was described as clean and there were no concerns about physical neglect of the children, although financial support was often requested for school uniform and the police were involved when there was a disturbance at the home allegedly due to visitors demanding that debts be repaid. 4.5 The condition of Family B’s home was a concern, with the children having been on a child protection plan for neglect in the past, as well as for emotional harm. Mother B has mental health issues, including a diagnosis of bipolar disorder and emotionally unstable personality disorder. She has a history of taking overdoses and voicing suicidal intent as a response to stress, including making numerous statements that the involvement of children’s social care (CSC) was the cause of her poor mental health. She was known to be impacted by the death of a close family member when she was a child and a previous intimate relationship was domestically abusive. 4.6 Stepfather B is known to have a history of alcohol and substance misuse. His previous relationships featured violent domestic abuse. Like Stepfather A, he has a criminal record for other violence, including possession of weapons. Those involved in 2021 had some concerns about his cognitive ability, and there was a plan in place to get this assessed. He reportedly attended a special school as a child due to behavioural and learning difficulties and was known to CSC due to concerns about physical abuse at home. He was described during the review as ‘unpredictable’ and ‘violent’. He often intimidated professionals, who also reflected on how this would be experienced by his partner and the children in the home. Mother B denied he was violent or intimidating at home and would not acknowledge that the children were at any risk. She was also adamant that her elder child was lying following their allegations about sexual abuse from Stepfather B5. This child has been consistently scapegoated by her mother and blamed for the involvement of CSC, which needed to be part of the wider assessment of the potential for emotional harm and neglect of the younger siblings. Stepfather B has children from a previous relationship and there were ongoing concerns about acrimony between Stepfather B and his ex-wife, and the threats and aggression showed to her by both Stepfather and Mother B. 4.7 The review has found that not all of those working with the families prior to the incidents were aware of all of the relevant background information. This was due to the families not sharing information, permission not being given to speak to other agencies (such as adult mental health) and the time involved in finding and reading historic agency information. Not fully understanding and considering the adult risks can mean that plans made for children are based on what parents report rather than what is knowable to professionals if they robustly check their own agency records and ask other professionals to do the same and share what is found. 5 Another family member had made allegations of child sexual abuse against Stepfather B around five years previously. V8 Sept 2022 5 4.8 Information provided by parents should always be verified. For example, the extent of Mother A’s health issues and the impact on her care of the children of the medication she was taking needed to be understood or explored with other professionals, including the possibility that she was not as physically unwell as she was reporting. Her scan’s showed no issues, yet she continued to seek pain medication and drugs to help her sleep. This needed considering and clarifying as it could be an indicator of substance misuse. GPs are a helpful source of information about a parent/carer’s health and medication, as well as someone with whom to discuss any concerns about the impact on parenting of certain medications. Information was sought from the GP prior to the birth of Child A3 when a S47 investigation was being completed. This was an opportunity for all the professionals involved in the child protection planning to be aware of the prescribed medication and what it might mean for mother’s parenting of the children. There also needed for consideration of the risk of prescribed drugs being taken into a house where both the Stepfather and Child A1 had known or suspected substance misuse issues. Seeking advice from a substance misuse agency on the impact of prescribed medication if taken alongside illegal substances would also have helped to understand the effect on the user and any related risk to the children. Learning point 2: Professionals require support when trying to work with resistant and hard to engage families who do not acknowledge professional concerns and refuse to ‘own’ a child protection plan 4.9 There were similarities in both cases about the difficulty professionals had in engaging with the families. Both were largely successful in keeping professionals at arm’s length and they consistently failed to acknowledge professional concerns. The nature of child in need or child protection planning is that it requires the parents to engage in assessments and plans in order to improve the assessed harm and risks to the children. In both cases, the parents largely did not acknowledge professional concerns or contribute to the plans made to improve things. This made it difficult for professionals to work with them and can lead to drift and delay and a feeling of helplessness about how to work with the family beyond monitoring what is happening. 4.10 When parents are negative about professionals it makes it difficult for the professionals involved in plans and for the children themselves. There were several examples shared about the children coming across as ‘closed off’, avoidant or directly antagonistic to professionals who sought their voices and tried to understand their lived experiences. In both families it was known that the children had been told that they might be taken into care and that professionals, particularly social workers, could not be trusted. As their older siblings had been taken into care when they spoke about what happened at home, this was a real fear for the younger children. Despite this there were numerous attempts to see the children in both families, balanced with an awareness that this was likely difficult for the children and indeed could increase the risk of emotional harm if the parents reacted badly to these visits. 4.11 Child B2 had significant special needs, so it was important to consider their non-verbal communication and monitor how they seemed to determine any deterioration in their presentation, as well as to consider what they might ‘say’ verbally or by their behaviour. His school noted concerns about his unkempt clothing and his anxiety that he may be taken away from home. Social workers had little engagement with him prior to the serious incident. A visit to see him at school would have been a way of ensuring that he was seen, but this raised a dilemma as there was a known risk that he would be removed from school if this was attempted. Because he had good relationships with school staff, they were well placed to provide support to the child and to provide his voice to social workers undertaking assessments. The school themselves worked hard to ensure they assessed Child B2’s voice by using their one to one ‘pupil voice activities’. They raised no concerns. 4.12 The voice of the older siblings who no longer lived at home needed to be sought and appropriately considered, as they had firsthand experience of growing up in the families and had ongoing contact. In both cases these children voiced clear concerns about their younger siblings and disclosed ongoing parental substance misuse and domestic abuse. They also made allegations of historic V8 Sept 2022 6 sexual abuse in the case of Family B. It appears that in both cases they had genuine concerns for the younger children and a lot was to be gained from ensuring they were listened to, including considering the response of their mothers to what they were sharing as part of an assessment of their ability to care for the younger children. 4.13 While both children in Family A were seen regularly by professionals there was little understanding of their experience of domestic abuse and their views about Stepfather A returning to the family home following his custodial sentence. During the review there was reflection on the difference between talking to children (for example about how they are finding school, whether they have friends, what their interests are and so on, as was evident in this case) and between seeking to understand their lived experience and relationships in the home and their views on the known concerns. In this case their experience of domestic abuse and parental substance misuse and their relationships with their parents and siblings needed to be explored. 4.14 Professionals working with both families reported that they could find the parents both dismissive and intimidating. Both families also made complaints about professionals. Family B regularly threatened legal action against the local authority, as did Family A against the midwife who made a referral when the mother was pregnant with Child A3. While the professionals were able to recognise that this was a way of avoiding scrutiny and professional persistence, it remained difficult for those involved who were trying to find a balance between trying to ensure the on-going engagement of parents in order to undertake a robust assessment and to support and protect the children, with the need to challenge the parents and address concerns and risks. When Mother B was told in 2020 that a child protection conference was to be held, she was very aggressive, made threats to kill the social worker and threw things at her. The police had to be called to the social work office where the meeting was held. 4.15 Professionals need support and guidance about how to respond when they are unable to work with families due to avoidance and/or threatening behaviour, as well as considering the impact on the children. Those involved in the review felt it would be helpful for their manager to be physically present with social workers and other relevant professionals when they are setting clear boundaries with families about what is and is not acceptable behaviour to secure both the children’s and professionals children’s safety and welfare. Procedures refer to this as a 'Contract of Expectation' or a 'Written Undertaking' and the review agrees that a manager needs to be present when these are drawn up with family members. 4.16 Professionals told the review that they are aware of the need to report any violent incidents or threats, and have a process available on their phones to do so. There is a recognised fatigue in regard to this however, and an acceptance that sometimes the job involves having to work with extremely difficult individuals. There are two relevant Pan-Sussex procedures that cover this issue. Firstly, Working with Families who are Uncooperative and or Not Engaging with Professionals6 and secondly Violence Towards Staff7. The procedures include the suggestion that a strategy meeting is held in these circumstances to reflect the concerns for the children living in these households and to support the staff who are concerned about them. 4.17 The picture was not one of straight refusal to work with professionals from Family A. Improvements were noted in their engagement following a period of custody for Stepfather A in 2018. It appears that they appeared to prefer the approach of certain professionals, and there was evidence that the situation in the home was more settled. The professionals view at the time was that Stepfather A had come off drugs when in prison and that this contributed to the improvements. There were indicators that these improvements were short lived however, with both of the older children (Child 6 https://sussexchildprotection.procedures.org.uk/tkyqyq/children-in-specific-circumstances/working-with-families-who-are-uncooperative-and-or-not-engaging-with-professionals/ 7 https://sussexchildprotection.procedures.org.uk/tkyqys/children-in-specific-circumstances/violence-towards-staff V8 Sept 2022 7 A1 and the older child who no longer lives at home) showing behaviour which indicated a response to on-going trauma and the eldest child making allegations of on-going domestic abuse in the home, both adults poor mental health, her mother’s habitual drug use (stating to professionals at the time that her mother had evidence of damage to her nose due to cocaine use), and voicing her fears for her then youngest sibling. When seen, Child A1 stated he wished to leave the family home, but was unable to articulate why, so it was not pursued with him. 4.18 The conference chair for Family A had pointed out her concern that the engagement of the parents was superficial and that they had been avoiding professionals, including not attending child protection conferences and often not being home for social work visits. It was also noted that no unannounced visits8 had been achieved. As both parents denied any further domestic abuse and there were no police notifications, it was agreed that the children would no longer be subject to CP plan. The family had agreed to cooperate with social work visits under a child in need plan that followed. The focus, however, was on providing support as requested by the parents. As the engagement was entirely on their terms, they were seen as cooperative. 4.19 It was noted that Family B were particularly hostile to CSC, and to a lesser extent the police. Experienced social workers told the review that the adults intimidating and threatening behaviour was extreme and unusual even in child protection work. They were more willing to work with other professionals, but only regarding the issues the family accepted. It is important in these circumstances that all professionals challenge families who make threats or refuse to work with one agency, particularly when their involvement is crucial, as was the case with CSC. It is understandable that they may be reluctant to do this too forcefully if the family are engaging with them to take the opportunity to positively engage with the children and make a difference. The schools, for example, were concerned that if they pushed too hard, the children may stop attending, particularly when this was permissible due to COVID-19 rules. There were examples of good practice from Child B2’s school in challenging the parents, for example about the physical care of Child B2. They also engaged with the children’s grandmother who would help to reason with their mother when she became agitated and upset, as was often the case. However, it is essential that all professionals involved with a family work together to ensure that a partner agency is not scapegoated and isolated by a family, and that all professionals are clear that this is not acceptable. Learning point 3: When the concerns or allegations do not meet the threshold for criminal charges , formal multi-agency consideration should be given to why this is and to the potential need to safeguard the child and/or their siblings 4.20 There were concerns across partner agencies about whether Stepfather B posed a risk of sexual abuse to the children who remained in the family home, but an assessment of the risk he posed to these and other children was outstanding at the time of the serious incident, as was an assessment of the mother’s ability to protect in light of her refusal to believe her older child9. There had been some delays in ensuring that there was a focus on this issue for the younger children as the older child had her own social worker, and the younger children were closed to CSC at the time that the allegations were made. It was agreed that a family assessment should be undertaken but the mother refused to engage with this, stating that in light of a lack of police action and the children not raising any concerns when they were spoken to, it was not required. The case was closed to CSC as it was felt there was not enough evidence to do anything further at this stage. This was despite the allegations made by the older child. 4.21 Stepfather B’s alleged physical and financial abuse of his frail elderly mother was also a concern at this time. She was suffering with emerging dementia and the family was living with her. The concerns 8 When children are on a plan there is an expectation that some social work visits are unannounced. 9 It is noted that despite the failure of her mother to believe her and the family scapegoating her and blaming her for the involvement of CSC with her siblings, the older child from Family B remained in care under S20. This has been raised with CSC as the review found that there was a clear need and grounds for care proceedings in her case. V8 Sept 2022 8 led to a number of adult safeguarding meetings, which were known about by social workers in children’s services, although this was not sufficiently communicated at the care planning meeting when a request was made for permission to hold a meeting before action, the first stage of legal proceedings. The review was also told that there were serious concerns about the state of Stepfather B’s mother’s property, which were considered when seeing if she could be discharged from a period in hospital. There was less consideration of this also being a home where children were living, despite a record of the home having no working amenities, including toilets. Adult social care was involved in this review, and they have noted learning in relation to the need for their staff to triangulate information and liaise with children’s services. 4.22 The police / Crown Prosecution Service (CPS) had not taken criminal action in regard to either the sexual abuse allegations or the allegations of abuse towards Stepfather B’s mother. Historic allegations of sexual abuse from another child in the family had also been made against Stepfather B some years before but the criminal case was not pursued. Those later involved with Family B were not entirely clear why this was. The police and the CPS require a level of evidence that will allow them to prove guilt beyond reasonable doubt. There can still be indicators that a person is a risk and the lack of a prosecution does not mean that there is no risk and that the matter will not meet the threshold for a S47 and/or legal response by the Local Authority. The review established that when this is the case, professionals need to discuss the decisions made with the police and not make assumptions about a decision not to pursue a criminal case against an alleged perpetrator. This could most effectively be undertaken at a review strategy meeting. Another CSPR was undertaken in East Sussex recently where sexual abuse was considered. The review highlighted the need for a further strategy meeting to be held when more or conflicting information emerges. The recommendation made in that review will ensure improvements in this area of safeguarding. 4.23 In the case of the alleged abuse from Stepfather B against his mother, her vulnerability means that she was unable to say what had been happening and this made prosecution difficult. In the case of the older child in the family, her level of vulnerability could also have had an impact on the decision of the police and/or the CPS. Both issues pointed to a risk of sexual abuse and violence from Stepfather A to those he was living with that required robust consideration, regardless of the police and/or CPS response. This risk was recognised at the CPF and was to be included in the assessments that were planned. 4.24 Not long after the case was closed to CSC the older child in Family B made further allegations about sexual abuse, stating that she felt safe enough in care to disclose more fully. A S47 response followed, with an agreement to hold an ICPC on her siblings. CSC allocated the case to two workers in order to mitigate the risk that was posed to them by threats from the family and to provide support in managing such a difficult case. This was good practice. Those involved recognised that there was little capacity or willingness to change from the mother or her partner, so it was also decided that the case needed to be discussed at the Formulations meeting where appropriate specialist assessments would be requested and at the Care Planning Forum (CPF) for legal advice. Despite this plan, there was a further delay in seeking the legal advice due to a concern that the threshold for legal proceedings was unlikely to be met when there was no new evidence or specific event that would lead to an agreement by the court for assertive action. There is a belief that courts will only agree that significant harm is present (the threshold for a care order) following a serious incident, rather than due to cumulative concerns over time. (See below.) 4.25 Family B was discussed at the CPF the following month, but no agreement was given for a legal meeting before action (MBA) at the time. The CPF is chaired by an experienced senior manager and attended by a senior ESCC lawyer. Other professionals from CSC also attend and advice is given to allocated social workers on how to progress a case. The lack of specialist assessments at the V8 Sept 2022 9 time, due to a delay in the SWIFT10 work, led to an agreement at the CPF to await the outcome of the assessments before considering if a legal response was required. This was accepted and was understandable when considering what was known at the time. 4.26 The review was told that there can be a degree of frustration across agencies when a plan is delayed waiting for specialist assessments. Even if it was not considered in this case, professionals need to feel confident in challenging the outcomes from the CPF or know that they can return again to share that they remain worried and why, even without the specialist assessments required being completed. It is acknowledged that this is not easy, as well respected senior managers and lawyers are involved in the CPF and are seen as the ‘experts’ in threshold. In order to ensure that all of the issues are known to the CPF and legal advisors, multi-agency information, evidence of cumulative harm and the evidence that the family have not responded to child protection planning needs to be available in order to convince the CPF of why ‘now’ is the time to progress to a legal response, even when the required assessments have not yet been completed. In this case the MBA may have provided a level of additional persuasion to ensure that the family engaged with the assessments planned, however the review acknowledged that a plan to consider the independent assessments before making this move was understandable, despite the delay it caused. Particularly as both parents agreed to cooperate with the assessments. 4.27 With this delay, and limited engagement from the family, the child protection plan in respect of the children in Family B left the professionals working with the family doing little more than monitoring the children and sharing information in the core group. This was a difficult time for the family and for the professionals involved. The parents had voiced their concern about the assessments due to be completed and the delay exacerbated their anxiety and impacted on the increasingly negative relationship with the professionals involved in the child protection planning. While there had been no progress in the face to face assessments, there had been consideration of agency records by SWIFT staff, who were concerned about managing the assessments while also keeping the children and their mother safe. They wanted to undertake the cognitive assessment meeting with Stepfather B at the same time as the assessment meeting with the mother, so as to ensure that Stepfather B was not present with his partner. The review was told that it was the cognitive assessment that delayed things, with both psychology staffing and capacity issues at SWIFT delaying this. A date had been set for the assessment meeting, which was just after the serious incident. The review was told that while resource and capacity issues were present at the time and had an impact on this case and others, there is now increased capacity at SWIFT and far fewer delays in assessments when children are on a child protection plan. Learning point 4: Professionals need to understand the ongoing and reoccurring nature of domestic abuse and parental mental health issues to fully appreciate the impact on children 4.28 There had been both historic and more recent domestic abuse in the majority of the adult relationships of both sets of parents. Both stepfathers witnessed domestic abuse during their childhood. This is known to have an impact on their own expectations of relationships, and research shows that children who have experienced parental domestic violence are ‘at greater risk of being victims or perpetrators as adults’ due to the intergenerational cycle of this type of harm.’11 It is also known that a long-term illness or disability, including mental health problems, increases the risk of being in a relationship that is domestically abusive.12 This was the case for all four parents. 4.29 It is essential that professionals consider the evidence of domestic abuse in the relationship in the past, at the time and also the likelihood of domestic abuse reoccurring. Particularly where there has been limited insight from the adults involved into the issue and little or no work undertaken to confront 10 A local jointly commissioned, multi disciplinary provider of specialist assessment and intervention. 11 NSPCC Research Review: Early Childhood and the ‘Intergenerational Cycle of Domestic Violence’ (2019). 12 Recognising and responding to domestic violence and abuse. Quick Guide. SCiE 2020 V8 Sept 2022 10 and address the problem. The Triennial Analysis of SCRs undertaken between 2011-2014 identified that a change is required in how we understand and respond to domestic abuse, ‘there is a need to move away from incident-based models of intervention to a deeper understanding of the ongoing nature and impact of domestic abuse.’ This is relevant to these cases, as there is evidence that professionals were reassured, and decisions were made in light of the lack police reports. 4.30 In both of cases there were no reported new incidents of domestic abuse in the months prior to the serious incidents in 2021. In Family A there was a presented picture from the family that after the stepfather’s release from prison in 2018 there had been no further domestic abuse, substance misuse or need for concern about the parent’s mental health. There had been no police involvement for some time, and social visits to the family as part of the child protection plans did not lead to any concerns being identified. Mother’s older child, who did not live at home, was very clear with professionals however that these risks were on-going. A child protection conference in October 2019 agreed that the children should no longer be subject to a child protection plan due to a lack of evidence that the concerns which had led to a plan remained. This was despite the child protection plan largely not being achieved, including no evidence of the required random drug testing, no psychological assessment of Stepfather A, no domestic abuse work and the evidence of on-going serious concerns about Child A1, who required on-going support and transition to adult services. (He was age 16 at the time.) 4.31 Shortly afterward the child in need plan was closed it became clear that Mother A was pregnant. Research shows that both pregnancy and the presence of a newborn baby increase the risk of domestic abuse significantly. The pre-birth period is a good time for reflection and reconsideration for professionals involved in a family where there have been long term concerns about domestic abuse, mental health, and substance misuse. The information available from CAMHS regarding the impact of his experiences on Child A1 provided evidence of long-term abuse and trauma to the children in the home, and it was known that no work had been undertaken by the parents to address the concerns. In fact, the family were clear when they were visited by social workers that they would not cooperate with an assessment regarding the new baby or the older children, and after undertaking agency checks it was agreed that the threshold for child protection response was not required. This was despite three contacts in recent months from different wider family members that the couple were misusing drugs (specifically crack cocaine and heroin), how vulnerable babies are, and the impact on the older children of a growing family. There was a discussion between the police and CSC to decide if a strategy meeting was required, but the police visited the family, had no concerns so it was agreed that no further action was required. Health agencies were not consulted. The assessment that was then completed was not a pre-birth assessment, did not take into consideration the parents not disclosing to midwifery that they had recent CSC involvement or their lack of cooperation with the assessment, and there was no evidence that the long history of concerns was considered or that the voice of the unborn baby or the impact of their experiences on the older children was considered. 4.32 The case was reopened for assessment two months later when the midwife made a referral to CSC to state that Mother A was not engaging with routine midwifery appointments or following medical advice. A strategy meeting13 considered this information and received updates on the older children and identified concerns about declining school attendance for Child A2 and police intelligence regarding the stepfather’s heroin use and dealing. It is good practice that police intelligence is considered but there is a limit to how it can be shared with families. This information however should have been considered alongside both the historic substance misuse and the information shared a few months earlier by family members. Without ongoing support from substance misuse services this was a risk that was likely to reoccur, along with domestic abuse and fluctuating parental mental 13 Single agency learning was identified about a member of staff from the midwifery service informing the parents about this strategy meeting, in contravention of procedures. V8 Sept 2022 11 health, both of which were likely to be exacerbated by substance misuse. Despite this the case was closed prior to Child A3’s birth. The allocation of a new social worker when the family was referred by the health visitor when Child A3 was three months old and good information sharing and awareness of risks in the family from the health visitor led to a full consideration of the history and a decision to hold an initial child protection conference. The serious incident happened before this could be arranged. 4.33 In respect of Family B it has been identified that professionals in adult services engaging with parents due to their own issues, require support and oversight to ensure that they are aware of the need to always consider the impact of the issues on any children living with the adults concerned. This includes the requirement to share information, even without consent, when the children are either subject to a S47 investigation or on a child protection plan. The impact of GDPR14 and the perceived limitations to information sharing requires ongoing and further clarification and support to ensure that information sharing is not a barrier to safeguarding children. 4.34 A few days before the serious incident, Stepfather 2 was taken to hospital by ambulance following a mental health episode and overdose at home. During this incident he apparently threatened his partner and appeared to be hallucinating, saying unknown people were in his home. This incident has identified several systemic issues, particularly regarding information sharing that had an impact on the response to this incident. Those working with the children were not aware of the incident. This is because it happened on the weekend and information sharing ‘out of hours’ is not as effective as during office hours. The review was told that there was significant pressure on services over the weekend in question. There were gaps in the information sharing from the police to the ambulance service and then from the ambulance service to the hospital. The mental health assessment then undertaken on the ward considered the overdose but not the detail of the incident, including the serious threats made to Mother B. The stepfather told the mental health professionals that he had no contact with his own children, which was the case, and at the hospital he attended there were no flags/alerts on his notes to show that he lived in a household where children were on a child protection plan. The Acute Trust have identified learning about the importance of thinking family when there is a presentation of this type and of records needing to reflect a patient’s living arrangements. There only reference on his mental health service notes to any contact with CSC about his partner’s children were strategy meeting minutes uploaded into correspondence, so not easily accessible to busy hospital staff. The mental health trust is completing a parallel serious incident review of what occurred during this episode in relation to use of the Mental Health Act and this will be shared with the ESSCP when it is finalised15. Learning point 5: There is cumulative risk of harm to a child when parental and environmental risk factors are present in combination or over periods of time. This need to be considered when plans are made, including when there may be a need for legal action 4.35 The national Safeguarding Practice Review Panel’s second Annual Report published in May 202116 states that ‘the recognition of cumulative17 neglect and its impact continues to be a key challenge for practitioners’ nationally. There is a danger when working with cases of long term neglect and /or emotional harm that agencies wait for a serious one-off incident to happen to provide evidence to each other or to the courts that the children are suffering significant harm on a given day. With 14General Data Protection Regulation - Data Protection Act 2018 15 The CSPR was told that the timescales for completion mean that the CSPR would be signed off and potentially published before this parallel review was completed. A recommendation has been added to ensure that the findings and actions from the review are shared with the ESSCP. 16https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf 17The terms ‘cumulative risk’ and ‘cumulative harm’ were first identified by Bromfield and Higgins in Australia in 200517 who defined cumulative harm as ‘the effects of patterns of circumstances and events in a child’s life which diminish their sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or layers of neglect.’ V8 Sept 2022 12 neglect and emotional harm, a number of smaller issues or concerns when collated may show significant harm over time. There is a cumulative impact on children of care that dips just above and then below ‘good enough’ on a regular basis. Both of these cases are good examples of this. Assumptions can be made about the resilience of children in cases where the concerns are chronic and long term. For example, Child A2 was fiercely loyal to her mother and step father and seemed to be managing her home life well. However it is known that experiencing long term emotional harm often manifests when a child reaches adolescence, and it is often then that their behaviour begins to decline and professionals become concerned. Those now working with Child A2 in secondary school have concerns about the impact of her experiences. 4.36 In the case of Family B, there was a plan following discussion at a Formulations meeting to undertake specialist assessments, including a cognitive assessment of step-father B18, an assessment of his sexual risk, and a psychological assessment of the mother, including her ability to protect the children. The face to face assessments had not started when the serious incident happened six months later. The social work team were concerned and felt that a meeting before action19 (MBA) was required, but the Care Planning Forum did not support this at this stage, despite recognising the risks. This has raised questions about the information shared and whether an argument for cumulative concern was shared and the confidence of senior managers and legal services that the court would consider this. The review has found that there was a rigorous consideration of much of what was known and that there was a view that following the assessment that were planned, care proceedings may be suitable. 4.37 In both families there were a number of different issues which posed a risk to the children, and the long term nature of these concerns added to the likelihood of harm and repercussions for the children. If risks are to be judged on a single day, they may not meet the threshold for statutory intervention, be that S47, CP planning or the PLO/care proceedings. But viewed over time, the impact of their experiences is magnified and the likelihood of significant harm increases. This was clearly the case with Child A1, and the older children in both families who were no longer living at home and were struggling with their own significant vulnerabilities. The likelihood that their experiences were going to be repeated with their younger siblings needed serious consideration. 4.38 As posed by the chronology author for CSC in respect of Family B, the review also asked how social workers can gain confidence in using historical patterns as evidence. The same question is relevant to all professionals. It is essential that patterns over time are considered when any professional is considering the threshold for a referral or an escalation of a professional disagreement when there are concerns that children are not being safeguarded. This, along with a clear understanding of the child’s lived experience and the family culture and the likelihood that concerns will reoccur over time without significant interventions and evidence of sustained change, is the answer to this question. When there is a clear case of reoccurring risks, the likelihood of ongoing harm to the children needs to be the focus of action taken, rather than professionals feeling helpless due to what they see as the burden of needing to prove that harm is present at a given point on a given day. 4.39 The review found evidence of resolve and persistence of professionals in supporting children in both cases despite the parent’s hostility. The social worker involved with Family B at the time of the serious incident knew the children well and was clear that they were likely to suffer significant harm. She felt however that she required the evidence that a specialist assessment would give in order take action. In both cases there was evidence of communication between the conference chairs and 18The review was told that Stepfather B said he had acquired a brain injury when young. SWIFT were going to consider this in his cognitive plus assessment as part of his functioning and because it may have impact on how he is worked with. His mental health records show that he has had a number of head CTs and MRI prior to the incident however and none indicated a brain injury. 19This is the local process for starting a Public Law Outcome (PLO) response, with the agreement of the CPF. V8 Sept 2022 13 those working the cases between conference, which was a reflection on the complexity of the work and a commitment to safeguarding the children. 4.40 Those involved understood the importance of a child centred approach, and the need to seek information on the lived experience of the children. This is complex process work however, and needs to take into consideration that children are often conflicted or scared to engage with professionals due to their fears of what might happen next or the response of their parent/s if they say the wrong thing. There is evidence of reflection about this in both cases, and some understanding that behaviour is a means of communication and what they might be saying without words.20 However the explicit concerns shared by the older children needed to be heeded with a clear focus on what this meant for the younger children, despite the parents attempts to discredit them. Learning Point 6: As children approach adulthood, those who are known to be vulnerable, particularly those that are on a child protection or child in need plan, require on-going and focused multi-agency support with a clear plan to ensure that they are not ‘lost’ to the system 4.41 Child A1 was a child for most of the time that the review considered in detail. It was his 18th birthday not long before the serious incident that led to this review. Much of the work undertaken with the family considered the risk to the younger children of Child 1A’s behaviour. Child A1 had ADHD with some obsessive behaviours and a difficulty in controlling his behaviour. He had been prescribed a number of drugs for his mental health throughout his later childhood. They included anti-psychotic medication, although the assessment undertaken by FCAMHS concluded that rather than having a psychotic illness A1’s presentation was more suggestive of extreme anxiety and learned relational/attachment behaviours, within the context of complex developmental trauma. There was a plan in place to reduce his prescribed medication, which he resisted. Those who knew him well believed he strongly identified with his mental health diagnosis and was reluctant to reconsider if it was valid. 4.42 Professionals were aware that there was a risk to him having large amounts of this medication available to him at any time, so they arranged for his prescriptions to be collected weekly. He was known to misuse drugs, as he did not hide this. Professionals were aware that he had gym equipment and used it very regularly, but not all were aware of his abuse of illegally sourced steroids. This was significant information as it is known that misusing steroids can have a negative impact on anger control, with people reportedly acting aggressively when misusing them regularly21. He was referred to substance misuse services but did not engage. 4.43 Child A1 had an EHCP and was known to CAMHS, EIP (Early Intervention in Psychosis) and FCAMHS (Forensic Child and Adolescent Mental Health Services). His engagement with mental health services while a child was sporadic, with his school taking much of the responsibility of ensuring he was seen when required. When he left school at age 16 his engagement with most mental health services declined. For the children in both families, school was a safe place where they received support. When this was no longer in place for Child A1, both his mental health and his ability to manage was impacted. 4.44 Child A1 was on a child protection plan until he was 17 years old, and he was then on a child in need plan until he was 18 years old. The last RCPC before his 18th birthday noted that he was not in education employment or training (NEET), despite his Education Health and Care Plan (EHCP). It was recorded that he had no plans to go to college and that he was not wishing to engage with mental health services as he blamed CAMHS for changing his medication against his wishes. The child protection plan ended without a clear steer that the child in need plan that followed needed a 20The voice of the child: learning lessons from serious case reviews. Ofsted 2010 21https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids V8 Sept 2022 14 formalised network of support specifically for Child A1 in respect of his future. There was no progress in this area for him prior to his 18th birthday and he had no key worker taking responsibility for him. 4.45 When a child/young person has an EHCP this can be in place until the age of 25 providing that they are engaged in appropriate education or training that provides a forward pathway. The EHCP is important in providing an oversight of needs and provision required, and has the potential to provide access and funding to support the engagement of the young person. In this instance the EHCP was ceased owing to a lack of engagement from the family, meaning he became an adult without a plan for his transition, despite his known vulnerabilities. The review was told that a plan is being devised to focus on this issue, and this case should be used an example of what is required to ensure that the hardest to reach young people are helped. 4.46 There were attempts to consider how he could receive support in his own right after leaving school, which was complicated by his lack of engagement with services much of the time. For example, when he was closed to CAMHS, Primary Care was asked to follow him up in regard to his remaining prescriptions. While this would meet the purpose, he was a very vulnerable young man who was likely to require support as he transitioned to adulthood, and support from his parents to do so. Those who knew him well told the review he required ‘holding’ as he approached 18 to ensure that he was not lost to services, and would have benefitted from a relationship with a key worker whose job it was to remain in contact with him and provide the advice and support that he was likely to require. At the time of his 18th birthday, adult mental health services were able to offer assessment and treatment with COVID 19 protocols in place for those open to their service. Child 1A was not open to them however but knew that he could access the Sussex Mental Health Line22. 4.47 Child A1’s previous school have identified a gap in service delivery as a systems issue for a lot of post 16 young people, with only those with serious disabilities or who are in care receiving effective support into adulthood. A national issue was also raised for young people like A1, because he received benefit payments due to his disability/vulnerability, this was a disincentive for him to consider his future. There may also have been a concern for Child A1 about his mother and younger siblings that made him want to stay home to care for them. This was not considered at the time. Learning point 7: COVID-19 had an impact on the families and the professional response 4.48 The NSPCC has highlighted the heightened risks to children during the COVID-19 pandemic due to the increase in social isolation, lack of access to some services, the ability for professionals to pick up on early warning signs, and financial insecurity23. There has reportedly been a negative impact on mental health, domestic abuse24, and potentially on substance and alcohol misuse. Both incidents happened during the pandemic and it is right that the review considered the impact. 4.49 In both cases Covid-19 was a challenging time for the families and for the professionals working with them. Research shows that social workers were often the only professionals going into family homes during the initial lockdown25, and this often took a lot of negotiation for families to allow this. As the Family B reflective chronology author for CSC stated, for some families COVID-19 was ‘a gift’, and this was indeed the case for both of the families being considered, with the parent’s history of reluctance to engage with professionals. 4.50 Professionals have reported generally that visiting families while wearing PPE and trying to practice social distancing, at a time when there was a genuine fear about contracting COVID-19, was very difficult. When colleagues needed to shield due to health conditions, this also had an impact on the capacity of those able to work face to face to see families as often as required. While necessary in 22 He did contact this helpline on one occasion around 10 days prior to the incident. 23 Both parents in this case were said to be stressed about their financial predicament and housing situation. 24 The Office for National Statistics states that the number of arrests for domestic abuse-related crimes between 1 April and 30 June 2020 increased by 14% compared with the same period in the previous year. 25 Harry Ferguson, University of Birmingham. Professional Social Work magazine 6.12.21 V8 Sept 2022 15 some cases, attempting to ‘see’ families via video technology was difficult and potentially provided false reassurance, particularly with families like these who had a history of avoidance of professionals. Despite this there was good evidence of effective and focused work from all agencies in East Sussex during the pandemic and challenge of families who tried to avoid scrutiny. In both cases there were a number of examples of admirable tenacity and care shown to the children by the professionals involved. 5 Conclusion and recommendations 5.1 There has been excellent cooperation with this review from partner agencies, which was essential in establishing the thematic learning. Single agency learning from both cases was identified during the review and recommendations have been agreed to address these, including single agency SMART action plans. For example Child A1’s school plans to negotiate the provision of a specialist post-16 service for pupils with SEMH needs26 who are unable to attend a post 16 mainstream setting for children like Child A1. 5.2 Having considered the learning not addressed in the single agency actions, the following additional recommendations are made: Recommendation 1: That the Partnership requests information and assurance from the relevant agencies regarding the identified need for improvements in processes and practice to support the transition of vulnerable school leavers, including those with an EHCP. Recommendation 2: That the partnership asks ESCC Children’s Social Care and Legal Services to consider how they can ensure that: - A multi-agency view of the need for a Meeting Before Action is sought and considered at the Care Planning Forum - Historic information across agencies, including patterns and cumulative concerns are available and considered at the Care Planning Forum - Social workers and core groups are supported and encouraged to challenge Care Planning Forum decisions if they don’t agree with them Recommendation 3: The Partnership to seek assurance from all relevant agencies that professionals are supported when working with threatening and abusive behaviour from family members. The partnership must also ensure that professionals consider the impact on the children of such behaviour, including promoting the use of the existing procedures that suggest a strategy meeting is held following a serious threat to a professional or if a professional is assaulted. Recommendation 4: The Partnership to seek assurance that the learning from this review is considered by all agencies and that the following areas of learning are routinely reflected in practice: - The serious impact of the cumulative and reoccurring nature of neglect and emotional harm - The need to ensure that information is sought and shared regarding parental/adult and family history that is likely to pose a risk to children Recommendation 5: 26 Social Emotional Mental Health needs V8 Sept 2022 16 That SPFT share the findings of their serious incident review of the application of the Mental Health Act during Stepfather B’s admission just prior to the serious incident, including any improvement actions that are being taken. Recommendation 6: The Partnership to challenge the relevant partner agencies about how professionals who work with adults/parents can be better involved in working with families where there are concerns about the children. Author: Nicki Pettitt |
NC52645 | Death of a 13-week-old boy in February 2021. Ollie's death was the result of a co-sleeping incident with his father which resulted in brain injury. Prior to his death, toxicological analysis of Ollie's urine revealed the presence of cocaine, which resulted in an interim care order for Ollie and his siblings. Learning themes include: identification of and response to neglect; the importance of home visits to identify poor living conditions; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; the role of disguised compliance; and the impact of Covid-19 on supporting families and the capacity of services to respond to their needs. Recommendations for the local safeguarding children partnership include: publish a multi-agency neglect strategy with actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with parental mental health and substance misuse; review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants (SUDI); develop a campaign targeting casual substance misuse amongst parents and carers and warning of the dangers to their children; undertake a review of the local impact on families of Covid-19, lockdowns and the absence of face-to-face visits; and deliver a series of locality based information events for parents and carers with access to advice and guidance.
| Title: Child safeguarding practice review: Ollie. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Ollie April 2023 Wirral Safeguarding Children Partnership Table of Contents Executive Summary 2 Introduction and Methodology 4 Terms of Reference 4 What was known about the Family ? 6 The Incident 8 Key Practice Episodes 9 • The identification of and response to neglect 9 • The effectiveness of safer sleep messages 11 • Additional stresses of parental mental health and 11 substance misuse • Disguised compliance 13 Out of routine: A review of sudden unexpected death in 14 infancy (SUDI) in families where the children are considered at risk of significant harm Strengthening Safeguarding Arrangements 16 Summary of Recommendations 19 Appendices 20 • Agencies involved in the review 20 • References 20 Wirral Safeguarding Children Partnership Page 1 Executive Summary 1.1 Ollie was 9 weeks old when he was seriously injured in a co-sleeping incident with his father on the 6th January 2021. Ollie’s had been unsettled during the night and his father had wrapped him in a blanket and fallen asleep with him on the sofa. Ollie was unresponsive and paramedics were called who managed to resuscitate him, and take him to hospital. Doctors informed his parents there was a significant chance he would not survive. 1.3 Both the attending ambulance crew and police officers who arrived shortly thereafter described the house as being cluttered and dirty. The electricity was off and the parents appeared to be sleeping downstairs. There was a Moses Basket in the front room but it appeared to be unused. 1.4 Later toxicological analysis of Ollie’s urine revealed the presence of cocaine. As a result of this the Local Authority were granted an interim care order for Ollie and his siblings and his parents were only permitted supervised contact. Ollie tragically passed away a few weeks later as a result of a significant hypoxic injury to his brain. A police investigation begun and the case was later referred to the Wirral Safeguarding Children Partnership who agreed to undertake a Child Safeguarding Practice Review. 1.5Four key practice episodes were identified and formed the basis of the review: identification and response to neglect; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; whether disguised compliance was a feature of the case and the impact of Covid-19 on the family and the capacity of services to respond to their needs 1.6 Identification of and response to neglect – the poor condition of the home was raised by services attending the property on the 6th January. The house was dirty and unkempt with parts of it in disrepair and visibly dangerous. Prior to this there had only been one previous concern recorded about the house being untidy – this was recorded by a health visitor following a visit in 2015, but there is no further detail or record of any follow up, or wider exploration of neglect. 1.7 Ollie’s parents did later admit that the condition of the house was ‘not acceptable’ but said this was a recent issue mainly causes by significant work which was being undertaken on the house. There are no reports from any agencies about neglect being a concern, but it is nevertheless the case that services only became away of the families poor living conditions because an ambulance had been called on the 6th January. 1.8 Effectiveness of safer sleep messages – Safer sleep campaigns had been running in Wirral for a number of years and practical messaging and advice for parents was a core, and expected, part of practice, particularly for health visitors and midwives. In this case health services confirmed that safer sleep messages were shared with the family. However, the family did not practice safer sleep with Ollie, as evidenced by the incident which led to his death and the downstairs Moses Basket appearing to be unused. This raises questions for the WSCP about the effectiveness of the messaging and whether a different approach is warranted. 1.9 Did professionals understand the additional stresses of parental mental health and substance abuse? – Both of Ollie’s parents had received treatment for depression and anxiety Wirral Safeguarding Children Partnership Page 2 issues, and in 2019 Ollie’s father was diagnosed with a panic disorder and referred for counselling. His mother had reported feeling low to her GP but had not returned for follow up appointments. Ollie’s father also admitted to recreationally using cocaine, although he stated this was never when the children were around.. However, there is no record of his drug use in any agencies reports, and therefore no concerns expressed. Similarly, wider agencies were also unaware of the mental health concerns, and therefore there was no triangulation of the issues being faced by the family. All the children in the family had traces of cocaine in their systems and it seems this was absorbed by them environmentally, rather than deliberately. Both parents were surprised by this but main-tained that the cocaine use by Ollie’s father didn’t have any impact on his care or safety. 1.10 Was disguised compliance a feature of this case and did the Covid-19 crisis impact on the circumstances of the family or on the capacity of services to respond to their needs? – It is not known whether Ollie’s parents deliberately tried to mislead services, but their behaviour did suggest elements of disguised compliance, such as not taking their children to some appointments, not attending some themselves, and listening to safer sleep messages but not acting on them. The impact of the Covid-19 pandemic and the subsequent lockdowns did remove families from the protective gaze of services, and unfortunately it did give families who wanted to be ‘missed’ the opportunity to avoid services. 1.11 Key findings: • Whilst Ollie’s death could not have been predicted, it is clear that unsafe sleeping was the primary cause of his death and therefore work to raised the awareness of safer sleep messages must be a priority action for the WSCP • Neglect doesn’t appear to be a significant factor in this case—it wasn’t explored in any detail, however, services were not sighted on the issues facing the family which resulted in a poor living environment which suggests the need for a more robust strategy and an offer of early help for families • Casual parental substance misuse was a feature of this case, and it is concerning that parents maintained that their drug taking did not affect their children. The WSCP should ensure a clear messaging campaign for parents and carers highlights the dangers for children • Covid-19 and its associated lockdowns removed a lot of families from being routinely seen by services. The WSCP needs to understand the scale of this in Wirral and whether there needs to be a wider offer of help to families who might still be struggling but are ‘under the radar’ of statutory services 1.12 Recommendations – Five recommendations are made: • To develop and publish a multi-agency neglect strategy • To review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants • To develop a campaign targeting casual substance misuse amongst parents and carers • To undertake a review of the local impact on families of Covid-19 and lockdowns • To deliver a series of locality based information events for parents and carers Wirral Safeguarding Children Partnership Page 3 Introduction and Methodology 2.1 On the 6th January 2021 an ambulance attended the home where 9 week old Ollie lived; the ambulance had been called because he was not breathing. The attending paramedics found Ollie to be unresponsive, and he was taken by ambulance to Arrowe Park Hospital where attempts to revive him continued, and later to Alder Hey Children’s Hospital in Liverpool for specialist care. 2.2 The paramedics, and police officers who attended the scene shortly afterwards both described the home as being messy and in poor condition. Ollie and his parents appeared to be sleeping downstairs and co-sleeping. 2.3 At hospital Ollie remained in a critical condition. His parent’s were informed that there was a significant chance that he would not survive. 2.4 Following a strategy discussion the Acute Life Threatening Event (ALTE) process was begun. Toxicological analysis indicated the presence of cocaine in Ollie’s system. It was agreed that the threshold for a Section 47 (child protection) investigation had been reached and the Local Authority applied for an Interim Care Order. 2.5 It was determined at hospital that Ollie had suffered a significant brain injury and his condition deteriorated. Ollie sadly passed away on the 4th February 2021. 2.6 The police opened an initial investigation based on a finding of cocaine in Ollie’s urine. 2.7 The case was referred to the Wirral Safeguarding Children Partnership Case Review Committee who undertook a rapid review to determine if a statutory Child Safeguarding Practice Review1 (CSPR) should be undertaken. The committee unanimously agreed that CSPR should be undertaken given that Ollie had died and the serious concerns about neglect, the condition of the house and co-sleeping that had been raised. The Child Safeguarding Rapid Review panel agreed with the decision to proceed with a CSPR. The CSPR was completed in September 2022. CSPR Terms of Reference 2.8 The Wirral Safeguarding Children Partnership agreed that the CSPR should consider: • the family’s circumstances—including the sleeping arrangements with Ollie, stressors and vulnerabilities • the potential impact of Covid-19 lockdowns and the family’s visibility • the delivery of safer sleep messages • the effectiveness of information sharing __________________________________ 1Child Safeguarding Practice Review (CSPR). A CSPR should be undertaken in circumstances where a local authority knows or suspects that a child has been abused or neglected and the child dies or is seriously harmed. The purpose of a CSPR is to establish what lessons can be learned in a case to strengthen safeguarding arrangements to reduce the risk of similar incidents occuring. Wirral Safeguarding Children Partnership Page 4 • learning from the National Panel’s report: Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm, relevant to this case • learning for the multi-agency partnership and individual agencies 2.9 CSPR activity in Wirral is coordinated by the multi-agency Case Review committee on behalf of the safeguarding partnership. The committee provides oversight to each review and ensures that the review has access to the relevant multi-agency expertise. Membership of the committee includes the Designated Doctor and Designated Nurse for Safeguarding Children, the Head of Safeguarding Children for the Local Authority, a Police Detective Chief Inspector, a consultant Head Teacher, and Early Childhood Services Service Manager, and a Practice Improvement manager. CSPR Methodology 2.10 The approach for completing CSPR’s is based on the Social Care Institute for Excellence Learning Together methodology2 which involves the gathering of information from agencies involved in the case and consideration on decision making—why certain decisions were made at the time and consideration of the family’s daily lived experience and whether there were any additional stressors on the family. The methodology also includes the identification of key practice episodes, which had a significant influence on the way the case was managed. 2.11 The views of the family were also gathered as part of the review process. Key Practice Episodes 2.12 Four key practice episodes (KPE’s) were identified and considered as part of this review are: • The identification of, and response to neglect • The effectiveness of safe sleep messages • Did professionals understand the additional stressors of parental mental health and substance misuse, and did these negatively impact the safety of the children? • Whether disguised compliance was a feature of this case • The visibility of the family and the extent the Covid-19 crisis impacted either on the circumstances of the family or on the capacity of services to respond to their needs __________________________________ 2Learning Together Methodology Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Methodology provides a framework for undertaking Child Safeguarding Practice Reviews where the identification of learning to strengthen safeguarding arrangements is key: https://www.scie.org.uk/publications/reports/report19.asp Wirral Safeguarding Children Partnership Page 5 Context What was known about the Family? 3.1 Ollie lived at home with his parents and three siblings in a semi-detached house in Birkenhead, Wirral. The family all identify as white British. The children, for their whole lives, have lived at home with their parents. The family genogram is shown below: 3.2 Prior to the incident which led to Ollie’s death, the family accessed universal services, including health care and schooling, but they hadn’t had any prior involvement with children’s social care. Analysis of the multi-agency chronologies of involvement evidence that the family were well known to community health—a consequence of having four young children, and the older children were well known by their school. There was evidence of some poor school attendance, and a number of missed health appointments, but generally the family weren’t considered in need or at risk. 3.3 Ollie’s father was known to Merseyside Police having been previously arrested for being drunken and disorderly some years before, and he was one of a number of people arrested at a private house disturbance for affray, and possession of cocaine for which he was given a Caution, and a Fixed Penalty Notice. 3.4 The three older siblings attended the same local Primary School. Between 2018 and 2020 there had been a number of conversations between the children’s parents and the school about challenging behaviour at home, reluctance of one child to attend, and late attendances by all the children. The parent’s had also raised some behavioural concerns about two of the children with the school and with health professionals—one of the children had been diagnosed with Sensory Processing Disorder which affected their behaviour. However, no safeguarding concerns had been raised in respect of any of the children, nor had any concerns been deemed serious enough to trigger a referral into Early Help or Children’s Social Care services. 3.5 Ollie’s father had been prescribed diazepam since 2018 for depression and a panic disorder. In 2020 Ollie’s mother was also treated by her GP for depression and anxiety and prescribed anti-depressant medication She complained of stress at home and challenges getting the children to school. Wirral Safeguarding Children Partnership Page 6 28 Ollie’s mother Ollie’s father 38 7 0 5 3 Ollie Born Nov 2020 Died Feb 2021 Sister 2 Sister 1 Brother 1 3.6 Recently there had been a number of non attendances by the children’s mother at telephone appointments and failure to keep GP and hospital appointments for the children. A number of ‘did not attend’ instances were recorded by the midwifery service in respect of the children’s mother. The hospital followed up the non attendances but no safeguarding or wellbeing concerns were noted. Ollie had three failed appointments in the 6 weeks before the incident which led to his death. 3.7 Following Ollie’s birth, a number of postnatal home visits were arranged. The first visit took place as planned at the home but no assessment of home conditions or Ollie’s sleeping arrange-ments were reported. Shortly afterwards the family reported that they were self-isolating due to Covid-19 therefore the following ‘visits’ were conducted by telephone and no assessment could be made of the living conditions. The final home visit from the midwifery service on the 24th November 2020 did not record any concerns. 3.8 The Health Visiting service similarly reported that home visits could not be undertaken due to the family self isolating or the children’s mother reporting to be sick. However, during a telephone virtual ‘visit’ on the 13th November 2020 the Health Visitor provided the children’s mother with safe sleep guidelines and signposted her to further information provided by the Lullaby Trust. This was in keeping with local guidance where, on a pan-Mersey basis, safe sleep messages were delivered as part of an ongoing campaign by health professionals. The messages included highlight-ing the dangers of co-sleeping. The local Safeguarding Partnership included the same messages on its website and signposted parents and carers to detailed guidance and advice from the Lullaby Trust. 3.9 It is notable, however, that the safe sleep messages are usually delivered in a home visit at the same time that baby’s sleeping area is viewed and assessed. There is no evidence in the records—including from the face to face visits, that Ollie’s sleeping arrangements were viewed, or that wider home conditions were assessed. And, even though it is recorded that safe sleep messages were shared, there is no record of what precisely was discussed or given to the family. 3.10 As this is not the first review undertaken locally where a child has died or been injured as a result of co-sleeping it suggests that an early recommendation for the Wirral Safeguarding Children Partnership will be to review the multi-agency processes for sharing safe sleep messages with families, and determine whether other, more effective means for communicating the messages need to be designed or adopted. 3.11 It is clear, however, that the family were known to services for a number of years by virtue of having four young children prior to Ollie’s tragic death. And, in that time the family were not known to children’s social care, or identified as being in need of additional services. 3.12 Home conditions at the time of Ollie’s death were described as being poor which strongly suggests that there was a deterioration in the living arrangements of the family in the months before his death. Prior to this, and prior to Covid-19 related lockdowns the family were much more visible to services and a number of ante and post-natal visits to the home had taken place, none of which had raised significant concerns. Wirral Safeguarding Children Partnership Page 7 The Incident 4.1 At approximately 11.15am on the 6th January 2021 a 999 call for an ambulance was received in respect of 9 week old Ollie who was reported as not breathing. An ambulance arrived a few minutes later at the home address and Ollie was found to be unresponsive and in asystolic cardiac arrest. His father was carrying out CPR when the ambulance arrived. Ollie was dressed in a nappy and had some bleeding from his nose. A Guedel airway was inserted and Ollie was given two doses of adrenalin. Spontaneous circulation resumed after a gap of approximately 23 minutes. 4.2 The ambulance staff reported the house to be cluttered and dirty. Police arrived on the scene and Ollie was taken to Arrowe Park Hospital accompanied by his parents. 4.3 Attempts to resuscitate Ollie continued in the ambulance and at hospital. Ollie’s parents were spoken to by the Paediatric Registrar at the hospital and his mother advised that Ollie had had a cough since Christmas, although his condition had been improving over the past few days. This had been reported to the health visitor during a visit about a week before. 4.4 Ollie’s parent’s reported that during the night of the 5th January he had been unsettled and wouldn’t sleep, but had taken good feed at 3am. At 6am his father wrapped Ollie in a blanket and lay on the sofa with him where he fell asleep. Ollie’s father was awoken at about 11.00am by his daughters and reported that Ollie was face down in his arm crease with his whole face covered and had blood around his nose. Ollie’s father shouted for his wife (Ollie’s mother) to call an ambulance, but she could not find a phone so ran to a neighbours house and an ambulance was called and arrived within a few minutes. 4.5 The police arrived at the property shortly after the ambulance staff and described presentation of the property as messy, in poor condition with no lighting and dog food all over the floor. Ollie and his parents appeared to be sleeping downstairs where there was a large sofa and Moses basket which appeared to be unused. The master bedroom contained a mattress which was stood up against the wall. There was also a small open swimming pool in the garden which was dirty and covered in algae. 4.6 The police reported that there was no immediate evidence of drug paraphernalia at the property and were told that the family were self-isolating due to a family member testing positive for Covid-19. 4.7 At hospital Ollie was described as being critically unwell and exhibiting symptoms consistent with accidental suffocation. He had no movement and was floppy, and his pupils were unresponsive and fixed. The Paediatric Consultant informed parents that there was a significant chance that Ollie wouldn’t survive and if he did he would certainly suffer from significant neurological problems. 4.8 A strategy discussion was held between health staff, children’s social care and Merseyside Police later on the 6th January and it was agreed that the Acute Life Threatening Event (ALTE)3 process would begin and an ALTE meeting would be held the following day. 4.9 The Paediatric Consultant shared that toxicological analysis of Ollie’s urine had revealed the presence of cocaine. In response to this it was agreed that parents could only have supervised Wirral Safeguarding Children Partnership Page 8 access to Ollie and their other children, who were to be temporarily looked after my their maternal uncle through an Interim Care Order. When informed of the presence of cocaine it was reported that Ollie’s father admitted to rubbing it into his gums to sooth toothache, but he couldn’t explain how it had got into Ollie’s system. 4.10 Agencies at the strategy discussion agreed that the threshold for a Section 47 assessment had been reached. 4.11 In the early evening of the 6th January Ollie was transferred to Alder Hey Children’s Hospital in Liverpool. Unfortunately, following a number of scans and interventions over the following few weeks it was determined that as Ollie had sustained such a significant hypoxic injury to his brain and brainstem any meaningful recovery was now not possible. Life support was withdrawn with the agreement of Ollie’s family, and he passed away on the 4th February 2021. A police investigation and children’s services involvement with Ollie’s parents and siblings are both ongoing. Key Practice Episodes 5.1 Four key practice episodes (KPE’s) were identified and considered as part of this review are: • The identification of, and response to neglect • The effectiveness of safer sleep messages • Did professionals understand the additional stresses of parental mental health and substance misuse, and did this compromise the safety of the children? • Was disguised compliance was a feature of this case and did the Covid-19 crisis impact on the circumstances of the family or on the capacity of services to respond to their needs? 1. The identification of, and response to neglect 5.2 Ollie’s parents had lived in the same home for almost 8 years, having moved in just before their eldest child was born. All their children have been raised there. 5.3 Neglect is defined as the persistent failure to meet a child’s basic and/or psychological needs4, and this includes the requirement to provide a safe and secure environment. Persistent poor home conditions are a common indicator of neglect. _________________________________ 3Acute Life Threatening Event (ALTE) Published as part of the Merseyside Sudden Unexpected Death of a child/infant (SUDiC) protocol, the ALTE procedure is initiated when there has been any sudden/unexpected collapse of an infant or child requiring some form of active intervention/resuscitation and subsequent intensive care / high dependency unit admission. A multi-agency meeting is held for the purposed of sharing information and determining whether further investigation or review is required. 4Working Together to Safeguard Children (2018) statutory guidance, page 108 Wirral Safeguarding Children Partnership Page 9 5.4 Poor home conditions were raised as a concern by agencies attending the property in response to the incident on the 6th January. The concerns included the house being dirty and unkempt, with parts of it in disrepair and visibly dangerous. It was also noted that there was no electricity in the house and light bulbs appeared to be missing. 5.5 Prior to this there was a record from 2015, made by a Health Visitor following a home visit who recorded that the house was ‘untidy with dirty bottles and dishes on the floor’. It is unknown what happened as a result of this, but it did not lead to a contact with children’s services or a referral to early help services. The next reference to home conditions in the multi-agency chronology was made five years later in 2020 where a visiting midwife reported home conditions to be ‘satisfactory’. Unfortunately, the use of terms such as ‘satisfactory’ is highly subjective but does indicate that there were no causes for concern. 5.6 Prior to January 2021 there is no record of any contacts or referrals being made to children’s services in relation to home conditions or any other indicators of neglect. However, here is no doubt that the condition of the home as witnessed by services attending on the 6th January was in a poor and unsanitary state, and it was an unsafe environment with sharp tools left within the children’s reach, and unsuitable for children to be living in. 5.7 In later conversations with children’s social care Ollie’s parents stated that they accepted that the home conditions on the 6th January were not acceptable, but maintained that this was an unusual situation and the state of the home environment had only recently declined from its usual high standard. The parents provided photographs to the children’s social worker which did evidence the home as being tidy and well decorated months before the incident in January 2021. In Court statements provided in early 2022 the parents stated that home conditions had started to decline as a result of rewiring work undertaken by their housing association. The work caused considerable damage to the interior walls of the house and created a lot of rubbish which the contractors failed to repair or remove. 5.8 The parent’s further explained that they were sleeping downstairs on the couch because of the work being done and this was planned to be a temporary measure whilst Ollie’s father redecorated the house room by room. He added that this was taking longer than he had anticipated due to the pressures of having a new born baby, and because lockdown had caused the house to be crowded. 5.9 The police recorded that when they attended the family home on the 6th January there was no electricity or lighting. The parent’s explanation for this was that their pre-pay meter had just run out of money—which was an unusual situation. The parent’s denied that they might be struggling with bills or debt and said that it was just unfortunate that the electricity had run out when it did. Unfortunately, there is no record of them being asked about the absence of lightbulbs, or any issues around possible debt being explored further. 5.10 It is clear that on the 6th January the home environment was unsuitable for the family to live in, and was a potentially dangerous place for the children to be. This is agreed both by the professionals who visited the property that day, and by the parents themselves. There is no evidence of neglect in any form having been reported previously which suggests that either the home conditions had not been witnessed by professionals, and other indicators of neglect had been Wirral Safeguarding Children Partnership Page 10 missed, or the situation in the house on the 6th January was out of the ordinary. The latter conclusion is the most supported, and reasons for the deterioration in the home conditions are explored in more detail below. 5.11 Apart from a previous recorded concern in 2015 there were no other recorded concerns by professionals and the family was not on any organisations safeguarding ‘radar’. 2. The effectiveness of safer sleep messages 5.12 Giving parents safer sleep messages has been an embedded part of practice in Wirral for a number of years. It is recorded in the Community Trusts chronology that safe sleep messages were shared with the family, including advice from the Lullaby Trust. However, it is clear that as the sleeping arrangements in the house were unsatisfactory, evidenced by the unused Moses basket downstairs and the mattress leaning against the bedroom wall upstairs, as well as the parents decision to sleep with Ollie on the sofa, that the importance of safe sleep was either ignored or not understood by the family. 5.13 The dangers of parents co-sleeping with their infant children, and the tragic deaths of children as a result has been a consistent feature of Child Death Overview Panel activity for the last several years, and is often cited as the most common avoidable reason for infant death in Merseyside. Consequently, local messaging and campaigns reinforcing safe sleep messages have a been a feature in Wirral and across Merseyside, including the Six Steps to Safer Sleep campaign. Safe sleep messag-es are typically given by health professionals such as midwives and health visitors and include a mix-ture of verbal messages and literature including leaflets, and branded resources such as forehead thermometers. 5.14 It isn’t known whether the safe sleep messages were followed up or reinforced, or what Ollie’s parent’s reasons were for not abiding by them. It is speculative to say that the parent’s decision making was blurred by substance misuse, but given the evidence of cocaine in Ollie’s system, it cannot be ignored that this was possibly a contributory factor, in the same way that using alcohol can result in poor decision making. 5.15 It is appropriate for the Wirral Safeguarding Children Partnership to review the effectiveness of local safe sleep messages and consider ways to consolidate the advice with families, perhaps through an update and publishing of a new Safe Sleep strategy. Any strategy must be informed by local parents about what type of messaging id the most effective for them. 3. Did professionals understand the additional stresses of parental mental health and substance misuse, and did this compromise the safety of the children? 5.16 Both of Ollie’s parents had recently received treatment for depression and anxiety issues. Ollie’s father had been treated for anxiety and depression on and off since 2009. In 2019 he was diagnosed with panic disorder and referred for counselling. He also later reported to children’s social care that his mental health declined following the loss of a close friend and concerns about his father’s health—who had recently suffered a stroke, and that this led to him using drugs as a coping strategy, although there is no reference to drug use or suspected drug use in any of the Wirral Safeguarding Children Partnership Page 11 health chronologies, and Ollie’s father was not known to the local substance misuse service. 5.17 The logical conclusion to draw therefore is that Ollie’s father had not discussed his drug use with any professionals, and that there was no suspicion of his drug use amongst any professionals. It is not known whether discussion of the link between his mental health issues and drug use formed part of his counselling sessions, but no referral to other services followed. 5.18 In conversations with children’s social care several months after the incident with Ollie, his father said that he felt that his mental health had not affected his parenting and would not affect it in the future, even though parental mental health concerns are a known feature of compromised parenting, and this would undoubtedly be exacerbated by drug use. 5.19 In early 2020, a year after Ollie’s father was diagnosed with panic disorder, his mother attended her GP and was diagnosed with anxiety and depression. In the GP chronology it is recorded that Ollie’s mother complained about stress at home and poor school attendance by her eldest child. This tally’s with what the school were reporting about school attendance, but it doesn’t appear that the disclosure to the GP led to a referral to early help services, as might be expected. It also appears that there was no ’join-up’ between Ollie’s mother’s mental health concerns and those of his father. It was advised, however, that Ollie’s mother should self-refer for counselling. 5.20 The following month Ollie’s mother attended a GP review, but did not attend any further reviews. She later reported to children’s social care that she has never suffered significantly from mental health issues, and went to the GP about her mood, feeling low and having panic attacks. She added that she was given medication but reported that she did not take it due to finding out that she was pregnant. 5.21 Unfortunately, this information was not seen in the context of any other concerns, such as those expressed by the school, and missed appointments, which taken individually may not raise safeguarding concerns, but when seen together may trigger assessments or at least conversations between services and families. The downplaying by the parents of the potential impact on children’s welfare of substance misuse is very concerning, but perhaps driven by thinking it isn’t a risk if it isn’t done in front of or near to the children. Unfortunately, as this case shows, parental drug misuse presents drugs into the environment where they can be absorbed by children, as well as the impact they can have on poor decision making by parents. 5.22 Ollie’s father in his statement to the court, commented that he used cocaine on the 5th January and considered whether he perhaps put Ollie’s dummy in his mouth or his bottle at any stage after administering cocaine onto his own tooth because of toothache but he added that he does not recall doing this. 5.23 After Ollie was born the parents had a new baby, a four year old, a five year old and a seven year old to look after which is a challenge for any parent for more so for those who already feel under pressure. This would have been exacerbated by the Covid-19 lockdown, particularly when the schools were closed, and the family were together for a prolonged period. However, during this time the family were not particularly on any agencies radar. Wirral Safeguarding Children Partnership Page 12 4. Was disguised compliance was a feature of this case and did the Covid-19 crisis impact on the circumstances of the family or on the capacity of services to respond to their needs? 5.24 Ollie’s parents did exhibit some of the features of disguised compliance, for example they listened to the safe sleep messages provided by the Community Trust but did not act on them, they cancelled appointments, but did attend some, and they claimed to be self-isolating—which may have been true, but if not was a plausible reason for not engaging with services. 5.25 It is an unfortunate side-effect of the Covid-19 pandemic that families became less visible to services—the majority of home visits ceased, and were cancelled or replaced with telephone or video calls. Services were subject to their own modifications, many of which in the health economy happened as part of wider efforts to support the Covid-19 response, particularly the vaccination programme. This inevitably led to some staff being redeployed and the knock on effect on frontline services. 5.26 All services also had to adapt to a general reduction in staff numbers, through infection with Covid-19 or isolation as part of strategies to prevent the spread of the virus. All of these factors would give a greater opportunity for families who wished to avoid services to become less visible. 5.27 Most services, including the Local Authority and health services used risk assessments during the pandemic to identify the most vulnerable families who required the most attention, for example families with children on a child protection plan were prioritised for home face-to-face visits. However, Ollie’s family didn’t fall into that category, and didn’t therefore receive the scrutiny that they otherwise might have. 5.28 In regard to the concerns about home conditions which declined around the time of the pandemic, it is likely that the additional scrutiny brought by home visits would have raised concerns about the home conditions and may have triggered interventions and raised questions about what other issues might be facing the family, and what other support might they might need. 5.29 The emergency services reported that Covid did not impact on their services. 5.30 It cannot be stated that the loss of visibility of the family due to the Covid-19 lockdowns directly or indirectly contributed to the death of Ollie5.28 As described above there was at least one occasion when the family claimed to be self-isolating due to another family member having tested positive for Covid-19. However, prior to this they had cancelled or not attended meetings. These had been followed up by individual agencies but there weren’t enough concerns for any one agency to initiate a multi-agency process to share information. 5.31 Health agencies have reported that due to the Covid-19 pandemic they are not delivering as many face-to-face services as before, but rather are holding meetings virtually and over the telephone instead. Wirral Safeguarding Children Partnership Page 13 Out of routine: A review of sudden unexpected death in infancy ( SUDI ) in families where the children are considered at risk of significant harm 6.1 The Child Safeguarding Practice Review Panel published a national review of SUDI5 in families where the children are considered at risk of significant harm in July 2020. Even though none of the children in this family were considered at risk of significant harm, or known to services, the findings of the national review are still relevant to this case because SUDI events represent one of the most common reasons why cases are referred to the Panel, and almost all of those incidents is caused by parents co-sleeping with infants in unsafe sleep environments, including those where parent’s had consumed drugs—as happened in this case. 6.2 A key question of the review was how professionals could best engage with and support parents to ensure that safer sleep advice is heard, understood and acted upon. As stated previously, Ollie’s case is not the first local incident where co-sleeping has had a tragic consequence, and it does suggest that the way in which services engage with families, especially those who may be vulnerable, needs to be reviewed to ensure the safe sleep messages are as effective as possible. 6.3 The review identified a number of risk factors which would make a SUDI more likely. These factors include: unsafe sleeping position; unsafe sleep environment—including co-sleeping; smoking during or after pregnancy; using alcohol or drugs; poor ante-natal attendance; poor post-natal care; low birth weight. Of the known risk factors, co-sleeping and drug or alcohol use are the most com-mon, and both were concerns in this case. Other factors such as poor ante-natal attendance, as part of wider non-attendance at health appointments were also features for this family. 6.4 The review added that social and environmental factors such as deprivation and overcrowding were known to increase the risk of SUDI, and that risk factors can be singular or add in combina-tion. Since the publication of the review an additional pressure caused by lockdowns in response to Covid-19 has had a negative impact on families, both through the removal of families from the protective gaze of services, and the additional home life stress caused by families being forced to live in close proximity with each other for extended periods of time. 6.5 Both parents in this case had stated that home life was causing them stress and Ollie’s father said that this was exacerbated by the lockdown. 6.6 The review explored the effectiveness of local arrangements for promoting safer sleep, and therefore reducing the risk of SUDI, through feedback from a number of safeguarding partnerships across the country. The review found that local safer sleep plans were fairly generic and included ___________________________________________ 5Out of routine: A review of sudden unexpected death in infancy ( SUDI ) in families where the children are considered at risk of significant harm. National Child Safeguarding Practice Review Panel July 2022: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf Wirral Safeguarding Children Partnership Page 14 promotion of breastfeeding, support for smoking cessation, key messages about the risks of co-sleeping, briefing materials for professionals and promotional activities. 6.7 The review explored the effectiveness of local arrangements for promoting safer sleep, and therefore reducing the risk of SUDI, through feedback from a number of safeguarding partnerships across the country. The review found that local safer sleep plans were fairly generic and included promotion of breastfeeding, support for smoking cessation, key messages about the risks of co-sleeping, briefing materials for professionals and promotional activities. All of these activities had been part of the Wirral strategy since the birth of the family’s first child, and continued to be the bedrock of ongoing local safer sleep work. 6.8 The national review concluded that such strategies can have mixed results, and parents often reported that messages were inconsistent and that materials were ‘too wordy’. Parents also said that utilising tools such as social media would help make the messages more manageable and would reinforce the key messages. 6.9 The national review did highlight good practice, including the use of high quality materials from the Lullaby Trust—although it did caution that the impact on families was reduced if resources were poorly printed, poorly presented or photocopied. Best practice was often achieved when safe sleep messages were part of a holistic public health strategy which included elements of supporting pregnancy and parenthood, alongside action to reduce health inequalities or poverty, whilst also identifying and simplifying access to early help and prevention services. 6.10 Since the incident which led to Ollie’s death, work in Wirral has continued to develop an easy to understand and easy to access early help and prevention system. This has included the develop-ment of the Family Toolbox, an online early help and prevention website for Wirral families, which allows them to directly access tools which can support parents and carers, details of people who can help, or places that parents can go for help, all without the requirement to be assessed or to reach a particular threshold, or to complete an application form. 6.11 The national review includes a proposed ‘prevent and protect’ practice model as a vehicle for developing and including local initiatives for preventing and reducing the risk of SUDI. Development of a local model in Wirral forms part of this review’s recommendations and will be informed by the key learning and recommendations from the Out of Routine report. Wirral Safeguarding Children Partnership Page 15 Strengthening Safeguarding Arrangements 7.1 It is the main aim of this review to help ensure that it is as difficult as possible for tragedies such as this to occur. This includes responding to the learning directly identified in this case, but also in considering whether the case ’shines a light’ on the strength of the wider safeguarding system. 7.2 This review has identified a number of concerns and stressors within the family, including poor home conditions, unsafe sleeping arrangements, parental mental health and parental substance abuse, as well as the impact of the Covid-19 pandemic and resultant lockdowns which removed the family from the gaze of services. 7.3 The review advises the WSCP that the immediate and wider safeguarding system can be strengthened in the following ways. Response to neglect 7.4 Neglect of children is the main reason for another reason CSPR commissioned by the WSCP, and it is a major or contributory reason in a number of learning reviews undertaken over the past few years. A common finding in all the cases is the absence of, or the limited use of evidence based assessment tools such as the Graded Care Profile, or the objective assessment of home conditions. Recent recommendations from local reviews include development and publication of a new multi-agency neglect strategy, which itself includes guidance and tools for the early identification of neglect, how neglect can be indicative of other issues, and pathways of support for families. 7.5 Professionals in this case did have evidence of poor home conditions and potential neglect and by exploring these in more detail may have become aware of other concerns. To support strengthening of the safeguarding system this review will endorse the recommendations from the CSPR about neglect, and the learning from this case will be shared with the multi-agency steering group currently developing the neglect strategy. Recommendation: 7.6 For the WSCP and the Safeguarding Adult’s Partnership Board to work collaboratively to develop and publish an integrated multi-agency Neglect Strategy. The strategy must include actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with, and is influenced by other factors including parental mental health and substance misuse. Safer Sleep strategy 7.7 Unsafe sleep is the main issue in this case which led to the death of Child Ollie. The report has already described how safe sleep safe messages are already bound in practice in Wirral, but how—cases such as this—suggest that they are not as successful as they need to be in encouraging safe sleep. 7.8 The ‘Out of Routine’ review includes a proposed ‘prevent and protect’ practice model for safe-Wirral Safeguarding Children Partnership Page 16 guarding partnerships to adopt to help them develop a strategic framework to reduce the risk of the sudden and unexpected death of infants (SUDI). The framework includes a strategy to promote positive safe sleep messages as part of a more holistic public health strategy. Recommendation: 7.9 The report recommends that the WSCP reviews its approach to safe sleep messaging and SUDI prevention and creates an updated practice model based on the ‘prevent and protect’ model suggested in the Out of Routine: A Review of SUDI in Families with Children at Risk report. The new model must be multi-agency and holistic in its nature and include the commissioning of services to promote safer sleeping, a review of the current thresholds of need, review of relevant local processes, and development of the workforce Parental substance misuse 7.10 There was regular parental substance misuse taking place in the house by Ollie’s father, and Ollie and his siblings all had traces of cocaine in their systems. Ollie’s father could not explain why the children tested positive for cocaine but theorised that perhaps Ollie came into contact with it via his dummy if he had put it in his own mouth when using cocaine for toothache. It was also sug-gested that perhaps the other children came into contact with traces of cocaine on their father’s clothes. 7.11 It is clear that neither parent saw the use of cocaine as a potential safeguarding issue because it was never used when the children were around. It is also clear that agencies were not aware that Ollie’s dad was using cocaine around the time of his death and it was not something he had raised with services. Recommendation: 7.12 For the WSCP to work with substance misuse services to create awareness raising materials aimed at parents/carers warning them of the dangers of their own social drug use to their children and others in the same environment. The WSCP to also ensure that the wider workforce are aware of the issue through its substance misuse training. Testing of understanding by professionals should take place through the Section 11 process. Hidden Harm and the legacy of the Covid-19 pandemic 7.13 The review strongly suggests that the issues facing this family were, to a lesser or greater extent, hidden due to the lockdowns caused by the Covid-19 pandemic. As previously stated the Covid pandemic led to changes being made to the wider delivery of services, including health services, resulting in the replacement of routine home visits with virtual visits and telephone conversations. Families could also tell services that they were self-isolating (whether they actually were or not), and avoid face-to-face visits. 7.14 During the Covid period this family were struggling, as indicated by the decline in home conditions, but services were not as sighted on the impact of the additional stresses brought by Wirral Safeguarding Children Partnership Page 17 Covid than they would have been under ‘normal’ circumstances. It is impossible to say whether the Covid pandemic and resultant lockdowns indirectly contributed to the death of Ollie, but it is clear that with additional support the issues facing the family may have been able to be addressed. Recommendation: 7.15 For the WSCP to undertake a wider piece of local research to determine the impact that the Covid-19 pandemic and lockdowns has had on families with young children, and to consult with families to ensure that the universal and early help and prevention offer to families includes support for issues identified in the research and by families. Recommendation: 7.16 For the WSCP to deliver a series of locality centred events for families including a market place of local services and access to advice and guidance, and for the WSCP to evaluate the impact of the events. Single agency learning 7.17 Each agency involved in the review should examine their own learning and ensure a robust plan is in place to improve their own policies, practice, procedures and guidance. Recommendation: 7.18 For individual agencies involved in the review to develop their own learning action plan and to share regular progress with the WSCP case review committee until all actions have been completed. Wirral Safeguarding Children Partnership Page 18 Summary of Recommendations 8.1 Six recommendations are made to the WSCP as a result of this review: 1) For the WSCP and the Safeguarding Adult’s Partnership Board (SAPB) to work collaboratively to develop and publish an integrated multi-agency Neglect Strategy. The strategy must include actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with, and is influenced by other factors including parental mental health and substance misuse 2) For the WSCP to review its approach to safe sleep messaging and SUDI prevention and creates an updated practice model based on the ‘prevent and protect’ model suggested in the Out of Routine: A Review of SUDI in Families with Children at Risk report. The new model must be multi-agency and holistic in its nature and include the commission-ing of services to promote safer sleeping, a review of the current thresholds of need, review of relevant local processes, and development of the workforce 3) For the WSCP to work with substance misuse services to create awareness raising ma-terials aimed at parents/carers warning them of the dangers of their own social drug use to their children and others in the same environment. The WSCP to also ensure that the wider workforce are aware of the issue through its substance misuse training. Testing of understanding by professionals should take place through the Section 11 process. 4) For the WSCP to undertake a wider piece of local research to determine the impact that the Covid-19 pandemic and lockdowns has had on families with young children, and to consult with families to ensure that the universal and early help and prevention offer to families includes support for issues identified in the research and by families 5) For the WSCP to deliver a series of locality based events for families including a market place of local services and access to advice and guidance, and for the WSCP to evaluate the impact of the events 6) For individual agencies involved in the review to develop their own learning action plan and to share regular progress with the WSCP case review committee until all actions have been completed. Wirral Safeguarding Children Partnership Page 19 Appendices 1. Partner organisations involved in the review 9.1 The following agencies participated in this rapid review: • Local Authority Children’s Services • GP • Merseyside Police • North West Ambulance Service • Wirral University Teaching Hospital NHS Foundation Trust • Wirral Community Health and Care NHS Foundation Trust • Grove Street Primary School (in respect of siblings) 9.2 A chronology of involvement, including key questions was submitted by each agency including analysis, identification of learning, and an assessment both of their involvement, and the effective-ness of multi-agency working. The minutes of the Acute Life Threatening Event (ALTE) meeting held shortly after the incident also informed the review. 2. References 9.3 Documents and resources referenced in the review: • Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Method-ology provides a framework for undertaking Child Safeguarding Practice Reviews where the identification of learning to strengthen safeguarding arrangements is key: https://www.scie.org.uk/publications/reports/report19.asp • Out of routine: A review of sudden unexpected death in infancy ( SUDI ) in families where the children are considered at risk of significant harm. National Child Safeguarding Practice Review Panel July 2022: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf • Pan Merseyside SUDIC Protocol: https://www.wirralsafeguarding.co.uk/wp-content/uploads/2020/07/SUDiC-0-18-YEARS-FINAL-23.6.2020.pdf • Working together to safeguard children (2018): Statutory guidance on inter-agency working to safeguard and promote the welfare of children. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 David Robbins April 2023 Wirral Safeguarding Children Partnership Page 20 |
NC52782 | Fatal stabbing of an adolescent boy. At the time of his death, Andre was subject to a child protection plan and to a youth referral order with intensive supervision and surveillance. The incident took place in a park where Andre should not have been due to an exclusion requirement as part of this order. Learning includes: to work effectively to support a parent in becoming a consistent protective factor where a young person is facing risk in the community, practitioners must understand the history and trauma of the past and current vulnerabilities in the parent's life which contributes to their style of parenting; relational practice with individual young people needs to sit within a strategic approach of developing community-based assets. Recommendations for the partnership include: prioritise and focus on acknowledging and reflecting upon what good culturally competent and anti-discriminatory practice is and how to embed it in safeguarding practice; ensure that multi-agency assessments and planning of children include an assessment of parenting in that goes beyond the practical capacity to provide care and explores the parent-child relationship in the light of the family's history of vulnerability and risk; ensure strategic oversight of the operational multi-agency arrangements for responding to young people who experience significant adversity and risk in different contexts; ensure that the nature of engagement with families is reflected upon, and that effective engagement is evidenced in changes made in the family.
| Title: Local child safeguarding practice review re Andre. LSCB: Enfield Safeguarding Children Partnership Author: Enfield Safeguarding Children Partnership Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final version for publication (v5) January 2023 1 Local Child Safeguarding Practice Review re Andre Introduction 1. A Local Child Safeguarding Practice Review was initiated in Enfield regarding Andre after the National Child Safeguarding Review Panel responded to the Rapid Review report, submitted on 02.09.2021. At the time of his death, Andre was subject to a Child Protection Plan and to a Youth Referral Order (YRO) with Intensive Supervision and Surveillance (ISS). The Rapid Review was necessitated as Andre had been stabbed to death in a park where he should not have been due to an exclusion requirement as part of this order. At the time of his death, he was wearing a tag, however learning has been identified in that a GPS tag had not been requested as part of this requirement. The Rapid Review had also identified good practice in engagement with this young person and in managing risk and some learning around information sharing, duplication in systems that supported working with young people, and difficulties in re-housing families. 2. The National Panel advised the Enfield Safeguarding Children Partnership regarding further areas of further inquiry to inform learning: “We thought your LCSPR should be proportionate and build on the learning you have already identified through your rapid review and should focus on the two identified areas of learning. In particular, to explore the interaction between diversity and culture and to look at how your newly established adolescent safeguarding service is working and how it impacted on this case”. 3. The National Panel also sent this link to their report on Child Criminal Exploitation “It was hard to escape”. The National Panel also noted its own focused activity around the challenges of securing appropriate housing for young people at risk of exploitation or involvement in gang activity as a short-term solution. This had been an issue raised by the ESCP as a result of learning from the Rapid Review. 4. The Rapid Review had also identified that there was merit in exploring further the theme of practice and planning when working with parents with parental mental health in terms of developing the parental capacity to be protective in the life of the young person. Therefore, these three themes, along with adding to any of the learning already identified through the Rapid Review process, are the focus of this review. the learning will be taken forward through the Safeguarding Partnership learning and action planning by the Practice Improvement sub-group. 5. A learning summary was provided for practitioners in the form of an Executive Summary in May 2022 with key findings shared with practitioners, whilst the criminal prosecution of Andre’s alleged assailants was pending. In November 2022, a teenager was found guilty of murdering Andre. Final version for publication (v5) January 2023 2 Methodology 6. With the suggested themes from the National Panel as a guide to the next steps for this review, the independent reviewer facilitated several conversations with different practitioners who had worked directly with Andre. The first conversation was held on 24th November, virtually, with a large group (approx. 25) of practitioners, their managers, and strategic leads. Key practitioners who had worked directly with that attended are listed at point 14 below. Also, the child protection chair; a specialist police officer from the exploitation team attended and all staff were appropriately supported by managers in attending the meeting as well as strategic leads for safeguarding. 7. The conversation was structured using the following questions as guidelines: i. What does this case tell us about how we work with culture, diversity, identity: what works well? what might we do differently? what needs to change in order to get this area of practice ‘right’? ii. What learning from this case might be useful for the new adolescent safeguarding service? Think good practice and what might we need to do differently iii. Working with parental mental health when working with a parent to help them respond and manage contextual risks to their child? what works well? what might we do differently? what needs to change in order to get this area of practice right? 8. The time allocated to this discussion was perhaps not enough given the complexity and the emotional investment by practitioners when working with Andre and the impact of the tragic ending of his life. Additionally, the conversation was rich and the content very in-depth and to do their practice and experience justice, further conversations were held those who came in to contact with Andre and his family. During December 2021, these included: • A meeting with staff at the Pupil Referral Unit (PRU) where he was on roll for two years with the two deputy headteachers; the YOS worker; the YOS psychologist; the YOS head of service, followed by attending weekly assembly at the school with all pupils present. • A meeting with the team managers and practice leads in the newly developed Adolescent safeguarding service in the local authority • A discussion with the allocated social worker to Andre and his family, now manager of the team working with the family • TBA – a discussion with the family GP; adult mental health service [this remains outstanding at the time of writing] • The independent reviewer wrote twice to Andre’s mother during January 2022 and made contact through two professionals in February 2022 with whom she was currently receiving services from. However, Andre’s mother felt she did not wish to engage with this review process. Final version for publication (v5) January 2023 3 The young person 9. It is essential to preserve the young person’s anonymity and that of his family, however the information in this section hopefully gives some insight in to the extent of the working relationships that professionals were able to form with Andre. There was significant detail shared with the reviewer regarding the nature of their relational practice with him. Some detail is also included to reflect the underpinning approach that practitioners emphasised to the reviewer and hopefully emulated in this review: that this is a “child first, offender second”. 10. Andre was well-liked by those who met him professionally. He was described as having “a presence”: there was something about him”. He was also described as “a pleasure to work with”, “polite and never rude”. Andre was mixed-heritage, from two diverse ethnic backgrounds. He was said to have been proud of his ethnicity. He was described as a “real family man” by one practitioner and very protective of his sibling. 11. Some members of this extended family, who lived in another part of the UK, were involved throughout in his life and were regarded as positive and protective factors for him. A grandparent had died when Andre was in his early teens. This loss was felt to have been a turning point and had had a negative impact on Andre in terms of his presentation. 12. Andre’s father is not thought to have been involved in his life, which may have led to a sense of rejection for Andre. It was reflected upon by some professionals that not enough had been done to engage with Andre’s father as a possible protection from the risk of exploitation and gang involvement, however this may have been led by Andre’s own view of his father. Andre lived with his mother, a sibling and sometimes his mother’s partner in a very small flat. Andre’s girlfriend, who he met at his school, sometimes stayed with them. Practitioners suggested that the family’s flat was very small, and that the situation had often felt “oppressive” for Andre. Often at the weekend, his mother and younger sibling went elsewhere, leaving Andre alone. Some practitioners suggested that Andre did not seem to like mother’s partner much and perhaps felt rejected when his mother went to stay with her partner. 13. During the last 18 months of his life, Andre had significant professional involvement with professionals, both within the criminal justice system and the child protection system. Prior to his death he was subject to a Child Protection Plan and to a Youth Referral Order (YRO) with Intensive Supervision and Surveillance (ISS). This sentence was felt to have been a rapid escalation in severity given that he had been involved in the criminal justice system for a relatively short period. An observation was made that the opportunity to work in the way that practitioners did with Andre only came with this level of involuntary intervention, however Andre took the opportunity and did engage in a meaningful way. Professionals included: a. An allocated Youth Offending Worker after he was place on the YRO b. An allocated C and F social worker who worked with him and his mother and sibling Final version for publication (v5) January 2023 4 c. A police officer from the Exploitation/ Gangs service. d. A specific intervention with the YOS psychologist e. Contact with the YOS nurse f. At the PRU there were 4 key staff members who Andre gravitated towards and who were in daily contact with him which he was in attendance – two of who are the deputy head-teachers. g. Gangs and mentoring worker from a third sector organisation, including activities such as football 14. The details of his offences which led to this sentence can be found in the Rapid Review however they related to carrying a weapon and possession of Class B drugs. Practitioners were clear that Andre did not use cannabis or even smoke cigarettes. As part of his ISS, he had been excluded from a specific area in the city, primarily for his own safety. Andre was not known to be involved in ‘county lines’ and was felt to be on the periphery of a gang he associated with. 15. Prior to this period, Andre had not been known to statutory services, and had not stood out until his exclusion from mainstream school when he was 14. An attempt at rehabilitation to mainstream school had not worked, resulted with him returning to the PRU. It was noted by practitioners that Andre felt he had no friends however observed that he had friends at the PRU but had also made friends in the mainstream school who were regarded as hard-working and high achievers. At the PRU, Andre a range of activities – staff observed that he enjoyed playing cards and games but also often sought solitude and like to read books intended for a younger audience, perhaps as a way of comforting himself. 16. The YOS worked with Andre on a daily supervision timetable which included educational activities provided within his full-time attendance at the PRU as well as pro-social activities such as helping at the food bank, which Andre was said to have enjoyed very much. He was subject to a 12-hour night-time curfew and wore a tag. Learning identified after his death and since them implemented for other young people was that Andre’s safety could have been increased by GPS tracking of his tag – he was fatally injured in the area that he had been banned from visiting. 17. Andre had a close relationship with his girlfriend who he had met at the PRU. The relationship appears as caring but intense, and when his mental health deteriorated, it was suggested that this relationship became less ‘healthy’ in terms of how Andre behaved towards her. Part One: Working with Andre’s culture and diversity. 18. Safeguarding professionals involved in the Rapid Review were curious about why Andre was drawn to carrying a weapon and to being part of a gang from another part of the city. They were also concerned as to how Andre’s mother seemed at times to be protecting him and at other complicit in enabling him to access situations which professionals felt compromised his safety. A useful challenge made was that to understand this more required more information about how practitioners made sense Final version for publication (v5) January 2023 5 of this family’s behaviours as representative of their culture and what was that culture? The learning arising is considered alongside some key publications. The following definition of culture was offered to the learning event held on 24.11.2021. Using this definition as a starting point, the review sought to understand what extent practitioners understood, responded to, and worked together using a culturally competent approach. “Culture can be understood as the social heritage of a group, organised community or society. It is a pattern of responses discovered, developed, or invented during the group's history of handling problems which arise from interactions among its members, and between them and their environment. These responses are considered the correct way to perceive, feel, think, and act, and are passed on to the new members through immersion and teaching. Culture determines what is acceptable or unacceptable, important or unimportant, right or wrong, workable or unworkable. It encompasses all learned and shared, explicit or tacit, assumptions, beliefs, knowledge, norms, and values, as well as attitudes, behaviour, dress, and language…. …Culture provides a context that made the behaviour of individuals understandable. "The only way in which we can know the significance of the selected detail of behaviour is against the background of the motives and emotions and values that are institutionalised in that culture” (Benedict, R, Patterns of Culture, 1934, published in referenced document) 1 19. Another recent publication by Her Majesty’s Inspectorate of Probation (HMIP:2021) is also relevant in the analysis it offers around the disproportional over- representation of black and mixed heritage boys in the criminal justice system 2 and their experience of racism which often results in the pathway that leads them into that system. As suggested by the HMIP research: “The skills, understanding, knowledge and integrity of the worker and the relationships they form with black and mixed heritage boys are the most important factors in supporting and promoting meaningful and effective engagement.” The ethnicity of the worker was not deemed to be so important, however, the evidence suggests that practitioners that acknowledge racism as one of the ‘problems’ which shapes a young person’s responses are demonstrating these factors. The practitioners in this review spoke of “honesty, integrity and transparency” in their work with Andre and his peers as the basis for successful engagement. 20. Andre worked with several practitioners who, during the conversations held, evidenced their understanding of his complex lived experience including the structural and individual racism he experienced; their willingness to explore the difficult aspects of this with him in very skilled and nuanced ways; and their capacity to meet his needs 1 Practice Guidance for safeguarding children in minority ethnic culture and faith (often socially excluded) communities, groups and families. Section 5.1 Accessed 03.01.2022 http://iscp.gg/CHttpHandler.ashx?id=110456&p=0 2 The experiences of black and mixed heritage boys in the youth justice system. A thematic inspection by HM Inspectorate of Probation October 2021. Accessed https://www.justiceinspectorates.gov.uk/hmiprobation/wp-content/uploads/sites/5/2021/10/The-experiences-of-black-and-mixed-heritage-boys-in-the-youth-justice-system-thematic-report-v1.0.pdf Final version for publication (v5) January 2023 6 for care and nurture. How they did this and continue to do so with other young people is described below. 21. Over the course of time, Andre had ‘self-selected’ 4 members of staff at the PRU who became trusted adults for him. One discussed how they had worked individually with Andre to reflect on his mixed-heritage identity, on how his peer group saw him and how more generally the world perceived him. This appears as an on-going exchange – this member of staff offered this opportunity flexibly, often in the context of engaging Andre in a practical activity or helping in the school. Andre was “exploring his masculinity and trying to work out where he fitted in”: this staff member emotionally supported him through that process. Different staff developed their own individual styles of relationship with him. They spoke about sometimes having to take a risk in how they responded to him, needing to recognise his demeanour when Andre arrived in the morning. Andre had been very clear when he started at the PRU that he did not like or appreciate any appropriate physical touch however one staff member recalled that he would sometimes take a risk with that and was important to do so as part of his connection with Andre. 22. This staff member reflected upon the experience he shared with Andre of being a black man, and how this led to instances where the police would stop them unfairly. They would discuss the bigger societal inequalities through to managing racist micro-aggressions in interactions with others. It was observed that Andre was developing an understanding of how he would be treated because he was black, echoing the comment in the HMIP research: the boys demonstrated a degree of fatalistic acceptance that they are treated differently based on their ethnicity. Police stop and search was discussed in this context and, while it was evident that this was a stressful experience, it had also become normalised and an accepted part of everyday life.3 We cannot speculate as to whether Andre ‘accepted’ this, but it does appear as though he was being helped within this positive relationship to navigate these challenging experiences. 23. Practitioners identified that racism had encroached in to and influenced his attachment relationship with his mother as the primary caregiver. Practitioners said that Andre’s mother had indicated that her family had wanted her to terminate the pregnancy with Andre because his father was black. Practitioners reflected their analysis that Andre’s identity had been conflicted and that he had sensed rejection from infancy resulting in his low self-esteem. Andre was not sure yet of his identify but seeking something and the practitioners spoke of working with him to try to help him construct his self so that he was confident in who he was. Like many young people this might result in experimenting. For Andre, being associated with a gang may well have driven in part by seeking his identity. 24. The practitioners from the YOS and the school understood the complexities of Andre and his peer group. Andre sometimes maintained that he had no friends, staff felt that due to his trust issues and fear of rejection, he may not have invested in peer 3 Ibid, p21 Final version for publication (v5) January 2023 7 relationships. Staff reflected on the intricacies of peer group dynamics and the techniques they used to work with peers who were all receiving services from statutory agencies. Several examples were shared of the (frequently deployed) technique of using third-party scenarios to support exploring dilemmas with young people: Andre’s friends approaching trusted practitioners with their concerns, describing hypotheticals regarding an anonymous friend’s difficulties, as Andre did regarding other young people. Practitioners would then talk through with the young people, resolving problems and helping them finding solutions, as well as identifying the positive in young people’s concern for their friends. One practitioner emphasised that friendship is a powerful and positive resource in the face of serious youth violence and should not be seen as a threat, suggesting that friendships between groups of black and mixed heritage boys should be understood with more nuance than through a negative lens which criminalises those friendships. 25. Staff worked hard to understand his perception of the fear Andre felt. Andre’s reality was that he lived in one area but stated he had affiliations to a gang from another part of the city. The roots of this fear were tangible for professionals – Andre had been involved as a victim in some fear-provoking incidents and it was acknowledged that to get to school, Andre had to cross an area where another gang were known to meet. Youth offending practitioners were clear they knew Andre’s anxiety about even stepping out of his front door: they worked to manage the risks posed in different geographical contexts. They also ensured the safety of young people who came to their offices by making it their business to use professional intelligence and information from young people themselves to understand what is happening on the streets, in schools, in young people’s networks and friendship groups; and in gangs – i.e., in all their contexts, each of which had their own cultures and rules. The Head Teacher at the PRU noted that she ensures that all staff are kept up to date with this contextual information/ intelligence as relevant to the need to safeguard each pupil. 26. Often Andre arrived at school seeking solitude. Again, practitioners were able to evidence the need to work at this pace of the young person. One staff member would sit outside with him on the sports area, sometimes in silence, if that was what was required, or would walk with him. Practitioners understood the intensity of his living arrangements as an unwanted aspect of his culture: the experience of deprivation, lack of choice and a poverty of opportunity. Andre had nowhere to escape to when his home was crowded. One of the school staff was emphatic in describing how substandard and overcrowded housing was the most significant factor for many of the young people in the school and describe how young people spoke of the inevitability of choosing to go out on to the street, rather than be cooped up. But to be out on the street comes with risk and so some young people also chose to carry a knife for safety. 27. Practitioners worked with Andre to develop different strategies to overcome his fear and poor mental health, acknowledging the different aspects of safety e.g., emotional, physical, or locational. It was recognised that he needed respite from the pressure of his life and so his order was varied so that he could go to stay with relatives. When went to visit the maternal extended family he described “feeling Final version for publication (v5) January 2023 8 free”, but he then returned to the city. The YOS psychologist recognised in how psychological interventions could be provided in flexible and different ways – understanding and intervening with mental health and illness to not only with a focus on the individual but the influence of and interaction with their context and environment upon their emotional wellbeing. This intervention allowed Andre to reflect and explore his behaviour as a response to the adversities which formed his responses - that were his culture. 28. Professionals note that Andre had stated he would only live until he was 17 – but it was hard to understand if he had meant he would commit suicide. When he was depressed, Andre had questioned what the purpose of life was and that he felt there was ‘no purpose’. The YOS psychologist recalls encouraging Andre to articulate where he had learned that fact – that there was no purpose, thus allowing him to explore some of the challenges and losses in his life. During sessions they discussed the ‘pros and cons’ of being alive and explored and spoke openly about his poor mental health. They also spoke of music and ethnicity which were central to Andre’s life. The psychologist observed that an everyday experience of racism and a sense of purposelessness was at the forefront of many young people’s poor mental health. 29. Andre had experienced racism at mainstream school and had been treated differently from white peers, however his experience of the PRU was different. The PRU’s embedded trauma-informed approach is aimed at tackling the commonly faced problems of the young people that attend of exclusion and of poor life opportunities to interrupt the development of a young person’s culture as violent and harmful. The setting recognises the trauma of being excluded from the mainstream education system and why it happens. Not re-creating this is central to their offer to young people and the PRU works to ensure that the ‘failures’ experiences are not internalised and that negative events, often driven by bias in the system, should not define them. 30. At the PRU, enrichments days are often celebration events which are based around celebrating the positives of the young people’s culture. The approach is visible throughout the school with posters, artworks, displays celebrating the unique culture symbols, practices, patterns and rituals of all of the young people that attend. The PRU also recognises that, for some children, there are not the supportive structures around them and that to recover from exclusion the school provides emotional support as central to their response and also in the preventative short-term interventions on offer for younger pupils on the edge of exclusion. 31. It was reported that Andre and his mother felt let down by the housing department in the area that they had planned to move to and felt as though they were turned down because they did not fit. This was compounded by additional hurdles in the housing application process department which delayed the plan to move Andre out of the city, which then led to his mother not pursuing the option to move. One practitioner spoke of structural racism that the family had experienced and the challenge for him as a professional in that Andre’s family deemed the practitioner as Final version for publication (v5) January 2023 9 not able to make a difference with their housing need. The family perceived him as “the same as us” i.e., as also struggling with racism as a black person. 32. Understanding Andre’s unique culture and experience of diversity was key to managing the extra-familial safeguarding risks to Andre and posed by him, especially where his perspective on that risk was opposite to that of professionals. Professionals worked to understand the ‘pull factors’ , the attraction of the gang that Andre was affiliated with. The gang provided clear rules and consistency in expectations in a way where other contexts did not – for example the difficulties of a teenager living with a parent who had challenging behaviours due to mental illness. It provided something which Andre recognised and wanted to be part of. Andre was clear that he felt safe when he went to the place where the gang, he associated with was based. Another draw for Andre was the music and the fashion. One practitioner suggested that the gang should not be considered ‘ a black culture’ , but a ‘young person’s culture’ that offers alternatives to boys and young men who did not have alternative role models such as fathers who would give the innate sense of belonging that was sought. Andre was very guarded in his conversations in terms of sharing information about what he did and where he went but practitioners describe using third party scenarios with Andre to examine the risks and rewards of being affiliated to the gang. Key practice pointers in working with culture and diversity: 33. There are some brief pointers which appear to underpin the approach to working with culture and diversity with young people such as Andre. • Ensuring that the young person’s voice is central to the intervention - “doing with, not to”. • Be transparent and honest about your role and statutory duties and who you work alongside e.g., courts, police, but also create safe spaces for young people to talk • Being informed about the young person and the contexts they move through – what is happening now that is relevant. • Working in a strength-based risk informed way with young people – risk is everywhere, everyday; as are resources and protective influences, and sometimes risk and resource can be found in the same place. • Communicating in real time with practitioners in partner agencies around new or relevant information which informs risk management • Reflect in real time with colleagues about the young person, events, changes and what they might mean. • Reflect with the young person about their experience. • Between the YOS worker and the psychologist, they spoke of “passing on the trust” Andre had in one professional, into the new professional relationship. Learning Point: the practitioners in this review demonstrated some excellent practice with Andre. There were many enabling factors support good quality practice – values, the context of practice, leadership, communication, clarity of purpose and approach, experience, skills, personal attributes which this account has only briefly touched upon. Final version for publication (v5) January 2023 10 Recommendation One: Acknowledging and reflecting upon the elements of good culturally competent and anti-discriminatory practice is and how to embed it in safeguarding practice in Enfield should be a priority and focus for Enfield Safeguarding Children Partnership over the next year. Part Two: Working with parental mental health. 34. Practitioners observed that the relationship between Andre and his mother seemed more sibling-like than parent-child and enmeshed and complex. Practitioners working with the family noted unpredictable nature of Andre’s mother’s mood and presentation. Even when Andre’s mother sought help from agencies, the communication and engagement often became difficult, with mother responding in a way that was described as ‘hostile’ and ‘aggressive’ by practitioners. Whilst practitioners understood this as due to her poor mental health, partly due to mother’s explanations for her behaviour, there was not a shared understanding of her mental health diagnosis and how it impacted upon her parenting: the mother had disclosed differing explanations to differing professionals as to what her diagnosis was. Some practitioners did evidence their very detailed understanding of Andre’s daily lived experience of his mother’s behaviours and described how they sometimes had to mediate over the phone between Andre and his mother. Andre’s day at school was observed as ‘mirroring’ how his morning at home had gone – his mood emulated the pattern of his mother’s different moods. 35. One practitioner who worked closely with mother evidenced a well-practiced strategy for supporting mother to engage with services. Some forms of communication were not useful but unannounced visits were, where Andre’s mother was found to be less confrontational. Working at the mother’s pace allowed this practitioner to access the home to assess the family. Positively, this mother was noted as tending to her children in driving Andre to school or cooking an evening meal every evening. However, whilst acknowledging this as a good basis for change in families, the focus on simply achieving visits or acknowledging a parent’s capacity to provide basic physical care may have fallen short of gripping the more complex and harmful aspects of the inconsistency or unpredictability in meeting a child’s emotional needs. 36. Practitioners found that mother sometimes swung between being authoritarian, then authoritative, then overly permissive towards Andre. At some points she appeared to act protectively – confiscating weapons from him, but at other times she was less so and bribed Andre with rewards. One key reward for Andre was that his mother would agree to take him to a place which was known to be the key area where a gang was based, where professionals had assessed that there were significant risks for him. This was a source of concern for the professionals whose key role was to manage this risk and an indicator of concern regarding the effectiveness of the plans made. 37. Whilst practitioners observed and understood Andre’s experience, the absence of a shared understanding of his mother’s diagnosis might have offered further points for how to build a relationship with her, and some indication of what might and might not Final version for publication (v5) January 2023 11 have worked in terms of interventions to help her keep Andre safe. Several practitioners observed that although mother did engage and speak with professionals, her actions did not always evidence that she followed their advice, and they felt she may not have been able to, due to the deeply entrenched patterns in her relationship with her son and her fluctuating mental well-being. Practitioners were seeking to develop his mother’s capacity to be a protective factor however did not fully understand the underlying factors in her behaviour her poor mental health as the possible manifestation of her own experience of childhood adversity. 38. Andre’s case was co-ordinated and managed through the local authority’s High-Risk Panel (HRP). A concern was identified through the Rapid Review and amplified in further discussions around the lack of key information shared with or explored by the professional network either at the HRP or in Child Protection Conferences regarding the mother’s history. Practitioners reflected that this would have significantly impacted upon how professionals engaged with the mother. It would also have made very different a key aspect of the safety plan for Andre which was made at the HRP. The fact that the safety plan was based around the possible source of mother’s own trauma had not been known although key details of this were known by one of the statutory agencies. There was enough evidence and information in the Child Protection system around this family to prompt curiosity about the underlying causes of this mother’s presentation and how it might impact upon her children, even though at times, she provided adequate care to her children. However, it was identified by some agencies that there was a gap in the assessment of parenting. Learning point: To work effectively to support a parent in becoming a consistent protective factor where a young person is facing risk in the community, practitioners must understand the history, the trauma, of the past risks and current vulnerabilities in the parent’s life which contributes to their style of parenting. Curiosity is required regarding where observed behaviours come from. They should be discussed openly with the parent and reflected upon overtly as to how these factors might contribute to their parenting style. Recommendation Two: The partnership needs to ensure that multi-agency assessments and planning of children include an assessment of parenting in that goes beyond the practical capacity to provide care and explores the parent-child relationship in the light of the family’s history of vulnerability and risk. Part Three: Information regarding the new Children’s Specialist Service established June 2021 39. In the Rapid Review meeting and follow-up practitioner event, it became clear that there was both duplication and gaps in the parallel statutory processes managing the risk of Andre offending and the risk of harm to Andre from familial and extra-familiar harm. Further inquiry has evidenced ongoing service development around the Children’s Services’ Adolescent Safeguarding service which works with young people who are experiencing these different statutory processes. Final version for publication (v5) January 2023 12 40. On 14.12.2021, a conversation took placed with a small group of senior practitioners and managers of the new Enfield Adolescent Safeguarding Service, established in July 2021 and colleagues from Children’s Services Assessment and Safeguarding teams. The National Panel suggested considering how the learning from practice in this case might support the development of their service. The focus of this inquiry was to ask what might be different in terms of intervention for a young person like Andre going forward? 41. There are two small adolescent safeguarding teams and a contextual safeguarding team within the service for which the case of Andre is particularly relevant. As well as social workers, there are youth workers, an embedded teacher and the Missing Co-ordinator. There are also close links to the Targeted Youth Support workers and a half time police post. 42. The service is still developing its delivery model and practice approach. Currently, cases come via a range of referral routes, and this is an area for developing and streamlining the route to the intervention in the service. Most workers in the service are new in role and therefore developing how they might intervene with individual young people, their families and in the communities that they live in. In the conversation there was there was evidence of some useful reflection about what the key objectives and challenges are for the service and of where the service could improve on what has been offered previously. A useful summary of what the challenge is: how can the service compete successfully with the ‘offer’ from exploiters and gangs. 43. The identified approach was felt to be ‘two-pronged’ by working with the young person to fully grasp their lived experience and to work with the community to develop protective factors for young people – one example was given of the local football clubs as well as other sports. Practitioners in the conversation articulated their work with young people as ‘relational’, and that they needed to be open and honest to gain that in return from young people. Their role as workers appears to be multi-faceted: pro-actively enabling young people to access community opportunities, but also to work with young people to develop self-protection skills. Practical approaches offered included working with young people to recognise themselves and their experience, and to support the young person in identifying where the ‘red lines’ were for them in terms of the risks they faced. Working practices need to be flexible and creative to engage young people earlier and effectively. 44. This echoed the reflection on good practice by those that had worked with Andre as described in Part One of this review – it is suggested that all the practitioners working with the same cohort are offered regular opportunity to reflect and develop their practice approach together – YOS, education-based practitioners, and the new Adolescent Safeguarding service. 45. Evidence of strategic planning also emerged in terms of considering what the workforce in the service needed in terms of skills development but also partnerships with other organisations who could offer appropriate interventions. Therefore, the Final version for publication (v5) January 2023 13 adolescent safeguarding team were embedding evidence-based Edge of Care interventions and engaging with more local services such as a local provider of therapeutic mentoring as well as more widely offered schemes such as the Aspire programme offered by Transitions UK, as well as a Home Office offer of training in Cognitive Behavioural Therapy. The service manager also identified that the staff would be accessing clinical supervision to divert them from compassion fatigue and possibly developing secondary trauma. 46. It is clear that those in this conversation were thinking creatively and drawing on their experience about how the new adolescent service could be and the key is to begin to try and test the model out and develop a clear articulation of the offer from the service and the outcomes they wish to achieve for the young people, their families, and their community. Getting the identification, assessment and practice interventions right were identified by staff members as being key, as is a need to clearly defined roles and responsibilities with key colleagues and partners. 47. The service manager articulated several other areas that were the priority for development. Some of these were more practice based, for example where and how is early help offered. Andre had had no early intervention – his first service response from the multi-agency network were around exclusion and alternative school placement. Additionally, there is an identified need to work more effectively with siblings in families in order to avoid the development of the same vulnerabilities and repetition of the same risk in subsequent children in the same family. 48. We discussed some of the findings of the Rapid Review in terms of the duplication of structures and processes, another area of priority. The service manager felt that there is a need to improve upon the internal navigation of complex policy and procedures around contextual safeguarding – echoing the issues raised in this case regarding more effective applications of statutory tools to keep young people safe. The conversation identified a need to ensure strategic buy-in to support the changes needed and that these changes were a work in progress. The strategic management roles have been identified and the development of the framework needed is underway. The SCP should ensure a focus on these development over the next year. 49. The other two priorities mentioned were particularly relevant getting the information / intelligence sharing arrangements clear with those in practice confident about the status of information, from ‘hearsay/gossip’ to information as part of criminal inquiries and how it can be used. This is as relevant to individual cases as to the community/ context information around where the risks were coming from and where community interventions could be made to divert young people from violence. The other priority which lies beyond the team but is in the grasp of the partnership is to consider how resources can be accessed across the LA, schools, health and police 50. There was a recognition from those attending who had been involved regarding how complex Andre’s case had been. The professional commitment and activity were there, the level of risk was understood, and the right interventions were in place, although the safety planning was not so well informed. Andre and his mother had Final version for publication (v5) January 2023 14 appeared engaged, Andre did talk and share with professionals and so there was a tangible hope that the plan to protect him would work. However, it is noted that the nature of engagement with parents with mental health issues is often hard to gauge – again, practitioners must reflect together on what ‘real’ engagement looks like with families. The evidence of engagement lies in the nature of the changes that families make to their ways, their patterns and their responses. Learning point: That relational practice with individual young people needs to sit within a strategic approach of developing community-based assets. The key to this is to ensure effective joint working strategically and operationally to address any potential obstacles regarding the basic of information sharing; shared service pathways; shared approach to engagement and interventions; shared priorities at different levels of need and risk. Some of this is in place and (anecdotally) is working well but there appear to be further improvements needed to ensure maximum impact. Recommendation Three: Enfield Safeguarding Children Partnership ensure they have strategic oversight of the operational multi-agency arrangements for responding to this cohort of young people, who experience significant adversity and risk in different contexts. This should be a priority for the partnership in the forthcoming year and activity should include working with the safeguarding ambassadors to understand impact upon outcomes. Recommendation Four: That Enfield Safeguarding Children Partnership ensure that the nature of engagement with families is reflected upon, and that effective engagement is evidenced in changes made in the family. PART FOUR: System issues that have arisen during conversations 51. An observation from the author was that whilst there was some excellent practice on an individual basis and from teams at the PRU and the YOS in working together, there is a sense that the structural challenges of disproportionality, racism and poverty experienced by black and mixed-heritage children works against positive outcomes for them and makes the experience of practitioners working in the system more difficult. One practitioner voiced his frustration at the gap between weak strategic planning and the reality of young people’s lives as not tackling the real issues- e.g., addressing and rectifying the overuse of stop and search with young black people. It noted that since the practitioner event in November 2021, the Enfield Targeted Youth Engagement Board is focusing on Disproportionality across services in Enfield – this is a significant and relevant workstream to the learning from this review. 52. There was also some learning in terms of implementing review mechanisms when a child or young person dies which will be addressed through the partnership of ensuring that the difficult experience of some practitioners in attending the CDOP rapid response meeting very soon after Andre’s death is not repeated. This has been addressed with the new CDOP lead as a practice improvement issue. 53. Other good practice areas in the system were identified: The Headteacher from the PRU identified that the SAFE panel was an excellent source of data but also supported Final version for publication (v5) January 2023 15 case direction. The PRU also has a social worker working full time with the children that attended and their families, who received her supervision from the Exploitation team based in the LA. This worker is able to ensure that prevention and effective early response is key to the offer to the children at the PRU. 54. It should also be noted that during conversations with the practitioners that it was clear that the interventions offered to Andre and his family during 2020-21 do not appear to have been impacted negatively by working within Covid restrictions. The YOS service spoke of finding new creative ways to do their work and fulfil their statutory functions; the social worker continued to visit the family home and the PRU did not close at all throughout any lockdowns – continuing to provide education and nurture to vulnerable young people throughout. Part Five: Conclusions and Recommendations Despite Andre’s tragic death, the picture that emerges of the help and interventions he experienced prior to his death from a range of professionals is one of a committed and caring approach and much skill in their practice. After his death and through the Rapid Review process, agencies had reflected upon what they might have done differently in terms of responding to him and on how some systems and processes might not have been working as well as they could to co-ordinate interventions. Some of the changes identified as a result of this reflection were made swiftly. This review has led to some recommendations in the body of the report which are repeated below: ➢ Recommendation One: Acknowledging and reflecting upon the elements of good culturally competent and anti-discriminatory practice is and how to embed it in safeguarding practice in Enfield should be a priority and focus for Enfield Safeguarding Children Partnership over the next year. ➢ Recommendation Two: The partnership needs to ensure that multi-agency assessments and planning of children include an assessment of parenting in that goes beyond the practical capacity to provide care and explores the parent-child relationship in the light of the family’s history of vulnerability and risk. ➢ Recommendation Three: Enfield Safeguarding Children Partnership ensure they have strategic oversight of the operational multi-agency arrangements for responding to this cohort of young people, who experience significant adversity and risk in different contexts. This should be a priority for the partnership in the forthcoming year and activity should include working with the safeguarding ambassadors to understand impact upon outcomes. ➢ Recommendation Four: That Enfield Safeguarding Children Partnership ensure that the nature of engagement with families is reflected upon, and that effective engagement is evidenced in the changes made in the family. |
NC049421 | Death of Child Y, a 14-year-old girl, from an overdose of prescribed and over the counter drugs at her home in February 2017. Child Y was sexually abused by Child Q, a 15-year-old, whilst she was visiting the home of her paternal grandparents in October 2014. Child Q was arrested and charged with sexual assault. Victim support services were declined by the mother; the father was not contacted. Child Y suffered health problems, struggled emotionally and her school work deteriorated. Child Q's sentence and partially successful appeal had further impact upon her mental health. She was referred to CAMHS and disclosed self-harm and suicidal thoughts. She began a relationship with an adult in January 2017 until her death. During the period between taking the overdose and her death (4 days), a Child and Families Assessment was completed by the social worker concluding Child Y had not displayed any concerning worries or behaviours. Findings include: single and multi-agency responses could have been improved in order to enhance suicide prevention efforts; the work to support Child Y after the sexual assault was characterised by incomplete multi-agency working, and a general lack of awareness of the potential impact of child sexual assault on the victim and their families. Makes 11 recommendations including: children or young people who are victims of sexual assault should be offered a referral to a Child Independent Sexual Violence Advisor; to ensure the voice of the child is central to any contact; GP practices should review the service they provide to victims of child sexual abuse; widely disseminate learning from this case to enhance practitioner awareness of potential suicide risk factors.
| Title: Serious case review following the suicide of Child Y. LSCB: Blackburn with Darwen Local Safeguarding Children Board Author: David Mellor Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review following the suicide of Child Y Independent Author: David Mellor BA QPM 2 Foreword by Local Safeguarding Board Chair This serious case review (SCR) was commissioned in April 2017 following information presented to me that Child Y had died and had been known to a number of services relating to abuse. Before I outline the response from Blackburn with Darwen Local Safeguarding Children Board (LSCB) to this SCR, I would like to offer my heartfelt condolences, on behalf of all the agencies involved in this SCR, to the family of Child Y for their tragic loss. I would also like to thank the family members that contributed very bravely to this SCR and for their insights into how services can be improved in the future. All SCRs identify findings that individual agencies and multi-agency systems need to learn from so that the future recurrence of similar circumstances can be reduced. This case is no different and as an LSCB, covering all services that undertake work to safeguard and promote the welfare of children, we have fully accepted the recommendations made by David Mellor. With these recommendations, the agencies directly involved with Child Y and her family have also identified a number of learning points so their practitioners improve their practice and the agencies improve their safeguarding processes. All of these actions are being monitored by the LSCB and it is anticipated that they will be fully implemented over the coming months. In particular the learning from this SCR is being implemented into the Lancashire and South Cumbria Suicide Prevention Plan. In addition to the recommendations from this SCR and the priorities in the regional Suicide Prevention Plan, the LSCB has prioritised improvement actions in its 2017-18 Business Plan aimed at continuing to develop the skills and competencies of practitioners that work with our children and families so that indicators of abuse or neglect are responded to and children and families receive the services that are available locally. Earlier this month I chaired the Quality Assurance Committee of the LSCB and I was provided with an update on all the progress made with implementing the recommendations from this SCR, both multi-agency and single-agency. A number of agencies had already implemented their action plans in full and others were on their way to fully implementing their learning in the coming months. The LSCB has been recommended by David Mellor to monitor changes to some safeguarding processes that were implemented very soon after this SCR was commissioned and I will make every effort to ensure the learning is embedded in practice and leads to processes and systems that consistently safeguard and promote the welfare of children in the borough as expected by statutory guidance and local procedures. Our collective aim remains to maintain a local safeguarding system that helps in preventing abuse and neglect, and where abuse and neglect does take place that children are effectively safeguarded. Nancy Palmer Independent Chair, Blackburn with Darwen LSCB January 2018 3 Contents Page number 1. Introduction 4 2. Terms of Reference 5 3. Glossary 6-7 4. Synopsis 8-29 5. Contribution of the family to the review 30-33 6. Analysis 34-48 7. Findings and Recommendations 49-57 8. Single agency action plans 58-60 References 61 Appendix A 62-63 4 1.0 Introduction 1.1 Child Y died in late February 2017 having taken an overdose of prescribed and over the counter drugs at her home address four days previously. At the time of her death she was fourteen years old. 1.2 In April 2017 Blackburn with Darwen LSCB decided to commission a serious case review (SCR) on the grounds that Child Y was known to have suffered abuse and had died. 1.3 The LSCB appointed David Mellor as the independent SCR report author. David is a retired police chief officer who has over five years experience as an independent author of SCRs and other statutory reviews. He has no connection to services in Blackburn with Darwen. It was decided to adopt a “systems” approach to conducting the review. A more detailed description of the process by which the SCR was conducted is set out in Appendix A. 1.4 An inquest took place in June 2017 which determined that Child Y had died by suicide. 1.5 Blackburn with Darwen LSCB wishes to express sincere condolences to the family and many friends of Child Y. 5 2.0 Terms of Reference 2.1 The timeframe for the SCR was from October 2014 until February 2017 (the date of Child Y’s death). 2.2 The following generic terms of reference were set: Understand precisely who did what for Child Y and the underlying reasons that led individuals and agencies/services to act as they did; Establish if there are lessons to be learnt about the way local agencies and services within these agencies worked together; Review of individual/agency adherence to agreed agency and multi-agency policies and procedures; and Inform and improve local inter-agency practice on safeguarding children so that it leads to reducing the risk of future harm to children. 2.3 The following specific terms of reference were set: Were indicators of unmet need, risk and/or compromised parenting appropriately identified by practitioners through assessments and any disclosures? Were service responses to indicators/disclosures of unmet need, risk and/or compromised parenting in line with single and multi-agency policy? Were service responses provided in a timely manner to promote the child’s welfare? What role did management oversight play to enhance the quality of practice? 6 3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Child and Family Assessment (C&F Assessment) The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability. Continuum of Need is the framework to assist all those whose work brings them into contact with children, young people and their families to identify the level of help and protection required to assist children to grow up in circumstances that achieve their best outcomes. Fraser Competent - the Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgment of the Gillick case in the House of Lords (1985), which apply specifically to contraceptive advice. Lord Fraser stated that a doctor could proceed to give advice and treatment: "provided (s)he is satisfied in the following criteria: 1. that the girl (although under the age of 16 years of age) will understand his/her advice; 2. that (s)he cannot persuade her to inform her parents or to allow him/her to inform the parents that she is seeking contraceptive advice; 3. that she is very likely to continue having sexual intercourse with or without contraceptive treatment; 4. that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer; 5. that her best interests require him/her to give her contraceptive advice, treatment or both without the parental consent." (Gillick v West Norfolk, 1985) Independent Sexual Violence Advisor (ISVA) is trained to provide emotional and practical support to survivors of rape, sexual abuse and sexual assault who have reported to the police or are considering reporting to the police. Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry 7 will involve an assessment of a child’s needs and those caring for the child to meet them. A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry. 8 4.0 Synopsis Significant Practice Episode 1 – October 2014 until August 2015 during which sexual abuse of Child Y took place, partner agencies responded and the support offered and/or provided to Child Y appeared insufficient. (A significant practice episode is an episode from which is is possible to gain an understanding the way the case developed and was handled.) 4.1 During a late evening in mid October 2014 Lancashire Police received a report from the paternal grandmother of Child Y to the effect that Child Y (then aged 12 years) had been sexually assaulted by Child Q (then aged 15 years) whilst Child Y was staying at the home of her paternal grandparents. Child Q lived with Child Y’s paternal grandparents. Child Y lived elsewhere with her mother. 4.2 The sexual assault caused Child Y to become distressed. Child Q asked Child Y not to tell anyone about the assault but she informed her father, who was also present at Child Y’s parental grandparent’s address at the time. 4.3 The police attended, safeguarded Child Y and preserved evidence of the offence. Child Q had left the scene. Child Y was taken to the SARC (Sexual Assault Referral Centre) where she arrived in the early hours of the following morning. She was accompanied by her mother and police officers. The SARC provides forensic examinations, advice and comprehensive support services for women, men and children of all ages who make a complaint of rape or sexual assault. 4.4 Child Y was examined by a forensic medical examiner who noted some injuries which were consistent with the account Child Y had provided to the police. Forensic samples were obtained and handed to the police. There were said to be “no concerns” in relation to Child Y’s general health and wellbeing. No requirement for a Genito Urinary Medicine (GUM) referral was considered necessary. Neither the police nor the SARC appear to have considered a referral to an Independent Sexual Violence Advisor (ISVA) at this time. 4.5 Child Y and her mother were later returned home by the police. A letter was sent to Child Y’s GP to notify them of her attendance at the SARC. The SARC also notified their local paediatric liaison team who passed the information to hospital paediatric liaison team and then on to the school nurse service. (See paragraph 4.15) 4.6 The police submitted a crime report in respect of this sexual assault. The crime report provides an opportunity for the need for victim support to be identified by tick 9 box. In this case the relevant box was not ticked. However, the investigating officer has advised this review that victim support was verbally offered during a subsequent joint visit by police and children’s social care. The officer recalls that mother made it clear that support was not required at that time. The police suggest that the verbal offer of victim support and the declining of that offer may be the reason why the relevant box on the crime report was not ticked. (The offer and refusal of support does not appear in either the police or children’s social care chronologies. Apparently not all contact including offers of service were recorded on the police victim management system. (Vicman)) 4.7 In mid October 2014 Child Q was arrested and interviewed. He was later bailed pending further enquiries. On the same date Child Y provided an achieving best evidence (ABE) interview in relation to the incident. 4.8 The same day the police informed children’s social care emergency duty team of the sexual assault on Child Y by Child Q. The police notification included reference to the Special Guardianship arrangement under which Child Q resided with Child Y’s paternal grandparents. The contact from the police was picked up by the multi-agency safeguarding hub (MASH) manager the following morning who decided that the case should be referred to children’s social care as the level 4 threshold on the continuum of need appeared to have been met. The case was allocated to a social worker and a strategy discussion took place involving a children’s social care team manager and police and the health representatives (specialist safeguarding nurse) from within the MASH. Neither the school nursing service, Child Y’s school or her GP were invited to participate in the strategy discussion. The health practitioner within the MASH would have been the conduit for obtaining information from the school nursing service and GP. 4.9 The outcome of the strategy discussion was that Section 47 enquiries were initiated. The social worker carried out a home visit at which an officer from the police public protection unit (PPU) was also present. Child Y and her mother were spoken to and the former was described as being “in good spirits”. Her parents were said to have acted appropriately and presented as being able to safeguard their daughter. It is unclear how confident children’s social care could be about these judgements about parenting capacity given that they did not contact father at this time. There appears to have been no exploration of why victim support services had been declined. The parents were also noted to be co-operating fully with the police investigation. The outcome of the Section 47 enquiries was to continue with the children and families assessment (C&F Assessment) which had also been triggered that day. 10 4.10 The same day Child Y’s elder sibling came into the latter’s school to collect Child Y. As the elder sibling was not recorded on the school’s list of contacts for Child Y, the school was initially unwilling to allow her to take Child Y home in the absence of consent from Child Y’s mother. The elder sibling then told Child Y’s school pastoral manager that Child Y had been sexually assaulted and needed to come home. This information was then shared with the school’s senior leadership team who gave permission for Child Y to leave school with her elder sibling as these were considered to be “exceptional circumstances”. 4.11 No further action was taken at that time by the school in respect of the information that Child Y had been sexually assaulted. 4.12 Two days later the police created a vicman record within their crime recording system which detailed contact with victim and family. Child Y was described as “vulnerable / intimidated”. 4.13 The next day the school nursing service was advised via the paediatric liaison information sharing form that Child Y had attended the SARC for examination following an assault. School nurse 2 reviewed this information and recorded that the referral was “for information only at this time” and took no further action. The school nurse was aware that the police were involved and that the case had been referred to children’s social care. 4.14 Subsequently (early November 2014) the police notified the school nursing service of the October sexual assault on Child Y by sending them a Protecting Vulnerable People (PVP) report. The consequent plan drawn up by the school nurse was to “await further contact from children’s social care” and the PVP was scanned onto the school nursing Electronic Care Records (ECR) for Child Y. No contact was made by children’s social care, nor was there any attempt by the school nursing service to initiate contact with children’s social care. 4.15 In late October 2014 children’s social care completed the C&F Assessment in respect of Child Y. Appropriate checks were said to have been undertaken with school and health. However, school and school nursing records do not indicate that further information was sought by or provided to children’s social care for the assessment. The assessment identified no further safeguarding concerns and the outcome was “no further action” on the grounds that Child Y had an “excellent support network and all the adults involved with Child Y are acting appropriately and with her best interests as their focus”. However, it was noted that Child Y was “upset and scared about what is going to happen next”. 11 4.16 The letter from the SARC was subsequently received by Child Y’s GP and placed in her patient records. It is assumed that receipt of the letter prompted the GP’s late October 2014 contact with the hospital to inform the paediatric department of the sexual assault and contact the following day with children’s social care, who subsequently advised the GP that they were aware of the assault on Child Y and her case had now been closed. The GP did not contact Child Y or her parent to ask if she required support and did not raise the issue at the next appointment with Child Y. 4.17 In late October 2014 the SARC manager telephoned Child Y’s mother to check on her daughter’s welfare. Mother was recorded as saying that Child Y “was doing OK”, “had no problems” and was said to believe that Child Y had “lots of support”. The SARC manager noted that Child Y and her mother had the contact numbers for the centre, should either of them feel the need to make contact. 4.18 In early November 2014 Child Y told her school pastoral manager that a peer had made a comment about the sexual assault. Although this conversation was recorded in the pastoral manager’s log book there is no record of any action being taken and the pastoral manager is unable to recall any further details. This represented a second opportunity for the school to intervene in respect of the sexual assault on Child Y. 4.19 The police kept Child Y updated on the progress of the investigation of the sexual assault by advising either her mother or paternal grandmother of progress. The police have advised the review that they were aware of the potential conflict of interest in providing updates to the paternal grandmother, given that she had had a special guardianship order in respect of Child Q (and his birth sister). However, the paternal grandmother was seen by the police as a strong character who appeared to act as the family spokesperson. (In her contribution to this review, Child Y’s mother disagreed that Child Y’s paternal grandmother was the family spokesperson at that time.) 4.20 In mid January 2015 Child Y became involved in an altercation with a peer at school which was resolved by holding a restorative justice session between Child Y and two peers a few days later. 4.21 In February 2015 the police further interviewed Child Q in respect of Child Y’s allegations following receipt of forensic evidence and telephone search history results. Following this interview, the police prepared a file for consideration of charges by the Crown Prosecution Service (CPS). 4.22 In early March 2015 Child Y was treated for an asthma attack at the urgent care centre (UCC). 12 4.23 Following consideration of third party material (relevant information retained in respect of Child Y and Q by other agencies), the CPS authorised the charging of Child Q with a sexual assault on a child under the age of 13 years. He was duly charged at the beginning of July 2015 and bailed to the Youth Court where he entered a guilty plea in mid August 2015. The case was adjourned for six weeks to enable the youth justice service to assess Child Q in order to prepare a pre-sentence report. Child Q was granted Court bail subject to conditions which included no direct or indirect contact with Child Y. 4.24 In addition to working with young people who have offended, the youth justice service also has a duty towards victims of crime, including having processes in place to ensure that victims of youth crime are involved, as appropriate, in a range of restorative processes which seek to put right the harm they have experienced. 4.25 Accordingly, in late August 2015 a standard letter was sent to Child Y’s mother to notify her of youth justice involvement and advising that this was a voluntary process from which victims of crime could opt out if they wished. Youth justice simultaneously made contact with the victim support service to find out if their service was working with Child Y so that options for contact such as a joint visit could be considered. The victim support service advised that their service had not had involvement with Child Y. Significant Practice Episode 2 – August until November 2015 including agency responses to concern about Child Y’s relationship with Young Person R, provision of support for Child Y and impact upon her of sentencing of Child Q and his partially successful appeal. 4.26 In late August 2015 a youth justice worker made a safeguarding referral to children’s social care in order to advise that Young Person R, who was known to the youth justice service because of his sexually harmful behaviour (having been convicted of the sexual assault of a child under 13 by touching in July 2015 and sentenced to a 12 month referral order), had disclosed that he was in a relationship with Child Y. The disclosure had been made whilst he was being interviewed for a pre-sentence report. It was suspected that the relationship may be a sexual one. This information was also shared with Young Person R’s social worker. 4.27 The referral appeared to be received by the MASH at the beginning of September 2015 and an advice and consultation social worker telephoned Child Y’s mother who said that the relationship between Child Y and Young Person R was now over. Mother added that she had not seen any evidence of texts, phone calls or social media contact since Child Y told her the relationship had ended. She also said 13 that she did not think that Child Y was sexually active. Mother accepted advice that she should safeguard her daughter to ensure that there was no further contact. 4.28 During the conversation, mother said that whilst Child Y had “a lot of support around her”, her mother felt Child Y needed someone independent to open up to regarding her experiences. Mother confirmed that support had recently been offered by the youth justice service as a result of the court proceedings in respect of Child Q. A telephone discussion subsequently took place between the social worker and the youth justice service worker in which the latter agency advised that whilst they could not offer counselling to Child Y they would be able to support her through the court process. 4.29 With Child Y’s mother’s permission, MASH subsequently contacted Child Y’s school in order to discuss appropriate emotional support for her. The school was advised that Child Y had recently been in a relationship with a “known sex offender” (Young Person R) which had now ended. The MASH was concerned that Young Person R may show up at Child Y’s school. (At that time Young Person R was dual registered at Child Y’s school and an alternative provision) The school was also advised that the young person who had sexually abused Child Y in October 2014 was due to be sentenced soon and that this had caused Child Y “significant distress”. As a result, the school’s child welfare officer said she would arrange to meet with Child Y and her mother the following week to discuss any ongoing support the school could offer. The child welfare officer advised that if counselling was needed, this would need to be accessed by mother via their GP. 4.30 Seven days after MASH received the referral in respect of Child Y, her case was closed to children’s social care. Two days later Child Y’s mother telephoned the MASH to report concerns of harassment towards Child Y from Young Person R and his family. Child Y’s mother was advised to contact the police. Mother was said to be acting appropriately by blocking Child Y’s phone and escorting her in the community. 4.31 The advice and consultation social worker later re-contacted mother who said that the situation was now calm, adding that she had been in contact with Young Person R’s mother who had “begged” her not to contact the police as the family did not want any further trouble. Child Y was also said to be unwilling to report the matter to the police. Child Y’s mother was said to have agreed not to report the matter, unless there were any further issues. Updates were subsequently provided to the youth justice worker and Young Person R’s social worker. (In her contribution to this review mother could not recall any contact with Young Person R’s mother) 14 4.32 Child Y’s mother’s view appeared to be decisive in not reporting this matter to the police. Child Y was said to be in agreement with this course of action but she does not appear to have been spoken to directly by the social worker. The suggestion that Child Y had been harassed by Young Person R and his family does not appear to have been treated sufficiently seriously and there appears to have been no consideration of whether the alleged harassment had played any part in Child Y or her mother’s reluctance to report the matter to the police. 4.33 Mother was advised to contact children’s social care or the police if she had any further concerns and Child Y’s case was confirmed as closed to children’s social care. 4.34 In mid September 2015 Child Y was seen by her GP and disclosed that she was experiencing flashbacks and panic attacks following the October 2014 sexual assault. She said she was struggling at home and in school. Her sleep had been adversely affected. School was said to be supporting her. She said she had experienced some bullying in school from other pupils who knew about the attack. She said she had received no victim support from the police and no counselling as yet. Child Y’s GP faxed a referral to Child and Adolescent Mental Health Services (CAMHS). 4.35 Also in mid September 2015 Child Y’s school contacted her mother who expressed concerned that Child Y was struggling emotionally and was not sleeping properly. Mother had taken Child Y to the GP to access counselling for her. Mother advised that Child Y has not heard from her “ex-boyfriend’ (Young Person R) for approximately two weeks. Mother said that she would contact school if Child Y needed support. Mother also advised the school that the offender in the sexual assault case (Child Q) was due in court at the end of that month. 4.36 Later the same day Child Y was spoken to by the school child welfare officer. She said she was feeling upset and struggling with what was going on with her court case. She said that she still had to complete an impact statement. Child Y said that she didn’t think that she would have any issues with her “ex- boyfriend” (Young Person R) and was said to be able to identify it as a negative relationship. Child Y was told that she could see the school child welfare officer about this incident at any time. Additionally, Child Y’s head of college was made aware. There was no contact between the school and the school nursing service at this, or any other time, in respect of Child Y. 4.37 Two days later a restorative justice worker from the youth justice service made a home visit to Child Y and her mother to explain the restorative justice process and describe the sentencing options available to the youth court. Both Child Y and her 15 mother said that they were struggling emotionally and mother confirmed that Child Y had been referred by her GP to CAMHS. 4.38 In late September 2015 Child Y was supported by the police to complete a victim impact statement at school. Her mother was also present and was advised by the school to seek information about counselling from her GP and a local sexual health service, which is a provider of sexual health and wellbeing support to people under the age of 25. (It is unclear what prompted this advice as the family GP had already referred Child Y to CAMHS.) 4.39 The following day Child Y’s mother contacted the school to say that Child Y would not be attending that day as she was upset about the impending court hearing in respect of the sexual assault. 4.40 Near the end of September 2015 Child Q was sentenced by the youth court to a Detention and Training Order for 18 months, was made subject to an indefinite restraining order and a Sex Offenders Notice for 5 years. Child Y was at school that day and was sent home early because of distress arising from the court hearing. The restorative justice worker offered to make a home visit to Child Y to provide support but her mother declined this saying that Child Y was “fed up of talking about it”. Youth justice contact details were left for Child Y should she change her mind about accessing support from the service. Support was also offered to her mother should she require it in her own right. 4.41 The following day the restorative justice worker referred Child Y to the National Probation Service (NPS) Victim Contact Scheme as this was a case in which a young person under the age of 18 (Child Q) had received a custodial sentence of 12 months or more for a violent or sexual offence. NPS victim services involve liaising with the victim about outcomes and protection that may be required when their offender is ready for release. 4.42 At the beginning of October 2015 Child Y disclosed to the school child welfare officer that she was struggling with the outcome of the court case. She added that her first appointment with CAMHS was imminent, but she wanted information about other places she could get help from. She was signposted to unspecified agencies which did not include the school nursing service. 4.43 In early October 2015 Child Y told the school child welfare officer that she was worried about her CAMHS appointment which was scheduled for the following day. During the conversation Child Y stated that she wanted to “end her own pain” but the welfare officer established that Child Y was not suicidal by asking her directly whether she planned to take her own life and receiving a reply that she was not. 16 It was agreed that Child Y’s mother would be contacted and this later took place. 4.44 The next day Child Y was seen by CAMHS. Trauma based individual therapy was offered and arrangements were made for a clinical psychologist to see Child Y. Child Y disclosed previous self harm behaviour and some suicidal ideation but she was said to have no plans to act upon these thoughts. (Child Y’s mother and elder sister have contributed to this review and said that Child Y began cutting her legs for a period. It is not known if this is the “previous self harm behaviour” referred to above.) 4.45 There does not appear to have been any consideration by CAMHS of whether a referral to children’s social care or use of that agency’s “advice and consult” offer may have been justified at this point given the disclosure of previous self harm, suicidal ideation and vulnerability to, and arising from, sexual abuse. 4.46 The following day Child Y informed the school child welfare officer that her CAMHS appointment had been “OK” and that they were going to offer her treatment. 4.47 In early October 2015 Child Y became distressed in a school lesson in which abortion was being discussed and left the lesson. She received support from the school child welfare officer. 4.48 In mid October 2015 Child Y missed one or more lessons because of distress arising from the first anniversary of the sexual assault. However, the individual paper log books kept by staff at that time do not provide any detail of how many lessons Child Y missed and what support was offered or provided. 4.49 For two consecutive days in late October 2015 Child Y was absent from school with mouth ulcers and cystitis for which she visited her GP. Whilst a full history of her physical symptoms was taken, Child Y’s sexual history was not taken as the outcome of physical examination supported the diagnosis of cystitis. 4.50 On her return to school the next day Child Y and three of her peers were involved in an unspecified disagreement. Pastoral staff were made aware of this. 4.51 The next day the NPS victim liaison officer closed Child Y’s case to the service after her mother did not respond to offers of support made by letter and telephone. 4.52 In late October 2015 Child Y’s GP received a letter from CAMHS advising that she had been assessed and that further psychology therapy sessions were planned. 17 The letter advised that Child Y had expressed thoughts of self-harm but had no plans to act upon them. 4.53 Towards the end of October 2015 the restorative justice worker contacted Child Y and her mother to advise them that Child Q had been allowed to appeal against his sentence. Mother advised that she had received the earlier letter from the NPS and was happy to be re-contacted. (See Paragraph 4.52) However, when a further letter was sent by the NPS, they again received no response from mother. 4.54 At the end of October 2015 Child Q’s appeal against sentence was successful in that the Detention and Training Order was reduced to a 12 month (non-custodial) Intensive Referral Order. The Sex Offender notification period was reduced from 5 years to 30 Months. The indefinite restraining order remained in place. The restorative justice worker telephoned Child Y’s mother to advise her of the outcome of the appeal. Mother was upset but declined a home visit, saying that she would rather speak to Child Y first. It was agreed that the restorative justice worker would make contact again the following week. 4.55 At the beginning of November 2015 mother advised the school child welfare officer of the outcome of the appeal and said Child Y was very upset about it. Mother was advised to contact youth justice and CAMHS and was informed that relevant school staff would be made aware and an email was subsequently sent to relevant staff. (not including the school nurse) The same day the school child welfare officer spoke to Child Y to see how she was feeling following the release of Child Q. Child Y felt she was doing better than she had been when she first found out and that she had support from both home and school. However, she did say that she was feeling overwhelmed in some lessons and finding it hard to concentrate. As a result, it was agreed that staff would be told she would be allowed to leave a lesson for 10 minutes if she was feeling overwhelmed. 4.56 On the same day the restorative justice worker followed up on her contact made in late October 2015. She was informed by mother that Child Y had been “in bits” but that she was receiving support from school and had had her first appointment with CAMHS. The restorative justice worker reiterated her offer of support. 4.57 From November 2015 until July 2016, multi-agency risk management meetings took place at three monthly intervals throughout the term of the Order in respect of Child Q. Safeguarding considerations in respect of Child Y were represented at these meetings by her restorative justice worker. No safeguarding concerns arising from the risks that the perpetrator could present to Child Y were said to have been noted 18 in any of the meetings. Restorative justice processes were not considered to be in the best interests of Child Y, given the sensitivities of the case. 4.58 In mid November 2015 a peer at school made a comment to Child Y and another peer that they would end up pregnant at a young age. Pastoral staff responded by bringing all three girls together to resolve the issue. On the same date Child Y spoke to the school child welfare officer about her mother who she had found crying in the early hours of the morning because of the “current situation”. Child Y was very upset about this. Child Y rang her mother and the child welfare officer spoke with mother and offered her support from the school. Mother was said to have had contact with victim support. (The reference to “victim support” may have related to the support offered by NPS.) 4.59 Also in mid November 2015 Child Y was seen by CAMHS and said that her mood swings were getting worse. She had also been experiencing disrupted sleep. She mentioned memories of her grandfather dying and the sexual assault. Two further sessions were arranged. 4.60 When Child Y attended her next CAMHS appointment in late November 2015 she saw Young Person R in the waiting room. During the session with CAMHS she disclosed that Young Person R used to be her best friend but he had told her that he was going to court for an alleged sexual assault on someone. She said that Young Person R had been found not guilty but then started to use drugs and a decision had been made to keep Child Y away from him. Child Y said that their relationship was never sexual. After discussing the matter with children’s social care, and obtaining a more accurate account of the risks Young Person R was considered to have presented to Child Y, CAMHS took steps to ensure that Child Y’s appointments would not coincide with those of Young Person R in future. 4.61 At the same appointment Child Y also disclosed to CAMHS that she had recently had consensual sex with a 13 year old boy. She added that she wasn’t in a relationship with him but felt that because all her friends were “doing it”, she wanted to fit in. Additionally, Child Y disclosed that whilst with her friends she had seen the perpetrator of the earlier sexual assault (Child Q) but he had walked away. 4.62 CAMHS considered the possibility of discussing the case with the Child Sexual Exploitation (CSE) team which works to identify and support children and young people at risk of sexual exploitation and their families, raise awareness of child sexual exploitation and bring offenders to justice. No referral was made after discussing this option with mother who said she wished to talk to Child Y before making a decision. CAMHS decided to revisit the question of a CSE team referral at 19 their next meeting with Child Y but there is no documented evidence that any such discussion subsequently took place with Child Y or her mother. 4.63 The following day Child Y informed the school child welfare officer that she had seen “another student” at CAMHS. Child Y said that it had been agreed that CAMHS would make sure that their appointments do not clash in future. From the information shared by the school with this review it does not appear that the identity of Young Person R was obtained from Child Y. 4.64 In early December 2015 Child Y was seen by CAMHS. An imagined “safe place” was discussed with her as were techniques for relaxing. 4.65 In early January 2016 Child Y told the school child welfare officer that she had been diagnosed with post traumatic stress disorder (PTSD) and that she was receiving treatment from CAMHS for this. This information was accepted at face value and with the permission of Child Y, was shared with her pastoral team. Steps could have been taken to confirm the diagnosis and consider whether there were any implications for the support Child Y should receive at school. (CAMHS has confirmed that the symptoms of PTSD seen in Child Y were within the clinical range of a PTSD diagnosis. The diagnosis did not change the treatment offered to Child Y which was consistent with the trauma pathway.) 4.66 In mid January 2016 Child Y was seen by CAMHS and disclosed that a friend had texted Child Y that week to say she had been raped by her 16 year old boyfriend. Her friend had later said that she had been raped by a stranger and not her boyfriend. Child Y said that her telephone had been seized as evidence by the police. Relaxation techniques were again discussed with Child Y. 4.67 A police investigation took place following the rape investigation referred to above. Child Y provided a statement. Her phone was taken by the police and returned to her later in January 2016. The school’s child welfare co-ordinator continued to provide support for Child Y as before. 4.68 In late January 2016 Child Y was treated by her GP for perineal irritation caused by thrush. She was asked whether she was sexually active whilst her mother waited outside. Child Y said that her last sexual intercourse had been several months ago and a condom used. CSE risk factors were not explored by the GP because it was assumed that the sexual intercourse disclosed had been consensual. Sexual health advice was provided. 20 4.69 When Child Y was seen by CAMHS later in January 2016, she disclosed that her friend had lied about being raped which had made her angry. Relaxation techniques were again discussed. 4.70 In February 2016 Child Y was seen at home by CAMHS when relaxation techniques were discussed. However, two subsequent CAMHS appointments were cancelled by mother and rebooked. 4.71 In early March 2016 Child Y was seen by CAMHS but struggled to focus on the therapy session. CAMHS has advised the review that their records indicate that Child Y found it difficult to access a safe place in her mind or to practice skills between appointments and in part this was due to Child Y reporting a decrease in the level of heightened emotion and arousal that caused symptoms to be present to a distressing or intrusive level. 4.72 In mid March 2016 Child Y asked the teacher if she had ever had chlamydia in a sex and relationships lesson during which sexually transmitted infections were under discussion. This was reported to Child Y’s head of college and Child Y was later spoken to and appeared to understand why the question was inappropriate. 4.73 After her early April 2016 CAMHS appointment was cancelled by her mother because of family illness, a week later Child Y was seen by CAMHS. Following a discussion with Child Y and her mother, discharge from the service was discussed and agreed. Child Y was considered to be much calmer and said she did not wish to talk about the sexual assault anymore, added that self-harm was no longer an issue when asked directly about this. Alternative therapeutic approaches were discussed before discharge from the service was agreed whilst retaining the option of re-referral. (Although Child Y told CAMHS that self-harm was no longer an issue, this appeared to be contradicted by her response to the health questionnaire in early May 2016 (Paragraph 4.76) where she said that she had self harmed seven weeks earlier.) 4.74 In their mid April 2016 letter to Child Y’s GP, CAMHS stated that there were no current difficulties to work with in therapy and Child Y was reporting to be much calmer at home and at school. She had received eye movement desensitization and reprocessing (EMDR) therapy over several sessions and an improvement in her symptoms had been noted by the child and the psychologist. The letter added that advice had given for self-help specifically relaxation, visualisation and safe space for the future together with re-referral if needed. 21 4.75 Also in mid April 2016 Child Y was said to have had issues with a peer at school. Lack of recording means that it is unclear what the “issues” were, or what the school response consisted of. 4.76 In early May 2016 Child Y completed a health questionnaire in school which is given to all school attenders of Child Y’s age by the school nurse service. The aim of the questionnaire is to identify individual and school population health needs in order to target services accordingly. Some of Child Y’s answers raised concerns about her emotional health and wellbeing. When asked “Do you often feel angry or lonely”, she answered yes to both questions. She also responded that she had worries about her “past” and her “family”. Child Y also wrote on the questionnaire that there had been sexual abuse in the past. When the questionnaire asked “Have you ever harmed yourself deliberately”, she answered yes and stated that this had taken place 7 weeks prior to completion of the questionnaire. The questionnaire asks if the young person would like an appointment with the school nurse which Child Y declined. Child Y’s responses also indicated that she had had a previous poor experience with health care provision. 4.77 It appears that Child Y’s response was reviewed by school nurse 3 and a decision made to follow up on the content of Child Y’s responses. It also appears that Child Y failed to attend the follow up appointment with school nurse 3 scheduled for late June 2016. However, it is not clear how details of the appointment were communicated with Child Y, or whether she received any such communication. There is no indication that Child Y’s non-attendance generated any further action. 4.78 Child Y had disclosed self-harm and also declined the offer of an appointment in the questionnaire. In these circumstances it is considered to be good practice to offer an appointment. However, no contact was made between the school nurse service and an adult with parental responsibility for Child Y regarding her disclosure of self-harm. It is important to document any rationale which informs decisions not to share significant health information with parents and there is no evidence of any such rationale within Child Y’s school health record. 4.79 In mid May 2016 Child Y attended at a sexual health clinic, which is a longstanding provider of sexual health and wellbeing support to people under the age of 25. She was accompanied by a female friend and was seen by a nurse who completed an under 16 years assessment which disclosed that Child Y was assessed as Fraser Competent; that she had had consensual sexual intercourse as a 13 year old on one occasion with a 14 year old boyfriend of three months with whom she was no longer in a relationship; that she said she was not currently sexually active and intended to wait until she was older before having sex again; that she was 22 concerned about pregnancy; was provided with contraceptives and that she disclosed details of the October 2014 sexual assault. 4.80 Child Y’s disclosure of previous sexual abuse should have prompted contact with local safeguarding children’s services, but not a referral. This did not happen. Nor was the sexual health provider’s safeguarding decision making proforma completed. And the rationale for the eventual decision to take no further action was not documented fully in the client notes. A safeguarding alert was not added to the service’s Caution Register which was significant as, had this been added, subsequent consultations would have been prompted to identify the missed disclosure of historic abuse and lack of referral to social care. 4.81 It is not clear why these omissions took place. The nurse concerned was a new member of staff and had yet to fully complete the service’s training but had a wealth of previous safeguarding experience. However, the nurse did discuss the case with a nurse manager but the details of this discussion are unclear and neither party has any recollection of the conversation. 4.82 Also in mid May 2016 Child Y was said to have fallen out with her (female) peers at school and presented as “very upset”. It is not known what was the reason for the dispute. The pupils “were sat down to resolve the issues”. 4.83 In late June 2016 school nurse 3 made an entry in Child Y’s school health records, to the effect that Child Y failed to attend the follow up appointment relating to the health questionnaire referred to earlier. At this time the school nurse also recorded that “records checked – concerns regarding sexual abuse dealt with previously by MASH team”. 4.84 In early July 2016 Child Y’s case was closed on the youth justice service system. Child Q was still subject to the restraining order and sex offender registration. 4.85 In late July 2016 Child Y’s mother attended the emergency department (ED) having fallen the previous night whilst under the influence of alcohol, hit her chin on the pavement and lost consciousness. Examination revealed a damaged tooth and lacerations to her chin. After treatment she was discharged and advised to visit her dentist. There is no evidence that mother was asked about any dependants she was caring for. There are no prompts in ED documentation to ask about responsibilities for children until the point at which an adult is admitted into hospital, which Child Y’s mother was not. 23 4.86 In early September 2016 Child Y attended the sexual health clinic with a female friend. A nurse completed an under 16 years review assessment which disclosed that Child Y was in an on/off relationship with Young Person S who was also 14 years old. Child Y said that her mother was aware of her previous sexual activity and she was advised to discuss the contraception provided with her mother. (When medication is dispensed by sexual health clinics, there is no requirement to notify the patient’s GP) No safeguarding concerns were documented. There is no evidence that the notes of Child Y’s previous visit to clinic were reviewed which would have disclosed the sexual assault. 4.87 In mid September 2016 Child Y attended the sexual health clinic and was seen by a nurse with whom she discussed some concerning symptoms experienced since commencing the oral contraceptive pill and was provided with advice including the need to see her GP for treatment. She was also advised to return for a pregnancy test later in the month. No under 16 review assessment was completed in accordance with policy and although there is evidence of reference to the previous assessment, there is no evidence that the initial consultation was considered which would have disclosed the earlier sexual assault. 4.88 There is no reference to Child Y visiting her GP following the sexual health clinic attendance in mid September 2015. 4.89 In early October 2016 Child Y was said to be spreading rumours about another pupil and was spoken to about this. The next day Child Y was said to have fallen out with one of her close friends and the school encouraged them to reconcile but Child Y was said not to be ready to do this. (It is noted that this was just before the second anniversary of the sexual assault on Child Y.) 4.90 In late October 2016 the school’s child welfare officer was alerted by a member of staff that Child Y had been talking to her peers about being pregnant. She met with Child Y who told her that she thought she could be pregnant. Child Y said she had had unprotected sex earlier in the month with a boy she was no longer in a relationship with. Child Y was advised how she could check whether she was pregnant. The welfare officer told her that she would need to speak to Child Y’s mother. When the welfare officer rang Child Y’s mother, she said she was shocked as she did not know Child Y had had a boyfriend. She said she would arrange for Child Y to have a pregnancy test. (There is no reference to Child Y returning to the sexual health clinic at this time.) Given that the school was aware of the October 2014 sexual assault, the Young Person R referral, the CAMHS referral and incident in school where a pupil had taunted Child Y about being pregnant at an early age, this could have prompted further professional curiosity and possibly a discussion with a school nurse. 24 4.91 During the latter months of 2016 Child Y began a “relationship” with Adult P, a 20 year old man. Her mother became aware of the relationship and has advised this review that she told her daughter to end the relationship because she was under age and he was much older. Child Y’s relationship with Adult P continued. 4.92 At the beginning of January 2017 Child Y attended the sexual health clinic and was seen by a nurse who completed an under 16 review assessment. Child Y said she was still in a sexual relationship with Young Person S and that this relationship began nine months earlier. She said that she spoke openly with her mother about sex and relationships. Once again, there is no evidence that the notes of the original consultation were reviewed. 4.93 In early January 2017 it is alleged that Child Q contacted Child Y in contravention of his restraining order by attempting to add her as a friend to his Facebook account. This alleged contact was unknown to any agency until after Child Y’s overdose. According to her family, the contact caused Child Y anxiety and upset and after a discussion with her parents, Child Y decided not to report the matter to the police. At the time of writing the alleged breach of Child Q’s restraining order has been investigated by the police and the Crown Prosecution Service has decided to prosecute. Significant Practice Episode 3 – from January 2017 until Child Y’s death, during which agencies responded to concerns about Child Y’s relationship with Adult P. 4.94 Also in early January 2017 the police received a report from a “concerned member of the public” that Child Y was in a sexual relationship with Adult P. Initial enquiries were made to confirm the identity of Adult P and the age and identity of Child Y. This involved contact with Child Y’s school who acknowledge that they should have told the police about the October 2015 pregnancy test and that Child Y was sexually active. The school could also have considered referring Child Y to the CSE team at this point. 4.95 The police then saw Child Y and her mother at a police station. Child Y acknowledged her friendship with Adult P but denied any sexual relationship. Mother expressed unhappiness with Child Y attending Adult P’s flat unaccompanied. Child Y was said to appear quite mature for her age and to understand that if Adult P had a sexual relationship with her, he would be breaking the law. Child Y was perceived to have a good relationship with her mother with “open lines of communication”. Child Y added that she felt comfortable speaking to her mother about any issues or pressures that may arise. (By this stage, agencies had information which challenged 25 the impression that lines of communication were open.) No immediate safeguarding concerns were noted and a PVP was completed by the officer and submitted to the MASH. The officer who had interviewed Child Y and her mother assessed the risk as standard but this was later increased to medium by police officers based in the MASH. The PVP was shared with children’s social care, school nursing service and the CSE team. As no disclosure had been made by Child Y no further police investigation was conducted and Adult P was not interviewed. 4.96 Three days later the PVP in respect of Child Y was received by the MASH. Consent had been given by Child Y’s mother for welfare checks to be carried out. Child Y’s school was informed and they stated that, on the whole, they had no concerns although they mentioned the October 2016 “pregnancy scare” which had been shared with her mother by school staff. The school advised that mother had been shocked by the news that her daughter might be pregnant but had been supportive. The school states that they have no record of this MASH contact and the social worker appears to have only become aware of the pregnancy issue in February 2107 when completing the C&F Assessment. No checks with health were requested by the MASH team manager at this stage as it was anticipated that these checks would be carried out as part of the forthcoming C&F Assessment. However, these checks had still not been carried out prior to the home visit to complete the C&F Assessment. (Paragraph 4.119) Had they been requested, the usual checks would be A&E attendances, GP and school nurse. Sexual health checks would not be undertaken as standard unless specifically requested by the MASH team manager. 4.97 Advice was sought from the CSE team Social Worker and her manager who agreed that it was appropriate to conduct a CSE assessment alongside children’s social care C&F Assessment. (The case was also discussed in the CSE Team as police shared the PVP with the team to discuss allocation.) 4.98 The same day Child Y truanted from a lesson but was located and later spoken to by her pastoral manager. 4.99 The next day the PVP completed by the police was received by the school nursing service where it was scanned onto Child Y’s record. The action plan recorded by a community staff nurse was to await the outcome from the MASH assessment. School nurse 5 was electronically tasked “for information only” at that time. Having reviewed the tasked information, the school nurse decided that no further action was necessary. There is no evidence that the information was considered in the light of earlier information about Child Y, including the sexual assault, nor is there evidence that case weighting school nurses allocate to prioritise health and social care unmet needs was reassessed. 26 4.100 At the end of January 2017 the MASH team manager decided that the threshold for children’s social care intervention had been met and that further assessment was required in order to address concerns about the relationship between Child Y and Adult P, in particular to determine if Child Y had been a victim of grooming/CSE and to consider if any preventative and awareness raising work needed to be completed. This case should have progressed from MASH within two working days as opposed to the actual time taken which was 13 working days. It is understood that factors in this delay included a high number of referrals at that time, reduced capacity in MASH and the requirements to attend a number of meetings which detracted the manager from the screening process. The MASH team manager’s decision appears to have been a further opportunity to prompt a CSE assessment. 4.101 At the beginning of February 2017 the case was allocated to a social worker. A joint visit with the CSE team was considered but after no response was received from the CSE team manager it was decided to go ahead with a single agency home visit and subsequently refer to the CSE team if appropriate providing Child Y and her mother consented. The co-working protocol between children’s social care and the CSE team envisages telephone or face to face discussion between the respective agency’s team managers to agree a plan for joint working, specifically the arrangements for joint visits. It is understood that the CSE team was affected by sickness absence just prior to this time. The child and family assessment was initiated by the social worker the next day. 4.102 In early February 2017 Child Y attended the sexual health clinic with a female friend and was seen by a nurse who completed an under 16 review assessment which disclosed that her relationship with Young Person S continued; she underwent a (negative) pregnancy test; she was advised to return in three weeks for a repeat pregnancy test and was said to openly confide in her mother. No safeguarding concerns were noted and once again, the initial consultation notes were not reviewed. 4.103 The next day the social worker made a home visit to Child Y and her mother in order to discuss the recent referral and begin to gather information for the C&F Assessment. Contact with Child Y’s father, who did not reside at the family home, was considered but apparently not acted upon. There is an expectation that prior to such home visits all welfare checks would be completed with agencies involved currently or in the past with the child. These checks had not taken place. Additionally, it appears that information from the MASH record that Child Y had had a recent pregnancy scare was not reviewed until after the overdose. And the home visit was significantly delayed, taking place a month after the allegation was first reported to the police. 27 4.104 On the same date the school contacted Child Y’s mother to raise concerns about Child Y’s attainment in maths. When contributing to this review, mother indicated that being placed on report had not caused Child Y undue worry. She then added that “Child Y was a very clever girl” which implied that being placed on report (for the first time) might have been an issue of more substantial concern to Child Y. 4.105 During a late evening in mid February 2017 Child Y visited Adult P at his flat. In the statement he provided for the inquest into Child Y’s death, Adult P said he had known Child Y about a year. He said he knew she was 14 but described her as “quite an adult teenager”. He described their relationship as close but not sexual although he said many people seemed to think it was and spread rumours to that effect. During January 2017 Adult P’s manager moved him from the shop where he normally worked to another shop because of concerns about Adult P’s relationship with Child Y who would call into the shop to see him. 4.106 In his statement, Adult P said that he and Child Y talked for several hours on the stairs leading to his flat. When she decided to go home he said he called a taxi for her. At this point he said her mood changed and she said she had been diagnosed with schizophrenia and had been hearing voices. She said she was not doing well at school and was concerned that she would be taken back into care after children’s social care had recently become involved in her life again. He said that Child Y then began intimating that she may take her own life by making comments such as “making all the problems go away”. He said he made her promise not to harm herself and called a taxi to take her home shortly after 3am the next morning. As agreed, Child Y texted him when she arrived home at around 3.20am. 4.107 Child Y’s mother was not at home as she had been working an evening shift at a local public house and then went to stay at the home of her partner. She had been unaware of Child Y’s whereabouts. Child Y’s elder sibling was at the family home. Child Y’s mother arrived home later that morning. She saw Child Y who told her she felt unwell following which her mother contacted school to advise them that Child Y would not be attending that day. Child Y’s mother later left for work. 4.108 Adult P said he awoke around 12.30pm the same day. He said he then received a telephone call from Child Y in which she was crying and he said he could hear what sounded like pills being pushed through foil. He said that Child Y then put the phone down on him before sending him two lengthy text messages which have been deemed to represent a “suicide note”. These were sent shortly after 1pm. 4.109 In these texts Child Y described herself as “the family fuck up” who had been strong once and internally beautiful but that that girl died at the age of 12 when “he ruined my body. And my mind, my soul, destroyed by one person.” (It is assumed 28 she was referring to Child Q) She mentioned her love for her mother but added that she (her mother) had been unable to cope and had resorted to alcohol. She said that she had longed for a relationship with her father but he wasn’t always there. She said she had fallen in love with Adult P in early December 2016. 4.110 Adult P said that after receiving these texts he tried to ring Child Y but was unable to obtain any reply. He then contacted the ambulance service anonymously via the 999 system and advised them that Child Y had taken “a load of pills” and provided her home address. He had no contact details for Child Y’s parents but managed to locate them via social media and sent them messages which Child Y’s father was able to pick up. Adult P’s relationship with Child Y was subsequently re-investigated by the police and they ultimately decided to take no further action. 4.111 Child Y’s father received the message from Adult P and contacted Child Y’s mother who returned home by taxi to find Child Y unconscious. Child Y’s elder sibling had been present in the house but unaware of Child Y’s actions. The family called an ambulance which arrived at 2.28pm to find Child Y in cardiac arrest having apparently taken an unknown quantity of mother’s prescribed drugs and over the counter drugs. The ambulance service contacted the police. 4.112 Child Y was initially taken to hospital but later transferred to a children’s hospital paediatric intensive care unit - as there were no local ICU beds available -where she died on four days later. 4.113 On the day on which Child Y took the overdose, the school decided that Child Y would be placed on report for two weeks due to concerns over her academic performance. During that period the pupil’s attitude and attainment in lessons would be monitored. 4.114 The police searched Child Y’s bedroom and removed a number of personal items to assist with their investigations. The police also examined the phones of Child Y and Adult P which confirmed they had been in a relationship and also indicated that there had been a disagreement between them which had been resolved prior to Child Y’s overdose. 4.115 During the period between Child Y taking an overdose and her death, the C&F Assessment was said to have been “completed” by the social worker and submitted to her manager who returned it for further information to be gathered. The C& F Assessment identified that Child Y’s mother was acting appropriately to ensure the safety and well-being of Child Y. Child Y had presented as happy and content and engaged in discussion about her home, school and personal life. Child Y presented as having a good understanding of appropriate relationships and denied 29 any sexual activity between herself and Adult P. Child Y had not displayed any concerning worries or behaviours and had said that through her involvement with CAMHS she had learned to deal with her feelings and emotions. Child Y appeared to have demonstrated resilience and strength in managing her traumatic experience of sexual assault. 4.116 The author of the assessment concluded that a further home visit was required with the CSE team in order for them to complete an assessment. Before this could be completed Child Y attempted to take her own life and remained in a critical condition with a poor prognosis. It was recommended that further exploration of Child Y’s relationship with Adult P and her parents’ capacity to safeguard Child Y from future harm would need to be undertaken. The C&F Assessment recommended that to ensure that Child Y was safeguarded from future harm, the family should be supported via a child in need (CIN) plan until fuller information had been gathered and that an assessment with CSE team should be completed. 30 5.0 Contribution of the family to the review 5.1 Child Y’s mother contributed to this review. Also present were an elder sibling of Child Y and her maternal grandparents. Child Y’s father was offered the opportunity to contribute but did not respond. 5.2 Mother was asked about the October 2014 sexual assault on Child Y but after describing how she received a phone call from Child Y’s paternal grandparents to say that Child Y was “in a state” she became too upset to talk about it. 5.3 When asked to comment on the support offered to Child Y after the sexual assault, mother said that she had tried to “block out” a lot of what happened during this period and so she found it difficult to remember specifics. She recalled that after the sexual assault, Child Y began trying to carry on with life, but the police investigation seemed long and drawn out, and she doesn’t feel that her daughter had sufficient support during this period. She referred to a long wait to access CAMHS and when Child Y did attend, this was for only a half an hour session every two weeks which she did not think was sufficient. She said that some of these appointments were cancelled. She commented that Child Y thought the sessions with CAMHS to be “pointless” adding that her daughter did not find the mode of therapy used to be helpful and did not relate to what CAMHS was trying to achieve. Mother said that she didn’t see any difference in Child Y as a result of the sessions and Child Y’s elder sibling felt that Child Y should have been offered a different form of therapy, to which she was able to relate. 5.4 Mother commented that prior to the referral to CAMHS Child Y was able to confide in the child welfare officer at school. Although she was not aware of what they spoke about, mother was aware that this relationship was positive and that Child Y felt she could approach the child welfare officer. During the period prior to Child Q’s trial, mother felt that Child Y seemed to be coping “OK”, but the family have since become aware that she may have been confiding concerns to others including her best friend. 5.5 Turning to the trial of Child Q, Child Y did not attend court but received a phone call to tell her what sentence he received. Within a short time, she received another phone call to say that an appeal had been lodged. Mother said that Child Y had had mixed feelings about the original sentence because prior to the sexual assault she had loved Child Q as an uncle and couldn’t understand why he would do that to her. Mother said Child Y wasn’t happy about the reduction in Child Q’s sentence following his appeal. 31 5.6 Mother commented on the impact of the sexual assault on family dynamics. She said Child Y began to spend less time with her father who became distant in mother’s opinion. Mother wondered if he may have felt guilty as the sexual assault took place in his parent’s house whilst he was staying there. Mother also felt that Child Y’s paternal grandmother appeared to be more upset about losing Child Q than about what had happened to Child Y. Child Y had been upset that Child Q’s sister continued to see him and generally felt that her father’s side of the family were not fully supportive of her. 5.7 Turning to Child Y’s contact with Young Person R, mother recalled receiving a phone call from children’s social care to say that Young Person R could pose a danger to Child Y, but she couldn’t recall them saying anything else. Mother said that they weren’t friends for long and that their relationship just “fizzled out”. Mother said that she had no personal contact with Young Person R’s family but recalled his uncle threatening Child Y via facebook because she had told a friend that Young Person R was a danger. When mother became aware of the threat from Young Person R’s uncle she wanted to report the matter to the police but she said that Child Y begged her not to because she was worried that this would only make matters worse. Mother commented that Chid Y’s faith in the police had been affected by the outcome of Child Q’s appeal for which she blamed them. 5.8 Mother said that she knew nothing about the health questionnaire Child Y completed in 2016 and had not heard about it until she was asked about it during her contribution to the serious case review. Family members present asked why mother was not told about the questionnaire if the answers Child Y gave raised concerns? 5.9 As time passed by Child Y talked about the impact of the sexual assault less. Family members said she sometimes appeared to be moody but they felt that this was “a teenage thing”. 5.10 Mother said she was aware that Child Y had been to the sexual health clinic twice with a friend but was unaware that she was taking a contraceptive pill until Child Y’s elder sibling told her. When mother spoke to Child Y about this she said she was taking the pill to get rid of her spots. 5.11 Turning to the contact from Child Q in January 2017, he sent Child Y a friend request on Facebook, which was deleted soon afterwards. Before the request was deleted, Child Y took a screen shot of it and sent it to her elder sibling who told her to tell mother about it, which she did. Mother said that they should contact the police, but Child Y again begged mother not to do so. Mother said Child Y had not 32 told her father even though she had been with him at the time she received it the friend’s request. Mother rang father to tell him what had happened. 5.12 Mother said she respected Child Y’s wishes and did not contact the police. She added that Child Y was very upset following the contact from Child Q but appeared to begin to feel better over the next few days. 5.13 The family said that they had recently become aware of a further contact with Child Q. This took place in a park. They were not sure when this happened but Child Y was with two of her friends when Child Q began shouting abuse. One of Child Y’s friends had disclosed this to them. (It is not known if this contact with Child Q relates to her disclosure to CAMHS that she had seen Child Q in Paragraph 4.63) 5.14 Turning to Child Y’s friendship with Adult P, mother said Child Y had told her about this. The family knew of Adult P as he worked in a local shop. Mother said that the friendship struck her as odd as he was older. Mother said that she tried to ban Child Y from seeing Adult P, but that Child Y did not accept this. She described her daughter as being quite angry from around November 2016, and mother added that she found it difficult to cope with this behaviour. This led to Child Y spending a few nights staying at her elder sibling’s house. Mother said that she couldn’t get to the bottom of why Child Y was so angry. 5.15 When the police became involved Child Y told them that the relationship was platonic, but mother said that she did not believe her daughter. Shortly afterwards a social worker visited, and Child Y was said to be worried about this. Mother said she did not know a lot about Child Y’s friendship with Adult P. Child Y’s friends have since disclosed to her that whilst Adult P appeared to be “lovely in his texts”, he abused her over the phone. Child Y’s elder sibling commented that it seemed like Adult P was manipulating Child Y and would ring her and demand she walk to McDonald’s to get him food and bring it to him at the shop where he worked. Child Y would oblige. Mother reiterated that she kept telling Child Y to stay away from Adult P. 5.16 Mother added that things were also not going too well at school at this time. The school said that they were going to keep an eye on Child Y’s progress. Mother and her elder sibling said she didn’t really talk about being put on report but that she probably didn’t see it as a “big thing”. 5.17 As the conversation with mother and other family members drew to a close, it was suggested by one family member that Child Y “tried to hide things” and had tried to block the sexual assault out of her mind. She seemed to feel that she could only confide in her friends and the school child welfare officer. Her elder sibling says 33 she noticed that in early 2016 Child Y began cutting herself on her legs which she described as “more like cat scratches” as they weren’t deep cuts. The elder sibling said that she felt that Child Y began cutting herself as a reaction to the sexual assault. Her elder sibling said that she spoke to Child Y and she stopped cutting herself. Her elder sibling added that Child Y had tried to conceal the cuts by wearing long pants to cover her legs. 5.18 When asked if anything more could have been done to help Child Y, the family felt that the court process could have been faster, that there should have been more support from CAMHS with different options offered in order to find an approach which suited her better. They added that the school nurse should have been in touch about the concerns raised in the health questionnaire. They said that there should have been more communication from the police who should have spoken to Child Y’s mother rather than her paternal grandmother. 5.19 Mother has read this final report with which she expressed herself satisfied. She said she had nothing further to add. Father was offered the opportunity to read the final report but did not respond. 34 6.0 Analysis 6.1 In this section of the report the following terms of reference were will be addressed: Were indicators of unmet need, risk and/or compromised parenting appropriately identified by practitioners through assessments and any disclosures? Were service responses to indicators/disclosures of unmet need, risk and/or compromised parenting in line with single and multi-agency policy? Were service responses provided in a timely manner to promote the child’s welfare? What role did management oversight play to enhance the quality of practice? Were indications of unmet need identified by practitioners and responded to in accordance with policy? Were service responses provided in a timely manner to promote the child’s welfare? 6.2 Following the sexual assault in October 2014, Child Y needed support. At the age of twelve she had been subjected to a sexual assault by someone she regarded as a close family member in a location where she expected to be safe. 6.3 Disclosing the sexual assault, which the perpetrator Child Q put pressure on her not to do, also had implications for her family. The perpetrator Child Q and his sibling had lived with Child Y’s paternal grand parents for many years under a Special Guardianship Order. As far as Child Y was concerned, they were very close family members. However, the sexual assault brought Child Q’s relationship with Child Y’s family to an end and it is understood that Child Q’s sibling later left the family. Child Y’s parents were no longer living together at the time of the sexual assault but it appears that this event placed her parent’s relationship under even greater strain and ultimately led to a rift between Child Y’s mother and Child Y’s paternal grandparents. 6.4 Little insight into how Child Y was feeling in the aftermath of the sexual assault can be gleaned from the chronologies provided to this review by the agencies which came into contact with her despite the fact that sexual abuse is categorised as “significant harm”. There were said to be “no concerns” about her general health and wellbeing at the SARC. (Paragraph 4.4) She was described as being in “good spirits” during a joint home visit by children’s social care and the police in the days 35 following the sexual assault. (Paragraph 4.9) Child Y was described as “vulnerable/intimidated” on the Vicman record created by the police. (Paragraph 4.12) The C&F Assessment completed by children’s social care described Child Y as “upset and scared about what is going to happen next”. (Paragraph 4.15) And when the SARC manager rang Child Y’s mother to check on her welfare, Child Y was described as “doing OK”, and having “no problems”. (Paragraph 4.17) Significantly this information about Child Y’s emotional state was provided not by Child Y herself but by her mother. A feature of this case is the extent to which agencies appeared to rely on mother to articulate Child Y’s feelings. 6.5 Additionally, the support offered to Child Y following the sexual assault also appears to have been quite limited. No referral appeared to have been considered to an independent sexual violence advisor or advocate (ISVA) whose role is to provide practical and emotional support to survivors of sexual violence. Typically, the ISVA would work with partner agencies to try and keep the survivor informed throughout the criminal justice process, support and empower the survivor to have their voice heard and make informed choices and accompany the survivor to important appointments. Specialist ISVAs for children – known as ChISVAs - are also available. 6.6 The review has been advised that whilst no ChISVA referral was considered when Child Y went to the SARC, a ChISVA referral was under consideration at the point at which the SARC manager rang Child Y’s mother in late October 2014 (Paragraph 4.17) and was ruled out because mother indicated that further support for Child Y was not required at that stage. It is unclear whether a ChISVA referral was specifically offered and declined at this point. In any event it does not appear that Child Y herself was directly offered the services of a ChISVA and the potential benefits explained to her in order that she could have been supported to make an informed choice. 6.7 Child Y was not referred to victim support services by the police. There is an opportunity to initiate a referral to victim support at the point at which the crime report is completed but the box for victim support was not ticked. As stated in Paragraph 4.6 the police have advised this review that victim support was verbally offered and declined by Child Y’s mother during a joint home visit by police and children’s social care. This offer and the declining of it was not recorded by the police or children’s social care. There is no indication that Child Y was directly involved in this interaction. 6.8 Child Y’s school was not informed about the sexual assault by any agency with knowledge of it. Nor was the school invited to participate in the strategy discussion which took place in mid October 2014 (Paragraph 4.8 and 4.9). However, the school inadvertently learned of the sexual assault the following day when Child Y’s elder 36 sibling came to collect her from school and disclosed that Child Y had been sexually assaulted. This information was shared with the school’s senior leadership team because it was necessary for them to authorise Child Y’s collection from school by a family member who was not on their list of contacts for Child Y. Had the school been invited to participate in the strategy discussion, they would have been much better placed to consider what action they should take to support Child Y. However, once the school became aware of the sexual assault, the absence of any follow up whatsoever is perplexing and practitioners and managers from the school were unable to suggest why there was such an absence of professional curiosity and exercise of the duty of care they owed to Child Y. The school has advised the review that at the time safeguarding concerns were recorded only within paper log books maintained by individual members of staff which may have prevented concerns being appropriately shared and escalated. 6.9 Having become aware of the sexual assault, actions which the school could have considered included making contact with the police, liaising with the school nursing service, and contacting Child Y’s mother in order to ascertain whether Child Y had any support needs which the school may have been able to meet or make suggestions as to how such needs might be met. It was possible that the sexual assault on Child Y had not been reported which would have placed an obligation on the school to make a safeguarding referral. As the school appears not to have asked any questions, they would not have known whether the assault had been reported or not. 6.10 The school missed a further opportunity to consider Child Y’s support needs following the sexual assault when Child Y told the school’s pastoral manager that a peer had made a comment about the sexual assault in early November 2014. (Paragraph 4.18) The school dispute that this represented a missed opportunity to consider Child Y’s support needs. 6.11 The school should have been contacted as part of the process by which the C&F Assessment was competed by children’s social care in late October 2014 but this does not appear to have been the case. (Paragraph 4.15) 6.12 A further route by which the school should have formally become aware of the sexual assault was through contact with the school nursing service which was notified of the incident in late October 2014 via a PVP report sent to them by the police. (Paragraph 4.13) The school nurse who received this information drew up a plan to “await further contact from children’s social care” and scanned the PVP onto Child Y’s electronic care records. The school nursing service accept that the response to this notification was insufficiently proactive and that it should have triggered contact with the SARC to ensure appropriate support had been offered to Child Y 37 and her family following her trauma. Had such an enquiry revealed any absence of support offered, actions should have been taken to obtain appropriate support and offer this to Child Y. 6.13 The school nursing service had not been invited to participate in the mid October 2014 strategy discussion although the health representative within the MASH, from the same organisation as the school nursing service, had participated. 6.14 At the time of this incident, the school nursing service advise that a clinical pathway for the management of PVP reports was in place for health staff to refer to. The pathway placed responsibility on health practitioners such as school nurses to use clinical judgement to analyse the information contained within the report and plan for further care as appropriate. Whilst it may be entirely plausible for there to be no health actions arising from a PVP (although not in this case), the rationale for any such decision should have been clearly evidenced within the health records. This did not happen in this case. A plan to merely “await contact” from another service is not considered to be a robust plan which ensures the health needs of a child are met. 6.15 The school nursing service has also advised this review that the school nursing service was in “business continuity” as a result of staffing shortages at that time. Business continuity is a process which involves the identification of core functions which are a priority to resource and other functions which are of lesser priority and may no longer be resourced or may be handled in a less resource-intensive manner. This review was initially advised that the adoption of a “for information” approach had been authorised by management as part of business continuity arrangements. The school nursing service has since advised that this information is incorrect and, in any event, business continuity arrangements should not have prevented a more substantial response to the notification of the sexual assault on Child Y. 6.16 Another response to business continuity was a management decision to cancel school drop-in clinics during this period. It is assumed that this decision may have contributed to a striking lack of contact between Child Y’s school and the school nursing service. The school nursing service has advised that school liaison was still in place and that there should have been regular contact with the school at this time although this case indicates no evidence of this. 6.17 The school nursing service emerged from business continuity in September 2016. (Blackburn with Darwen LSCB has advised this review that they were not advised of the school nursing business continuity arrangements at Board level or in their quality assurance returns which are the method by which the LSCB collates performance and quality assurance information. In the return agencies are 38 specifically asked about the implications for business continuity of their performance data.) 6.18 The C&F Assessment completed by children’s social care for Child Y represented a further opportunity to ensure she was offered appropriate support. However, the assessment identified no further safeguarding concerns and the outcome was “no further action” on the grounds that Child Y had an “excellent support network and all the adults involved with Child Y are acting appropriately and with her best interests as their focus”. It is difficult to see how such an optimistic assessment could have been arrived at given the implications of the sexual assault for Child Y’s wider family. Children’s social care acknowledge that further exploration of the emotional needs of Child Y and the impact of the sexual assault should have been undertaken. They say there was also an absence of analysis of the role of Child Y’s father, given that the assault took place at the home he shared with Child Y’s paternal grandparents. Additionally, there is no evidence that referrals were made or signposting information shared with Child Y and her parents. Children’s social care state that there was, and remains, an expectation that the relevant team manager would have challenged the limitations in the assessment but that this did not happen. There is no indication that either the Child in Need (CiN) or Child and Family Assessment (CAF) processes were considered following the C&F Assessment completed at Section 47 Children Act level. 6.19 Child Y’s GP was not invited to participate in the mid October 2014 strategy meeting but became aware of the sexual assault when they received a letter from the SARC. (Paragraph 4.16) The GP did not contact Child Y or her parent to ask if she needed support. The Clinical Commissioning Group (CCG) advises that the GP would have assumed the provision of support by the SARC. The GP did not raise the issue at the next appointment with Child Y. The CCG advises that had the consulting GP seen an active alert in Child Y’s patient records this may have prompted further enquiry. However, no visible alert had been placed on Child Y’s records to inform others within the practice that there was a live concern when accessing her patient records. 6.20 The GP now feels that the practice could have made contact with the SARC to clarify the nature of the assault and that the incident should have triggered a “significant event” meeting. These meetings take place when cases are reviewed at practice meetings or on a case specific individual basis. A significant event meeting is triggered when a concern or issue is raised internally at the practice or externally. The GP practice has a policy/protocol around significant events. Had the “significant event” meeting taken place the health visitor could have been the link into school health services in terms of raising concerns. 39 6.21 It has been recognised that it would be best practice for the GP to revisit safeguarding issues at the patients’ first presentation after an event if the safeguarding concerns are highlighted in the patient’s records – which they were not in Child Y’s case. 6.22 Child Q was not charged with the sexual assault on Child Y until July 2015 which triggered an offer of support to Child Y by the youth justice service the following month. This offer was initially made by letter to Child Y’s mother who did not respond. 6.23 The August 2015 safeguarding referral by youth justice arising from concerns that Child Y was in a sexual relationship with Young Person R who had been recently convicted of a sexual assault on another child (Paragraph 4.26) appears to have enabled agencies to become aware that Child Y needed support. 6.24 When contacted by children’s social care in early September 2015, mother said she felt that Child Y needed someone independent to open up to. Children’s social care also contacted Child Y’s school to advise that Child Q was due to be sentenced shortly and that this was causing Child Y “significant distress”. This prompted the first intervention by the school in response to the October 2014 sexual assault with the school child welfare officer meeting Child Y and her mother to discuss what support the school could offer. Prior to that meeting Child Y’s mother took her daughter to their GP who referred her to CAMHS after hearing that Child Y had been experiencing flashbacks and panic attacks following the October 2014 sexual assault. Child Y’s mother subsequently told the school child welfare officer that Child Y was struggling emotionally and not sleeping properly. Child Y herself later told the child welfare officer that she was feeling upset and struggling with what was going on with the forthcoming court case. 6.25 The first recorded indication that mother might also be having a difficult time was when a restorative justice worker visited Child Y’s home in mid September 2015 and was advised that both Child Y and her mother were “struggling emotionally”. Child Y subsequently told the school child welfare officer that she had been very upset to find her mother crying in the early hours of the morning because of the “current situation”. (Paragraph 4.68) The child welfare officer offered mother support from the school but there is no indication that other support options were discussed with her although mother is recorded as saying she was in touch with “victim support” which is assumed to have referred to the support offered by NPS. 6.26 Child Y experienced further distress as a result of the trial and sentencing of Child Q which was completed in late September 2015 and asked the school child welfare officer for further sources of support in addition to CAMHS. The school has 40 advised the review that Child Y was signposted to unspecified agencies which did not include the school nurse. 6.27 It was around this time that Child Y made her first recorded mention of suicidal ideation (Paragraph 4.43) which she reiterated to CAMHS on her first appointment which took place in early October 2015 – almost a year after the sexual assault. 6.28 Child Y attended seven scheduled CAMHS appointments between October 2015 and February 2016. Thereafter, two appointments were cancelled by mother, an appointment then took place at which Child Y struggled to focus, a further appointment was cancelled by mother before the final appointment took place at which Child Y was considered to be calmer and an improvement in her symptoms noted. It may have been prudent to schedule a further appointment to gain assurance that the improvements noted had been sustained after a period of appointment discontinuity. 6.29 CAMHS has advised the review that the decision to discharge was made in conjunction with Child Y and her mother. Various options were discussed including re-referral if Child Y experienced further difficulties. The case was not seen as complex and was considered to have progressed well with Child Y engaging in therapy. Child Y said she was feeling better. CAMHS feel that there was no rationale to have continued therapy. (In her contribution to this review, mother appeared dismissive of the value of the service provided by CAMHS although CAMHS records indicate that mother may have been sceptical of the benefits from the outset as she is recorded as commenting that she wanted to “shake Child Y” out of it, as the sexual assault had happened a year ago and talked of wanting Child Y to “move on”.) 6.30 The impacts of child sexual abuse: A rapid evidence assessment (July 2017) which was commissioned by the Independent Inquiry into Child Sexual Abuse (IICSA) found that being a victim and survivor of child sexual abuse (CSA) is associated with an increased risk of adverse outcomes in all areas of victims and survivors’ lives. (1) 6.31 Areas of her life in which Child Y appeared to experience adverse outcomes were “emotional wellbeing, mental health and internalising behaviours” where she suffered emotional distress, PTSD, anxiety and depression; “externalising behaviours” such as risky relationships with Young Person R and Adult P; “interpersonal relationships” appear to have become less stable particularly with her father and paternal grandparents; “socio-economic” specifically lower education attainment which led to her being placed on report by her school just prior to her death and “vulnerability to re-victimisation” which is also evidenced by her contact 41 with Young Person R and Adult P in which her vulnerability appears to have been exploited by the males concerned. 6.32 Tellingly for this case, the study also found that the risk of CSA victims and survivors attempting suicide can be as much as six times greater than in the general population. (2) 6.33 Additionally, the study found that the impacts experienced by non-offending parents – and, in particular, mothers – as a result of their children’s CSA victimisation “can mirror those outcomes experienced by victims and survivors”. Additionally, it was found that parents “can find it challenging to support a child who has been victimised at a time when they themselves might be struggling to cope with the emotional and practical strain following CSA”. “This can create a vicious circle in which the support that parents are able to provide to their child is compromised, thereby reducing the child’s chances of experiencing resilience or recovery”. (3) 6.34 In Child Y’s case the indications of this “vicious circle” are evident in the difficulties experienced by mother which agencies only gradually became aware of. Father – who decided not to contribute to this review – appears to have responded to the challenges of supporting Child Y by distancing himself from the situation. Were indications of risk identified by or disclosed to practitioners, responded to in accordance with policy? 6.35 The impacts of child sexual abuse found that victims and survivors of CSA may be more than four times more likely to experience sexual assault in adulthood compared with those who had not experienced CSA. (4) The study noted that sexual revictimisation could also occur in younger childhood and adolescence. And one study also highlighted CSA as a potential risk factor for also experiencing child sexual exploitation (CSE). 6.36 When Young Person R disclosed that he was in a relationship with Child Y which was suspected to be sexual, this prompted a referral by youth justice to children’s social care. (Paragraph 4.26) Young Person R had recently been convicted of a sexual assault on a child under 13. Children’s social care responded by contacting Child Y’s mother in order to try to establish the facts and ensure that mother was able to safeguard Child Y. On this occasion, information was shared with Child Y’s school who then offered support to her. Young Person R was registered as a pupil at the same school although his education was taking place through an alternative provision away from the school site. It is unclear if any plan was put in 42 place to safeguard Child Y should Young Person R have reason to be present on the school site. 6.37 Within five days of their initial contact with mother, children’s social care appear to have closed the case before mother re-contacted them to report concerns of harassment towards Child Y from Young Person R and his family. Children’s social care placed the onus of reporting the matter to the police on mother who decided against this course of action following representations from Young Person R’s family. Child Y’s mother provided a different account of events to this review saying that it was Child Y who had implored her not to report the matter to the police after she (Child Y) had been threatened via Facebook by an uncle of Young Person R. 6.38 The impression gained is that the potential seriousness of this referral was not fully appreciated by children’s social care. Child Y was a thirteen year old girl who had been sexually abused by Child Q ten months earlier. Indications had emerged that she was struggling to cope with the impact of this sexual assault and the ongoing court proceedings. It was suspected that she had been “in a relationship” which may have been sexual with a recently convicted sex-offender. Additionally, they became aware of some harassment by the sex offender’s family. The possibility that an extremely vulnerable Child Y may have been groomed by Young Person R did not appear to be considered and on the basis of two telephone conversations with mother, children’s social care concluded that she was able to safeguard Child Y. Of the “underlying CSE risk factors” from Blackburn with Darwen’s CSE toolkit, “history of abuse including familial child sexual abuse”, “emotional and/or mental health difficulties” and “sexual activity at an early age” were present or suspected to be present. 6.39 During the course of this contact between children’s social care and Child Y’s mother the focus appeared to shift away from any risks that Young Person R might present to Child Y towards the latter’s disclosures that she was struggling to cope with the impact of the October 2014 sexual assault and the consequent court proceedings. 6.40 It is of interest to note that in the school records Young Person R is described as Child Y’s “ex-boyfriend” which does not appear to be an appropriate way to describe a relationship between a vulnerable 13 year old girl and a young male who had recently been convicted of sexually harmful behaviour towards a person under the age of 13 years. Normalising this relationship by referring to Young Person R as Child Y’s “ex-boyfriend” suggests a lack of awareness of the dynamics of sexual exploitation and may offer a partial explanation of why the school did not offer support to Child Y when it became aware of the October 2014 sexual assault. 43 6.41 The school’s child welfare officer has contributed to this review and has said that in using the term “ex-boyfriend”, she was simply quoting Child Y. 6.42 When Child Y was first seen by CAMHS in early October 2015 there does not appear to have been any consideration of a referral to children’s social care or use of that agency’s “advice and consult” offer following Child Y’s disclosure of previous self harm, suicidal ideation and vulnerability to, and arising from, sexual abuse. (Paragraph 4.53) 6.43 Had a referral been made it is assumed that children’s social care may have gained a degree of assurance that Child Y was accessing support from CAMHS. However, a referral may have presented an opportunity to conduct a further assessment which may have shed light on mother’s ability to safeguard Child Y given the emerging indications that her (mother’s) mental health may have been adversely affected by the sexual assault on her daughter. In their contribution to this review CAMHS questioned the practicality of referring all cases involving suicidal ideation to children’s social care although in this case additional risk factors were present that indicated unmet needs for Child Y. 6.44 CAMHS acknowledge that they discussed the possibility of contacting the CSE team with Child Y’s mother who said she wanted to talk to Child Y before making a decision. It was planned to revisit this issue at the next session with Child Y but this appears to have been overlooked. Having reflected on their decision making, CAMHS have concluded that, with the history of a previous sexual assault and Child Y’s own admission that she had sex because all her friends were doing it and wanted to fit in, these may have been indicators of risk of child sexual exploitation to be explored further. 6.45 Some of Child Y’s replies to the school nursing service health questionnaire completed in May 2016 raised concerns about her emotional health and wellbeing which were not followed up on. (Paragraph 4.89) It would have been good practice for the school nursing service to liaise with pastoral staff at Child Y’s school to ensure she had access to appropriate emotional support. Contact with Child Y’s GP and CAMHS were also options. The school nursing service has confirmed that follow up actions for individual children were not the subject to any business continuity limitations. If follow up action was discounted for reasons of confidentiality, then the analysis and rationale behind this should have been recorded and it was not. 6.46 There is no indication that Child Y’s non-attendance at the appointment offered as a follow up to the questionnaire generated any further action by the school nursing service. The service advises that the standard operating procedure (SOP) for the school health needs assessment questionnaire states that “the legal and ethical 44 view of the Trust is that in most cases Year 9 pupils themselves should be regarded as the primary decision makers about whether to participate or not.” This is in relation to the young person’s ability to make decisions around completing the questionnaire and does not relate to the decision to attend a clinical appointment. The school nursing service suggests that is possible that the school nurse understood this to mean that the young person had made the primary decision to refuse contact. The SOP further states that children at year 9 and above (as in Child Y’s case) were more likely to satisfy Fraser guidelines around competence to consent to or refuse treatment but that any concern relating to competence should be further assessed. Child Y had disclosed an episode of self-harm and her answers on her questionnaire indicated that she was struggling emotionally. Whilst this is not an unusual presentation in a year 9 pupil, the lack of any further documented exploration or analysis of these issues leaves unanswered questions regarding Child Y’s competence to refuse intervention relating to her emotional health difficulties. 6.47 Nor is it evident from school nurse records that Child Y’s reports of self-harm and emotional difficulties were considered in the context of a young person who had been the victim of a sexual assault and the further conflict this may have raised for Child Y due to the fact that the perpetrator of the assault was another young person and a family member. The questionnaire also suggested that Child Y had had a previous negative experience with health care provision. She had answered “no” to the following questions regarding her most recent contact with health professionals; ‘Were you given enough information?” “Did you understand everything you were told?” “Do you feel that you were listened to?” This may also have influenced Child Y’s decision to attend the offered school nurse appointment. It is not known to which contact with health professionals Child Y was referring. In the recent past she had had substantial contact with CAMHS as well as contact with her GP, A&E and the SARC. 6.48 The time lapse between Child Y’s completion of the questionnaire and the follow up appointment was almost seven weeks. Guidance at the time was that any follow up was a matter for clinical judgement, but should be before the end of that cohort – in this case between Easter and Summer. New guidance based on a “risk sensible approach” is that for high risk cases – which this would have been considered to be – follow up should be within two working days of the review of the records. 6.49 When Child Y’s “relationship” with Adult P came to the notice of agencies in early January 2017 the initial police investigation was limited. The College of Policing guidance (5) states that CSE can encompass a range of different offences including sexual activity with a child under 16 and that CSE investigations require a proactive approach. The police made contact with Child Y’s school which neglected to inform 45 the police that she had been sexually active and that she had been worried that she might be pregnant recently. When the police interviewed Child Y and her mother the information elicited appeared to be taken at face value and the risk to Child Y was assessed as standard although this was later increased to medium by police officers based in the MASH. The decision that an interview of Adult P was unnecessary as Child Y had not disclosed a sexual relationship, did not appear to be consistent with adopting a proactive approach to investigating CSE. No immediate safeguarding concerns were noted and a PVP was submitted. 6.50 When the PVP was received in the MASH no checks with health services were requested by the team manager at that point as it was anticipated that these checks would be carried out as part of the forthcoming C&F Assessment. However, these checks had still not been carried out prior to the home visit to complete the C&F Assessment. (Paragraph 4.119) Had they been requested, the usual checks would have been A&E attendances, GP and school nurse. Sexual health checks which would have alerted children’s social care to Child Y’s engagement with the sexual health clinic would not be undertaken as standard unless specifically requested by the MASH team manager. The sexual health clinic has identified that they should have made contact with children’s social care after Child Y disclosed the 2014 sexual assault on their first presentation to the service. Such a contact would have alerted children’s social care to the fact that Child Y was accessing services from the sexual health clinic. 6.51 There was a lengthy delay in the case leaving MASH (13 working days as opposed to the target of two working days) and the expected joint home visit with a CSE team worker did not take place. The home visit to commence the C&F Assessment did not take place until a month after Child Y’s relationship with Adult P had been made known to agencies. In addition to the underlying CSE risk factors mentioned in Paragraph 6.38 the high risk CSE factor of “relationship with significantly older adult” was now suspected to be present. 6.52 When the PVP in respect of Child Y’s “relationship” with Adult P reached the school nursing service it was scanned onto Child Y’s electronic record. The action plan recorded by a community staff nurse was to await the outcome from the MASH assessment. School nurse 5 was electronically tasked “for information only” at that time. After reviewing the tasked information, the school nurse decided that no further action was necessary. There is no evidence that this information was considered in the light of earlier information about Child Y, including the sexual assault, nor is there evidence that case weighting was reassessed. (The school nursing service was no longer in business continuity measures by this time but the response to the PVP appeared to be consistent with the limited approach taken during the business continuity period which suggests that factors other than 46 business continuity may have contributed to the general passivity of school nurse responses noted in this case.) 6.53 The school nursing service has observed that there were fifteen entries recorded in the electronic records for Child Y during the period from April 2014 until her death and that eight separate members of staff made those recordings, including four qualified school nurses and three community staff nurses. At no time was a case load weighting review completed which should take place whenever a new need is identified. The case weighting is determined by the anticipated level of school nurse involvement in the case. 6.54 Additionally, the school nursing service state that Child Y remained in the “Corporate Pot” and as such never had a named health professional overseeing her case which would have been triggered if a higher level of case weighting had been calculated. The service adds that whilst having a named health professional may not have changed the course of action offered by school health services, it would have ensured that one health professional had an overarching knowledge and understanding of Child Y’s evolving needs and may have resulted in a more individual and holistic approach to her care. 6.55 No agency was made aware of the contact that Child Q initiated with Child Y via Facebook in January 2017. (Paragraph 4.93) Child Y’s family decided not to report this matter at the time but say that she seemed very upset about the contact. This may have been an event which significantly increased the risk that Child Y could intentionally harm herself. In Suicide by Children and Young People (6) researchers concluded that the circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build up of adversity and high risk behaviours in adolescence and early adulthood, and a "final straw" event which is said to take place in the three months prior to death. 6.56 This “final straw” event may not seem severe to others, making it hard for professionals and families to recognise suicide risk unless the combination of past and present problems is taken into account. The unreported contact from Child Q may have been such a “final straw” event. 47 Were indications of compromised parenting identified by practitioners and responded to in accordance with policy? 6.57 Throughout the period covered by this serious case review, agencies appeared to hold the view that mother was able to effectively safeguard Child Y and that the open dialogue between mother and daughter assisted her in doing this. Agencies appear to have accepted what they were told by mother and Child Y about the openness of communication at face value. And when information came to light which challenged the view held by agencies, they did not appear to question their assumptions about mother’s ability to safeguard Child Y. 6.58 Mother acted as a gatekeeper in deciding whether to accept or decline services and also appeared to be the decision maker over whether to report matters to agencies. There appeared to be insufficient exploration of why services were declined and assurances about the strength of Child Y’s family support network were accepted at face value despite the likely strain that the October 2014 sexual assault appeared likely to impose on family relationships. 6.59 Mother would have been in a stronger position to safeguard Child Y if agencies had shared relevant information with her such as her daughter’s responses to the health questionnaire overseen by the school nurse service and the indications of suicidal ideation which her school, CAMHS and her GP became aware of. 6.60 There was limited appreciation of the impact the sexual assault on Child Y may have had on mother and no consideration of the implications of this for her ability to safeguard Child Y from harm. The almost complete absence of father from the picture appears to have gone unnoticed. What role did management oversight play to enhance the quality of practice? 6.61 Section 11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children. This duty includes management oversight through having a designated professional lead and appropriate supervision and support for staff for example. However, management oversight played only a limited role in enhancing the quality of practice in this case. 6.62 The 2014 C&F Assessment had a number of deficiencies. The assessment required further exploration of the emotional needs of Child Y and the impact of the 48 sexual assault; lacked analysis of the role of Child Y’s father; omitted referrals and/or signposting for Child Y and her parents. Children’s social care’s expectation that the relevant team manager would have challenged these limitations was not met. (Paragraphs 4.15 and 6.18) 6.63 When the senior leadership team of the school became aware of the sexual assault on Child Y they did not provide any direction on actions which the school could have considered including offering support to Child Y. (Paragraphs 4.10 and 6.9) 6.64 The decision by the school nursing service leadership to adopt business continuity measures for the school nurse service resulted in some changes to the way in which that service operated for a time which appear to have been communicated to some partners but were not communicated to Blackburn with Darwen LSCB. (Paragraphs 6.15 to 6.17) 6.65 School nurse service case load weighting did not happen when new needs were identified for Child Y and as a result, the allocation of her case to a named professional did not take place. (Paragraphs 6.53 and 6.54) These omissions appear to have gone unnoticed and unchallenged by management. 6.66 The workload pressures which contributed to the absence of the CSE team from the 2017 C&F Assessment of Child Y do not appear to have been picked up on by management. (4.100) 6.67 When Child Y accessed sexual health services for the first time there were a number of departures from expected practice. (Paragraph 4.80) However, the nurse concerned did discuss the case with a nurse manager but the details of this discussion went unrecorded. (Paragraph 4.81) 6.68 The police investigation of Adult P’s “relationship” with Child Y was limited as was the assessment of risk. Although the police officers in the MASH intervened to raise the risk level there was little indication of supervisory oversight of the investigation. (Paragraph 4.95) 6.69 Child Y’s GP practice missed opportunities to assess her vulnerabilities to sexual exploitation in her last attendance as well as during her earlier presentations with cystitis. The absence of a visible flag in Child Y’s patient records appears to have been a factor in this. It is unclear what role the GP partners and the practice manager in Child Y’s GP practice played in exercising oversight to enhance the quality of practice. It would be of value for the CCG and the GP practice to reflect on this question. 49 7.0 Findings and Recommendations 7.1 Deaths from intentional self harm in children aged 10 to 14 have been included in published suicide statistics only relatively recently due to the very small numbers involved. In 2014, which is the latest year for which data is available, there were six deaths of girls between the age of 10 and 14 where death was as a result of intentional self harm and a further five deaths where intent could not be fully determined. So the suicide of Child Y at 14 years and nine months was a rare event. 7.2 However, the sexual abuse suffered by Child Y as a twelve year old appears to have significantly increased her risk of death by suicide. “Abuse or neglect” is one of the ten common themes in suicide by children and young people and the risk of victims of child sexual abuse attempting suicide can be as much as six times greater than in the general population. 7.3 This tragic case therefore represents an opportunity to consider how single and multi-agency responses to Child Y could have been improved in order to enhance suicide prevention efforts. Working with families to provide support to vulnerable children is considered to be key to suicide prevention. (7) The work to support Child Y in the wake of the sexual assault in October 2014 was characterised by incomplete multi-agency working, insufficiently probing assessments in which information was accepted at face value and a general lack of awareness of the potential impact of child sexual assault on the victim and their families. Independent Sexual Violence Advisor support 7.4 Child Y was not offered the support of a ChISVA. The review has been advised that this was under consideration when the SARC manager rang Child Y’s mother to check on her daughter’s welfare. (Paragraph 4.18) Mother’s assurances that no further support was required at that point were accepted and a referral to ChISVA was not offered. 7.5 Had Child Y been offered, and accepted, the support of a ChISVA, that service would have been well placed to help Child Y access earlier and perhaps more joined up support than she received and would have been able to support her through the court process in particular the partial success of Child Q’s appeal which appears to have caused her considerable distress. 7.6 It is not known whether the absence of a referral to ChISVA in Child Y’s case is typical of cases in which children and young people are victims of sexual assault in Blackburn with Darwen. The LSCB may wish to seek assurance that where a child or young person is a victim of sexual assault, they are offered a referral to a ChISVA. 50 Recommendation 1 That Blackburn with Darwen LSCB obtains assurance that when a child or young person is a victim of a sexual assault they are offered a referral to a Child Independent Sexual Violence Advisor. Inclusiveness of Strategy Discussions 7.7 It was entirely appropriate to hold a strategy discussion following the sexual assault on Child Y in October 2014. However, participants were limited to children’s social care, the police and the health representative in the MASH. Child Y’s school, the school nurse service and her GP were not invited to participate nor the outcome of the discussion shared with them. Had the strategy discussion been more inclusive it may have led to a more holistic approach being adopted and increased the likelihood of Child Y being offered appropriate support. It might also have led to earlier and more active engagement from Child Y’s school and the school nurse service. Child Y’s school did not appear to have been formally informed of the sexual assault until August 2015 although there were other factors in this communication deficit. 7.8 It is challenging to ensure that strategy discussions are appropriately inclusive but the technology exists to overcome the difficulty in promptly arranging a meeting at which every relevant agency is physically represented. It is understood that following an earlier SCR, processes have been put in place to ensure the inclusiveness of strategy meetings including the use of teleconferencing. However, the LSCB may wish to seek assurance that this new process is delivering on inclusiveness of strategy discussions and the appropriate sharing of the outcomes of such discussions. Recommendation 2 That Blackburn with Darwen LSCB obtains assurance that strategy discussions are sufficiently inclusive and that outcomes of such discussions are appropriately shared. Quality of children and family assessments 7.9 C&F assessments were conducted by children’s social care in response to the sexual assault of Child Y in 2014 and the concerns over Adult P’s “relationship” with her in January 2017. Although the latter assessment was incomplete at the time Child Y took the overdose which would prove fatal, neither assessment was satisfactory. The 2014 assessment did not fully explore the emotional needs of Child 51 Y and the impact of the sexual assault, there was no analysis of the role of her father and there was no evidence that referrals were made or signposting information shared with Child Y and her parents. Despite these omissions, the assessment went unchallenged by supervision. The 2017 assessment also excluded Child Y’s father, was not informed by contact with relevant partner agencies and the opportunity to jointly conduct the assessment with the CSE team was not taken. 7.10 As a result of the lack of depth of analysis in the 2014 C&F Assessment, an over optimistic view was taken of the support Child Y may require and her file was closed without consideration of managing the case under CiN or CAF arrangements. The LSCB may wish to seek assurance in respect of the quality of C&F Assessments, in particular the depth of analysis, contact with relevant partner agencies, consideration of the role of the father and the extent to which assessments are challenged by supervisors. This review has been advised that the absence of a CSE assessment by the CSE team, which should have accompanied the 2017 C&F Assessment, has been addressed by the introduction of a system by which a CSE episode is triggered by the MASH team manager which automatically brings such referrals to the CSE team manager’s attention and prompts allocation to a CSE worker for a specialist CSE assessment. The LSCB may wish to seek assurance that this system is working effectively. Recommendation 3 That Blackburn with Darwen LSCB obtains assurance in respect of the quality of child and family assessments, in particular the depth of analysis, contact with relevant partner agencies, consideration of the role of the father and the extent to which assessments are challenged by supervisors. Recommendation 4 That Blackburn with Darwen LSCB obtains assurance that the system by which CSE referrals are brought to the attention of the CSE team manager is working effectively. Joint working between the School and School nurse 7.11 Joint working between Child Y’s school and the school nurse service was entirely absent in Child Y’s case. Contact between the school and school nurse service should have taken place after both parties became aware of the October 2014 sexual assault on Child Y, when concerns arose over Child Y’s relationship with sex offender (Young Person R) in 2015, when the school nurse administered health 52 survey disclosed concerns about Child Y’s emotional health and wellbeing in 2016 and when concerns arose about Child Y’s contact with Adult P in January 2017. 7.12 The school nurse service did not appear to feature in the school’s thinking. For example, when Child Y asked the school welfare officer about sources of support in addition to CAMHS, the latter did not consider directing her towards the school nurse. A factor in this disconnect between the school and the school nurse service was the fact that the latter service had entered business continuity measures as a result of staffing shortages for much of the period covered by this review. The health trust providing school nursing services did not inform the LSCB of the decision to adopt business continuity measures which involved temporarily ceasing some activities such as school drop-ins. However, throughout the period covered by this review, including the period when the service was in business continuity and the period after it emerged from business continuity, the response to all concerns about Child Y was essentially passive. Time after time, the plan formulated by the school nurse service was to await contact by other agencies. The various contacts about Child Y were handled by a series of different members of staff who appeared to treat each event in isolation. Opportunities to review Child Y’s case and consider escalating it to a higher level of school nurse oversight were missed and these omissions went unchallenged by management. 7.13 Additionally links between the school, school nurse service and GP do not appear to have been particularly strong in this case. Had there been more effective communication and sharing of information between these agencies and CAMHS then an enhanced understanding of Child Y’s needs might have been achieved through the noticing of emerging discrepancies in how Child Y and mother were presenting to agencies. 7.14 This review has been advised that Child Y’s school introduced a programme of meetings with the school nurse every 4-6 weeks during which open safeguarding cases and any safeguarding concerns can be discussed. Although these meetings were introduced in November 2016 the PVP completed in respect of Child Y in January 2017 was not discussed. 7.15 The LSCB may wish to seek assurance from health trust providing school nursing services that the learning from this case is leading to a more proactive approach to managing risk and that links with schools have been renewed following the period of business continuity. It is understood that similar assurances have already been sought by the LSCB following earlier SCRs. In seeking assurance, the LSCB may wish to assure themselves that communication between schools and the school nurse service is a strong two way process. The LSCB may wish to remind partner agencies of the need to advise the board of any resourcing issues which 53 have a substantial impact on service delivery and which may necessitate the implementation of business continuity measures. Recommendation 5 That Blackburn with Darwen LSCB obtain assurance from health trust providing school nursing services that the learning from this case and others is leading to a more proactive approach to managing risk and that links with schools have been renewed following the period of business continuity. In seeking this assurance, the LSCB may wish to assure themselves that communication between schools and the school nurse service is a strong two way process. Recommendation 6 That Blackburn with Darwen LSCB reminds partner agencies of the need to advise the board of any resourcing issues which may have a substantial impact on service delivery and which may necessitate the implementation of business continuity measures. The role of GPs in safeguarding victims of child sexual abuse 7.16 Child Y’s GP was not involved in the strategy discussion which followed the October 2014 sexual assault. The GP quickly became aware of the sexual assault but no “significant event” meeting was held and the GP did not take the opportunity to check on how Child Y was coping with the implications of the sexual assault when she next visited the GP. Amongst the factors suggested for the issue not being discussed with Child Y was her young age – then 13 years old. And although the incident was recorded on Child Y’s electronic patient record there was no visible flag placed in her records which would have alerted others within the practice that there was a live concern when accessing Child Y’s records. 7.17 Whilst Child Y’s GP practice’s single agency action plan (see Section 8 of this report) provides assurance that they have reviewed the service they provide to victims of CSE, the LSCB may wish to seek assurance from the CCG that GP practices generally have reviewed the service they provide to the victims of CSA in the light of the lessons emerging from this case. Recommendation 7 That Blackburn with Darwen LSCB obtain assurance from the Clinical Commissioning Group that GP practices generally, have reviewed the service they provide to the victims of child sexual abuse in the light of the lessons emerging from this case. 54 MASH Health Practitioners 7.18 The presence of a health practitioner within the MASH, from the same health trust as the school nursing service, did not appear to assist in facilitating timely and inclusive engagement and communication with relevant health practitioners in respect of the 2014 sexual assault or the 2017 concerns about Child Y’s contact with Adult P. It is appreciated that the health economy is complex and various elements of the health economy may not always have compatible electronic system, but it seems reasonable to expect health practitioners in the MASH to act as a conduit for all of the health services involved in a particular case. It is understood that this issue has recently been addressed through new MASH practice guidance and a revised CCG contract with the health trust providing the specialist safeguarding nurses in MASH. The LSCB may wish to seek assurance that these new arrangements ensure effective communication and engagement between the MASH and relevant health services. Recommendation 8 That Blackburn with Darwen LSCB seeks assurance that recently introduced arrangements to ensure effective communication and engagement between the MASH and relevant health services are working effectively. Voice of the Child 7.19 Child Y was twelve years old when she was sexually assaulted by Child Q and three months short of her fifteenth birthday when she died. Despite her growing maturity, most agencies tended to communicate with her mother about her rather than communicating directly with Child Y. This effectively handed mother the role of “gatekeeper”. In this role she frequently declined support for Child Y without Child Y’s wishes apparently being ascertained by agencies despite the high level of concern for Child Y’s welfare. Given the distress that mother may have been feeling, she may not have been ideally placed to make decisions about support for her daughter. 7.20 There was also a period during which the police regarded Child Y’s paternal grandmother as the family spokesperson, which given her obvious conflict of interest as the special guardian of Child Q and his sibling, was unwise. 7.21 CAMHS succeeded in providing Child Y with a private therapeutic space and the sexual health clinic was also able to support Child Y on a one to one basis. However, these and other agencies who made direct contact with Child Y tended to accept what she told them at face value even when discrepant information was 55 available. For example, many agencies accepted the Child Y’s assertion that she confided in her mother including matters of a sexual nature despite accumulating evidence that this was not the case. 7.22 Child Y appeared to develop a trusting relationship with her school’s child welfare officer but the potential value of this was somewhat diminished by the school’s safeguarding practices which included inadequate recording systems and a lack of awareness of the impact of child sexual abuse on the victim. 7.23 Insufficient consideration of the voice of the child is regularly highlighted in serious case reviews and is equally regularly the subject of recommendations. The practitioners and managers involved in Child Y’s case absolutely recognised the need to listen to her voice. There seemed no lack of appreciation of the importance of this issue. Yet the voice of the child continues to receive insufficient attention. Practitioners and managers suggested that their work had become excessively process driven which had impacted on the extent to which the service they provided was tailored to the needs of the person. 7.24 Rather than make the type of voice of the child recommendation common in serious case reviews, such as auditing cases to check on the extent to which the voice of the child is present, it is suggested that when the learning from this case is disseminated to practitioners a strong focus of any briefing or training or workshops is a session in which practitioners and managers are asked to identify what is stopping them from listening to the voice of the child. Analysis of the answers to this question may yield some clues as to how this persistently challenging issue might be addressed. Support for families of victims of child sexual abuse. 7.25 In this case agencies saw mother as the key figure providing support to Child Y in the period following the October 2014 sexual assault. It only gradually became apparent that the sexual assault and the surrounding circumstances were also having an effect upon her emotional health and wellbeing. It is possible that the sexual assault on Child Y may also have had an effect on father who appears to have responded by distancing himself from the situation. 7.26 As stated in Paragraph 6.33 The Impacts of child sexual abuse study found that the impacts of child sexual abuse on the parents – particularly the mother – can be profound and may actually mirror the impacts experienced by the child. As a result, parents may find it challenging to provide support to the child which can create a “vicious circle” in which the support the parent is able to give to their child is compromised, thereby reducing the child’s chances of recovery. This serious case 56 review has benefitted from the strong engagement of practitioners and managers involved in Child Y’s case. They found this research finding extremely revealing and felt that greater consideration should be given to supporting the parents of children who have been the victims of child sexual abuse and child sexual exploitation. 7.27 The LSCB may wish to review the support provided to the families of children who are the victims of CSA and CSE in order to identify whether further support is required in order to help parents support their children to cope with the impact of CSA and CSE. Recommendation 9 That Blackburn with Darwen LSCB conducts a review of the support provided to the families of children who are the victims of CSA and CSE in order to identify whether further support is required in order to help parents support their children to cope with the impact of CSA and CSE. Suicide prevention 7.28 Recognising suicide risk in children and young people is acknowledged to be extremely challenging for professionals. (8) Child Y’s suicide texts strongly suggest that the October 2014 sexual assault by Child Q had a devastating effect upon her life. With hindsight, the delay in providing therapeutic support to Child Y following that sexual assault, the lack of recognition of the impact of that sexual assault upon Child Y’s parents and the lack of practitioner awareness that Child Y’s risky contact with Young Person R and Adult P might constitute “externalising behaviours” prompted by the October 2014 sexual assault represent opportunities missed. 7.29 However, practitioner awareness of potential suicide risk factors did not appear to be high, despite several agencies becoming aware of Child Y’s suicidal ideation, and did not inform single or multi-agency decision making. Research suggests that this situation is not uncommon. (9) This case therefore presents an opportunity to both raise practitioner awareness and potentially develop an enhanced approach to suicide prevention amongst children and young people. 7.30 It is suggested that the learning from this case is widely disseminated in order to enhance practitioner awareness of potential suicide risk factors including self harm which research suggests is a crucial indicator of risk. The LSCB may also wish to make use of the learning from this case to help inform a review of suicide prevention services for children and young people. 57 Recommendation 10 That Blackburn with Darwen LSCB widely disseminate the learning from this case in order to enhance practitioner awareness of potential suicide risk factors. Recommendation 11 That Blackburn with Darwen LSCB make use of the learning from this case and relevant research findings to inform the Blackburn with Darwen suicide prevention strategy for children and young people. 58 8.0 Single Agency Action Plans Sexual Health Clinic Introduction to Safeguarding training Level 2 to be delivered to all client- facing staff as a refresher. To improve the frequency of safeguarding monitoring meetings. To improve recording of minute taking. To ensure that all new staff who work in a client facing role, have attended the agency’s Introduction to Safeguarding Training prior to seeing clients alone. To complete a record keeping audit on 40 sets of Nurse 1’s consultations to determine if any client records indicate that safeguarding concerns require further action. To implement peer review of records for all clinical staff following the agency’s new peer review procedure. The agency’s national monthly teleconferences to be held by the Designated Safeguarding Lead, and Head of Education and Wellbeing, to update all staff on safeguarding policies and procedures including any recent revisions, and time to be allocated for all staff to have the opportunity to dial in. To complete an internal investigation to establish the facts surrounding the failure to refer a previous historic abuse case to social care. Children’s Social Care In relation to sexual health referrals that MASH undertake checks with school nurse, GP and sexual health services. Hospitals NHS Trust To ensure that where CAMHS identify children as being at risk of CSE that appropriate action is taken to safeguard the child. 59 To strengthen safeguarding supervision for CAMHS from the Trust’s Safeguarding team. Child Sexual Abuse / Child Sexual Exploitation risk indicators to be highlighted in patient records. NHS CCG (GP practice) All practitioners within the practice to have an awareness of and the ability to act in identifying and protecting children who are at risk or experiencing sexual abuse. Review of GP Practice policy to include CSE. Criteria to be identified within the practice as to when to ‘flag’ or implement an alert onto a patients electronic records and the visibility of this with the practice on a need to know basis. Awareness raising within the practice of the need to further review and appropriately investigate when patients attend with an alert on their patient electronic record to highlight a sexual assault. Community NHS Foundation Trust (School Nurse Service) Improve information sharing & communication by practitioners within the Child & Family Health Service with partner agencies. School Nurse Duty system to be reviewed. Risk Sensible Model to be continued to be embedded in practice. To improve adherence to the Case Weighting Tool SOP. School Health Needs Assessment (SHNA) SOP to be reviewed. Police Police Officers when conducting investigations involving children should listen to and speak to the child and take into consideration the voice of the child. 60 Child victims who are identified as being at risk of CSE or risky sexual activity should be assessed as High Risk when PVP risk assessments are submitted into the MASH. This will allow for information to be shared with relevant agencies and safeguarding to be expedited. This complies with current advisory criteria. School School is to implement a mental health policy. School is to make informing and training staff in and around mental health and wellbeing a priority. School is to continue developing their electronic recording system for safeguarding supported by staff training. All safeguarding reports are now seen by the head teacher and senior staff and these form the basis of regular planning and action with the Child Welfare Officer and senior pastoral staff. Training has been delivered to pastoral staff on the impact of sexual assault and child sexual exploitation on children’s lives so that they are aware of potential implications of these events on children and so ensure their response is appropriate to disclosures. A tier 2 information and sharing agreement has been signed between the school and school nursing service which formalises and standardises the information that will be shared between the school and the service. Protocols have been put in place so that outside agencies seeking information sharing from school will always be referred to the head teacher, senior staff or the child welfare officer to assess the level of information to be shared to ensure effective safeguarding and support for the child. 61 References (1) Retrieved from https://www.iicsa.org.uk/key-documents/1534/view/IICSA%20Impacts%20of%20Child%20Sexual%20Abuse%20Rapid%20Evidence%20Assessment%20Full%20Report%20%28English%29.pdf (2) ibid (3) ibid (4) ibid (5) Retrieved from https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/child-sexual-exploitation/#investigating-cse-cases (6) retrieved from http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/cyp_2017_report.pdf (7) ibid (8) ibid (9) ibid 62 Appendix A The process by which this serious case review was completed It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. The following agencies contributed to this review: Sexual health clinic provider (sexual health and wellbeing for under 25s) Children’s Social Care Hospitals NHS Trust (CAMHS) NHS Clinical Commissioning Group (GP practice) Community NHS Foundation Trust (School Nurse Service) Police; and Child Y’s school. Each agency completed a chronology of relevant contacts with Child Y and her family and an agency report in which they reflected on that contact and identified single agency learning. After these agency reports had been quality assured a practitioner learning event took place at which practitioners and managers involved in the case clarified what happened and why, identified significant practice episodes and potential learning themes. The independent author then prepared an initial draft report which was subsequently shared with a recall practitioner learning event at which practitioners and managers commented on the draft report and went on to consider what needed to change in order to improve practice. 63 Child Y’s mother contributed to the SCR and also commented on the final draft of the SCR report. The independent author prepared a final report following consultation with the agencies which contributed to this SCR which was subsequently presented to Blackburn with Darwen LSCB. |
NC50853 | Sexual assault of a 14-year-old child. The young person reported in November 2015, at the age of 18, that RS had sexually assaulted them some years previously. Sibling of young person also made a complaint of sexual assault against RS in May 2016. RS had a history of violent offences and imprisonment; recalled twice on being released due to risk he posed to others. Made subject of Multi Agency Public Protection Arrangements (MAPPA). RS groomed parents and carers to gain the trust of young people in their care to commit offences against them. RS arrested and another five young people disclosed that they had also been sexually assaulted by RS. Convicted of numerous serious offences and received a significant period of imprisonment. Ethnicity or nationality of young people not stated. Learning includes: understanding of risk and how that can be managed needs to be better; agencies need to identify persons who present a risk to children and flag those persons within their agencies to enable them to be managed in a multi-agency fashion; parents and carers need to be equipped to identify grooming, especially when a risk is known or perceived. Recommendations include: ensure that organisations can effectively flag and monitor persons identified as presenting a danger to children; ensure that staff feel confident in identifying and referring persons who present a danger to children; review how effective disclosures can be achieved from children and young persons where there is a lack of verbal disclosure.
| Title: Learning report: Case P. LSCB: Cambridgeshire and Peterborough Safeguarding Children Board Author: Cambridgeshire and Peterborough Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Cambridgeshire and Peterborough Safeguarding Children Board Learning Report Case P May 2018 2 | P a g e Learning report This learning report is to inform practitioners and professionals of the learning from a Serious Case Review (SCR) undertaken by the Peterborough Safeguarding Children Board. The SCR was undertaken using a practitioner focused methodology. The purpose of an SCR is to illicit learning from a case and this report is to ensure that the learning is available and used effectively to inform and where required to improve practice. What were the circumstances that led to this SCR? In November 2015 an 18 year old young person made an allegation of serious sexual assault against a man called RS. The victim stated that this had occurred when they were 14 years of age. In May 2016 the sibling of the first victim also made a complaint of sexual assault against RS. The appropriate intelligence checks were not made at the time of the report and had they been it would have been revealed that there was significant evidence and intelligence to suggest that RS presented a risk to young persons as a sex offender. This information would have allowed for more immediate action and earlier intervention. RS was subsequently arrested and after his arrest another five young people came forward and disclosed that they had also been subjected to serious sexual assaults and offences of rape by RS. RS was subsequently convicted of numerous serious offences and received a significant period of imprisonment. Why was the SCR undertaken? The Peterborough Safeguarding Children Board considered the circumstances and agreed that serious harm had been caused to the young persons and that there were concerns as to how organisations had worked together to protect the young persons. The review looked at an extended period of time, from 2008 to the time that RS was arrested. Due to other legal processes there has been a delay in the publication of this review, these processes have not prevented the learning identified from being acted upon and used to improve processes and practice. What did we know about RS? RS had a significant offending history including a number of offences of violence. It was clear that the potential risk that RS presented to others, including young persons, had previously been recognised. RS served a lengthy term of imprisonment and on being released was twice recalled to prison due to the risk that he presented to others. 3 | P a g e On release RS was made the subject of Multi Agency Public Protection Arrangements (MAPPA)1. He moved between areas and there was confusion over the ‘ownership’ of these arrangements. He was for a period on bail for a separate serious sexual offence but was ultimately found not guilty of the offence. Due to his moving areas and the fact that he was managed on bail conditions for a period, when the bail conditions ceased to exist not enough consideration was given to how RS could be managed and he effectively ‘fell off the radar’. It is fair to say that over time agencies had concerns regarding his behaviour and association with young persons and children but these concerns did not translate to effective multi-agency management. RS and his offending RS befriended a family and by doing so was able to form relationships with two of the children aged 14 and 15 years at the time. The parent trusted RS and considered him to be a friend. There were occasions when RS demonstrated that he was a protective factor in the life of the children, for example protecting them from bullying from other youths, and through this the trust in him was enhanced. RS also befriended a carer who had responsibility for a 12-year-old and through this relationship was able to gain the trust of the young person and commit offences against them. Through these relationships RS was able to gain access to his other victims aged between 10 and 14 years of age and over an extended period commit the most serious offences against them. RS demonstrated that he was adept at not only grooming children but also their parents and carers. What did the SCR find? Identification and management of risk – The risk that RS presented was well documented, he had been assessed by various agencies on a number of occasions. The risk in the early stages was dealt with robustly with him being recalled to prison on two occasions, a course of action which is not taken lightly. As time passed this recognition of risk diminished and RS was allowed to fade into the background. If he had continued to be managed within the MAPPA framework this would have allowed agencies to be aware of the risk he presented. Information sharing and coordinated action – Information, particularly with regard to the risk RS presented was not effectively shared between agencies. It is apparent that agencies had their own concerns regarding RS and his relationship with vulnerable families allowing him access to young persons, but did not act in a coordinated fashion to try to deal with these concerns. There was evidence of warnings being given to families but the right information not being passed to allow them to protect their children. There was also 1 Multi Agency Public Protection Arrangements (MAPPA) - Multi-agency public protection arrangements are in place to ensure the successful management of violent and sexual offenders. 4 | P a g e instances of written agreements being made with families that had no ability to be followed up or enforced. Decision making – The decision making by agencies was on occasions poor, there was a lack of recognition of previous information which could have better informed decisions to mitigate the risk RS presented. Decisions were taken in isolation without appropriate and available consultation with other agencies. Community and third party information – In this case there was repeated concerns voiced by members of the community and indeed health professionals. Not enough emphasis was given to these concerns both taken on their own merits and when taken cumulatively. Recognising the potential signs of sexual abuse – There were occasions when the young persons were spoken to and asked about the relationship they had with RS. When no direct verbal disclosure was made concerns were closed. There were other signs available such as over sexualised behaviour. One child was receiving support through a therapeutic programme and comments were made by them that warranted following up but they were not. Learning points from the SCR There needs to be a better understanding of risk and how that can be managed. Agencies need to be able to identify persons who present a risk to children, to be able to flag those persons within their agencies to enable them to be managed in a multi-agency fashion. Professionals need to be able to identify potential signs of sexual abuse and be able to act appropriately as a result. Decisions need to be made with consideration to all information that is available and relevant. Decisions should be made, where possible, in consultation with other agencies. Due regard should be given to community intelligence, in particular where it is received from more than one source. Professionals need to be confident in their ability to effectively share information to protect children. When offences are reported, the action taken and the priority of that action, should be based on all available information and intelligence. Parents and all other carers need to be equipped to identify ‘grooming’ activity and in particular when a risk is known or perceived. Recommendations 1. The LSCB should seek reassurance that all staff within contributing organisations feel confident to be able to identify and refer persons who present a significant danger to children, and should review what mechanisms are available to manage such persons, considering both the MAPPA and IOM frameworks. 2. The LSCB should seek reassurance that organisations have a method to effectively flag and monitor persons who are identified as presenting a significant danger to children. 3. The LSCB should review how effective disclosures can be achieved from children and young persons where there is a lack of verbal disclosure, which should include an 5 | P a g e emphasis on other factors such as the child demonstrating sexualised behaviour and the emphasis given to community intelligence. 4. The LSCB should seek reassurance that staff are equipped and able to identify signs of grooming and risk indicators of sexual abuse and report it appropriately. This should include staff working closely with children and young persons on therapeutic interventions. 5. The LSCB should review what the offer is to Young People in Peterborough both as offenders and potential victims of sexually harmful behaviour. 6. The LSCB should seek assurance that written agreements with parents are appropriately used and monitored. |
NC049010 | Significant brain injury to a 4-month-old baby in June 2014, which resulted in severe and lifelong disability. Father was found guilty of one count of child cruelty and sentenced to three years' custody. Child F was brought to Accident and Emergency Department in June 2014 seriously unwell and fitting. Examination revealed bilateral brain haemorrhages and bruising. Child F had been in the care of his father during the evening; when mother returned she found the baby unwell and called emergency services. Mother had been in long-term foster care and moved to a semi-independent living placement in 2012; she informed her personal assistant that she was pregnant in June 2013. Child F had been admitted to hospital on two previous occasions the same month as mother had concerns about the size of his head circumference; he was diagnosed with gastroenteritis. No child protection concerns recorded. Ethnicity or nationality not stated. Findings: the role and responsibilities of a personal assistant in supporting care leavers is not consistently understood across agencies indicating a need for all agencies to consider incorporating this into a single agency training; the fragmented health record systems do not ensure timely and reliable information sharing; fathers appear to continue to be of secondary or sometimes given little or no consideration by professionals. No recommendations are included but several questions related to the findings are made to the LSCB.
| Title: Child F: serious case review. LSCB: Cornwall and Isles of Scilly Safeguarding Children Board Author: Karen Dale Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CORNWALL AND ISLES OF SCILLY SAFEGUARDING CHILDREN BOARD Child F- Serious Case Review SCR REPORT September 2016 Report Author: Karen Dale, Senior Manager (Safeguarding) Lead Reviewer: Deborah Jeremiah Trainee Reviewer: Lorraine Bateman 2 Contents 1. Introduction 3 2. Consideration for Review and Timescale 3 3. Summary of case 4 4. Parallel processes 4 5. Scope of Review 5 6. Methodology 5 7. Contributors to the review 7 8. Timeline 9 9. Appraisal and analysis 9 10. Findings and Questions for the LSCB 16 Appendix One – Acronyms and Glossary 20 3 1. Introduction 1.1 This serious case review concerns a four month old baby (Child F) who sustained a significant brain injury. Child F was brought into hospital by ambulance in June 2014 fitting and with bruising to the left buttock. Child F survived but has been left with a severe disability, which will be life-long. The injury sustained by Child F was subject to a police investigation, which culminated in Child F’s father being charged. The matter was heard by the court in July 2016 resulting in Child F’s father being found guilty of one count of child cruelty and being sentenced to 3 years custody. 2. Consideration for a Review and Timescale 2.1 This case was considered by the serious case review subgroup for the Cornwall and Isles of Scilly Safeguarding Children Board (CIOSSCB) on 30 July 2014. 2.2 The CIOSSCB Independent Chair made the decision that the circumstances of the child’s injuries met the criteria for a serious case review, as set out in Regulation 5 of the Local Safeguarding Children Boards Regulations 2006. This requires the LSCB to undertake a serious case review in specified circumstances. 2.3 Regulation 5 (1) and (2) sets out the LSCB’s function in relation to serious case reviews, namely:- 5 (1) (e) undertaking reviews of serious cases and advising the Authority and their Board members of lessons to be learned (2) For the purposes of paragraph (1) (e) a serious case review is one where;- • abuse or neglect of a child is known or suspected; and • either- (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.4 An independent lead reviewer was commissioned to conduct the review with a trainee reviewer and it was agreed to use systems methodology. The first meeting of the review team was on 10 November 2014. This was followed by five further meetings and also conversations with fifteen key frontline professionals bringing the review to June 2015. There was then a pause in the process for the criminal investigation, as the police were awaiting medical reports from a number of specialists. 2.5 The police eventually made the decision to charge the father in November 2015. The first court hearing was 17 December 2015. Following the police decision not to charge the mother it became possible to involve her in the review, along with other family members and the foster carers as the mother was a care leaver. The review team meeting to consider the first draft pre-trial report was on 18 November 2015. The police further advised on 15 January 2016 that a not guilty plea had been entered and that the matter would be 4 going to a full trial in July 2016. This is the reason for the delay in publishing the report of the serious case review. 3. Summary of case 3.1 The family composition is set out below and pseudonyms are used in the main body of this report to protect the identity of the individuals: Child F Mother Father Paternal Grandmother Maternal Sister 3.2 Child F was brought to the Accident and Emergency Department in June 2014 seriously unwell and fitting. The explanation from his parents was that he had been in the care of his Father during the evening and into the early hours while his Mother was out with friends. Child F’s Mother had planned to be out overnight but came home early at 2.00 am to find the baby was clearly not well, “staring and twitching”. Mother tried to settle him for some hours and then called 111 at 07.41 am and informed the service that her baby had been waking up screaming all night. As well as staring and twitching, she said he would not take his bottle. His breathing was described as heavy and his head floppy. The 111 team deemed this a medical emergency and an ambulance arrived at 07.53 am. The audio recording of this call to 111 has been heard. The baby is heard in the background in obvious distress with grunting respirations. He was taken to the nearest hospital Emergency Department arriving at 08.22 am. He was still fitting and noted to be pale. He was found to have bilateral brain haemorrhages and bruising to his left buttock. 3.3 Examination revealed injuries considered to be non-accidental. He was stabilised but then urgently transferred to a specialist unit in Bristol by Air Ambulance. He remained in a specialist unit for some months. Currently he no longer requires in-patient hospital care and is being cared for by his Mother with the support of a number of professionals to meet his various needs. He has been left with a significant disability as a result of his brain injury, the real extent of which will be become clearer as he develops and grows. 4. Parallel Processes 4.1 An initial strategy discussion was held after Child F was taken to Accident and Emergency involving police, health and social workers. Steps were put in place to prevent either parent having unsupervised access or contact with him while a police investigation commenced. 4.2 The police investigation took longer than normal to complete as numerous medical expert opinions were required from appropriate specialists. The police investigation needed to consider any potential issues of neglect as well as ascertaining the possible perpetrators of the injuries and to ascertain if there were any historic injuries to be detected. 5 4.3 This review was not completed within six months, which is the preferred timetable for serious case reviews, due to the on-going police investigation which took primacy. The police investigation was dependent upon receiving medical evidence which is not unusual for cases of this nature and can be complex in establishing the facts and securing clear expert evidence. It was agreed that the review could include the involvement of Mother and other family members and this took place in November 2015. This was done within strict parameters around what could and could not be discussed so as not to prejudice the police investigation and potential criminal proceedings. 5. Scope of the Review 5.1 At the start of the case the review was scoped and terms of reference agreed. 5.2 The focus of serious case reviews is on how safeguarding systems and practices within the agencies operate together to safeguard the child. The review did not go back in history because systems have changed over time. This does not mean that family history and contextual information is overlooked but what is relevant is whether the professionals working with the family during the period under review knew about the family history, whether information was shared effectively and whether the system in which they operate supports working together effectively. 5.3 It was agreed that the main focus of this review would be the events from Child F’s birth to the point of his admission to hospital in June 2014 and how professionals worked together to identify and reduce any risks to his welfare. 6. Methodology 6.1 Working Together states LSCBs may use any learning model which is consistent with the principles within the guidance, including systems methodology. 6.2 The Department for Education has set aside a proscribed model procedure in favour of the principle of learning. This allows local safeguarding children boards (LSCBs) and reviewers more freedom to explore what happened, whether any weaknesses can be identified and rectified, with the aim of preventing tragedies like this. Any application of the principles will be considered by the Department for Education to be consistent with systems methodology. 6.3 The systems methodology and appreciative inquiry was the agreed approach of the LSCB for this review. The review has been approached with the five principles of appreciative inquiry in mind. See below. 6 6.4 The LSCB identified that this serious case review held the potential to shed light on particular areas of practice. 6.5 The main statutory and non-statutory guidance to protect and safeguard children is contained within:- Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. March 2013 (now revised to 2015). 6.6 In Chapter 4: “Learning and improvement framework” there is a set of principles which LSCBs should apply to all reviews, including serious case reviews.) These are:- 7 • ‘A culture of continuous learning and improvement across the organisations that work together…; • The approach taken to reviews should be proportionate…; • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; • Families, including surviving children, should be invited to contribute to reviews…; • Final reports of SCR’s must be published… The impact of SCRs…must also be described in LSCB annual reports and will inform inspections; and • Improvement must be sustained through regular monitoring and follow up…’ 6.7 SCRs and other case reviews should be conducted in such a way which: • ‘Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings’ 7. Contributors to the Review 7.1 The review team consisted of a senior manager from each of the agencies involved during the period under review, none of whom had had line management of the case, and two independent reviewers. 7.2 The review team consists of:- Deborah Jeremiah, Lead Reviewer Lorraine Bateman, Trainee Reviewer Principal Officer, Child and Adult Protection Designated Doctor, Hospital Supervisor, Family Nurse Partnership Principal Officer, Child Protection Service Manager, Multi-Agency Referral Unit Team Manager, Child Protection Principal Social Worker Named Nurse, Hospital Senior Service Manager and Professional Lead for Health Visiting and School Nursing Detective Sergeant, Public Protection Unit GP, Primary care 8 7.3 The Ambulance Service did not join the review team as they considered their involvement minimal. This did not limit the review in any way. The Housing Service provided information into the review across two local authority areas. 7.4 The engagement of the review team was positive. The lead reviewers are grateful to those review team members who maintained their engagement and attendance for review meetings throughout the process. The lead reviewers would also thank the safeguarding administrator who supported the review throughout in an excellent and efficient manner. 7.5 The case group was made up of the key frontline professionals who had been working most closely with the family during the period under review. Seven professionals contributed directly to the group and additional conversations were held with another eight professionals. This provided a rich source of information as to what was known about the family at the time and also to understand the rationale of decision making around the family and unborn and born child in a system context. Those contributing from this group included: • Police officers • Midwives - from both counties providing antenatal and postnatal care • Health service safeguarding leads • Personal Assistant (Leaving Care Service) • The manager of the Multi-Agency Referral Unit (MARU) • Health Visitor • Junior and senior doctors who attended Child F at both hospital admissions prior to the serious injuries being sustained 7.6 There was ongoing interaction between the two groups to test out accuracy, developing analysis and findings. 7.7 Documents considered for the review include: • Integrated chronology • Conversation notes • Hospital medical records including discharge summaries (n.b. some records were lost) • GP summary records • Housing records • Care leaving documentation and pathway plan • NICE Guidance re antenatal care standards • Transcripts and audio of all 111 calls • Personal assistant records and supervision records • Head circumference measurements and centile information from the Red Book (handheld child’s medical record) • Safeguarding polices and pre-birth assessment criteria • MARU referral and protocols • South West Safeguarding Procedures including escalation policy. • Care Leavers Legislation • “Staying Put” guidance HM Government • Relevant previous SCR’s 9 7.8 The involvement of family members in serious case reviews gives a helpful perspective that can provide a rich source of learning. Child F’s Mother and Maternal Sister were helpful in contributing to the review and the review team were grateful for the time all family members gave in meeting with the lead reviewers and report author and providing their important perspectives. 7.9 Father’s family understandably declined to contribute to the review and as a result of the police investigation it was not appropriate to approach Father to participate in the review. This review is limited by the lack of his perspective and contribution. As a result we do not know what support or service needs he may have needed from the time he knew he was going to be a Father and in the context of his relationship with Mother before and after his child was born. 8. Timeline 8.1. Set out below is a timeline of key points on the story of the child and family. This is not an exhaustive chronology but a timeline in keeping with systems methodology. This is taken from an integrated chronology prepared for the review by the agencies involved with the family. 8.2 The identification key for the professionals is as follows:- • Personal Advisor, Social Care 16+ Team – PA • Health Visitor – HV • First Community Midwife - MW1 • Second Community Midwife - MW2 • Third Community Midwife - MW3 • Safeguarding Midwife, Cornwall - MW4 • Safeguarding Midwife, Plymouth - MW5 • General Practitioner – GP • Multi Agency Referral Unit - MARU 8.3 There is a glossary at Appendix 1 9. Appraisal and Analysis 9.1 Statutory guidance requires that serious case reviews provide an analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of recurrence. These processes should be transparent, with the findings of the review shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone has an interest in understanding both what works well and also why things can go wrong and what can be done to improve the safeguarding systems and practice. 9.2 In February 2012, Mother moved from a long term foster placement (previously subject to a Care Order) to an open door semi-independent living placement. This meant a change in the key professional supporting her at this time, from a Social Worker to a Personal Assistant (PA) as the Post 16 Service became involved. The 16+ Service is a partnership between the Local Authority and Action for Children. The Service works in accordance with the statutory duties under the Children (Leaving Care) Act 2000. Open Door is an established supported lodging scheme for care leavers aged 16+ to help prepare them for 10 independence. The PA becomes the key worker for advice and support. The PA is not a qualified social worker but has had training for this role and was experienced in supporting care leavers making the transition to independence. 9.3 Mother informed her PA she was 9 weeks pregnant in July 2013. On this day Mother also saw a midwife (MW1). MW1 thought Mother had a Social Worker and she advised Mother to ensure her Social Worker was aware of her pregnancy. The midwife knew that Mother was a care leaver but was not familiar with the care pathway for care leavers or the role of PAs. This was because she did not encounter care leavers in transition that often and also there was nothing in her training and experience to inform her that the PA is not a qualified social worker. [Finding One] 9.4 Child F was born on 25 February 2014. At the point of discharge the midwife completes a form that addresses the medical fitness to be discharged rather than any social circumstances. There were no concerns at this time. The midwife discharging Mother had no knowledge of the involvement of the PA or of the role of the PA in supporting care leavers. 9.5 On 27 February 2014 MW3 visited Child F and Mother at home on day 2 after the birth. MW3 recalled Mother was worried about the baby’s breathing and she gave reassurance that his respiration and temperature appeared normal but that if Mother continued to be worried she could see the GP. MW3 gave the relevant contact numbers. Father was present on this occasion but did not involve himself in the appointment. MW3 said that she, “never got much from him” and “he didn’t seem interested”. She said, however, there was nothing in the interaction between him and Mother to concern her. MW3 did not observe him with the baby. No observation was made of Father’s parenting or attachment although this should apply to both parents. All the professionals and review team accepted that culturally there is a still a tendency for professionals to focus on mothers and not to pay sufficient attention to fathers. [Finding Three] 9.6 MW3 visited again on 28 February 2014 (Day 3) which is normal practice for a first baby. Child F was weighed and had lost a little weight in line with expectations. He was a little jaundiced but MW3 was happy with progress. She does not recall anything about his head size. MW3 was led to believe that the Parental Grandmother (PGM) was offering support at this time and got the sense she may have been promoting breast feeding. The next contact was on 2 March 2014, (day 5) when Mother and Child F were seen by a different midwife. 9.7 On 4 March 2014, (Day 7) Mother and Child F were seen again by MW3. This appointment is likely to have been arranged because of the move from bottle to breast feeding. MW3 weighed Child F who had not lost weight. He had good skin tone and yellow stools so “all normal”. There is no recollection of concerns around head size. The last visit by MW3 was on 10 March 2014, (Day 13) and MW3 discharged Mother. MW3 had no concerns. That was the last contact MW3 had with Mother and Child F. MW3 was not aware that Child F was also being seen by the GP (27/02/14 and 10/03/14) and MW3 had not had any direct contact with the GP. For this review the GP stated that communication with the health visitors tended to be stronger but even that interface, in their view, had been weakened when health visitors had moved out of GP surgeries and were managed separately following changes in NHS organisation. 11 9.8 For Mother and Child F their experience of guidance and support provided through health practitioners proved more complex, due to a number of changes of address and a resulting delay in their health notes being transferred. When a baby is delivered the hospital will notify the health visitors who will also provide support in the post-natal period. As Mother had remained with the GP in the other county she was unknown to the health visitors in the area to which she moved after leaving Father’s family home. There was no previous information other than that provided by the hospital when Mother and Child F were discharged. This contains basic information around the clinical aspect of the birth and physical checks done on the baby at birth. The head circumference is taken at birth and Child F’s head size was within normal parameters. 9.9 The first visit by the HV was made to Child F at home on 11 March 2014 (14 days old). The HV's expectation at this point would be that the midwife would have weighed the baby at day 3-5 and done blood screening. The baby’s head circumference is often done by the HV at this visit. The HV did not take this measurement on this occasion as he was asleep. Mother was friendly and welcoming and was on her own. The accommodation was appropriate and noted to be warm and clean. During the visit they discussed the birth and throughout Mother presented as mature and positive. Child F was described as settled and feeding well. There were no concerns that warranted liaison with Mother’s PA. 9.10 Mother informed the HV that Paternal Grandmother was supportive and she had stayed with them for a few days following discharge from hospital. Mother said that her own brother and sister lived locally and were also supportive. 9.11 The HV made an appointment for Mother to attend clinic with her baby on 25 March 2014. The HV wrote in the clinic book that the baby required weights and measures to be done, so her colleagues would see it. There was nothing of any note recorded about his head circumference. Mother was unable to attend the clinic on 25/03/14 and the HV followed it up with a call to her on 28/03/14. Mother apologised and a further clinic appointment was made. 9.12 On 1 April 2014 (at 5 weeks old) Mother and Child F attended the clinic where they saw a nursery nurse and weights and measures were taken and found to be normal. These will have been recorded in the red book if the parent has it with them. These are not always plotted on the centile chart. The Mother’s PA visited her at home on the same day. 9.13 The HV received a notification that Child F had attended the hospital with Mother on 8 June 2014 and that he was discharged on the same day with gastroenteritis. The HV was not sure when she first saw this notification. 9.14 The HV said she was later alerted to another notification of a hospital admission on 11/06/14 (discharge on 13/06/14) where Child F had similar symptoms to admission on 8 June 2014. The HV said she rang Mother to ask how things were, given that there had been two hospital admissions, which may have suggested something may not be right. The HV had a follow-up telephone conversation with Mother on 23 June 2014, which is regarded as good practice and Mother described that her baby had been unwell but was now better, “back 12 to himself and feeding better”. Mother said she felt that she was not listened to or her concerns taken seriously in the hospital. Mother told the HV about the diagnosis of a heart murmur. 9.15 The HV acknowledged a delay in notifications being available in the child’s records to the health visiting team, for example from any hospital admissions, as these can sometimes take 2 weeks to arrive/be uploaded and are not date stamped to show arrival date. The HV describes communication with colleagues within the team as effective but largely informal. There is no formal mechanism for transfer of information from midwife to health visitor or from GP to HV. The HV’s have “open door” access to the GPs so if they need to talk they will wait outside the GPs door until there is a gap in patients. This process relies on one seeking out the other, area based knowledge and the quality of working relationships and informal contact. These arrangements do not appear to work so well across larger areas or across health area borders. [Finding Two] 9.16 In contributing to this review, Mother reported that the immediate postnatal period was difficult. She describes feeling low about Father not helping and not wanting to be a dad. He liked living with his mum and dad and watching television and doing what he wanted and she described the relationship as not working. If she asked him to watch the baby while she did the washing up, she said she would come in and he would sometimes be asleep on the sofa. She felt that Father was jealous of the baby getting attention. She felt she was doing everything and he would rather just go out with his friends. They did come to an agreement that Father would have the baby regularly, on a Wednesday and Saturday, so that she could go out with her friends and on those days he would stop over with the baby in Mother’s flat. Mother made the decision to co-parent with Father but to end their relationship. Mother and Father were initially supported by the Paternal Grandparents in the first few weeks. Mother said she was close to her own brother and sister but didn’t see them that often. She said she was also seeing less of Father’s parents after the first few weeks. It is important to repeat that it has not been possible to ascertain Father’s perspective about becoming a parent, his relationship with Mother and his experience of services. So the review is limited in this respect. 9.17 Before being taken to the hospital with a serious brain injury on 30 June 2014, Child F had had two previous admissions to hospital that month as Mother felt there was something wrong with him, also expressing concerns about the size of his head circumference on the second occasion he was seen in the hospital. In both cases he was examined thoroughly, diagnosed with gastroenteritis, assessed as having improved and he was discharged home to the care of his parents. There were no concerns recorded that warranted a referral to children’s social care. 9.18 First hospital admission. On 8 June 2014 Child F was seen at hospital. This is the first time that indicates that Mother felt all was not well with her baby and led to concerns about his physical health. He had had his second immunisations some days previously having had his first on 30 April at the same time as his eight week check. On 30 April his head circumference was 43.5cm against a measurement of 36cm at birth and 39.5cm on 1 April. A further measurement had been done on 10 March but not recorded. 13 9.19 Mother called 111 at 8.32 am on 8 June 2014 and said that her baby was crying inconsolably. She described coming home late at night (7 going into 8 June) and he was screaming and vomiting. Father had been caring for him as she had a night out as they had agreed between them. The 111 records state that Mother reported that her baby had been vomiting and screaming all night. The baby was not limp, floppy or unresponsive but Mother described “red veins” on his head that were “lumpy” to touch. His vomit was milk coloured and he had been distressed all night and he appeared to be in pain. It is recorded that Mother was very upset as the baby had not stopped crying. Mother was advised to take her baby to the GP within two hours. In the meantime she was advised that if he had breathing problems, became limp, floppy, and unresponsive, had new marks like bruising or bleeding under the skin or if he had a fit that she must ring 999 immediately. He was subsequently admitted to hospital on 8 June but discharged later that day. 9.20 Mother felt that her baby had started to become unwell after his second immunisations which were administered on 3 June 2014. She had noted blood in his nappy and the GP said this was a side effect of the injections. Mother had been out with friends on 7 June 2014 going into the early hours of the 8 June 2014 and when she came back there was lots of baby vomit on the floor and she noticed a mark on his head, “like a bruise” (this was the term that Mother first used). She took advice from her Maternal Sister, who was training to be a nurse, and then took the baby to the GP after speaking to the 111 service the next morning. 9.21 The GP sent Child F to the hospital and he was admitted to the assessment ward and was seen by a Consultant Paediatrician. This doctor concluded the marks on the baby’s head were likely to have been self-inflicted from the baby’s nails scratching his head. The Consultant conducted a thorough examination and nothing else was noted and Child F had settled well. The head circumference was not measured nor other investigations undertaken as the marks were considered to be self-inflicted scratches. Child F was observed to be touching his head in that area and scratching there on numerous occasions with local inflammation and redness and some minor discoloration. Child F was later discharged having been observed to settle. The possibility of non-accidental injury was considered by the Consultant Paediatrician and discounted as it was considered that Child F had a gastric infection and had settled in hospital. Mother told the review that she did not challenge this discharge. 9.22 Mother made further calls to 111 on 9 June 2014 (11.13 am and 11.49 am) and the advice given was to take Child F to the GP. Child F was seen in the urgent clinic at 2.15 pm and it was noted that he has been vomiting on and off but had no diarrhoea. The GP examined the baby and he was well hydrated and alert and his skin tone and fontanelle were noted as normal. The fontanelle is an important indicator of the health of a young baby. The GP concluded that Child F had a viral illness and gave advice to Mother around keeping up fluids and to come back if anything changed. 9.23 Second hospital admission. Father rang 111 at 4.09 am on 11 June expressing concerns that Child F was unwell and “not right”. Father told 111 that the baby had been vomiting, crying and unsettled for three nights, seemed in pain and was crying inconsolably and was hot to touch. The advice was to 14 take the child to the GP and advice was given around administering medication to reduce the child’s temperature and pain. Child F was brought into the GP by Mother mid-morning and was seen by a different GP. This GP was concerned as in his view Child F was “not handling properly, was floppy and not right”. 9.24 The GP referred Child F to the Paediatric Service. The GP describes no problem with that referral, which was immediate and reflected good communication. In hospital Child F’s head circumference raised concern and the admitting nurse found Child F to be irritable and floppy and Mother reported he had been like that for the last few days. The nurse also noted that he seemed to be in pain on handling and that when taking his blood pressure she noted his left eye was deviated towards his nose while his right eye stayed midline. His head circumference was noted to be on the 99th Centile at 44cms and his head looked large in proportion to his body. Mother told the nurse that she had noticed his head was getting larger for some time. 9.25 On further assessment by Ophthalmology there was no sign of optical damage or abnormality and the doctors concluded that Child F had a viral illness. There were no neurological problems and Child F improved in hospital. The Consultant saw Child F on 12 June and noted the results and on a thorough examination a heart murmur was detected, which led to a referral for a cardiology assessment. The heart murmur was seen as not serious and was addressed through an out-patient appointment. Child F’s other symptoms were reducing and professionals were reassured that the ophthalmology report showed no abnormalities. 9.26 Mother became tearful when she was told that her baby would be discharged and she maintained he was not right. She felt there was something more serious than a viral illness and as a result he was kept in another night for observation. The doctor’s reflection in this review is that the news that Child F had a heart murmur seemed to shock and worry Mother and she was anxious as to what that might mean. The doctors reassured her that this was not an uncommon occurrence and that Child F would be assessed by a heart specialist who would advise further. 9.27 It was not entirely clear to professionals what was causing his head circumference to increase and it was difficult to accurately see the head circumference in relation to the birth and other measurements as the relevant records were not readily accessible. Child F had records in several places; birth records, GP records, health visitor records, and historic hospital records, in addition to the Red Book, which is a record held by parents. For this review the Consultant explained that a number of conditions can cause the head circumference to increase and it was difficult to have a clear picture or plot the increase over time. As Child F was settling and was well he wanted to bring him back into clinic and measure his head circumference again. He stated that there was no evidence or indicators to suggest that Child F had sustained any trauma to the brain at that time. 9.28 For this review the doctor explained that a large head circumference does raise questions and he would be thinking of several possible causes and scenarios including non-accidental injury. Had there been any brain trauma or head injury they would have expected to see other bruising marks, for example 15 changes in the fontanelle and changes in the back of the eyes indicating bleeding. The Consultant saw Child F at the clinic who was well and behaving normally for a baby of his age. The doctor suggested he would like the head circumference to be monitored by the HV and this request was communicated to the GP, HV and the supervising consultant. Mother and Father were observed to be interacting with Child F and each other appropriately during this hospital admission. 9.29 Prior to the outpatient appointment Mother and Child F were seen at the baby clinic for baby massage and although a formal assessment was not made, as this is a drop in clinic for baby massage, he was seen to be well. Mother also told the HV on 23 June that Child F was back to himself but criticised the hospital, which she considered did not take her concerns seriously. 9.30 Outpatient appointment. Mother and Father attended the Outpatient appointment at the fast track clinic on 27 June, which is a clinic for children up to the age of 16 who require a swift appointment. The rationale for this appointment was to check the head circumference and general health of Child F. When the parents arrived it was clear that they thought the appointment was for the heart murmur but the doctor explained that the appointment for that would be on 1 July. The doctor observed Mother to be anxious about that and needing reassurance. The parents had forgotten the Red Book where earlier head circumferences would have been plotted and the doctor had the previous admission records before him. Both parents were happy that their baby was much better, and back to his normal self and all developmental checks were normal. The baby was examined and he was smiling and fixing on objects visually which was considered normal. His head circumference was in line with the last measurement and his head looked normal to the health practitioners. There was nothing to note of concern and he was discharged with a request that the HV keep an eye on head circumference. 9.31 Third hospital admission. At some point between 28/29 June 2014 Child F became seriously unwell and was subsequently admitted to hospital with significant injuries to his brain and bruising to his left buttock. 9.32 The account given was that he had been in the care of his Father during the evening while Mother was out with friends. Mother returned home at around 2.00 am to find the baby was clearly unwell and ‘twitching’. She tried to settle him and then eventually called 111 at 07.41 am and informed the service that her baby had been waking up screaming all night and was described as “staring and twitching” and would not take his bottle. His breathing was described as heavy and his head floppy. 111 assessed this as a medical emergency and an ambulance arrived at 07.53 am. Child F was taken to a hospital Emergency Department arriving at 08.22 am. Child F was still fitting and noted to be pale. The medical examination found he had bilateral brain haemorrhages and bruising to his left buttock. These were considered to be non-accidental injuries. These injuries and the circumstances surrounding them became the subject of a police investigation and medical expert opinion. 16 10. Findings 10.1 The review team concluded that it would not have been possible to have foreseen the actions taken by Father on the night he injured Child F. The review team acknowledged that there was neither indication of nor concern from a range of professionals who saw Child F, about neglect or abuse until the hospital admission and medical examination on 29 June 2014 and there was no cause for concern previously that warranted a referral to be made for either support as a child in need or safeguarding. The review has identified general learning for agencies which is detailed below. 10.2 The review team has identified three findings for the Cornwall and Isles of Scilly Safeguarding Children Board to consider, which are summarised and then explored further individually in reference to the appraisal and analysis. Finally, each finding raises questions for the Board to consider in accordance with systems methodology. The LSCB is then free to deliberate and decide within the learning what, if any, they consider are priorities for improving the safeguarding system and practice in order to do everything possible to prevent a recurrence of this form of harm. FINDING ONE -The role and responsibilities of a PA in supporting care leavers is not consistently understood across agencies indicating a need for all agencies to consider incorporating this into single agency training. FINDING TWO - The fragmented health record systems do not ensure timely and reliable information sharing, which is at the core of an effective safeguarding system FINDING THREE - Fathers appear to continue to be of secondary or sometimes given little or no consideration by professionals 10.3 Finding One: The role and responsibilities of a PA in supporting care leavers is not consistently understood across agencies and a misunderstanding could lead to unsafe assumptions. 10.3.1 Some health professionals do not understand the role and responsibilities of a PA (Personal Advisor) or the nature of support for care leavers. They were aware that the PA was supporting Mother but were less clear about the nature and extent of that support. The PA saw Mother 5 weeks after the birth and occasionally before the birth. Some health professionals said they assumed that the PA had met Father pre and post birth but they did not check this out. The review concluded that professionals were focussed on Mother and baby but no one had a good enough understanding of Father or his ability to parent or if he had any service needs in his own right as a new parent. 10.3.2 Mother was keen that although the relationship had broken down she wanted Father to “step up” as the father and take some childcare responsibility and provide her with help for the care of their baby, which he did. Health 17 professionals observed on one occasion that he was rather distanced but on another occasion that he was interacting well with Mother and their baby. 10.3.3 The Care Leaving Service works with many young parents. Mother’s PA felt confident that she was able to support Mother because of their positive relationship and had no concerns that warranted greater involvement. The PA believed that other professionals knew she was involved and would contact her if they had any worries relating to Mother or the baby. The absence of any such reports indicated the view of health professionals that they had no concerns about Mother’s care of her baby and that all was well both before and after Child F’s birth. 10.3.4 Questions for the Board – Finding One • What measures will the Board put in place to improve multi-agency understanding of the support for care leavers? • How will the Board clarify the parameters of role of the PA in the care leaving system to all other agencies to prevent confusion and any misplaced assumptions going forward? 10.4 Finding Two: The fragmented health record systems do not ensure timely and reliable information sharing, which is at the core of an effective safeguarding system. 10.4.1 This manifested in this case in several ways:- • There can be limited communication between GPs and wider multi-agency professionals. This is seen as a generic issue and not specific to this particular case or practice. This can distance GPs and primary care from known risks and safeguarding concerns about a family. Mother moved home during pregnancy and was able to opt out of antenatal care with no knowledge of her GP. • GPs and Health Visitors do not work as closely as they did when Health Visitors were based in GP practices. GPs used to meet with Health Visitors to go through all cases in preparation but no longer since NHS structural changes. • Whilst Midwives pass information to a central information system to be available to colleagues, the fragmented nature of antenatal records works against continuity of assessment of needs and care. One midwife stated there are “too many systems that do not talk to each other” which impairs information sharing amongst health colleagues. Another Midwife said she was “horrified” to find during the review that the e-booking system held further information she was not aware of. • During the admissions of 9 and 11 June, the doctors very much dealt with what was before them but they lacked context and this was not easy to capture given the practical difficulties in accessing information about Child F, which was held in numerous places across the NHS. One might say, like the professionals stated, that this is ever thus but SCR 18 after SCR states the risks exposed by the fragmented nature of information held on an individual across the NHS and, while the reviews look to multi agency information, the NHS in itself has a great challenge in this regard. 10.4.2 Questions for the Board - Finding Two • How will the Board work to support, primarily health organisations to improve their information systems to allow the free and accurate passage of information across the NHS and cross county so that professionals can access the fullest information when they first become involved with an individual? • How will the Board support professionals in a care standard that requires midwives to actively seek information and explore the social circumstances of a family and risk prior to discharge after birth. • How can medical records be flagged to alert professionals that a mother and/or father is working with other key agencies or professionals such as a PA. 10.5 Finding Three: Fathers continue to be of secondary or sometimes given little or no consideration by professionals in the safeguarding system 10.5.1 Whilst some professionals did make observations of Father, hearing from Mother about his reaction to becoming a father and his contribution to the care of their baby; as well as noting his distance on one occasion and appropriate interaction on another; and the fact that he sought help when he thought his baby unwell, it appears no one actively approached him pre or post birth to ascertain his views on becoming a father; his expectations on what that may involve or what he considered he could offer in terms of parenting. The review identified that Father had been excluded by professionals and his views, support and coping mechanisms were unknown and no one knew if he presented any potential risk to the family or if he would cope as a father. 10.5.2 Mother was expressing that she wanted to end the relationship but that she expected Father to undertake his responsibilities and provide care for his baby, including looking after him while she was out with friends. While all agencies said for this review that they are aware of the dangers of focussing just on the mother, that awareness did not translate into an appropriate level of curiosity about Father, and a good enough understanding of his strengths, needs or risks. 10.5.3 Learning from national serious case reviews show that professionals will focus upon mothers particularly where the father may not live with the family all the time. No assessment was made with regards to the impact upon Father as a young father of an unplanned baby with a mother with whom he had no enduring relationship. Nor do we know of the maturity of Father to meet the challenges of becoming a parent for the first time or being left to care for his baby alone. Professionals were not able to say whether he was well equipped to 19 do so in terms of maturity or ability. This was even more important given the health problems their baby had experienced in the first few weeks of life and the parents’ anxiety about his wellbeing. As previously indicated, it has not been possible to ascertain Father’s perspective as to what support needs he may have needed pre and post birth of his baby. 10.5.4 Questions for the Board - Finding Three • How can professionals from all agencies be supported to ensure an appropriate focus on fathers, as much as mothers? • How can professionals be supported to work more actively with young fathers in particular? • How can the Board be reassured that fathers are not being excluded in any considerations around parenting and safeguarding? 20 Appendix 1 - Acronyms and Glossary Working Together to Safeguard Children, 2013. The statutory guidance for inter‐agency working to safeguard and promote the welfare of children. This guidance was updated in 2015 111 – Out of Hours medical service when GP surgeries are closed CAF – Common Assessment Framework. Inter-agency assessment framework to identify the needs of children and young people with additional needs. Care Leaver – a young person who has previously been in the care of the Local Authority FNP – Family Nurse Partnership. A programme of support for vulnerable first time mothers. GP – General Practitioner HV – Health Visitor LSCB – Local Safeguarding Children Board MARU - The Multi-Agency Referral Unit provides a response to referrals of concern about children and young people NHS – National Health Service NICE – National Institute for Health and Care Excellence PA – Personal Assistant (within Social Care Leaving Care Service) Red Book – a small book that remains with the parent and where information about a child's growth and development is recorded. SCARF – Safeguarding Children Assessment and Referral Form internal safeguarding notification used within Health to indicate concern about a family's vulnerability but not concern at a level that meets threshold for a referral to Social Care. Centiles- a graph with lines showing average measurements of height, weight, and head circumference compared with age and sex, against which a child's physical development can be assessed. The lines of growth on the graph are called centiles (or percentiles), and the number of a centile predicts the percentage of children who are below that measurement at a given age; for example, the 10th centile means that 10% of the age- and sex-matched population will be smaller and 90% will be bigger. Children whose growth lies outside the 97th or 3rd centiles may need to be investigated. |
NC049453 | Death of a 13-year-old boy from complications arising from his medical condition. Child Z complained of headaches in the days leading up to his death and instead of following a previously agreed pathway to go straight to the emergency department, his father, who is a GP, made a scheduled appointment at the hospital for a few days' time. On the way to this appointment, Child Z's condition worsened and he died later that day. Child Z was born with a disability that resulted in complex needs and restricted mobility. There was a history of disagreement between parents and professionals over Child Z's care and treatment including putting in place mobility adaptations. There were concerns about Child Z's lack of formal education, the adversarial stance of the parents and the mother's mental health. Issues identified include: the importance of a multi-agency approach and Child in Need status for children with disabilities; the neglect of children with complex needs; keeping the focus on the child whilst dealing with challenging parents; dealing with child protection concerns with professionals who are also colleagues; the need for decision making panels to have a safeguarding focus. Makes recommendations to: oversee an audit of cases of children with complex needs to ensure each child has a multi-agency plan in place; ensure all children with plans have regular reviews; identify the lead professional for children with complex needs; provide training for staff where parents present a challenge to engage; conduct a review of home educated children; provide appropriate support available for parents of disabled children to help them come to terms with their child's condition or disability.
| Serious Case Review No: 2018/C7068 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Child Z SUMMARY OF FINDINGS FROM SERIOUS CASE REVIEW Jane Doherty, Independent Social Work Consultant 2 1. Introduction 1.1. This Serious Case Review (SCR) was commissioned by a Local Safeguarding Children Board (LSCB) to examine the practice of the multi-agency network surrounding Child Z and his family. The circumstances leading to his death are as follows. 1.2. Child Z was born with a disability resulting in him having very complex health needs for which he required on going, lifelong treatment. His mobility was very restricted due to his condition. 1.3. Over the course of his life Child’s Z’s parents had many disagreements with the professionals involved with him including health professionals, education and the Local Authority. The difficulties agencies’ experienced in the relationship with his parents led to Child Z being made the subject of a Child Protection Plan (CPP), shortly before his death, as they believed that he was at risk of social isolation and medical neglect. 1.4. In the days leading up to his death Child Z had complained of headaches – a symptom that in the past had been connected with complications arising from his medical condition. Child Z’s parents however did not follow the recommended pathway by taking him straight to the Emergency Department (ED); instead his father (who is a GP) made a scheduled appointment for a few days time at the hospital responsible for his ongoing care. On his way to this appointment Child Z’s condition worsened and his father took him to the nearest ED. 1.5. On arrival at the hospital Child Z was already unconscious and despite the best efforts of the medical team he died later that day. 2. Arrangements for the Serious Case Review 2.1. After the death of Child Z, LSCB took the view that the criteria for an SCR had been met which are entirely consistent with the guidance in ‘Working Together’1 (WT) 2013. In this case the following criteria is met; abuse of a child is either known or suspected and the child died; and there are concerns about how organisations or professionals worked together to safeguard the child. 1Working Together to Safeguard Children (Working Together) is the government’s overarching guidance on safeguarding. The guidance was revised in 2015 but in the period under review for Child Z the 2013 version would have been the relevant guidance. 3 2.2. Working Together (2013) Chapter 4 Para 11 states a Serious Case Review should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 2.3. The purpose of the review is to look at what happened in the case and why and what action will be taken to learn from the review findings identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children. provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children. 2.4. Arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. An Independent Chair and Overview Author independent from the LSCB were appointed. 2.5. The LSCB appointed a Review Panel to manage and oversee the review and met a number of times. The panel members were made up of senior representatives from those agencies that had worked closely with the family. These agencies also provided information to the review in the form of a detailed chronology and reports. The panel also included a lay member who provided further independent scrutiny and challenge. 2.6. The LSCB held a series of SCR Panel meetings, chaired by the Independent Chair, where all the agencies and the overview author contributed to the process of gathering and analysing the material provided. 4 2.7. Consultation and learning events were held during the course of the review to enable those practitioners who worked with the family to contribute to the overall findings and lessons from the review. 3. Family Contribution 3.1. In line with expectations laid down in WT consideration was given to involving the family in the review process and family members were advised that the review was underway. 3.2. The child’s father (Mr B) was consulted as part of the review and his views are included. It was not however possible to consult with the child’s mother (Ms A) as the panel considered to have done so would cause her further unnecessary distress. This decision was taken after much deliberation by the panel and members of the LSCB, and following receipt of advice from the appropriate professionals. 4. Summary of Professional involvement 4.1. The decision to publish only an anonymised summary was taken to prevent further distress to the family and extended family members. As such the following is a very brief account of agencies contact with the family and Child Z. This summary covers a period of ten years and is intended to be thematic rather than a chronological account of agency contacts. 4.2. Child Z was born with a disability that resulted in him having complex needs and meant his mobility was severely restricted. Very early indications from professionals’ records available show that Child Z had positive family relationships and his parents seemed to be coping well with his additional needs. As his mobility was so restricted his parents were very hands on in terms of his personal care and throughout his life he needed assistance with everyday tasks such as washing, toileting and moving around his house. 4.3. Child Z was treated and assessed by many doctors and consultants who were responsible for various aspects of his ongoing care. In addition Child Z also saw a number of physiotherapists, occupational therapists and social workers, some attached to the community paediatricians and some who worked in the multi-disciplinary setting and employed by the LA. 5 4.4. Child Z would occasionally suffer from headaches and there is a history of these being caused by his complex medical condition. On at least one occasion he was hospitalised in order to have a medical procedure to relieve the cause of the headaches. This was a potentially life threatening situation and the agreed pathway was for him to be presented to an Emergency Department (ED) if such headaches persisted. 4.5. Records provided by professionals for the review indicate that Child Z’s parents struggled to accept his condition from a very early stage in his development. 4.6. In the history provided there are two episodes when professionals recognised that Ms A’s mental health seemed to be deteriorating and became acute. There are also other times particularly during health appointments regarding child Z where professionals questioned her mental stability and ability to be rational. 4.7. Throughout the review period the parents raised queries with health staff about the management of Child Z’s condition. The parents were concerned that not enough was being done about strengthening child Z’s muscles. This was an issue that the parents raised frequently throughout Child Z’s life. 4.8. In addition the parents’ disputed the consultant’s view that surgery would not help Child Z and his condition. The consultant and the physiotherapists working with the family considered that a more beneficial approach would be to concentrate on the stronger parts of Child Z’s body and help him to adjust to using adaptations. This would have the effect of making him as mobile as possible and increase his independence as he got older. Despite this advice, the parents were reluctant to give up specialist equipment that the health professionals considered Child Z did not need and could be harmful to him in the long run. 4.9. Children’s Social Care (CSC) identified the need for adaptations to the family’s property at an early stage but many of the recommendations did not come into fruition and caused a great amount of conflict between the family and professionals. 4.10. As Child Z got older an Occupational Therapist (OT) based within CSC assessed the family’s property and made several recommendations for improving access for Child Z. These adaptations did not progress. 6 4.11. In the meantime, Child Z had adjusted to using his own adaptations and had a number of sporting interests and hobbies that were good for him socially and physically. As he got older he grew in confidence and was able to articulate his thoughts and feelings with those who came into contact with him. 4.12. The issue of adaptations however, became a major source of contention between the LA and the parents. Child Z’s parents continued to provide him a significant amount of physical support (moving and handling) and this was becoming increasingly difficult, as he got older and heavier. Various assessments were carried out and the OT made some firm recommendations. The parents were not happy with these and suggested some alternatives. Their main concern was that any adaptations should not isolate Child Z from the rest of the family, as he was too young and his condition made him too vulnerable to be on his own at night. The parents’ suggestions were more expensive but they were prepared to contribute to the overall cost. 4.13. Agreement could not be reached and the case was closed to the department responsible without agreement on how the adaptations should be made. The parents made a complaint about the OT department that went through the 3 stages of complaint in line with the council’s policy. This eventually went to the Ombudsman to resolve and although he sided with the LA, he also said that both parties should work together in the interests of the child. 4.14. The parents continued to request adaptations (supported by various professionals) in the house to improve Child Z’s access within the home. They also requested respite care due to limited family support. 4.15. CSC stepped up their involvement with the family and an initial plan was created in relation to respite. Child Z was to receive some respite but not overnight which was their original request. The family expressed a preference for direct payments for 4 hours respite per week. 4.16. The parents did not however comply with the regulations around direct payments e.g. they were slow in setting up a separate bank account and spent the money on equipment rather than care and this became a further bone of contention between the parents and the LA. 4.17. The parents persisted in raising the issue of Child Z’s medical care with many professionals they came into contact with. On each occasion they were advised about the most appropriate options but this issue continued to cause conflict between the parents and professionals. 7 4.18. In addition to this, when the time came to consider Child Z’s transfer to secondary school the parents did not agree with the options presented by the LA and entered into dispute with them resulting in a tribunal. The parents had some suggested alternatives but these were not thought to be suitable. Child Z was withdrawn from school and educated at home for the academic year prior to his death. The tribunal found in the LA’s favour. 4.19. As Child Z became older he began to play a more active part in his health appointments and during many of these Child Z’s mother in particular was described as angry, emotional and aggressive. She was not accepting of the rationale for the advice being given about various aspects of Child Z’s health. All professionals involved with the family were growing increasingly concerned at Child Z’s exposure to angry and confrontational appointments with the parents and expressed concerns about Ms A’s ability to remain calm and rational. 4.20. The situation was exacerbated by the number of disputes and complaints the family had lodged which are as follows: A complaint under the Disability Discrimination Act (DDA) to the school as the parents claimed Child Z did not have the right specialist equipment when changing for PE, the parents were in dispute with the LA about Child Z’s school place and had made a complaint that his Statement Educational Needs (SEN) was overdue, a complaint to NHS England that Child Z was being denied a Continuing Care Assessment a formal complaint had been sent to Patient Advice and Liaison Service (PALS) about his current physiotherapy package, and Mother had lodged a disagreement with the social worker about the care package. The issue of the adaptations to the house had still not progressed. 8 4.21 These concerns were mounting and professionals working with the family found it increasingly difficult to work together with the parents for Child Z’s benefit. Concerns were raised amongst professionals about: The parents’ apparent disregard for medical advice Child Z’s lack of formal education and the unsuitable choices of school his parents were pursuing The dangers associated with the lack of adaptations in the family home Parents’ lack of co-operation for hospital appointments The adversarial stance the parents were now taking in making complaints rather than working with professionals for the benefit of Child Z. Concerns about Mother’s poor mental health 4.22 As a result of the growing concerns a multi-agency meeting was held and s47 (child protection) enquiries were commenced. The parents were informed of the decision to commence child protection enquiries but were uncooperative with workers trying to conduct the assessment. Child Z and his sibling were seen but limited assessment took place. At the meeting they discussed the fact that Mr B was the safeguarding lead at his GP practice and was therefore known as a colleague. A referral was made to the Local Authority Designated Officer (LADO). 4.23 CSC received a written complaint from parents about the s47 enquiries and process. 4.24 A legal planning meeting was held, the outcome of which was that the threshold for proceedings was met. The parents were issued with a ‘Letter before Proceedings’ and at a meeting with their legal representation and the LA, agreed to co-operate with the s47 enquiries. 4.25 The s47 enquiries concluded and the parents were informed that the decision to progress to an Initial Child Protection Conference (ICPC) had been made. This was on the basis that the situation had not improved for Z during this time. 4.26 Child Z’s name was removed from the Elective Home Education (EHE) list as the parents agreed they were not in a position to provide him with appropriate education. 9 4.27 Just prior to Child Z’s death an ICPC was held and a Child Protection Plan was made for him under the categories of neglect and emotional abuse. No plan was made in regards to Child Z’s sibling. 4.28 At a meeting soon after the ICPC the parents informed the social worker of their intention to move out of the area. They refused to sign the written agreement saying that they wanted to consider its contents first. 4.29 A few days after the ICPC the events surrounding this SCR unfolded and Child Z became unwell on his way to a hospital appointment to discuss his headaches. His father took him to the nearest ED. It was unfortunately too late to save his life and he died the following day. 5. Parental/family contribution 5.1. The author and the Independent Chair of the Panel met with Mr B in January 2017. 5.2. In general terms Mr B said that the partnership working didn’t work in this case. Child Z’s mother attended the majority of the appointments and he was not present during many of the difficult conversations that were taking place (though he was there at some). He would have liked to have had more of a frank conversation with those professionals who were expressing concerns about safeguarding long before it got to the point of s47 enquiries. He was however unaware of the seriousness of the situation and was then unable to retrieve it. That said he also felt that there were no grounds for s47 enquiries and that is why he had made the complaint to CSC. He disagreed with the need for a Child Protection Plan. 5.3. Mr B felt that his wife treated information she was given by professionals with suspicion and assumed that Child Z was not given particular things because of resource issues. As he was a GP he would try and explain things to her but she did extensive research into entitlements, benefits and rights and talked passionately about why she felt that Child Z should have certain things rather that what was on offer. She was very upset by the all the ‘battling’ with authorities and this is why he feels that she became mentally unwell just prior to Child Z’s death. 5.4. When talking about the many complaints made by the family in relation to various aspects of his son’s life, Mr B gave the following information. 10 Adaptations 5.5. Mr B acknowledged with hindsight that it would have been better to move sooner than they did. He felt that Child Z had adapted to his surroundings and therefore within the family this was not a major issue. As Child Z got older however he was more difficult to carry and through the lack of adaptations they realised as a family that they needed to move to enable him to move around the house more easily. 5.6. The disagreement over the adaptations went on for some time and Mr B said that there were times when they did not keep appointments but equally the LA were slow to respond to their requests. They ultimately made the complaint because they did not agree with the proposals. Apart from his medical needs at this time Child Z was afraid to sleep on his own and as they were prepared to contribute financially to their preferred proposals, they thought this would better meet Child Z’s needs. 5.7. The complaint went to the Ombudsman and although he sided with the LA his recommendation was that the LA should work with the family for Child Z’s benefit. They however did not do this and the matter did not progress any further. Mr B also stated that at the time they were offered an option that was more in line with what they had asked for. According to Mr B this offer was then withdrawn. Choice of school 5.8. In relation to Child Z’s education Mr B said that they disagreed with the LA’s recommendation for the school that Child Z should attend. It was becoming more difficult for them to care for Child Z at home and they thought a residential school was a good solution. Their preferred school had a good teacher – pupil ratio and they were expecting a grant to be able to make adaptations. 5.9. Mr B did not believe that the school allocated was the best for his son. He also mentioned that the dispute over the school place and the resulting tribunal had made his wife ill and that is how she came to be so unwell around the time of the ICPC. 11 5.10. Mr B said that his son was educated in the library every day and although it would have been better for him to be in school he did receive an education during that time. He also talked about the importance of the family’s community, their extended family and the church. In this respect because they have a lot of family and church events Child Z was not isolated in the way that professionals were expressing concern about. He had friends and other children within the family that he regularly mixed with. His sporting activities stopped he believed as result of his wife distrusting those running the group as things were starting to be said that she did not like. This coincided with the other challenges to Child Z’s care and it all came to a head. Medical treatments 5.11. There were many disagreements over medical options for Child Z. Again Mr B said that as his wife’s understanding of what was on offer and what could be done was different to his. His view about the medical interventions was that surgery was not necessary and would not benefit Child Z but he saw ‘no harm’ in the use of some of the other equipment provided. 6. Lessons Importance of a Multi-agency approach and CIN status for children with disabilities 6.1. Child Z’s status as a Child in Need ostensibly due to his complex needs and then later as a safeguarding matter was never acknowledged by those working with him. This meant that there was no formal multi-agency plan in place, no Lead Professional and no regular TAC/TAF meetings to support the work with the family and promote partnership working. It is important that all children with complex needs have a plan commensurate with their assessed needs and that these are reviewed and evaluated on a regular basis. The LSCB will need to satisfy itself that this is the case. 6.2. Various professionals assessed the family on a number of occasions but there is no evidence that any of these resulted in a clear package of care or clarity about what services Child Z was entitled to or should receive. In view of this when professionals had concerns about Child Z there was no natural forum in which to raise them. As a consequence there was no one professional with an overview of what was happening for Child Z. 12 Neglect of Children with complex needs 6.3. Assessments of Child Z’s needs were haphazard and did not follow an established pattern e.g. his care needs were not reviewed annually and were often in response to requests for support for the family. These assessments concluded with recommendations that the family challenged and because of this often reached a further stalemate that led to them being ‘lost in the system’ and not resolved. The question of adaptations and respite care are significant examples of these. 6.4. The review highlighted the neglect of Children with disabilities and their various needs. This includes the important issue of the lack of adaptations that over time placed him at risk and should have been the subject of a multi-agency response much earlier in his life. Children who are home educated 6.5. Much has been written in SCRs about the needs of children who are home educated and how their education is often neglected. It can also have the effect of isolating the child from peers and from professionals. This was a very difficult situation as Child Z was home educated with a statement that (because of his complex needs) could not be fulfilled by his parents. Little negotiation happened between the LA and the parents to try and advance Child Z’s educational needs. The LA found themselves in a situation where they could not legally fulfil the obligations of his statement but were unable to insist on monitoring the work provided. 6.6. To this end it would have been helpful for the LA to take a more authoritarian stance and challenge the parents’ ability to educate Child Z to the letter of his statement given the lack of resources they had to offer. His lack of education ultimately became one of the reasons for the initiation of the CP processes but it was not resolved while he was still alive Keeping a focus on the child whilst dealing with challenging parents 13 6.7. There is a lack of documented evidence of recorded views expressed by Child Z and limited evidence of systems and processes to support practitioners in keeping the child in focus. For example reflective supervision is crucial when addressing safeguarding issues. Practitioners received little support about their unease and tensions in dealing with the family and were not challenged to keep child Z at the centre of their work. Being in the thick of it, practitioners were unable to see how the parents were influencing their practice. The lack of a coherent multi-agency plan was another missing link. 6.8. The role of the manager is to provide an opportunity for reflective thinking and to challenge the worker to consider whether assessment processes have been sufficiently broad and robust. This is a challenge faced by health, social care and other professionals working in the field of safeguarding. Supervision in this case was not robust in any agency and did not assist workers in either dealing with challenging parents or helping to keep the worker child focused while facing these issues. A wide range of professionals were involved and the LSCB may want to consider alternative supervision models to aid practitioners who work in this field. 6.9. Child Z was described by those who knew him as a lively child, who was mischievous and full of character. He had a great sense of fun and those around him found him to be engaging and intelligent. He rarely complained about his lot and his family life was observed to be warm and loving. He had a good relationship with his all members of his family. 6.10. What has been gleaned from information gathered throughout the review that he had done very well in his primary school education and was looking forward to a transition to secondary school. He was able to communicate well so it is surprising that there is little documented about his views. Where they have been recorded they added weight to a complex situation. In some information provided he is said to have led some discussions about his medical needs and what he felt would be best for him. This is however recorded all too infrequently but more importantly his lived experience was not understood by professionals Dealing with child protection concerns with professionals who are also colleagues 6.11. Both parents were professionals and there was consideration in the review of whether their status influenced how practitioners dealt with them. While there is no evidence of this in respect of Ms A, Mr B is a GP who was working in the borough and was the safeguarding lead in his practice. 14 6.12. Mr B was regarded as a colleague by many of the professionals dealing with the family. Advice was given in circumstances that was in danger of being compromised by those giving it. Furthermore the advice given did not result in moving the situation forward. These situations need to be dealt with very sensitively and a lesson from this review has been that health staff in particular were unaware of the need to seek more independent advice when the Child Protection concerns arose. The need for business processes and decision making panels to have a safeguarding focus. 6.13. The issue of adaptations for the family home was a major bone of contention for this family and was a necessity in terms of basic human rights for Child Z. To be able to achieve his potential and develop independently Child Z needed to be able to move about freely in his own home. The business process and the panels dealing with the administration of these failed to take into account the child at the centre of the wrangling between the LA and the parents. The LSCB needs to assure itself that this situation could not be repeated. 7. Recommendations 1. The LSCB to oversee an audit of cases for children with complex needs to ensure that each child has a multi-agency plan in place commensurate to their assessed need e.g. CP, CIN, CLA, EH or EHC. 2. In line with the above recommendation the LSCB to ensure that all children with plans in the categories above have regular evaluation and review of their plans in line with statutory expectations. 3. LSCB to ensure that a system for identifying Lead Professionals for children with complex needs is in place. 4. The LSCB’s training programme to include (or review if it already does so) training for staff on dealing with situations where parents present a challenge to engage. This to also include how professionals challenge each other and how to escalate concerns when necessary. 5. The Head of Targeted Services and Joint Commissioning to give assurances to the LSCB that all panels and decision making forums; Have an audit trail and minutes of how decisions regarding specialist equipment and/or adaptations are made In cases where adaptations are not made or equipment is not provided, a record of how this may affect the child is available including any safeguarding concerns that may arise because of it 15 Minutes of panels demonstrate that safeguarding concerns have been considered and mitigated against if necessary Are transparent about what the appeal process is for parents and how the LA will work with the parents in the best interests of the child and reach a satisfactory conclusion before closing the case. 6. The LSCB to conduct a review of all children who are home educated who also have a SEN or EHC plan to ensure that the obligations with the plan are being fulfilled. The Protocol for EHE and the annual report on EHE to be presented to the LSCB Main Board. 7. The LSCB to reassure itself that practitioners and managers are aware of when to refer to the LADO. 8. In line with the above the LSCB needs to add to its existing LADO guidance where practitioners should seek support when there are safeguarding concerns about their colleagues including when they are subject to CP procedures 9. In line with the above, for the LSCB to receive assurances from the SEN team that each child who is EHE and who has a Statement of SEN or an EHCP is reviewed on at least an annual basis with colleagues from across the multi-agency network. 10. As part of the Section 11 audit programme the LSCB to ensure that the Disability Service has appropriate supervision for its practitioners including consideration of alternative models of supervision i.e. group supervision for those staff working in multi-agency teams. 11. The LSCB to assure itself that there is appropriate support available to parents of disabled children to help them come to terms with their child’s condition or disability. Advocacy should also be available for children and young people. 12. The LSCB to review its training programme to ensure that practitioners have access to cultural competence training. This to provide practitioners with an understanding of the differing meanings of disability across different cultures and communities and how these are assessed in the best interests of the child. Jane Doherty Independent Social Work Consultant January 2018 16 Appendix 1 Explanation of health roles involved with the family and Child Z 7.1. As there were so many health professionals involved in the care of Child Z the differing roles and responsibilities are outlined here for ease of reference for the reader. During his lifetime Child Z saw several different specialists who had expertise in different areas. 7.2. In Community Paediatrics Child Z had a named consultant who was the lead clinician ensuring that he was receiving all appropriate health, education and social care services that he needed and also monitored his development. There were several (at least five) consultants that held this post and saw Child Z. 7.3. At Hospital 1 Child Z saw a neurosurgeon who provided necessary surgical intervention when he was very young and monitored him throughout his life. Two other doctors monitored other aspects of his condition. 7.4. The two doctors treating Child Z at Hospital 2 were both neurologists. They were involved in running the multidisciplinary clinic and had an overview of his medical condition. In addition they made sure he saw all the specialists he needed to. Another doctor saw Child Z to oversee other symptoms caused by his condition. 7.5. Child Z also saw 3 different orthopaedic consultants 17 7.6. Supporting the medical teams Child Z also saw a number of physiotherapists, occupational therapists and social workers, some attached to the community paediatricians and some who worked in the multi-disciplinary setting and employed by the LA. Whilst the consultant paediatrician acted as the Lead Professional (LP) for health there was no such equivalent role allocated to those professionals working in other agencies. |
NC049434 | Neglect of three siblings aged 0-1, 5 and 3 years, who were removed from mother and mother's partner in December 2015. The family had been known to children's services since April 2013, after moving to Manchester from the south of England six months earlier. There were 4 children in the family at the time. Home conditions were poor, and the children had complex needs. Father moved out with two of the siblings in March 2014. In April 2014 the children became subject to child protection plans under the category of neglect. An initial child protection conference was held in September 2014 in respect of the unborn child (Child I1), the child of mother and mother's partner. Mother's partner is described as a transgender person and identifies themselves as female. Mother identifies as male. In May 2015 the children were removed from the child protection plan but continued to receive support under a Children in need plan. In December 2015 ChildI1 and siblings were removed from the home following an unannounced visit by a social worker. Methodology: a systems methodology approach focusing on multi-agency professional practice. Findings include: there was a fixed and overly optimistic view of the case by some of the professionals; at times the parents' needs received more professional attention than those of the children; professionals did not always feel confident in their responses to some of the issues, particularly around gender roles and transgender issues. Recommendations include: the voice and daily lived experience of the child should be the primary focus of all agency interventions; agencies should work closely together in cases of long term neglect, especially if there is concern about disguised compliance.
| Title: Child I1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Valerie Charles Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD I1 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14th December 2017 INDEPENDENT LEAD REVIEWER: Valerie Charles April 2017 MSCB Child I1 SCR Page i Contents Section 1: Introduction .......................................................................................................................... 1 1.1 Context of the serious case review .............................................................................................. 1 1.2 Decision to conduct a serious case review .................................................................................. 2 1.3 Brief background and summary of contacts ................................................................................ 2 Section 2: Serious Case Review Methodology ....................................................................................... 3 2.1 Systems methodology .................................................................................................................. 3 2.2 The Review Team ......................................................................................................................... 4 2.3 Scope of the Review ..................................................................................................................... 5 2.4 Key lines of enquiry ...................................................................................................................... 6 2.5 Structure of the review process ................................................................................................... 6 2.6 Status and ownership of the overview report ............................................................................. 6 2.7 Parents contribution to the Serious Case Review ....................................................................... 6 Section 3: Analysis of agency involvement and Key Practice Episodes ................................................. 9 3.1 Key Practice Episodes ................................................................................................................... 9 3.2 Key Practice Episode 1: April 2014 – Initial Child Protection Conference ................................... 9 3.3 Summary appraisal of practice within Key Practice Episode 1 .................................................. 12 3.4 Key Practice Episode 2: July 2014 - Review Child Protection Conference ................................. 15 3.5 Summary appraisal of practice within Key Practice Episode 2 .................................................. 16 3.6 Key Practice Episode 3: September 2014 - ICPC for Unborn Child I1 ........................................ 19 3.7 Summary appraisal of practice within Key Practice Episode 3 .................................................. 20 3.8 Key Practice Episode 4: May 2015 - De-escalation from CP to Child in Need ........................... 22 3.9 Summary appraisal of practice within Key Practice Episode 4 .................................................. 24 3.10 Key Practice Episode 5: Child in Need Planning & Review - June to December 2015 ............. 25 Section 4: Conclusion ........................................................................................................................... 30 Section 5: Findings ............................................................................................................................... 32 5.1 Finding 1: Voice of the Child ...................................................................................................... 32 5.3 Finding 2: Assessments in cases of neglect ............................................................................... 33 5.5 Finding 3: Multi-agency working ............................................................................................... 33 MSCB Child I1 SCR Page 1 of 35 Section 1: Introduction 1.1 Context of the serious case review 1.1.1 This review concerns three children within the family who experienced significant harm through neglect. Concerns were highlighted about the ways in which agencies worked together to safeguard the children. 1.1.2 There are also two older siblings who went to live with their father and paternal grandparents during the period under review. 1.1.3 The three children were removed from mother and mother’s partner on 24th December 2015 when the social worker visited the home unannounced and found the house and circumstances in a very poor condition. Some areas of the house including the kitchen and bathroom were unusable. All three children were accommodated under Section 20 Children Act 1989 agreements. 1.1.4 The task of the review is to establish what lessons can be learned, for the purpose of learning and improvement in safeguarding services and in inter-agency working, in order to better safeguard and promote the welfare of children in Manchester. 1.1.5 The extent and quality of professional involvement and support given to the children and their family over a two-year period, from February 2014 to December 2015, has been considered by the review. The involvement of agencies during this period of time was in response to concerns about poor home conditions and parents not meeting the significant health needs of the children. The children became subject to child protection plans in April 2014 in the category of neglect. 1.1.6 In the months leading up to the incident in December 2015 the children had been removed from child protection plans and were subject to Child in Need (CiN) planning. During the period prior to the incident there had been deterioration in the home conditions and in the level of engagement from parents. 1.1.7 The review found evidence of good practice and some success in working with the family, but also areas that the review felt could be improved upon. These have been presented within this report as findings for Manchester Safeguarding Children Board to address. 1.1.8 This report was presented to the Manchester Safeguarding Children Board in August 2017. 1.1.9 Throughout the report the use of acronyms for the various people involved is kept to a minimum. The three children are referred to as CHILD I1 (aged 0-1 year during the period under review), SIBLING 3 (aged 5 years old), and SIBLING 4 (aged 3 years old). The older siblings are referred to as SIBLING 1 (aged 8 years old), and SIBLING 2 (aged 7 years old). Members of the family are referred to in terms of their relationship with the children – i.e. mother, father, mother’s partner, paternal grandparents etc. In this case there are two biological fathers. The biological father to the four eldest children is referred to as father. The MSCB Child I1 SCR Page 2 of 35 biological father to CHILD I1 is referred to as mother’s partner. Professionals are referred to in respect of their professional role. 1.2 Decision to conduct a serious case review 1.2.1 The Local Safeguarding Children Board Regulations 2006 (regulation 5) requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the statutory criteria and procedures that are set out in Working Together to Safeguard Children, 2015 (chapter 4)1. 1.2.2 The LSCB should always undertake a Serious Case Review (SCR) where abuse or neglect of a child is known or suspected and either the child has died or the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2.3 The rationale for undertaking this review is that the three children were seriously harmed by neglect and concerns were highlighted about the ways in which agencies worked together to safeguard the children. 1.2.4 The case was reviewed by the Serious Case Review Subgroup at two meetings and, based on the collation of information received from agencies, it was agreed at an extraordinary meeting held on 22nd April 2016 that the criteria for a Serious Case Review were met. 1.2.5 The independent chair of the MSCB approved the recommendation for a SCR on 22nd June 2016. 1.2.6 There was some delay before the review was commissioned. The review did not get underway until January 2017. This was due to a review of the commissioning processes taking place and a high volume of serious case reviews being managed at that time. 1.3 Brief background and summary of contacts 1.3.1 The family had been known to Manchester Children’s Social Care (CSC) from April 2013. An anonymous referral to NSPCC led to an unannounced home visit by CSC. It was identified that the family had moved from the South of England into the Manchester area six months previously. Since that move, the family were unknown to all agencies, including Health and Education. They were not registered with a GP or a dentist. 1.3.2 Home conditions were very poor and unsatisfactory. The home was unclean with food on the floor and furniture was piled high blocking doorways and windows. There were three beds in the living room with no bedding on these beds. 1.3.3 There were four children in the family at the time. Following child protection medicals the community paediatrician identified that all four children had complex needs which had not previously been recognised. 1 Working Together to Safeguard Children, 2015 HMSO. MSCB Child I1 SCR Page 3 of 35 1.3.4 The eldest child, SIBLING 1, was aged seven years old and had a severe squint and had never been to school. The second child SIBLING 2 was aged five years old and did not speak and was still in nappies (subsequently diagnosed with autism). The third child SIBLING 3 was aged 2 years old and had walking difficulties (subsequently diagnosed with cerebral palsy). The fourth child SIBLING 4 was aged 11 months old. 1.3.5 Various Health referrals were made to address all the children’s health needs and a referral to Families First2 was made. 1.3.6 Families First began a six-week assessment and intervention programme with the family in July and August 2013 to work on parenting and living standards of the family. The three goals identified were: to attend all health appointments for the children; to address the children's educational needs; and the home conditions to be addressed i.e. clutter and mice infestation. 1.3.7 The outcome of the Families First intervention identified that the family had worked hard to make changes with some success. However, concern remained that without support or instruction, or if the family experienced any major setbacks, matters could deteriorate again. Further support and assessment of their ability to maintain the changes was required. 1.3.8 A period of Child in Need (CiN) planning was then put in place until February 2014, when due to a significant deterioration in the case it was decided to escalate to child protection. 1.3.9 In April 2014, the four children became the subjects of child protection plans under the category of neglect. Section 2: Serious Case Review Methodology 2.1 Systems methodology 2.1.1 This review is based on a systems methodology approach3 focusing on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – ‘what happened’ and ‘why’ – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case, and changing them will contribute to improving practice more widely. A systems approach uses a particular case as a ‘window’ on the whole system. 2 Families First is a city-wide service and is part of the Family Recovery Team. The team provides up to six weeks of intensive intervention for families experiencing crisis. When their usual ways of dealing with problems stop working, Families First practitioners will explore the family’s own solutions and guide them through the process of change. The family’s own social worker commissions the service, and remains closely involved throughout the six week period. 3 Recommended best practice developed by SCIE. Learning together to safeguard children: developing a multi-agency systems approach for case reviews, SCIE (Social Care Institute for Excellence) 2009. MSCB Child I1 SCR Page 4 of 35 2.1.2 Using a systems methodology approach for studying a system in which people and context interact requires the use of qualitative research methods to improve transparency and rigour. The key tasks are data collection and analysis. Data comes from involved professionals and others including family members, case files and contextual documentation from organisations. 2.1.3 Due to particular time constraints in order to complete the review in a concise timescale i.e. within three months, it was decided that the review would be based on a systems methodology approach, but would be proportionate to the timescale set. Instead, for example, of conducting individual conversations with the involved professionals (which can be very involved and time consuming) it was agreed that a structured practitioner and manager’s learning event would be held over the course of a full day. 2.2 The Review Team 2.2.1 The membership of the review team includes agencies from Manchester multi-agency child protection system and is represented by senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review, as follows: Homelessness Service Service Manager, North District, Children’s Social Care Named Nurse for Safeguarding Children (CMFT) Head of Safeguarding CCGs Designated Doctor CCG Specialist Protective Services, Greater Manchester Police (GMP) Case Worker, Education. 2.2.2 The Manchester Safeguarding Children Board (MSCB) commissioned Valerie Charles an independent lead reviewer with appropriate experience and training to co-ordinate and manage the review. 2.2.3 Valerie Charles works as an independent consultant and is registered with the Health and Care Professions Council (HCPC). Valerie has been qualified since 1991 and has a professional social work qualification and MA in Child Protection. She has extensive experience of working in children’s services in both the local authority and voluntary sector. She was a senior manager for NSPCC from 2006 to 2012. Valerie has worked in different roles within local safeguarding children boards, including chairing and authoring serious case reviews and has experience in systems methodology case reviews. Valerie has undertaken training for independent reviewers. 2.2.4 Key lines of enquiry were identified from the combined multi-agency chronology. Individual agencies were asked to provide a summary of their agency learning to the review. 2.2.5 The review team identified the ‘case group’ which comprised of practitioners and managers from services that would provide information and participate in the review. MSCB Child I1 SCR Page 5 of 35 2.2.6 In March 2017, a practitioner and manager learning event was held. Group discussions with the case group were undertaken, facilitated by members of the review team and the independent lead reviewer. The staff roles of those involved in group discussions was as follows: Social Worker x 2 Specialist Resource Team officer Team Leader, Homelessness Support Worker, Homelessness Greater Manchester Police officer x 2 Deputy Head, Specialist Support School Teacher, Specialist Support School Nursery worker x 3 Health Visitor Health Visitor Manager Speech and Language Therapy (SALT) worker x 2 School Nurse Physiotherapist x 2 Midwife Occupational Therapist Manager Occupational Therapist Consultant Child Psychiatrist – Child and Adolescent Mental Health (CAMHS) Officer, Manchester Safeguarding Improvement Unit, MCC Consultant Paediatrician. 2.2.7 The independent lead reviewer used the information from the combined multi-agency chronology to identify key practice episodes for particular learning in this review. 2.3 Scope of the Review 2.3.1 The scope and timetable of the review were agreed. The time period under review is from February 2014 when the decision to convene an Initial Child Protection Conference (ICPC) was made, up to the children being removed on 24th December 2015. 2.3.2 The following agencies have provided information and contributed to the serious case review in accordance with Working Together to Safeguard Children (2015), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks: Central Manchester Foundation NHS Trust (CMFT) Pennine Acute Hospitals NHS Trust - midwifery services (PAHT) Manchester NHS General Practitioner – CCG North West Ambulance Service (NWAS) Manchester Education Services Greater Manchester Police (GMP) Manchester Children and Families - Children’s Social Care (CSC) Homelessness Team, MCC NSPCC (did not provide any services to the family) MSCB Child I1 SCR Page 6 of 35 Greater Manchester Fire and Rescue Service (GMFRS) (did not provide any services to the family). 2.4 Key lines of enquiry 2.4.1 The review team identified and agreed key lines of enquiry for consideration in addition to analysing individual and organisational practice, as follows: 1. The extent, to which the impact of neglect was recognised, assessed and acted upon. 2. The adequacy, level and quality of risk assessments and interventions, including, the escalation and de-escalation of the case. 3. The adequacy of child protection plans, the functioning of core groups, the attendance and impact of non-attendance by agencies, oversight and challenge of the child protection case conferences, including robustness of decisions to cease child protection plans. 4. The quality and robustness of child in need assessment, planning and decision making. 5. How effective was inter-agency working, communication and decision making. 6. Professional’s roles and responses when attending a neglect case. 7. The ‘voice of the child’ and ‘daily lived experience’ – were the children spoken to/listened to? Were their views, wishes and feelings appropriately sought and taken into consideration? What factors impacted on this issue. 8. The extent to which mothers/parents own health needs had an impact on parenting capacity. 2.5 Structure of the review process 2.5.1 Over the course of this review, between January 2017 and April 2017, the review team met on three occasions. The review findings were presented to the Manchester Safeguarding Children Board in August 2017. 2.6 Status and ownership of the overview report 2.6.1 The overview report is the property of the Manchester Safeguarding Children Board (MSCB) as the commissioning board. 2.7 Parents contribution to the Serious Case Review 2.7.1 The parents were made aware of the Serious Case Review (SCR) by letter and were invited to make a contribution to the review. Mother and mother’s partner have not made contact. Father attended a meeting involving the independent reviewer in April 2017. Father attended a further meeting in November 2017, when the independent reviewer shared the findings of the review. MSCB Child I1 SCR Page 7 of 35 2.7.2 The meetings with father provided an opportunity for him to discuss some of the services provided to the family from his perspective. 2.7.3 Father confirmed that he moved out of the family home with SIBLING 1 and SIBLING 2 in March 2014 and that his marriage had broken down. 2.7.4 Father said that initially regular contact was maintained and SIBLING 1 would stay with mother at weekends. In 2015, father saw less of the family and SIBLING 1 and SIBLING 2 had contact with their mother only 2-3 times in that year. Communication between father and mother became non-existent. 2.7.5 Father stated that he was concerned about the lack of contact and was intending to contact the social worker to see if there was anything he needed to be aware of. When the younger children were taken into care at the end of December 2015, father described being shocked and did not understand how the situation had deteriorated to such a degree when agencies were involved. 2.7.6 In 2013, when Children’s Social Care became involved with the family, father stated that the social worker was excellent and the help and advice given to them was invaluable. Father felt that they were given a chance at a time when they were really struggling as a family. Father stated that he has since been able to make positive changes in his life. Father stated that the social worker was courteous and struck a good balance between support and being clear about expectations. 2.7.7 During the period under review, father felt that he was not told enough, about his younger children SIBLING 3 and SIBLING 4, by the agencies involved. Father did acknowledge that he could have been more proactive and should have contacted Children’s Social Care himself. 2.7.8 Father stated that it was always made clear to him that Children’s Social Care were focussed on the children. Father confirmed that he has his own mental health issues and that a separate social worker or department to support him may have been helpful. 2.7.9 During the meeting when the findings were shared with father, he clarified from his perspective a number of points made within the report. Father stated that at no time was there any domestic abuse between him and mother. In relation to the reference, within the report, that an incident at the house in 2015 may have been an indication of domestic abuse, he stated that at that time he had not visited the house for a long period. 2.7.10 Father clarified that he had not stated that SIBLING 1 was bisexual. There had been a conversation between parents when they said that they would not be surprised if SIBLING 1 became bisexual when older. Father shared this conversation within a core group. 2.7.11 Father has no recollection of mother making a planned arrangement with him to care for the children when she went into labour. Mother did contact him at the time of delivery, MSCB Child I1 SCR Page 8 of 35 to ask if he could care for the children, but he declined as he felt that he would not be able to manage all of the children together. 2.8 Diversity considerations of the family 2.8.1 The family’s cultural and ethnic heritage is white British. 2.8.2 Mother’s partner who is the biological father of CHILD I1 is described as a transgender person – who identifies themselves as female. 2.8.3 Mother now identifies as male. MSCB Child I1 SCR Page 9 of 35 Section 3: Analysis of agency involvement and Key Practice Episodes 3.1 Key Practice Episodes 3.1.1 An important tool in the organisation and analysis of data using a systems methodology case review approach is the identification of key practice episodes. These are a selection of practice episodes that were key, in that they were significant to the way the case developed and/or was handled. These were identified by the independent lead reviewer with the benefit of their overview perspective of the case and provide a useful way of summarising the most significant agency contact and involvement during the period under review. The information cited within the key practice episodes has been sourced from the group discussions with practitioners and managers, documentation and the combined multi-agency chronology. 3.1.2 The five key practice episodes that have been identified for more detailed analysis are: April 2014 – Initial Child Protection Conference July 2014 - Review Child Protection Conference September 2014 - Initial Child Protection Conference for Unborn Child I1 May 2015 - De-escalation of Child Protection to Child in Need Child in Need Planning and Review - June 2015 to December 2015. 3.2 Key Practice Episode 1: April 2014 – Initial Child Protection Conference 3.2.1 An Initial Child Protection Conference (ICPC) was held on 10th April 2014 in respect of the four eldest children (CHILD I1 was not born at this stage). The conference was held due to the deterioration of the home conditions (which were poor and unclean with mouse droppings, flies, clothes piled high, bin bags, newspaper on the windows, beds and sofas covered in clothes with nowhere to sit, and large furniture stored inside and outside the property), missed children’s health appointments, the complex dynamics of the adult relationships and parental mental health. 3.2.2 A friend of the parents (described as a transgender person – who identifies themselves as female) had moved into the family home. Mother reported that the family friend was her girlfriend. There were arguments and disagreements between the adults which resulted in a high degree of discord. Subsequently, the family friend became mother’s partner and biological father of CHILD I1. 3.2.3 The decision to convene the ICPC appears to have been prompted by concerns being raised with the social worker on 3rd February 2014, relating to deterioration in the home conditions and the relationships between the adults. There had been a significant period under Child in Need (CiN) planning without sufficient progress. MSCB Child I1 SCR Page 10 of 35 3.2.4 On 5th February 2014, a referral was made to the police by Children’s Social Care (CSC) for a strategy meeting/discussion as part of Section 47 enquiries4. A telephone strategy discussion took place on 10th February 2014. Information was exchanged and it was noted that there had been a previous referral for neglect in April 2013. Police had not visited the address or seen the children but were in agreement for the matter to proceed to ICPC. 3.2.5 It is unclear whether the children or the house were seen as part of the Section 47 enquiries, as the recorded visit by the social worker is dated 27th February 2014, which is outside of the timescale for section 47 enquiries. 3.2.6 On 27th February 2014, SIBLING 2’s school raised concerns about poor hygiene and a rash on the child, in addition to lack of stimulation and poor home conditions. The paediatrician expressed concern that the carers were unable to meet the children’s needs but felt that a medical was not necessary as the evidence of neglect had been seen by the school. 3.2.7 The same day, 27th February 2014, an unannounced joint visit was made by the social worker and CSC team manager. Home conditions were poor, the social worker gave the carers (father, mother and mother’s partner) five days to ‘clean up the house’, change the hygiene standards of the children and sort out the living arrangements so the children were better cared for, stating a consequence of not complying would be legal advice being sought. 3.2.8 A follow-up unannounced visit was made by the social worker on 7th March 2014, and the home conditions had improved somewhat. 3.2.9 By the time of the ICPC, mother was eight weeks pregnant to her new partner. Father had moved out of the family home with the two eldest children to live with paternal grandparents in a neighbouring authority. Neither parent attended the ICPC but did submit reports detailing some of their health issues. 3.2.10 The ICPC identified the risks as follows: The children had been living in chronically neglectful conditions, albeit there had been some recent improvement in the home. It was questioned how long this could continue, as the family had had previous interventions, over a twelve month period, where improvements could not be sustained and there was little evidence of change. The three youngest children all had significant developmental delays and there was a lack of stimulation for the children: o SIBLING 1 had a squint that had not been treated at an early stage. 4 Section 47 Children Act 1989 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. MSCB Child I1 SCR Page 11 of 35 o SIBLING 2 had significant developmental delay (delayed speech and language development), a diagnosis of autism (13.1.14), and was still in nappies. All of which has been impacted by a lack of early assessment. o SIBLING 3 had cerebral palsy and significant learning and social communication difficulties and immunisations were outstanding. Physiotherapy appointments were cancelled nine times, and progress in eight months had been slow. Parents did not follow the physiotherapy programmes they were given for SIBLING 3. o SIBLING 4 was significantly developmentally delayed and presented as autistic. Immunisations were outstanding and appointments were missed for orthoptics. SIBLING 4 had been witnessed banging their head against the window in distress and there was possible lack of stimulation. The parents had not demonstrated insight into their children’s learning and development needs, and physical disabilities. They had a lack of understanding of their children’s needs and consistently had failed to act on advice given to them. Both parents had been reluctant to engage with professionals and when they had, the focus was on themselves and not their children. Home visits were monopolised by mother and her own issues, and she failed to act upon advice given to her. Parents were both said to suffer mental health problems - father had stated he had a counsellor for depression and was ‘bipolar’ (not formally diagnosed) and mother suffers from anxiety. Mother was diagnosed with chronic fatigue syndrome, was seen regularly by GP, and also had fibromyalgia and endometriosis. Mother was not acting appropriately or taking the children to medical appointments. There had been approximately twenty three missed health appointments in eight months. Minimal protective factors in the family home - no risk assessment had been completed. There was concern about the role and background of mother’s new partner. The nature of parents’ work was also a cause for concern and requiring further exploration – mother was said to work in ‘web fantasy’ and father worked within the pornography industry. 3.2.11 It was a unanimous decision of the ICPC that all four children should be made subject to child protection plans under the category of neglect. A comprehensive outline child protection plan was drawn up, identifying the need for Health to complete a chronology of all the families’ health needs, including attendance and non-attendance, with reasons for this, to assess patterns of behaviour. It was also stated that CSC should combine this Health information into a social work chronology. Significant assessments were required to be undertaken – including risk assessments in respect of parents’ apparent mental health problems, further parenting assessments, a risk assessment in relation to mother’s new partner, and a risk assessment in relation to paternal grandparents. 3.2.12 It was a recommendation of the ICPC that a strategy meeting involving the police needed to take place within 24 hours – this was to discuss the current home conditions, and MSCB Child I1 SCR Page 12 of 35 the concern that the family were a possible ‘flight risk’ (parents had not attended the ICPC and they had talked of moving house) and to explore the nature of both parents’ employment. It was specifically stated that following the conference there needed to be a joint home visit by police and social worker to the family home. A strategy meeting was held, but it did not take place until 24th April 2014. No joint visit with the police ever took place. 3.2.13 Due to the level of concern at the ICPC, and the recognition that there had already been significant drift in the case, a recommendation was also made that the social worker should consult about a legal planning meeting. 3.2.14 A first core group took place on 14th April 2014. Minutes of the ICPC were not received by Health for 5 months (19th September 2014) – significantly outside of timescale. 3.3 Summary appraisal of practice within Key Practice Episode 1 3.3.1 This key practice episode is particularly significant as it marks the escalation of the case from child in need status to child protection. 3.3.2 There is some evidence of attempts at multi-agency working within this key practice episode - the liaison between professionals to convene the ICPC, and to formulate a child protection plan. There is recognition that there had been some drift. There is clear identification of the many areas of concern, and there is recognition that the plan needed to be based on thorough assessment. There was also some references to the need for legal planning and advice to inform planning – both in the ICPC, and in the direct interactions with the family. These are the more positive and appropriate aspects of the interagency working identified in this key practice episode. 3.3.3 At the same time, there are many aspects of the interventions which are of significant concern. This includes examples of further delay and drift, not following procedures, poor recording and communication, and some loss of focus on the experience of the children. 3.3.4 The CiN plan had been in operation for a year before a CiN meeting concluded that the case should be escalated to an ICPC. The review has seen evidence of some good, task-focussed work carried out within the CiN plan. At times there had been some areas of improvement, although there was also a lot of evidence that any (temporary) improvements (such as in home conditions, or health appointments being made) were always reliant upon professionals taking responsibility, rather than the parents. 3.3.5 It is not clear to this review why the decision was taken at this point, in February 2014, to proceed to ICPC, rather than some months earlier. Deterioration in the already poor home conditions is cited. A deficit in the agency interactions and recordings in this key practice episode (and elsewhere) is in lack of specifics or details about these poor home conditions. An indication of the extent of the ‘clutter and mess’ in the house is in the fact that the family and professionals had been referring to the need to get a skip to help with a clear up since the previous summer (indeed this continues to be referred to throughout the period under review). 3.3.6 Analysis of the agency recordings and the professionals’ comments about the process of the section 47 enquiries, strategy discussion and the convening of the initial conference MSCB Child I1 SCR Page 13 of 35 indicates some confusion about these processes. It remains unclear why there was a significant delay between the concerns being raised on the 3rd February 2014, and the conference being held on 10th April 2014. This two month period was marked by a lack of urgency and lack of focus on the experience of the children, and there are clear examples of the agencies not working effectively together in a timely manner. The family was not visited in this period by CSC until 27th February 2014, and whilst the children were seen then and in the follow up visit a week later, the recordings do not include the voice of the child, or the daily lived experience of the children. 3.3.7 It has been suggested to the review that a culture had developed – particularly within the police and CSC - of responding in a very process-driven and routine way to requests for strategy meetings/discussions. This meant that they became seen as a necessary step to be taken in order to trigger an ICPC, rather than an opportunity to properly consider the facts and plan enquiries. In the record of the confidential discussions in the ICPC, the social worker explains that, on advice from the team manager, it was felt that a phone call to the police was adequate as they only wanted agreement from another agency to go to ICPC. There were a lot of agencies involved – particularly from Health – and they should have been invited to be part of the strategy discussions, and that this should take the form of a face-to-face meeting with full consideration of the need for home visits/the children being seen, etc. Indeed, it is notable that there was no apparent consideration at this point (or at any other point throughout the timeframe of this review) of the need for a police visit to the family home as part of an investigative process into possible neglect. Similarly, there is no indication that CSC or other agencies considered requesting police visit the house when conditions were deemed to be inadequate – particularly on the CSC visit on 27th February 2014. 3.3.8 Police have advised this review that key learning is that in circumstances where there is a request for a strategy meeting in relation to neglect, they should be involved in joint visits to the address to ascertain if the threshold for criminality has been reached. 3.3.9 The interagency working within the ICPC itself led to recognition of the complexity of the situation, identifying the many areas of risk. The voice of the child was not adequately captured (the consultation booklets ‘Have your Say’ were not completed at this point – or indeed for subsequent core groups). Whilst this booklet may not have been appropriate (given the children’s needs) guidance from the specialist agencies involved could have helped with obtaining the children’s views on their daily lived experience. There was, however, an appropriate identification of important actions to be taken within the outline child protection plan, not least the recommendations for a further strategy meeting and joint visit with police, the need for clear assessments and chronologies, and the recommendation for a legal planning meeting. It is of real concern that none of these was adequately followed up and that the failure to complete actions did not result in escalation by any agency. 3.3.10 In relation to the recommended strategy meeting, Health have recorded that the CSC team manager appears to have made a unilateral decision not to proceed to a strategy meeting without giving any explanation. There is no evidence of any consideration about this being challenged or escalated. A strategy meeting was held on 24th April 2014 - not within 24 hours from conference as the agreed plan. The health visitor attending the case conference was from another clinic and was not able to attend and the CSC report to this review states that it was unclear from notes what the purpose of this strategy meeting was, and little MSCB Child I1 SCR Page 14 of 35 information was exchanged. Concerns about parents work were not recorded as being discussed in the meeting, and there was no consideration of the need for a joint visit involving police. Police records show that a recommendation of this strategy meeting was for a legal planning meeting to be convened. 3.3.11 The handling of the issue of legal advice (at this stage, and throughout the timeframe of this review) appears particularly significant, not least because it seems to give an insight into the way the case was perhaps perceived by some professionals (as not meeting the threshold for legal intervention). It also serves to highlight some of the ways in which interagency working was not effective, with some indications of what the barriers to this may have been – some difficulties in professional relationships, coupled with lack of understanding of roles and responsibilities amongst some of the professionals. There was a lack of understanding of the issue of legal thresholds and the responsibilities of each agency. Professionals appear not to have adequately recognised their role in evidencing their concerns and following escalation procedures as appropriate. Instead, there was an over reliance on CSC having responsibility for case planning decisions. 3.3.12 Given the gravity and complexity of the many concerns identified at the ICPC, and the fact that over a long period of intervention no adequate change could be sustained, it was right that legal advice needed to be sought, carefully followed and reviewed throughout any proposed interventions. A decision to seek legal advice is for CSC to take rather than other agencies. Despite the various references to the need for this (at this point and elsewhere), the only contact with CSC legal services at this point was a planning meeting with the legal service on 23rd June 2014. 3.3.13 It is interesting to note that in the referral form for the legal meeting the social worker stated that the majority of the Health professionals believe the children should be removed – there is no other reference to this view of the Health professionals in the CSC case notes or recordings of interagency meetings. There was no evidence provided to the legal planning meeting as to why Health professionals held that view. The minutes of that meeting indicate that it was noted that ‘had the case come to legal planning at an earlier stage’ then it would have been a ‘Public Law Outline (PLO)5 case’. However, at the point of the discussions the social worker advised that the child protection plan was being effective and was addressing areas of concern, and therefore it was decided that PLO was not indicated. It was made clear that if there were any further concerns raised or care of the children slips again then it should ‘come back for legal planning swiftly given the history and children’s health needs’. 3.3.14 It has been commented to the review that CSC professionals (social worker and CSC team manager) did not view this as a case that was serious enough to merit legal action being taken. It is interesting to note that the message given to the other agencies involved was always that the case ‘did not meet the threshold’. There was never any significant challenge or escalation from any other professional to evidence that a different basis of intervention was required, or that the threshold may have been met. Legal advice was not sought again until the children were ultimately removed from the family home. 5 Public Law Outline (PLO) - this formal meeting is often known as a “pre-proceedings meeting” or “PLO meeting”. In some cases the social workers may feel that the risk of harm to a child is so great, or the case is so urgent, that the case should go straight to court. MSCB Child I1 SCR Page 15 of 35 3.4 Key Practice Episode 2: July 2014 - Review Child Protection Conference 3.4.1 A Review Child Protection Conference (RCPC) took place on 3rd July 2014. Three core groups had taken place since the ICPC. The CP Chair for the RCPC was different from the CP Chair who had chaired the ICPC. 3.4.2 It was decided that the meeting would take place in two parts to reflect the living arrangements for the children. Part one therefore considered SIBLING 1 and SIBLING 2 who had been living with their father in a neighbouring Local Authority area since before the ICPC. Part two of the meeting considered SIBLING 3 and SIBLING 4 who remained living with their mother and mother’s partner in Manchester. The same professionals were in attendance for each of the two parts of the RCPC. Parents again did not attend the meeting. 3.4.3 Part one of the meeting identified that: SIBLING 1 was doing well at school. Father was said to be taking action to address the children’s health needs. Since separating from mother some difficulties were said to have been removed and this had had positive effects for the children. There was regular contact with mother – although this needed more structure. Health services from the new Local Authority needed to be obtained for SIBLING 2 without further drift/delay. SIBLING 1 no longer at significant risk – SIBLING 2 needed a plan to prevent drift and to prioritise the services required. 3.4.4 A majority decision was taken to remove SIBLING 1 and 2 from child protection plans and to continue managing the case under CiN. The children were felt to be no longer at significant risk. The case was transferred to the neighbouring Local Authority on 14th August 2014 and closed to Manchester. 3.4.5 Part two of the meeting identified that: There had been some improvement in home conditions. There was progress with some tasks on the child protection plan – such as immunisations for the children, attending some appointments, and accessing some nursery and Stay and Play provision. Mother had taken the children to a dentist but it was said that SIBLING 4 and SIBLING 3 would not cope with treatment at the time so the paediatrician was asked for a referral to specialist dentist service. Mother and mother’s partner had been spoken to about behaving inappropriately (embracing/kissing) in the reception area – example of their lack of social awareness. Mother’s partner has poor hygiene and was inappropriately dressed (‘see-through nightie’) when the health visitor visits. The social worker was completing a family assessment which other professionals were contributing to. No problems with mother allowing professionals into the home. MSCB Child I1 SCR Page 16 of 35 Mother was still anxious, pre-occupied by her concerns and stresses and could present as stressed and tearful. In respect of the children, mother tends to focus on the smaller concerns rather than the main ones. There was mention of mother showing signs of disguised compliance and being likely to ‘revert’ if not under scrutiny and services are withdrawn. The CP Chair challenged the social worker about the children’s poor daily lived experience and how long this could continue. It was the CP Chair’s view that a substantial and sustainable improvement was needed. The CP Chair also commented that improvements can only be sustained when a child protection plan is in place. The social worker stated that CSC would always be involved to some extent – risks could be reduced but the need for services would not. Discussion took place with CSC team manager and a legal planning meeting was held on 23th June 2014 - plan is effective/making good progress to date, no immediate safeguarding risks of harm, no role for legal as the threshold for proceedings/PLO was not met. Concerns about the two older children when visiting mother's address. Mother 20 weeks pregnant - referral to midwifery team and ICPC required. Daily lived experiences of the children needed to be assessed further. Father labelling SIBLING 1 as bi-sexual. 3.4.6 In Part two the unanimous decision was for SIBLING 3 and SIBLING 4 to remain subject to child protection plans. 3.5 Summary appraisal of practice within Key Practice Episode 2 3.5.1 The decision to hold the meeting in two parts, and the way it was organised, meant that there was decision making in respect of two of the children before there had been full information sharing about all aspects of working with the family. Indeed, it is notable that in the second part of the meeting (after decision had already been reached to discontinue the child protection plans in respect of the two older children who were in father’s care) there was further information fed in to the conference specifically about the care of these two older children – including they regularly stay with their mother, and as well as information about their father identifying that SIBLING 1 (six years old) is ‘bisexual’. 3.5.2 It appears that significant aspects of the original child protection plan had been ‘lost’ at this RCPC. There is in the minutes, for example, no mention of the fact that the ICPC identified the need for strategy meeting to happen within 24 hours to consider a joint visit with the police. The issue of looking into the parent’s work/employment does not feature in the minutes of the RCPC. Risk assessment of mother’s partner was said to be ‘on going’, and that ‘there appear to be no concerns’ – yet there are concerns expressed at the meeting about mother’s partner being young and lacking experience as well as concerns about being inappropriately dressed for visits and having poor personal hygiene. It was stated that the social worker was preparing a chronology in connection with the family assessment. No timescale was discussed for these assessments. There is no mention of a parenting assessment. MSCB Child I1 SCR Page 17 of 35 3.5.3 It is notable that some information given to the RCPC conflicts with information recorded in minutes of Core Groups that had taken place. One example relates to the combined health and CSC chronology that had been requested as part of the child protection plan at the ICPC. Whilst the social worker said to this review meeting that a chronology was being prepared, they are recorded as having said in a preceding core group that a chronology is not necessary – stating that health had already completed a ‘comprehensive chronology’ presented at ICPC, and that CSC only had two referrals to add to it. This was not challenged in the core group. Health information to ICPC was, in fact, in the form of various reports, not a full chronology, and the CSC had a great deal of information about their involvement (as well as referrals) to include in a chronology. No combined chronology was ever produced, and this could have been crucial in enabling people to see how the case had progressed over a long period. Health and neglect concerns needed to be mapped, and issues in relation to parental health also needed mapping. 3.5.4 The social worker advised the RCPC that there has been no problem with mother allowing professionals in to the house – as this had been recognised as a significant issue. The Health chronology for this review, however, states that mother would not allow the health visitor access due to anxiety caused by unplanned visits, and the health visitor visit on 2nd July 2014 (day before RCPC) had to be a doorstep visit for about forty minutes. It is not clear why this appears to not have been challenged in the meeting – the health visitor was present. It was commented in the RCPC that the health visitor has not been allowed upstairs in the house. 3.5.5 The child protection plan included that an assessment was needed of the parents’ mental health issues. This was reviewed in the core group on 6th May 2014. The core group record states that neither parent had suffered with their mental health to a point that emergency steps have had to be taken and that both parents had sought advice from their GP. It states that the onus was on Health professionals to identify if any safeguarding concerns arose and to advise CSC of their risk assessment. At that point the social worker would undertake a risk assessment of the children’s needs. There is brief recorded discussion of the issue of mother’s mental health in the RCPC. The outreach worker (from the GP surgery) reports that the doctor wanted to make conference aware of concern for mother’s mental health. The social worker advised that she lacked sufficient knowledge in this area to be able to say how much of mother’s presentation is due to ‘personality and social and communication skills rather than actual mental health issues’, stating that this would need to be evaluated by someone with that expertise. However, there was no plan for any such assessment to take place, and no apparent challenge (from the CP Chair or anyone else present) about the lack of any plan for this assessment. 3.5.6 Given the history of the children’s basic needs not being met and changes not being sustained, at this point there needed to be a clear focus on carefully evidenced assessment from the various professionals. This needed to include each child’s individual welfare and development needs and robust assessment of the carers’ motivations and capacity to meet these needs. In response to concerns from the health visitor about parenting in the mother’s household, the social worker agrees there are ‘doubts’ (about parenting capacity) but that she needs to ‘establish all the evidence before considering legal’. In the confidential section of part two of the RCPC the social worker states that she has spoken with the legal department, but ‘cannot say there are immediate safeguarding risks of harm’. She goes on to MSCB Child I1 SCR Page 18 of 35 comment that the next step will be to see how mother copes with the extra child and if not ‘whether the response to the plan contains evidence for removal’. One of the two changes made to the child protection plan at the RCPC was for ‘focus to be on the daily lived experience of SIBLING 3 and SIBLING 4 as a contingency that legal planning is needed’ – it is not clear to the review team what is meant by this. What is clear is that no agency challenged the lack of adequate and evidenced assessment to inform the on-going risk management and intervention. 3.5.7 The review has heard repeated comments from professionals involved at the time indicating that they did raise, in core groups and other discussions, concerns about the nature of the risks. It has been said that whilst some progress was being made and tasks within the child protection plan were being achieved, the level of progress appeared small, and the daily experience of the children was not good enough, leading them to talk about whether the children should be left in these home circumstances or removed by legal action. The apparent response (from the social worker) was said to be that legal advice was that ‘the threshold was not reached’. The review can find no such record of these discussions within the records of meetings or discussions presented to the review. Indeed, it is noticeable that core group meeting records, record little in the way of comment from other agencies – they are recorded by the social worker. As highlighted earlier, however, the referral to legal department by the social worker does include comment that most Health professionals want the children removed. 3.5.8 It is notable that within the minutes of the RCPC the social worker makes reference more than once to their view that CSC would ‘withdraw from case at some point’. Considering the early stage in the child protection process, and particularly that this view is not informed by the completion of any assessments, and that there are still lots of concerns about the needs of the children not being met, it seems premature and overly optimistic to be expressing such a view. 3.5.9 There appears to have been little in the way of management oversight from the CSC team manager. Certainly, there was little or no CSC management presence at multi-agency forums – did not attend the ICPC or the RCPC’s. The CSC team manager did attend the legal planning meeting in June 2014, but was again reliant on the social worker for all information and perspective on the progress of the case. 3.5.10 The CP Chair did comment about how long the poor daily lived experience of the children could be allowed to continue – and did highlight how that experience for the children needed to be assessed further. The CP Chair has an important role in ensuring there is an appropriate plan in place, overseeing the working of the core group and challenging practice. There was not sufficient challenge to the loss of focus on important aspects of the child protection plan – such as the assessment of mental health, of parenting capacity, of the need for a comprehensive chronology, or any attempt to evidence or escalate concerns about progress within case planning. It cannot have been helpful that – due to resource issues – that the CP Chair chairing this RCPC had not been involved in the initial ICPC. 3.5.11 A summary of the analysis of the interagency working at this point would be that over-optimism was based on some progress with specific tasks and mother being quoted as MSCB Child I1 SCR Page 19 of 35 acknowledging the problems and the need to make ‘significant changes’. Insufficient attention is on the actual evidenced daily experience of the children. The overall understanding of the situation needed to be based on clear assessments – assessments of parenting capacity, informed by a good understanding of the parent’s backgrounds and abilities - including a formal specialist assessment of the mental health problems that they had presented as having and the impact of these - and underpinned by a clear combined chronology. 3.6 Key Practice Episode 3: September 2014 - ICPC for Unborn Child I1 3.6.1 An Initial Child Protection Conference (ICPC) was held on 12th September 2014 in respect of the unborn child (CHILD I1). Mother was approximately thirty-one weeks pregnant. The pre-birth assessment was completed on 5th September 2014. 3.6.2 The CP Chair who chaired this meeting was a different CP Chair to the two previous conferences. 3.6.3 The decision was made that the child be made subject to a child protection plan, under the category of neglect. 3.6.4 An outline child protection plan was completed and a core group was held to develop the child protection plan on 22th September 2014. The following actions were identified for mother and mother’s partner: to attend parenting course and implement the tools learned; to ensure that when born the baby’s health, emotional and developmental needs are met; to take on the support offered. 3.6.5 A midwifery detailed care plan was in place from 23rd September 2014, stating that a discharge planning meeting must be held prior to mother and baby’s discharge and that key professionals must be notified of the birth of baby. Additional information was included that mother’s partner (the biological father) is transgender and intended to use an artificial aid to feed the baby whilst as an inpatient. There was no plan to address how the two other children would be cared for (or by whom) when mother went into labour and how the emotional impact on them would be managed. 3.6.6 Recording from the social worker’s visit on 17th October 2014 indicates that the house was ‘smelly’ but ‘clean’ and that planned work on the children’s daily lived experience would happen after the baby was born. It is not explained why it was felt this work should be further delayed, and there is no record of this delay having been discussed within core groups. 3.6.7 Midwife home visit on 20th October 2014 identified poor living conditions, unclean, upswept floor, crisp packets, no curtains at the windows (sofa cushions used instead) and unable to sit on the sofa due to the hygiene level. Mother made clear she wanted to be referred to as "dad" and mother’s partner as "mum". 3.6.8 On 23rd November 2014, CHILD I1 was born at home at 17:00hrs. A call had been made to the North West Ambulance Service at 17:10, the ambulance arriving at the home at 17:19. This was after CHILD I1 had been born – the call had not been made during labour or delivery or after the membranes had ruptured, as is usual. As mother was declining to come into hospital and there were concerns that the placenta had not been delivered, a midwife MSCB Child I1 SCR Page 20 of 35 attended the home arriving at 18:00. Mother’s own hand-held midwifery record could not be located until just leaving the home (possibly further avoiding professional linking details). It is also thought significant that when the call was made the family gave a completely different name for mother – which had not been used before. There was reason to think that the family had been covertly preparing for a home delivery – for example, they had purchased a shower curtain to protect the bedding or flooring. Previous discussions with mother (7th July 2014) had made it clear that a hospital birth was appropriate as there was a significant risk to both mother and baby - as mother had had two previous caesarean births, and SIBLING 3 has cerebral palsy. Amongst the concerns noted on the day of the birth was that SIBLING 3 and SIBLING 4 were distressed, crying and agitated by the activity – and were not comforted by the adults who stated that SIBLING 3 was best ignored. 3.6.9 On 24th November 2014 mother and CHILD I1 were discharged home without the discharge planning meeting taking place. The mother wanted to return home as SIBLING 3 was upset without her and was smearing faeces. It was said that mother’s partner could not cope with looking after the two children and their distress was apparent. The decision to agree the discharge of mother and CHILD I1 without the discharge planning meeting was taken with the involvement of the Local Authority Emergency Duty Service (EDS) social worker. The EDS social worker took the decision that the discharge meeting could take place the following day at home, and in the meantime mother and CHILD I1 could go home – this was on the basis that the main risks were identified as neglect rather than domestic violence or substance abuse. 3.6.10 There was a midwife home visit the following day, and the social worker also attended the home and explained the need to tidy up the clutter, as there was difficulty in moving around the room freely (described as untidy, smelled, two pushchairs, large cardboard boxes in the hallway). Mother appeared restless and was tidying up on arrival of the midwife. The midwife observed mother’s partner to appear childlike in manner and demeanour, required simple instructions, and was seen to sit on bed, stare and rock periodically. It was questioned by the midwife whether mother’s partner had some degree of learning disability. 3.6.11 Over time (eight post-natal home visits were made by the midwife), the midwife observed the environment to look less cluttered, more space in room/on floor, ammonia smell persisted (later the smell reduced and the smell of cleaning products was apparent) smell did later return as SIBLING 3 was reported to be potty training. When the midwife queried the smell in the house a problem of mice were mentioned. 3.6.12 On 3rd December 2014, a health visitor new birth visit was undertaken and the home conditions were recorded as satisfactory. 3.7 Summary appraisal of practice within Key Practice Episode 3 3.7.1 Given that the pregnancy was known about in April 2014 the timing of the pre-birth ICPC was late (outside of timescale). The social worker’s assessment was completed on 5th September 2014, giving no time for input from other agencies before the pre-birth ICPC. Indeed, the assessment appears as a single agency assessment, is brief, does not give any voice to the children, did not clearly identify risks to the unborn child and, given the history, appears over-optimistic. The assessment does signpost the need for other assessments to take place, such as a parenting assessment. MSCB Child I1 SCR Page 21 of 35 3.7.2 The need for planning to be based on careful assessment – particularly of parenting capacity - is starkly demonstrated around the time of the birth of CHILD I1. There are clear indications from the observed behaviour of mother’s partner at the time, from comments made by mother that her partner could not cope, as well as from the distressed presentation of the children, that mother’s partner was not able to manage alone to meet the needs of two children with disabilities. There had been reason to be concerned about the abilities and vulnerabilities of mother’s partner previously, and indeed at the pre-birth ICPC on 12th September 2014 there are concerns that mother’s partner gets angry with people if confronted about behaving inappropriately, is said to be ‘quite volatile’, and is felt to have Asperger’s syndrome. It is perhaps most concerning that, even with this new information from the time of the birth no assessment of parenting capacity took place until much later (when the case was in proceedings). It has not been possible to understand why the planning around the birth of CHILD I1 did not include a practical plan about how the two other children would be cared for (and by whom) when mother went into labour and how the emotional impact on them would be managed (subsequently the RCPC in December 2014 was informed that father had agreed to look after the children but then let mother down – although there is no record of this agreement being part of the plan). 3.7.3 Parents chose not to seek assistance from medical professionals at the time of the labour and delivery, thus ignoring the risks that had been clearly highlighted. It appears they had been planning for a home delivery, and they then gave a false name when they did ring midwifery services. It is apparent from agency records, as well as from comments to this review, that professionals at the time recognised that the circumstances around the birth of CHILD I1 were of real concern. However, there appears to have been little or no consideration – by any agency - of how to respond to the risks. At very least, in such circumstances for children subject to child protection plans, there should have been consideration of triggering s47 enquiries, and having formal multi-agency discussions. 3.7.4 There is real concern about functioning of the core group at this time. It has been commented that the circumstances of CHILD I1’s birth were not discussed within the core group, and indeed a core group meeting held on 25th November 2014 (the day after mother returned home) even includes comments (from the social worker) about the fact that the monitoring that was needed for the family could be done under a CiN plan led by Health, rather than a child protection plan. The recording on the core group documents is brief in the extreme – not only is there no mention of the circumstances of the birth, there is no focus on risks. The review has been told that the core group document was updated by the social worker each time and this was not routinely then circulated to the other professionals, although sometimes the social worker would bring the record of the last meeting to the following core group (but not routinely). It was stated to this review that core group members were raising concerns within core groups – about the state of the house, the needs of the children, and the capacity of the parents to meet these. It has further been stated that ‘the core group wanted the children removing’– yet this is not reflected within any records of core groups. 3.7.5 Repeated comments to the review about working with the parents of CHILD I1 indicate that professionals found them at the time to be very ‘self-absorbed’, and wrapped up with their own pre-occupations. An example given of this, which is also borne out by some of the MSCB Child I1 SCR Page 22 of 35 agency recordings at the time, is that they regularly wanted to make clear to professionals how they wanted to be called (that CHILD I1’s biological father was to be called ‘Mum’ and biological mother was to be ‘Dad’), and that this was highlighted above the needs of the children. It has been further explained that the parents of CHILD I1 brought discussions about the needs of the children back to their own needs. 3.7.6 In the pre-birth ICPC there was some discussion of the fact that mother’s partner was planning on using an artificial aid to feed the baby. The CP Chair did question whose need this was meeting – that of CHILD I1 or of mother’s partner. It was left that this would be followed up in a joint visit with both the social worker and midwife. It appears no such follow up occurred about this. A housing Connect support worker was asked about having this conversation, but understandably felt it was not their remit. Practitioners have commented that issues around gender identity, sexuality and CHILD I1’s parent’s preoccupations with their roles often clouded attempts to address issues around the needs of the children. There was some challenge to the comment from father that SIBLING 2 (at 6 years old) was ‘bisexual’ at an earlier core group, and professionals did have some concerns about sexual and social boundaries and the emotional impact on the children of issues that were potentially confusing to them. However, professionals were apparently fearful that by exploring some of these concerns there was the potential for appearing discriminatory. This may go some way to explaining why these issues were never appropriately addressed. 3.7.7 Repeated child protection visit recording indicates that the children are not being seen alone by the social worker or any member of the core group, and indeed some recordings of visits do not mention the children, which falls below expected practice. On a number of occasions family are on the point of leaving when professionals visit, and it is speculated that this was a deliberate strategy by the family to avoid the house being seen properly. 3.8 Key Practice Episode 4: May 2015 - De-escalation from CP to Child in Need 3.8.1 A RCPC took place on 14th May 2015. This was the third review for SIBLING 4 and SIBLING 3 and the second review for CHILD I1. Monthly core groups had been held. The children’s mother attended this conference – this was the first conference that any of the parents had attended. Yet again there was a different CP Chair chairing the RCPC who had not been involved in any of the previous meetings. 3.8.2 Information was presented to the RCPC from professionals that there were no safeguarding concerns raised in the review period and there was progress and engagement from CHILD I1’s parents. The social worker reported that there were no escalating risks. Mother had ‘changed her life’ since the ICPC, mother and mother’s partner presented as a happy loving couple and put their children first. Furthermore, mother was said to be proactive in getting support for the children and addressing concerns. An example given of this was mother removing excess furniture from the house. 3.8.3 Tasks on the child protection plan were explored. There was progress with getting appointments – dates were in place for some more immunisations, a dentist was due to visit SIBLING 3, parents had taken SIBLING 3 for physiotherapy, CHILD I1’s health needs were being met and weighed monthly. It was stated that parenting assessments were completed as part MSCB Child I1 SCR Page 23 of 35 of pre-birth assessment and Children and Parents Service (CAPS) completed an assessment which did not raise any concerns. 3.8.4 One aspect of the plan was for risk assessment of parents’ mental health to ascertain if future support was needed. This action was said to be completed as an Edinburgh Post Natal Depression Scale6 had been completed in March 2015 with mother and she had shown no signs of low mood or depression. It was further stated that no concerns had been identified in the review period with parents’ mental health. 3.8.5 In relation to the voice of the child, it was stated that SIBLING 3 expressed their wishes through noises, smiling or leading you by the hand to what they were interested in. SIBLING 4 was happy in the home, CHILD I1 smiled and seemed happy and had toys. It was noted that the three children were not seen on their own due to their ages and learning needs. 3.8.6 There was talk about home conditions. The family had got a skip to get rid of some furniture. The house was said to be very dark (mother stated sunlight can make SIBLING 3 distressed), and the social worker reported on-going concerns about mice infestation in the property, and that it was difficult to keep the home clean and tidy because of the children’s particular needs. 3.8.7 The CP Chair gave a very positive summary of the RCPC and recommended that there was no evidence of significant harm, but a need for on-going support under a CiN plan for a minimum of three months. It was the unanimous decision of the RCPC that the children should be removed from the child protection plan. A CiN meeting was arranged for 11th June 2015. 3.8.8 In the period leading up to the RCPC, there was evidence of some concerns and a pattern of missed appointments and difficulty in contacting the family was beginning to emerge. It is unclear if this was fully recognised and discussed within the core groups. In January 2015, core group minutes and child protection plan show little evidence of update since the last meeting. The child protection plan states that professionals believe that parents were doing all they can to meet the children’s needs (which seems to be a shift from previous conference discussions). 3.8.9 In February 2015, the home conditions were described as ‘could be better’ and within the CSC recordings there are contradictory comments, ‘mother must do more to meet the complex needs’ and the ‘child protection plan has been completed’. 3.8.10 In March 2015, the social worker reports having to take a ‘hard line’ with mother as the home conditions were a ‘little messy’ and the next RCPC will be to ‘de-register the children’. 3.8.11 In April 2015, the children were recorded by CSC as ‘thriving’. 3.8.12 In May 2015, the week before the RCPC, the family were said to be hiring a skip and were going to re-decorate. The home condition was still ‘variable’, but (as is the theme 6 Cox, J.L., Holden, J.M., and Sagovsky, R. (1987) Detection of postnatal depression: Development of the 10 -item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150: 782-786. MSCB Child I1 SCR Page 24 of 35 throughout) there is little detail about what this means. Mother was reported to be wearing dark glasses and had a puffy eye. Mother was reported to attend school and was seen by health staff wearing dark glasses and had a puffy eye. Mother said that something had happened at the weekend and father was not allowed in the property. This information was shared with the social worker, school and the health visitor. It appears this may have been an indication of a domestic abuse incident which was explored at a home visit by the health visitor to which mother denied. The information was not raised in the RCPC. 3.9 Summary appraisal of practice within Key Practice Episode 4 3.9.1 This was a very significant stage in the handling of the case as the decision to discontinue the child protection plans for the three children signified that they were not at risk of significant harm, and that their parents were able to meet their needs with the support of a CiN plan. 3.9.2 There had been areas of significant progress. The core groups had happened regularly, and mother had attended all of these in this review period. The family were being seen regularly, and some areas which had been a cause for concern had been addressed. 3.9.3 The RCPC was a long meeting and many areas were discussed, and in most of these some progress was highlighted. However it appears – from analysis of the records at the time, and from comments from the practitioners involved - that the concerns about lack of full information sharing, consideration of all the facts and any real challenge that was a feature of core groups, were also a feature of this RCPC. 3.9.4 Professionals involved have considered why it was felt appropriate at this time to discontinue the child protection plans. Comments have highlighted that there were still concerns about issues such as the state of the house, and indeed, that this fluctuated generally over the months of involvement, and that this was not significantly better or worse at this time, than at any other. Tasks on the child protection plan had been ticked off and others that remained could be followed up within the CiN process. Again, it has been stated that different professionals were concerned about whether the parents had the capacity to meet the needs of the children, and that this had been raised repeatedly (which is not reflected in recordings), but the response was always that the case did not meet the threshold for legal action to be taken. 3.9.5 The CP Chair’s summary of the situation, in reflection of the discussion at the meeting, was a very positive one. Having different CP Chair’s chairing each meeting clearly gives scope for different approaches as well as a potential loss of issues or themes. It is notable, for example, that the CP Chair who chaired the previous RCPC (in December 2014) put emphasis on some of the aspects of the case that had not been assessed (such as the role of mother’s partner, and mother’s own mental and physical health), and highlighted the significance of the history which showed that the adults have struggled to meet the needs of the children. 3.9.6 It is clear that throughout the handling of this case much more weight is attached to completing specific tasks than to overall assessment which took into account history and MSCB Child I1 SCR Page 25 of 35 evidenced how the needs of the children were being, and could be met, by the adults7. There had been no real assessment of mental health of mother – the assessment quoted as happening in March 2015, is not an assessment of mental health needs, is used to identify the possibility of post-natal depression. Despite concerns about mother’s partner’s functioning and talk of possible learning disability or autism, there had been no assessment of this8. There was no challenge to the statement that the pre-birth assessment had included assessment of parenting capacity. 3.9.7 Many of the tasks that were achieved within the child protection plan could be seen to be very largely due to professional involvement (rather than parents) – availability of a chronology or clear history might have shown how this mirrored time when there was some progress before it became subject to child protection planning. There was some challenge by the CP Chair in this meeting to the fact that it took two health visitor visits before mother did take CHILD I1 to the doctor for a chesty cough as advised, but this pattern of professionals having to take responsibility for tasks happening is not drawn out. There was no mention, for example, in the meeting of the fact that the stated (and somewhat questionable) improvement in the home conditions was due to professionals taking a ‘hard line’ with mother in order to achieve the ending of the child protection plans. 3.10 Key Practice Episode 5: Child in Need Planning & Review - June to December 2015 3.10.1 The first CiN meeting was arranged for 11th June 2015. The CiN plan was developed and meetings were held every six weeks. 3.10.2 The case was re-allocated to newly qualified social worker on 24th June 2015. At the point of re-allocation of the social worker there was no formal handover of the case and it was allocated on the understanding that it was ‘low level CiN’ case and would close in 2/3 months. The CSC management records show a plan to de-escalate to universal services. 3.10.3 On 25th June 2015, the health visitor was informed that mother had repeatedly cancelled home visits with speech and language therapy (SALT) over recent period and had given medical reasons. It was agreed that the health visitor would discuss this with mother. By July 2015, the health visitor had last seen the home in May 2015. 3.10.4 A joint home visit by Health professionals took place on 8th July 2015. This detailed a number of concerns indicating a significant deterioration had taken/was taking place. These included: prolonged waiting for door to be answered; window not fixed as previous visit; strong chemical smell (felt to be an attempt to mask other smell of dirty laundry); food in the buggy; being ‘ushered’ into the back room so not seeing other part of the house; bed in the room; conditions had deteriorated, more toys and clutter, visible dirt and rodent droppings, rodent observed in the living room and a skip filled with father’s belongings. 7 The review has been advised that the use of Signs of Safety (SOS) approach (The Signs of Safety, developed by Andrew Turnell and Steve Edwards, 1994) in case conferences may be a beneficial approach to risk assessing. 8 A visit was completed with the PAM’S (Parent Assessment Manual - PAM) assessor, who did not appear to identify learning difficulties. CSC records are unclear about what kind of parenting assessment was carried out involving the PAM’S assessor, but it should be recognised that CSC did attempt to get a learning disability specialist involved. MSCB Child I1 SCR Page 26 of 35 3.10.5 At the next CiN meeting on 16th July 2015, it was recorded that all professionals expressed that parents ‘need to keep on top of housing conditions and liaise with landlord regarding the ‘damp’. It is not evident that there was any discussion about the fact that significant Health appointments were being missed and was difficulty in contacting the family. Indeed, it was recorded that mother ‘continues to attend meetings and is working with professionals (and that mother) has ensured that the children's health needs are being met by attending appointments and allowing professionals access’. 3.10.6 The pattern of missed appointments/difficulty in seeing the family continues over the following period with a number of cancellations of home visits by mother. Mother was using emails to communicate with Health professionals. 3.10.7 A CiN meeting took place on 1st October 2015. There was discussion about the fact that there had been three failed health visitor home visits and the non-attendance for CHILD I1’s nine months’ developmental assessment (which was subsequently attended on 15th October 2015). It was identified that the health visitor had not seen the home since May 2015. 3.10.8 There was an unannounced social worker visit on 5th November 2015. The three children were seen in timescales and described as well. The family had a skip and were de-cluttering the house and redecorating. 3.10.9 On 9th November 2015 a SALT report confirming SIBLING 3’s progress since starting school over twelve months, interactions had improved. On 12th November 2015, a further health visitor appointment was cancelled via email from mother due to family sickness. 3.10.10 On 10th December 2015 in supervision the CSC team manager considered whether CHILD I1’s case should remain open as there had been no concerns about their care and no additional needs were identified, and it was that closure of CHILD I1’s case would be considered subject to information from Health and other professionals about needs and developmental progress. However, in the CiN meeting the following day (11th December 2015), it is identified that CHILD I1 had missed immunisations again and it is not clear whether they had been weighed recently. Professionals queried what support could be put in place if the case was closed to social workers. Mother referred to having had a seizure and was going to a GP appointment. 3.10.11 On 15th December 2015 a planned home visit was cancelled as the health visitor was off sick. Mother was advised that she could contact the duty health visitor if she required any support in their absence. On 16th December 2015 the GP advised mother to go to A&E regarding blood results. Mother wanted to consider this as she was worried about the children. On 18th December 2015 there was a telephone consultation between GP and mother to discuss blood results, which showed increased concerns about mother’s health due to increased infection markers. However, mother was not keen to go to A&E, despite medical advice, due to childcare issues. A further GP consultation the next day advised mother that she needs A&E attendance as she could have serious illness, and it was said that she understands that she may be putting her life at risk if a significant infection. 3.10.12 On 24th December 2015 there was an unannounced social worker home visit. It was felt that the children were evidently suffering from neglectful parenting. There was a vermin MSCB Child I1 SCR Page 27 of 35 infestation with mice clearly running around the floor and excrement on the floor. There was no running water, no flushing toilet and rubbish overflowing from the bins. There was limited, if any, walking space on the floor, and rubbish, including dirty nappies cluttering the house. There was no edible food in the house. The three children appeared to be in distress and were rocking and upset. CSC removed the children with agreement of mother under Section 20 of the Children Act 1989. 3.10.13 The incident on 24th December 2015 was attended by police response officers. The incident was coded incorrectly, which meant that the appropriate updates were not made on the log and the attending officers provided no risk assessment of the matter. As a result, the incident was not escalated to the Public Protection Investigation Unit (PPIU) by the attending officers and therefore crimes were not submitted, Police Powers of Protection (PPP)9 was not utilised and medical examinations of the children do not appear to have been requested10. However, the children were safeguarded and removed from parental care. 3.11 Summary appraisal of practice within Key Practice Episode 5 3.11.1 There had been some recognition in previous meetings that the important time for seeing whether the adults could meet the needs of these children adequately might be when the framework of the child protection plan was withdrawn and there was not so much support, scrutiny or pressure from the professionals. In addition to any message that the decision to end the child protection plans may have given the family, it does appear from comments from the professionals involved and analysis of agency records, that that decision also had a significant impact on how the professionals viewed the case and their role. 3.11.2 It is clear that there had been emphasis by some professionals on trying to achieve ‘de-registration’ (the ending of the child protection plans). Once this had happened, it seems that the focus was on providing a level of support to the family – notably to mother – and not so much on the daily lived experience of the children, and whether this was good enough. 3.11.3 This was always a complex situation. There were three young children who had multiple needs and were not able to communicate verbally, and the CSC team manager had rightly identified at an earlier stage that they would require parenting that was above the expectation for most parents. Whilst there had not been clear assessment of the histories and parenting capacities of the adults, it was very apparent that the parents themselves had their own complex needs – mental health needs, possible hoarding behaviours, possible learning disability, some physical health concerns, poor histories, etc. There were difficult dynamics between the adults, a mother who was articulate but with a clear history of avoidance and not working openly with professionals, and above all a history of not being able to make and sustain the necessary change and to prioritise the needs of the children. Whilst it is not well 9 Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. 10 GMP have already identified learning in relation to the inactions of the initial responding officers on 24th December 2015 and this has been addressed via the PPIU Detective Sergeant and their line manager in relation to the submission of crimes once offences had been disclosed. MSCB Child I1 SCR Page 28 of 35 documented, there had been numerous discussions about whether the children should be with the family, and consideration of legal action. 3.11.4 Despite this context, it is clear that the case was at this point seen as a straight-forward, and ‘low-level’ case. It was therefore felt appropriate to allocate to a newly qualified social worker. The new social worker inherited the case from an experienced colleague and was then managed initially by the same CSC team manager who previously was responsible for the case, who had the view that the case was heading towards the CSC withdrawal. The social worker received very little in the way of management supervision at this time – the review has been advised that there were no formal supervision sessions for nine months. The social worker was not experienced in working with children with disability, and it has been highlighted to the review that they therefore lacked confidence to challenge an articulate mother who was used to confidently asserting her views, and came across as knowing her children and what they needed. It is also would seem that the social worker was unlikely to find it easy to challenge the prevailing view of the case within CSC. 3.11.5 This optimistic view of the case appears to have been shared by the other agencies involved. Certainly, there is no indication of any significant challenge, or anyone highlighting that there was reason to be very concerned about a possible deterioration in the circumstances for the children. There was a clear pattern emerging – about mother avoiding professionals, missed appointments, deterioration in the conditions within the house – all of which ought to have triggered concern about whether the needs of the children were being prioritised. 3.11.6 The fact that all of these problems were clearly present within a very short while (i.e. with the first two months) after the ending of the child protection plans, should have alerted those involved to the need for a robust response, and a clear plan to tackle the issues such as the home conditions and meeting specific appointments to meet the health needs of the children. There is no evidence of any consideration about the case being re-escalated at any point within this key practice episode. Instead there was an acceptance that various appointments were being cancelled or missed – there appears to have been little communication between the professionals about this, as well as no real challenge of the family. 3.11.7 With regards to the lack of response to the deterioration in home conditions within this period, it has been commented that the professionals felt that the daily demands on mother – such as taking the two children to nursery, to appointments etc. – meant that there was some ignoring of how bad home conditions were. 3.11.8 It appears that there was no lack of communication with family, but much of this was by email. It is (now) recognised that mother may have been deliberately using emails to keep dialogue going with professionals, to be in control of what was said (it is stated that emails would be about her issues rather than the needs of the children) and at the same time this was communicating without allowing access to the home. 3.11.9 It is notable that most of the interaction that took place in this time was with mother. There is little reference to the role of mother’s partner and their role. In the discussions with the GP mother gave indications that she did not feel that she could leave the children in the care of her partner. This was significant information that should have been explored further MSCB Child I1 SCR Page 29 of 35 and been made known to the other professionals working with mother. It appears the GP did not inform other professionals of the risks to mother’s health in the late stages of this period, or of the reasons why mother would not get medical help (going to A&E) as she was being advised. Other professionals were concerned about mother’s health – particularly following her disclosing she had had a seizure – but this did not trigger any liaison with GP. MSCB Child I1 SCR Page 30 of 35 Section 4: Conclusion 4.1.1 It will be apparent from the foregoing analysis that the case under consideration was a very complex one and posed significant challenges for the professionals involved over the timeframe of this review. The process of trying to understand what influenced decisions and practice – and the systems in which these operated at the time has also presented some real challenges. Whilst there are undoubtedly some significant questions about professional actions and influences which have not been fully understood, there are some clear themes that emerge from the scrutiny of agency actions within the five key practice episodes identified as the focus for this review. These include poor communication between agencies, poor recording, loss of focus on the voice of the child and the daily lived experience, focus on task-completion rather than on on-going assessment of impact of the work being done, lack of recognition of the importance of chronologies to show the context of previous history, lack of challenge, and lack of healthy scepticism amongst the professionals working on the case. 4.1.2 There has been much scrutiny of interagency working in situations where children are subject to neglectful parenting – indeed, neglect has been a factor in sixty per cent of recent serious case reviews11. The work in such situations is rarely a simple or straight forward process. Adults who neglect children often have their own complex needs, and have entrenched patterns of behaviour and are very resistant to change12. Undoubtedly, working with this family at the centre of this review was always going to present real challenges to the many professionals involved. 4.1.3 A fixed and overly optimistic view of the case - that the children’s needs could be and were being met by the parents - quickly came to define how the case was seen and responded to by key professionals in the core group. This view did not change in response to new information. It has been identified that the social worker was influential in the development of this over-optimistic view, but it is also clear that other professionals also shared this view and contributed to the over emphasis on the perspective of the parents, rather than on the daily lived experience of the children. This view, which was never effectively challenged within the core group, can be seen to drive decision making and influence how the case was handed to the new social worker. The focus of much of the work was on completion of tasks within the child protection plan, rather than on assessment of the outcomes, or of the impact of completing these tasks. 4.1.4 The multi-agency core group did not function effectively. There were real deficits in information sharing – both within and between meetings – which included significant information not being shared. Comments from practitioners have highlighted that significant professionals were not always invited to core groups – and it seems, were not sufficiently proactive in ensuring their input to these meetings. There were significant deficiencies in the way multi-agency meetings were recorded – being very brief, not reflecting discussion, 11 Brandon, M. et al. (2013) Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC. 12 Working Effectively with Neglected Children and Their Families – What Needs To Change? Farmer & Lutman (2014). MSCB Child I1 SCR Page 31 of 35 disagreement or challenge that did take place, not highlighting the risks or impacts on children, and not being circulated in a timely or useful way. 4.1.5 The CP Chair service has a crucial role in overseeing and quality assuring the multi-agency working. There were examples of good identification of risks and issues by CP Chairs in particular meetings and of some good challenge of the prevailing view of the core group. However, the overall challenge provided by the CP Chairs - particularly to the loss of emphasis on intervention being informed by careful and on-going assessment of the experience of the children within an appropriate overall context - was not sufficiently robust or consistent. The fact that there was no consistency of CP Chair throughout the period was undoubtedly a contributory factor to this. 4.1.6 The parents’ needs were, at times, more evident and a greater focus of professional attention, than those of the children. Within conferences there had been recognition of the need to undertake some assessments of parental mental and physical health problems, assessment of the role and background of mother’s partner and, most significantly, of parenting capacity. Perhaps the most significant deficit in the interagency interventions in this case over the timeline of this review is the failure to carry out evidenced based assessment, which could inform the interventions, and might have identified whether there was capacity for change. 4.1.7 The different ways in which the parents acted to deflect professional attention from what was happening for the children have been highlighted. It is understandable that individual professionals did not always feel confident in their responses to some of these issues. More than one comment was made to the review, for example, about professionals not feeling comfortable in discussing with parents some of the issues they presented with around gender roles/transgender issues, and sexuality. However, more effectively functioning multi-agency working would have helped identify how far these issues might be impacting on the children, or indeed, on the agencies’ attempts to work with the family. There is little evidence that the professionals were able to challenge each other effectively and to consider all new information with a greater degree of healthy scepticism. This meant that despite some reference to disguised compliance by the parents, there was never any appreciation of the significance of each missed visit or health appointment. 4.1.8 The review notes that during the period of under review the latest Ofsted inspection identified significant concerns about how children were being safeguarded at the time. There is an improvement plan in place, which addresses issues highlighted by Ofsted13. 4.1.9 The analysis of these key practice episodes has led the review team to produce three significant recommendations in the form of Findings that it is felt the Manchester Safeguarding Children Board should address. 13 The Ofsted overall judgement is that children’s services and the Local Safeguarding Children Board are both inadequate - Manchester City Council Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board Inspection date: 25 June 2014 – 16 July 2014 Report published: 01 September 2014. MSCB Child I1 SCR Page 32 of 35 Section 5: Findings 5.1 Finding 1: Voice of the Child 5.1.1 In examining reports and records, and the comments from professionals, there is a marked absence of reference to the perspective and the daily lived experience of the children. The children through age and complex needs had difficulty with communicating. This creates an imperative to look closely and with healthy scepticism - and with clearly evidenced observations - at what the daily lived experience of the child might be in order to better understand their views and ensure their voice is heard. 5.1.2 One illustration of this failure to highlight the daily lived experience of the children is the absence of any recognition of the specific needs (such as routines, response to change and environmental impacts) of a child with autism within the plan that was in place. Indeed, there was little attempt to illustrate within the planning – through SMART plans – what improvements were being sought in terms of the daily lived experience of the children throughout the interventions. 5.1.3 Whilst services were provided to the family, without the necessary focus on the child’s experience and specific improvements in outcomes, it is hard to quantify whether the daily lived experience of the children was ever good enough. 5.1.4 In instances of work with children with disabilities and complex needs the process of understanding their daily lived experience is necessarily more complex. The involvement of practitioners specialising in work with children with such needs would be beneficial in helping to assess their needs and perspective. 5.1.5 In contrast to these concerns about the voice of the child not being sufficiently heard, it is apparent that there was significant professional focus on the perspective of the adults, particularly mother. These concerns – too much focus on working with parents and insufficient emphasis on the voice of the child – reflect the key findings from an evaluation of other serious case reviews14. 5.2 Issues for MSCB to consider in regard to learning and improvement 1. The MSCB needs to ensure that consideration of the voice of the child and the daily lived experience of the child is the primary focus of all agency interventions. 2. Is the MSCB satisfied that there are arrangements in place for the involvement of practitioners with particular experience and expertise in working with children with disabilities and complex needs to ensure that their views, needs and daily lived experience are fully understood? 3. Is planning sufficiently SMART, and do the plans focus on the required improvements in terms of quantifiable outcomes for the children? 14 The voice of the child: learning lessons from serious case reviews, Ofsted, 2011. MSCB Child I1 SCR Page 33 of 35 5.3 Finding 2: Assessments in cases of neglect 5.3.1 In cases of neglect interventions need to be informed by thorough multi-agency assessment based on clear understanding of history, for which a combined multi-agency chronology is an essential tool. Assessments must always focus on children’s needs and required outcomes to ensure that progress of plans can be regularly and realistically reviewed. 5.3.2 In this case the need for various assessments was recognised, but no adequate multi-agency assessment ever took place. In the absence of assessment there was significant drift, a failure to recognise the importance of previous history, and interventions became overly focussed on the parental perspective. Planning and reviewing relied on the completion of tasks rather than on on-going assessments of impact on the children. 5.4 Issues for MSCB to consider in regard to learning and improvement 1. Is the MSCB satisfied that professionals undertaking assessments are supported by appropriate and robust frameworks and tools?15 2. Are assessments in cases of neglect being informed by the completion of comprehensive multi-agency chronologies? 3. Is the MSCB satisfied that there is sufficient management oversight and quality assurance in place for these assessments? 5.5 Finding 3: Multi-agency working 5.5.1 In cases of concern about long term neglect it is important that the agencies work closely together to ensure there is good sharing of information and consideration about the progress of interventions. This is particularly important in cases – such as this - which involve difficulties in engaging with families, and especially where there is reason to be concerned about disguised compliance16 17. 5.5.2 There were significant difficulties and deficits in the multi-agency working in this case. At times there was poor sharing of significant information between professionals. Meetings were not always appropriately attended. There were times when there needed to be multi-agency meetings (including strategy meetings in relation to significant concerns), to reflect on information and plan work, but instead there was brief, (process-driven) discussion between just two key agencies. 15 For example: - CANDO Health Neglect Tool and the Graded Care Profile a tool for assessing neglect. 16 Disguised compliance involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention - Disguised Compliance NSPCC Factsheet, 2010. 17 Disguised compliance by parents was a common feature in cases reviewed by Ofsted in their national report on professional responses to neglect. The report noted that there was significant variation to the extent to which clear strategies were adopted to manage such behaviour - In the child’s time: professional responses to neglect. Ofsted, March 2014. MSCB Child I1 SCR Page 34 of 35 5.5.3 One key issue identified was the repeated failure of the multi-agency group to provide appropriate challenge. Some of the child protection conferences did include some challenge to the prevailing view of the case by the professionals, and questioning of whether alternative plan was appropriate. However, there is no evidence that other multi-agency meetings routinely included the group questioning whether the view about the concerns and risks posed, or the progress of the interventions was sufficient or appropriate. Whilst there are comments that within meetings there was some discussion and challenge (which apparently included repeated reference to whether the children’s needs could be met by the parents), these concerns or challenges were not appropriately robust or persistent and are not reflected in the records of core group meetings. 5.5.4 Records of core group meetings were of poor quality, showing little detail of discussions and often do not make clear where the information and plan has been updated from the previous meeting. Records of meetings were not routinely circulated in a timely and useful manner. 5.5.5 One issue that illustrates many of these concerns about the multi-agency working is that of the agencies’ discussions and understanding around legal planning. At various points, including in child protection conferences, the need for the work to be informed by legal advice was indicated. It has been stated to the review that on a number of occasions various professionals expressed their view that the children should not be in the care of the parents, but they report being told by CSC that the threshold (for legal action) was not met. However, what was required was for agencies to work together sharing their areas of expertise to highlight evidence of the capacity of the carers, of the welfare and development needs of each child and their daily lived experience. This could have led to more appropriate risk assessment and management, or else to appropriate escalation if the response to this assessment was not felt to be adequate. Similarly, there was little consideration (by any professional) about the need for police investigation and what this would have required – particularly for a home visit involving the police to look at evidence for a possible prosecution. 5.5.6 Professionals were unclear about their roles and responsibilities as part of the multi-agency group. There appears to have been some power imbalance in terms of how different professionals felt able to contribute to the meetings and share their views and concerns. Individual practitioners have said that they felt uncomfortable about discussion in relation to transgender and sexuality issues, and the response seems to have been to avoid raising the concerns that they (legitimately) had about how these might be impacting on or obscuring the needs of the children. 5.5.7 There was no attempt at escalation and professionals have reported being unclear about escalation processes. There was a lack of management oversight and support to ensure there was appropriate reflection about the handling of the case. Management oversight within individual agencies should have highlighted how the MSCB Multi-Agency Escalation Policy18 could be implemented, but this did not happen. 5.5.8 Whilst the review has noted some positive practice from the many CP Chairs who chaired the meetings, the overall input from the CP Chair service did not provide the required 18 MSCB Multi-agency Escalation Policy issued by the MSCB in June 2015 as supplementary guidance to the Greater Manchester Safeguarding Partnership (GMSP) Escalation Policy. MSCB Child I1 SCR Page 35 of 35 level of consistent and robust challenge to the planning and loss of focus on the important aspects of the children’s experience. 5.6 Issues for MSCB to consider in regard to learning and improvement 1. The MSCB needs to satisfy itself that professionals across all agencies are confident and empowered in their contributions, roles and responsibilities within multi-agency working. This includes their responsibilities in respect of challenging considerations, decisions and planning made by the multi-agency team. 2. Is the MSCB satisfied that professionals across all agencies are aware of the multi-agency escalation policies and procedures and in what circumstances these should be implemented? 3. In cases of neglect where there is a request for a strategy meeting, should the MSCB review its procedures to ensure that a full multi-agency, face-to face meeting MUST take place? Should a request for a strategy meeting in such cases of neglect always involve the police in a home visit to ascertain if the threshold for criminality has been reached? 4. Should the MSCB consider a review of the multi-agency paperwork/tools and the way they are used, and circulated? 5. The CP Chair service has a key role in overseeing the effectiveness of multi-agency working. Is the MSCB satisfied that workload and management support to CP Chairs enables them to effectively fulfil their statutory duties to monitor and quality assure this work – including monitoring progress of cases between meetings and appropriate escalation as required? 6. Is the MSCB providing adequate training and support to member agencies specifically around transgender and sexuality issues (and how they may or may not impact upon the parenting) to ensure that professionals feel confident in raising any concerns they might have when working in cases where such issues add to the complexity of planning? 7. Does the MSCB agree that there is a need for a programme of training and support to ensure that professionals across member agencies have an adequate understanding of their roles and responsibilities in relation to risk management and legal planning? Specifically, such training and support could focus on professional roles and responsibilities in relation to ensuring that assessments are informed by clear evidence, and in relation to agency escalation processes in situations where there is drift or delay in the response to such evidenced assessments. |
NC51182 | Death of an 8-week-old baby in 2017. KS was placed in bed next to Mother where they both fell asleep. Mother's partner awoke to find KS still in bed lying on their back and not breathing. Ambulance services were called and attempts to resuscitate KS were made, but KS was declared deceased at hospital. Parents were arrested and a police investigation was conducted and concluded with no further action. Mother had seven children including KS and twin, with some the subject of child protection plans, care proceedings and child in need plans. History of domestic abuse between Mother and children's fathers. Mother had failed to attend and bring KS to many health appointments and had a history of substance misuse. Methodology based on the 'Welsh Model'. Key findings include: KS died from an unascertained cause and there was no known action that professionals in Sandwell could have taken to prevent this death; if agencies had better shared information and complied with both national and local procedures, the level of support to Mother and her family could have been more effective but would not have affected the final tragic outcome for KS. Ethnicity or nationality not stated. Recommendations include: undertake a review of safeguarding training to ensure that pre-birth procedures are understood and implemented appropriately; seek assurance that health professionals engaged in antenatal and post-natal work are trained in the appropriate use and application of escalation procedures, issues of disguised compliance and over optimistic assessments.
| Title: Serious case review: Child KS. LSCB: Sandwell Safeguarding Children Board Author: Steve Ashley and Mick Brims Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Sandwell Safeguarding Children Board Serious Case Review Child KS Author: Steve Ashley Lead Reviewer: Mick Brims 2 CONTENTS SECTION ONE – INTRODUCTION 4 1.1 What this review is about 4 1.2 How this review was conducted 5 1.2.1 The Review Panel 5 1.2.2 The Terms of Reference 5 1.3 Methodology 6 1.3.1 Chronologies and Management Reports 6 1.3.2 Practitioner’s Event 6 1.3.3 Family Engagement 7 1.3.4 Parallel investigations 7 1.4 How this report has been structured 7 SECTION TWO – THE STORY OF KS 8 2.1 Introduction 8 2.2 The background 8 2.3 The facts of this case 9 2.3.1 Phase one – Pre-birth engagement 9 2.3.2 Phase two – April 2017 to June 2017 12 SECTION THREE – ANALYSIS OF SIGNIFICANT ISSUES 13 3.1 Significant Issue One 13 3.2 Significant Issue Two 17 3.3 Significant Issue Three 19 3.4 Significant Issue Four 24 3.5 Significant Issue Five 27 SECTION FOUR – KEY THEMES 28 4.1 The use of child protection assessments and pre-birth procedures 28 4.2 Dealing with non-attendance at appointments 29 4.3 Multi-agency working and information sharing 29 4.4 Disguised compliance 29 SECTION FIVE – KEY LINES OF ENQUIRY 32 5.1. Was support offered to the family appropriate, timely and adequate? 32 3 5.2 Was sufficient scrutiny of drug use by parents provided? 32 5.3 Was there sufficient challenge by practitioners if the parents did not comply with advice and instructions? 33 5.4 Was there appropriate safeguarding supervision of front-line practitioners? 33 5.5 Was appropriate advice provided and followed regarding safer sleeping practices? 33 SECTION SIX – KEY FINDINGS 33 SECTION SEVEN – RECOMMENDATIONS 34 6.1 Recommendation one 34 6.2 Recommendation two 34 6.3 Recommendation three 34 6.4 Recommendation four 34 6.5 Recommendation five 34 6.6 Recommendation six 34 6.7 Recommendation seven 35 SECTION EIGHT – CONCLUSION 35 APPENDICES 35 Appendix One – Terms of reference 35 Appendix Two – Pre-birth procedures 37 Referral 37 Pre-birth assessment 38 Pre-birth Strategy Meeting/Discussion and Section 47 enquires 38 Pre-birth Child Protection Conferences 39 4 Section One – Introduction 1.1 What this review is about This serious case review concerns a child known, for the purpose of this review, as KS. The brief circumstances of this case are as follows: Baby KS was born in April 2017, the second of twins. 8 weeks after the twins were born, both babies were fed and put down to sleep together in a Moses basket in their mother’s bedroom. KS’s mother (F1) went to bed 4 hours later. S1 (KS’s twin) woke at 4am and was taken downstairs for a feed then put back in the Moses basket. F1 then fed KS at 6.30am in bed. At this time KS was reported to be fine and smiling. S1 woke again and was taken downstairs by F1’s partner, M1. After the feed, F1 placed KS in bed next to her (on their side) with their head on a pillow and they both fell asleep. There was a light blanket over them and a king-sized quilt folded under the sheet on top of the mattress. F1 was woken by a telephone call at 1.15pm and found KS still in bed lying on their back, blue and not breathing. Following attempts by M1 to resuscitate KS, they were transferred to Sandwell Hospital Emergency Department by ambulance and sadly declared deceased. A post mortem later stated KS’s exact cause of death was “inconclusive”. M1 and F1 later provided positive drug tests to the police. F1 and M1 were arrested. A police investigation has concluded with no further action. Sandwell Safeguarding Children Board (SSCB) agreed this case met the criteria laid down in Working Together to Safeguard Children 2015 for a serious case review to be conducted. The Independent Chair of SSCB agreed with a recommendation of the Serious Case Review Panel that this case should be the subject of a serious case review; under the requirements of the Local Safeguarding Boards Regulations 2006, section 5(1) (e) and (2). The statutory basis for conducting a serious case review (SCR) and the role and function of a Local Safeguarding Children Board is set out in law by: The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90. Regulation 5 requires the Local Safeguarding Children Board (LSCB) to undertake a review where – (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Guidance for Local Safeguarding Children Boards (LSCBs) conducting a serious case review (SCR) is contained in Chapter 4 of Working Together to Safeguard Children 2015. This version of Working Together was used when deciding upon the serious case review process, as it was the most current at the time decisions were taken around the review process (it was published in March 2015). The purpose of this serious case review is to establish the role of services and their effectiveness in the care of KS, whether information was fully shared by the professionals 5 involved and child protection procedures were appropriately followed. This process ensures that any deficiencies in services can be identified and lessons learned, to minimise the risk to other children or young people. 1.2 How this review was conducted 1.2.1 The Review Panel The author of this report was Stephen Ashley who has extensive experience in the compilation of high-level reports into child protection issues, having been a senior police officer for thirty years and worked for Her Majesty’s Inspectorate of Constabulary. He has conducted several serious case reviews and is the independent chair of two safeguarding children boards. The lead reviewer was Mick Brims who is a qualified social worker and has extensive experience in children’s social care across a number of areas. The author and lead reviewer are independent of Sandwell Safeguarding Children Board in accordance with Working Together to Safeguard Children 2015 chapter 4 (10). In addition, a review panel was established. Meetings were held at regular intervals and the panel was consulted about the progress of the review and provided further information where appropriate. The panel included a senior manager from each of the key agencies. The Sandwell Safeguarding Children Board (SSCB) business unit supported the panel. 1.2.2 The Terms of Reference This SCR has been conducted using a methodology adapted to suit the circumstances of this review and is described in more detail in the next section. The methodology established how well systems have worked, and where they can be improved. It is not a criminal or disciplinary review designed to attach blame to individuals. The methodology is based on the ‘Welsh Model’1 This review looks at the period from August 2015 until the point of KS’s death. This period was selected following a Serious Case Review Panel meeting and is of a sufficient range to include all of the key episodes of engagement that KS had with agencies in Sandwell. Whilst this period was the basis for the review, contextual and relevant information falling outside of this period was also included. The review was conducted in a way which: • Recognised the complex circumstances in which professionals work together to safeguard children; • sought to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did; • sought to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • was transparent in the way data is collected and analysed; • made use of relevant research and case evidence to inform the findings. 1The ‘Welsh Model’ - This process consists of several inter-relate parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an extended review which involves an additional level of scrutiny of the work of the statutory agencies. 6 Agencies that are involved in child safeguarding are required to follow the statutory guidance laid down by government. The guidance is called Working Together to Safeguard Children. It contains all the processes that agencies are required to follow. Working Together has been through several iterations. This review benchmarks against the statutory guidance contained in Working Together to Safeguard Children 20152. This is the version that professionals would be working to during the timeframe of this case. The review worked to terms of reference agreed with the Chair of the SSCB and contained at Appendix A. The terms of reference proposed 5 ‘lines of enquiry’ that are dealt with in Section Five. The author took full cognisance of the third annual report of the national panel of independent experts on serious case reviews that was published in November 2016. 1.3 Methodology The methodology agreed by the Sandwell Safeguarding Children Board (SSCB) review panel is based on a model consistent with the requirements of Working Together to Safeguard Children 2015. It ensures that: • A proportionate approach is taken to the SCR; • it is independently led; • professionals who were directly involved with the case are fully engaged with the review process; • families are invited to contribute. This methodology is based on the Welsh model. 1.3.1 Chronologies and Management Reports Agencies were asked to compile a report detailing their contacts with the individual involved in this case, resulting in a combined chronology of events. In addition, each agency was asked to highlight areas of concern and good practice. Where appropriate, an action plan, detailing those areas for improvement, and the work being undertaken to address those issues, was included. All the agencies that were asked for a report provided the information requested. In cases where further clarification was required, agencies responded in an open and honest way. In some cases, where contact with the subjects was minimal, agencies were only asked to provide a chronology. In addition, interviews with front-line staff and managers took place. 1.3.2 Practitioners’ Event The practitioners’ event with front-line practitioners is an essential part of the process. In the practitioners’ event front-line staff that had had contact with KS and family were brought together for discussions around themes that had been identified from the chronologies and reports. This engagement provided a view of their engagement with KS that enriched the information provided by agencies and ensured that all the relevant facts were recorded. It 2 Working Together to Safeguard Children March 2015 - https://www.gov.uk/government/.../working-together-to-safeguard-children--2 7 was the most effective way of triangulating the evidence and ensuring that an accurate picture of KS and the traumatic events is provided. This review seeks to determine why events occurred and not just record the facts of what happened. The front-line view is invaluable in achieving this. Whilst the details of discussions that took place were recorded, the comments made by the staff involved were non-attributable and their comments are not quoted directly in this report. 1.3.3 Family Engagement A criminal investigation was taking place at the time of this review and as a result there was no direct engagement with the family. Findings of this review are shared with family members prior to publication and they are given an opportunity to comment. 1.3.4 Parallel investigations Throughout the period covering the review there was a police investigation taking place. This investigation has now concluded with no further action. 1.4 How this report has been structured Following the introduction, Section Two provides the story of what happened to KS. There is a description of KS and family and then the detail of what happened to KS over the timeframe agreed within the terms of reference. Section Three analyses the significant issues exposed in Section Two and explains WHAT happened and WHY. From this analysis, the key themes are discussed in Section Four. Section Five contains the key lines of enquiry raised by the Serious Case Review Panel and Section Six, the key findings. The recommendations in Section Seven have been developed from these findings taking account of the work carried out by agencies since these events occurred. There is a conclusion at Section Eight. This report has been written so that it can be read by the public without redaction. As a result, the names of the main subjects are not used and there are no dates that might readily identify KS or the family. In this report, the following initials represent the main subjects: ❖ KS – the baby who is the subject of the review ❖ F1 – mother of KS ❖ M1 - partner of F1 ❖ M2 – biological father of KS and S1 ❖ S1 – sibling - KS’s twin ❖ S2 – half sibling ❖ S3 – half sibling ❖ S4 – half sibling ❖ S5 – half sibling ❖ S6 – half sibling 8 Section Two – The Story of KS 2.1 Introduction This section sets out the facts in this case. It begins with a description of KS’s family circumstances and the environment they were born in to. 2.2 The background This section will provide a background history of the family describing their personal circumstances. F1 had 7 children including KS and twin. F1 has been in a relationship with M1 for more than 20 years and he is the father of S2, S3, S4, S5 and S6. M2 is the father of KS and S1 and is a relative of M1. When the relationship with M2 finished in 2016, M1 resumed his relationship with F1. At the time of KS’s death, M1 lived with F1 for about half of the week and spent the rest of the week at his mother’s home. They later described their relationship as being: “friends with benefits”. F1 has a long history of drug abuse but stated she had been ‘clean’ for between 18 months and 2 years prior to the death of KS. F1, M1 and M2 have a significant history of criminal convictions, although F1 has not had a conviction since 2008. None of the family have any known health issues. Following the birth of each of her children, F1 was monitored by Sandwell Children’s Social Care (SCSC). S2, S3 and S4 have never lived solely with their mother. S2 lived with relatives and S3 was the subject of a child protection plan and care proceedings that resulted in a residency order to relatives. S4 has lived with a relative from birth. Information supplied by agencies present a picture of F1 that indicates the concerns over her care for children were justified. F1 had, by her own admission, been a long-term abuser of opiate drugs and also used cocaine and cannabis. F1 also had a record of failing to attend appointments. F1 missed 34 GP appointments in a 3-year period and there were periods of engagement punctuated by periods of no engagement with services. This was a family who were of concern to agencies and yet records demonstrate that little action took place when appointments were missed. In mid 2015, a child in need (CIN) plan3 relating to S5 & S6 commenced. Concerns were held that F1 may have been using drugs and neglecting S5 and S6, although a single assessment did not identify significant risk of harm at that time, instead recommending that a child in need plan be put in place to ensure the children’s needs. Concerns about non-attendance at appointments for the children continued throughout the period the CIN plan was in place, although when the CIN plan closed, it appeared that there had been improvement in this regard. Financial issues were also noted, however over time evidence grew of regular repayments regarding housing issues. F1 remained engaged with a family support worker throughout 2015 although, at the final CIN review in November 2015, there was mention of some appointments again being missed. The CIN plan was closed in November 2015 despite the fact that F1 continued to miss key health appointments for the children often appeared in crisis, with problems relating to debt management still evident. 3 Child In Need Plan - A Child in Need Plan (also known as a Child's Plan) should be drawn up for children who are not Looked After but are identified as Children in Need who requiring services to meet their needs. It should be completed following an Assessment where services are identified as necessary. 9 At an unknown point in 2016, F1 began a relationship with M2 who had been released from prison in late 2015. There were a number of reports to the police of domestic violence incidents involving the couple. It is understood that M1 may have been in prison at the time the relationship between F1 and M2 commenced and it is also believed M1 and M2 are related. In mid-2016, there had been a serious house fire at F1’s home and as a result she had been required to vacate the premises while it was restored. F1 resided with her mother for several months whilst work took place and she moved back to her home by the end of 2016 (some sources suggest F1 and family returned at the end of summer 2016, others suggest this occurred by Christmas 2016). In June 2016 F1 attended her GP complaining of asthma. The GP did not take this opportunity to challenge F1 about her previous history of failing to attend appointments. In July 2016 the school nurse had made attempts to contact F1 regarding S4 and S5 but, while messages were left, she received no response from F1. Throughout the summer period of 2016 both F1 and M2 had been to their GP reporting mental health issues. At some point in 2016 F1 ended her relationship with M2 and resumed the relationship with M1. This followed at least two reported domestic abuse incidents between F1 and M2. During the summer of 2016, it is clear that F1 was in crisis. There had been a number of reports of domestic abuse involving her and M2, she had had a termination and her home had been gutted by a fire. F1’s relationship had broken down with M2 and she had resumed a relationship with M1. F1 had reported having “suicidal thoughts”. 2.3 The facts of this case 2.3.1 Phase one – Pre-birth engagement In October 2016 F1 was pregnant with KS and S1. At the time she provided a positive pregnancy test she believed she was between 4 and 5 months pregnant. F1 was a ‘late booker’, however she stated to the Community Midwifery Service that she “did not know” she was pregnant. Further exploration of this at the practitioner’s event suggested that F1 had shared a range of reasons for late presentation, stating that she had: “had babies before”; and other factors such as “being busy”, “ill” or “having to do the school run”. F1 said these issues had prevented her coming in to book in her pregnancy with the Community Midwifery Service. F1 was seen by a midwife and disclosed some of her previous history. Whilst this history was not complete, it did include the fact that F1 had previously used methadone. The midwife was also aware of domestic abuse issues and submitted a ‘cause for concern’ form which was shared with midwifery services, the GP and the safeguarding midwife. The safeguarding midwife made a referral to SCSC to obtain more information. At the beginning of November 2016, M1 attended F1’s address and an altercation took place. The police attended but no offences were disclosed and M1 left. Domestic violence notifications were made to all relevant partners including SCSC and health care professionals. Black Country Women’s Aid (BCWA) were contacted to offer F1 support, however were unable to contact F1. BCWA have stated that F1 has never engaged with their service around domestic abuse. In mid-November 2016 F1 missed the first of her ante-natal midwifery appointments. Between this point and the end of March 2017 F1 missed at least 7 midwifery appointments. When F1 missed her first appointment a follow up letter was sent, and the midwife chased up the appointment and booked another appointment for F1. 10 At the end of November 2016 SCSC provided the midwife with further information about the domestic violence incident that had occurred. They stated that Women’s Aid were to be informed but, since none of the children had witnessed the incident, there would be no further action by SCSC. The email received by the midwife from SCSC also stated that they were aware of “historical” issues, but there were no current concerns. The midwife was advised to complete a Multi-agency Referral Form (MARF) if she had any further concerns. In mid-December 2016, SCSC reported to the midwife that M2 had informed his probation officer that F1 was back on drugs and a referral took place. SCSC stated to the midwife that they had conducted an “assessment” and F1 had informed them she was not using drugs. They also stated that they had spoken to the school attended by F1’s other children and no concerns were raised. As a result, they were taking no further action and considered this to be a malicious referral. It is unclear whether the assessment referred to by SCSC was a formal process such as a MASH assessment or single assessment (no evidence of this has been located) and it is not clear whether this engagement with education professionals and the midwife constituted a formal child protection meeting in terms of a strategy meeting or Section 47 investigation. At this point, professionals had sufficient information about F1 and her history to raise their concerns. F1 had a history of domestic abuse and drug use and had previously been unable to look after her children. During her pregnancy to this point, F1 had missed several ante-natal appointments and an ex-partner had reported she was using drugs within 6 months of the pregnancy being reported. There had been 3 recent (non-crime) domestic call outs between September and November 2017, some related to M1 being out of prison and presenting as upset that F1 was in a relationship with M2. Events during the early part of her pregnancy raised concerns with the allocated midwife. By the end of December 2016, taking into account both family history and recent events, there were sufficient grounds for SCSC to initiate a pre-birth assessment. Sandwell would be expected to follow pre-birth procedures as outlined in the West Midlands Safeguarding Procedures4. In mid-January 2017, F1 missed 2 further midwifery appointments. As a result, the midwife instigated a ‘call and report’ protocol and went in person to F1’s home. The midwife made this visit in late January 2017. It took 2 further visits before she was able to see F1 at home. At the practitioners’ event, the midwife reported that F1 did not give her any real cause for concern and F1 was open with the midwife in explaining that with her previous pregnancies she had been using opiates and she wanted: “to do things properly this time”. The midwife made an appointment for F1 to attend for a scan a week later. F1 failed to attend her next 2 appointments and, as a result, a second ‘call and report’ visit took place at the end of February. In mid-March 2017 the midwife again attended F1’s home and discussed safe sleeping with her. It was noted that F1 was a smoker but did not want to stop. The GP reviewed F1’s case on 15 March when F1 failed to attend an ante-natal appointment. It was noted that the midwife made checks with other health partners and established that F1 had missed numerous appointments including those for scans. An appointment was made for F1 to attend for an urgent scan and it was agreed there should be a MARF submitted and a further ‘call and report’ visit. Several attempts to visit F1 were made over the next 3 days without success and F1 failed to attend for her scan. On 21 March 2017 the midwife submitted a MARF. On 27 March 2017 the referral from midwifery was assessed by the Multi-agency Safeguarding Hub (MASH)5. This was 6 days after the form had been submitted which is, in itself, a concern. The MASH noted that Health services had engaged with F1 in February and 4 West Midlands Safeguarding Procedures - http://westmidlands.procedures.org.uk/ykpqq/statutory-child-protection-procedures/assessment 5 Multi-agency Safeguarding Hub (MASH) – a multi-agency team responsible for assessing referrals regarding child protection and deciding appropriate action 11 March 2017. They concluded that she may have missed appointments because of a house fire (this had occurred in mid- 2016 and F1 and her family are understood to have returned to the house by December 2016 at the latest). The MASH took the decision that health services would provide support to F1 on a universal services basis going forward. Health services could consider completing an early help assessment (EHA) if future concerns arose. This was an inappropriate response given the history of F1 and her children and the evidence of concern provided by midwifery in the MARF. As noted elsewhere, the MASH Assessment of 27 March 2017 cites feedback from the health visitor that she had seen the family recently and had no concerns about the home environment or preparation for the arrival of the twins. It is noted in the MASH Assessment that: “Mother reports she moved out of the home for a short while to reside with her mother due to a fire. This may be why she has missed appointments however mother does have a history of not attending appointments”. The source of this information in the MASH Assessment is not explicitly clear, however this appears to be from the health visitor. The conversation between the MASH and the health visitor is significant as it appears to have influenced MASH decision-making. There may have been some misunderstanding in the MASH as to the health visitor’s feedback regarding this family. When the health visitor spoke to the midwife the next day she stated that she had spoken to the MASH team the previous day. She informed them that she had seen F1 at home and not identified any concerns and, further, that the home environment was good and F1 was reported to be attending the twin clinic. The health visitor noted that she did not appreciate, when she spoke to the MASH on 27 March, the level of missed ante-natal appointments and that this was an ongoing concern. However, this suggests that the MASH assessment gave greater weight to the health visitor’s positive comments (made before she was aware of the ante-natal non-engagement concerns) over the midwife’s written MARF outlining several months of ante-natal non-attendance. The health visitor also noted to the midwife that she had previously seen F1 at her own mother’s address, prior to the house fire (in 2016). The health visitor passed on F1’s mother’s address. The reviewers understand this to mean that the health visitor gave the midwife this address as another possible place to try and find F1, not that the house fire was relevant to current concerns in any way. On 30 March 2017, the community midwife visited F1, who stated that she had been unwell and that was why she had missed appointments. The midwife reported that F1 presented well and had no problems. The midwife referred F1 to the hospital for a further scan. Throughout the remainder of March 2017, a further 4 appointments were missed or F1 did not respond to calls. In a Hospital interview on 3 April 2017, staff were concerned about F1’s lengthy recent history of non-attendance at hospital and midwifery appointments. As a result, a further MARF referral was made to SCSC by the hospital around these issues, however they did not speak to community midwifery before submitting the MARF form. Finally, a further MARF was sent by the hospital on 6 April 2017, noting concern that the case had been closed despite the history of concern regarding non-attendance at ante-natal appointments. As with contact made on 3 April 2017, SCSC informed the referrer that the MASH had considered these concerns, as they were similar to those sent in the first MARF on 21 March 2017, and that no further action would be taken at this time; with health services to follow up. The failure by the MASH to consider the MARFs in the light of all the available evidence provided and to predominantly rely heavily upon (and misinterpret) the feedback of one 12 professional resulted in poor decision making and an increase of risk for KS and S1. This issue is analysed in detail at Section 3.3. 2.3.2 Phase two – April 2017 to June 2017 In April 2017 F1 gave birth to twins KS and S1. F1 received a primary visit by the health visitor. The health visitor established that F1 was generally well but fed up with her ex-partner (M2) who she was no longer in a relationship with. The health visitor noted that M2 was: “bombarding her with text messages and calls”. F1 reported that M2 had had no contact with her during her pregnancy but had attended the hospital and abused F1 in front of patients and staff and threatened to assault her. F1 reported that M1 was going to support her and the children for at least 6 weeks, but he was presently at work. Health advice was given including the importance of getting rest. Smoking cessation advice and risks to babies were discussed as F1 and M1 both smoked and had no desire to give up. Safe sleeping was also discussed and F1 reported to be sleeping on the settee because her bedroom was being decorated. A Moses basket was seen downstairs which was in good condition, with clean linen. F1 was informed by the health visitor that as soon as the Moses basket went upstairs she would review the upstairs bedroom. The living room was reported to be tidy and at an appropriate temperature. The health visitor said she would conduct a review in one week. The health professionals involved in the review were satisfied that the discharge from hospital was appropriate and proportionate. The midwife at the hospital had also made a referral to SCSC following the birth of KS and S1. This was based on the fact that M2 had attended the ward and threatened F1 and was escorted out of the hospital by security personnel. Later in April 2017, the health visitor met a social worker by chance outside F1’s home prior to a visit being conducted. The social worker stated that a Single Agency Assessment had been carried out and there were currently no concerns. They were considering Early Help6. A further two visits took place and in late April 2017 community midwifery discharged the twin’s case to the health visiting service. In early May 2017, a health visitor conducted a follow up visit. F1 and all 4 children were present at the house. F1 stated she did not go to a wedding as she was too tired and her physical and emotional wellbeing were discussed. F1 disclosed that she had changed her mobile number and the text messages and calls from M2 had ceased, although M2 had confronted her in public whilst she was in a queue and was verbally abusive to her. This altercation occurred the previous week and there had been no further incidents since. KS was dressed in a white baby grow and cardigan, was alert and had good tone and colour. KS was taking 3.5 ounces of formula and feeding at least every 4 hours. S1 was reported to be a very long thin baby, dressed in white baby grow. S1 was alert and of good colour and tone. S1 was taking 3.5 ounces of formula every 3 hours and was not left for longer than 4 hours at night. The living room was reported to be tidy. On 15 May 2017, the health visitor spoke to a social worker by phone. The social worker stated that SCSC were happy with the care the twins were receiving and have no further concerns. They believed that F1 had taken appropriate actions to safeguard the children and so the case was closed. 6 Early Help - Providing early help is more effective in promoting the welfare of children than reacting later. Early help means providing support as soon as a problem emerges, at any point in a child's life, from the foundation years through to the teenage years. 13 On 16 May 2017 the single assessment was completed. F1 had stated to social workers that she was not aware that M2 was still using drugs and denied advising the hospital midwife she thought M2 was: "going to hit her". F1 stated she did not intend to allow any further contact between M2 and KS and S1 until he changed his behaviour. The single assessment states that there had been a further incident whereby M2 had verbally abused F1. F1 also stated she had told M2 he should arrange a DNA test on KS and S1. M1 was now living with F1 most of the time. One of the children had told the social worker that F1 had “smacked [them] in the face” when they were naughty and M1 had shouted at them. F1 denied the allegations stating there were current concerns with the child being untruthful. It was the social worker's opinion that F1 was genuine. Observations of KS and S1, including F1’s care of them, had raised no concerns. The case was closed to SCSC the following day. An analysis of the assessment process conducted at this point is contained at section 3.5 below. In early June 2017, a 6-week check was made by the health visitor. F1 was reported to be well, happy and that she was: “clean at present”. F1 stated to the health visitor that she would not take drugs again. F1 said that although she smokes she does this outside and away from the children. A postnatal depression and NICE questionnaire was undertaken and F1 stated she felt she had recovered from the birth. M2 had not contacted or approached her. S1 was seen and was appropriately dressed, smiling and looking around. S1 weighed 6lb 10oz and plotted below 0.4 centile. KS was dressed in a baby grow and made lots of eye contact and was looking around. KS was stated to take 5oz formula regularly and would sleep for 6 hours through the night. KS weighed 6lb 8oz. F1 stated KS liked to be in a cot with S1. The living room was tidy with a clothes airer in the corner of the room with washed clothes on. F1 reported that she would be getting support from family and friends. As a result F1 would now receive universal services, as it was considered there were no further concerns to warrant additional intervention. F1 stated to the police that the night before KS died, at approximately 10pm, KS and S1 were fed and put together in a Moses basket in F1’s bedroom. F1 and M1 watched a film and had a meal and went to bed at approximately 2am. S1 woke at 4am and was fed. F1 fed KS in her bed at approximately 6.30am and then fell asleep. M1 took S1 and the other children downstairs and went to sleep. F1 woke up at 1.15pm and found KS unresponsive. KS was taken to hospital and was declared deceased. A post mortem was conducted which concluded that KS was a small baby who showed signs of dehydration consistent with the fact that they had been suffering from diarrhoea prior to their death. The pathologist found no evidence of overlay and could not ascertain a cause of death but was able to state that there was no suspicion of non-natural causes of death. The cause of death is stated as “Unascertained SUDI [Sudden Unexplained Death in Infancy].” The police interviewed both F1 and M1 and initiated a criminal investigation having established that both F1 and M1 had tested positive for opiates, cannabis and cocaine. This police investigation has concluded with no further action. Section Three – Analysis of Significant Issues 3.1 Significant Issue One There was a significant family history of agency engagement in this case which should have alerted professionals to potential risks to KS and siblings and resulted in more structured protection and support. 14 There is a considerable history of agency involvement with F1 and her children over a number of years. F1 had a number police records regarding recorded crimes committed by her (although none since 2008), and there are a number of records regarding F1 being a victim of domestic abuse together with a history of drug abuse and mental health issues. Regarding the children: • S2 and S3 have always resided in the care of relatives. When S2 was born, F1 resided in the home with relatives and was involved in S2’s care for some time, until her heroin use caused concern in 1998; • S3 also lived with relatives soon after birth, and S3 was subject to care proceedings with a residency order to live with relatives; • S4 went to reside in the care of a relative from a young age, after an assessment by SCSC; • prior to the scoping period for this serious case review, S5 and S6, who were in the care of F1 at the time of KS’s death, had previously been subject to child protection plans and a child in need plan due to parental drug use and neglect concerns. In addition to the involvement of services with F1’s children, information provided suggests that F1 has had several additional pregnancies that were not carried to term. Sadly, F1 is known to have had a miscarriage, a reported miscarriage, a possible miscarriage and four terminations of pregnancy in addition to the birth of 5 children over a 20-year period between the mid-1990s and 2016. Taking into account F1’s experiences of pregnancy and motherhood, she is likely to have been managing many periods of substantial grief and loss, when pregnancies have not progressed to term, or when, due to statutory intervention, her children have gone into the care of her extended family. F1 gave birth to her first child at approximately 17 years old and appears to have had documented issues with substance misuse soon after – the first available information to the reviewers indicating concerns were highlighted in 1998 regarding heroin use. This suggests that F1 had, in many ways, had to manage experiences of ongoing loss as a parent whilst also going through periods of drug use combined with possible periods of abstinence from drugs for up to 20 years. The emotional impact of these losses as a parent must have had a significant impact on F1’s psychological well-being. Furthermore, whilst acknowledging disguised compliance concerns in this review, it must be remembered that F1 and M1 are likely to have had little trust in many partner agencies; not only had they suffered the loss of children but both had significant involvement with criminal justice services. The degree of engagement summarised above is further exacerbated when looking at the detail of the contacts over that 20-year period. When S5 was born, despite being placed on a pre-birth child protection plan a few weeks before birth (due to concerns about domestic abuse, drug misuse and neglect), this child remained in the care of F1, with the child protection plan ceasing in November 2010. A pre-birth single assessment was completed during S6’s pregnancy due to F1 not engaging with ante-natal care. Whilst this assessment is well before the scoping period of this review, the reviewer notes that: “case was closed due to both parents complying with methadone programme and engaging with CAF [Common Assessment Framework]” (now known as Team Around the Family (TAF)) process]. The outcome of this single assessment was that the case was ‘stepped down’ to the Early Help Service to work with F1 and M1 under the CAF 15 framework. The health visitor at this time had no concerns for the children’s development and described the family as well presented and well-nourished. In 2013 the Early Help Service referred the case back to SCSC due to: “F1 not engaging; the police raising concerns regarding the state of the property; lack of food in the house; and empty methadone bottles accessible to the children”. A single assessment was completed, however concerns were not substantiated and F1 was noted to have “abstained from drugs”. The outcome of this single assessment was “universal services to monitor”. Further referrals were received in 2015. The first anonymous referral initially raising concerns that F1 was using drugs (crack cocaine and alcohol) and “leaving the children”. A further referral was then received from a family friend raising concerns that S6 had been left in the care of an adult friend who had been drinking alcohol. The outcome of the subsequent single assessment was for a child in need plan to commence; this plan was open for several months to November 2015. The plan seems to have had a degree of success. The minutes of the last CIN review in November 2015 suggests substantial progress by F1 in engaging with IRIS (substance misuse service) to commence and eventually complete a methadone reduction program. IRIS noted that whilst “contact was sporadic” a “planned reduction from substitute prescribing was completed”. This is significant, as in addition to being a real achievement, F1 appears to reference her abstinence from substances in future contact with professionals from this time onward. The CIN review also noted improvements in F1’s ability to set boundaries with the children, better management of family finances/outstanding debts, improved conditions within the family home and that S5 was now attending school regularly. It is of note however that F1 refused any after care support from IRIS and November 2015 is the last recorded contact between F1 and IRIS. It is also significant that at the time that the multi-agency network and F1 agreed that the CIN plan should cease, S6’s school attendance was at approximately 65%, although there is reference to S6 spending some days in hospital and subsequent days at home, which may have lowered the attendance rate in what was the first term of that school year. The CIN review minutes also focus on the work and achievements of F1 in improving outcomes for the children without any real mention or focus on the role of M1 in the parenting of S5 and S6. Despite all of these historical issues, F1 had cared for S5 and S6 since their birth until the death of their sibling KS. S5 and S6 did spend a period of time subject to child protection plans (between December 2009 and October 2010) due to ongoing concerns about drug misuse by F1 and M1, domestic violence and neglect. In 2016, F1 entered into a relationship with M2; her long-term partner (and father of all children to this point) M1 having received a custodial prison sentence. A succession of domestic abuse referrals were made in late 2016, when it became apparent that M1 had been released from prison and was concerned that F1 may have been in a relationship with M2. In October 2016, F1 attended an appointment with the midwifery service for a ‘late booking’ whilst 4-5 months pregnant. Information supplied suggests that a cause for concern form was sent to SCSC to obtain information as to previous SCSC involvement with the family – it was clarified by the community midwife at the practitioners’ event that unless there is a specific ‘obstetrics’ issue, then midwives have to access family history via SCSC. It is unclear what information was shared with midwifery at that time. So throughout 2016, there were concerns as to missed health appointments for S5 and S6, concerns about domestic abuse and potential mental health concerns for F1, who on one occasion was reported, in a 111 call by another person, to be feeling suicidal whilst suffering abdominal pain and bleeding. It was noted by health services that F1 had had a recent 16 termination and that these symptoms – a potential further miscarriage - were not followed up and engagement at that time could have led to a potentially helpful assessment of F1’s emotional well-being. As noted elsewhere, between September and November 2016, there were a range of non-crime domestic incidents coinciding with M1’s release from prison and concern about F1 being in a relationship with M2. The last of these incidents occurred shortly after the booking appointment noted above. Community midwifery sent in a further ‘cause for concern’ form to SCSC, which according to file information led to no further action at that time. An anonymous referral was received by SCSC in December 2016 that F1 was using drugs. SCSC information notes that in December 2016: “enquiries by MASH concluded - no concern. No further action taken”. Additional information later in December 2016 indicated that SCSC contacted community midwifery, noting a recent referral after M2 told his probation officer that F1 was: “back on drugs”. Midwifery were informed by SCSC that they had carried out an assessment, F1 denied drug use and no concerns raised by school regarding F1’s children. SCSC indicated that they would be taking no further action, believing this to be a malicious referral and were told to submit a MARF if there were any further concerns. As noted above, this information does not appear to have been recorded within a formal contact process, such as a MASH assessment. This was a family with a significant history of engagement with agencies. The use of a child in need plan in 2015 demonstrated that agencies were able to support F1 to create positive change for her and her children in a positive way when a meaningful plan was put in place. When the CIN plan was closed at the end of 2015 there were no further child protection interventions and all support thereafter was provided as part of universal services. There were numerous opportunities to put in place more formal support once F1 became pregnant with KS and S1. Ultimately, a number of professionals were engaged with the family from a number of agencies. When F1 became pregnant with the twins in 2016 they should have pooled their knowledge of the family to develop a support programme. There was no record of a child safeguarding multi-agency meeting conducted by the hospital. It is common practice in many hospital trusts for the lead safeguarding nurse to conduct a monthly meeting where all pre-birth cases that have been a cause of concern are discussed. It would be usual for children’s services to attend this meeting along with the full range of health providers. It would also be useful for drug and alcohol and mental health service providers to attend. In some cases this meeting is chaired by the safeguarding lead from the Clinical Commissioning Group. A meeting of this type would have ensured that all elements of health services were aware of this family and provided SCSC with better information. Professionals described how at Russells Hall Hospital, Dudley, an ‘Unborn Baby Network’ meeting has just been established that fulfils this function. It should be considered as a potential model by health services in Sandwell. This review concludes that: Insufficient work was conducted to ensure that all of the professionals working with F1 and her family were aware of the full history of drug abuse, missed appointments and potential child neglect that had been apparent over the previous 20 years. Whilst family history is not the only predictor of future risk, in this case it would have provided professionals with a good indication of likely future risks to F1’s children. Services had previously provided periods of support that had proved successful. When F1 17 became pregnant with KS and S1, professionals should have shared all of the information they had, initially via the MASH process, and provided a comprehensive support package. 3.2 Significant Issue Two F1 had a history of failing to attend appointments for herself and her children. Agencies did not fully consider the implications of these continued missed appointments. F1 had a history of failing to attend appointments over a number of years which had, on a previous occasion, resulted in a child in need plan to provide her with support. However, F1 continued to miss appointments and the list below shows the extent to which she avoided contact with professionals during the pregnancies of KS and S1: • February 2016 – S6 discharged from a health service due to 3 missed appointments; • June/July 2016 – School Nursing made several attempts to contact F1 by telephone without success; • August 2016 – S6 missed immunisation appointments with GP; • October 2016 – S6 missed immunisations appointment with GP; • November 2016 - S6 missed immunisations appointment with GP; • November 2016 – S6 again not taken for vaccination (despite mother attending GP just six days earlier when unwell herself); • November 2016 – Did not attend (DNA) – Community Midwife (CMW) Appointment; • January 2017 - DNA – CMW appointment (two records); • January 2017 - Call and report visit by CMW to home address due to repeated DNAs. Partner answered said mother was out and would not be back until late afternoon, CMW stated she would return tomorrow and the partner stated mother would be in all day; • January 2017 - Home visit made CMW – no reply; • February 2017 DNA – CMW appointment (two records); • February 2017 Call and report carried out due to repeated DNA, mother advised to attend appointments; • March 2017 DNA – CMW; • March 2017 - Call and report carried out by CMW – No answer, unable to contact via phone (two records); • March 2017 - Call and report carried out by CMW – No answer, unable to contact via phone. Both upstairs and downstairs windows open; • March 2017 - Call and report carried out by CMW – No answer, unable to contact via phone (two records); • March 2017 - DNA – CMW appointment. This list represents a significant and sustained pattern of avoiding ante-natal care. There are also patterns in the way F1 explains these missed appointments. On a number of occasions, F1 stated this was due to family illness and some professionals and F1 linked the problem with the house fire the family had suffered in 2016. At the practitioner’s event the community midwife was clear that there was concern amongst midwives around the number of appointments that were being missed. Community Midwifery Service had a policy whereby 3 missed appointments resulted in ‘contact and report’ visit to the home address and a MARF to SCSC. 18 In response, 3 multi-agency referral forms (MARF) were submitted by health professionals between 21 March 2017 and early April 2017. SCSC received a MARF on 21 March 2017 from the community midwife raising concerns about F1’s attendance at her ante-natal appointments. Considering the previous family history, she considered a referral was required. The referral went to the Multi-agency Safeguarding Hub (MASH). The MASH checks revealed that F1 had been seen in February and March 2017 by health professionals and that there was a house fire which could have been the cause of the missed appointments. It is noted that the house fire had occurred 10 months earlier. The MASH established that information provided by school and other health professionals was positive and there was no evidence of any current concerns in relation to drugs. MASH agreed a single agency follow up by health services and stated health services could consider an early help assessment if further concerns arose. On 28 March 2017 the community midwife (CMW) was informed by a health visitor that the MASH had made contact with the health visitor who informed them she had visited F1 in February and March and there were no concerns. When the issue about the missed appointments was raised and the concerns that hospital appointments for scans had also been missed, the health visitor acknowledged she had not been aware of this concern prior to giving feedback to the MASH. The CMW contacted MASH regarding the MARF referral and was informed that no further action was being taken and that the health visitor was going to contact F1 to ensure she attends all of her appointments. On 30 March 2017 the CMW made another home visit and discussed the missed appointments with F1. F1 reported that she had been unwell. The importance of attending appointments was discussed and the CMW arranged for F1 to be seen the next day at hospital for a scan and to be seen by a consultant. In February 2017 a home visit was carried out by the CMW. When asked about missed appointments F1 stated she had been to a hospital appointment. There was no evidence she had attended. In summary: • Between 16 November 2016 and 29 March 2017, F1 did not attend 7 offered midwifery appointments; • F1 did not actually successfully attend any midwifery appointment at ante-natal clinic Whilst she missed 7 appointments, there were no additional appointments that she attended at the clinic after the initial booking appointment in October 2016; • community midwifery managed to see F1 on 3 out of a further 9 ‘call and report’ visits carried out by the Community Midwifery Service as concerns about the lack of attendance at ante-natal appointments grew; • it is clear from the information provided that at some of these call and report visits there was some concern about avoidance, including one visit where there was no answer despite open windows (upstairs and downstairs). F1 would often state that she was unwell and consequently did not attend; • during this pregnancy, F1 did not attend 5 appointments at Hospital for ante-natal scans or attend consultant’s appointments; • F1 did attend hospital a few days prior to delivery when concern was held that the twins were quite small and that one twin was: ”severely growth restricted”. Inducement was planned a few days thereafter. 19 When F1 was found to be pregnant with twins, it may have been anticipated that any significant level of missed appointments, in conjunction with a previous history of similar concerns, would be sufficient to trigger a single assessment and potentially a strategy meeting. Health visitors had gained sufficient access to conclude they were not concerned (prior to learning of the non-engagement issues) and SCSC decided that the missed appointments did not warrant further action. This was despite the fact they had received 3 MARFs from health professionals. Midwives invoked their ‘call and report’ procedure, but when they raised further concerns were reassured by SCSC that there was no requirement for further formal child protection procedures to be considered. F1 had also missed appointments with the GP over time and there had been several missed appointments for immunisations for S6. The surgery could have considered calling a multi-agency meeting given the F1’s history of non-attendance. This review considers that professionals in children’s social care and health failed to properly review the issue of missed appointments and recognise this as a potential indicator of neglect. When midwives raised the issue as a risk with children’s social care, their views were not properly considered. 3.3 Significant Issue Three F1 had a history of not attending appointments, drug use and being subjected to domestic abuse. SCSC had used formal child protection procedures to protect F1’s first 3 children. In October 2016, when F1 was 4-5 months pregnant, SCSC should have considered a pre-birth single assessment and strategy meeting. This review has already considered issues relating to non-attendance at meetings, a significant family history of potential neglect, domestic abuse and drug use by F1. In October 2016 F1 had presented as 4 to 5 months pregnant. This late booking was, in itself, an issue of concern and the midwife made a referral to SCSC based on F1’s admissions around her previous drug taking. The referral provided the opportunity to hold a strategy meeting and invoke pre-birth procedures. In March and April 2017, 3 further MARFs were submitted which again provided an opportunity for intervention. The first of these MARFs is the most significant and is analysed below: The first MARF was submitted by Community Midwifery to SCSC on 21 March 2017. At this time, 6 scheduled appointments with the community midwife had been missed by F1. A further 8 ‘call and report’ home visits had been made by the community midwife due to non-attendance at appointments, with a successful unannounced home visit occurring only once, in February 2017. At the practitioners’ event, the community midwifery noted that there is a policy in place of referring cases to SCSC if they are unable to access a mother after the third missed appointment; community midwifery agreed that the MARF to SCSC could have been sent at an earlier stage. The MARF clearly referenced: • Previous concerns re: substance misuse, domestic abuse and housing issues; • recent domestic abuse in late 2016 and M2’s claim in December 2016 that F1 was using drugs; 20 • that F1 was 35 weeks pregnant with twins, had not been accessing ante-natal care with community midwifery, hospital scans or consultant appointments; • in addition to difficulties seeing F1 and appointments at home or at hospital, community midwifery are unable to reach F1 by phone; • concern that F1 may not be prioritising the health and well-being of the unborn children. In response to this MARF, the MASH worker attempted to contact F1, however, was unsuccessful in doing so on 23 and 24 March 2017. It is noted that this may be an example of the difficulties other professionals were having in engaging with F1. Thus, the case was put out to MASH partners (consent overridden) for multi-agency information gathering. The reviewers note a timeliness issue at this point – the MARF was dated 21 March 2017, however attempts to contact F1 were not made until 48 and 72 hours thereafter. With a weekend in between, the decision to ‘MASH’ the case with multi-agency partners in effect took 6 days (4 working days). This is well outside of accepted MASH timescales to make initial decisions on ‘referrals’ (24hours) and the reason for this delay is not referenced in the MASH decision. Given that this MARF arrived just a few weeks before the child’s birth in April 2017, this delay could have been crucial in terms of available planning and intervention time. The MASH information responses from partner agencies are crucial and raise varying levels of concern for the welfare of the unborn children. Police noted that there had been 4 domestic abuse reports between 2010 and 2016 (presumably including the three acknowledged reports in late 2016 as outlined above) and F1’s criminal history (no convictions since 2008). Police recommended: “Single Assessment. There have been previous DV, CA (child abuse) and drug issues, however the concerns are now (F1’s) lack of antenatal care and the effect this may have on the unborn children”. The SCSC MASH worker provided a detailed case history but did not provide a recommendation. The Early Help Service however indicated that the case should be passed on for single assessment: “There are concerns that mother is expecting twins therefore it is a riskier pregnancy yet she is still not attending ante-natal appointments. The health and wellbeing of the twins is at risk. Mother has also done this with previous pregnancies. There is a history of non-engagement, DV, drugs and neglect. It needs to be ascertained what is happening within the family environment, how the children are being looked after, if their medical needs are being met and if mother is prepared for the babies. SA recommended.” Education did not explicitly recommend an assessment, noting that: “MASH discussion is required due to the family history, but that F1 appears to be managing the needs of S5 and S6 and getting them to school. Education does not however [note] that ..this could be hampered when the twins arrive so mum’s parenting ability may need assessing”. Housing noted that there had been a report of anti-social behaviour in September 2016 where concerns regarding: “nightly drop offs to property and reports of the smell of weed coming from the property, F1 is not attending ante-natal appointments and what the effect may be on the unborn twins if F1 is using drugs again, and recommends that ‘appropriate assessment to be undertaken”. The probation service also recommended the same action. Health noted concerns about F1’s lack of engagement with ante-natal services given the expected twins, however goes on to state: “However, the health visitor information was very positive”. Details of this health visitor feedback are not included in the multi-agency section of the MASH Assessment document. This health visitor intervention appears to have had considerable weight in the final MASH decision. The reviewers understand that a ‘MASH discussion’ may have then taken place, with the MASH decision being recorded afterward. No details of this discussion are available. The MASH decision is brief given the extensive case history and imminent birth of twins. Despite 21 these issues, the decision states that: “MASH feel the positives currently outweigh the negatives”. The MASH decision goes on to note that F1 was seen by the health visitor in February and March 2017 and no concerns noted regarding drug misuse and that health would monitor concerns about smoking. The MASH decision goes on to state that F1: “moved out of home for a short while due to a house fire and that this may be why she missed appointments, although there is a history of missed appointments.” The MASH decision notes that the health visitor reports that F1 is prepared for the twins and has no concerns about the family property, that Education have not expressed concerns for the children and that Housing report rent arrears that F1 is paying off. The MASH decision also states that police note no criminal activity for F1 since 2008 and that whilst there had been recent domestic abuse incidents, F1 was not in a relationship with the suspect. What is not outlined is that the health visitor gave the positive feedback before she was aware of the midwifery concerns regarding non-attendance at ante-natal appointments. It is also noted that at least one of the non-crime domestic incidents involved M1 coming to the home to seek out M2, out of concern that he was in a relationship with F1. The final decision is that: “MASH agree single agency to support mother and consider EHA if required, Health to visit mother again and advise she attend all hospital appointments. MASH health rep to action.” The reviewers acknowledge that this MASH decision appears to be the agreed multi-agency approach to this case from a MASH discussion. However, based on what is recorded in the decision itself, the reviewers note the following issues: Professional Over-Optimism Despite the range of potential concerns outlined by agencies (at least prior to a MASH discussion) with regards to family history, potential impact of non-engagement with ante-natal appointments and previous history of missed appointments, the final MASH decision does not address why or how these identified risks are mitigated. Furthermore, the MASH decision does not directly mention community midwifery or address the specific concerns raised in the MARF around the pattern of non-attendance at ante-natal appointments over the previous 3-4 months. Instead, the decision seems to select the positive aspects of agency feedback (e.g. no criminal involvement with F1 for 9 years; no education concerns raised by the school) without providing a rationale for how initial concerns held by the same MASH partner agencies may have been alleviated in a subsequent MASH discussion. The MASH decision does not provide a clear rationale as to why a single assessment will not be completed here, whether all partner agencies have come to agree with the position that a single assessment is not completed and, if there were dissenting views, why these were overruled. Finally, the MASH decision also seems to attach considerable weight to the positive feedback of the health visitor, which are not recorded in the decision record. In this case, there was clear evidence of professional over optimism. In some cases professionals need to understand how to ask difficult questions. Disguised Compliance The MASH decision does not locate the decision to essentially signpost this case to Health services within the context of family history and previous documented instances of F1’s non-attendance at ante-natal appointments and non-engagement with services. The MASH itself was unable to make contact with F1 during the MASH process, potentially an example of F1’s 22 previous pattern of engagement with professionals and current pattern of non-engagement with the Community Midwifery Service. The possibility of disguised compliance is also not directly referenced in the MASH decision. Key potential characteristics of this behaviour, such as avoidance of appointments or professionals, allowing access to one professional over another and avoidance of contact with professionals by phone, were not located within the context of possible disguised compliance. Finally, a house fire is mentioned as a potential reason for missing appointments that is accepted by the MASH service, however file information suggests that this fire occurred approximately 10 months prior to the MARF on 21 March 2017 and that F1 and the children were back in the family home by the end of 2016 at the latest. How this house fire came for part of the MASH decision is referenced elsewhere in this document. Early Help Assessment Bearing in mind these issues, no rationale is given as to why an early help assessment (EHA) would not have been immediately completed as health services had already expressed concern for the welfare of the children in future. Given that the Early Help Service had indicated in MASH feedback that in its last period of engagement with this family (in 2013), when the episode was closed due to non-engagement with the TAF process, it is surprising that the EHA was not undertaken immediately. Health Visiting Feedback The feedback noted in the MASH decision, that the health visitor had gained access to F1’s home in February and March 2017, is given significant weight, although detail of this feedback is not recorded in the MASH assessment at any point. To the reviewers, it would appear that this feedback has been given greater precedence than the information provided by of the community midwife, who at this point had attempted to access F1 at 7 scheduled appointments and a further 9 unscheduled ‘call and report’ home visits. In addition, there were missed appointments at the hospital for F1 and the unborn twins. No rationale is provided in the MASH decision as to why the health visitors input has allayed concerns to the point where a single assessment may not be required. As noted above, it seems that this health visiting feedback was been given to the MASH before the health visitor was aware of the non-attendance concerns raised by midwifery. This has significant ramifications, given that the MASH appeared to give primacy to the positive health visiting feedback in taking the decision not to assess at that time. Voice of the Child Despite reaching a course of action that the health services would continue to support F1 and consider an early help assessment as required, the MASH decision does not directly reference the perspective of the children (born or unborn). The MASH decision does not weigh up the potential impact upon these children of either commencing an assessment or what the potential outcomes could be if SCSC did not become involved at that time. No further rationale is provided as to the potential impact of this multi-agency decision. There appears to have been little consideration of the allegation made by one of the children on 2 occasions that they had been slapped around the face by one of their parents. It is also noted that no child’s name is actually referenced in the MASH decision at any point. The Role of M1 23 The MASH decision does not reference the role of M1 in the family home or whether his own history may be significant in terms of risk assessment or whether this may contribute to a need for assessment. Risk Management Protocols The MASH decision does not locate the case concerns and recommended action within Sandwell’s Multi-Agency Threshold Document, thus this opportunity to clarify how risk has been assessed and an outcome reached has not been utilised. The MASH decision does not locate the concerns or recommended action within Sandwell’s Pre-Birth Procedures, as found at the West Midlands Safeguarding Procedures website. How the family history, recent concerns and apparent non-engagement with services did or did not reach the threshold for a pre-birth single assessment is not elucidated. There is no evidence that at any of these points, the pre-birth procedures were considered and there is no recorded evidence of a rationale as to why it was not considered. The pre-birth procedures are contained in the West Midlands Safeguarding Online Procedures in which SCSC are a partner. An extract of pre-birth procedures is contained at Appendix Two. The procedures describes the circumstances in which a pre-birth assessment should be conducted are: “A pre-birth assessment should be undertaken on all pre-birth referrals as early as possible, preferably before 20 weeks, where: • a parent or other adult in the household, or regular visitor, has been identified as posing a risk to children • a sibling in the household is subject of a child protection plan • a sibling has previously been removed from the household either temporarily or by court order • the parent is a looked after child • there are significant domestic violence issues • the degree of parental substance misuse is likely to impact significantly on the baby's safety or development • there are significant concerns about parental ability to self-care and/or to care for the child e.g. unsupported, young or learning disabled mother • any other concern exists that the baby may have suffered, or is likely to suffer, significant harm including a parent previously suspected of fabricating or inducing illness in a child or harming a child • a child aged under 13 is found to be pregnant.” Whilst it might be considered understandable that SCSC had reached a point where they considered previous family issues as historical, that seems an over optimistic view in the circumstances. There was sufficient evidence that a number of these points were apparent in this case. If the assessment had been completed it would have resolved a number of issues including the fact that all of the agencies would have become aware of the family history. An assessment may also have resulted in a strategy discussion or network meeting and at the very least a child in need plan could have been developed. This would have ensured that plans were in place to mitigate any risk and an effective support package could be developed for this family. 24 Assessment As A Positive Intervention Risk assessment issues aside, if a single assessment is commenced, it can be utilised as a positive method of intervention within which to fully understand and support a family expecting a new baby whilst also managing risk. As noted by some professionals, F1 had shown the ability to provide basic care and meet key aspects of S5 and S6’s needs over time and had in 2015, demonstrated some ability to enact change and improve outcomes for the children on a CIN plan. A single assessment may have assisted in bringing the network together to consider the likely impact of having new-born twins, in addition to managing the needs of two older children and develop plans to support the family before the twins were born. This could have included collaborative discharge planning and support from the first day that the twins left hospital, in addition to the support provided routinely by universal services. The second and third MARFs were submitted by the Hospital on 3 April 2017 and a Sandwell e-CAF was received from health services on 6 April 2017. In both instances, it appears that health professionals making the referral had not been in contact with midwifery colleagues, with SCSC not progressing these referrals given that presenting concerns had ostensibly been addressed in the MASH assessment document of 27 March 2017. However, in both instances, no further action was taken on these MARFs, citing the outcome of the MASH assessment on 28 March 2017. Taking into account the family history, recent concerns and presenting concerns in the first MARF dated 21 March 2017, it is the view of the reviewers that this case did meet the criteria for a pre-birth assessment both under Sandwell’s Multi-Agency Threshold Document and Pre-Birth Procedures. There are a wide range of factors, including children historically coming into care/care of others, domestic abuse, drug use, neglect concerns, recent domestic abuse issues, potential allegations of drug-taking and over three months of very limited engagement with ante-natal services after a late-booking when F1 was pregnant with twins. The reviewers are clear that opportunities were missed to engage with the family and assess risk at a pre-birth stage, which may have enabled a longer period to plan and support F1 with her upcoming twins, whilst also being able to make contingency plans if concerns did arise. An assessment at an earlier stage would also have assisted in understanding whether any risks present met the threshold for child protection procedures. Despite the lengthy case history, KS and S1 were not subject to an assessment until after they were born, when domestic abuse concerns in Hospital arose regarding M2’s behaviour. This review has established that there were sufficient grounds to utilise the pre-birth procedures, but this was not considered in the case of KS and S1. As a result, an opportunity was missed to reduce risk to KS and S1 and put in place an effective support package for the family. The MASH assessment was not comprehensive and does not outline how it balanced risk and need, given the available evidence. It was a missed opportunity to work with the family. 3.4 Significant Issue Four Following the birth of KS and S1 a single assessment was conducted. There appeared to be limited consideration and exploration of disguised compliance patterns within the context of family history, recent concerns and potential risk and need for KS, S1, S5 and S6. 25 A single assessment was commenced in mid- April 2017, after concerns were raised about M2’s aggressive behaviour at hospital when he perceived that F1 had left the hospital and spent too much time away from the twins. This appears to have escalated into verbal threats and intimidation, with F1 deciding that no contact would take place between the twins and M2 in the immediate future whilst considering family court options. The SCSC manager who provided the management summary at the commencement of the assessment highlights a number of areas for the allocated social worker to address, including: - “Reviewing all family history; - Assessment of parental safeguarding capacity given domestic abuse concerns, including impact of exposure to domestic abuse upon children; - Consider ‘current substance abuse’ given long history of concern around this, including understanding whether F1 was involved with drug support services and/or what drugs or substances F1 may be taking at this time; - Obtain feedback from hospital staff as to interaction and care provided to the twins; - Arrange to speak to M2 separately and gather his understanding of impact of domestic abuse upon children; - Complete agency checks, consider family networks and given history of involvement, whether s.47 investigation or Initial Child Protection Case Conference required”. This single assessment does provide a concise history of several key events in SCSC involvement. Attempts were made to speak with M2, however he refused to engage with the assessment process at all, thus it was not possible to understand his perspective on domestic abuse. F1, however, was noted to have followed the advice of professionals in seeking to distance herself from M2 and create a safe environment for herself and the children at home. The single assessment notes the historic concerns around drug abuse, but only provides very limited evidence of discussion and exploration around this issue with F1, simply noting that F1 had not used drugs since 2009 and ceased methadone 18 months earlier. There is no evidence of the recording of a discussion to explore this issue in any depth in the assessment document. It is noted that F1 and M1 should obtain support should they relapse. There is also no evidence in this assessment of contact being made with IRIS to clarify if there had been any further involvement since the end of F1’s methadone program in late 2015. Finally, there is no evidence of exploration with M1 or IRIS as to his previous or current substance misuse. Despite the concerns noted only a few weeks earlier, this single assessment does not provide evidence of exploring the non-engagement with ante-natal services any further with F1 or M1. Despite listing this concern in the assessment document, the information provided suggests that F1 stated she: “admits not attending 4 ante-natal appointments as her ankles had swollen up so much that the health visitor came to her home to do visits”. This information is not challenged, despite the MARF on 21 March 2017 indicating that a much higher number of appointments and hospital appointments were not kept. The assessment does not evidence any further discussion or exploration of these issues with the allocated community midwife, instead focusing on the positive parenting feedback from midwifery since the twin’s birth. The single assessment does not seek to examine potential patterns of disguised compliance behaviour either currently or over time with F1. There is no evidence of exploration of recent non-attendance issues within the context of the historical non-attendance or engagement with ante-natal services in previous pregnancies or around other times in the past when the family have not always engaged with services. The assessing social worker does not appear to have challenged F1 about her claim of swollen ankles, which may fit into previous patterns of illness for F1, or the children, leading to non-engagement with services. 26 The single assessment does provide considerable information from professionals such as the community midwife and health visitor about how well F1 was coping with the twins since birth, including positive feedback from the allocated health visitor who had known the family for some time. Observations of the children in the home were positive and direct work undertaken did not raise any specific concerns, with the exception of one of the children stating that their mother had slapped them in the face and that M1 shouted at them. They repeated this during direct work and F1 was confronted over this and denied it. The assessing social worker took the view that F1 was being truthful around this. The other child living with F1 did not indicate or disclose any information regarding being slapped in the face or physically disciplined in any other way. The single assessment does include multi-agency feedback, although some of this is pulled through from the MASH assessment. It is noted that there does not appear to be evidence of direct contact with the GP to obtain their perspective of this family’s circumstances. Whilst the single assessment analysis does address some risk areas and in particular focuses on the ramifications of the recent domestic abuse incident at the hospital, it does not locate the way the family presents currently within the history to date. When referencing previous family history, the assessment analysis falls back on MASH decision stating that “the positives currently outweigh the negatives”, revisits MASH’s initial rationale for not opening an assessment on 27 March 2018 and then goes on to outline that signposting needs to take place to support the family. The assessment analysis does not contain any evidence of exploration or challenge of the patterns emerging from family history, recent concerns just prior to birth and how the assessing social worker sees these factors in terms of risk to these children. The analysis similarly does not (whilst acknowledging that the situation at home was positive at the time of this assessment) consider how over time F1 and M1 will manage the care of two new-born twins alongside two older children and what support the family might need to ensure that the children remain safe at home with their needs met. The analysis does not speak to specific support or signposting beyond universal services for this family, despite the considerable history of poor engagement and neglect concerns at times in the family history. The assessment analysis does not consider the position of the child, in terms of the potential outcomes for these children if a higher or lower level of support is offered. This decision is also not couched within local threshold documents to help outline how this decision was reached. Finally, the single assessment is largely silent on the issue of M1. Whilst there is some information about how F1 and M1 see their relationship with each other, there is no evidence of direct discussions with M1 to understand his parenting capacity, how he will assist in keeping the children safe, and an assessment of any issues related to his history of drug misuse and domestic abuse in the home. There is no evidence of observations of M1 with the children. The assessment analysis does not outline whether there were difficulties engaging with M1 or why information about his role within the home, or his views on previous non-engagement with ante-natal services. The single assessment contains a lengthy management oversight section that speaks initially to the presenting issues of domestic abuse involving M2. However, this then goes onto examine wider concerns, such as the role of M1 (who is only briefly addressed in the single assessment itself). The assessment oversight section notes that there are conflicting views that M1 - who had previously been seen as a concern due to the history of M1 and F1 using drugs and being involved in domestic abuse – was now seen as supportive by professionals. 27 However, there is no further comment as to why this situation is now justifiably safe and supportive, beyond noting that M1 and F1 have: “come a long way’. Given that there were potential domestic abuse concerns about M1 coming around to the house in late 2016 due to concern that M2 may have been there with F1, it is unclear how far this relationship has progressed, although F1 did feel that they were supportive of one another. This analysis is not balanced against the historic domestic abuse concerns and does not provide any evidence of how M1 had changed to become a supportive factor. The assessment oversight section makes no reference to the previous (yet recent) concerns of midwifery around ongoing non-engagement. It is noted that the family have declined early help support despite now having two children under 12 months of age, but that the family will receive support from universal services. The history of child protection plans and child in need plans are noted, however this does not lead into any analysis of whether this history has any bearing on need or risk going forward, beyond the need to inform agencies of the outcome of this assessment. The assessment oversight section goes on to note - “…that this seems to be a family who will always need to be on professionals radars. Whilst parents should be commended for the reported progress to date, it seems there are still situations and decisions such as F1’s brief relationship with M2 when knowing he had misused drugs which hark back to the past.” Unfortunately, after acknowledging this view, the assessment oversight section does not go on to outline a plan or intervention that will support this family to work towards not being regularly known or engaged with safeguarding services. The single assessment in June 2017 commenced in very unfortunate circumstances, following the Sudden Unexplained Death of Infant (SUDI) KS just days earlier. The content of this assessment is understandably coloured by these events and may have influenced how some issues, such as substance misuse, were explored with the family. By way of counterpoint to the single assessment in April/May 2017, the June document goes into considerable depth with both M1 and F1 around current drug misuse, although when M1 and F1 were interviewed in July 2017, it had become apparent through toxicology testing that they had been using drugs at or around the time of KS’s death, which may have led to a more honest account from M1 and F1 about the drugs they had used and how frequently. This assessment also incorporated more information and direct discussion and observation of M1, and also sought information from extended family. This review concludes the assessment conducted in mid-April 2017 failed to accurately explore or challenge current and previous information regarding the family to adequately inform an assessment of risk to KS and siblings. It was a missed opportunity to initiate a greater level of protection and support to KS and siblings. 3.5 Significant Issue Five This case drifted, and whilst professionals engaged with the family, there was a lack of leadership to ensure a robust plan was in place to provide protection and support. There were clearly grounds in this case for a multi-agency meeting and the development of a plan to mitigate any risk to the unborn babies and ensure a plan for providing ongoing support. 28 Whilst some professionals sought to address concerns within their own safeguarding roles, there was never one person or agency that took a lead and pulled others together to formulate a medium to long-term plan. This was exacerbated by a complete lack of cooperation by F1 with the Community Midwifery Service. She failed to attend appointments and was able to demonstrate a degree of disguised compliance that on occasions led to an overly optimistic view of the family. More should have been done to deal with the issue of missed appointments and the pre-birth procedures should have been adopted. There was no clear leadership to ensure a holistic approach. Individual team leaders did take a leadership role within their own field, but this did not extend across agencies. As a result, the lack of any clear leadership resulted in some professionals, who were clearly concerned, not pursuing any escalation when their requests for more intervention were declined. Whilst there was clearly some level of supervision, there is a complete lack of management oversight in this case. This review has found that there was a lack of leadership shown by professionals and no agency took responsibility for ensuring that this family had a plan in place to protect the children and provide support. Section Four – Key Themes 4.1 The use of child protection assessments and pre-birth procedures Pre-birth procedures were not considered by SCSC in this case. These procedures would have provided the framework for a more consistent approach and better partnership working. Opportunities in October and November 2016, when information was shared with SCSC by the midwifery service, were missed to explore the family circumstances further. Similar opportunities were missed in December 2016, when information was shared with SCSC that F1 could be using drugs again. The MARFS submitted to SCSC by health professionals immediately prior to the birth of KS and S1 provided sufficient evidence to invoke these procedures. The MASH assessment that resulted from these submissions did not consider all of the evidence and gave disproportionate weight to professionals who had positive feedback regarding the family’s circumstances, whilst it appears that some of this feedback from professionals may have been given before knowledge of non-engagement concerns came to the attention of said professionals. The MASH failed to initiate appropriate child protection procedures following these referrals. The fact that the Sandwell pre-birth procedures are not referred to by any professional in documents, or at the practitioner’s event, leads to the conclusion that they are not well understood by those professionals. The single assessment completed following KS’s birth did not reflect the level of potential risk and need for KS and siblings that was apparent in the evidence that had been gathered. 29 Risk assessment thresholds, pre-birth procedures and the quality of analysis in assessments were not, at times, applied in an appropriate way. This is an issue that needs to be addressed. 4.2 Dealing with non-attendance at appointments There is a long history of F1 missing appointments. This extends to essential appointments for her children. F1 presented late for a pregnant mother and missed numerous appointments during her pregnancy; including scans at the hospital. Given the previous history of F1 and the fact that she was pregnant with twins, this should have caused more concern for professionals. Whilst midwifery services had a policy in place to deal with these missed appointments the same does not appear to have applied to other agencies. It is clear that SCSC did not see the missing of appointments as particularly relevant. There needs to be better training of staff to understand the nature of missed appointments and their significance. This needs to be supported by clear policies and supervision. 4.3 Multi-agency working and information sharing There is clear evidence that SCSC did not disclose information to health agencies and health did not always share information between themselves. GPs did not receive all of the information they needed and were not involved in the child protection process. GPs should, as best practice, ensure that their surgery holds regular child safeguarding meetings to ensure they understand the needs of all the children registered with them. A multi-agency monthly review meeting conducted at the hospital, but including SCSC, would provide an opportunity for better information sharing. Agencies need to consider why information sharing broke down in this case and put in place clear guidelines to improve information flow. 4.4 Disguised compliance F1 had a long history of engagement with agencies and this was not always in a positive way. As a result, F1 appeared adept at being able to satisfy professionals she was complying with their requests. F1 had considerable help with her drug use over time and had reported periods of abstinence that were accepted by professionals. This transpired to be untrue once drug-testing took place after the death of KS. F1 avoided appointments but would make promises about attending in future or excuses around family illness, and the fact she had had a house fire. Professionals appeared to accept these excuses or had difficulty in effectively challenging them. This process of challenge may have been enhanced by a multi-agency approach to supporting this family. Domestic abuse incidents between September and November 2016 resulted in a referral to Black Country Women’s Aid but F1 did not engage with the service. The MASH tended to dismiss disguised compliance concerns (such as not engaging with ante-natal services) on the basis of a relatively low level of reassurance from some professionals despite the lengthy family history. It is entirely reasonable to retain a level of optimism for the future of children in the care of their parents and to wish to support parents, despite their family history. F1 had clearly managed to care for 2 of her children for some years and it may have 30 been that work with F1 to build trust and to understand what may have been driving her avoidance of midwifery services may have led to an outcome a plan could have been put in place to support and keep the children safe at home. It is perhaps not surprising that F1 may have avoided booking her pregnancy and then wanted to avoid services further given her previous experiences of carrying children to term and the suffering the loss of them going into the care of other family members. The opportunity to explore this avenue with F1 was lost however when the presenting concerns were not placed within the wider family history, and a pre-birth assessment that could have explored disguised compliance concerns was not conducted. When a single assessment was commenced post-natally, there was insufficient exploration and challenge of these concerns. Professionals should be aware of the dangers of disguised compliance and this case provides a good case study to consider when engaged in multi-agency training. The reviewers acknowledge that disguised compliance can be a difficult issue to challenge and work with effectively to safeguard children. Whilst there is no evidence that disguised compliance issues had any role in the death of KS, this case has provided several examples of potential disguised compliance factors. • F1 had a long history of engagement with agencies and this was not always in a positive way. As a result she was clearly adept at being able to satisfy professionals she was complying with their requests. F1 had considerable help with her drug issues and was able to convince professionals she was “clean”. This transpired to be untrue; • F1 avoided appointments but would make promises about attending in future or excuses around family illness and the fact she had had a house fire. Again, professionals often believed these excuses or at least were prepared to accept them; • domestic abuse incidents between September and November 2016, resulted in a referral to Black Country Women’s Aid but she did not engage with the service; • the MASH tended to dismiss disguised compliance concerns (such as not engaging with ante-natal services) on the basis of a relatively low level of reassurance from some professionals despite the lengthy family history. It is entirely reasonable to retain a level of optimism for the future of children in the care of their parents and to wish to support parents, despite their family history. F1 had clearly managed to care for 2 of her children for some years. It may have been that work with F1 to build trust and to understand what may have been driving her avoidance of midwifery services may have led to an outcome where a plan could have been put in place to support and keep the children safe at home; • It is perhaps not surprising that F1 may have avoided booking her pregnancy and then wanted to avoid services given her previous experiences of carrying children to term. The opportunity to explore this avenue with F1 was lost however when the presenting concerns were not placed within the wider family history, and an assessment of disguised compliance concerns was not conducted. Professionals should be aware of the dangers of disguised compliance and this case provides a good case study to consider when engaged in multi-agency training. 31 The NSPCC website7 contains a range of risk factors and areas to recognise around disguised compliance. In this case, the following have been identified: Professional Over-optimism The reviewers believe that there was an element of professional over-optimism at times in working with this family and that had some of the risks identified in the time prior to the birth of KS and S1 been located within threshold and pre-birth protocol documents, this may have led to an assessment of need at an earlier stage. Given the extensive family history and immediate concerns about non-engagement, it is felt that a level of optimism was applied and that other, positive feedback about the family‘s circumstances was given primacy despite the likely impact of caring for an additional two infant children in the near future. Parents Deflecting Attention Information provided suggests that, in this case, F1 did engage with one group of professionals whilst disengaging with another. Just prior to birth, F1 engaged with the health visitor in February and March 2017. This decision to engage with the health visitor at the expense of midwifery, who had attempted to engage with F1 over a period of months, suggests deflecting of attention. Failure To Engage With Services Information provided suggests that this has been a longstanding issue across several years, with instances of not engaging with services and not attending appointments going back at least to the pregnancy of S6, where there were issues around non-attendance at ante-natal appointments. In the interim, prior to the birth of KS and S1, there have been reported instances of non-attendance with agencies such as the family GP, Orthoptist, vaccination appointments, Speech & Language Therapy Appointments, some missed appointments with a Family Support Worker, some missed appointments with IRIS and, most recently, a considerable history of missed appointments with community midwifery and the Hospital prior to the birth of KS and S1. Furthermore, there appear to have been a range of reasons given for non-attendance, such as illness and child illness, coupled with instances where concerns regarding evasion may have arisen due to midwifery attending a property that has clear signs of occupancy but there has been no response at the door. Avoiding Contact with Professionals In addition to non-attendance, there appears to have been issues over time with being unable to get hold of F1 by telephone. At times, this may have been due to changing telephone numbers around domestic abuse issues, however there appear to be other periods where this may not necessarily have been applicable when professionals have not been able to get in touch with F1 directly. Effective Work With Disguised Compliance Regarding working effectively with disguised compliance, the NSPCC note a range of factors, all of which are applicable to this case, such as establishing facts, not accepting presenting behaviour or reasons for non-engagement, understanding exactly what is occurring, recording the child’s perspective and identifying positive outcomes to be achieved to assist families in 7 NSPCC risk factors - https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/disguised-compliance/ 32 moving on from disguised compliance behaviour. Completing this type of work with families would have been assisted by a multi-agency approach in this case. The reviewers also note the issue of chronologies in addressing disguised compliance. Chronologies are widely recognised as an effective tool in conveying knowledge and assisting effective risk assessment around a wide range of safeguarding issues. Regarding disguised compliance, a complete chronology can provide clear, easily identifiable patterns of disguised compliance behaviour and can assist professionals in placing current behaviour within the context of family history. Reviewing the SCSC chronology provided for this case, this appears to have been developed to cover the scoping period of this review from the beginning of 2015. The document notes some key events, however does not highlight disguised compliance concerns or history of non-attendance at appointments, although SCSC may not have been fully aware of this behaviour happening within other agencies (such as health) over time. The combined chronology put together for this serious case review – where examples of these instances appear across the safeguarding partnership in one document – highlights the importance of multi-agency collaboration and information-sharing to build a clear picture of issues such as disguised compliance across the safeguarding network when working with families. Section Five – Key Lines of Enquiry The terms of reference asked 5 key questions that were to form the lines of enquiry for this review. They were: 5.1. Was support offered to the family appropriate, timely and adequate? F1 had received support in a period that extended over 20 years. When her children were born SCSC made interventions that were appropriate and proportionate. This ensured F1’s first 3 children were living in a safe environment. F1 was given support and help with her drug use issues over this period. This support was assessed as part of the Early Help programme. When F1 became pregnant with KS and S1 she received universal services. SCSC did not, despite 4 MARFs from health professionals and earlier cause for concern notifications, put in place any specific assessment processes or support and made a decision that F1 would receive universal health services. This was not sufficient, and the invocation of pre-birth procedures would have provided the opportunity to put in place more timely and supportive services. 5.2 Was sufficient scrutiny of drug use by parents provided? Prior to F1 becoming pregnant she had received significant support for her drug issues. Neither health professionals nor SCSC were given any reason to believe that this had not been successful. F1 avoided appointments and did not readily seek further help; it is noted that drug testing does occur periodically throughout pregnancy as a matter of course and one hypothesis may be that F1 (and M1) may have avoided ante-natal care so as to avoid drug-testing 33 Given none of the children resident with F1 were on any form of child protection plan and, without further evidence of drug abuse, any form of testing would have been considered disproportionate. It is noteworthy however that there is no evidence of contact with IRIS to understand whether M1 or F1 had had any further interaction with that service or to understand in greater depth what they key issues (e.g. usage triggers, patterns of use and abstinence) may have been for both M1 and F1 to consider in any assessment or support of this family going forward. 5.3 Was there sufficient challenge by practitioners if the parents did not comply with advice and instructions? There is no evidence that F1 did not comply with instructions by professionals. The exception was the attendance at appointments. This issue is dealt with in the report, but it is clear in this case there was insufficient challenge on this issue by any professional. 5.4 Was there appropriate safeguarding supervision of front-line practitioners? In the case of health professionals there were clear lines of supervision that were followed. However, given the issue around missed appointments and the fact that SCSC did not follow up on MARFs submitted by health professionals, there needs to be clearer levels of supervision in safeguarding cases. Supervision occurred on a sufficiently frequent basis on this case, however records reviewed were not sufficiently reflective and did not appear to locate current concerns or behaviour within previous concerns. This was also observed in management decisions on the MASH assessment of 27 March and the single assessment in mid-April 2017. 5.5 Was appropriate advice provided and followed regarding safer sleeping practices? Health visitors, midwives both ante-natal and post-natal provided safer sleeping advice and smoking cessation advice in an appropriate way. Section Six – Key Findings KS tragically died from an unascertained cause. There was no known action that professionals in Sandwell could have taken to prevent this death. This case has demonstrated that if agencies in Sandwell had better shared information and complied with both national and local procedures, the level of support to F1 and her family could have been more effective but would not have affected the final tragic outcome for KS. 34 Section Seven – Recommendations 6.1 Recommendation one The Board should undertake a review of safeguarding training to ensure that pre-birth procedures are understood and implemented appropriately. 6.2 Recommendation two The Board should seek assurance from the Health Forum that health professionals engaged in antenatal and post-natal work are trained in the appropriate use and application of escalation procedures, issues of disguised compliance and over optimistic assessments. 6.3 Recommendation three The Board should conduct a review of training and procedures to ensure professionals are aware of the significance of frequent missed appointments by individuals and disguised compliance behaviour, particularly in the case of pregnant women. They should also consider a review of policies regarding the procedure to follow when an individual regularly fails to attend appointments. 6.4 Recommendation four The Board should consider conducting a multi-agency learning event to examine issues of: • information sharing; • disguised compliance; • professional curiosity; • over optimism; • lack of hypothesis forming; • escalation procedures; • pre-birth procedures. 6.5 Recommendation five The Board should satisfy itself that the processes within the MASH are fit for purpose and professionals understand their responsibilities with regard to the Sandwell Multi-Agency Thresholds Document, the Sandwell Pre-Birth Procedures document and the way in which they are applied. The Board should ensure there is appropriate risk thresholds training. 6.6 Recommendation six F1’s difficult parenting history has been recognised in this review. The Board should consider what support is available for parents who have grappled with ongoing drug use, mental health and domestic abuse. In particular, the Board should consider the connectivity between adult services (drug and alcohol and mental health services in particular) and those cases that involve a child at risk. 6.7 Recommendation seven Work is currently underway, within health, to develop a safeguarding children group. This group should include representatives from across the health spectrum and Children’s 35 Services. The terms of reference for the group should ensure that the focus of this group is to share information around children and families at risk and need of support. There needs to be clarity about the way in which this group interacts with current MASH arrangements. The Clinical Commissioning Group may be best placed to manage this process. Section Eight – Conclusion This is a tragic case in which a 2-month-old baby has died, and the cause of death is unascertained. The pathologist was able to say that there was no evidence of overlay or any form of non-natural causes of death. This review has established that there was no action any professional could have taken to prevent this tragic death. There are however a number of areas where agencies need to consider improving their safeguarding services. F1 had a history of drug abuse and her first 3 children had been placed with relatives because there was a concern that they would suffer from neglect if left in her care. This family history should have alerted to professionals to the risks that F1’s unborn children might face and the potential impact of the demands of caring for twin infants alongside two older children. In fact, the twins were due immediately after a particularly traumatic time in F1’s life which further heightened risk to the unborn babies. Several referrals were made to Children’s Services but on each occasion, it was decided that assessment and potentially child protection procedures did not need to be considered. This was a mistake and Sandwell’s Pre-Birth Procedures should have been adhered to. Sandwell Children’s Services have now been placed in a Trust and the issues considered in this report should form part of improvement planning. Appendices Appendix One – Terms of reference Sandwell Safeguarding Children Board Terms of Reference in respect of KS The period of Review for this Serious Case is from August 2015 when mother finished a methadone reduction programme to the date of death. Reference should however be made about the extent of agency involvement prior to this period (if relevant and appropriate). The focus of this SCR will be on KS and their mother, father and step-father. However, please incorporate information about siblings and wider family if you feel this directly influenced any decision-making in the safeguarding of KS. A family key for the immediate family will be sent separately. Agencies that identified significant background history (where relevant) on family members predating the review period and subsequently should submit a brief summary account of that history. 36 All agencies should review all records held electronically, on paper or in patient held records. At this point, in-depth chronologies only are being requested and should be completed using the template provided by Sandwell Safeguarding Children Board. Please note any learning, opportunities for improvement, or good practice in the comments section of the chronology. Genogram A family key is supplied with paperwork. All agencies should submit a genogram if there is additional information. Chronologies The following agencies should submit chronologies on the template provided by Sandwell Safeguarding Children Board: • Children’s Social Care • SWBH NHS Trust • Sandwell and West Birmingham CCG (GPs) • Birmingham Community Healthcare NHS Trust • West Midlands Police • Black Country Women’s Aid • Sandwell Drug and Alcohol Support Service o Education have been requested to provide an overview report o Police have been requested to complete criminal background checks Information from Agencies is requested by the 31 January 2018. The Terms of Reference are as described in Working Together • To keep under consideration whether further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews. • To establish a factual chronology of the action taken by each agency. • To assess whether decisions and actions taken in the case comply with safeguarding procedures. • To determine whether appropriate services were provided in relation to the decisions and actions taken in the case. • To recommend appropriate interagency action and learning from the case in the light of the findings. • To assess whether action is needed in any agency. • To examine interagency working and service provision for children. • To establish whether interagency and single agency policies and procedures supported the management of the case. • To consider how and what contributions can be sought from family members. • To establish lessons for practice and clear recommendations and an action plan from the overview report. Key Lines of Enquiry and Scope of the Review When completing a chronology could agencies please consider the following points: 1. Was support offered to the family appropriate, timely and adequate? Practitioners should review how support was assessed and evaluated. 2. Was sufficient scrutiny of drug use by parents provided? Both by the Drug and Alcohol support service and the midwifery service. 37 3. Was there sufficient challenge by practitioners if the parents did not comply with advice and instructions? Practitioners should comment on instances requiring challenge and whether actions taken and outcome were satisfactory. 4. Was there appropriate safeguarding supervision of front-line practitioners? Was supervision carried out within timescales and monitored appropriately? 5. Was appropriate advice provided and followed regarding safer sleeping practices? All agencies should consider whether their policies, procedures, management and supervision resources adequately supported practitioners working with this case and aided appropriate decision making and professional judgement. In addition to the requirements of Working Together to Safeguard Children the overview report writer will: • Comment on whether individual agency chronologies have addressed these Terms of Reference and all relevant issues. • Arrange meetings / interviews with practitioners as appropriate • Interview any relevant family members if appropriate • Analyse the inter-agency working assessments and provision of services. • Determine whether actions taken, decisions made were in accordance with current safeguarding policies, procedures and practice. • Comment on professional judgement and decision making based on evidence. • Consider what different decisions if any may have led to a different conclusion. • Identify whether more could have been done, the lessons learnt and make findings and recommendations. • Involve agency decision makers in an interim and final analysis of the decision making in this case based on the available information and case material presented • Provide an executive summary. • Present the findings to the Sandwell Safeguarding Board and Partner agencies as a learning event if so invited. Sandwell Safeguarding Children Board will follow Working Together 2015 which states: ‘The LSCB should oversee the process of agreeing with partners what action they need to take in light of the SCR findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.’ Appendix Two – Pre-birth procedures Referral Where agencies or individuals anticipate that prospective parents may need support services to care for their baby or that the unborn child may have suffered, or be likely to suffer, significant 38 harm, a referral to local authority children's social care must be made as soon as concerns are identified. A referral should be made at the earliest opportunity in order to: • provide sufficient time to make adequate plans for the baby's protection • provide sufficient time for a full and informed assessment • avoid initial approaches to parents in the last stages of pregnancy, at what is already an emotionally charged time • enable parents to have more time to contribute their own ideas and solutions to concerns and increase the likelihood of a positive outcome for the baby • enable the early provision of support services so as to facilitate optimum home circumstances prior to the birth. Early referral is also essential if legal action is required to protect the unborn child. Statutory guidance advises local authorities to take into account the risk of early birth and to send pre-proceedings letters/letters of issue before 24 weeks. The referrer should clarify as far as possible, using the local early help assessment arrangements or the equivalent, their concerns in terms of how the parent's circumstances and/or behaviours may impact on the baby and what risks are predicted. Concerns should be shared with prospective parent/s and consent obtained to refer to local authority children's social care unless obtaining consent in itself may place the welfare of the unborn child at risk e.g. if there are concerns that the parent/s may move to avoid contact with investigative agencies. Pre-birth assessment A pre-birth assessment should be undertaken on all pre-birth referrals as early as possible, preferably before 20 weeks, where: • a parent or other adult in the household, or regular visitor, has been identified as posing a risk to children • a sibling in the household is subject of a child protection plan • a sibling has previously been removed from the household either temporarily or by court order • the parent is a looked after child • there are significant domestic violence issues • the degree of parental substance misuse is likely to impact significantly on the baby's safety or development • there are significant concerns about parental ability to self-care and/or to care for the child e.g. unsupported, young or learning disabled mother • any other concern exists that the baby may have suffered, or is likely to suffer, significant harm including a parent previously suspected of fabricating or inducing illness in a child or harming a child • a child aged under 13 is found to be pregnant. Pre-birth Strategy Meeting/Discussion and Section 47 enquires The need for a section 47 enquiry should be considered and, if appropriate, initiated at a strategy meeting/discussion held as soon as possible following receipt of the referral. The expected date of delivery will determine the urgency of the meeting Consideration of the need to initiate a section 47 enquiry and hold a strategy meeting/discussion should follow the procedures described in chapters 8 and 9 of these procedures (Strategy Meeting/Discussion and Child Protection Enquiries). Ideally the strategy meeting/discussion 39 should take place at the hospital where the birth is planned or expected, or where the responsible midwifery service is where it would be if the parents have not booked for service provision. The meeting must decide: • Whether a section 47 enquiry and pre-birth assessment is required (unless previously agreed at any earlier ante-natal meeting). • What areas are to be considered for assessment. • Who needs to be involved in the process. • How and when the parent/s are to be informed of the concerns. • The actions required by adult services working with expectant parent/s (male or female). • The actions required by the obstetric team as soon as the baby is born. This includes labour/delivery suite and post-natal ward staff and the midwifery service, including community midwives. • Any instructions in relation to invoking an emergency protection order (EPO) at delivery should be communicated to the midwifery manager for the labour/delivery suite. The parents should be informed as soon as possible of the concerns and the need for assessment, except on the rare occasions when medical advice suggests this may be harmful to the health of the unborn baby and/or mother. The section 47 enquiry must make recommendations regarding the need, or not, for a pre-birth child protection conference. Pre-birth Child Protection Conferences A pre-birth conference is an initial child protection conference concerning an unborn child. Pre-birth conferences should always be convened where there is a need to consider if a multi-agency child protection plan is required. This decision will usually follow from a section 47 enquiry and pre-birth assessment. A pre-birth conference should be held where: • a pre-birth assessment gives rise to concerns that an unborn child may have suffered, or is likely to suffer, significant harm • a previous child has died or been removed from parent/s as a result of significant harm • a child is to be born into a family or household that already has children who are subject of a child protection plan • an adult or child who is a risk to children resides in the household or is known to be a regular visitor. Other risk factors to be considered include: • the impact of parental risk factors such as mental ill health, learning disabilities, substance misuse and domestic violence • a mother under 18 years of age about whom there are concerns regarding her ability to self-care and/or to care for the child. A pre-birth conference has the same status as an initial child protection conference and must be conducted in a comparable manner (see Child Protection Conferences). The conference should be held as soon as the assessment has been completed and at least 10 weeks before the due date of delivery. Where there is a known likelihood of a premature birth, the conference should be held earlier.” |
NC52739 | Death of a 15-week-old baby boy in July 2021. Kubus died while sleeping on an inflatable mattress along with his mother and was sleeping on his stomach. Learning themes include: pregnancy care through antenatal, perinatal and postnatal stages; housing; disclosure of domestic abuse; cultural competence; inaccuracies in documentation and record keeping; communication and escalation pathways; and risk assessment processes embedded during Covid-19, which may have contributed to reduced visibility and support. Recommendations include: explore the barriers and operational challenges to having contemporaneous accessible electronic records, with a view to identifying solutions to prevent gaps in information sharing which can lead to risk and result in harm; gain assurance that operational systems are robust in ensuring they hold the most recent contact information for service users; commission and sustain Identification and Referral to Improve Safety (IRIS) provisions in primary care; ensure that staff understand the cultures of the demographic that they work with; if English is a second language ensure that information delivered and received is checked to avoid miscommunication and consider an offer of an interpreter if necessary; recognise the importance of including fathers in assessments, whether absent or living in the household; and ensure that accurate quality documentation is maintained, irrespective of the challenges posed to staff.
| Title: Child safeguarding practice review: Kubus. LSCB: Waltham Forest Safeguarding Children Board Author: Sabeena Pheerunggee and Ghislaine Stephenson Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page | 0 Child Safeguarding Practice Review February 2023 Kubus Review authors: Sabeena Pheerunggee, Named GP for Safeguarding, NHS North East London and Ghislaine Stephenson, Think Families Lead Nurse, Barts Health. Page | 1 Contents 1. Introduction and circumstances for the review .................................... 2 2. Methodology and agencies involved ..................................................... 2 3. Background .............................................................................................. 3 4. Sudden Unexpected Death in Infancy (SUDI) ..................................... 4 Identified impacting factors during the timeframe of the review: 5. Covid-19 ................................................................................................... 5 6. Pregnancy care (ante, peri and postnatal) ........................................... 6 7. Housing .................................................................................................. 10 8. Domestic abuse ..................................................................................... 12 9. Cultural Competence ............................................................................ 15 10. Father ..................................................................................................... 16 11. Documentation ...................................................................................... 17 12. Conclusion ............................................................................................. 19 Page | 2 1. Introduction and circumstances for the review 1.1 Under Working Together 2018, the Local Safeguarding Children Partnership known as Waltham Forest Safeguarding Children Board agreed to a recommendation from the One Panel (multi-agency forum that takes referrals for local or statutory reviews and makes recommendations against the statutory criteria) to undertake a child safeguarding practice review (CSPR). 1.2 This CSPR concerns the unexpected death of a 15-week-old baby boy, who we are calling Kubus, as well as the services provided to Kubus and his family during his mother’s pregnancy and his short life, in which domestic abuse was a significant feature. The cause of death was recorded as sudden unexpected death in infancy (SUDI). 1.3 It is imperative that Kubus and his family have their identity protected. The name Kubus was chosen by his mother and is the term of endearment she would use to refer to him. We have referred to mum as Agata and father as Pawel to maintain their anonymity. 2. Methodology and agencies involved 2.1 This review has been carried out using the Waltham Forest ethos of a Think Family approach with strength-based principles. 2.2 The review seeks to understand why things happened in the way that they did. Broadly this means using Kubus’ circumstances as a ‘window on the system’, asking the question: What does Kubus’ and his mother’s experience tells us about how systems work? This systems approach focuses on multi-agency professional practice. The aim is to look for areas that relate to systemic issues, which will lead to changes in practice. The review is not about blame. Its focus is very much on learning and improving practice for the future. 2.3 Data was gathered from a variety of sources, including the review of existing documentation alongside data provided by front line practitioners and their managers / senior managers in the review team. We have used an evidence-based approach to support our recommendations, sought through a literature review. 2.4 A key part of undertaking a CSPR is to gather the views of the family regarding the services they received from agencies and share findings of the review with them prior to publication. The reviewers met with Agata to hear and understand her experience to ensure the voices of her and Kubus were reflected in the review 2.5 The final report has been authored by Dr Sabeena Pheerunggee, Named GP for Safeguarding, NHS North East London and Ghislaine Stephenson, Think Families Lead Nurse, Barts Health. The process has had oversight by the Independent Scrutineer / Chair of the Waltham Forest Safeguarding Children’s board, Dave Peplow. Page | 3 2.6 The review period is from September 2020 until 24 July 2021, covering the antenatal period as well as the 15 weeks of Kubus’ short life. It should be noted that increased stress had been placed on health, social care and policing services due to the Covid-19 Pandemic, in which modified working practices were in place. 2.7 The review group comprised senior managers from all agencies involved with Kubus and his family in the 10 months before his death. The review group took part in a workshop with frontline practitioners who knew Kubus and his family. The professional, open and honest way all concerned conducted themselves throughout the process was noted and valued by the authors. 2.8 Agencies in attendance: • London Borough of Waltham Forest o Safeguarding Team o Early Help Team o Housing Department • North East London Foundation Trust (NELFT) – Health Visiting Services • Metropolitan Police Service • Hertfordshire Community NHS Trust 2.9 It should be noted that whilst the authors represent Barts Health NHS Trust and General Practice (Newham), apologies were received from the practitioners actually working with the family. Their input could have provided case context and nuance that may have generated greater understanding of some of the detail. 3. Background 3.1 Agata came to the UK from Poland as a teenager. She advised us of her exposure to domestic abuse as a child in Poland. This continued during her life in the UK in her family network and in her intimate partner relationships. Agata explained to us that domestic abuse was normal to her, and she did not believe that agency intervention would make a difference to her lived experience. 3.2 Information submitted to the review identified Kubus’ Father, as being previously arrested for domestic common assault and discussed at a multi-agency risk assessment conference (MARAC). We know that he is also of Polish Background. 3.3 During the antenatal period, Agata and Pawel were living in a privately rented house of multiple occupancy (HMO) in Newham. Agata was receiving primary care in Newham and antenatal care from the high risk team at the Royal London Hospital, Tower Hamlets, due to severe high blood pressure in pregnancy. 3.4 At the time of his birth Kubus’ parents had been evicted from the HMO in Newham; their landlady had told them they could not bring a baby back to that address. Kubus’ mother and father were unaware of the law in relation to evictions during Covid-19. Whilst Kubus’ mother was an inpatient, post-delivery, her partner had moved them into Page | 4 an HMO in Waltham Forest. However, Universal Services (0-19) in Health had the old address in the neighbouring borough of Newham. 3.5 The first disclosure and reporting of domestic violence and abuse (DVA), in the postnatal period resulted in multi-agency involvement, despite which there was escalation of DVA which resulted in the relocation of Agata and Kubus to Hertfordshire. 4. Sudden Unexpected Death in Infancy (SUDI) 4.1 The Coronal report identified the cause of death as SUDI. Kubus died while sleeping on an inflatable mattress along with his mother and was sleeping on his stomach. This does not comply with safe sleeping guidance. In addition, the SCR process revealed that smoking and alcohol were present in the households that Kubus lived in. 4.2 SUDI is a descriptive term applied to any infant death that was not anticipated. Child Death Reviews 2019i, exploring SUDI, identified that the major risk factors are well known and include families living within a context of background risks such as, deprivation and overcrowding and co-sleeping, domestic violence, smoking and alcohol and / or poor mental health. The advice on reducing the risks is evidence-based and well established. Despite this, the report states that ‘it is apparent that while the safer sleep messages may be rigorously delivered by health professionals, many of those families who are most at risk are either unwilling or unable to receive or act on those lessons for a multitude of reasons.’ ‘And to bring about more effective working, we need to have a better understanding of the circumstances in which these babies are dying, how and why their parents are making choices about their infants’ care and sleeping arrangements, and how practitioners are seeking to engage and work with families whose children are at risk.’ This was further identified in the 2020 report ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harmii’. 4.3 Co- sleeping with an adult on a bed is a recognised risk factor for infant death, especially in babies under 6 months of age. The risk is greater if co-sleeping occurs on a sofa or a chair and if the adult has consumed alcohol. The possible mechanisms involved include accidental overlay and / or alterations in the baby’s body temperature (overheating). Section 6.4 provides further narrative. 4.4 During the course of this review, we will explore in greater detail the contributing factors that are applicable to this family and the system level learning. These will include but are not limited to domestic abuse, housing, partnership working with a number of points for consideration for the Strategic Partnership. i Child Death Reviews: year ending 31 March 2019 ii Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm Page | 5 Identified impacting factors during the timeframe of the review: 5. Covid-19 5.1 The Covid-19 Virus was first noted in the United Kingdom in January 2020, with the first national lockdown being announced in March 2020, and various amendments to lock down measures in place until December 2021. 5.2 Due to the extraordinary circumstances presented by Covid 19 and the need to ensure adequate infection control measures, working practices were rapidly modified and heavily reliant upon virtual interactions with service users. Furthermore, staffing across the operational safeguarding partnership was affected due to the redeployment of staff, direct and /or indirect leave (i.e. shielding, bereavement, stress and anxiety). Therefore, caseloads for front line staff increased exponentially. 5.3 The balance between controlling infection rates universally, and the requirements for seeing a service user face-to-face, meant that by default, most services had to initially use a virtual / telephone contact model. This may account for the lack of face-to-face visits in the home from 0-19 universal and social services, consultation in GP surgeries and community health services. Thus, having an impact on visibility and disclosure of safeguarding concerns, creating the paradox of staying safe at home, while questioning if home is a safe place. One of the natural consequences of virtual / telephone contact is the lack of non-verbal cues and information the professional might receive during an assessment. 5.4 A study conducted by UCL iiigathered the views of 663 health visitors to understand how Covid-19 affected their work. The study reflects the working practices adopted in the borough during the period that this review covers. Health visitors were unanimously worried about domestic violence and widening health inequalities, due to the challenges placed by staff redeployment, inadequate PPE and increasing caseloads. A Nursing Times article ivreflects that urgent workforce planning needs to take place because “robust delivery of the work of health visitors with all families is an essential way in which governments can ensure more positive outcomes not only for children and families, but also for society” 5.5 Police data from the Office of National Statistics vfrom 2020, demonstrates domestic abuse cases flagged were on the rise with an 18% increase from the same period in 2018. Refuge, one of the leading domestic abuse organisations reported that calls to the UK Domestic Violence Helpline increased by 25% in the seven days following the announcement of tighter social distancing and lockdown measures by the government. During the same period, there was a 150% increase in visits to the Refuge website (as cited in ‘The pandemic paradoxvi’ research). iii UCL - The impacts of COVID-19 on Health Visiting in England iv Nursing Times – survey shows 60% of health visiting teams affected by Covid-19 redeployment v Domestic abuse during the coronavirus (COVID-19) pandemic, England and Wales: November 2020 vi The pandemic paradox: The consequences of COVID‐19 on domestic violence Page | 6 5.6 The impacts of the Covid-19 Pandemic are a significant feature throughout this review, affecting service delivery and sustained, modified ways of working the ‘new norm’. We will explore further in other identified impacting factors discussed below. Question to the board / areas to strengthen practice Reflecting on the impact of Covid-19 to service delivery and quality outcomes, how does the partnership ensure that should we see another such crisis, we ensure that core services are maintained and provided with timely adequate resource to support their functions? Identified impacting factors during the timeframe of the review: 6. Pregnancy care (ante, peri and postnatal) 6.1 Agata experienced a high-risk pregnancy due to a diagnosis of hypertension (high blood pressure). This meant her care was transferred to the Royal London Hospital, a tertiary centre and consultant–led, with increased frequency of antenatal assessment with doctors (secondary and primary care) and midwifes. This is opposed to low-risk pregnancies with the care being midwifery-led. In addition, she was assessed and monitored by the renal, cardiology and endocrine teams. This means that Agata had high visibility to numerous health professionals in the antenatal period. The reason is that hypertension early in pregnancy, in young women, is not common and can hold significant risks during pregnancy. While the medical management cannot be faulted, the psychosocial assessment by health was absent and not considered to be a potential contributing factor to her condition. This is a significant factor considering medical records do not reflect enquiry to facilitate disclosure of the domestic abuse, including coercive control she was experiencing in the antenatal period. This aligns with findings that victim / survivors of domestic abuse will have up to 35 encounters with health before disclosure. 6.2 Her perinatal experience at the Royal London Hospital was distressing due to her experience of racism from the midwifery team. This was a further contributing factor to not sharing her social circumstances. She advised us had she been asked about abuse and her circumstances, she would have disclosed but was reticent on what they would do, due to her previous experiences with services. 6.3 The table below demonstrates what best practice should be in the postnatal period, the adaptations in place due to Covid-19 and what actually happened for Kubus and Agata, and why this matters. Postnatal time frame: Prior to Discharge Covid-19 service modification: No change What should happen? What happened? Why does this matter? - Breast feeding facilitation and support. - Baby check - Maternal check (wound, blood pressure, bowels and bladder) - Check discharge address - Ensure car seat is available for transportation - Discuss safe sleeping / smoking / alcohol and the risk factors from the wider household - Discuss next steps regarding her hypertension Postnatal baby check: - Bruise on right side of babies head - No escalation from midwife who noted bruise - No further documentation from other practitioners - No communication in the discharge summary to the GP. - Discharge summary does state home BP monitoring and escalation plan if not controlled - Failure to establish discharge address Agata advised: - she did not feel supported for breast feeding despite asking - No one rechecked her address or housing situation The bruise could have been related to: - birth trauma - non-accidental injury from professionals or parents or another patient on the ward. A lack of professional curiosity meant there was no escalation and communication to the wider teams for assessment and monitoring. See further reasoning below Breast feeding has many protective factors for mother and baby such as: - child immunity - protective for SUDI (check literature) Postnatal time frame: Day 1 Covid-19 service modification: No change What should happen? What happened? Why does this matter? Midwife led new birth visit (at home) Failed postnatal home visit, because Kubus and his family were no longer residing at the Not having correct contact details creates: - a delay for new mums (which is a very vulnerable time especially during Covid-19 when there were a number of social distancing measures in place meaning wider social Page | 8 address documented in Newham. Significant because, best practice would be for the correct address and contact to be confirmed before discharge. networks may not have been available to support mum) and the support they may require in the immediate postnatal period: o Maternal physical health o Child health o Breastfeeding o Psychosocial challenges o Safeguarding risks Additional workload to an already understaffed over stretched service, compounded by the challenges of service delivery during Covid-19. Postnatal time frame: Day 5 Covid-19 service modification: No change What should happen? What happened? Why does this matter? - Community midwife visit for blood spot sample from baby - Review of baby including: o weight o feeding o jaundice - Postnatal review of mum including: o Wound healing o Mood / bonding o Blood pressure Blood spot took place, however, the documentation on paper records was brief. There had not been a transfer of paper records onto the electronic record system (ERS), in line with Bart’s process. Blood spots detect 9 conditions and are essential to prevent disability and save babies’ lives with early treatments and improve health outcomes. Inadequate documentation including incorrect contact / address details, plus failure to transcribe to the ERS system have the following implications: 1) If an issue was detected, how would the team follow up, to ensure timely and correct treatment? 2) Inability to establish how mother and child were progressing post-discharge, and if there were any health or social care concerns that needed monitoring and that would form part of the risk assessment and management process with future interactions 3) Organisational risk due to failure to adhere to professional standards for record-keeping, thus having medico-legal implications Page | 9 Postnatal time frame: Day 10 Covid-19 service modification: Due to the infection control risk posed, assessments took place to establish if the home visits could be changed to virtual contacts What should happen? What happened? Why does this matter? Health visitor new birth home visit for: - holistic visit - review of mother and child - assessment of environment and safety - provision of advice on feeding, safe sleeping, vaccinations and adjusting to life as a new parent Visit happened on day 14 and was virtual. The delay was due to: 1) Needing to make contact with Agatha and determine their new address. 2) Transfer of care from Newham 0-19 universal services to NELFT 0-19 universal services (commissioned at the time, in Waltham Forest) Due to not establishing the discharge address, there were delays in service delivery because of the way systems are set up. Postnatal time frame: 6 weeks Covid-19 service modification: Primary care Visit - X1 face-to-face visit for baby for physical examination and documentation in the red book X1 face-to-face visit for mum to assess physical / mental / emotional health and wellbeing and explore any potential safeguarding challenges she may be experiencing What should happen? What happened? Why does this matter? - The 6-week baby check was delayed until 8 weeks (with first childhood immunisations) as part of infection control measures at the time. - The maternal check was now virtual, and should a physical examination be required, this would take place at the 8-week visit for baby Kubus not seen until 10 weeks, due staff sickness / absence. The maternal check also happened at 10 weeks There was an absence of appreciative inquiry as to why they had come from Hertfordshire to the appointment Staffing provision was significantly affected during Covid-19. Therefore, unavoidably impacting service delivery. In the case of domestic abuse, virtual and reduced face-to-face contacts remove opportunity to facilitate disclosure and support for mother and child. The absence of professional curiosity, create barriers between service users and professionals, as they may not feel important and cared for. It also fails to support the safeguarding ethos of making every contact count. Page | 10 6.4 A child’s life journey starts from the point of conception. The challenges faced by the mother in the ante, peri and postnatal periods reflect that services had not employed a professionally curious practice. Furthermore, it brings to question if the perinatal experience of discriminatory practice influenced the quality of care received by Agata and Kubus, in respect to escalation, investigation and information sharing of the bruise, and ascertaining correct contact details. In short, there is a snowball effect from the lack of professional curiosity, resulting in ill-informed risk assessment and onward care delivery. Questions to the board / areas to strengthen practice o Barriers to professional curiosity, workforce challenges, especially with the additional multi-factorial pressures created by Covid-19 - how do we overcome this? o Despite having the question regarding domestic abuse on antenatal forms, how can we assure ourselves that 1) the question is asked 2) the question is asked in such a way that supports and facilitates disclosure? o All partners have non-discriminatory values and policies to reflect this in practice. How, do we ensure that service users do not experience discrimination due to their protected characteristics, that may differ from those of the professionals working with them? The barriers and operational challenges to having contemporaneous accessible electronic records should be explored, with a view to identifying solutions to prevent gaps in information sharing which can lead to risk and result in harm. This may require work between commissioners for maternity care and the clinical leads, in conjunction with secondary and community care. Identified impacting factors during the timeframe of the review: 7. Housing 7.1 Migration has always and will continue to remain a significant aspect of living in London, in part due to the availability and cost of housing. During the antenatal and perinatal period, there was an absence of professional curiosity or understanding of Agata’s living circumstances and any risks this may pose to Kubus. The housing in Newham and Waltham Forest were both privately rented HMOs. When professionals fail to understand the living circumstances of service users, this creates challenges to contextualising risk and the support offered. The significance, in the context of SUDI, complicated by domestic abuse, is the risk posed by overcrowding, environmental factors such as smoking, drugs & alcohol, damp & cold. 7.2 When living in unsecure tenancy this means that migration across boroughs and sometimes beyond the local area is highly probable. This is evidenced twice in Agata’s and Kubus’ circumstances; the first due to eviction, so moving to a neighbouring North East London (NEL) borough and the second due to needing a safe residence. Thus, seeing them moving to Hertfordshire. The wider implication of migration is access to Page | 11 services because community health and social care services are commissioned at a borough level. Therefore, as previously referenced the quality and safety depends on effective, timely information sharing, otherwise there will be gaps in service delivery. This has been evidenced throughout. 7.3 Pawel and Agata were unaware of their tenancy rights and of the law in relation to evictions during Covid-19. They also did not know who to contact for support and guidance. The impact on housing circumstances during the pandemic was managed at government level under the Corona Virus Act. Instructions for landlords and tenants stated that rental evictions should not take place in this time, in addition to notice periods being extended. This was in place throughout the timeframe of this review. This brings into question how authorities support private renters to receive information about their rights. This may be more of a challenge for those who are not native to the UK. Had Agata and Pawel always resided in Waltham Forest they may have received information on their rights via the connecting communities’ work that is alive in Waltham Forest, (the only London Borough to be part of a government pilot scheme which aims to connect communities and improve social integration.) 7.4 It is imperative to examine Agata and Kubus’ experience when they moved to Hertfordshire to stay with Agata’s mother and younger sister. She describes the property as small with the second bedroom being like a store cupboard. Agata told the reviewers she did not have a cot and was sleeping on an inflatable mattress in the lounge, with Kubus. She has no recollection of anyone asking her about safe sleeping or whether she had a cot for Kubus in Hertfordshire. In this residence the challenges of over-crowding, smoking and alcohol in addition to the absence of safe sleeping provision are significant risk factors contributing to SUDI. Furthermore, the review established absence of information sharing from Waltham Forest to Hertfordshire, thereby rendering the family invisible to universal and social services in Hertfordshire. Questions to the board / areas to strengthen practice o As a results of migration, every health encounter should confirm that the service user’s address and contact number are up to date. This does not have to be an additional workload, because when we are confirming patient identity this can be part of the check. This is a system that is inbuilt with most corporate companies and forms part of their script when in contact with service users. For health, this can form part of a risk assessment and identify social housing issues which can potentially have wider physical and mental health implications as well as potential safeguarding concerns. o How can the board gain assurance that operational systems are robust in ensuring they hold the most recent contact information for service users? o A ‘wicked’ issue is that some people may be reticent to share new addresses for a number of reasons such as fear of needing to find a new GP, without understanding the impact of the community services that they will require due to commissioning. Therefore, awareness to service users could be considered to improve their understanding of the need to provide up to date addresses and contact details which will ensure they receive correct and timely service support when required. o How are private tenants informed of their housing rights? Page | 12 Identified impacting factors during the timeframe of the review: 8. Domestic abuse 8.1 Domestic abuse is well documented in pregnancy, which is why all pregnant women are routinely asked in their antenatal and postnatal appointments if they have experienced DVA. The impact of domestic abuse on the unborn and all children within relationships where domestic abuse is a feature has a strong evidence base that is documented. Recent research demonstrates that maternal stress causes an increase in the stress hormone cortisol. When excess cortisol crosses the placenta, this can have a long-term physical and psychiatric health impact on the offspring. Babies, children and young people, will also have a sustained cortisol response to domestic abuse. These are considered to be adverse childhood experiences (ACEs), a term originally founded in the United States following landmark studiesvii. These found a significant relationship between the number of ACEs a person experienced and a variety of negative outcomes in adulthood including poor physical and mental health, substance use and risky behaviour 8.2 The first incident of abuse was reported to the police when Kubus was approximately 4 weeks old. Following Agata’s engagement with services, she revealed the first incident of domestic abuse was in the second trimester of pregnancy. According to researchviii, this is the time that the developing foetus is sensitive to sound and would also be affected by increased maternal cortisol levels. 8.3 When we met with Agata she disclosed whilst the first incident of physical violence in her relationship was during the second trimester, she also shared that there were frequent arguments due to Pawel’s drinking with another tenant in the HMO and his dislike of her leaving the house. When considering what domestic abuse is, the Serious Crime Act 2015 and the Domestic Abuse Act 2021 recognise coercive control as a form of domestic abuse. However, people affected by this may not recognise it as domestic abuse and only consider physical violence as abusive. While safeguarding training undertaken by all operational staff clearly states the different ways domestic abuse may occur, there often is still a failure to recognise and facilitate the disclosure of coercive control. 8.4 Her reason for nondisclosure of abuse and housing difficulties respectively was due to not being asked by health professionals, throughout the antenatal period. Her perinatal experience at the Royal London Hospital was distressing due to her experience of racism from the midwifery team. This was a further contributing factor to not sharing her social circumstances. She advised that had she been asked about abuse and her circumstances she would have disclosed but was reticent on what they would do, due to previous experiences with services. Earlier in the review, the authors noted the number of missed opportunities professionals had to ascertain the challenges Agata was facing at home. vii Adverse Childhood Experiences (ACEs) viii The Impact of Maternal Stress on the Fetal Brain – A Summary of Key Mechanisms Page | 13 8.5 Review of primary care records have no evidence of psychosocial assessment in the postnatal visit. This could have allowed Agata to feel empowered to share her experience of DVA. There was an absence of professional curiosity when Agata stated she came from Hertfordshire, hence lateness to her GP postnatal appointment. 8.6 She called the police during the physical abuse she experienced postnatally in her instinct to protect her child. Pawel was assaulting her while holding Kubus and continued after he put Kubus down. While the police did go on to arrest Pawel and issue a domestic violence protection notice (DVPN), no steps were taken to arrange a health check to ensure no internal injuries to Kubus who was 4 weeks old. 8.7 A recent review by the national Child Safeguarding Practice Review Panel ix(CSPRP) identified that perpetrators of physical abuse causing injuries in under ones are predominantly the birth fathers. The CSPRP have identified that evidence suggests that some men are very dangerous, but that service design and practice tends to render fathers invisible and generally ‘out of sight’. In this case there was an absence of curiosity to question if dad had injured Kubus during the altercation, or in moments when he may have been alone with Kubus. 8.8 The risk assessment required to determine if face-to-face visits were required was largely influenced by Covid-19 risk factors and staffing. However, this meant that there was an oversight to the risks the HMO placed in the context of domestic abuse. Virtual visits will only allow the professional the window of what they are told and can see on the screen. This creates a blind spot for professionals as they would not be able to ascertain other risk factors in the house such as alcohol, drugs, signs of modern slavery, the other residents etc. and the risks they may pose. In this case the other resident was an enabler for Pawel and his drug and alcohol use, in addition to being a port of access to the property. Therefore, when Agata went to use the bathroom on the first floor of the property she crossed paths with Pawel on the first floor, where his friend’s room was, at which point he assaulted her. At this point, there was a DVPN in place and he should have not been at the property. 8.9 Research from the University of Lincoln in collaboration with academics in Poland x and Austria, revealed a level of normalisation of domestic abuse, often which developed in pregnancy, with alcohol being a strong contributing factor. Agata’s shared lived experience reflects the findings from the research. Furthermore, her decision for not accessing the therapeutic marketplace for domestic violence offered by agencies was informed by her lack of understanding and miscommunication of the offers available. 8.10 Reflecting on our meeting with Agata, in which she provided her narrative and emotions, and drawing on the research from the University of Lincoln, we noted a commonality, these being: • Prior understanding of DVA is derived from the home country • Normalisation of DVA ix “The Myth of Invisible Men” x Polish women’s experiences of domestic violence and abuse in the United Kingdom Page | 14 • Lack of knowledge of services in the UK, and indeed fear about services • Language barriers, and socio-cultural / religious and political context which may shape their understanding of their situation and perceptions about possible options Questions for the board / areas to strengthen practice o Boroughs with the Identification & Referral to Improve Safety (IRIS) service have a greater recognition and disclosure of all forms of domestic abuse in primary care, in comparison to boroughs that do not have this service. Therefore, the authors would recommend that IRIS provisions in primary care are commissioned and sustained. o How do secondary care staff facilitate the disclosure of domestic abuse and are the current provisions in place working? o For a non-ambulant child, who is unable to communicate and who is present during a DVA incident, what are the thresholds to determine if this child needs examination? Can we rely on the word of parents saying that the child was not harmed during conflict? Are their accounts accurate? Why we are asking this question: In this case what assurance do we have that the child was ‘placed’ when English is a second language? Do we need to consider the nuance of vocabulary and meaning in context? How do we know that when the child was being held during the altercation, there wasn’t inadvertent injury? Do agencies as a matter of routine enquire / risk asses around time spent alone with the perpetrator, and what considerations are given for child protection medical in the non-ambulant and non-verbal child? What can we draw upon from the national review of Arthur and Star? We need to remember injury is not always visible i.e. shaken baby and fractures o Within our current risk assessment strategies, do we consider the complexity of HMO and the other ports of access a perpetrator may have to the victim(s) / survivor(s)? o Following an alert of DVA, is it best practice to continue with virtual assessment or would all measures be taken to facilitate face-to-face assessment due to the risk factors, irrespective of Covid-19? Page | 15 Identified impacting factors during the timeframe of the review: 9. Cultural Competence 9.1 During the course of this review the lack of consideration to cultural competence and reasonable adjustment was explored. In doing so, we started by looking at the definitions. 9.2 Culture is defined by the Oxford English Dictionary as ‘the way of life of the people, including their attitudes, values, beliefs, arts, science, modes of perception and habits of thought and activity’. With this in mind, the concept of cultural competence is having the knowledge and understanding with the application of reasonable adjustments to facilitate engagement with individual(s). In the context of cultural competence, we also need to examine the role of language and perceived understanding when English is a second language. 9.3 During the workshop session with professionals, the review found, from a language perspective, that Agata had a command of both written and spoken English, from being in the UK since her teenage years and was able to sustain employment and engage with services. However, when we met with Agata she shared that despite having a working knowledge of the English language she sometimes struggled to fully understand. This was reflected when we explored why she declined the support of Solace. She advised her understanding was that services on offer by the therapeutic marketplace was in unison with moving to a refuge and was not available if she went to live with her mum. She explained that as she was a first-time mum she wanted to be with her mother. 9.4 For a person where English is a second language, there may be communication difficulties in the way that language is understood, communicated, and expressed. Native speakers may not fully recognise the complexity and nuance of language and how the shade of meaning might seem small, but greatly affect how what is being said is understood. It is important to reflect and understand that professionals may also not be native English speakers and they may also fail to understand and be understood. Therefore, as professionals it is imperative to check understanding and reasonably adjust our communication until we are understood, and we understand. Questions to the board / areas to strengthen practice o Cultural competence ensures person-centred care and supports making safeguarding personal. Best practice would ensure that staff have an understanding of the cultures of the demographic that they work with at place. It would enable staff to have an understanding when English is a second language that information delivered and received needs to be checked to avoid miscommunication. Consideration should be given to the offer of an interpreter, due to nuance of language and what is understood. o Consideration to an Eastern European open access worker could facilitate with communication and understanding of culture Page | 16 Identified impacting factors during the timeframe of the review: 10. Father 10.1 Very little was known about Pawel during the timeframe of the review and what was known was relayed by Agata, when she spoke to us, in addition to police records. In the antenatal health records, there was no mention of Pawel. This could be attributed to the restriction secondary to Covid-19. However, best practice would be to ascertain information to support person centred care. National and local reviews identify that it is not an unusual situation when undertaking child safeguarding practice reviews for fathers / partners to have little or no visibility. Making it difficult to ascertain if they are a positive factor or if they pose a risk to the child and / or mother and to what extent that may be. 10.2 In the new birth assessment, which was delayed due to the change of address, which was completed by video the only reference of father was in relation to his smoking and the risks to Kubus. Further risk factors in relation to Pawel were ascertained afterwards, when safeguarding procedures were underway. Intoxication was a contributing factor to the abuse which was established after police involvement. 10.3 Speaking to Agata, provided us with her insight into Pawel. She believes he is a good father to his son from a previous relationship and to Kubus. She maintained he would never hurt his children and paternal presence is important. Literature xi supports the importance of paternal presence is a core value held in the Polish community. 10.4 The NSPCC in 2017 xii highlighted that, professionals rely too much on mothers to tell them about men involved in their children’s lives. If mothers are putting their own needs first, they may not be honest about the risk these men pose to their children. While it is evident Agatha did recognise the risk at the point of assault and therefore sought help from the police, she did have her own biases which would understandably be emotionally driven, especially during and after pregnancy when oxytocin (the bonding hormone) levels are raised. Previous studies regarding learning from SCRsxiii, the Triennial Analysis of Serious Case Reviews and Lord Laming in his review into the death of Victoria Climbié, xiv indicated that it is important to maintain a respectful uncertainty of parents / carers. It is suggested that it is possible to do this without affecting the professional / patient / client relationship. 10.5 The NSPCC review highlights the reason for the assessment of fathers is to contextualise their experiences which may include poor parenting, exposure to abuse and neglect which could result in his adult social difficulties with alcohol, substance and healthy relationships. By understanding parental experience in the antenatal xi Two worlds of fatherhood—comparing the use of parental leave among Polish fathers in Poland and in Norway xii Infants: learning from case reviews xiii Complexity and challenge: a triennial analysis of SCRs 2014-2017 xiv The Victoria Climbie Inquiry Page | 17 period, it may allow for early signposting and support to change the narrative for their future child. Question to the board / areas to strengthen practice o The importance of including fathers in assessments, absent or living in the household should not be underestimated. How do organisations ensure visibility and ascertain further information on fathers / partners and households, to factor within assessments; to make safeguarding personal and provide the opportunity for both protective and risk factors to be effectively elicited? o Given the ‘think family’ approach embedded in the work of the board, should future statutory reviews include more detailed chronologies and analysis of the father / co-parent / perpetrator? The authors recognise that this was an oversight in this review Identified impacting factors during the timeframe of the review: 11. Documentation 11.1 Discrepancy in documentation in contrast to actual events is a theme. Prior to calling the police Agata was never asked about domestic abuse, however antenatal records suggest otherwise. When we met with Agata we explored all the possible ways and terminologies that could be used to enquire about domestic abuse. Agata was very clear that no professional had enquired in any way. Agata also stated that had she been asked she would have disclosed, although she was reticent about what would have been done. In Hertfordshire she did not have safe sleeping provision yet virtual assessment documentation advises Kubus was sleeping in a cot. These inaccuracies were substantiated from the coronal report and through conversations with Agata. 11.2 Reflecting on the challenges Covid-19 posed it could be hypothesised that the pressures staff were under during this period (both professionally and personally), meant they became unintentionally mechanical in their approach. Compassion fatigue is a well-documented phenomenon amongst front line staff with caring responsibility. However, it should be remembered that staff have accountability to a professional body as well as the public they serve. 11.3 Analysis of primary care records, demonstrate lack of request for collateral information from the GP and information sharing to the GP in relation to the Section 47 and MARAC. These took place respectively due to the initial reporting of physical assault and with the escalation of abuse and continued reporting to the police. The primary focus of the MARAC is to safeguard the adult victim. It will also make links with other fora to safeguard children and manage the perpetrator’s behaviour. At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety. The victim does not attend the meeting but is represented by an independent Page | 18 domestic violence advocate (IDVA) who speaks on their behalf. The domestic abuse, stalking and harassment (DASH) Risk assessment that fed into the MARAC stated that Agata was isolated from friends and family and that Pawel’s behaviour had been getting worse. The GP was oblivious to any safeguarding concerns until after the death of Kubus. Work will need to take place to ensure that in the future, systems and processes always remember to communicate with primary care and, there is full attendance and/or information from all services involved, in safeguarding meetings, including the GP. It is not possible to assess families and risk if there is key information missing. Furthermore, it prevents practitioners from proactively engaging with their patients to offer support. 11.4 The practitioner event revealed that there was an absence of information sharing, regarding the relocation to Hertfordshire (to Kubus’ Maternal grandmother), from children’s social care to NELFT. Also, communication errors occurred, with Waltham Forest children’s services closing the case after the referral to Hertfordshire. (However, Hertfordshire did not receive the referral and were only aware of Kubus, due to inquiry following his death.) Consequently, NELFT were then unable to hand over and support local health visiting input, at her new address. The family were hidden from Hertfordshire’s children’s social care. If effective handover had taken place there potentially could have been support to address the overcrowding, safe sleeping arrangements, facilitation to re-register at a local GP practice in Hertfordshire, with the aim to reduce stress on Agata attending appointments to meet their health and social care needs. Questions to the board / areas to strengthen practice o How do we ensure that accurate quality documentation is maintained, irrespective of the challenges posed to staff? o Are there adequate consistent quality supervision systems in place across all organisations to support staff, at various levels? o How do we support staff with increasing workloads from reaching burnout and becoming mechanical in their approach? o Are the information-sharing systems in place between safeguarding partners robust? What are the barriers to information sharing between agencies and within agencies (e.g. health visiting and primary care)? How do we ensure primary care and the information they hold are accessed from the beginning of any safeguarding process? o Do we need to examine processes and pathways to ensure referrals are received and acknowledged prior to closing a case? How can this be embedded into practice? Page | 19 12. Conclusion and recommendations 12.1 “The sudden and unexpected death of an infant is one of the most devastating tragedies that could happen to any family. Despite substantial reductions in the incidence of sudden unexpected death in infancy (SUDI) in the 1990s, at least 300 infants die suddenly and unexpectedly each year in England and Wales” as referenced in The Child Safeguarding Practice Review Panel’s 2020 report into SUDIs xv 12.2 During the course of this review, the authors examined SUDI in the context of domestic abuse, during the Covid-9 Pandemic, examining key themes that have impacted the family, with consideration to the pathways to harm, prevention and protection framework as per the Triennial Analysis of SCRs report. xvi 12.3 One of the most important findings during the review has been the cumulative risk to mother and child with the varying health, social and environmental risk factors present from point of conception. This particularly relates to missed opportunities for disclosure of domestic abuse, challenges with housing, and paternal alcohol use, but also includes other risk factors such as mother’s experience of domestic abuse and lack of trust in services. While isolation of victims / survivors is a common feature of domestic abuse, this was compounded by the Covid-19 Pandemic. 12.4 Following the government’s public consultation on ‘Transforming the response to domestic abuse’ in 2018, the draft domestic abuse bill 2019xvii which set out 123 commitments to protect and support victims and their families from domestic abuse was passed as an Act of Parliament in 2021. The majority of provisions were to come into force during 2021 / 22. For the purposes of this review, Section 3 of the Domestic Abuse Act 2021 came into force on 31 January 2022 and specifically provides that a child (under 18 years old) who sees, hears, or experiences the effects of domestic abuse and is related to the victim or the suspect is also to be regarded as a victim. This is significant and brings into question how the safeguarding partnership will ensure that the systems in place support identification and referral for timely responses to reduce adverse childhood experiences created by domestic abuse for babies, children and young people. In essence this means that the adult parent / care giver needs services to be open and professionally curious to enable disclosures. The review established that both primary and secondary health services did not facilitate an environment safe for disclosure. The authors have reflected on the potential barriers which may be related to educational need, confidence and time. Therefore, they recommend sustained commissioning of evidence-based providers to support the health system, examples of providers are IRIS for primary care, Hestia for community allied health care and victim support in secondary care. The authors would like to be clear that these are suggested providers who provide an evidence-based trauma informed service, but commissioners would need to explore the wide range of providers on offer for sustained commissioning. xv Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm xvi Complexity and challenge: a triennial analysis of SCRs 2014-2017 xvii Domestic Abuse Bill Page | 20 12.5 The authors were able to identify a wide range of lessons for practitioners across the partnership. Many of these examined systems working; communication and escalation pathways, in addition to risk assessment processes embedded during Covid-19, which may have contributed to reduced visibility and support. The authors’ questions to the board / areas to strengthen practice have emphasised the importance of professional curiosity, robust record keeping, credence to fathers and acknowledging the role they have in the family dynamic. They examined the need for cultural competence and ensuring that all service users experience a safe, trusting environment, to be seen as an individual, to be able to speak freely and be listened and heard whilst being treated with respect. This is key because if not in place they create additional barriers and complexities to supporting families. 12.6 The authors hope the above recommendations are embedded into operational practice and strategic policy implementation promptly to ensure that fatal / life-changing outcomes are reduced from the findings of this review. |
NC52804 | Possible neglect of a boy since birth until an incident in January 2019 when he was 11-years-old. Harry was seen with facial injuries by staff at a local leisure centre where he attended alone. Police were initially unable to contact his mother and she was later arrested for neglect. Learning themes include: the voice of the child; recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity; supervision, sharing information, communication and record keeping; professionals working together, compliance to policies and procedures and escalation processes; disguised and varied compliance; and child protection medical examinations. Recommendations to the Safeguarding Practice Review Group include: be assured that all partners keep focussed on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns; review and update the local 'Multi-Agency Threshold Guidance '; make sure all staff utilise the available 'Neglect Strategy and Tool' to assist in identifying the signs and symptoms of neglect and abuse and to take immediate and necessary action if required; ensure agencies' record keeping systems are robust, accurate and efficient for purpose and staff are complying with policy; ensure staff are supported and trained in dealing with difficult and confrontational parents or guardians; include within child protection training the range of options practitioners can take, including legal advice when a parent or guardian refuses consent to a child protection medical.
| Title: Child safeguarding practice review: Harry (TT): overview report. LSCB: Slough Safeguarding Partnership Author: David Byford Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Harry (TT) Overview Report A Slough Safeguarding Partnership Commission. Independent Author – David Byford 2 Table of Contents Chapter 1 ......................................................................................................................... 3 Executive Summary- Introduction and Background ................................................................... 3 Periods of Concern- key areas for consideration and Initial Findings .......................................... 5 Chapter 2 ......................................................................................................................... 7 Terms of Reference (TOR) summarised ..................................................................................... 7 Chapter 3 ....................................................................................................................... 10 Circumstances of Harry’s life, case and background history of the family ................................. 10 Police Investigation and Harry’s current situation ................................................................... 21 Chapter 4 ....................................................................................................................... 22 Analysis of Profesional Practice using the KLOE’s, SPR Findings and Recommendations……..……22 Chapter 5 ....................................................................................................................... 32 Conclusions- Predictability and Preventability ......................................................................... 31 Appendix 1- Bibliography ................................................................................................ 35 Appendix 2-Glossary ...................................................................................................... 36 3 Chapter 1 Executive Summary 1. Introduction 1.1 This Child Safeguarding Practice Review (SPR) was commissioned by the Slough Safeguarding Partnership (SP) in respect of Harry (not his real name) an 11-year-old, Black British Boy of African origin and of Muslim faith. This Overview Report (OR) has been anonymised to protect the identity of Harry and his family. 1.2 In January 2019, Harry was seen with facial injuries by staff at a local leisure centre where he attended on his own. The injuries were significant enough for the staff to call both Police and South Central Ambulance Service (SCAS). Police called to the scene, saw Harry had fresh and bleeding injuries and took him to the local Hospital Accident & Emergency Department (ED) prior to the arrival of an ambulance. At the hospital, Harry gave differing accounts to police and hospital staff as to the causation of the injuries sustained. He stated he had injured himself skateboarding two days previously. However, this was inconsistent with the medical diagnosis and the account given to clinicians. 1.3 Police were initially unable to make contact with his mother. In order to safeguard Harry, he was placed into Police Protection (PP) and remained overnight in hospital for treatment. Slough Children’s Services Trust (SCST), acted promptly to safeguard Harry’s health and wellbeing, pending scrutiny of the facts at the time. Harry was subsequently placed into a foster placement after his discharge from hospital. 1.4 The Safeguarding Practice Review Group (SPRG) were informed of Harry’s injuries from a referral received from the acute Hospital Foundation Trust following his presentation. A Rapid Review (RR) was carried out by agencies due to the injuries sustained and previous child protection concerns (he and his family were known to Children’s Social Care (CSC) and health care and teaching professionals since his birth). 1.5 A Section 47 Investigation was instigated at the time of the disclosure following the incident. The circumstances of Harry’s case of Neglect and Physical Abuse is currently being investigated by Thames Valley Police (TVP) and has resulted in the arrest of Harry’s mother who is currently released under investigation. 1.6 Harry’s case was considered by the SPB and SPRG, and after safeguarding partners and agencies involved with Harry contributed to the Rapid Review, the Independent Scrutineer and Chair of this group made the decision that the criteria was met to commission this SPR. The criteria is in accordance with s5(2)(a) and (b)(i) LSCB Regulations 20061 and Working Together to Safeguard Children 2015 and 20182: - ‘Abuse or neglect of a child or young person is known or suspected and 1 2006 Section 5 (2) (a) and (b) (i) Local Safeguarding Children Board Regulations 2 Working Together to Safeguard Children, 2015 and 2018, Guidance - HM Government 4 the child or young person has died or been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child or young person.’ 1.7 Statutory Guidance 1.8 The DfE,3 provides statutory guidance and requirements on how to conduct a SCR which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led to individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data was collected and analysed; and Makes use of relevant research and case evidence to inform findings. 1.9 Purpose of the review 1.10 The purpose of this SPR is to: - Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people. Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and as a consequence, improve inter-agency working and better safeguard and promote the welfare of children and young people. 1.11 Background 1.12 The Rapid Review showed significant involvement of SCST social care services with Harry. He had been in care for a year from birth when he was a baby due to concerns about his birthfather, who had schizophrenia. Harry was returned to his mother’s care in 2008, as she was no longer in a relationship with Harry’s father. There were further concerns in 2011, when his father wanted contact. CSC did not agree with this contact and it never materialised. 1.13 His school had long standing concerns for Harry and his mother (this is discussed further within Chapter 3 and 4 of this report). He had behavioural issues, frequent injuries and health issues with his diagnosed skin condition. The school concern was further compounded with the behaviour and confrontational attitude of Harry’s mother’s parenting, and her relationship with the school when challenged about her parenting and concerns for her son. Harry was often reluctant to speak or give a plausible explanation regarding causation of presenting reported health and wellbeing concerns when questioned by school staff. 3 Working together to safeguard children 2015 and 2018, Chapter 4 Guidance - HM Government. 5 1.14 The school made a referral to CSC in 2016, regarding a concern of possible neglect of a significant foot injury which became infected due to the delay in his mother seeking treatment. A Section 47 investigation was conducted, and he was subsequently made subject to a Child Protection (CP) Plan. This was later stepped down to a Child In Need (CIN) plan which is subject to comment within the analysis in this report. A Children and Family (C&F) assessment was then carried out. The outcome was that no further action (NFA) would be taken as it was determined there was no evidence of neglect. Harry’s case was closed to CSC in December 2017. Key events for Harry which arose subsequently, are addressed within Chapter 3 of this report. 1.15 Family 1.16 The family unit subject to this SPR consists of: - Harry - The subject in relation to neglect and physical abuse of Harry. Mother - The suspect of neglect and physical abuse of Harry. Father - Estranged from both Harry and his Mother and referred to only in the background of Harry’s life history. 1.17 Harry is a child of black African heritage. His mother and his father come from different African countries which are not recorded in order to protect their identity. His parents’ religion is Islam and Harry is known to celebrate ‘Eid.’ 1.18 Periods of concern and key areas of consideration. There are several periods of concern for Harry. These concerns are discussed within Chapter 3, details of Harry’s life and the analysis of the terms of reference (TOR). Key Lines of Enquiry (KLOE) and Professional Practice are discussed within Chapter 4. The periods of concern are: - Period 1 - History and background of family and previous child protection concerns. Period 2 - Child Protection concerns within the terms of reference (TOR) scoping period and action taken. Period 3 - Disclosure of incident which led to Harry’s Physical Abuse and Police Criminal Investigation. 1.19 Findings. The SPR identified the following findings which are detailed and analysed further within Chapter 4 together with SPR and Agency Recommendations are: - Finding 1 - The need for practitioners to remain child focused in order to capture the voice of the Child and a review of the Slough Multi-Agency Threshold Guidance form children. Finding 2 - Recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity. Finding 3 - Supervision, sharing information, communication and record keeping. Finding 4 - Review of the TVP function within the Multi-Agency Safeguarding Hub (MASH). Finding 5 - Professionals working together, compliance to policies and procedures and escalation processes. Finding 6 – Further Multi-Agency training in disguised and varied compliance. Finding 7 - Child Protection Medical Examinations. 6 1.20 This SPR has identified seven SPR Overview Report Recommendations outlined in Chapter 4 of this report. There are nineteen Individual Agency Recommendations which form part of a SPR Action Plan which follows the completion of this review. 7 Chapter 2 2 Terms of reference (summarised) 2.1 The terms of reference (TOR) for this SPR have been summarised below. Slough Safeguarding Partnership retains a full version of the TOR for reference. 2.2 Introduction 2.3 The TOR relate to the SPR for Harry and sets out the statutory requirements, followed by a brief case summary. The Key Lines of Enquiry (KLOE) are questions to be addressed by the SPR review process and methodology as agreed by the Slough Strategic Safeguarding, Leaders Group. 2.4 The purpose of reviews of serious child safeguarding cases is to identify improvements to be made to safeguard and promote the welfare of children. Learning will be relevant locally, but it may also have a wider importance for all practitioners working with children and families and for government and policymakers. Understanding whether there are systemic issues, and whether policy and practice need to change and if so how, is critical to the system being dynamic and self-improving. 2.5 Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage. 2.6 In Slough, the statutory safeguarding partners are the Slough Borough Council, who commissions the Slough Children’s Services Trust to deliver the statutory services; East Berkshire Clinical Commissioning Group and Thames Valley Police. 2.7 Working together to Safeguard Children (WTSC) 2018 guidance indicates that safeguarding partners must make arrangements to: identify serious child safeguarding cases which raise issues of importance in relation to the area, and Commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken. 2.8 The three safeguarding partners have equal duties in this regard. Safeguarding partners met on 4 July 2019 as the safeguarding practice review panel (SPRP). Having carried out the Rapid Review and unanimously agreeing the case met the criteria for commissioning a SPR. A summary of the Harry’s case is outlined in Chapter 1 – Introduction. 2.9 Key lines of enquiry (KLOE) 2.10 Information available from the RR the SPR Group hypothesised that Harry had been living with neglect and abuse all his life. This overview report analyses the five identified KLOE’s from 8 agency Individual Management Reports (IMR) submitted for the SPR process and from the Practitioners Event held, as outlined within Chapter 4 of this report. 2.11 Scope of the review: 2.12 The rationale for the proposed timeframe is that practice and arrangements have changed considerably during Harry’s lifetime. Learning is most likely to be of benefit when considering the last 3 years and especially the last year. 2.13 The review considered information available from partners from July 2016 when a referral was made in relation to a report of an injury until January 2019 which includes the incident reported which led to the commissioning of this SPR. Further emphasis and analysis for the year leading up to the trigger incident, to help examine recent practice, was assessed. 2.14 All partner agencies were asked to complete a short summary of their knowledge of Harry’s history from birth in order to provide a background history to inform their IMR’s and this review. 2.15 Methodology 2.16 David Byford was commissioned as the SPR Independent Reviewer and Author for this SPR. He has no involvement with the case or agencies involved in the review. 2.17 There are six stages to this review: Stage 1 – Background and agency reports; Stage 2 – Practitioners and management engagement. This involved a Practitioners Event which was held and subject to analysis in Chapter 4; Stage 3 – The completion of the overview report and consideration of engaging with the family. (In the circumstances neither Mother (Police investigation) nor his estranged Father were asked to participate in this review. His Father is believed to be accommodated in a mental health hospital and was not part of Harry’s life during the scoping period for this review. Stage 4 – The overview report will be shared with Slough Strategic Safeguarding Leaders group who will sign off the report and agree to ensure an appropriate action plan is delivered and monitored; Stage 5 – The publication of the finalised report; Stage 6 – The Safeguarding Practice Review Group will monitor the delivery of both the multi-agency and single agency action plans, delegating tasks to other groups, such as the quality assurance and/or the learning and development groups where appropriate. 2.18 A Practitioners Event was held that was well received and attended by agency practitioners involved in the SPR. The issues submitted for discussion were elicited from the analysis of agency submissions including the KLOE’s and practitioner’s own views and opinions at the event. The information received was taken into consideration and analysed within Professional Practice and KLOE’s and subject to the Findings and SPR OV Report Recommendations in Chapter 4. 2.19 Agency involvement 2.20 The following agencies were involved in the SPR process and completed Individual Management Reports (IMR) or a summary of their agency involvement: - 9 Primary Care - Report completed on behalf of Primary Care by East Berkshire Clinical Commissioning Group (CCG). Education/School - Report completed. Frimley Health NHS Foundation Trust- Report completed. Slough Children’s Services Trust - Report completed. Solutions 4 Health - Report completed. Thames Valley Police - Report completed. South Central Ambulance Service (SCAS) - No information obtained. 2.21 Publication - There is an intention by Slough Safeguarding Partnership Board to publish the Overview Report in an anonymised version to preserve the identity of Harry and his family. 2.22 Acknowledgements 2.23 The Independent Author would like to take the opportunity to thank Slough Safeguarding Partnership and participating agencies and key professionals who contributed to the SPR. The review could not have been completed without theirs and the valued assistance of the Independent Chair of the Slough Safeguarding Partnerships Board, the Safeguarding Partnership Manager and Business Support staff and SPRG members. 10 Chapter 3 3 Period 1 - Circumstances and details of the events in Harry’s life and background history of the family 3.1 This SPR covers the period from July 2016 until January 2019, however, the family background history and Harry and his parents are also recorded for context of the events in order to capture the life of Harry. 3.2 Harry’s parental family background 3.3 Harry’s mother and father were both born in the same African country (redacted) in 1983. The maternal grandmother (MGM) died during child birth and Harry’s maternal grandfather (MGF) remarried. Harry’s mother moved to the UK in 1995 with her step mother and the MGF joined them later. The MGF followed the Muslim way of life and as a teenager Harry’s mother rebelled against this and at the age of 15 years was placed into the care of a London Borough. 3.4 A preliminary report from her previous London Borough Children’s Services (LBCS), at a Looked After Child (LAC) review in 2001, disclosed Harry’s mother’s behaviour was very challenging including several episodes of dishonesty, additional concerns about lying, anger, hygiene and self-care issues, with a history of criminal behaviour and involvement with the Youth Offending Team (YOT). Harry’s mother sought support as she felt she would like some further help with aggression and anger management. Whether this occurred prior to her moving to the Slough area is not known to this review. 3.5 Harry’s parents were reported to have been in a relationship since they were in their teens. Their relationship ended prior to Harry being returned to his mother’s care in November 2008 which is detailed further below. 3.6 Harry’s life prior to the TOR scoping period. 3.7 In December 2007, Harry’s parents moved into the Slough area. Harry’s mother was pregnant with him at the time. A referral was received from the London Borough they had moved away from, informing Slough Children’s Services of child protection concerns about the safety of mother’s unborn child (Harry). This was due to the father’s criminal history. He had mental health difficulties and posed a risk to children and both parents were reluctant to engage with professionals. 3.8 The LBCS had completed a core assessment and was initiating care proceedings in respect of the unborn baby when the parents moved out of their area. Both parents were known to have a history of violent behaviour towards each other and other persons and were known by several Police Services. This was good safeguarding practice to communicate the concerns by the previous LBCS with Slough whose CSC acted positively to protect the unborn Harry. He was born later that month and put into foster placement under an Interim Care Order (ICO) by the LBCS. 11 3.9 In January 2008, an Initial Assessment (IA) was completed by SCST4. Harry’s case was transferred to Slough and an ICO granted to them. 3.10 In July 2008, police record allegations between Harry’s parents, made against each other of domestic abuse (DA). This was concluded after police took advice from the Crown Prosecution Service (CPS) who decided NFA should be taken. Harry was not mentioned in the report and from the dates, it is suggested, this would have been likely due to Harry being in his foster placement. Harry was returned to his mother’s care in November 2008, aged 10 months old under ICO, Placement Parents Regulations. 3.11 The ICO was discharged on the 9 March 2009 and a Supervision Order (SO) was granted for one year. During the period of CSC involvement, it was consistently noted that Harry was meeting developmental milestones. Harry had eczema whilst in foster care and this was treated with ‘Vaseline’. The case was closed on 30 June 2010 when Harry was 2 years old. After the CP plan ended, he became subject to a Child in Need (CIN) plan. 3.12 Between 2011 and 2015, there were episodes of involvement with CSC, Police and the School. 3.13 2011 - Harry’s birth father wanted contact with him, but this was not recommended by CSC and never occurred. In August, mother reported a domestic incident with her new partner (not Harry’s birth father) which amounted to a verbal exchange in the street. No offences were identified. Harry was not listed as present or involved. 3.14 2012 - There was a Domestic Abuse (DA) incident between mother and her partner. Harry was present during the DA. Appropriate CP enquires and a joint Section 47 investigation were conducted with police. All necessary action to safeguard and protect Harry was taken by his mother by her ending the abusive relationship with her partner. SPR Comment: Mother refused to engage with police officers investigating the DA. Harry was 5 years old at the time and was listed as “child other” within the police report. The report gives no indication as to whether Harry was seen or spoken to at the time. If he was present, he should have been spoken to and if he was not present police should have enquired where he was. TVP have addressed this as learning within their report to the SPR. 3.15 2013 - In March there was police contact with Harry’s mother’s ex-partner who was sending texts and telephone calls to Harry’s mother in breach of a non-molestation order. NFA was taken as she was deemed to have taken appropriate action and the partner was issued with a harassment warning by police. 3.16 Later in June, Harry’s school reported that he had a mark on his cheek. When asked what had happened, he thought for a while before saying “It wasn’t my mummy.” When asked again, he said he did not know. The Head teacher (HT) spoke with his mother and warned her regarding hitting a child which she denied. NFA was taken. It is reported in the school chronology submitted to this review that Harry had a similar mark on his face before this and he had said to his teacher his mum had done it. (The education submission to the review does not give a date for the previous mark observed by staff on Harry’s face). 4 SCST only came into being in 2016, prior to this services were provided through the SBC. 12 SPR Comments: The school should have reported both incidents to CSC as there was, in the first occurrence, an element of assault accusing his mother and, on the second occasion, where he had a mark on his cheek, he clearly contemplated his response insisting his mother did not do it. (There is a reasonable assumption by his response; his mother had spoken to him after the first incident about alleging she had caused the marks and possible element of grooming his answers to professionals). It has been pointed out to the review that this action was taken by a former head teacher. The school believe there were very different procedures and expectations in place within social care at the time. It is suggested many schools were trying to do the best, but Slough CSC were struggling and rated inadequate. The view of this review is that the incidents should still have been shared at the time. It has also been acknowledged these incidents would now be shared by the school. Following an inspection, the leadership of the school changed in April 2014 with a substantive head teacher taking up a full-time role in 2015. The school then brought about rapid change to safeguarding procedures and the concerns alluded to were identified and shared at Harry’s ICPC subsequently. 3.17 2014 - In February, the school noticed Harry had a cut of approximately 2cm on his forehead which was slightly scabbed over. He said he did it skateboarding. When asked when it had happened, he said it was in the garden. When asked what he hit his head on he said, “I’ve changed my mind, I actually hit it on the door.” This was reported to the school Family Support Worker (FSW) who spoke to Harry. He said his mother had put ice on it and made him comfortable. He was reminded that he could speak to staff if he had any worries or concerns. SPR Comment: This was a third opportunity to share the information regarding facial injuries Harry had sustained to CSC. This information was provided by the school in the Rapid Review completed for the SPR. 3.18 Home alone occurrence (1) aged 6 years. In July 2014, an anonymous referral reported Harry’s mother was leaving him home alone while she went to the shops or visited friends. CSC followed up the information and carried out an unannounced Home Visit (HV) and Harry was spoken to alone (he was not home alone on this occasion). He presented as being healthy and well dressed. His mother denied leaving him home alone. NFA was taken and his mother was given suitable advice and the NSPCC leaflet on ‘Leaving children home alone’ and referred to Early Help. The school were unaware of this incident and it would be good practice to have shared the information with them. 3.19 2015 - In June, on the way back from a school walk, Harry was noted to be limping. He told school staff his foot hurt as he had fallen off his bike the previous day. He had marks on his head and cheek. Harry refused to take off his shoe at school saying the school first aider had looked at it the day before which was not the case. School staff were concerned as he had told the first aider that his brother had bitten him and that’s why he had marks on his face and head (he does not have a brother). As a result, the Head Teacher (HT) arranged an appointment with Harry’s mother who came into school. His mother was very defensive and said his foot was fine and Harry was making it up as he was tired from the walk. She said he should take part in all activities as per normal. SPR Comment: This was the fourth occasion when Harry was found with marks on his face at his school. Professional curiosity should have been applied regarding sharing the information with CSC. If the events in 2013 and in February 2014 had been shared there may have been a different outcome, and this was another missed opportunity as it was another element of concern. (The 13 information was subsequently shared later at the ICPC in July 2016, see below). The SPR Independent Author is satisfied the school would have no hesitation in referring to CSC if similar circumstances occurred now. If reported at the time, the information could have been investigated further and added to the historical child protection concerns Harry faced and these were missed opportunities. 3.20 Home alone occurrence (2) aged 7 years. In August 2015, similar concerns were reported when CSC received an email from a member of the public, expressing concern about Harry’s mother leaving him home alone. It alleged his mother was shouting, drinking, smoking and being in an unsuitable relationship (a man known for drug offences allegedly staying at the family home). The school were unaware of this incident. 3.21 CSC received a further email sent by the same person a few days later; retracting the concerns, saying it was all a misunderstanding. CSC in any event conducted an unannounced home visit which was good practice and later confirmed NFA. Information showed ‘Early Help’ were already involved and it was agreed these issues should be addressed as part of a Team around the Child Meeting. 3.22 On the 1 September 2015, as part of the referral, Harry’s voice was heard. He was spoken to alone and expressed his upset about visits by the police and social services. He is noted as having said he did not want to go back into care and (if this was to happen) he would prefer to live with his maternal grandfather (MGF). 3.23 At the same time the school recorded an incident between an older girl and Harry at school. His mother had allegedly shouted at the girl the next morning resulting in the girl being very upset (this was evidence of her aggression towards others and a worry). 3.24 Period 2 - Harry’s Key Events within the TOR timeframe of the SPR 3.25 2016 - Home alone occurrence (3) aged 8 years. In May 2016, the school reported a staff member walked past Harry’s house at 7am on the way to work. She saw him leaving the house and asked him where his mother was. Harry told the staff member his mother left for work at 6:30am which left him on his own for 30 minutes. Harry walked to the school with the staff member. The school phoned his mother. Harry’s mother phoned the school back as they could not initially get hold of her. She said that she never leaves him for more that 2 to 5 minutes. Harry’s mother was warned previously by CSC about leaving a child home alone, however, she did not heed the warnings and was continuing to flout this appropriate and good advice. 3.26 Foot Injury - On the 15 June 2016, at a Breakfast Club in school, it was noted Harry was not walking properly. He said he fell at home but would not show his leg to staff, who were concerned. He fell asleep at the table in the club and said he had not gone to bed until midnight as he was doing his homework. The school’s cumulative concerns at the time were his bad leg, the inconsistent account of the reason for this and his tiredness and refusal to show his injury. The HT made a decision not to allow Harry to go on a school trip that day as he was unable to walk. When his mother was telephoned at her employment, Harry became very distressed at this and said, “mum would be angry.” When his Mother was later seen at school, she said he had hurt himself jumping off the stairs. She had considered asking his grandparents to look after him as he complained to her about his leg that morning, but he wanted to go on the school trip. The school are of the opinion the information presented was by both Harry and his mother were both credible. 14 3.27 There was a follow up meeting at the school with mother who was invited to attend a couple of days later and talk to the FSW. Harry’s mother disclosed about him being removed from her at birth and her personal background details. She disclosed the fact she has told Harry about his birth father including rape and his mental illness. This was the first time the school had learned of his past. She agreed with the school’s request for Harry to be referred to the Educational Psychologist (EP). Harry felt his mother’s work was more important than him, but she stated she is working so that they can be independent. 3.28 Foot Injury referral - In July SCST received a referral from Harry’s school in respect of an injury to his left foot as he was struggling to walk. He had told the school he had stepped on a drawing pin but was reluctant for school staff to examine his injury. The HT managed to persuade him to remove his shoes and noticed he had a cut like wound to his foot which looked infected and swollen. Harry and his mother were seen at the school. The school remained concerned there was no clarity as to whether mother had sought medical support for Harry’s foot. Mother was reported as being defensive and angry and was advised to take him to his GP. The school referred the injury and possible neglect by mother to obtain medical treatment to CSC. The school state they had to insist someone from CSC attended the school. They sent photographs of the injury to his foot which stimulated a SW to attend after the school had finished whilst the school were managing Harry and his mother. 3.29 A strategy discussion took place the following day between CSC and the Protecting Vulnerable People (PVP) Referral Centre (pre Multi Agency Safeguarding Hub - MASH). A Sec 47 single agency Investigation was agreed for CSC to be carried out. There followed a strategy meeting attended by the MASH Supervisor. CSC indicated they would keep the MASH5 updated and disclosed that Mother had refused a full medical assessment however, Harry agreed to go to hospital for treatment to his foot. This resulted in him being admitted as an in-patient for three days for treatment due to the infection, but no formal child protection examination was conducted as Harry was aware his mother did not want this. The examining doctor however, treated him and confirmed the injury was consistent with Harry’s explanation and that the injury had become infected. SPR Comment: It is confirmed that the school were not invited to participate in the strategy discussion. Considering they were the referrer of suspected neglect and his mother’s delay in seeking treatment, they should have been made aware by SCST and invited to participate in the discussion. 3.30 A Local Authority Designated Officer (LADO) meeting was held later in the month and information was shared by CSC and the school. Mother had been suspended from her job (care role) where she had been completing a level 2 apprenticeship and the reasons were not known whether it was as a result of the safeguarding concerns raised or for a separate matter. The LADO reserved any final decision pending the planned ICPC on the 26 July 2016. Police from the Child Abuse Investigation Unit (CAIU) assessed the threshold for a criminal neglect case was not met. SPR Comment: Subsequently a later C&F assessment was completed in November 2017, which recorded Harry’s mother worked ‘in adult services as a carer.’ There is no additional information to say where she worked, her hours and her child care arrangements for Harry in the context of him being reported as home alone. 5 This case arose at a time when the PVP Referral Centre was being replaced by the MASH. 15 3.31 An Initial Child Protection Conference (ICPC) was held on 26th July 2016 and Harry was made the subject of a Child Protection Plan (CPP) under the category of Neglect. This was primarily due to the delay in his mother seeking medical attention for his foot injury. It was known at the time that Harry had severe eczema and a fungal infection on his scalp which smelt and was weeping and required treatment and medication. Harry would not allow his hair to be cut which may have aided treatment. The GP along with other agency practitioners were made aware of safeguarding concerns relating to Harry when they were asked to complete a report of their agency involvement for the ICPC. The school reported to the ICPC that Harry had a number of injuries which had been observed by school staff and when asked how they occurred, they said he would not say, or he made it unclear how they were caused. SPR Comment: The school shared the information of previous injuries from 2013, 2014 and 2015 at the ICPC. This information should have been referred to CSC at the time of the occurrences and discussed at the review conference when Harry’s case was stepped down after 9 months from the ICPC CP Plan to a CIN Plan. Areas of concern required further examination as there was no retrospective analysis of the long-term cumulative history. Furthermore, details regarding his father were not known; what his mother’s childcare arrangements were for him; being left home alone and what support the extended family were able to offer to reduce the concerns for Harry’s welfare. The CP Plan should have remained open for a sufficient period to demonstrate sustained change. These same outstanding actions are concerns which still persisted at the time of the current event in 2019 and have been addressed in this review within a CSC IMR and SPR Recommendation in Chapter 4. 3.32 The GP provided two case conference reports for Harry, with no reported GP safeguarding concerns for Harry or his mother. The Primary Care IMR states that it must be appreciated; however, the GP’s interaction with Harry was for a short duration only when attending surgery appointments. Other agencies it was suggested were better placed who saw him for longer periods on a daily or more frequent basis to assess him. This SPR believes that GP’s should still be mindful of neglect and be professionally curious and to question, challenge and verify possible safeguarding concerns, especially when there is knowledge of a child’s previous CP history, who comes into the practice. 3.33 Breakdown in the relationship between School staff and Harry’s SW. The School Deputy Designated Safeguarding Lead (DDSL) consulted with the School Nurse (SN) for clinical advice on the management of Harry’s skin condition, while not identifying Harry. The SN advised the school to be proactive and suggested he saw a special paediatrician. The DDSL then spoke to Harry’s mother and she asked the DDSL to write her a letter so she could inform her GP. The DDSL informed the SW that Mother then denied the advice. The DDSL felt her relationship with the SW had broken down as the school felt their views on Harry and his mother were not being appropriately considered by the SW as the SW informed the DDSL “she does not have to follow advice” which the school believed was an unhelpful response. The school’s opinion was the SW may be undermining their challenge of his mother. The school sent a formal complaint on 23 December 2016 to CSC. A response from the SW’s line manager was not promptly received. SPR Comment: The school, should have used the Pan-Berkshire multi-agency child protection escalation policy that was in place at the time which is now called the Resolving Professional Disagreement and Escalation policy updated in 2019 as laid out in the CP manual, thereby keeping 16 Harry at the centre of concern. The tension between agencies obscured the focus on Harry and his needs even though it may have been for a short time. 3.34 2017 - In January 2017, the Head Teacher escalated the situation with the SW with an email to the CEO of the SCST who forwarded it onto the Director of Operations who, later visited the school. The school felt however that nothing changed, and the promise of an investigation did not materialise. Eventually there was a subsequent meeting between the DDSL and the same SW which focused on their relationship rather than Harry. The school further reported that his mother removed Harry for a month during January 2017, blaming the HT and DDSL for bullying her. At no time did the school lose sight of Harry during this time but when the meeting occurred the focus needed to be on Harry and not on the disagreement between two agencies. 3.35 At a core group meeting held in January 2017, there was a discussion with his mother about the fact she had taken Harry out of school as she had alleged that he was being bullied and she was not happy with the school’s handling of this. Harry’s mother was advised about seeking an alternative school place. As confirmed by the SCST IMR, there was no one from Harry’s school in attendance at this meeting and it is not known or recorded if they were invited. Considering their level of involvement with Harry and his Mother, this was a serious omission. At a core group meeting held in March however, it was noted Harry had returned to the same school where he had been absent for a period of 4 weeks from the 20 January 2017. SPR Comment: At a meeting with the HT and DDSL at the school, the Independent Author asked whether Harry was subject to bullying due to comments made together with the insinuation that the school were bullying his mother as outlined above. The school reported no record of Harry being bullied and deny ever bullying his mother who resented the school’s involvement with Harry. It is not known if Harry was seen when he was allegedly off school. Professional curiosity should have been used to check on his welfare to see if there were any other underlying reasons for his school absence. 3.36 The SCST IMR states at a Review Child Protection Conference (RCPC), in April 2017 the CP plan ended. There is reference to therapy having not been available for Harry and it was noted that it was hoped that this might happen as a referral was made for his mother to receive counselling through ‘New Horizons’ and it was hoped that Harry could join in with this. There is also no record of Harry ever having been offered one to one support or counselling despite being identified as a need in assessments and core group meetings. The lack of direct work with Harry is an agency finding and subject to a CSC IMR Recommendation. SPR Comment: In assessing this period, the SCST IMR concludes there were timely CP visits conducted with seven core groups held, and Harry’s case was stepped down. A CIN Plan was initiated and this concluded on the 9 August 2017 with no final meeting taking place or Lead Professional (LP) being allocated, both of which should have occurred. He was then made subject to a C&F assessment which concluded in December 2017. These aspects have been addressed within the CSC IMR and SPR Recommendations in Chapter 4. 3.37 Following the RCPC in April 2017, the GP and the school were informed by CSC there had not been any significant incidents since the last conference in October 2016 and the CP plan had ended. CSC informed the GP that a CIN meeting would be held on the 2 May 2017. The GP did not receive any further information from CSC until December 2017 when a SW requested a report with up to date health information as part of Harry’s C&F assessment. The GP sent a report and also informed CSC his mother acted in a timely manner and had no concerns about her managing Harry’s chronic 17 skin problem. It transpired, the origins of Harry’s fungal infection were deemed consistent with accounts from Harry and his mother who claimed treatment of his eczema was hindering him from washing his hair or allowing his mother to cut his hair. The HT reported to the chair that the plan had progressed slowly, and the SW advised that a referral should be made to the wellbeing and coaching service, but this hub was not available and had been discontinued. At the last core group meeting on the 12 December 2017, when Harry’s mother had started counselling through the Coaching and Wellbeing Service, it was suggested that perhaps Harry might also become involved in this but there is no evidence that this happened, it was agreed there will be a referral to family therapy. The SW sent a letter to the school informing them that Harry had been removed from the CP process and the SN had seen him and had no concerns beside his appearance which is taken to mean he appeared unkempt. SPR Comment: Whilst subject of the CP Plan for nine months, the CSC IMR reports he was being seen regularly and there were notable improvements in his appearance and overall demeanour. He was reported to be smiling more, was doing better in school and generally engaged more positively with professionals. At the point when the case was closed in August 2017, Harry was 9 years, 8 months old. The CSC IMR stated the CSC records did not provide a detailed picture of Harry as a child and do not describe his personality, including information on his likes and dislikes and what he did for fun which should have been obtained and considered by professionals. This has been addressed by a CSC IMR recommendation and within SPR Recommendations in Chapter 4. 3.38 Referral. On the 7 November 2017, a Family Support Worker (FSW) from school expressed concern when Harry attended school with a swollen eye following a period off school for a reported skin infection. School had asked him about his injury, and he told the FSW that he had not been to the GP as his mother was treating it. A Multi Agency Referral Form (MARF) was submitted to CSC who advised the school to seek mother’s permission for the School Nurse (SN) to look at Harry’s eye and to contact his GP. The outcome was that the school informed CSC that mother had given permission, although had been hostile and defensive accusing the school of “persecuting her.” In light of previous concerns, CSC progressed the referral through the ongoing C&F Assessment which, concluded on 20 December 2017 with NFA taken, as according to the assessment, no evidence of parental neglect. The focus was on Harry’s sore eye; however, the assessment should have considered the wider historical information and the cumulative effect on Harry. 3.39 Home alone occurrence (4) aged 9 years 11 months. On the 29 November 2017, information obtained from the TVP IMR state that South Central Ambulance Service (SCAS) reported a request for assistance to force entry to his home address as he had been left home alone in the premises. SCAS had referred to the Fire Service to assist in gaining entry as there were no police resources available. The police downgraded and closed the incident to a telephone resolution. 3.40 The TVP IMR records that SCAS raised concerns regarding Harry being left alone at the address. Harry eventually opened the door to SCAS, and the assistance of the Fire Service was no longer required. They again contacted police regarding child protection issues for Harry being left home alone. They also managed to make contact with his mother. When she returned home, SCAS paramedics apparently described her as being irate. 3.41 The incident was originally downgraded by TVP but was appropriately reopened by TVP as Harry was found home alone by SCAS. Police officers were sent to the address and spoke with Harry who they described as scared. SCAS managed to contact his mother who came home and who they 18 described as irate. He was seen by police at the scene and spoken to. Police stated when Harry’s mother returned home, she was ‘upset and defensive.’ An ABCDE vulnerability assessment6 was completed and police assessed that Harry was not mature enough to be left alone. His mother insisted a neighbour was nearby and would have kept an eye on Harry. Police made enquiries and established this was not a firm arrangement with the neighbour. Police sent a tasking request to MASH who made a referral to CSC. The case was already open to CSC and the incident was considered as part of the ongoing C&F assessment. SPR Comment: It would appear as Harry opened his door to SCAS, the fire service was no longer required. As he was found home alone, the police correctly upgraded their response and attended the scene. The police attendance has been addressed within their IMR and Agency Recommendation to this review. SCAS could not initially find details of this call for the purposes of the review. The logged call was subsequently identified but there was no details of any record made by paramedics who had attended the scene being located. This is a clear recordkeeping issue for SCAS to address, as defined in Recommendation 5 within Chapter 4. Mother was again inconsistent with her explanations to professionals. Appropriate questions were asked to establish Harry’s competence to be alone, such as whether he knew what to do in the event of a fire etc but despite the answer being unsatisfactory, and his mother being very difficult and argumentative, NFA was taken beyond the creation of a CP occurrence. Police in their IMR believe this was potentially because of the failure to identify the significance of previous Police and CSC involvement and as a minimum CSC should have been consulted whilst Police were still in attendance at the address. This would have led to a more holistic exploration with partner agencies information and potentially a trigger for the removal of Harry under S46 Children’s Act Police Powers at the time if necessary. It was felt by the TVP IMR Author that a strategy meeting (SM or discussion) should have taken place and this review agrees with this as it was the fourth occasion when Harry was left home alone. The C&F assessment should have put more significance on the possibility of neglect and the family background history and, at the least should have been extended the period in order to assess the cumulative occasions and impact on him being left home alone. The neglect concerns were continuing despite the advice from practitioners to Harry’s mother who, was agreeing but then ignoring safety advice and is an element of disguised compliance. 3.42 On the 20 December 2017, as alluded to above, the C&FA was completed. It noted Harry’s “chronic skin condition” was described by his GP as “atopic dermatitis - eczema” (a long lasting and chronic condition which flares up periodically). The assessment which commenced at the conclusion of Harry being taken off his CIN plan as outlined above, concluded there was no evidence of parental neglect and CSC closed the case. 3.43 2018 - In July 2018, Harry attended two GP appointments with his mother due to a hand injury he had sustained. He informed the GP that this had been as a result of an incident with another child at school, which was being investigated by the school. 6 The ABCDE model was devised in 2013. Initially it was an assessment tool purely for mental health issues. Several Police forces, including TVP, are now using it to assess a wider spectrum of vulnerability. The tool consists of 5 areas: Appearance, Behaviour, Communication, Danger and Environment. 19 SPR Comment: The GP should have applied more professional curiosity and made a referral to CSC for it to be duly investigated. 3.44 Period 3 - The disclosure of Harry’s injuries on 7 January 2019 and the police investigation. 3.45 2019 - On the 7 January 2019, at 7.39pm, Police were called to a local leisure centre to Harry (aged 11 years) who had attended the location. Leisure centre staff noticed he had several recent facial injuries. He was unaccompanied and stated he had injured himself skateboarding two days previously. This was, however, inconsistent with the current state of his injuries as subsequently reported to both Police and later to the hospital. Police who attended the leisure centre also noticed Harry had fresh injuries to his face and hands which were actively bleeding. He had given the police officers differing accounts as to the cause of his injuries which were not believable. He also told police he had 'room surgery' for his injuries and was not in pain but could not explain what this term meant or where it had taken place and by whom. Police were unable to make contact with his mother and as a result Police Protection (PP) powers were used to safeguard his health and wellbeing and to have his injuries tended to at the hospital. The Frimley Health NHS Foundation Trust (FHNHSFT) Trust IMR states SCAS were also called to the scene but there is no record they attended. It is reported both by the FHNHSFT and TVP IMR’s that police took Harry to the Hospital ED and SCAS confirm they did not. 3.46 At the hospital, Harry was reviewed by a nurse and then a senior doctor in the ED. Harry still insisted he sustained the injuries falling off his skateboard but changed his story saying it occurred before Christmas’ (2018), two weeks previously but was unable to recall the date. Medical practitioners confirmed the injuries were new and not consistent with his explanation. 3.47 It is reported he remained steadfast that the injuries were old and stated that no person had inflicted them. He reported that he lived with his mother and disclosed his father lived elsewhere which he said was complicated and he was not willing to expand further regarding his father. He denied substance misuse and gang activity, sharing that he mostly enjoyed school, had good friends but had been beaten up by the same pupil in his class, many times. Bullying at school is not recorded as having occurred or confirmed from the education submission to the review. 3.48 The triage nurse in ED reported that Harry was wearing a cap and was very reluctant to remove it. He eventually agreed to remove his cap so the nurse could clean his wound. The nurse observed his face had ‘make up foundation applied’ to a healing 1-inch cut. It was also observed that there was a dry blood-soaked plaster/bandage at the back of his head covering a healing injury. The numerous injuries, as outlined below, were treated with ED nursing and medical staff liaising with the CSC Emergency Duty Team (EDT). Police and EDT stated that Harry was not to be discharged to the care of his mother and that she could not visit him on his hospital ward as he was to be detained for treatment. A SM was arranged later the same day (8 January 2019). 3.49 Harry was reviewed by the paediatric registrar following his transfer to the ward. Harry was placed in a side room to afford privacy, where police presence remained. The police shared their concern with the paediatric registrar as presented to them and that his injuries are inconsistent with the explanations given. Police were initially unable to make contact with his mother and following subsequent contact she stated Harry’s injuries were a few days old. She was unclear as to their mechanism. The FHNHSFT IMR reported that neighbours said Harry did not have the injuries at school that day as he had not attended school. It is presumed this information came from the police during their investigation and communicated later and will form part of any evidence in subsequent 20 criminal proceedings. The school were not informed immediately of Harry’s presentation with head injuries to hospital until they were contacted by SCST the following day when they were told he was in hospital with several injuries under police protection. The school was invited and attended a strategy meeting on the 9 January 2018 for Harry. 3.50 There was further good communication between the paediatric registrar and CSC Emergency Duty Team (EDT), where a brief history of Harry’s social care involvement was shared and confirmed with the registrar, there was no current social care involvement with him. 3.51 Harry’s account to medical practitioners as to the causation of his injuries. Harry told the paediatric registrar that he did in fact attend school on the 7th contradicting his statement to Police earlier that he had not. He went to the Park Arcade after school having first gone home (it is not known if his mother was home, but police tried to contact her) and then to a Sainsbury’s supermarket. He stated his injuries happened “before Christmas” when he was trying to do a trick on his skate board but again was unable to recount the exact date. He denied that an assault had caused his injuries. He stated that he was happy in hospital and compared the hospital room to a hotel. 3.52 Child Protection Medical. The same day, a CP Medical was completed by a Consultant Paediatrician. There was a small-time delay in completing the medical as Harry’s mother refused to consent. This was the same scenario previously when she did not want him to have a CP medical for his foot injury in 2016. On this occasion his mother’s objection was overridden by Slough CST, as Harry was under police protection, who consented to the CP medical being carried out. SPR Comment: There must be parental consent for Harry to have had a child protection medical which his mother had declined. SCST could have decided at that stage to apply for an ICO or an Emergency Protection Order (EPO) in order for the Local Authority to attain parental responsibility allowing them to give consent which in this case they did not. SCST took the decision, as he was under police protection, to authorise the medical. Where a medical assessment or treatment is required as an emergency, parental consent is not required. The question is whether Harry’s case was considered as an emergency. This SPR believes there was a sufficient case to say it was as the welfare of the child is paramount, as Harry was required to become an inpatient for the treatment of his injuries. In the event, the CP medical confirmed significant and unexplained acute injuries which resulted in this SPR being commissioned. The issue of parental consent has been addressed as learning in this review in Recommendation 7 in Chapter 4. 3.53 The history taken from Harry at his CP Medical by the Consultant Paediatrician records that he persisted in saying he fell off his skate board ‘before Christmas.’ He reported the linear marks which extended from the top of his back to the bottom and on his chest were “caused by sunburn” and he was observed as being unkempt. 3.54 Injuries observed at the CP Medical were: - Cut on right lower lip. Labial frenulum intact. Fresh blood inside his nose. Smaller cut below right eye. Open cut above left eye. Blood and swelling on the right ear lobe. Matted blood on right side of the back of his head. 21 Left lower cheek 2cm linear cut – fresh blood. Numerous linear marks all over his body ranging from 2.5cm to 7.5 cams. Linear cut on left side of neck. Steri-strips on eyebrows and periorbital swelling. Numerous keloid scars all over his body. Superficial scratch upper right arm. Blood round index finger nail. Scattered scratches on neck. Swelling to lower jaw. Dried blood on back of his head. Multiple linear marks on his back. Some healed, some with scabs. X-rays reported no obvious facial bony injury and his left index finger: recent injury, not acute. 3.55 Conclusion of the CP Medical: The acute injuries are not consistent with a history of falling from a skateboard more than two weeks previously. There were several marks and scars with no clear explanation of how they might have occurred. Acute injuries include a swollen left eye, dried blood on scalp not consistent with the history of skate boarding accident before Christmas. Other marks noted have no clear explanation of how they occurred. 3.56 Police Investigation and Harry’s current situation 3.57 Harry remained overnight in hospital under Police Protection with police having made a formal referral to CSC. At the SM held on 8 January 2019, it was decided there would be a Joint Section 47 investigation with a follow up SM held the following day. CSC confirmed Harry was placed in foster care direct from hospital with Care Proceedings initiated. 3.58 Harry’s mother was arrested for neglect at her home address the same day. The premises were searched, and a small quantity of cannabis was seized along with two grinders. Blood stained clothing together with mother’s blood-stained pillow was also seized for potential evidence. Harry’s mother denied the drugs and grinders were hers and stated the blood stains came from her which forensic examination confirms this was not the case. This may form part of the evidence in any potential criminal proceedings. Harry’s mother has denied any involvement in her son’s injuries. 3.59 A police investigation by the CAIU into criminal neglect is ongoing and has resulted in the arrest of his mother who is currently released under investigation pending further enquires. There has been a delay in concluding the police investigation, compounded by a delay in receiving third party material from the Family Court care proceedings which Slough Children’s Service Trust, had commenced in order to safeguard Harry. 3.60 This SPR awaits the outcome of the police investigation and the decision of the Crown Prosecution Service (CPS) whether there will be any subsequent criminal proceedings instigated against any person. 22 Chapter 4 4 Analysis of Professional Practice using the KLOE’s, SPR Findings and Recommendations 4.1 This Chapter analyses professional practice. It assesses responses from Agency IMR’s submitted to the SPR and from professionals’ views from the Practitioners Event (PE) held to consider and evaluate Harry’s case. The analysis has identified for each of the five KLOE’s, seven Findings and SPR Overview Report Recommendations. They should be read in conjunction with the preceding Chapter which discusses Harry’s key events and interaction with practitioners. It must be noted, several KLOE have similar elements in the question asked. These are highlighted with reference to the KLOE, Findings and SPR Recommendations below. 4.2 KLOE 1 - Was Harry’s voice listened to, heard and acted upon? 4.3 What were the issues in this case? There was good communication by some practitioners who attempted to communicate with Harry which, the narrative in Chapter 3 describes. There were, however, concerns identified by agencies to the review. This includes the actions of practitioners including within the CP, CIN meetings and core groups who must be child focused and consider all presenting options which was not consistent in Harry’s case. The school attempted to capture the voice of Harry, but this was a very difficult situation for the school as he was heavily influenced by his mother. There were however, as highlighted in agency IMR’s, missed opportunities to hear his voice and work with him. His mother presented differently towards professionals with a particular animosity shown towards the school. No professional managed to really understand Harry without him reflecting on what his mother would say or think. It appears he did not have his own voice by his reluctance to speak about current concerns within and outside the home and how he felt being left home alone. 4.4 The practitioner’s event suggested there no focus on Harry who was lost amongst adults, particularly his domineering mother. It is the view of this report that practitioners did put Harry at the centre of concern, but the focus was temporarily lost when there was tension between partners (the school and social worker). However, the school are of the opinion although they were not always able to fully capture Harry’s voice, they constantly tried to engage with him which this SPR agrees with, as evidenced within the narrative in Chapter 3. There were, however, many instances when Harry was listened to by professionals, such as when TVP were called to the leisure centre. They listened and supported him and took him to the ED. Harry’s voice, however, was not always consistently captured to consider his inner thoughts. From Harry’s perspective, practitioners 23 engaged with him and made every effort to help him articulate what was happening to him, but practitioners felt that his voice, wishes and feelings were not fully expressed because he was afraid of and was deeply loyal to his mother. Also, his mother’s volatile and difficult behaviours required a focus on her, so overall his voice did not have sufficient weight. Therefore, opportunities to work with him, to obtain an overview of his lived experience, was not always taken, as outlined in Agency IMR’s to the review. The following finding and themes have been identified: - 4.5 Finding 1. The need for practitioners to remain child focused in order to capture the voice of the child and a review of the Slough Multi-Agency Threshold Guidance for children. 4.6 What should be considered? Finding 1 - It is incumbent on practitioners to listen to the voice of the child and consider and look at the child’s life experience and how they present to others. Any child protection concerns must be recognised and acted upon. Practitioners should always ‘Think children first’ with an emphasis on the priority of a child’s welfare over a parent or guardian. There must be awareness for the need to apply professional curiosity and act on concerns of disguised compliance. Some practitioners had no concerns regarding his mother, contrary to the impression the school had. There were missed opportunities to ensure the whole picture of Harry’s life was captured and assessed. There must be proactive engagement with children to actively capture their voice. The school attempted to capture his voice but felt they were left to deal with Harry without effective support from other professionals. A professional meeting can be instigated by any partner to share concerns and should always be considered. It is acknowledged this can sometimes be difficult as social workers may not or be unable to attend a non-statutory meeting, but this should not stop a meeting being held. It is imperative that practitioners, must have the confidence to challenge and talk to people. Furthermore, the Safeguarding Practice Group should review the current Slough Multi-Agency Threshold Guidance (2018), which provides a framework for all professionals working with children and young people, to ensure it is up to date and relevant in order to support and guide practitioners. The following SPR Recommendations 1 and 2 are made: - SPR Overview Report Recommendation (1) for all Safeguarding Agencies to the Review The need for practitioners to remain child focused in order to capture the voice of the child. It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry that the voice of the child is always captured and the focus remains on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns. SPR Overview Report Recommendation (2) for the Slough Safeguarding Practice Review Group A review of Slough Multi-Agency Threshold Guidance It is recommended that Slough Safeguarding Practice Review Group, review and update the Slough Multi-Agency Threshold Guidance (2018) for all professionals working with children and young people. 4.7 KLOE 2 - Were there missed opportunities to provide appropriate interventions to help Harry? 24 4.8 What were the issues in this case? There were clear elements of neglect or the concern of neglect in practitioner’s involvement within Harry’s life since his birth. He was subject to CP and CIN Plans and most recently a C&F assessment. There were persistent concerns of his presentation and behaviour at school. He appeared intimidated and was defensive of his mother with both giving inconsistent accounts when challenged regarding Harry’s health concerns, injuries sustained and questions over the mother’s parental care. The concerns raised should have stimulated a more robust response and assessment of risk. There were missed opportunities to consider the risk with signs and symptoms of possible neglect and abuse being present and not considered or identified. Capturing and understanding the family dynamics and other family support available should always be established which, was not sufficiently carried out in Harry’s case. The four occasions when Harry was left home alone should have stimulated more action to be taken using professional curiosity. Other action could have been taken into consideration such as police protection and having a strategy discussion on the occasion Harry made a 999 call which, TVP have addressed within their Agency Recommendation to the review. There were also missed opportunities by the GP to question further or consider a referral to CSC, when Harry attended appointments with his mother, during the period he was subject to a CP Plan. This included the delayed presentation for treatment with his infected foot, injuries to his hand allegedly occurring at school and his recurring skin infection, all were never fully assessed. Furthermore, there were four missed opportunities by the school when injuries to Harry’s face were noticed. They were dealt with internally and his mother spoken too. These events should have been referred to CSC at the time, in order to assess and consider the wider picture of what had occurred. 4.9 The review has disclosed issues of failure to effectively communicate, share information and concerns with the quality of recordkeeping, a continual theme in SPR’s and in serious case reviews previously. This also includes practitioners increasing the use of professional curiosity. All these issues have been identified by CCG, Solutions 4, SCST and TVP in their IMR’s and subject to their own agency recommendations. When dealing with a child known to be or has been the subject of child protection, they should take account of the previous history when assessing current concerns. All staff should be aware and comply with the Slough Neglect Tool 20197 which is currently being updated, to identify the signs and symptoms of neglect, including physical and emotional abuse; to act at the earliest opportunity; making sure the family dynamics are known, with a full assessment of risk conducted. There needs to be a more consistent approach to the neglect of leaving a child of Harry’s age home alone by developing and agreeing a ‘Home Alone” multi-agency strategy with particular emphasis on repeat occurrences. The CSC IMR also confirms there should have been more unannounced visits during the assessment period and more communication with his mother about what support was available, which this review concurs with. 4.10 Not all relevant safeguarding minutes of meetings were completed and shared with relevant agencies in a timely way. In this case it did not always occur and when they were shared, they were not received expeditiously. There is limited evidence of any management oversight of delivery of the scrutiny of chairs of meetings or supervisors, as some actions remained outstanding throughout the CP and CIN plans. No Lead Professional was allocated for Harry as the final CIN meeting was never held and this is an omission, and this was not picked up in reviewing and supervising the CIN process. Furthermore, the CSC team managers summary at the conclusion of the SW’s C&F 7 Slough Neglect Tool, 2019 25 assessment completed in November 2017, records it was thorough, analytical and reflective, providing a summary of past concerns which, would appear optimistic in light of the findings in this review. Overall this SPR and the opinion from the practitioner’s event, questions whether the step-down arrangements were carried out too soon when actions to be taken in the CP and then the CIN Plans were still unresolved. 4.11 The TVP IMR reports that this particular MASH had an expectation that the conference chair persons would escalate matters when necessary, as the police do not have the capacity to review every set of CP conference or minutes of meeting. This SPR agrees with the TVP IMR Author, that this creates an area of risk, placing too much expectation on the conference chair, or other non-police personnel to recognise what is relevant to a criminal investigation. It also creates a danger of new evidence or intelligence from other agency sources not being brought to the attention of the police and raises a risk of intelligence or allegations of crime being missed. The following findings and themes have been identified: - 4.12 Finding 2. Recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity. 4.13 Finding 3. Supervision, sharing information, communication and record keeping 4.14 Finding 4. Review of the TVP function within the Multi-Agency Safeguarding Hub (MASH). 4.15 What needs to be considered? Finding 2 - Greater professional curiosity should have been applied by professionals as identified by CCG, Solutions 4, SCST and TVP in their IMR’s and subject to their own agency recommendations. All relevant agency staff involved in this SPR should be aware of and comply with the Slough Neglect Tool 2019 which is currently being updated, to identify the signs and symptoms of neglect, including physical and emotional abuse; to act at the earliest opportunity; making sure the family dynamics are known, with a full assessment of risk conducted. There needs to be a more consistent approach to the neglect of leaving a child of Harry’s age home alone by developing and agreeing a ‘Home Alone” multi-agency strategy with particular emphasis on repeat occurrences. He had been left home alone on four reported occasions, with advice previously given to his mother about not leaving him home alone, was clearly not being followed. Professionals should have considered the cumulative effect it was having on Harry which, if there was an agreed strategy, would outline the action that should be considered and expected to be taken. The CSC IMR identified, and which this review agrees with, there should have been more direct work with Harry to assess his needs, his ability to ask for help. They should have confirmed what supporting networks were available both professional and with his extended family such as his MGF which he spoke about on occasions in conversation with practitioners. The following SPR Recommendation 3 is made: - SPR Overview Report Recommendation (3) for all Safeguarding Agencies to the Review Recognising the signs and symptoms of neglect, the assessment of risk and enhanced professional curiosity It is recommended that Slough Safeguarding Partnership Board are assured by all safeguarding partner agencies to the Safeguarding Practice Review for Harry, that all staff are reminded to comply with the following: - 26 Knowledge of National and Local Child Protection Policies and Procedures and guidance, utilising the available Slough Neglect Strategy and Tool 2019 to assist in identifying the signs and symptoms of neglect, physical and emotional abuse and to take immediate and necessary action if is required. To conduct enhanced multi-agency risk assessments to include capturing and analysing the history and family dynamics, to obtain a fuller picture of a child and young person’s life, in order to take immediate and appropriate action. Professionals must use more professional curiosity and follow up unanswered concerns, questions and inquire into child protection issues, to ensure a satisfactory outcome is obtained and accurately recorded. To develop an agreed Multi- Agency Home Alone strategy to ensure a consistent approach and expectation of agency action to be taken within Slough. 4.16 Finding 3 - All relevant safeguarding meetings such as ICPC, RCPC, CP, CIN and core group minutes and assessments records must be completed and shared with relevant agencies in a timely way without fail. There should be support for management oversight for chairs of meetings or supervisors, to ensure all actions identified in a child protection case are completed. If an action remains outstanding, the reason why must be assessed and record if there is likely to be any impact on the child if the action is not taken. Agencies must be reminded to take the opportunity to refer possible child protection safeguarding concerns to CSC and agency partners or at the very least call a professionals meeting to communicate and discuss the concerns at the time. Agencies should ensure their recordkeeping practice and systems are effective to ensure records are current and effective to support professional practice. There should be compliance with the SCST CIN guidance and standards. 4.17 If a child subject to previous CP, comes to notice, this should incur additional supervision and scrutiny and where a lead professional is required at the final CIN meeting, one must be appointed. This will ensure all aspects of a child’s case can be assessed, with all key decisions and available support is considered, together with an accurate record of the action taken and shared if relevant. In the foot infection referral in 2016, the referring school were not invited to the subsequent strategy discussion that followed which should have occurred. Communication and sharing information therefore failed in this respect. Also, if a final CIN closure meeting is not held, as in Harry’s case, supervision should identify the fact and take the necessary action. Minutes of meetings should be completed promptly and shared to all participating and relevant practitioners so that the accuracy of the minutes can be agreed and confirm what actions individual agency practitioners are expected to complete, which the CSC IMR has addressed within their agency recommendations. SCAS could not initially identify the call to TVP and had no record of the home alone incident when Harry made an emergency call. Information within the TVP IMR confirms the incident stemmed from SCAS who called police to Harry who had been found home alone. SCAS have since located the emergency call log and accept there are recordkeeping issues for SCAS which this finding and the following recommendation also applies to. The following SPR Recommendation 4 is made: - SPR Overview Report Recommendation (4) for all Safeguarding Agencies to the Review Supervision, sharing information, communication and record keeping 27 It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry, that: - Chairs and supervisors will ensure minutes from child protection meetings and assessments are expeditiously shared to relevant agencies and practitioners. All relevant practitioners and referrers of safeguarding concerns must be invited to meetings and discussions to ensure all child protection concerns are captured and addressed. All actions agreed at child protection conferences and core groups must be completed. Where actions are not completed, the likely impact on the child of not delivering the actions must be recorded. Remind staff where there are possible CP concerns that the information must be shared with prompt referrals where concerns are identified. Following a child protection step down, a final CIN meeting must always take place and the role of lead professional to support the child going forward, should be appointed. There is audit compliance with CP procedures on CP and CIN plans and step-down processes. Practitioners should be made aware of the SCST CIN guidance which is now in place and for all agencies to use and comply with the guidance for consistency of professional practice. Agencies should ensure their recordkeeping systems are robust, accurate and efficient for purpose and staff are complying with policy. 4.18 Finding 4 - In respect of the TVP issues in this particular MASH. The TVP IMR Author informs the review that the approach of those police departments involved with child protection (i.e. MASH and CAIU) have since evolved to be more professionally curious and to consider such cases in a wider context, due to the concerns and potential for missed information and action required in child protection cases. TVP have made a recommendation to this SPR for TVP to reassess its process for the handling of case conference notes and review police action within the MASH. This will be an opportunity to look into the function and resource capacity of the MASH to ensure standards of safeguarding children and young people are maintained to expectations. There is therefore no requirement for a SPR Recommendation, as TVP are addressing this finding. 4.19 KLOE 3 - Were partners sharing information appropriately and formally, both during the times when Harry was and was not subject to a child protection plan? 4.20 This KLOE refers to sharing information which has been addressed within the narrative in Chapter 3 and within KLOE 2, in Finding 3 and SPR Recommendation 4 above. 4.21 KLOE 4 - Where an agency had a concern, were the procedures followed to address that concern including the application of escalation procedures where appropriate? 4.22 What were the issues in this case? This SPR has identified a requirement to highlight to professionals working together that they must take account of another agencies concerns and opinions. Policies and procedures as well as the Pan-Berkshire Multi-Agency Child Protection Dispute Resolution Procedures (which has been updated and referred to below in 2019), are current and were not always followed. Every agency who reports a safeguarding issue must be given the respect 28 and receive an effective response, to ensure any request for help and support in a CP case is addressed and appropriate action taken if found necessary. The relationship between the school DDSL and the SW broke down with disagreements, leaving the school feeling undermined with the SW and CSC response. The focus was on a relationship between two professionals rather that maintaining focus on Harry. Even though this was of a short duration in comparison to the period under review, the school believed CSC were not supporting them. CSC did not appear to have had the same issue with Harry’s mother which the school had, whereas the school were seeing Harry daily, highlighting concerns which his mother clearly resented. The SW it is believed, was not taking the view of the school who believed the SW was appeasing his mother. It became necessary for the HT to raise a record of concerns against the SW and had to wait until December 2016, some three months later for a response from the SW manager. CSC were emailed again about the response and made a formal complaint, which escalated to the CEO of SCST and forwarded onto the Head of Operations (HO) who made a visit to the school. The HO listened to the school’s concerns and promised an investigation as they felt unsupported. The school never received an outcome. Adopting the dispute resolution procedure should negate the need for an agency to make a formal complaint against another. The following finding and themes have been identified: - 4.23 Finding 5. Professionals working together, compliance to policies and procedures and escalation processes. 4.24 What should be considered? Considering agencies are working to the same ends, they need to work together. The delay in responding to the initial school concern is unacceptable and after the visit by senior management and the promise of an investigation the outcome should have been reported to the school. Therefore, when an agency has an issue or complaint, agencies should use the Berkshire Escalation Process for Professionals with Safeguarding Concerns. This policy was reviewed and was updated in April 2019. It is now the called ‘Resolving Professional Disagreement and Escalation.’8 The resolution processes must be treated expeditiously. Harry’s mother and her dislike of the school came between the working professionals and took the focus off of Harry. It is not unreasonable to make sure that in future, school staff are listened to and their opinions taken seriously. The school raised an issue with the SPR Independent Author regarding cases which do not meet thresholds (addressed in KLOE 1 and Recommendation 2 below). It was also an opportunity due to the concerns for the school or any safeguarding practitioner to call a multi-agency professional meeting to discuss the concerns, of the advice ignored by Harry’s mother, safeguarding concerns and the relationship the school had with her and the CSC, to maintain the focus on the child protection and thus keeping Harry at the centre of concern. The following SPR Recommendation 5 applies: - SPR Overview Report Recommendation (5) for all Safeguarding Agencies to the Review Professionals working together, compliance to policies and procedures and escalation processes. It is recommended that Slough Safeguarding Partnership are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry that: - 8 Berkshire ‘Resolving Professional Disagreement and Escalation Policy.’ 2019 29 In practice, every agency and practitioners should be treated with respect, and their contributions are given equal weight and status as other professionals. All agencies should comply with the Pan-Berkshire - Resolving Professional Disagreement and Escalation Policy (April 2019) in resolving disputes between agencies and safeguarding professionals. Professionals should respond as expeditiously as possible, ensuring any issues are addressed with the referrer. 4.25 KLOE 5 - Was there an element of “professional accommodation” to Harry’s situation? (In other words, did professionals get used to Harry’s situation which might have affected their perception of his condition and toleration of his home circumstances? 4.26 What were the issues in this case? Generally, agencies to the review identified that there was a lack of professional accommodation to Harry’s situation. Harry’s defensive and sometime inconsistent accounts to reasonable requests from school staff who, only had Harry’s welfare at heart, were difficult and his mother was particularly demanding. There are clear elements of his mother’s control which worried Harry as to how his mother would react when concerns were discovered and raised by school staff. She was evidently strict with him, but his home life was never properly assessed from the information submitted to this review. She appeared to be compliant with the SW and the GP but that did not make Harry safe. Mother had displayed a varied and superficial compliance dependent on who she interacted with. There was no professional accommodation from the perspective of the school. 4.27 This report suggests there were elements of disguised compliance such as when Harry’s mother was given appropriate safeguarding advice not to leave Harry home alone but, she continued to do so. The Primary Care IMR is of the opinion there should not be too much emphasis and weight placed on the GP’s assessment of Harry when considering the degree of neglect and the mitigation of the related risks. His mother always presented well to the surgery and the appointments were only for 10 minutes duration. As the CCG state, there were no reports from primary care about safeguarding concerns but acknowledges learning for the GP practice in their IMR to the SPR. Harry’s mother when dealing with Harry’s SW appeared compliant, but this was not the case with her interaction with the school. 4.28 The school stated, his mother was extremely aggressive (a trait from her youth) towards another young girl at school. Furthermore, his mother told the school she had shown Harry his birthday presents but since he had lied to her (no details), she was no longer giving him the gifts but will provide him educational books to read. The school provided books for him which the mother appeared grateful for and agreed to take another book titled “boy in the dress.” Harry’s mother subsequently accused the school of encouraging him to become a transvestite because of the title of the book. The GP treated Harry and his mother regularly, mainly related to his skin infection. The CCG IMR Author suggests the reoccurrence of his skin infection was ‘normal’ in their opinion. It was not seen as a related cause and again when there was a delay in Harry receiving treatment for his infected foot injury where neglect was not considered. The CSC team manager’s summary at the conclusions of the SW’s C&F assessment regarding the robustness of the assessment that Harry was not at risk of significant harm considering Harrys’ history and concerns identified, this SPR suggests these highlighted comments could possibly be an element of professional accommodation. 30 SPR Comment: The C&F assessment was reviewed for the purposes of this review. The view of the SPR is that the assessment was not robust. It would appear the answers Harry’s mother gave when questioned regarding safeguarding concerns were accepted with little challenge. A capacity test concluded that Harry should not be left unattended as he was unable to give the right answer when asked what he would do in the event of a fire. The assessment also does not say whether the further work identified with Harry to teach him how to respond appropriately in an emergency, was conducted. It is not recorded whether the neighbours confirmed there was a satisfactory agreement in place when he was left home alone. The poor relationship his mother had with the school is highlighted. She said she felt targeted and tarnished given her history and was struggling to repair her relationship with the school. There was only advice given to Harry’s mother to try to improve her relationship with them. It is known from the school, the SW did not consult with the school regarding the assessment findings before the conclusion of the assessment, in order to resolve the issue between Harry’s mother and the school. A professionals meeting with agency partners should have been considered to discuss the wider impact on Harry before closing his case to SCST. 4.29 Harry’s mother, on two significant occasions would not consent to a child protection medical examination of Harry. The first occurrence was when he sustained a significant infected wound to his foot and again at the disclosure of the significant injuries which resulted in the current police investigation and this SPR. The mother finally agreed with much persuasion in the first instance for the medical as the wound needed hospital treatment and Harry himself wanted to go to hospital for the wound to be treated. In the circumstances of this current case and because Harry had been taken into police protection, CSC made the decision and agreed to allow a CP medical for Harry without his mother’s consent. The following findings and themes have therefore been identified: - 4.30 Finding 6. Further Multi - Agency training in disguised and varied compliance. 4.31 Finding 7. Child Protection Medical Examinations. 4.32 What should be considered? Finding 6 - Training in dealing with confrontational parents or guardians must be made to instil confidence and support for practitioners This should include concerns regarding Harry’s silence and posing the question whether there were any elements of his mother grooming his responses to practitioner’s scrutiny. From his presentation, comments and answers made to practitioners, as disclosed within the narrative in Chapter 3, this is highly likely. Where these situations are suspected or exist, all local and national policy and procedures need to be enacted to ensure the welfare of the child remains paramount. Threshold training has already been implemented within Slough, but it should be open to all safeguarding partners as the school particularly asked it to be open to CSC. 4.33 In dealing with confrontational parents, as in this case, a family needs to be appointed with an experienced SW. Practitioners should not be diverted off course if a parent or guardian is difficult. Where a parent does not wish to be challenged and who becomes defensive, it is imperative that practitioners still continue to take all necessary action to protect the health and welfare of a child or young person. Safeguarding action taken must be recorded, assessed and checked for accuracy and 31 referred or shared in the appropriate way. Practitioners must be aware that a parent or guardian can be telling different things to different professionals. Therefore, there is a need to ensure a joined-up approach by professionals, mindful of disguised compliance of a parent or guardian who purports to comply or varies their compliance when interacting with practitioners, especially when there are repeated and ongoing concerns. Recommendation 6 below, will go towards mitigating professional accommodation when dealing with difficult parents who could intimidate or manipulate some practitioners. The following SPR Recommendation 6 applies: - SPR Overview Report Recommendation (6) for all Safeguarding Agencies to the Review Multi- Agency training in disguised and varied compliance. It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry, ensure: - Staff should always consider disguised or varied compliance in any safeguarding case and to take appropriate action. Staff are supported and trained in dealing with difficult and confrontational parents or guardians and who may be grooming a child and young person’s responses to practitioner’s scrutiny. 4.34 Finding 7 - At the practitioner’s event, there was a request for the SPR to consider seeking legal advice and clarity from Slough Legal Services in order to agree an understanding between Health, Police and CSC. This is regarding obtaining consent for child protection medical examinations and action to be taken if a parent or guardian refuses to give consent. In Harry’s case, it was well managed by professionals within this review on the two occasions it arose. If no parental consent is forthcoming, the usual process would to be for the Local Authority to make an application to the court for an Interim Care Order or Emergency Protection Order. This did not happen in Harry’s case as the SCST took the view he was in Police Protection and it is suggested, assumed temporary parental consent to allow Harry’s CP Medical. In fact, no parental consent is required if it is felt that a medical examination and treatment is needed in an emergency which it is suggested, it was an emergency in Harry’s case. SCST considered the welfare of Harry was paramount and the subsequent hospitalisation and diagnosis of the significant injuries he sustained would go to support that the action required for a medical and treatment of his injuries was urgent. What would help is to make it clear in child protection training that when parents refuse a medical, in each case there is a range of options which should be explored, including legal advice. The following SPR Recommendation 7 applies: - SPR Overview Report Recommendation (7) for Slough Borough Council Legal Service Child Protection Medical Examinations It is recommended that Slough Safeguarding Partnership, should include within child protection training, the range of options practitioners can take, including legal advice, when a parent or guardian refuses consent to a child protection medical and added to the Pan Berkshire policies and procedures as a result of the learning from this SPR. 32 Chapter 5 5 Conclusions 5.1 This SPR Overview Report for Harry is Slough Safeguarding Partnership Board’s response to establish future learning to provide child protection safeguarding within the Slough Borough Council area. 5.2 Predictability and Preventability 5.3 Predictability - The circumstances of this SPR for Harry outlines persistent child protection concerns of possible neglect of Harry since birth until the incident in January 2019 when this review was commissioned. Due to his family background and child protection history, the likelihood Harry would be a victim of neglect was predictable as signs and symptoms of neglect existed throughout his 11 years of age at the time. There were elements of his mother possibly showing disguised compliance when interacting with some professionals particularly when Harry was subject to CP, CIN plans and C&F assessment. His school had persistent safeguarding concerns of his mother’s care. Advice given to her regarding addressing Harry’s chronic skin condition, the promptness of treatment of injuries and the requirement not to leave him alone, were made to sustain improvements to her child’s life, but she failed to comply with the advice. Neglect and the possibility of physical and emotional abuse is considered predictable in Harry’s case. 5.4 Preventability - The significant and extensive injuries Harry sustained in January 2019 may have been mitigated if the learning as identified in this review was being carried out. Although neglect was predictable, the persistent injuries Harry presented to the GP and within school were never fully explored as to the causation, not assisted by Harry and his mother’s inconsistent accounts. The outcome of the current police investigation and if any criminal proceedings are instigated, will determine whether Harry was subject to physical abuse by his mother. The view of 33 the SPR is there were previous warnings and clear signs and symptoms not only of neglect, but as suggested above, physical and emotional abuse which was never fully assessed when attempting to understand Harry’s life with his mother. The opinion of the SPR therefore is that Harry’s case could have been prevented, which the learning and recommendations from this review will hopefully address for future learning. Particularly as previous work with the family when Harry was subject to CP and CIN plans, there appeared compliance by Harry’s mother to care and provide for Harry. 5.5 Engagement with professionals - Practitioners Event 5.6 A Practitioners Event was held that was well received and attended by agency practitioners involved in the SPR. The issues submitted for discussion were elicited from the analysis of agency submissions including the KLOE’s and practitioner’s own views and opinions at the event. The information received was taken into consideration and analysed within Professional Practice using the KLOE’s, and subject to the Findings and SPR OV Report Recommendations in Chapter 4. 5.7 Participation of Harry’s family 5.8 Harry’s Mother and Father were not offered the opportunity to participate in the review due to the fact that Mother was subject to a police investigation of Harry’s neglect and physical abuse and it would not be appropriate at this stage of proceedings. The exact details and location of his Father is unconfirmed. He was, however, not part of Harry’s life during the scoping period of the SPR. Professionals did not capture or further consider Harry’s MGP’s either by contact or through his CP and CIN plans or in the C&F assessment. The views of the family have not been incorporated in the report. Therefore, questions as to the care and support that could have been provided to Harry have not been obtained from them. The voice of Harry’s mother is captured throughout the SPR and is subject to extensive comment within the report. 5.9 Culture and Diversity 5.10 This review identified Harry followed the Muslim faith and when he became a Slough Looked after Child (LAC) the foster placement was unaware of his religious culture which should not occur in future placements. Otherwise culture and diversity was not an issue identified within this SPR. 5.11 Previous SPR’s and initiatives 5.12 The NSPCC database for previous SCR and SPR’s was reviewed. There are similar learning as outlined in the analysis of the KLOE’s and SPR Recommendations in Chapter 4. This supports the fact that lessons are not being learnt. The SPR action plan which follows this report should ensure the learning is appropriately disseminated and the lessons are learnt, forming professional practice for the future of child protection in Slough. 5.13 Conclusions 5.14 Harry is now safe, and his health and well-being have considerably improved since he went into care. The SPR had no concerns about how agencies responded to concerns presented in January 2019. Correct child protection procedures were followed at that time which this SPR confirms. 5.15 The SPR reviewed the long-term cumulative effect of his neglect and abuse, in addition to the presence of numerous injuries amounting to serious harm. Specifically, why Harry was living in 34 such conditions for such a long time. There is a need to improve working together and information sharing, learning about neglect, the cumulative nature of neglect and abuse and the necessity to respond swiftly to prevent delay and long-term harm of a child or young person. 5.16 A Slough Multi-Agency Neglect Strategy and Tool 2019 has been published with intensive multi-agency training implemented. Learning from this review will identify what more can be done to make and better inform practice improvements as it is planned for the strategy to be reviewed and updated again in the summer of 2020. 5.17 Safeguarding practice in Slough was rated inadequate (from 2013 until March 2019 when Slough was inspected by Ofsted and rated as requires improvement to be good with a number of recommendations made as a result of the inspection. The school believes that overall, schools were left wanting during this period. This SPR cannot realistically address this view as it is outside the remit of the terms of reference. The review, however, has actively listened to agencies and practitioners involved in the SPR and has attempted to address and improve working relationships, particularly as highlighted in the disagreement between the school and CSC, through Recommendation 5 in Chapter 4. 5.18 Submission 5.19 This SPR overview report for Harry is submitted to Slough Safeguarding Partnership to consider the findings and to promulgate the recommendations for learning to ensure the health and wellbeing of children and young people in the Slough Local Authority area. 35 Appendix 1 - Bibliography and Glossary Bibliography - Additional to the foot notes in the report, the following legislation, documentation and guidance was consulted for the process of completing this SPR: - Guidance Department for Education database. Working Together to Safeguard Children 2015 and 2018. Care Quality Commission (2010) Guidance about compliance: Essential standards of quality and safety. Slough Borough Council, Safeguarding Partnership Board website. Bullying in UK Schools – House of Commons Library, February 2020, a briefing paper discusses the prevalence of bullying amongst pupils in schools across the UK, and policies to prevent and tackle bullying in English, Welsh, Scottish and Northern Irish schools. Serious Case and Safeguarding Practice Reviews NSPCC database for previous SCR’s and SPR’s - 2015 to 2020. 36 Appendix 2- Glossary CCG Clinical Commissioning Group C&F Children and Families CP Child Protection CPP Child Protection Plan CPS Crown Prosecution Service CSC Children’s Social Care CIN Child in Need DSL Designated Safeguarding Lead ED Emergency Department FSW Family Support Worker HOS Head of Service IA Initial Assessment ICO Interim Care Order ICPC Initial Child Protection Conference IMR Individual Management Reviews IA Independent Author LAC Looked after Child MASH Multi-Agency Safeguarding Hub MGF Maternal Grandfather MGM Maternal Grandmother NFA No Further Action PP Police Protection 37 PVP Protecting Vulnerable People RCPC Review Child Protection Conference RR Rapid Review SCAS South Central Ambulance Service SCST Slough Children’s Services Trust SD Strategy Discussion SM Strategy Meeting SO Supervision Order SPB Safeguarding Practice Board SPR (G) Safeguarding Practice Review (Group) SW Social Worker TVP Thames Valley Police TOR Terms of Reference YOT Youth Offending Team WTSC Working together to Safeguard Children |
NC048430 | Death of a 5-month-old child of Lithuanian parentage from a brain injury in March 2015. Father was found guilty of murder of Child D in February 2016 and also found guilty of injuries caused to siblings DD and LD. Child D was a twin who was born prematurely and spent 2 months in hospital after their birth; Child D's sibling had further health complications that required hospital appointments. Child D's parents came over from Lithuania in 2010 and started a family 3 years later. They were not known to children's social services until the death of Child D. The family were under financial pressures and away from the main support system of their extended families. There was contact with health visitors, GPs and hospitals before the birth of the twins. Findings included: considering all children in a family; fathers must be included in assessments and plans for children; highlights the importance of interpreters. Good practice was noted at the neonatal unit the twins attended and the health visitor was pro-active in seeking help for the family. Finds that improved arrangements would not have prevented the death of Child D, but there are opportunities for services to make some changes to develop their services.
| Title: Serious case review: BSCB2015-16/01: born in 2014: died on 1st April 2015 aged 5 months. LSCB: Birmingham Safeguarding Children Board Author: Jim Stewart Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Independent Author: Jim Stewart Serious Case Review BSCB2015-16/01 Born in 2014 Died on 1st April 2015 aged 5 months 2 Contents Page 1. Reason for the Review 3 2. Methodology 3 3. Independent Lead Reviewer 4 4. Family Composition and Background 4 5. Ethnicity, Culture and Identity 4 6. Family Background 5 7. Parental and extended Family Involvement 5 8. Criminal and Care Proceedings 6 9. The Birmingham Context 6 10. Summary of Key Events 9 11. Analysis 14 12. Service Developments since April 2015 27 13. Conclusions and Lessons Learned 29 Appendices Terms of Reference Bibliography Acronyms 33 37 39 3 1. Reason for the Review 1.1 The subject of this Serious Case Review is Child D, a twin who was born prematurely on 14 November 2014 and died on 1 April 2015. An ambulance was called to the family home following an emergency call and Child D was taken to hospital where a devastating brain injury was identified which was assessed to have been a non-accidental injury. On the afternoon of 1st April life support was withdrawn and Child D died peacefully in parents’ arms. 1.2 Following a police investigation and criminal trial, Father was convicted of murder on 22 February 2016. Mother was exonerated in court from any blame in causing injuries to Child D and all charges against her were dropped. Birmingham Children’s Services have safeguarded the welfare of siblings DD and LD through care proceedings. 1.3 The twins, Child D and DD, had been born very prematurely and required significant health involvement. Child D spent almost 8 weeks in hospital before discharge and her sibling 9.5 weeks, a little longer because the child required abdominal surgery to address complications due to prematurity. Both twins were visited at home by the Health Visiting Service and seen by the family GP. 1.4 Children’s Social Care had had no involvement with the family. They became involved on 1st April 2015 following Child D’s hospital admission and death and have remained involved with Child D’s surviving twin and LD. 1.5 The Chair of Birmingham Safeguarding Children Board was notified on 29th May 2015 of the recommendation made by the Serious Case Review Sub-Group that a Serious Case Review should be undertaken and the Chair ratified the decision following a peer review discussion with another LSCB Chair on 6th July 2015. 1.6 The Chair subsequently decided that this Serious Case Review should be considered alongside a separate Serious Case Review in respect of the death of a child in a different migrant family; although the circumstances of the cases were very different it was judged that similar themes may arise which could usefully be compared and contrasted in an additional issues report. 2. Methodology 2.1 Scoping reports were requested from West Midlands Police, Birmingham Community Healthcare NHS Foundation Trust, Birmingham Children’s Hospital NHS Foundation Trust, Sandwell and West Birmingham NHS Foundation Trust, Sandwell and West Birmingham Clinical Commissioning Group, West Midlands Ambulance Service, Birmingham Children’s Social Care, Birmingham Early Years and the United Kingdom Border Force. 2.2 The Lead Reviewer has considered the information provided in a multi-agency chronology and in brief agency reports produced primarily by the Health 4 Trusts involved with the family. He has also reviewed information gathered by West Midlands Police as part of their criminal investigation and also information subsequently gathered by Birmingham Children’s Services during assessments and care proceedings undertaken in respect of Child D’s surviving siblings. 2.2 A learning event took place on 2 December 2016 with representatives of the Health Trusts involved and some members of the SCR Sub-Group and this was facilitated by the Lead Reviewer. 2.3 The Lead Reviewer has discussed the detail of drafts of this report with the Serious Case Review Sub-Group and made final revisions in the light of the feedback and further information received from agencies and the members of the group. 3. Independent Lead Reviewer 3.1 Jim Stewart is an Independent Social Work Consultant with over 26 years’ experience of working in children’s services, child protection practice and management, including the coordination of complex case investigations and the conduct of Serious Case Reviews. He qualified as a Social Worker in 1986 and is registered with the Health and Care Professions Council. 4. Family Composition Child D Date of birth: 2014 Date of Death: April 2015 Sibling - DD Date of birth: 2014 Sibling – LD Date of birth: 2013 Mother Date of birth: 1992 Father Date of birth: 1989 5. Ethnicity, Culture and Identity 5.1 Mother and father were both born and brought up in Lithuania, a European country which is a member of the European Union. They moved to this country as adults and had three children together whilst living in England. 5.2 Father spoke Lithuanian and a little Russian when he moved to England. His English has improved whilst living in the country and whilst an interpreter was present during the Lead Reviewer’s meeting with him, he demonstrated a good grasp of the language. 5.3 Father stated that he is not very religious. He is Roman Catholic but had not been baptised and did not practice his faith. Child D was baptised shortly before their death. 5.4 Lithuania became a member of the European Union in 2008 and both parents were able to come and work in England legally. 5 5.5 Authorities in Lithuania, the parents’ country of origin, were informed of Child D’s death and care proceedings for the two surviving children, and reported that they ‘were watching things closely’. 6. Family Background 6.1 Neither mother nor father had been known as children to Children’s Services in Lithuania. They grew up in villages close to each other. Father described a happy childhood in Lithuania. Father’s father had been an alcoholic and his mother had separated from him. Father is physically healthy; he fell from a tree and broke ribs, bones in his hand and nose in an accident before he was five years old, but made a full recovery. He stated the he and mother did not have any problems with alcohol or substance misuse and there was no domestic abuse in their relationship. 6.2 Father had worked restoring old cars in Lithuania. 6.3 Mother moved to England in 2010 when her aunt offered her work. Her aunt’s partner was also looking for someone reliable to work for him and father joined mother. 6.4 Father and mother briefly separated in England during their first year here. Father returned to Lithuania for Christmas. Mother’s brother continued to live with father and he and mother remained in contact and eventually father and mother decided to resume their relationship. 6.5 The couple both wanted children; LD was a planned pregnancy. The twins were not planned but father described the couple as being happy about the pregnancy. 6.6 The couple were reliant upon their earnings from low paid jobs and at times it is understood that they supplemented their income by taking on additional work. Mother bought and re-sold cosmetic items through Ebay and father repaired computers and cars. Father told the Lead Reviewer that mother sent money back to her family in Lithuania each month which increased the couple’s financial pressures. 6.7 Both parents had brothers living in England and there were other relatives in Birmingham. Father’s mother had been invited to live with the family in Birmingham but she missed Lithuania and returned before the birth of the twins. Father told the Lead Reviewer that he and mother both had friends in Birmingham. 7. Parental and Extended Family Involvement 7.1 Birmingham Safeguarding Children Board invited Child D’s parents to meet the Independent Lead Reviewer to contribute their views to this Review. Father agreed to meet and his views are included. Mother chose not to take part in the review. 6 8. Criminal and Care Proceedings 8.1 A police investigation took place following Child D’s death. Father was charged with murder and causing injuries to the children. Mother was charged with allowing the death of a child. 8.2 A criminal trial began on 12th January 2015 and concluded on 22nd February 2016 when Child D’s father was convicted of murder and all charges against the mother were dropped. 8.3 A Finding of Fact Hearing had taken place on 10th December 2015 as part of the care proceedings for Child D’s surviving siblings and the Judge found that the father was responsible for the death of Child D and for the injuries to DD and LD. 9. The Birmingham Context Census Information 9.1 The 2011 census reported that: 1.073 million people lived in Birmingham. The city has a young population with 66% aged under 44 and 19% within the 20-29 years’ age group Birmingham is the ninth most deprived of the 354 Local Authorities in England. Birmingham is the most ethnically diverse city in the United Kingdom. In its 2015-16 annual report, Birmingham Safeguarding Children Board references academic research that found people from over 200 countries have made their home in the city. Over 60% of the population under 18 years of age is from a non-white British background (2011 census). Some 7.5% of households do not have English as their main language. Ofsted noted in their 2016 inspection report that 22.2% (238,300) of Birmingham residents were born outside the UK. 9.2 The document, An Overview of the Joint Strategic Needs Assessment for Birmingham 2012, organises information around the six Marston Review policy areas of which the first is ‘Give Every Child the best start in life’. The subsection ‘Starting well: conception and childhood’ provides the following information: Birmingham has high rates of perinatal and infant mortality. The infant mortality rate is 7.7 per 1,000 live births, compared to the England average of 4.7. Rates are significantly higher in ethnic minority groups. 7 10% of babies born in Birmingham weigh less than 2.5kg compared to 7.5% in England. Low birth weight is as high as 29% in some areas of the city. Breast feeding initiation in Birmingham is low at 68.1% compared to 74.6% nationally. Immunisation rates vary across the city. Rates of Measles, Mumps and Rubella vaccination are lower in the south Birmingham area compared to the rest of the city. 9.3 The Joint Strategic Needs Assessment (JSNA) also highlights the following information about worklessness in the city: The worklessness rate is 18.5% – higher than a year earlier (18.0%). It is higher compared to the West Midlands (13.7%) and England (11.9%). Of the eight core cities, Birmingham’s worklessness rate is the second highest, and it is nearly two-thirds higher than the England rate. Worklessness is highest in the wards with the highest deprivation rate (IMD). Birmingham City Hospital Neonatal Unit 9.4 This ward has 29 beds; 5 intensive care beds, 5 high dependency unit beds and 19 special care beds. The unit has a high admission rate and is regularly at capacity. 9.5 Two Paediatricians were involved in running the unit at the time covered by this Review. At least 35 Nurses,17 Doctors and 3 Advanced Neo-Natal Nurse Practitioners were involved in the care of the twins whilst they were in the unit. 9.6 There are different levels of care within the NHS which reflect the level of care provided and the needs of babies which are met: Level 1 Special Care Baby Unit (SCBU) is for babies who need continuous monitoring of their breathing or heart rate, additional oxygen tube feeding, phototherapy recovery (to treat neonatal jaundice) and convalescence from other care. Level 2 Local Neonatal Unit (LNU) is for babies needing short-term intensive care with apnoeic attacks who require support, including receiving continuous positive airway pressure (CPAP). Some babies receiving parenteral nutrition (tube feeding) may also need this level of care. Level 3 Neonatal Intensive Care Unit (NICU) is for babies needing respiratory support (ventilation) weighing less than 1,000g, born at less than 28 weeks’ gestation and needing significant CPAP support 8 (continuous positive airway pressure). Babies with severe respiratory disease who also require surgery may need this level of care too. Transitional Care: where babies who still have some needs but are almost ready to go home. Parents become the main carers with support from a Nursery Nurse or other staff on the unit. 9.7 The City Hospital Neonatal Unit is a high functioning level 2 unit which is regularly undertaking level 3 work and caring for babies born at 27 weeks onwards. 9.8 There are four family overnight stay rooms attached to the unit (two of which can accommodate siblings). 9.9 There is a Discharge Planning Nurse within the Unit staff team. Unfortunately, this member of staff was off sick during the period that the twins were in the hospital. The Unit is a member of the Southern West Midlands Maternity and Newborn Network. The vision of the Network is to oversee that the hospitals in the network provide high quality care for the right mother and right baby in the right place as close as possible to home. 9.10 Prior to discharge, staff talk to parents about safe handling and safe care. Information is also provided about basic life support (resuscitation). 9.11 A Care Quality Commission inspection published in March 2015 judged Birmingham City Hospital to be requiring improvement overall and found maternity and gynaecological services to be good. Birmingham Children’s Hospital Neonatal Surgical Ward 9.12 The Ward comprises of 16 cots including four cots for babies requiring high dependency care and admits children between the ages of 0 and 6 months old. The main reason for admission is either emergency or elective surgery and babies can be transferred back to their original hospital or discharged home. It provides level one (special care) and two (higher dependency care required) care to babies requiring surgery. If level three care (ventilation support) is required, babies are transferred to the Paediatric Intensive Care Unit (PICU). 9.13 There are 12 surgical consultants linked to the ward which also has a Ward Manager, 28 nurses, 6 healthcare assistants and an outreach nurse. 9.14 Parents are encouraged to stay with their baby and participate in their care. Interpreters are used when necessary. The GP, Health Visitor and Community Midwife are routinely informed of admission and at time of discharge. A Family Common Assessment Framework is routinely completed after 21 days and again 60 days post admission. However, DD only spent 10 days on the ward. 9.15 The Neonatal Surgical Ward staff are required to attend Level 3 in – house Child Protection Training and have access to the Trust Safeguarding Team 9 including a CAF Lead. The Trust training compliance is at 91.9% although it is slightly lower on the ward. The ward has been involved in nearly 50 child protection cases between 2012 and December 2016. 9.16 The Care Quality Commission inspected Birmingham Children’s Hospital in 2016 and judged that the Hospital was ‘outstanding’ and that its Neonatal Services ‘requires improvement’. It highlighted the need for better recognition and review of serious incidents on the ward, improved performance information and work to ensure that nurse staffing levels meet national standards. The Role of Children’s Centres with babies 9.17 In the period under review, children’s centre staff routinely visited parents following a birth as part of early help arrangements to make them aware of support and services available. This service is currently under review; the early information to centres about new births and the co-location with services are examples of very good practice. However, recognition of the potential duplication in centre workers making home visits given the role of Health Visitors is being considered in this review. 10. Summary of Key Events Date Event 2010 Mother moved to England to work and was later joined by father. 2012 5 July Mother registered with a GP and had a new patient appointment; Mother was 19 years old, her pregnancy was confirmed and an antenatal referral was made. Her low BMI indicated that she was slim, possibly underweight. 20 July Mother attended A&E at Worcestershire Royal Hospital. Father recalled that she may have fainted at work, reported lower abdominal pain and was 12 weeks pregnant. 25 July Mother was registered with a local Children’s Centre. July Mother began to attend antenatal services at S Children’s Centre. 2013 19 January LD was born by emergency caesarean section at full term (39 weeks’ gestation) at City Hospital. 21 January Mother discharged herself from hospital against medical advice. 1 February Mother attended GP for a measles, mumps and rubella immunisation 10 for herself. 5 February LD was readmitted to hospital because they had not regained their birth weight. 22 February A new birth home visit to see LD took place. 13 March A male caller requested an ambulance stating that his one-month baby could not breathe. Father has confirmed that he made this call when LD was choking and he panicked. He became frustrated at the routine questions being asked and put the phone down. When called back, he confirmed that he no longer needed an ambulance. 24 April LD received first immunisation and first child health examination at 13 weeks. No concerns recorded. June Father’s mother visited from Lithuania and spent 2 weeks with LD. 16 August Mother was seen by her GP; she was pregnant but she later suffered a miscarriage. As she appears not to have sought medical help it is not known how many weeks pregnant she was when the pregnancy ended. 2014 26 January West Midlands Police received a call about a drunken man smashing the house up. Officers attended. Father recalled that a drunken neighbour had joined a small party and had kicked father in the face and father asked mother to call the Police. Father stated that the Police took the neighbour home, but this is not indicated in the Police record. 11 February Mother attended GP with some vague symptoms/health concerns. Bloods taken. GP gave mother reassurances. June Father’s mother visited again from Lithuania and stayed for 2 months. Father has explained that the plan had been for his mother to live in the small room in the house permanently but she did not settle in Birmingham and decided to return to live in Lithuania. 9 June Mother attended GP surgery, GP noted pregnancy and referred her to Midwifery services. 14 June Mother attended pregnancy booking appointment and marker placed on record that mother described difficulties understanding English and requiring an interpreter. 22 July Mother attended A&E due to bleeding and mother’s pregnancy with twins confirmed. 11 23 July GP made telephone call, uncle spoken to uncle and requested that LD attend for a 13 month assessment (which was completed on 28 July. 14 November DD and Child D were born significantly premature at 28.5 weeks of gestation at City Hospital. 14 or 15 November Mother discharged herself from hospital. The children remained in hospital until January 2015. 19 November The allocated Health Visitor received reference ecards for the twins for a new birth home visit but it was noted that the babies remained in hospital. 28 November The Health Visitor made a home visit and was informed that the twins were still in hospital. 3 December Child D was moved from the special care unit to a side room due to developing a bacterial infection. 15 December The Health Visitor made a telephone call to the City Hospital Neonatal Unit for an update. She was informed that Child D was doing well but DD was poorly with an infection. She also learned about the hospital’s concerns about a lack of visiting; for example, parents had not visited since 12th December. 15 December The Health Visitor made a home visit. 2015 2 January A Sister from the Neonatal Unit at City Hospital telephoned the Health Visiting Team. 7 January Child D was discharged home and DD remained in hospital. 11 January DD was transferred to Birmingham Children’s Hospital Surgical Neonatal Unit because of failure to tolerate feeds and development of a distended abdomen. A colonic stricture (an abnormal narrowing of the colon – in this case in the large bowel) which required surgery was diagnosed. January DD had a laparotomy which is a major surgical procedure that involves a cut being made in the abdominal wall to allow a surgeon access to the contents of the abdomen in order to identify and repair any emergency problems that have occurred. DD had required a bowel resection which left only 20cm of bowel. 14 January A Health Visitor undertook a new birth home visit following Child D’s 12 discharge home. Child D’s weight was on the 2nd centile (9 - 25th centile adjusted for prematurity). 21 January DD was discharged home. The Neonatal Unit at Birmingham Children’s Hospital telephoned the Health Visitor to make her aware. The impact of DD’s surgery meant that stools would be passed every two hours and need a special milk feed. DD’s weight would require regular checks. 22 January Parents did not bring DD to an Ophthalmology appointment. Worker(s) from a Children’s Centre visited the family at home and updated the family registration to include the birth of the twins. 23 January The Health Visitor made a new birth home visit following DD’s discharge home. The Health Visitor weighed DD and observed that mother seemed to have a good relationship with the baby and was coping with DD’s needs. The assessment took place in the bedroom the family used and mother was encouraged to register Child D with the GP as this had still not taken place. The Health Visitor accurately recorded that mother had had a traumatic birth, a long separation and parental concerns for the wellbeing of the babies. Mother was described as well and positive. 28 January Child D was taken to an Ophthalmology appointment and discharged. 30 January The Health Visitor saw Child D and DD at home with their mother and an aunt present. Child D had gained weight but DD’s weight remained static. The Health Visitor discussed DD with surgical ward staff and was advised to ask the parents to bring DD to hospital the following Monday for review. 2 February The twins were registered with a GP. Also, DD was taken to Birmingham Children’s Hospital (BCH) due to weight and lower respiratory tract infection. 6 February The twins were registered with the family GP and DD was taken to BCH Children’s Eye Hospital Eye Clinic Department. A Nursery Nurse made a home visit but there was no reply. 20 February A Nursery Nurse weighed the twins at home and advised to contact the GP re a lump in DD’s groin. 24 February The Twins attended for respiratory problems. DD again attended BCH Emergency Department because due to an enlarged testicle, the child was not passing urine and a hernia was diagnosed. 11 March The Health Visitor records attending a Team Around the Family (TAF) Panel and discussed the family’s housing issues. Early 13 support confirmed that they could potentially provide support to the family. Police representative also suggested that the Health Visitor should contact NASDOM which is a multi-lingual advice centre aimed for communities who do not speak or have very poor English language skills to offer help and advice as needed. Children’s Social Care/Early Help have reported back that the family were not on the agenda and there was no formal discussion of the family at the TAF meeting on this date. 23 March The Health Visitor spoke to father during a home visit as mother was reported to be out shopping. Child D had gained weight steadily and DD had also gained weight. The Health Visitor discussed the potential benefits of a Family Common Assessment Form (fCAF) and father stated that he would discuss this proposal with his wife. 30 March Mother began a new job working nightshifts which she had found through a friend. Father had the care of the children. 1 April An ambulance was called to the family home at 00.45. On arrival Child D was unresponsive and suffered a cardiac arrest. Child D had bleeding in the lungs due to severe blood clotting problems. A CT scan showed a devastating injury, brain swelling and bleeding within the brain. Child D showed no signs of life; Child D was removed from the ventilator in the afternoon and died peacefully in parents’ arms. DD had a child protection medical on the same day and there were no obvious signs of any inflicted injury. 2 April LD had a child protection medical by a Community Paediatrician which like DD showed no outward signs of concerns. 7 April DD had a planned admission for completion of the child protection medical assessment. The CT head scan results were normal. Skeletal survey results showed multiple fractures: Bilateral rib fractures, bilateral fractures of the distal femoral (thighbone) metaphysis and proximal tibial (shinbone) metaphysis and distal tibial metaphysis. The radiologist reported that the appearances of rib fractures suggested that they were of different ages. Note: The metaphysis is the wide portion of a long bone which contains the growth plate, the part of the bone that grows during childhood. The epiphysis is the rounded end of a long bone, at its joint with adjacent bone(s). The diaphysis is the shaft or central part of a long bone. 1. Distal means situated away from the centre of the body or from the point of attachment and Proximal means situated nearer to the 14 centre of the body or the point of attachment. 9 April Police informed Children’s Social Care that they had discovered photographs showing facial injuries to LD when reviewing the contents of parents’ mobile phones. Children’s Social Care successfully applied for Interim Care Orders to safeguard both surviving siblings. Father and mother insisted that LD had fallen whilst out shopping with mother and this was the cause of the injuries observed in pictures on a mobile telephone. 11. Analysis Good Practice 11.1 This review has identified a number of examples of good practice: The Midwife asked screening questions about domestic abuse at ante-natal appointments. The general quality of health visiting recording; this included a comprehensive GP liaison form written by the Health Visitor to share with the GP the issues she had identified with the family and the action she had taken to meet their needs at the beginning of March 2015 The Health Visitor checked and fed back to the family regarding hospital appointments, medical advice and prescriptions for the specialist milk and sought support for their housing situation. There was written and verbal transfer and discharge information communicated by hospital staff in writing and verbally to the Health Visitor when the discharges from the Neonatal Unit took place. The Health Visitor explained the Family Common Assessment Framework (fCAF) process to mother and father and encouraged them to agree to completion of an fCAF. The Eye Clinician recognised the risk of non-attendance at screenings for Retinopathy of Prematurity (an eye disorder affecting premature babies – see below for further information) and was proactive in completing the first review before DD’s discharge. There was a thorough medical examination of DD at the Children’s Hospital Emergency Department on 2 February 2015. Key Issues 15 11.2 The review has also highlighted a number of areas of practice which would benefit from further consideration and learning and action to make arrangements and professional practice more robust. The vulnerability of babies, the particular challenges of parenting premature children and twins and the significance of neonatal care 11.3 During the first post discharge home visit to Child D on 14th January 2015, the Health Visitor recorded that mother had experienced a traumatic birth experience, a long separation and parental concerns for the babies’ welfare and recognises that this can impact on maternal emotional wellbeing. 11.4 DD was transferred from City Hospital to Birmingham Children’s Hospital on 11 January 2015. DD was discharged from hospital on 21st January at 10 weeks old. In addition to prematurity and being a twin, DD the sibling twin had significant bowel surgery prior to discharge and then needed a strict regime of two hourly feeds and weekly weight reviews. DD’s skin was vulnerable due to frequent stools and required additional attention to skin care routine and weekly assessment. DD also had a hernia which caused pain. DD was slow to gain weight. 11.5 DD attended the Accident and Emergency Department with respiratory problems on 2nd February 2015 and again on 24th February due to concerns about the ability to pass urine. At the second attendance, a consultant identified that DD had an inguinal hernia (a lump or swelling in the groin) as well as an umbilical hernia (a painless lump in or near the belly button). 11.6 Both Child D and DD required assessment for Retinopathy of Prematurity (ROP) which is an eye disorder affecting premature babies. It affects the immature blood vessels of the retina and occurs weeks after birth. Complications can lead to vision problems or blindness if left untreated and therefore babies need to be reviewed regularly so that problems can be identified and treated early if necessary. DD was confirmed to have stage 2 ROP on 21 January 2015. (Stage 1 is mild and Stage 5 is severe). 11.7 A number of the national reviews of Serious Case Reviews have highlighted the vulnerability of babies aged under one-year-old and that the potential risk to children is increased by prematurity and multiple births. The authors of the Triennial Review of Serious Case Reviews 2011-2014 published in 2016 note that ‘We know from our past biennial reviews that the very young are particularly vulnerable, and that premature babies, babies with a low birth weight and/or requiring initial (or in some cases lengthy) special care baby unit nursing, and babies born with neonatal abstinence syndrome potentially pose challenges to their parent(s) over and above the considerable demands of any new-born infant.’ 11.8 The Biennial Review of Serious Case Reviews 2005 - 07 published in 2009 included seven sets of twins (4%), double the small number (2%) in the 2003-05 study. This was higher than the national average of 1.5% of all deliveries (NHS maternity statistics England 2005-6). The 2005-07 review noted that: 16 ‘The extra demands made by multiple births are known to place increasing pressure on parents - particularly when the babies are premature or more difficult to feed or care for.’ ‘Babies born prematurely with low birth weight are harder to look after, more difficult to feed and may cry more. This may in turn prompt angry reactions from a parent,’ ‘A baby’s stay in the hospital special care baby unit can inhibit the bonding process’. ‘These early disadvantages can have lasting consequences and prematurity and low birth weight can be markers for difficulties throughout the life course’. 11.9 In the 2011 report Ages of Concern: Learning from Serious Case Reviews, Ofsted also highlighted the ‘fragility of babies’ and the potential for practitioners to underestimate this fragility and also the risks resulting from parents’ own needs given this vulnerability. 35% of the 602 children subject of the 471 Serious Case Reviews between 2007 – 11 evaluated by Ofsted were babies under the age of one-year-old. In the Triennial Review of Serious Case Reviews, 73% of the 48 children who died from fatal physical abuse were aged under 2 years old. 11.10 Working Together guidance (2013, 2015 and the 2017 update) includes an expectation that Local Safeguarding Children Boards should ensure that training should cover how to identify and respond early to the needs of all vulnerable children, including unborn children and babies. It is important that these risk factors are clearly highlighted in both Early Help and Child Protection training, procedures and guidance within hospitals and in the wider multi-agency documents. 11.11 Birmingham Safeguarding Children Board supported a ‘Never Shake a Baby’ campaign in April 2012 which involved the distribution of an information leaflet in community healthcare settings across the city. In 2016 the Board launched the ‘Keep me safe while I sleep’ Safer Sleeping Campaign designed to promote safe sleep arrangements and the steps parents and carers can take to reduce the risks. Health Visitors issue resource packs at the 28-week antenatal visit and discuss the information at the first post-natal home birth visit. 11.12 There were significant issues in respect of both the Child D and DD around feeding, frequency of parental contact, and parent-child attachment. Breastfeeding. 11.13 The reviewer for the Sandwell and West Birmingham Hospitals NHS Trust has raised questions about the level of advice given to mother at Birmingham City Hospital about breastfeeding. The discharge summary for LD and mother 17 indicated that mother was not observed to breastfeed well. This may have been the reason for LD’s poor weight gain. 11.14 When there was a discussion about the use of the breast pump and sterilising equipment on 16 November 2014, it is not clear whether this included advice about attending a breastfeeding support group and where and how to store expressed milk. 11.15 On 29th November a Neonatal Nurse made mother aware that there was not enough expressed milk for the twins and an alternative may have to be given. There is no record of any discussion about how she was expressing milk or her dietary intake which would affect her production of milk. 11.16 Mother visited the babies twice on the evening of 29th November 2014. She stated that she was struggling to express milk for both twins and received advice. A plan to refer to the Infant Feeding Team was recorded but the referral was not made. Mother was given an expression log with a plan to review on 3 December 2014. The log was never reviewed and no further support was recorded. 11.17 During a hospital visit on 19th December, mother informed staff that her breast milk had finished and that she planned to return the borrowed breast pump to the unit. Attachment 11.18 When mother visited on 3rd December 2014, this was the first recorded visit for four days. Mother stated that she did not wish to hold the baby because she felt like she had a cold. During a short visit (10 minutes) on 20 December, mother again stated that she did not want to touch the babies stating that she had a sore throat. There was no record of any discussion about her reluctance to hold her babies on either occasion. 11.19 Nurses recorded positive interaction between mother and Child D on the ward on a number of occasions. These notes needed to be considered in the context of limited and irregular visiting. Parental visiting in hospital and communication with hospital staff 11.20 There is an early entry in the hospital records that the parents ‘would appear not to want to be in hospital’. 11.21 The family are recorded as not having a car and relying on public transport. The twins were born during winter and spent nearly two months in hospital. The family home was approximately 6 miles from the City Hospital Unit. 11.22 During a home visit on 16 November, mother informed a Midwife that she was visiting the babies daily. This information was inaccurate. This was the only home visit by the Midwifery Service because the babies spent so much time in hospital. 18 11.23 The records indicate that mother and father did not visit the twins on at least 21 days between mid-November and 2 January 2015: 21/11/14, 25/11/14, 27/11/14, 30/11/14 (Sunday) – 02/12/14, 04/12/14, 05/12/14, 07/12/14 (Sunday), 09/12/14, 11/12/14, 13/12/14 (Saturday), 14/12/14 (Sunday), 17/12/14, 18/12/14, 21/12/14, 22/12/14 (Sunday), 25/12/14, 26/12/14, and 02/01/15. 11.24 Mother visited on 30 November and interacted well with the babies and took photographs. Father has told the Lead Reviewer that he kept in touch with the babies’ progress through photographs. 11.25 When mother visited on 3rd December 2014, there is no record of staff enquiring as to why father was not visiting or why mother was visiting so infrequently. 11.26 On 8th December mother visited the twins with LD; this is a rare reference to their older sibling whose presence was accepted as a reason for keeping the visit brief. 11.27 When the Health Visitor learned through a telephone call to the Neonatal Unit on 18th December that parents had not visited for 3 days and previous visiting was limited, she visited the family home to discuss the hospital’s concerns. Mother told the Health Visitor that she could not visit because LD had been unwell. 11.28 A Nurse expressed concern to mother about her level of visiting on 27th December and mother stated that she was unable to visit due to LD. Mother planned to leave the ward but was encouraged to provide care and feeds and eventually stayed over an hour. This demonstrates that when there was challenge and encouragement, a positive outcome for the twins was achieved and perhaps could have been achieved on other occasions. 11.29 On 29 December 2014, a Neonatal Nurse attempted to contact the Health Visitor regarding the lack of visits and a statement by mother that she did not have the funds available to travel. 11.30 A Nurse gave a Unit booklet to mother with its telephone number on 27 December and mother called the Unit on 30 December 2014 when a Nurse advised her that the babies were stable and also enquired about when she would next visit. 11.31 Both parents visited the babies on 31 December and it was noted that father fed Child D. 11.32 On 2 January 2015 a Sister from the Neonatal Unit telephoned the Health Visiting Team who returned the call. The Sister shared her understanding that mother was struggling to see the twins on the Unit because she was caring for her older child. 19 11.33 An Advanced Neonatal Nurse Practitioner recorded on 15th December that ‘on discussion with the Health Visitor I have not referred the babies to Social Services today but will give the mother another couple of days to demonstrate appropriate visiting’. Then on 16th December a Doctor states that mother is to be referred to Social Services if no visits or infrequent visits observed or continues. Any referral would be for the twins and the Sandwell and West Birmingham Hospital Trust reviewer has appropriately noted that there should have been further conversation with mother, the Health Visitor and consultation with Midwifery Services about any previous concerns. 11.34 The planning process and recording in the City Hospital Neonatal unit in 2015 did not ensure that actions which were not completed were rolled on to the next care or action plan. The concern about the level of visiting to the twins should have been referred to the Safeguarding Lead in the hospital and could usefully have been discussed in more detail with both parents. If this had not led to improved contact, a referral to Children’s Services could have been considered. 11.35 This situation raises important questions about the support offered to parents whose children have to spend time in the Neonatal Unit and the threshold where concerns about poor levels of parental visiting should lead to action, potentially including a referral to Children’s Services. 11.36 DD transferred from City Hospital Neonatal Unit to Birmingham Children’s Hospital Neonatal Surgical Ward on 11th January 2015 and during this admission mother visited on seven of the eleven days DD spent on the Surgical Ward but very briefly. One visit lasted for 10 minutes. Father did not visit and neither parent telephoned the unit during DD’s admission. On 12th January mother had stated that she had to look after Child D and LD. 11.37 Birmingham Children’s Hospital summary of involvement for this Review noted that staff in the Neonatal Surgical Ward did not explore the fact that father did not visit or raise the lack of visits with the GP or Health Visitor. If this issue had been recognised, staff could have discussed it with parents and contacted the Trust CAF lead for support and advice. The Lead Reviewer acknowledges that DD had a relatively short stay on the Unit. 11.38 The Biennial Review of Serious Case Reviews 2005 – 07 included an example of one case ‘where a baby was in the neo-natal unit for some weeks, family members were only able to visit infrequently and most days “staff noted that there were no enquiries or visits from the family” and expressed their concerns’. Distance from the hospital, lack of finance and lack of child care arrangements contributed to this situation and a difficult early environment for the baby.’ There appear to be some similarities with the circumstances of the family but it is important that staff explore these practical issues for each individual family. They may be common issues for families but cause and effect should not be assumed. 11.39 In interview after Child D’s death, mother told the Police that she sometimes borrowed money from her aunt and from her brother’s partner for bus fares to 20 visit. Staff from the City Hospital Unit informed the Lead Reviewer at a learning event that there are strict criteria for parents to qualify for financial assistance from the hospital. Quality and depth of assessment in providing universal and early intervention services 11.40 It appears that no professional involved with Child D or DD clearly understood the family’s circumstances. This case highlights the importance of careful consideration of the level of support to new parents within the wider family and environment in all assessments (early help, child in need family support or child protection). This can usefully include a genogram. 11.41 Mother attended antenatal services at S Children’s Centre where she registered with father. Father recalled that they attended antenatal classes together. Mother attended S Children’s Centre again when pregnant with the twins. 11.42 The family made alterations to their rented property to allow multiple occupancy. A couple with a two-year old child lived in the property for a period when LD was born but before the birth of the twins. The sub-tenant provided some support in caring for LD. Records do not indicate that this was understood by Health professionals involved with the family. 11.43 There is a section in the form for the Neonatal Unit weekly review to record parental communication and safeguarding issues. The Lead Reviewer agrees with the reviewer for Sandwell and West Birmingham Hospital Trust correctly that the fact that these were left blank (on 22nd December 2014) demonstrates a focus on medical issues rather than holistic assessment. Communication between hospital and community health professionals and Discharge planning 11.44 Ofsted advised LSCBs to ‘scrutinise local systems for transfer of cases between the Midwifery Service, the Health Visiting Service and GPs in its 2011 Ages of Concern report. 11.45 On 19th November 2014 the twins were allocated to a Health Visitor for a new birth visit. The record noted that the babies were still in hospital. The Health Visitor made an introductory home visit on 28th November and met mother. 11.46 The Health Visitor and the Neonatal Unit discussed the lack of parental visits in telephone conversations on 15th December 2014 and 2nd January 2015. On 15th December the Health Visitor telephoned the Unit for an update and visited mother at home to discuss the hospital’s concerns about the frequency of visiting. 11.47 There is no single child electronic patient health record in Birmingham accessible by all health professionals in the city. Staff in the Neonatal Unit can access Maternity records for mothers and children. 21 11.48 A Neonatal Nurse attempted to contact a Health Visitor on 29th December about the lack of parental visiting and parents’ statements about limited finances and left a message. A Neonatal Nurse contacted a Health Visitor on 2 January to request a home visit (in advance of discharge) and was advised that a Health Visitor would be allocated the following week. There was a telephone handover between the Neonatal Nurse and the Health Visitor on 7th January 2016 prior to Child D’s discharge from hospital. 11.49 When DD was transferred from City Hospital to Birmingham Children’s Hospital on 11th January 2015, the neonatal discharge summary letter received in the transfer did not mention any safeguarding concerns. 11.50 A key question is whether the discharge of a premature baby with associated additional health needs should have been discussed at a meeting prior to discharge. 11.51 At a medical review on 2nd January, a Doctor confirmed the plan to continue with the current care arrangements and to prepare the twins for discharge. On the same day, the Ward Sister at City Hospital Neonatal Unit telephoned the Health Visitor and expressed concerns about parents not visiting. The Ward Sister also informed the Health Visitor that discharge planning had started. 11.52 There was communication between the Unit and a duty Health Visitor and the mother’s GP by telephone on 7th January about discharge. The GP refused to give Nutri-prem 2 formula milk (food for the dietary management of the additional nutritional needs of preterm and low birthweight infants post discharge) for at least a week as they could not register the baby until then. A Midwife confirmed Child D’s discharge in telephone calls to the GP and Health Visitor via her administrative staff the following day. 11.53 There is no hospital record outlining what time on 7th January 2015 Child D went home and who with, or what information parents were given regarding Child D’s care. 11.54 A discharge planning meeting involving hospital and community health professionals could have usefully clarified the knowledge of the family’s circumstances at that time and also ensured that planning was proactive and not reactive. A timetable of outpatient appointments and home visits could have been agreed with the family and avoided any clashes. 11.55 On 21st January 2015 a Nurse from the Children’s Hospital Neonatal Surgical Ward telephoned the Health Visitor to make them aware that DD had been discharged and to request that they monitor DD’s weight weekly. It is not clear what discussion took place, if any, about the impact of DD’s return to the family would be and parents’ capacity to cope. 11.56 When DD was discharged on 21st January, the Consultant had asked for a follow up in clinic in 4-6 weeks and also at the Neonatal Unit at City Hospital. 22 There was no appointment made for a review at the Children’s Hospital and the Trust has not identified the reason for this oversight. 11.57 The Orthoptist made telephone calls to the GP and Health Visitor on 2nd April 2015 to follow up DD’s non-attendance at orthoptist appointments. It had been identified in discussion at the TAF Panel that Children’s Centre could support attendance at orthoptist appointments and it would have been more useful to have addressed this issue and also the prescription of specialist milk for Child D at a planning meeting prior to discharge. Consideration of all the children in a family 11.58 LD, the couple’s first child, had been readmitted to hospital briefly on 5th February 2013 due to failing to regain birth weight. LD had not been observed to breast feed well which may have been a reason for poor weight gain. Parents had been anxious to leave hospital and LD was discharged with an appointment to re-attend in two days for a weight check. There is no record that LD was taken to this planned appointment. 11.59 There were delays in LD receiving routine assessments and immunisations. LD received the 13 month immunisations five months late. 11.60 LD was one year and ten months old when the twins were born. There is no record of the care arrangements for LD whilst the mother was in hospital and father was visiting. Father told the Lead Reviewer that he and mother felt that the unit was not an appropriate place to take LD due to the lighting, number of wires and sensitive equipment. 11.61 In relation to LD, the Birmingham Community Healthcare Trust summary noted ‘minimal indication or voice of the 22 month old in the records and no additional record or reassessment was made of the child’s needs in view of the issues identified in care and assessment plans’. 11.62 LD’s own needs and the potential impact on the child’s care of the arrival of twins with additional needs required consideration by health professionals. Sidebotham et al (2016) state that ‘Hearing the voice of the child’ requires safe and trusting environments for children to be seen individually, speak freely, and be listened to. This is particularly important when children display early signs of neglect or emotional abuse, but are unable to express their concerns. In a case involving a six month old, premature baby……. engaging with the older sibling may have led to a better understanding of the family context’. The difficulty in feeding LD, the parents’ pattern of not visiting or wishing to avoid hospital and also not bringing LD to appointments were early indicators of issues which arose again with the twins. Non- attendance at health appointments 11.63 Staff responded to poor attendance by parents at appointments. It is positive that the Hospital’s policy and practice highlight that the child ‘was not brought’, an approach which the recent Triennial Review noted ‘can help maintain a 23 focus on the child’s ongoing vulnerability and dependence, and the carers’ responsibilities to prioritise the child’s needs’. 11.64 Child D was not taken to an ophthalmology appointment on 22nd January, the day after DD was discharged, and DD then missed an ophthalmology appointment on 30th January. By 31st March 2015, DD had missed four orthoptist appointments. The Orthoptist made telephone calls to the GP and Health Visitor on 2nd April 2015 to follow this up. Letters were sent to the family home about appointments but the ability of the parents to read English appears not to have been assessed. 11.65 Child D was not taken to a hospital baby clinic appointment on 3rd March 2015. LD was not brought to a GP appointment on 23rd February but it is not recorded what the appointment was for. 11.65 The Health Visitor has recorded that during the discussion about the family at the TAF Panel on 11th March that Early Support could assist with retinopathy of prematurity; presumably this meant help with attendance at appointments. As highlighted earlier, it is unfortunate that this discussion had not taken place at a discharge planning meeting in January. Threshold for escalation of cases including Referral to Children’s Social Care 11.66 Hospital staff recorded consideration of a referral to Children’s Services on two occasions. The Lead Reviewer agrees with the opinion of the reviewer for the Sandwell and West Birmingham Hospital Trust that it is not clear that the threshold for referral to Children’s Social Care had been met. However, there should have been consultation with the Trust’s Safeguarding Lead to highlight and consider how to respond to the concerns about a lack of parental visiting to the twins. There should have been closer pro-active planning between hospital and community staff and this would have been assisted by discharge planning meetings prior to the discharge of each twin back to the care of their parents in the community. Working with Diversity 11.67 Birmingham is a ‘super diverse’ city in which services are having to adapt to meet the needs of families from a considerable number of countries who speak a wide range of languages. The number of people/adults who have moved to Birmingham from those countries which joined the European Union in 2008 including the number of adults from Lithuania have increased yearly up to 2013. Providing information to parents and interpreting and translation services 11.68 In the 2011 Ages of Concern report, Ofsted recommended that LSCBs ‘check on the quality, availability and relevance of materials and educational programmes which support the development of parenting skills, especially for teenage and young parents’. This Review has highlighted the importance of 24 interpreting and translation services for parents whose first language is not English to ensure good communication and informed consent. 11.69 Father describes learning to speak English whilst he was living in Birmingham. When father called an ambulance in March 2013 because he was concerned about LD’s breathing, there was a language barrier and the call handler had to ask questions multiple times. The father was frustrated and it is recorded that he was aggressive. 11.70 When father called emergency services on 1st April 2015 he requested the use of Language Line (a professional interpreting service which can provide translation services twenty-four hours a day; an operator requests the language required by the caller and facilitate a three-way conference call with the caller providing information through the interpreter). However, the call handler was unable to obtain an interpreter who spoke Lithuanian. 11.71 There was an inconsistent approach across Health Services to providing interpreters and establishing the parents’ level of verbal comprehension before and after the children’s births: The initial ante-natal information mentions the need for interpreters but there is no record that they were used in hospital. There is no reference to mother’s understanding of English or her communication needs when she attended a new patient appointment at the GP practice in July 2012 which confirmed her pregnancy. On 14th June 2014 mother told the Midwife at her pregnancy appointment that she had difficulty understanding English and required an interpreter and a marker to that effect was added to her maternity record. When the twins were born at City Hospital on 14th November 2014, the Doctor noted that parents’ English was reasonable but an interpreter should have been used to explain complex information about Child D’s health condition and treatment. Nurses also gave mother information in English about breastfeeding and the need to obtain a steriliser. On 19th November 2014, hospital staff talked to parents about consent to participate in SIFT, a controlled trial of two speeds of daily increment of milk feeding in very preterm or very low weight infants. They had been given a leaflet in English and stated that they were uncertain about whether to go ahead. On 24th November a Doctor spoke to mother without an interpreter about Patent Ductus Arteriosus (PDA) and its treatment with medication. PDA is an extra blood vessel between a lung artery and body artery. It may 25 eventually heal by itself in the first few days of life but can remain in pre-term babies but is moderate and can be treated. On 28th November 2014 the Health Visitor noted during a home visit that mother may need interpreter services to understand technical information. A Neonatal Nurse telephoned the parents on 8th December 2014 to inform them that Child D required a blood transfusion but there is no indication that Language Line was used. On a positive note, Hospital records note that before DD’s discharge, staff met mother with an interpreter to explain discharge information. When mother visited on 17th December, she was given a Basic Life Support (resuscitation) leaflet by a nurse and an explanation of its contents although there was no interpreter. Mother stated that she would take the leaflet home as she ‘cannot read very good English’. During a hospital visit on 27th December a Neonatal Nurse checked whether mother had the telephone number of the unit and provided mother with a Unit booklet with the number highlighted. Mother was encouraged to call for an update on the babies’ progress if she could not visit. The twins had been on the ward for over a month at this point. On 14th January 2015 the Health Visitor recorded that she felt that mother’s understanding of basic English was good. She had not arranged an interpreter but noted that she would do so for future visits to ensure mother’s understanding and to give her more opportunity to ask questions. Letters were sent to the family home in 2015 about appointments but the ability of the parents to read English appears not to have been assessed. 11.72 It is usual practice at Birmingham Children’s Hospital Neonatal Unit to book an interpreter in advance to explain the care plan and treatment of a patient and Language Line can be used at other times. It is recorded that an interpreter was present to assist in obtaining consent to treatment on 12th January and prior to DD’s discharge on 21st January. 11.73 Written information in Lithuanian was not provided to the parents in any of the health settings they had contact with. Father shared with the Lead Reviewer his view that providing information in the red book is a very old fashioned way of communicating with parents and he would have preferred a DVD or online video to learn about parenting and the stresses which can occur. He also suggested that it would be useful to have had more information about what parents should not do with young children and about the frustrations and agitations parents can experience. 26 Working with Fathers 11.74 Father has been found guilty of causing the fatal injuries to Child D. Professionals had limited contact with him. Father recalled two occasions when he had contact with professionals in the community. On 15th December 2014, the Health Visitor met with father during a home visit to follow up poor parental visiting and suggested that father looked after LD to allow mother to see the twins in hospital. The Health Visitor later met father during a home visit on 23rd February 2015 and on 23rd March 2015 when he agreed to discuss the offer of an fCAF assessment further with mother. Mother told Police that father had safely cared for LD on many occasions and she did not have concerns about him caring for the children when she went to work. 11.75 Hospital records indicate that father visited the twins in hospital 6 times between November and December 2014; five times in November and then one more time on 31st December. These were always joint visits with mother. 11.76 The Health Visitor saw father during a home visit on 23rd March who informed her that mother was out shopping. Father described symptoms of colic for Child D and the Health Visitor gave him advice on winding. He agreed to discuss the potential completion of an fCAF with mother. 11.77 Mother told the Police that father had called Child D a demon because the baby cried a lot. Also, father took time off work in 2015 citing the twins as the reason. Mother had worked some of his shifts but this arrangement did not work out. 11.78 The 2011 Ofsted Ages of Concern report noted that Serious Case Reviews concerning babies ‘concluded that too often there had been insufficient focus on the father of the baby, the father’s own needs and his role in the family’ and prompted LSCBs to ‘take a strategic overview of the involvement of fathers in assessments of risk and safeguarding concerns, with a particular focus on unborn children and babies, in line with locally determined procedures’. The Triennial Review of Serious Case Reviews 2011-14 found that biological fathers were the perpetrator in 29% of the 48 fatal physical abuse cases; the actual figure is likely to be higher given that in 40% of the final reports it was not clear who the perpetrator was. 11.79 There had been limited opportunities to assess father. This Review highlights the importance of involving fathers. Consideration of the Wider Family and Environment 11.80 The Health Visitor identified a housing pressure for this family and was proactive in trying to assist the parents in addressing this. The Ofsted Ages of Concern report highlights the special importance of suitable housing for parents of new babies. Child D died before the actions proposed at the TAF Panel in March were taken forward. 27 Recording 11.81 In 2014, a Health Visitor could not create or add to a child’s record until the child was born. This is why information about ante-natal involvement had to be added to records following the birth of the twins. 11.82 There were a number of hospital recordings only entered on one of the twin’s records when they should have been entered on both. 11.83 There was limited recording about the interaction between parents and the twins on visits and recording did not include the length of visits to the Neonatal Units. The Ages of Concern report highlights a learning point that practitioners should ‘confidently use and share the evidence from their direct observation and knowledge of parents and their babies to inform assessments of risks’. This author would also emphasise that this equally applies to the assessment of children’s needs. The Hospital Trust have highlighted one example of a detailed record by a student Midwife in December. It included observation of the interaction between mother and the twins and also included details of the care provided by mother during the visit. Early Help 11.84 On 22nd January 2015, a worker from a Local Children’s Centre made a home visit and updated the family’s registration following the birth of the twins and completed a pre-assessment. 11.85 This Review has noted the recent development in November 2016 of the Early Help model and processes in Birmingham. This case raises questions about the level of communication and joint working between Children’s Centre workers and Health Visitors and the quality of recording at TAF Panels in 2015. 12. Service Developments in Birmingham since April 2015 City Hospital Neonatal Unit / Sandwell and West Birmingham Hospital NHS Foundation Trust 12.1 At a Learning Event facilitated on 2nd December 2016 by the Lead Reviewer, staff and managers at the City Hospital Neonatal Unit outlined a considerable number of changes/improvements which have taken place since early 2014. 12.2 Since 2016 two Consultants provide separate/dedicated cover to the Neonatal Unit 8.30am to 5pm on weekdays and 8.30am to 2pm at weekends. They are on call and provide long-arm cover at other times. 12.3 The Neonatal Unit has recently introduced a family integrated care approach to partnership working with parents. This involves parents more closely in the care of their babies and encourages them to complete a parents’ log/journal. The model of care is underpinned by parent education and includes the 28 completion of a contract of care with parents at the outset. Training of all staff in the Unit will be completed in the coming year. 12.4 In November 2016, the Neonatal Unit introduced a new care planning document which encourages Doctors and Nursing staff to highlight and continue to include in daily plans actions which have not been achieved. This provides an opportunity to monitor progress and includes nurse led formal review dates. 12.5 In 2016, the Trust have enabled the Unit to offer free car parking and meals vouchers to mothers which addressed two considerable pressures on families with a child in a Neonatal Unit. 12.6 The Unit have recently changed documentation and practice around breastfeeding if a mother is not providing 350 millilitres by day 7. Birmingham Children’s Hospital Eye Department 12.7 The BCH report notes that the Eye Department have improved their recording practice to include the time of any calls made and also the reason given for any failed appointments. Birmingham Children’s Hospital Neonatal Surgical Ward 12.8 Staff complete individual care plans including discharge plans in conjunction with the parents. The nursing care plan for the neonate and the care discharge plan forms were updated in April 2016 and will be reviewed again in April 2017. The multidisciplinary discharge action list form was devised and introduced in 2015. 12.9 The roll out of the ‘Right Service, Right Time’ practice guidance across BCH continued in 2015 to increase staff awareness of the importance of early assessment of needs and risk and offer of early support including communication with community professionals and use of the Family Common Assessment Framework (fCAF) process. Birmingham City Council and Birmingham Safeguarding Children Board 12.10 In November 2016, Birmingham have introduced new Early Help procedures and a Signs of Safety and Wellbeing model with revised documentation. As part of the new developments, Early Help Panels have replaced the Team around the Family Panels. 12.11 Ofsted re-inspected Children’s Services in Birmingham in 2016 and their report, published in November 2016, made a number of recommendations including two particularly relevant to the matters under review: Ensure that Local Authority staff and partners, through the Local Safeguarding Children Board, understand the early help offer and are able to undertake assessments of need and offer appropriate 29 interventions at an early enough stage to prevent escalation to statutory intervention. Strengthen assessments and plans to ensure that they fully reflect and respond to all children’s and young people’s diverse needs. 13. Conclusions and Lessons Learned 13.1 Child D was murdered by his father. Her death could not have been predicted. Mother and father were a couple who came to England, worked hard to achieve a better life, and started a family. They were young parents living in another country where some relatives lived but they lived away from parents and other members of their extended family. They were clearly facing a challenge in parenting a one-year-old child and two premature twins, one of whom had further additional needs due to having required bowel surgery. The family lived in a privately rented multiple-occupancy house and had limited extended family support. 13.2 The National Institute for Health and Care Excellence (NICE) published guidance in 2010 setting out a model for service provision for pregnant women with complex social factors. These factors include poverty, homelessness, substance misuse, recent arrival as a migrant; asylum seeker or refugee status, difficulty in speaking or understanding English; becoming a parent aged under 20 and domestic abuse. Child D’s family had lived in Birmingham for more than two years at the time of the twins’ birth, the young parents experienced financial and housing pressures, English was not their first language. 13.3 The father has been found guilty of causing the fatal injuries to Child D and he alone is responsible for Child D’s death. He suggested to the Lead Reviewer that the pressures babies can place upon parents and carers should be emphasised further to parents in the advice and information given to them. Many Serious Case Reviews and reports have noted the particular vulnerabilities and needs of pre-term babies and babies under the age of one-year-old and the pressures they can place on parents. 13.4 Child D and DD were provided with complex specialist care and a number of lessons have been identified to strengthen assessments and planning of early help to families in these circumstances, discharge planning and communication between hospital and community services. 13.5 The Review has recognised some examples of good practice. This case highlights the expert specialist health care available on busy hospital wards which helps premature babies to survive and the complex needs such children have. It is important to recognise the pressures and high demands on staff in providing this complex care in the Neonatal Units. The Health Visitor was pro-active in seeking help for the parents to find better accommodation. She discussed the family at the local Team around the Family Panel in March 2015 although not apparently as a formal agenda item. 30 13.6 This Review has not found that improved arrangements or practice would have prevented the death of Child D but rather there are opportunities for services to make some changes as part of their commitment to continuously developing and improving services. 13.7 Some staffing issues affected the service provided to the family but did not contribute to Child D’s death. The level of staffing in the Neonatal Unit did not meet national best practice but is reported to be improving. There was some confusion around the allocation of a Health Visitor to the twins. BCHC records indicate that a Health Visitor was allocated at an early stage whilst the twins were in hospital and she sought to arrange appropriate cover during a period of leave. However, hospital records state that a Neonatal Nurse was informed on 2 January 2015 that the case would be discussed for Health Visitor allocation the following week. It appears that this was a reference to finding alternative cover whilst the allocated Health Visitor was not available and the covering Health Visitor was off work due to illness but this was not clearly conveyed to the hospital Nurse making enquiries. 13.8 The needs of Child D, the family and their home circumstances were not clearly understood by any professionals involved with the family. The absence of discharge planning meetings for Child D and DD meant that a significant opportunity was missed to explore the complex needs of the twins, their parents’ capacity to meet their needs, the significance of poor parental visiting in hospital, cramped home conditions, and for joint planning between hospital and community health professionals. A number of learning points have been identified to make assessment, planning of early help (including discharge planning) and recording practice within the hospital units more robust. There are also lessons about communication and joint working between hospital and Community Health Services. 13.9 The Review has considered questions about the depth of assessment by professionals in universal services necessary to understand the needs of children with complex and additional need and the support required by their parents. A number of the learning points from this Review around assessment have been common findings in other Serious Case Reviews in Birmingham and nationally which suggests that they need to be continuously highlighted and addressed in staff supervision, workforce development and practice guidance. Learning Points 1. The vulnerability of all children under one-year-old and the potential additional risks associated with prematurity, multiple births and inadequate housing cannot be underestimated; it should be emphasised in Early Help and Safeguarding procedures and guidance. It may be useful for Birmingham Safeguarding Children Board to revisit again the actions recommended in the Ofsted 2011 Ages of Concern document. 31 2. All children in a family should be considered in assessments. The voiced or interpreted experiences of an older child, their parenting and progress can provide insight into the care needs of new babies. 3. It is essential for professionals to engage and work with fathers or male partners and to include them in assessments and plans for their children. 4. There should be careful consideration of the wider family and environment in any assessment. 5. Care Plans should be regularly reviewed, any obstacles to addressing risks or needs highlighted and concerns escalated to ensure that they are addressed. 6. Multi-disciplinary discharge planning meetings should be held to coordinate services and address the needs of babies in particularly complex cases. 13.10 The City Hospital Neonatal Unit does not operate a key worker system for babies in hospital and Managers have not indicated that this is necessary to improve services. 13.11 This Review has highlighted the importance of appropriate interpreting and translation services to ensure good communication and working with parents. This is a considerable challenge given the number of languages spoken by parents in Birmingham, a very diverse city. However, efforts must continue to be made to ensure that interpreters are available either in person or by telephone. 13.12 The planned development of parent led care in the neonatal unit is welcomed; it provides another opportunity to explore and understand parents’ circumstances more fully and to promote partnership working. Also, the introduction of a visiting log provides an opportunity to make patterns of visiting, the length of visits and the quality of interaction very clear. 13.13 Father has suggested that information in the Red/Child Wellbeing Book could be made available electronically. This merits further consideration as it could provide opportunities to share information in a wide range of languages. Any development would have resource implications and may be usefully taken forward on a regional or national basis. 13.14 There is an intention in the development of the new Early Help Panel to address issues around the quality of recording of discussions at Panel. The developments in the City Hospital and in Early Help Services in Birmingham, which were not made as a consequence of this case, provide opportunities to improve practice, multi-agency working, service delivery and outcomes for children, particularly those who are born prematurely. 32 Further Learning Points from this Review are: 7. Parents will always benefit from interviews undertaken in, and information provided in, their first language and the common first languages of parents in Birmingham will continue to change due to the city’s super diversity. 8. Some parents will benefit from information in easy access formats and through a variety of media. There may be opportunities using the internet and smart media to further develop the range of information available for families. For example, it would be useful if the Welcome Guide for parents used in Sandwell and West Birmingham Hospital NHS Trust could be available in a range of languages or translated by an interpreter or in an easy access version using symbols available for parents where literacy or level of understanding are an issue. 9. It is important that the availability and delivery of interpreting services and translated information and any challenges experienced are regularly reviewed and addressed with providers by all agencies. 10. A sufficient number of telephones are required to ensure access for staff and parents to telephone interpreting services on the neonatal ward at Birmingham City Hospital. 11. Staff at Birmingham City Hospital Neonatal Unit will benefit from their new assessment recording and planning tool which clearly indicates where risk factors such as poor visiting are not being adequately addressed and supports implementation of the escalation procedure whereby staff raise concerns with senior colleagues, including the Safeguarding Lead, as necessary. 12. The completion of a visiting log in the Neonatal Unit – completed by parents and staff and overseen and reviewed by hospital staff – will improve understanding of the pattern and quality of contact between parents/carers and their children where a child’s circumstances are particularly complex. Birmingham Safeguarding Children Board will consider the learning points and any further action required to ensure the necessary developments in arrangements and practice are achieved. Jim Stewart Lead Reviewer 28 February 2017 33 Appendices A) Terms of Reference BIRMINGHAM SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE SERIOUS CASE REVIEW – BSCB 2015-16/1 Date of birth - 2014 Date of death 01.04.2015 1. Background On the 31st March 2015 an ambulance was called to the home address for Child A in respiratory distress, Child A was transported to Birmingham Children’s Hospital where CPR commenced. CT scans showed a devastating brain injury which is felt to be non-accidental. Child A was admitted to PICU however life support was withdrawn. Both parents were arrested on suspicion of murder. 2. Information Known About the Family Initial discussion around the table indicated that this family were unknown to a number of agencies; no safeguarding concerns were noted by Health Visiting or Primary Care teams. 3. Process of Decision Making The case was discussed at Serious Cases Review Sub Group on 8th May 2015. It was established that the case met the criteria for a Serious Case Review, as abuse/neglect was suspected to be a factor in the child’s death. Working Together to Safeguard Children March 2015 “Regulation 5 (1) (e) and (2) set out an LSCB’s function in relation to Serious Case Reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.” The Independent Chair of the BSCB was formally notified on 29th May 2015. Following consideration of the SCR Sub-Group recommendation, scoping document and Terms of Reference, and after a peer review discussion with a colleague chair the Independent Chair ratified her decision to commission a SCR. The target date for completion and submission of the SCR Report is 5th April 2016. The commissioning of chronologies has commenced with a target date for completion of 7th November 2015. This case is subject to criminal proceedings, the SCR will not be published until the conclusion of these and relevant information from there considered. However, the learning will be agreed and action taken to use the learning as soon as possible during the conduct of the review. The Board will ensure that any emerging findings are acted upon by agencies to ensure that any early lessons are fully implemented. 34 3. Terms of Reference 4.1 Aim To review the circumstances leading to the incident that caused the death of the child and to the subsequently identified previous injuries to siblings, and establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result. To improve intra and inter-agency working and to better safeguard and promote the welfare of children. 4.2 Process A Lead Reviewer will be appointed to work with the SCR Sub-Group to manage the process. A representative to be seconded from Housing to consider any related issues. A representative to be seconded from Save the Children (or other independent organisation offering specialist cultural advice) to advise upon any cultural or language issues identified. 4.3 Time Period to be considered by this Review The SCR should focus on the period from 14th November 2014 up to the date of death 1st April 2015. The Review should also consider scoping chronologies from each agency containing relevant information relating to agencies’ contact with the mother, her father and the eldest sibling outside that time frame as far as it impacts on the experience of the children in their care, their lifestyle and relationships, their ability to meet the children’s needs and the environment in which the parents and children were living. 5. Scoping the Review – Key Issues 5.1 The review will fully consider each agency’s contact with Child D, mother, father, and any relevant contact with siblings and agency knowledge of other adults in the household over the time period of the review. 5.2 The SCR Report will consider relevant research and any relevant nationally published reviews to inform this review. 5.3 The Lead Reviewer will consider how and when the most appropriate method of securing family members’ involvement with the SCR process whilst adhering to BSCB’s guidance on the involvement of family members and being mindful of the criminal investigation. 5.4 Consideration needs to be given to the racial, cultural, linguistic and religious background to this case and to the issues for migrant families in the city. 35 5.5 BSCB will obtain legal advice as necessary. Current BSCB legal advice relating to SCRs and other publication will be adhered to. 5.6 Relevant information to emerge from criminal proceedings planned for some point in the future will be taken into account by Lead Reviewer, in liaison with the SCR Sub-Group. 5.7 The social care representative will be responsible for provision of information from family proceedings. 5.8 Agencies will implement the learning from this case prior to publication. 5.9 At the conclusion of the Serious Case Review agencies will debrief those staff involved in the case. BSCB will agree a method of disseminating key learning and monitoring through the Learning and Development Sub-Group with SCR Sub-Group. 6. Issues to be addressed within the Review Fully consider the circumstances of this family and their needs collectively and individually. Identify the degree to which these needs were recognised and responded to by those professionals in contact with this family. Consider and explore the significance and implications of the family members’ migrant status and the impact of this on the way professionals responded to them and they responded to professionals. Explore agency knowledge of individual family members and whether any relevant information was shared between agencies about the household. Review what advice and support is given to frontline staff in all agencies about meeting the needs of migrant families. Examine whether the early help offer available in the city and information provided for the parents is adequate and appropriately designed for migrant families. Consider the opportunities and barriers afforded by the implementation of national legislation and policy with regards to migrant families and whether this results in avoidance of statutory agencies and a reduction in engagement and opportunities to meet needs and safeguard children. If necessary, examine the themes arising in this case in the light of other similar situations. 7. Additional guidance is also available to Chronology Authors Chronolator Guidance Chronolator Template 8. Methodology and Timetable The Lead Reviewer will offer advice to Individual Agency contributions Authors as required to ensure a focus on analysis of involvement and the specific issues and broader safeguarding factors. Chronologies, genograms and summary reports will be completed by 6 November 2015. The Lead Reviewer will seek specialist advice as necessary in October/November 2015 from the Housing and Save the Children representatives and also request information about 36 migrant families in the City and identified general service needs from Birmingham Council and the Director of Public Health The Lead Reviewer will liaise regularly with the LSCB Manager or Chair of the SCR Sub-Group about progress of the Review. The Lead Reviewer will meet with the Serious Case Review Sub-Group on 18th December 2015 to discuss initial key findings identified, actions required and a draft Serious Case Review report. The Lead Reviewer may arrange a review with the SCR Sub-Group Chair a learning event with practitioners, their managers and agency review authors in January 2016 to test hypotheses and develop learning. A revised and updated Serious Case Review report will be agreed with SCR Sub-Group by the end of January 2016 and shared with LSCB members. Agreed actions will be developed into an implementation plan. Also a decision will be made in the light of progress of criminal proceedings and any Coronial involvement about the potential for involvement of family members in expanding learning and the potential to achieve the target submission date of April 2016. 37 Bibliography Birmingham City Council/BDP - International Migration in Birmingham 2012-13 Service Development Team, Planning and Regeneration (2015/01) Birmingham Health and Wellbeing Board – An overview of the Joint Strategic Needs Assessment for Birmingham 2012 Birmingham Safeguarding Children Board - Right Service, Right Time Delivering effective support for children and families in Birmingham: Guidance for Practitioners March 2015 (Version 2) British Association of Perinatal Medicine Service - Standards for Hospitals Providing Neonatal Care (BAPM 2010) Department for Children, Schools and Families - Improving safeguarding practice: study of serious case reviews 2001-2003 - Rose W and Barnes J (2008) Department for Children, Schools and Families - Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 - Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J and Black J (2008) Department for Children, Schools and Families - Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005-2007 - Brandon M, Bailey S, Belderson P, Gardner R, Sidebotham P, Dodsworth J, Warren C and Black J (2009) Department for Education - Building on the learning from serious case reviews: a two-year analysis of child protection database notifications 2007-2009 - Brandon M, Bailey S and Belderson P (2010) Department for Education - New learning from serious case reviews: a two-year report for 2009-2011 - Brandon M, Sidebotham P, Bailey S, Belderson P, Hawley C, Ellis C & Megson M (July 2012) Department for Education - Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: final report –Sidebotham P, Brandon M, Bailey S, Belderson P, Dodsworth J, Garstang J, Harrison E, Retzer A and Sorensen P (2016) Harvey M, Regender A and Denny, E - Exploratory study on meeting the health and social care needs of mothers with twins (Article in Community Practitioner 87(2); Feb 2014) Lang C, Cox M and Flores G – Maltreatment in multiple birth children (Article in Child Abuse and Neglect: The International Journal 37 (2013) The Migration Observatory/University of Oxford – EU Migration to and from the United Kingdom (October 2015) 38 MEL Research – Newly Arrived Migrants and their Health Needs: A report for Birmingham City Council (April 2010) Nandyal R, Owora A, Risch E, Bard D, Bonner B, and Chaffin M - Special care needs and risk for child maltreatment reports among babies that graduated from the Neonatal Intensive Care (Article in Child Abuse and Neglect: The International Journal 37 (2013)) NICE - Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (Clinical guideline CG110) (September 2010) Obeidat, Bond and Callister - The Parental Experience of Having an Infant in the Newborn Intensive Care Unit (The Journal of Perinatal Education Summer 2009) Ofsted - Learning lessons from serious case reviews 2009-2010 Ofsted's evaluation of serious case reviews from 1 April 2009 to 31 March 2010 (2010) Ofsted - Ages of concerns: learning from Serious case reviews (October 2011) Research in Practice – Confident practice with cultural diversity: Frontline Briefing (July 2015) Royal College of Nursing guidance for nursing staff – Safeguarding children and young people Every nurse’s responsibility (2014) Udry-Jørgensen, Pierrehumbert, Borghini, Habersaat, Forcada-Guex, Ansermet F and Muller-Nix (University Hospitals Lausanne and Geneva, Switzerland) - Quality of attachment, perinatal risk, and mother-infant interaction in a high risk premature sample (Article in Infant Mental Health Journal Vol 32/3 2011) 39 C. Acronyms BCH: Birmingham Children’s Hospital BCHC Birmingham Community Healthcare NHS Foundation Trust BSCB: Birmingham Safeguarding Children Board CPAP: Continuous positive airway pressure fCAF: Family Common Assessment Form JSNA: Joint Strategic Needs Assessment LNU: Local Neonatal Unit LSCB: Local Safeguarding Children Board NICE: National Institute for Health and Care Excellence NICU: Neonatal Intensive Care Unit PDA: Patent Ductus Arteriosus PICU: Paediatric Intensive Care Unit ROP: Retinopathy of Prematurity SCBU: Special Care Baby Unit TAF: Team Around the Family |
NC52743 | Death of 16-year-old boy who was stabbed in the street and fatally injured by a 17-year-old boy in November 2020. Learning includes: young people who have disengaged from education can be motivated to obtain employment; referral orders can be effective in supporting young people and reducing their offending behaviour; prompt and effective liaison between police youth offending service (YOS) and children's social care in both local authorities when a child involved with gangs moves to live in another area; usefulness of better arrangements for criminal justice liaison and diversion (CJLD) to have timely access to background information about the children they see in custody; usefulness of CJLD staff sharing information with YOS about the children they see in custody as standard practice; awareness of the employer's responsibility to do a risk assessment for any employee working in construction who is under 18; when children subject to a care order are placed with parents at short notice a statutory review should be held to discuss this and ensure the meeting and care plan includes attendance or a contribution from all practitioners working with the child and parents; deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area; children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency; the importance of practitioner and agency records being clear; and where children have moved areas to keep them safe from gangs the importance of reciprocal information sharing between police forces if they are different in the host and home authorities.
| Title: Child safeguarding practice review report: Children N and O. LSCB: Northamptonshire Safeguarding Children Partnership Author: Karen Perry Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD SAFEGUARDING PRACTICE REVIEW REPORT Children N and O Lead Reviewer: Karen Perry Publication Date: 7 June 2023 1 CONTENTS 1. Introduction page 2 2. Learning page 2 3. Details of the families and case context page 3 4. Story of each child: Child N page 3 5. Story of each child: Child O page 5 6. Summary of both children’s stories page 7 7. Thematic analysis page 8 8. Child O’s comments page 25 9. Positive Practice page 26 10. Conclusions page 27 11. Recommendations page 28 2 INTRODUCTION 1.1. This Child Safeguarding Practice Review is in respect of Child N, age 16 years, who was stabbed three times in the street and fatally injured by Child O age 17 years. Child O has been convicted of murder. Child N and Child O knew each other through peers within their social network but had no contact until a few days before the murder. They had had an argument over the phone a few days before the murder because of contact between respective friends. The meeting in the street which resulted in Child N’s death occurred by chance. 1.2. This review involves two Safeguarding Partnerships: LA1: MK Together Safeguarding Partnership where the victim lived and LA2: Northamptonshire Safeguarding Children Partnership as the perpetrator was a child in the care of LA2 although placed in LA1. LA1 took the lead for this review although relevant staff from both areas participated. Both partnerships will ensure that learning is widely disseminated locally and publish the full report on both Safeguarding Partnership websites. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The Child Safeguarding Practice Review takes into account multi-agency involvement: for Child N: from April 2019 (decision-making that Child N no longer needed to be the subject of a child protection plan) to the time of his death in November 2020. For Child O: from March 2019 (when Child O returned to a placement in LA2) to the time of Child N’s death in November 2020 1.3. The safeguarding partnerships agreed to undertake this review using a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time. Family members and Child O were also offered the opportunity to speak to the lead reviewer. Child O agreed to do so; his comments have been included in section 8 of this report. 2. LEARNING 2.1. All learning points are listed in section 5, at the end of each theme. What follows is a summary of the most significant learning from this review. 2.2. Partnership working with vulnerable children who have police, social work and youth offending service (YOS) involvement due to offending and links to gangs is inherently complex. This complexity is exacerbated when a child is in care and moves placements between local authorities. It is important that practitioners and agency records are clear about which local authority is responsible for a child and that arrangements to ensure that information is shared promptly with that local authority are effective. Where children have moved areas to keep them safe from gangs it is important to have reciprocal information sharing arrangements between police forces if they are different in the host and home authorities. When the Criminal Justice Liaison and Diversion (CJLD)1 service practitioners are involved there would be benefits to improved information sharing arrangements that enable CJLD to have access to background knowledge about a child and for them to share information about their involvement with the Youth Offending Service (YOS). 1 The CJLD service identifies those who have mental health, learning disability, substance problems or other vulnerabilities when they first meet the criminal justice system. Staff will assess needs, inform criminal justice decision making and help the individual access the right health and social care support as you move through the criminal justice system. 3 2.3. Children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency, multi-disciplinary risk management plans which are reviewed at key points eg when they move placements or when incidents indicate increased risk or vulnerability. Deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area. This needs to be considered in any re-housing of families and requires both social workers and housing authorities to have arrangements to ensure they have or can obtain sufficient local knowledge to make good judgements. Care plans and statutory reviews for looked after children in care who have been placed with their parents should include consideration of the vulnerability of the parent and any risks they pose. 2.4. Being engaged in education is a protective factor for children, and when a child is not in school for any reason this needs to be addressed promptly. There needs to be a range of choices of work experience and other education and training-based opportunities for older children who have disengaged from education or been excluded from school. These children can be highly motivated to obtain employment. They benefit from support to assist getting and keeping a job e.g. work experience, careers guidance, mentoring to develop foundation and interview skills, and practical and financial support. 2.5. Practitioners having strong relationships with young people is a significant factor in reducing offending behaviour and improving outcomes in general, and there is a need to manage the impact when these relationships are disrupted for any reason. When practitioners have raised concerns about a child’s safety that are not resolved they should escalate the difference of opinion through their own agency or by using their safeguarding partnership’s policy. 3. DETAILS OF THE FAMILIES AND CASE CONTEXT 3.1. Family members will be referred to by their family relationship to each child eg Child N’s or Child O’s Mother, Sibling etc. At the time of his death Child N was living with his mother and three younger siblings. Child N was described as good to work with once a relationship had been established; he could be insightful and had a good sense of humour. He was said to have hidden his sensitivity with bravado. He had a strong initial defensive reaction to being challenged or when he thought he had got things wrong/when receiving negative feedback. He was loyal and very protective of his family. He was good with his hands, at making things for others and DIY, and was keen to have a career in construction work. 3.2. At the time of the murder Child O was subject to a care order and living in supported accommodation commissioned by LA2 but located in LA1. Child O was described by practitioners as seeming quite vulnerable and wanting people to like him and to “fit in”. He was also described as having a good sense of humour, and could be caring, kind and thoughtful, and he had several friends. He was reported to be very protective of his younger sibling, with whom he was very close. Child O had enjoyed family picnics in the park and supported a premier league football team. He was keen to obtain employment and was interested in specific types of construction work. 4. EACH CHILD’S STORY: CHILD N (victim) 4.1. Some history prior to the scoping period is relevant. Child N had four younger siblings. During his childhood he was exposed to domestic abuse, alcohol and drugs misuse by his mother who also suffered from mental ill-health. From mid-2015 to mid-2017 Child N lived with his father because Mother could not manage his behaviour. During 2016 and 2017 Child N was offending, went missing several times and was assaulted twice in the community. Father and Child N did not accept offers of 4 help from the Early Help and Targeted Support services and he moved to live with his mother in 2017. 4.2. Child N was subject to a child protection plan (category neglect) from December 2017 to April 2019 because there were concerns about him offending, being involved in gangs, going missing overnight on several occasions, and being vulnerable to violence in the community, all coupled with the inability of Mother to offer adequate care and protection. 4.3. In May 2018 Child N had transferred from Academy 1 to Academy 2. Prior to April 2019 Child N refused to attend school. For the summer term of 2019 Academy 2 provided him with weekly one-to-one tutoring. His first application to a college was rejected due to his offending history and he was Not in Education, Employment or Training (NEET) at the end of October 2019 despite a second college interview. 4.4. From April 2019 a Child in Need Plan replaced the child protection plan, records show this was because Child N was engaging well with the LA1 YOS; there had been no recent missing episodes, he had been working, was motivated to seek further work, and there had been good engagement with Mother. 4.5. LA1 YOS had become involved in February 2019 to provide Bail Support after Child N was arrested for two offences of assault and four offences of intimidating a witness committed between May 2018 and February 2019. These offences were thought to be gang related. Whilst on bail Child N was subject to a curfew from 7pm until 7am, monitored by a tag from February to August 2019. This intervention by the YOS and the tag was successful; by April 2019 it was felt that Child N should no longer be subject to a child protection plan. In June 2019 Child N was made subject to a Referral Order2 for six months for a robbery committed in September 2018. In August 2019 this was extended by six months due to the other offences committed in 2018/19. 4.6. Public Law Outline (PLO)3 proceedings were instigated in August 2019, for Child N and his siblings due to concerns that Child N’s Mother continued to misuse drugs, was not consistently engaging with the relevant specialist service and that the school attendance of the siblings was poor. The PLO ceased due to Mother’s reduced drug use. 4.7. Child N’s behaviour deteriorated quickly in August 2019, with missing episodes restarting. Child N missed a referral panel meeting in December 2019, as well as a YOS appointment in January 2020, which meant he was told about a risk of being returned to court by the Referral Order panel. During 2020 Child N was referred twice by police to the Criminal Justice Liaison and Diversion (CJLD) team for a welfare check when he was in custody. 4.8. In early May 2020 the social worker ceased involvement after a Signs of Safety4 reflective discussion in supervision. Records show that all members of the Team Around the Child including Mother agreed with the decision to cease social work involvement with Child N, especially as statutory involvement by the LA1 Youth Offending Team was continuing. 2 A referral order is the community sentence most often used by the courts when dealing with 10 to 17 year olds, particularly for first time offenders who plead guilty. Referral orders require that an offender must appear before a local panel of trained volunteers to agree a contract of rehabilitative and restorative elements to be completed within the sentence, and attend the panel every 3 months for reviews. 3 Public Law Outline (PLO) meetings are called if the Local Authority is concerned about the care that a child is receiving where consideration is being given to the potential or actual necessity of starting care proceedings. These are attended by social worker and team manager with the parents who should be encouraged to bring a solicitor; unless the risks are so serious that an immediate application is required their purpose should be to explain to the parents what they need to do to avoid proceedings. 4Signs of safety system of working which engages child and parents alongside practitioners to plan and deliver intervention after analysis; What do you think is going well?” “What are you worried about?” “What needs to change?” 5 4.9. In May 2020, because of a new initiative, the police identified Child N on police records as being at serious risk of youth/gang violence. In June 2020 Child N was arrested for driving a car without a licence and insurance. Because he was still subject to a Referral Order an out of court disposal was not an option. Child N subsequently pleaded guilty at a court hearing in August 2020 and received a conditional discharge and six points on his provisional licence. 4.10. In early July 2020 intermittent compliance with LA1 YOS requirements over a few weeks had resulted in a warning letter. Records show that by July 2020 Child N was getting frustrated with continuing to have YOS involvement although he did recognise that it had helped him. At the end of July 2020, the Referral Order panel discharged his order. 4.11. Between September and early November 2020, Child N came to police attention three times. The first two were for threats to commit criminal damage and robbery. The third occasion was in early November when his girlfriend accused him of assaulting her and her two friends in her home causing minor injuries. Referrals were made to the Multi-Agency Safeguarding Hub (MASH) on both occasions resulting in letters to Mother, the first (after consultation with the previous social worker) suggesting Mother contact them for help if needed and the second advising her of agencies that may be able to assist. Whilst consideration could have been given to contacting Child N directly this would not likely have been successful as he had disengaged from services at this time. 4.12. In mid-November 2020 a chance encounter in the street between Child N and Child O resulted in the stabbing for which Child O was convicted of murder. Both families have been given support by agencies since. 5. EACH CHILD’S STORY: CHILD O (perpetrator) 5.1. Some history prior to the scoping period is relevant. Child O has one considerably younger sibling. From an early age Child O was neglected and witness to domestic abuse and violence between extended family members. His parents misused substances and he was physically abused by his father who had an extensive criminal history. Before Child O reached the age of 10 years records show that his school and Mother were having difficulty managing his behaviour which included physical aggression. In 2016 Child O was permanently excluded from school aged 12 years for aggressive and threatening behaviour; he had assaulted a pupil. As a result of this he was admitted to specialist provision for children with Behavioural Social and Emotional Disorders (BSED). 5.2. In June 2017 Child O became the subject of an Interim Care Order (ICO) due to neglect and was placed with kinship foster carers. In October 2017 the LA2 Youth Offending Service (YOS) became involved due to Child O being subject to a Community Resolution Order5 after committing two assaults. In January 2018 he was shot with a shot gun; the police believed the perpetrators were from a rival gang. Via a local emergency foster placement, Child O moved to residential care. He was moved to another set of foster carers in May 2018 and then had three residential placements out of county in the north of England between June 2018 and March 2019. He then came back to LA2, where he had three further residential moves. 5.3. During 2018 - 2020 strategy meetings were held in response to Child O going missing on three or more occasions. These meetings were regularly attended by Police, Social Workers and Education professionals. Attempts were made to mitigate the missing episodes. 5 A Community Resolution Order requires the subject to admit guilt where the victims have agreed they do not want the police to take further action. These do not give someone a criminal record although they can be taken into account by the police if the person commits further offences. 6 5.4. In April 2019 Child O was the victim of a stabbing by a peer which required stitches. In April 2019 Child O appeared in court for the first time when he was sentenced to a 9-month Referral Order for an offence of possession of an offensive weapon. The Team Around the Child thought it was crucial to get him out of LA2, away from gangs, to keep him safe. In May 2019 Child O was placed with his mother, initially in a hotel in LA2 for about a week pending a family assessment placement being set up in LA1. This was initially a temporary placement for 12 weeks. 5.5. By now attempts to secure a place at a specialist school had been successful, unfortunately it was an hour’s journey away in LA2; Child O requested nearer provision in mainstream school. In mid-November 2019 Child O was offered a place in specialist provision in the sixth form (although he was still year 11). Child O was permanently excluded and removed from roll in June 2020 after assaulting another student. In September 2020 Child O secured a place at college but he refused to attend. 5.6. Between mid-August and November 2019 records show consideration was given to an application for a secure order for Child O, because he was going missing and the relationship with his mother had deteriorated. However, the situation had improved, and social work staff thought such a decision was difficult to justify as he was not offending. Although he was going missing, there was no evidence at that time of gang affiliation locally or renewing contacts in LA2. 5.7. At the beginning of January 2020 Child O and his mother were placed in temporary accommodation in LA1 after presenting as homeless. Soon afterwards there were further signs of the relationship between Child O and his mother breaking down including Mother calling the police during an argument after refusing his request for money. At the end of January 2020 came the first report that Child O might be keeping a knife for self-protection. Child O went missing overnight for the first of several times during the remainder of the scoping period and he was also leaving school premises. Over the next few weeks Child O reported threats, including with blades, and an assault. In February 2020 Child O reported an attempted robbery in the street where one of the three people involved threatened him with a knife. At the end of February 2020, Child O was arrested and bailed (but not subsequently charged) regarding an incident for stabbing another young person in their leg and arm. He was seen while in custody by the Criminal Justice Liaison and Diversion (CJLD) team and the only issue of concern was flashbacks for which he declined support. 5.8. In early March 2020 a complex strategy meeting was held due to concerns about whether Child O’s placement was meeting his needs and the risks posed by the geographical area he lived in given the level of gang activity. For the first time intelligence had been received that Child O might be pressurised into drug dealing activity in LA2. A move to supported accommodation was being considered, which occurred a week later, and a safety plan was put into place. Child O’s social worker made a referral to the National Referral Mechanism (NRM).6 5.9. In April 2020 a final Referral Order panel was held, and Child O’s Order was signed off as successfully completed. LA 1 YOS offered involvement on a voluntary basis, as they routinely do to avoid an abrupt step down in support. This ceased at the end of July 2020 because Child O had not engaged with this, despite several attempts made by LA1 YOS to contact him. 5.10. In May 2020 Mother returned at short notice to live in LA2 as she did not feel safe where she was living. Whilst in supported accommodation Child O consistently told practitioners that he did not feel supported, and he wanted to live with his mother. 6 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. 7 5.11. In May 2020, because of a new initiative, the police identified Child O on police records as at serious risk of youth/gang violence. In early June 2020 Child O was arrested twice, once in another part of the country, after being missing from placement for nearly a week, in possession of a large amount of class A drugs and cash, and once for Grievous Bodily Harm7 after an assault on a fellow student. 5.12. At the beginning of September 2020 Child O attended the A&E department for treatment with a laceration to his finger said to have been caused at work laying bricks. This was confirmed by his support worker, so the hospital staff accepted an accidental explanation and concluded there were no safeguarding concerns. 5.13. At the end of September 2020 Child O was seen with a knife and threatened someone with it. In mid-October 2020 he was presenting as very down and unhappy as he had split up from his girlfriend and lost his job, he hadn’t got the college course he wanted, and his request (at a LAC review) to live with his mother was refused. The supported accommodation worker took him to be seen by nurses at the local Urgent Care Centre who provided information and reassurance. 5.14. At the end of October 2020, the national Single Competent Authority declared that Child O was a victim of modern slavery; this meant that the identified exploitation would be considered and may influence whether any criminal proceedings against him continue and be used by him as a statutory defence. 5.15. During October 2020 Child O went missing from his accommodation on a couple of occasions. He was then allowed to stay overnight with his mother without permission from his social worker (this had been requested by email). 5.16. The next contact agencies had with Child O related to the murder of Child N. 6. SUMMARY OF BOTH CHILDREN’S STORIES 6.1. The children had very similar backgrounds; neglect, exposure to domestic abuse and parental substance misuse. Neither child had a positive role model. Child O’s father physically abused him and had an extensive criminal record for violence and drug offences. From an early age he influenced Child O to be anti-police. Both children had extensive involvement with social workers, and their parents had difficulty managing their behaviour. For Child N this meant moving to live with his father for two years and then moving back to live with his mother. When living with his mother Child N was made subject to a child protection plan. Child O was made subject to a care order and had had multiple placements, mostly outside of his (home) local authority (LA2), until May 2019 when he was placed with his mother in LA1 to keep him safe. Mother did not settle there and after about 12 months returned to LA2 and Child O then went into supported accommodation. 6.2. Youth Offending Services were involved with both children, and each was made subject to Referral Orders for offences which included violent or intimidating behaviour. Both children were involved in gangs, and at risk of violence. The precipitating factor for Child O to move to LA1 was being stabbed by a peer. Prior to coming into care, he had been shot with a shot gun, probably by rival gang members. Moving to LA1 did not keep Child O safe from gang involvement, especially after he moved to an area of LA1 known for gang activity and, after he was found a long way from home with a large amount of cash and drugs having gone missing for a few days, a successful referral was made to the National Referral Mechanism (NRM). 7 The offence of GBH means causing extremely serious injuries which severely affect the health of the victim. These can include broken bones or permanent disfigurement. 8 6.3. Both children had disengaged from education, including being excluded from school/college. They each had a strong desire to obtain employment in a trade using their hands. Although Child O had a long history of vulnerability to criminal exploitation, each child had periods of relative stability and progress during the scoping period, with sudden deterioration in behaviour. During the two months before the murder, with the benefit of hindsight, Child N became more vulnerable due to disengagement with the YOS after the completion of the Referral Order and Child O was heading for a crisis due to not wanting to be in supported accommodation, not having a college place or work and having broken up with his girlfriend. 7. THEMATIC ANALYSIS 7.1. The learning from this review was identified from information and opinions provided in the agency reports and at the practitioner event and from Child O. The themes are: • Exploring the relationship between Child N and Child O • Response by agencies to both Child N and Child O’s criminal activity including risk of Child Criminal Exploitation and involvement in gangs and knife crime • Decision-making and information sharing about Child O’s placement with his mother, their move to LA1 and his subsequent placement in supported accommodation • Meeting educational and health needs • Continuities of service including complexities of cross border working • Impact of Covid and any other relevant organisational contexts Theme: Exploring the relationship between Child N and Child O 7.2. Child N and Child O knew each other through contacts within their social networks. They had had an argument over the phone a few days before the murder because of contact between their respective friends. Whilst evidence given to the court suggests that Child O had threatened to kill Child N during that phone call, the murder occurred during a chance meeting in the street. Child O subsequently claimed that the person threatening him with a knife during the attempted robbery in the street in February 2020 was Child N, and that this was why he was carrying a knife because he assumed Child N carried one. Neither Child N, nor either of his two friends who were with him at the time of the murder, were carrying a knife at the time. Child O had not co-operated with the police investigation at the time of the assault against him and declined to do so during the police investigation after the murder. Theme: Response by agencies to both Child N and Child O’s criminal activity including risk of child criminal exploitation and involvement in gangs and knife crime 7.3. Both children were associated with gangs. Gang membership can range from as little as using a hashtag on social media, or living in a particular street, to serious involvement in crime including violence. In 2010 government guidance identified three different categories. Being in a transient “peer group” (which may, or may not, describe itself as a gang), being part of a “street gang” with a specific identity (and where crime and violence are part of that identity) and being part of an 9 “organised criminal gang”.8 The relationships between these categories are complex and fluid, for example gangs might compete or merge. However, the three elements that tend to be consistently present for street gangs that link back to organised criminal gangs are violence, drugs and defined geographical location. When children move area they often retain their gang membership and are regarded by other gang members to do so. Agencies were aware of the potential risks arising from a rival from a gang in LA2 also relocating to LA1. After the murder consideration was given about keeping Child O safe in custody. 7.4. The 2019 British Crime survey data9 suggested that 27,000 children and young people in England identify as gang members. In a recent study published in 2019 the Children’s Commissioner for England and Wales estimated there were 313,000 children aged 10-17 years linked to gangs, including 33,000 who are a sibling10 of a gang member and 34,000 who have been the victims of violent crime in the last 12 months and are either a gang member or know a gang member. It is this latter group of 34,000 victims of violent crime about whom the Children’s Commissioner feels authorities should be most concerned. Both Child N and Child O fell into this definition. When remanded in custody Child O described his gang links in terms of the one he was most closely affiliated to, another he had links with and two others from whose members he would be at risk. Child N was also believed to be associated with a gang, but practitioners told this review his links were weaker. 7.5. From May 2019 when Child O was living in LA2, until December 2019 after he moved to LA1, Child O was supported by staff from the Community Initiative to Reduce Violence (CIRV) which is a LA2 police led multi-agency gang intervention programme designed to reduce gang violence and help those involved in gangs to live a life free of crime. This included mentoring from an ex-gang member and other support to provide an alternative pathway to successful adulthood. After a strategy meeting in early July 2019, which was convened to discuss missing episodes, Child O agreed to voluntarily wear a Buddi tag11. However, records show that within days he was requesting it be removed. He only had it for less than three weeks, and half of this time it was not charged. Records show there was a recognition of his desire for work experience and then employment in the construction industry, which would require basic literacy and numeracy skills. This was followed by a focus on support to get a national insurance card (which is less straightforward for children in care) in time for his sixteenth birthday and foundation skills (eg health and safety, first aid) for getting a Construction Skills Certification Scheme (CSCS) card. The involvement of the CIRV co-ordinator was most intensive in the first few weeks, which included liaison with LA1 Neighbourhood Policing Team, and after that she remained in occasional touch with Child O until December 2019 because of the risk of him going back to LA2. 7.6. A child involved with gang related activity is often a victim and an offender over time and possibly at the same time. When children are found in possession of controlled drugs consideration should be given as to whether they are victims of trafficking; Crown Prosecution Service (CPS) guidance reflects that for all but the most serious sexual or violent offences there is a statutory defence for children accused of possession of controlled drugs; that their action was a consequence of being exploited and that a reasonable person with the same characteristics in the same circumstances would have done the same. Police, local authorities and Youth Offending Services can all make 8 Children’s Commissioner (2019) Keeping children safe; improving safeguarding responses to gang violence and criminal exploitation Children’s Commissioner 9 Children’s Commissioner (2019) Op cit 10 As well as being at risk of being recruited into the gang, siblings are at also risk of reprisal physical and sexual violence 11 The tag is designed to be worn securely around the ankle and provides GPS location data on a continuous basis 10 referrals to the National Referral Mechanism (NRM) and the threshold for a referral is low; “suspect but cannot prove” is included in the criteria. 7.7. In March 2020 Child O’s social worker made a referral to the NRM. By the time the Single Competent Authority declared that Child O was a victim of modern slavery he had been arrested in another part of the country, after being missing from placement for nearly a week, in possession of a large amount of class A drugs and cash. Practitioners told this review that although there were concerns that Child N was involved in a gang, the associated behaviour and risks had not put him near the threshold for referral to the NRM. 7.8. In June 2019 Child N was made subject to a Referral Order for 6 months for a robbery committed in September 2018. In August 2019 this was extended by 6 months due to other offences. The LA1 YOS worker provided an intensive package of support: understanding consequences, managing conflict, being organised, sharing problems to find solutions, victim awareness, positive peer relationships grooming, and reparations activity. In May 2019, whilst Child N was on bail, a YOS police officer had begun offering support for Child N to get a Construction Skills Certification Scheme (CSCS) card,12 the application for which children’s social care subsequently agreed to fund. 7.9. Child N’s behaviour deteriorated quickly in August 2019, with missing episodes restarting. This seems to have been a combination of him no longer being on a tag and believing he could do as he wished now as he was aged 16. Mother asked for help, in particular for YOS to convene a meeting with the social worker. While it was unclear what specifically had been the outcome of that request, practitioners told this review that there had been several joint meetings with the social worker and YOS officer and that the social worker had offered support to Mother. 7.10. After Child N had been refused a college place due to his history of offending, and particularly because he needed help to obtain the Construction Skills Certificate Scheme card, his engagement with YOS improved for a while. However, he missed a referral panel meeting in December 2019, as well as a YOS appointment in January 2020, which meant he was told about a risk of being returned to court by the Referral Order panel. The Information, Advice and Guidance (IAG) worker helped him get a National Insurance Card and arranged work experience from early 2020. 7.11. Once the Covid pandemic started Child N began disengaging again. Practitioners told this review this was because he was demotivated due to not being able to get a job and contact with his YOS officer only being by phone. Practitioners told this review that he had missed a couple of appointments and panel could have returned him to court for sentencing for the original offences. However, in practice the order had only a few weeks to run, he had completed the work required and a return to court would have likely resulted in a fine, which would have had to have been paid by his mother. When discharging his referral order in July 2020 the panel recognised the importance of being in Education, Employment or Training and they hoped that he would continue to engage with the Information Advice and Guidance (IAG) worker; everyone recognised that Child N was much happier when in work. 7.12. Child O’s Referral Order was made in April 2019 in LA2. Where children in care are placed in another local authority it is not unusual for the YOS in that local authority to be asked to caretake the order. However, for a few weeks after the order was made it was unclear where Child O would be living and then, because Child O’s initial placement with his mother in LA1 was for a 12-week assessment period, LA2 YOS continued to hold responsibility for the RO. This, and Child O not attending assessment meetings, even at his home address, meant that there was a delay in holding the first referral panel until mid-July 2019. Child O did not attend this as his social worker was worried about 12 CSCS cards provide proof that individuals working on construction sites have the appropriate training and qualifications for the job they do on site. 11 the risk from others if he went back to LA2. LA2 YOS had had previous experience of making a request for caretaking and then Child O moving before intervention could start so the caretaking request was not made until October 2019. There was a further delay in holding a panel meeting involving both YOS teams until just before Christmas 2019. This was due to a need to confirm the input required from LA1 YOS and that Child O would be staying in LA1 with his mother and remaining subject to a care order. While a service had begun to be offered by LA2 YOS the delay in requesting and finalising the caretaking arrangement meant that Child O did not benefit from LA1 YOS’s local knowledge in managing risk. 7.13. The handover in December 2019 involved a review panel where both YOS officers were present. Caretaking arrangements usually include conducting assessments and holding review panels in the area where the child is currently living, however they continued to be held in LA2 at the request of LA2 YOS, because he had engaged with the panel in LA2 and because LA2 YOS had had experience of Child O refusing to engage with previous caretaking arrangements. At the time it was also anticipated that this would best provide continuity of YOS officer (although that was later disrupted by Covid related issues). It also meant that the referral panel did not know LA1 and the characteristics of the local community which made them more dependent on the YOS officers’ recommendations for suitable content of the order. 7.14. At the review panel meeting in December 2019, it was discovered that, despite Child O engaging with the contract of work from July 2019, and with subsequent panels, perhaps because he did not attend the first one in July 2019 and had never actually signed the contract of work the order had technically never started until December 2019.13 Although he would have known the alternative was to return to court for resentencing, it was positive that Child O agreed to continue working with YOS in LA1, despite having to engage for several more months than he had anticipated. 7.15. Work done by LA1 YOS with Child O included intervention about knife crime, gang involvement, peer influence, substance misuse, obtaining education and relationship building between Child O and his mother. Given his involvement with gangs had affected his motivation and capacity to change, practitioners believed he may have benefitted from more specialist intervention, e.g a programme on criminal exploitation which could include access to a gang mentor. After the Referral Order finished in April 2020 LA1 YOS offered voluntary intervention, which Child O declined to take up. 7.16. A report14 produced by the inspectorate for probation services about Referral Orders (RO) provides a relevant context for this review. These community orders are said to provide an ideal opportunity to help young people cease their offending behaviour before it becomes entrenched. The report stated that ROs are believed to be consistently more effective than other sentences and that YOSs generally performed well. However also that some issues were evident. The report identified two relevant to Child O; the importance of engaging young people in agreeing the intervention and of managing the period after sentence well up until the panel met, to avoid loss of impetus and meaning for the Referral Order. Child O had never signed the contract from the panel meeting in July 2019 and the subsequent panel, when LA2 became formally involved was not until December 2019. 7.17. The Referral order was the main form of intervention to tackle Child N’s offending behaviour. His risk level was identified by LA1 police as well below the threshold for involvement by the Problem-Solving Team. Due to involvement in an alleged robbery and an alleged assault in October 2020, he was offered support from another part of the police service; officers from the Violence Reduction 13 The referral order finished in April 2020, in line with intended timing when the court originally made it as both YOS felt Child O had completed the necessary work 14HM inspectorate of Probation (2016) Referral Orders, do they achieve their potential? HM inspectorate of Probation (2016) 12 Team visited him and his mother to offer support to get him involved in constructive activities. They were told he had just started a new job and was not interested. Practitioners told this review that perhaps more police proactive support could have been offered during the previous 6 months, when there were some signs his behaviour was escalating, but his circumstances did not distinguish themselves significantly from the other 250 local young people then regarded as at serious risk of youth/gang violence. 7.18. Child O also had contact with and support from the two different police forces covering LA1 and LA2. While the police force from LA2 promptly notified police force in LA1 that Child O had moved to LA1, this was done by sharing of intelligence rather than a formal notification to the police force. This should then have resulted in the neighbourhood policing team and the Problem-Solving Team being proactively aware of his arrival as soon as he had moved for safeguarding and risk assessment purposes. During May, June and July 2019 there were five brief missing from home episodes. In June LA1 police received intelligence that Child O may be used as a “money mule” which prompted the first contact from the Problem-Solving Team.15 In early July 2019 LA2 police requested a flag on his address due to a threat to kill from another gang member. This was treated as an administrative matter rather than prompting a conversation between the two police forces as it should have done. In Mid July 2019 the Problem-Solving Team created a Risk Management Occurrence to manage the risks around Child O. This was two months after Child O had arrived in LA1 and, given his history and vulnerability as a looked after child, this review was told that this should have been considered earlier. 7.19. At the end of July 2019 Child O was discussed at a multi-agency Strategic Exploitation Panel (SEP) meeting. At that time LA1 YOS were not aware whether there was YOS involvement and were tasked to find out, this was still not clear at the time of the next SEP meeting in September 2019, for reasons that are not known. From August 2019 the frequency of missing episodes increased and by September 2019 this has resulted in another Risk Management Occurrence, which was running alongside the one created in July 2019. There is no evidence that the two Single Points Of Contact (SPOCs) liaised, and it would have been preferrable if oversight had been maintained by one person rather than two. Notes from the Strategic Exploitation Panel (SEP) meeting in October 2019 suggest there was no evidence of gang affiliation in LA1, by this stage it was also known that he was subject to a Referral Order to LA2 YOS so his name was removed from the SEP agenda. For the same reasons the RMO raised in July 2019 was also closed. For reasons that are not known there was no liaison with the police force in LA2, or the police officer dealing with him as a repeat missing person. 7.20. A summary of the international research prepared in 201616 found a range of features of intervention that had consistent positive (or negative) outcomes. The majority of the studies were from the US rather than the UK. However, whilst some of the programmes of intervention might not be transferable given the different legal systems, the principles on which they are based are. Effective intervention considers: the individual’s risk of re-offending, matching the intensity and type of services to that level of risk; the needs of the individual, focusing attention on those attributes that are predictive of reoffending; the individual’s ability to respond, taking into account their learning styles, motivation, abilities and strengths. The literature review found that although some young people will always need to be sentenced to custody, the evidence suggests ccommunity-based 15 The police Problem-Solving Team (PST) in LA1 work intensively with ten young people at any one time. They are identified through scoring criteria for the number of times someone had been a victim, suspect, and missing, considering how seriousness and how recent incidents were. The PST was involved with Child O from June 2020 through the rest of the period covered by this review. 16 Adler J et al (2016) What works in managing young people who offend? A summary of international evidence. Ministry of Justice 13 interventions tend to be more effective. In addition, diversionary approaches, including restorative justice, which direct these individuals away from the formal justice system may be appropriate for some young people because drawing young people who commit low level offences into the formal youth justice system may increase their offending. In the UK diversionary activity involves judgements about the likelihood of desisting criminal activity, the safety and wellbeing of the child and risk of harm to the public. There were some decisions made by LA1 police not to proceed against Child O for relatively minor offending eg possession of small amounts of cannabis, and damage at the supported accommodation. 7.21. The literature review also identifies the benefits of multiple services: addressing a range of offending related risks and needs rather than a single factor. It is important to consider the wider offending context: considering family, peers and community issues. There is evidence that each of the agencies working with both children took a risk-based approach and considered the individual circumstances of the children. For example, each YOS held internal risk management meetings at key points. However, the multi-agency approach for Child O at key points was fragmented and there is no evidence of an overarching closely managed operational, multi-agency, multi-disciplinary risk management plan which the national panel report previously mentioned noted was effective in the local authorities seen to be using them. If the thinking was that due to his “looked after” status the care plan and statutory review function should have served that purpose this was not effective. At a basic level it became clear during the review that agencies did not have the same addresses for him while he lived in LA1. More importantly, there was no statutory review before Child O moved in with Mother. The next statutory review was held in August 2019, by coincidence at crisis point, which was attended by a LA2 YOS worker who described the referral order as unworkable, for reasons that are not recorded, and who was considering taking it back to court. Records for the statutory review in October 2019 show that Child O was much more settled but there was no attendee from YOS or reference to their involvement which one would have expected given the situation in August 2019. For the August and October 2019 statutory reviews there was no police representative in attendance, and reference to continued involvement from CIRV (LA2) but no reference to liaison with or involvement by the LA1 police force. This was despite evidence of attempts in CIRV records to arrange a multi-agency meeting because of the level in risk in September 2019. There were difficulties in contacting a social worker or practice manager, who were then unable to attend. The next statutory review in March 2020 was held just before the move to the supported accommodation as it should have been, the records are more detailed and holistic than the previous ones. The YOS officer was in attendance, there is evidence of liaison with the LA2 police and recognition that Child O may be more vulnerable when his referral order comes to an end. By the next statutory review in June 2020 Child O had been permanently excluded from school due to the assault. He was working with the Problem-Solving Team (PST) police officer who was in attendance.17 7.22. Practitioners told this review that close working relationships between police YOS and social workers were key to success in their experience of working with the highest risk children. LA1 police felt that one area for improvement to support this would be more consistency by PST team members in producing and sharing chronologies with YOS and social workers which included all incidents and intelligence. Whilst there is evidence of close working relationships for both children, practitioners were not supported by systems and arrangements to promote this and a co-ordinated approach to risk management, which facilitates multi-agency discussions and planning at key points. For Child O examples of these would be: at the point he moved into LA2; when the placement with Mother appeared to be breaking down; when he was excluded from school; when he moved to the supported accommodation and when he was found in another part of the country with cash and drugs. Children 17 All the statutory reviews from August 2019 until the end of the period covered by this review were attended by the relevant placement provider and an education representative when he was in school as they should have been. 14 like Child O are subject to several separate but potential duplicatory meetings to manage risk and plan care: meetings because of a legal status (statutory reviews) or a risk of significant harm (strategy meetings) or going missing. None of these operated successfully to bring all the right people together to produce and monitor a holistic risk management plan. 7.23. Young people who had stopped offending who contributed to a report from the probation inspectorate18 put great store on a trusting, open and collaborative relationship with a YOS worker or other professional, seeing it as the biggest factor in achieving a reduction in offending. This was also a finding from the 2020 National Safeguarding Panel report about children involved with gangs and vulnerable to criminal exploitation.19 It can be difficult to build trusting relationships with children like Child N and O due to them often having been let down by adults. This can often be even more challenging for children in care, who may have had many changes of placement and changes of practitioners, sometimes at short notice, and without any control. 7.24. Despite their histories of poor care and changes in placements, multiple times for Child O, both children were able to respond to practitioners’ attempts to build relationships. There was evidence that several practitioners had persevered with this, but also of a significant impact when those relationships ended for some reason. However skilled the practitioner, building relationships with young people takes time, time spent in understanding the history as well as engaging with the child, and there is evidence that sometimes changes in practitioner adversely affected Child O’s engagement in particular. 7.25. More than one SPOC made a determined effort to establish and maintain a relationship with Child O. He engaged particularly well with one and he expressed dissatisfaction when that person was no longer involved. This review has been given different reasons for that police officer ceasing involvement. From Child O’s perspective the critical issue is that he no longer had regular contact with him. Whilst Child O did engage with the successor, this was at the point his overall engagement was reducing. The timing of the change was unfortunate as this was the beginning of a very difficult period for Child O. The previous SPOC stayed in touch20, attempted to follow up with Child O a report he had made about his phone being stolen. The new SPOC contacted him after he had “stormed out” of the LAC review in October 2020. On this occasion Child O expressed frustration at all the “help” he was being offered and “all the people involved in his life” that he had not necessarily asked for. 7.26. During the period under review there were discontinuities of staff, due to workers changing jobs and the Covid pandemic (see section below). Just prior to the period under review the social worker who had been allocated to Child O for the previous two years changed. From March 2019 until the end of the scoping period Child O had four more social workers. Two of these were involved for less than three months. Social worker 5 became involved in June 2020 after Child O had been found with cash and drugs in another part of the country shortly after moving into the supported accommodation. This was because the previous social worker was absent from work, and it was good practice to re-allocate given the escalating risks. 7.27. SW5 built a good relationship with Child O but she reflected that for young people recently allocated to her who were new to supported accommodation in future she would visit more frequently to build up a relationship which might better enable young people to confide when they felt unsafe. Having said that the report from the national panel previously mentioned described that many young people 18 HM inspectorate Probation 2016 Desistence and young people 19 National safeguarding Panel 2020 It was hard to escape; safeguarding children at risk from Criminal Exploitation 20 Contacts between the end of September and November 2020 were not recorded until after the murder. They should have been recorded contemporaneously to keep the Problem-Solving Team updated 15 involved with gangs are not able to be honest about their circumstances as this may put them at more risk. The careers advisor at the academy changed jobs in October 2019 which was unfortunate timing for Child N as her normal practice would be to stay in touch in the Autumn term. This is because it is not unusual for young people to experience setbacks with planned destinations, and it is very hard for a new person to support young people as effectively without the benefit of a previous relationship. 7.28. From March 2020 neither child was able to see their usual YOS officer face to face due to the Covid pandemic. Practitioners told this review that this had a huge adverse impact on the children’s previous good levels of engagement. They suggested that rather than attempt to introduce new people who did not have a relationship with them it might have been better to be more flexible and offer virtual contact with the original officer once the arrangements were up and running. Learning Points: • Partnership working with vulnerable children who have police, social work and YOS involvement due to offending and links to gangs is inherently complex. This complexity is exacerbated when a child is in care and moves placements between local authorities. • Young people who have disengaged from education can be highly motivated to obtain employment. They benefit from support to assist getting and keeping a job e.g. work experience, careers guidance, mentoring to develop foundation and interview skills, and practical and financial support. • Referral orders can be very effective in supporting young people and reducing their offending behaviour, but this is undermined if referral panels are not convened promptly. • When a child involved with gangs moves to live in another area the importance of o Prompt and effective liaison between police YOS and Children’s Social Care in both local authorities o The police force in the new area having effective force wide arrangements to provide monitoring of risk and support • Children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency, multi-disciplinary risk management plans which are reviewed at key points e.g. when they move placements or when incidents indicate increased risk or vulnerability. • The importance of all key practitioners being involved in statutory reviews. • The importance of practitioners having strong relationships with young people, and the need to manage the impact when these relationships are disrupted for any reason. Recommendations A and C Theme: meeting educational and health needs 7.29. Receiving appropriate education is an important protective factor for young people. Apart from improving their employment opportunities and impacting on a range of other life chances, being in school or college provides access to supportive adults who are positive role models and someone 16 to turn to in times of difficulties. It also provides constructive occupation which reduces time at a loose end and opportunities to get into trouble. Research consistently shows that risks for children significantly escalate when they are permanently excluded from school, partly due to the difficulties of providing alternative full-time education.21 7.30. Both children had chequered educational histories. Between May 2018 until April 2019 Child N refused to attend Academy 2. From April 2019 Academy 2 provided him with weekly one to one tutoring. Out of a possible 43 sessions he attended almost two thirds. When present, the tutor thought Child N was engaging well and making academic progress and he obtained GCSEs in Maths and English. The Academy has since reflected that it would have been helpful to have included more diverse educational opportunities including work experience alongside the tutoring. Practitioners told this review that there were very limited choices for young people in LA1 to provide alternatives to school or college placements when children either won’t attend or are prevented from being offered a place due to level of risk. These could also enhance and support educational placements by providing work experience or other practical learning opportunities for older children who struggle to engage with more academic options. Those children might be more accepting of the need to achieve a basic level of literacy and numeracy if delivered by an alternative provider. More leisure activities would also be helpful to occupy children at risk of offending behaviour. 7.31. In June 2019 Child N completed his secondary education at Academy 2 with a destination confirmed with the Careers advisor who intended to stay involved until October 2019. Child N achieved his wish for a practical job with relatives in July 2019, the careers advisor believed he was still employed in October 2019. However, the job had ended because, although relatives were keen to offer him work, Child N had not wanted to make it a work experience placement. His first application to a college was rejected due to his offending history and he was Not in Education, Employment or Training (NEET) at the end of October 2019 despite a second college interview. YOS records show he was highly motivated to find work, accepted help to produce a CV and applied for jobs on his own initiative in the Autumn 2019. Unfortunately, the work experience placement he started enthusiastically in early 2020 closed due to Covid, and subsequently he was discouraged by the lack of response to job applications. 7.32. Child O’s education had been severely disrupted by the number of placement moves he had after coming into care. He was the subject of an Education Health and Care Plan which meant that the lead agency for securing provision was the Special Educational Needs (SEN) service in whichever area he was living at the time. Whenever he moved across local authority boundaries, which he did several times, the responsibility changed, which built in discontinuity and delay. Records suggest that more than one social worker and the IRO were not clear who was responsible for leading on securing educational provision and mistakenly thought it was the Virtual School. The role of the Virtual School is to advocate for children in care to support activity to secure appropriate provision. There is also evidence of misunderstanding that it is SEN teams rather than the Virtual School being responsible for reviewing Education Health and Care Plans. Records for statutory reviews show that social workers did not know when the EHCP had been last reviewed. 7.33. The education placement Child O had when first placed in LA1 was in fact one which had been secured after he had returned to LA2 in 2019. It was in LA2, which was an hours’ journey, and located in the local authority from which he had moved away to ensure his safety. There is no evidence that this was considered in the placement planning led by children’s social care (see placement theme below) as it was not until June 2019, some weeks after he had moved to LA1, that the social worker informed LA2 Education Health and Care (EHC) Team that Child O could not return 21 National safeguarding Panel 2020 It was hard to escape; safeguarding children at risk from Criminal Exploitation 17 to the LA2 school and requested alternative provision because other pupils were frightened regarding his gang connections and threats of violence. 7.34. In July 2019 the LA2 SEN team asked the SEN team in LA1 to take over responsibility for finding provision. Because he could not attend the site due to his bail conditions and had not previously engaged with tutoring, they also removed Child O’s name from the school’s roll which meant the school no longer had responsibility for providing some form of education. This should not have happened until alternative arrangements were in place, especially as this was near the end of term and meant nothing was in place for the next academic year. There were some delays for the SEN staff in LA1 getting involved because they had not had all the necessary information from LA2; staff told this review that in future similar circumstances they would get involved more quickly, perhaps by convening a meeting of relevant people rather than waiting for written information to be supplied. In mid-September 2019 Virtual School staff requested a tutor be provided; this did not start until mid-October and ended within three weeks as Child O would not co-operate. Children in care should have a Personal Education Plan which is reviewed every six months with consideration of it being done at the same time as the EHCP for children who have those. PEP review meetings should still be held irrespective of whether children are on a school/college roll. PEPs were held for Child O in October 2019, December 2019 and Jan 2020, i.e. more than minimum frequency because he was not on a school roll. 7.35. Child O had requested a place be found in a mainstream school, because being in a special school made him feel different. Practitioners told this review he did not understand that he was not ready to thrive in mainstream education. However, they also told this review that, for a child of Child O’s age, attempting a placement if the setting thought it was safe could be the difference between a child having some education as opposed to none. In mid-November 2019 Child O was offered a place in specialist provision in the 6th form (although he was still year 11). The school requested a professionals’ meeting to discuss risks which was held in the last week of the autumn term. Child O commenced attending three days a week mid-January 2020. This is the standard level of attendance for all students in sixth form, which is less than would have been expected for a pupil in year 11. Despite poor attendance/going missing during the school day, by May 2020 he had managed to achieve a level 1 certificate in construction, engage in work experience and obtained a place at college. 7.36. Practitioners told this review they had significant engagement with the college to get Child O a potential place there because of the perceived risks. Unfortunately, not only was he placed on a construction course of a type that he was not expecting that started with bricklaying, no-one was informed of this in advance of his first day at college. Practitioners told this review that this change of course may have been because he did not have the entry requirements for the specific course he wanted and so was placed on an access course with a wider range of activities which unfortunately had not started with the one he wanted. The outcome was Child O refused to attend college, and the assault at the school in June 2020 meant he had no backup plan. The social worker and LA1 police Problem Solving Team continued to support him to find a college place; he obtained a constructions skills course place to start after the October half term 2020. 7.37. Both children were seen while in custody by the Criminal Justice Liaison and Diversion Service. Child N was seen in February 2020. Discussion and use of a mental health screening tool identified that the only concerning issue was the daily use of drugs. Child N declined a referral to substance misuse services. In September 2020 the worker was unable to contact Child N the police or Mother by phone despite confirming the numbers with the MASH (and checking no social worker was involved). Mother did not respond to two further attempts to contact her, or to a message left the following day. 18 7.38. Child O was seen by CJLD twice; in February 2020 and after being arrested for the murder. The only issue of noted to be a particular concern was periodic anxiety and flashbacks to traumatic events which he said he coped with by using distraction techniques. The worker reported his daily use of cannabis to the social worker, this was believed to be funded by money given by, or taken from, his mother. 7.39. The CJLD practitioners told this review it would have been helpful to have had some background information about both children and that this can be particularly difficult to access outside of office hours and at weekends. They said they are reliant on those NHS records which they can access which may not be detailed, or what the investigating officer can tell them which is sometimes not very much. Phone calls to MASH usually result in a worker’s contact details rather than actual information and then practitioners being busy means they often don’t respond for a few days. Some organisations will tell them that they cannot share information without the consent of the chair of a particular meeting. 7.40. Practitioners from LA1 also told this review that it was not standard practice for CJLD staff to contact the YOS after seeing children; there is no evidence they contacted them regarding either child. YOS practitioners felt this would be useful. If the child is known, then having information from the assessment would be helpful. If the child is not known this would act as an early warning regarding young people who had moved into or were offending in LA1. Since the beginning of 2022 CJLD have been emailing a dedicated YOS email with information about children seen in custody who they know are involved with YOS LA1. However, no-one directly involved in this review knew what happened to these messages and whether they were getting through to allocated officers. This system does not include all children and this is practice by the daytime service. There is another commissioned service for weekday evenings and nights and no-one knew if they had equivalent arrangements. 7.41. Both children were regular users of cannabis by their early teens. In April 2019 Child N attended a first session with a YOS drugs worker but was late to the second and missed the third. Records show sessions with his YOS worker were more difficult when he was asked about his drug use and he declined intervention for this. Records for Child N in February 2020 show reflection by CJLD about how he was funding a daily drug habit without a job, but there is no evidence of any liaison with YOS about this. During an annual health assessment in April 2019 Child O stated he had been smoking cannabis since age 13. 7.42. At the beginning of September 2020 (age 16) Child O attended the A&E department for treatment with a laceration to his finger said to have been caused at work laying bricks. This was confirmed by his support worker. The hospital staff accepted the injury was caused by an accident and concluded there were no safeguarding concerns. A nurse from the health trust reviewed the hospital summary about a week later, noted the lack of safeguarding concerns and concluded there was no role for the school nurse. Neither agency considered whether working as a bricklayer was appropriate or enquired about the nature of the working environment for reasons that are not known. Both agencies could have made enquiries to check whether his social worker knew he was working. The social worker did in fact know he was working, had checked it appeared to be a reputable company and had tried to contact the owner, but he did not respond to phone messages. Practitioners were not aware of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18. 7.43. In September 2020 Child O seemed low in mood. He refused to attend his annual health assessment with the LAC nurse despite several contacts from her. He also refused a referral to the LAC mental health team but agreed to see his GP. Unfortunately, the GP had removed his name from their patient register. This was because they assumed when his mother moved that he went with her after making unsuccessful attempts to contact him. The GP practice has since put in place systems to 19 prevent children being removed from the patient register without being registered at another practice. The supported accommodation worker took Child O to the local urgent care centre. The nurses there appeared sympathetic and reassuring, clarified he was not self-harming encouraged him to “think positive” and gave him information about a range of online resources. Learning Points: meeting educational and health needs • Being engaged in education is a protective factor for children, and when a child is not in school for any reason this needs to be addressed promptly. • The importance of a range of choice of work experience and other education and training based opportunities as substitutes for, or enhancement to, school placements. • The need to raise awareness amongst social work staff of the responsibilities of the SEN team for identifying school placements for children who are subject to Education, Health and Care Plans, including when they are looked after. • The potential usefulness of better arrangements for CJLD to have timely access to background information about the children they see in custody. • The potential usefulness of CJLD staff sharing information with YOS about the children they see in custody as standard practice. This would provide YOS with helpful early warnings about any children newly moved to the area as well as support their work with children known to them. • Practitioners need to be aware of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18. Recommendations B, E and F Theme: Decision-making and information sharing about Child O’s placement with his mother, their move to LA1, including subsequent placement in supported accommodation 7.44. Understanding the timing and decision-making for some of the placement changes for Child O during the period under review has been difficult due to a combination of some characteristics of the social work electronic record (where some key details are only visible in contact records) plus gaps or lack of detail in contact records, coupled with social workers and team managers who were involved before March 2020 not being available to participate in this review. In addition, some agencies who had provided placements or support for Mother were not identified until a late stage in the review and have not provided any information.22 7.45. In January 2019, a meeting was held involving social care staff and a legal representative due to concerns regarding Child O’s risk-taking behaviours within LA2, alongside the breakdown of placements. The outcome of the meeting was that Child O did not meet the criteria for a secure order application23 at that time. Advice given by the then Assistant Director, was that all other placement 22 The provider of the supported accomodation placement and substance misuse services in both local authorities 23 Secure orders are made under section 25 of the Children Act 1989. The order allows children’s services to place a looked after child under the age of 16 in secure accommodation on welfare grounds if one of two conditions applies: the child has a history of running away. The order may be made if the child is likely to run away from any other type of 20 options needed to be considered/exhausted prior to going down the secure accommodation route. This is in line with national and local guidance. After he was stabbed, a second legal planning meeting was held in May 2019. This led to a Secure Panel meeting two months later in July 2019 (no reason for the delay is recorded) where it was agreed that the threshold was met to make an application to court for a secure order for Child O. Agreement was given by the Director of Children’s Services that, pending an application to court, Child O should be placed in secure accommodation without an order for 72 hours. Unfortunately, no placement of any kind was available which could meet his needs. Because of this the Assistant Director agreed it was appropriate to explore the possibility of a placement with Mother. There is no evidence of anyone considering trying to find a bespoke unregulated placement for supported accommodation for Child O, for reasons that are not known. However, given the level of risk and need it might have been difficult to keep him safe in such a placement and the emerging concerns nationally about the use of unregulated accommodation for children under 16 years might have been a relevant context. 7.46. By this time, Child O’s mother had been engaging in support services to address her substance addiction and was willing to care for Child O. Child O was very clear that he would not return to any placements ‘Out of County’ as he missed his mother and the regular contact he was having with his sibling. Child O’s mother was willing to leave her council flat, in order for Child O to be placed with her in LA1. A suitable placement was identified in LA1 which could undertake a specific parenting assessment, and the court responsible for the care proceedings directed that it would be safer for Child O and his mother to move into a hotel (family room) in a town in LA2 for a few days rather than live in Mother’s flat until the placement was ready. Records show that Child O was in court on the day of the move to LA1 and that the judge had made clear that if this placement was not successful then it might be necessary to consider secure accommodation. 7.47. Records show that the schedule 3 report assessing the suitability of the placement with Mother was signed by a senior manager before the family moved to LA1 but three days after they had moved into the hotel together in mid-May 2019. Whilst this may have been an emergency placement, which was endorsed by the court, approval should have been given beforehand, although it is clear from the schedule 3 report that information gathering for it had begun sometime previously and that there had been discussions with senior managers. References to YOS noted the need for ongoing involvement due to the recent making of the Referral Order but did not consider which YOS service would provide this. The report stated Child O had an education placement in LA2 due to start in a few weeks. Whilst this was not in the town where he had previously lived there was no reflection on whether its location was suitable given that it was still in LA2, where it was not deemed safe for him to live, nor reflection on the fact that he had previously expressed reluctance to attend there. It is not known whether anyone considered whether any of the other pupils might have knowledge of him via involvement in gangs. The report indicated that they would have sole use of a family sized home during the parenting assessment and that CIRV had been involved in a risk assessment of the safety of the location. 7.48. This review was told that the IRO endorsed the decision for Child O to live with his mother, alongside an extensive support package, which included intensive family support, specialist input to help Mother continue to stay drug free, CIRV, NRM and education outreach, but there is no evidence that a statutory review took place either prior to this move or shortly afterwards as it should have done.24 There is no requirement in the schedule 3 report to indicate the view of the IRO or the date of a placement, and they would be likely to suffer significant harm if they did run away; the child is likely to injure himself or someone else if they were kept in any other form of placement. 24 https://northamptonshirechildcare.proceduresonline.com/p_look_aft_rev.html Children Act 1989 Guidance and regulations (2021) Volume 2 care planning placement and case review Chp 3 DfE 21 statutory review to endorse the placement. Although the care plan was sanctioned by a court and the plan indicated the IRO’s agreement with it, local procedures indicate that a statutory review should be held soon after placement. The absence of a statutory review before August 2019 meant there was no opportunity for all the agencies involved with Child O to get together and discuss the plan. This would have been particularly useful just after the family had moved to LA1 as it would have enabled the staff delivering the parenting assessment to meet other practitioners and for everyone to have an opportunity to discuss their roles and nature of their intended involvement. This might have made more visible the challenges faced by YOS in initial delivery of the referral order and the complexity of the potential involvement of both police forces and their need to be kept informed. 7.49. Between May 2019 and July 2019, most of the occasions of police involvement with Child O involved him going missing for brief periods (five times). Otherwise, records show the placement seemed to be going well from the point of view of family relationships and engaging with the social worker and YOS. 7.50. LA1 was only 30 minutes travelling distance from Child O’s previous address, and therefore placed a heavy reliance on him to co-operate with keeping himself safe. Overall, for a few months Child O’s situation seemed relatively stable in terms of not offending in the community. However, records show that concerns about him going missing between mid-August and October 2019 had been at a level where consideration was given to an application for a secure order. Some agency records show a belief that secure accommodation was appropriate without necessarily having a detailed understanding of the legal requirements, however records also show that at least one agency tried, without success, to get an understanding of why a decision to pursue a secure order had changed. No secure panel was arranged as the situation had improved; social work staff thought seeking secure accommodation was difficult to justify as he was not offending. In addition, practitioners told this review that secure orders could only usually be justified for a few months and whilst they might be necessary sometimes to protect children without a good transition plan they were not long enough to do much more than provide a safe pause to try and engage the child who would revert back to the previous behaviour if there was not a good follow-up plan once they were released. 7.51. From August 2019 his relationship with his mother deteriorated, including him asking for money with threats and aggression. In fact the statutory review record shows that the placement was considered to be breaking down in August 2019 to the extent that Mother returned to her accommodation in LA2 while Child O remained in the placement with 2:1 staff support pending an application for secure accommodation. This was unsuccessful for reasons that have been described previously and Mother agreed to return to the placement and resume caring for him. By the next statutory review in October 2019, it was clear that things had improved considerably in terms of family relationships. In addition, three potential school placements had been identified, although the only educational input imminently available was two hours a day tutoring. 7.52. The final care plan produced for court in November 2019 indicated that the outcome of the parenting assessment had been sufficiently positive for Child O to remain in the care of Mother, but that he needed the ongoing protection of a care order to ensure his needs were met. It also stated that Mother had engaged “meaningfully” with the substance misuse service in LA2 and proposed that Child O be supported to understand living with a parent with an addiction. It is unclear what “meaningful engagement” meant, but whilst it is accepted that a person’s struggles with substance misuse may mean relapses, by August 2019 there was evidence that Mother was using drugs again. The fact that the family assessment placement had to frequently provide food vouchers, at least partly because Mother was spending money on drugs, suggests the protection assumed from 22 engagement with services implied more optimism than was warranted. There is also no evidence of the work with Child O on living with a parent with addiction. 7.53. Managers from the family assessment placement told this review that, looking back, they believed that all the practitioners focussed too much on Child O improving his behaviour and overlooked the risk his mother posed. There needed to be a holistic plan that also looked at mother’s functioning and risky behaviour and there is no evidence that this was considered after the care plan was presented to court. As is the case nationally, the local authority’s recording tools for care planning and statutory reviews are designed for most children in care who are living with foster carers, or in children’s homes or supported accommodation. The starting point is therefore that the actual placement is safe and the carer(s) protective, so they are not well suited to placement with parents arrangements where, by definition, since the threshold of significant harm has been met in a court, there are likely to be some risks associated with the parent. 7.54. It is unclear which agencies knew that Mother had started using drugs again by August 2019 and appears to have continued to do so throughout the time caring for Child O. There is some evidence in agency records of individual practitioners sharing information and concerns about mother’s substance misuse with other individual practitioners. However, there is no evidence of any multi-agency discussion (including at statutory reviews) about what drugs she was using and how often, how she was getting them, what the impact on Child O might be (e.g on household income, contact with people dealing drugs etc) or what support she might need to cease using again. There is a fleeting reference to Mother possibly taking up substance misuse services in LA1. It has not been possible to gain any information about this from the agency concerned as they have been taken over and the records archived. 7.55. The parenting assessment provider allowed Mother and Child O to live in one of their properties after the assessment had finished, pending them finding an alternative. During a social work visit in mid-December 2019, when only Child O was at home, Child O stated that the provider had given them 28 days to find somewhere else to live and that Mother had an appointment with housing in LA1 that week. Records show that the social worker was intending to attend with Mother. It is not clear whether they did, but housing records show that the housing authority was aware that police and social workers from LA2 were involved, and that it was not safe for Child O to return to LA2. The property was not available indefinitely but there is no evidence that the social worker had planned ahead for follow on accommodation. 7.56. Records suggest it was necessary for Mother to present again at housing early in the new year when she was accompanied by the LA1 YOS officer. The family were offered temporary accommodation that the housing authority deemed suitable and affordable. Unfortunately, this was in a part of LA1 where gangs were operating. There is no evidence of a detailed discussion about the nature of the risks which might have enabled housing staff to recognise that there could be parts of LA1 which would not be suitable for the family. In addition, housing staff told this review that they did not have a detailed understanding of risks in different areas and that one of the constraints in rehousing people was the limited amount of temporary accommodation available. 7.57. The LA1 YOS officer had raised his concerns with housing and was informed this was temporary housing. The concerns were also shared by Thames Valley Police and the LA1 Exploitation Lead. Challenges were made to LA2 social workers querying why they had not taken action to house the family and instead the family had to present themselves as homeless to housing which then had potentially increased the risks to Child O in relation to gangs and exploitation, both in terms of the nature of the local area and because insecure housing makes children more vulnerable. Records show this was escalated to the team manager whose response repeated that the accommodation 23 was temporary and described Mother as having support from the parenting assessment provider to complete some unspecified tasks to secure permanent accommodation. The team manager did not directly address the concerns about the nature of the area itself. This reply seems to have been accepted as there is no evidence of any further escalation. Records show that SW2 was aware that this was a “poor area” where Child O would be at “greater risk” and had in fact asked colleagues to provide evidence and challenge to the housing authority, but this was after the accommodation had been offered. 7.58. The care planning regulations and the Schedule 3 report previously referred to require consideration of the safety of the area in which a child in care is going to live. At the time of the original placement in LA1, there is evidence that SW1 had sought reassurance from the LA1 police that the proposed address was a safe area for Child O to live. There is no evidence of a proactive approach by social work staff in late 2019 to identifying which would and wouldn’t be safe areas for Child O and Mother to be offered accommodation. After the family had moved into the temporary accommodation there was no of evidence of consideration being given to any options for moving them, for example, by providing financial support to enable the family to rent accommodation elsewhere in LA1, despite the YOS officer passing on Child O’s fears to the social worker about being approached in the area where he now lived to deal drugs. It may be relevant that Mother soon became more committed to the solution being to move back to LA2. She was worried about losing her tenancy there and finding it hard due to Covid restrictions to have contact with Child O’s younger sibling. 7.59. During this review practitioners expressed differing views about the impact of Child O being housed in an area where he was vulnerable to becoming involved again in gangs. Whilst deterioration in Mother’s ability to care for him might have been expected after the cessation of the additional support and monitoring provided by the parenting assessment provider, the nature of the area was a compounding factor which could have been avoided. 7.60. By March 2020 agencies had serious concerns about several things: Child O offending, the risks the behaviour posed to others and himself; Mother’s ability to supervise him and to prioritise her finances to ensure there was sufficient food in the house for him; and the two of them were not getting on. In addition, Mother wanted to move back to LA2. Child O moved to supported accommodation in March 2020, after risk assessments had been completed which took into account that other residents were in stable circumstances and included seeking confirmation from LA1 police that the address was in a safe area. 7.61. Within two weeks of entering supported accommodation missing episodes increased including overnights with at least one being known to be outside of LA1. Child O was upset about how the impact of the Covid pandemic prevented in person contact with his mother and sibling. There was also the issue of getting used to a new group of staff, which was a challenge for both parties given his history. Social work practitioners involved with Child O during his stay in supported accommodation told this review that, especially as he had only been 16 years old when he had moved into supported accommodation, they had not reviewed the nature, level and purpose of the purchased care package (seven hours per week, with 24-hour access to a staff member on site) during his stay. They also felt that perhaps it had needed increasing, and that in future they would monitor packages more frequently and review them more proactively for other young people in similar circumstances. 7.62. Since the murder Child O has spoken to his social worker about his time in LA1. He said that he was worried about informing practitioners that he was scared and unhappy, for fear of being moved 24 further away from his family. Child O had previously been moved to placements in other local authority areas which affected his close relationship with his sibling and family members. Ideally Child O would have felt confident to raise such concerns without the fear of being moved away from his support network. If this worry had been shared, consideration could have been given to ensure he remained close to important family links. Learning Points: • A requirement to add the IRO’s opinion or the date of a statutory review which had endorsed the placement of a child subject to a care order back with their parent on the schedule 3 report may assist in ensuring that the care plan is updated to include all multi-agency involvement. • When children subject to a care order are placed with parents at short notice, including at the direction of a court, a statutory review should be held promptly to discuss this and ensure the meeting and care plan includes attendance or a contribution from all practitioners actively working with the child and parent. This is particularly important when children are placed outside their home authority. • Some children in care who have not thrived in multiple residential care placements can do better when placed with their families if there is a good package of support. • Care plans and statutory reviews for looked after children placed with their parents should include consideration of the vulnerability of the parent and any risks they pose. • Deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area. This needs to be considered in any re-housing of families and requires both social workers and housing authorities to have arrangements to ensure they have or can obtain sufficient local knowledge to make good judgements. • When practitioners have raised concerns about a child’s safety that are not resolved they should escalate the difference of opinion though their own agency or by using the relevant safeguarding partnership policy. Recommendations D, E and G Theme: Continuity of services, including complexities of cross border working 7.63. Working with children who offend, who may be victims as well as perpetrators and who also have social workers brings with it a lot of complex partnership arrangements. This applied to both children. Both Child O and the practitioners working with him also had to deal with the challenge of cross border arrangements. These meant more people were involved, sometimes with overlapping roles, or a change from someone familiar to someone who was not because Child O had moved to LA1 requiring a change in agency delivering a service. Records show more than one example of Child O feeling there were “too many people” involved in his life. This was exacerbated by agencies’ uncertainty about whether the move to LA1 was going to be more than temporary. This resulted in some duplication or delay in YOS, SEN and police services. 7.64. Whilst there is evidence of strong partnership working with both children there is also evidence of misunderstandings and gaps. Agencies in LA1 were not always clear that the responsibility for the 25 care order lay with LA2 rather than LA1 as it would for most young people living in LA1. Nor were they aware that police in LA2 needed to be consistently kept informed due to the risk that Child O might be drawn back to previous activity with gangs there. The police in LA1 needed to be kept informed regarding any incidents that came to the notice of LA2 police. The communication with and by Child O’s social workers about incidents and changes in plans was not always consistently good. Police officers told this review that, when there was an incident in LA1 requiring notification, although they always tried to communicate directly with Child O’s social worker because of the intensity of the police Problem Solving Team involvement, in practice LA1 police would share information with the local MASH in LA1 (who should contact their counterparts in LA2 so Child O’s social worker was aware). Taken as a whole, police records in LA1 show some confusion as to which local authority was responsible for Child O. This makes the MASH-to-MASH communication important as a safety net. Learning points: continuity of services including complexities of cross border working • The importance of practitioner and agency records being clear which local authority is responsible for a child in care and that arrangements to ensure that information is shared promptly with that local authority are effective. • Where children have moved areas to keep them safe from gangs the importance of reciprocal information sharing between police forces if they are different in the host and home authorities. See recommendation A 7.65. Impact of Covid and any other relevant organisational contexts 7.66. The Covid pandemic is known to have had a huge impact on services and young people. Both children engaged best with practitioners in person, but engagement with practitioners was often limited to phone and video conferencing, which took a while to put into place. Overall service continuity and capacity was reduced due to staff sickness and vulnerability to infection and the need for redeployment to meet service priorities. These things also had a big impact on individual staff; they increased the challenges of what are already demanding roles. 7.67. Child N was not able to re-sit the test for the construction skills card. Nor was he able to get a job or engage with a training agency which closed due to Covid restrictions. He was also not living at home for a while when he would not comply with Covid restrictions because Mother worried this would put a vulnerable family member at risk. Child O found restrictions due to the Covid pandemic on his contact with his mother and younger sibling particularly upsetting. 8. CHILD O’s COMMENTS 8.1. Child O agreed to have a virtual meeting with the author in the company of his current probation officer. When talking about relationships with practitioners, there were a number who Child O felt he had a good relationship with; the YOS workers from both LA1 and LA2, a police officer from LA1 and two of the supported accommodation staff. Characteristics he identified which helped build his confidence in these people included: having a long term relationship with them; their taking time to seek him out; their being friendly and interested in him and his family and in what he was doing; feeling he could chat about anything without being judged; and practitioners being “straight up” (honest) with him. He also appreciated sometimes being brought snacks and drinks. Child O’s top 26 tips for practitioners working with young people would be to “Listen to them, relate to them and put yourself in their position”. Mostly he felt listened to, two occasions where he didn’t were decisions about placements: when being placed in a particular part of LA2 in 2019, and in temporary accommodation in LA1 (circumstances discussed in section 7 above). 8.2. He was pleased to be able to live with his mother and thought it was a good idea to go to LA1 in the family assessment placement where he could have a fresh start and they could get used to living with each other again. The YOS worker and the police officer in LA1 both tried to get him into clubs to do activities and make friends to avoid getting in with the wrong crowds but this was prevented by the Covid pandemic. He felt being placed in temporary accommodation was a big mistake because the area was unsuitable for both him and his mother because they were “surrounded by gangs and drugs”. He confirmed there were times when he felt very unhappy and scared but had found it hard to tell people that because he thought he would be removed a long way away from his family, because this was what had happened when he had previously confided being unsafe. 8.3. In talking about his experiences in education Child O was sorry that he had been out of education for so long after returning to LA2. He wanted to be in a mainstream school as he thought this was more likely to be an environment where he would make more progress with his learning. He would have been enthusiastic about more practical learning opportunities to help him get a job in the construction trade. He was disappointed with the college course offered as it was not what he thought he had signed up to. He had done bricklaying before, and he did not want to do art as he feels he is not artistic. He would have liked to have done more carpentry, to build on what he had learnt at school, and other skills relevant to the construction trade his uncle and grandfather engaged in. 9. POSITIVE PRACTICE 9.1. When undertaking a review, it is important to also consider the kind of positive practice that might have broader applicability to protecting or supporting other children and families. A number of examples have been previously referred to, others are listed below. Protective and supportive actions by practitioners Children’s Social Care asked the GP for information which was provided promptly to social workers and the child protection conferences When Child N was made subject to a Referral Order confirmation of allocation of the YOS worker he knew was prompt. Information Advice and Guidance worker was able to motivate Child N to improve his CV and apply for a number of jobs Addiction services changed provider in 2020. Arrangements were made for Mother to continue her treatment with the same worker Child N attended the child protection conference and acted as scribe School staff attended the police station with him to find out the outcome of his bail Educational provision was provided for Child N to sit his GCSEs YOS police officer assisted Child N to prepare and practice to obtain a Construction Skills Certification Scheme card IAG worker engaged with Child N and helped him complain about unfair treatment at the test centre which was the context for him failing the test the first time. The complaint resulted in him being given a free resit 27 Police officer from the Problem-Solving team knew Child N well and visited his mother to offer support and liaised well with his social worker, including calling in at the office and attending core group meetings LA1 social worker provided support even though Child N was no longer open to her e.g. helping get a birth certificate, which helped with funding support activities The post 16 centre staff built sufficient rapport with Child O that he was able to be honest about his current circumstances and feelings including anxiety and panic attacks Regular liaison by college staff with supported accommodation staff, SW and YOS and Mother Supported accommodation worker was persistent in helping Child O to obtain support when he was feeling low in October 2020 Strong working relationship established between SW5 and police officer from PST who engaged well with Child O CIRV co-ordinator stayed engaged after Child O moved to LA1 Child O’s LA1 YOS officer engaged well with him, and provided him with cooked food and food parcels and liaised well with LA2 YOS Child O has had the same IRO since 2017 The referral to the NRM was made as a matter of routine practice by the local authority and LA1 YOS at an appropriate moment There was a close working relationship between LA1 and LA2 YOS which benefited Child O 10. CONCLUSION 10.1. Several practitioners were persistent and thoughtful in the support they provided to each child. Both children responded particularly well to help that they thought would give them a future in terms of obtaining employment. As well as disrupting some key relationships with practitioners, the actual timing of the Covid pandemic was unfortunate at their age in reducing their opportunities for training and employment. Having said that, even without the pandemic, practitioners told this review that training and work experience opportunities for children who have disengaged from education or who have been excluded from school are limited in LA1. 10.2. It is It is striking that for both children a quick deterioration in behaviour could follow periods of relative stability. Placing Child O with his Mother out of LA1 to protect him from violence from gangs in LA2 was both a last resort due to the lack of any alternative viable placement and a positive move with potential for better outcomes given that he was, initially at least, highly motivated to live with his mother. The deterioration in Mother’s ability to care for him eventually resulted in him living in supported accommodation with a low number of hours of proactive support at a young age. This deterioration and his involvement in further offending behaviour might have been expected after the cessation of the additional support and monitoring provided by the parenting assessment provider. However, the nature of the area where they moved to was a compounding factor which could have been avoided. 10.3. These children barely knew each other. It was tragic for Child N that they met at a time in Child O’s life of significant stress, when, with the benefit of hindsight, it is clear there was a risk of some kind of serious incident but without any practitioners either knowing how precisely that might present itself or about the conflict between the children which led to the murder. 28 11. RECOMMENDATIONS. 11.1. The individual agency reports have made single agency recommendations. Both Safeguarding Partnerships have accepted these and will ensure their implementation is monitored. To address the multi-agency learning, this Child Safeguarding Practice Review identified the following recommendations. A. That each partnership supports the development of arrangements which will result in detailed operational multi-agency, multi-disciplinary risk management pathway for individual children most vulnerable to being involved in violent incidents due to their involvement in gangs. These arrangements should always include children moving areas for their own protection and risk management plans should be reviewed at key points e.g. when children move placements or when incidents indicate increased risk or vulnerability. B. That MK Together Safeguarding Partnership supports the development of more alternative educational and training options for children who have disengaged or been excluded from school. C. That both partnerships reinforce with practitioners the importance of young people having strong and enduring relationships with practitioners and the risk of changes, especially if these are more than one practitioner at the same time. Partnerships should seek assurance from all agencies that they recognise the impact on young people when practitioners changes so that this is avoided where possible and steps taken to mitigate the impact where it is not. D. For children who have moved areas for their own protection. I. that each partnership supports the development of arrangements which will support the nature of the local community being risk assessed for every potential change of address prior to accommodation being confirmed. Such checks are a regulatory requirement for looked after children. II. That MK Together Safeguarding Partnership seeks assurance from Milton Keynes City Council that housing staff are aware of the learning from this review and supported to develop arrangements to ensure such checks are completed for looked after children. E. That Northampton Safeguarding Children Partnership seeks assurance from the Children’s Trust that: I. Work has been done to review the attendance at LAC reviews to ensure that the right people are in attendance II. Work has been done to ensure social workers and IROs understand the respective roles of the SEND service and the Virtual School in securing educational provision and reviewing Education, Health and Care Plans (EHCPs) for looked after children III. That the learning from this review is used to improve the quality of the care planning, monitoring and review for looked after children who are placed with their parents 29 F. That MK Together Safeguarding Partnership supports the development/review of information sharing arrangements to I. provide timely information to the Criminal Justice Liaison and Diversion (CJLD) service about the backgrounds of children they see and II. for Youth Offending Service to receive timely information from CJLD about the children CJLD see G. To improve the availability of placements for children at risk in the community I. That the two Partnerships consider together whether there are any mutually beneficial joint commissioning arrangements that could be made. II. That the two Partnerships jointly draw the attention of the national panel to the learning from this review about the difficulties in finding placements for young people who meet the criteria for secure accommodation and seek their view on whether they can do anything to improve this situation. H. That each Partnership seeks assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them. I. That each Partnership agrees what arrangements will monitor the impact of action arising from addressing these recommendations. |
NC51272 | Death of a 1-year-old boy, Child K, in June 2018. A post mortem revealed injuries including bruises, scratches and a fractured skull. Child K was born 10 weeks prematurely in June 2017; an older sibling was born in October 2016. The family were known to multiple agencies. In December 2017 Care Proceeding were initiated after a paediatric review found Child K had bruising and a suspected broken femur. He was made subject to an interim care order and placed with foster carers. He returned home in February 2018 after the application to court was withdrawn based on contradictory medical evidence. Following Care Proceedings Child K's mother did not co-operate with children's social care, or attend hospital appointments for Child K. Family members expressed concern about mother's parenting including allegations she left him home alone. Evidence of domestic abuse and mother reported to have low mood, financial problems and relationship difficulties. Lessons learned include: the importance of focusing on the child's experience; remembering that a number of minor injuries, including bruising on a baby, may be an indication that the child is at risk of harm; and ensuring family history, background and contextual information is taken into account during the referral process. Sets out findings using the Partnership Learning Review model. Recommendations include: embedding the Early Help assessment process across the local authority; ensuring that staff are regularly reminded about the significance of bruising in non-mobile babies; and all agencies should be confident to question medical opinion provided as part of Care Proceedings.
| Title: Serious case review: Child K. LSCB: Wiltshire Safeguarding Children Board Author: Karen Tudor Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD K Report author: Karen Tudor August 2017 Report author: Karen Tudor August 2017 SERIOUS CASE REVIEW KAREN TUDOR INDEPENDENT REVIEWER FEBRUARY 2019 SCR Child K, Final Report Page 2 CONTENTS Page Number INTRODUCTION Events leading to this Serious Case Review The Process of the Review Method Family Participation in the Review 3 4 4 4 SUMMARY OF KEY EVENTS Child K - Pregnancy and Early Life Recognition of Vulnerability Maternal Ambivalence 6 7 8 9 LEARNING THEME 1 - Early Help, Assessment and Planning 9 LEARNING THEME 2 - The Significance of Bruising in Non-Mobile Babies 12 LEARNING THEME 3 - Child Protection Investigation and Care Proceedings Referral A Cluster of Medical Presentations Challenging Medical Opinion Referral Outcome of the Care Proceedings Impact of the Withdrawal from Court The Value of Multi Agency Assessment 13 14 15 16 17 18 18 20 LEARNING THEME 4 - Domestic Abuse 21 LEARNING THEME 5 - Hidden Men 23 SUMMARY OF LEARNING 26 CONSIDERATIONS FOR THE WSCB 28 SUMMARY 27 SCR Child K, Final Report Page 3 INTRODUCTION Events leading to this Serious Case Review 1. This Serious Case Review concerns a one year old child who died in 2018. At the time of writing the cause of Child K’s death was unknown but the initial post-mortem report had identified injuries including an old skull fracture. To protect his privacy the child is known as Child K. 2. The family were well-known to a number of agencies because Child K had been born prematurely with significant health problems; this meant that following his birth, he spent 10 weeks in hospital before being discharged home. 3. When Child K was six months old he was found to have a number of injuries which led to the initiation of Care Proceedings. The application to the Court was later withdrawn on the basis of contradictory medical evidence and Child K returned home, having spent 8 weeks with foster carers. 4. Following the Care Proceedings, Child K’s mother was unwilling to work with Children’s Social Care who subsequently closed the case; the family continued to receive support from Health Visiting and a local Children’s Centre up until Child K’s death in the summer of 2018. Agencies involved with the Family GPs Midwifery Health Visiting Primary Care Liaison Service (PCLS) – Adult Mental Health Services Hospital Emergency Department Hospital Paediatric Department, Bath and Bristol Hospitals Neo-natal Intensive Care Unit (NICU) and Outreach Service Police Children’s Social Care (Safeguarding Team, Emergency Duty Service, Legal Services, Fostering Team, Contact Workers) Children’s Centre Family Court Conducting a Serious Case Review 5. When abuse or neglect of a child is known or suspected and either the child has died or been seriously harmed and there is cause for concern as to the way in which services have worked together to safeguard the child, the Local Safeguarding Children Board (LSCB) has to consider whether a Serious Case Review should be carried out. SCR Child K, Final Report Page 4 6. The Wiltshire Safeguarding Children Board carried out a Rapid Review1 and decided the criteria were met for a SCR and notification of the decision was made to the National Safeguarding Practice Review Panel2. 7. The purpose of the Review as defined by Working Together (2015) was: • To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; • Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; • As a consequence, improve interagency working and better safeguard and promote the welfare of children.3 The Process of the Review 8. An Independent Reviewer was commissioned and the process overseen by a Serious Case Review Group4, this is a sub-group of the Local Safeguarding Board comprised of senior managers and clinicians none of whom had had direct involvement with the case. This group set out the Terms of Reference and agreed the timeframe for the review; from January 2016 to June 2018. This timeframe covers the pregnancy with Child K’s sibling (born October 2016) to Child K’s death, (June 2018) a period of 20 months. 9. As part of the analysis the Independent Reviewer was asked by the SCR Group to consider the following areas of practice which had been identified by the Rapid Review: • Early Help: what can this case tell us about the Early Help system and the attitude of professionals/agencies to Early Help assessments and integrated working? • Domestic Abuse: what does this case tell us about our ability to understand the impact of domestic abuse and coercive control on parenting and about our response to women as perpetrators of domestic abuse? • How effective are agencies in working with fathers? Method 1 Rapid Review – Safeguarding Boards are required to undertake a rapid review into all serious child safeguarding cases within fifteen working days of becoming aware of the incident. Working Together to Safeguard Children, 2018 2 National Safeguarding Practice Review Panel will be responsible for identifying and reviewing serious child safeguarding cases which the panel believe raise issues and themes that are complex or of national importance. It will look at what could be done differently to improve the protection and welfare of children, and what implications these cases have on current and future policy or practices. 3 Working Together to Safeguard Children, 2015 4See Appendix for a list of SCR Group members SCR Child K, Final Report Page 5 10. The Review must be conducted in line with government guidance, Working Together to Safeguard Children, 2015. In view of the move towards using systemic models and practitioner involvement to promote learning, a model known as a Partnership Learning Review was used. 11. A chronology of events was requested from the agencies who had worked with the family, along with a reflection on their practice in which agencies were encouraged to consider what could be learnt from the case. Two practitioner meetings were held where those who worked with the family came together as a group, to reflect on their practice, to agree who did what and why and contribute to the identification of learning from the case. Consideration was given to the range of factors which can impact on the nature of the work and present barriers to best practice; where relevant, these are reflected in the analysis. 12. The findings are reflected in the Learning Points and Considerations for the Safeguarding Board. Family Participation in the Review 13. At the time of writing the investigation into Child K’s death was still ongoing. The Reviewer was advised not to contact any family members until investigations were complete in order not to compromise any potential legal proceedings. For the purposes of publication events have been summarised and names anonymised. Members of the family are: Child K Subject of the Review Child KS Child K’s sibling Ms KM Child K’s mother Mr KF Child K’s father SCR Child K, Final Report Page 6 SUMMARY OF KEY EVENTS October 2016 Ms KM suffered with pre-eclampsia. Child KS born prematurely and spent 15 days on the neo-natal unit before going home. January 2017 Ms KM is assaulted by a former partner (she later disclosed that this had been an eight-year abusive relationship.) January 2017 Ms KM is pregnant with Child K and requests referral for a termination. April 2017 Ms KM has decided to continue with the pregnancy and books with midwifery. Ms KM is referred to the Primary Clinical Liaison Service (PCLS) for assessment, she is allegedly depressed and has suicidal thoughts. June 2017 Ms KM is prescribed anti-depressant medication. June 2017 7 weeks after booking, Child K is born by C-section, prematurely at 30 weeks and later develops a problem requiring colon surgery. He spends 10 weeks in hospital. (2 hospitals involved.) Ms KM requires post-natal treatment and doesn’t see Child K until he is 4 days old. Staff note concerns about Ms KM’s and Mr KF’s frequency of visiting and lack of telephone contact. September 2017 Child K is discharged home. September 2017 Ms KM is reported to be struggling with financial and housing problems, emotional and relationship difficulties. Comments are made about her lack of attachment to Child K. November 2017 An outreach worker noticed a bruise on Child K’s face. Ms KM provided an explanation which is accepted by the worker and discussed with Health Visiting. The protocol on “bruising in pre-mobile babies” is not followed. Ms KM and Mr KF’s relationship is said to have ended. December 2017 Child K is taken for a routine paediatric review where he is noted to have a sub-conjunctival haemorrhage5, a bruise on his eye-lid and a lesion on the roof of his roof of his mouth. A subsequent skeletal survey reveals a suspected fractured femur. Child Protection Procedures are followed and Care Proceedings initiated, Child K is made subject to an Interim Care Order and placed with foster carers. 5 Sub-conjunctival haemorrhage is a medical condition that happens when the small blood vessels located just beneath the eye ruptures. Although common in adults, this is rare in children and can be a finding after non-accidental trauma. SCR Child K, Final Report Page 7 February 2018 Ms KM’s family members raise concerns about Ms KM’s parenting including concerns about her “bonding” with Child K. They allege she leaves him alone at home. Children’s Social Care visit and Ms KM denies all the allegations saying they are malicious. February 2018 An independent doctor reports to the Court that the x-rays have been misinterpreted and there is no fractured femur. The Judge indicates that the application will no longer reach the threshold for an Order and Children’s Social Care withdraw the application. Child K returns home with a plan for further assessment and continued involvement with Children’s Social Care through the Child in Need process. March 2018 Ms KM will not cooperate with Children’s Social Care or allow them to visit. The planned assessment is completed on this basis and recommends the case is closed and that Health Visiting initiate a CAF as they continue to have a working relationship with Ms KM; however, the Health Visitor reports she is unaware of the plan. March 2018 Ms KM assaults Mr KF and breaks his nose, he is treated in hospital; a family member informs the police who in turn inform Children’s Social Care and Health Visiting. Children’s Social Care Emergency Duty Service make a home visit, confirm the children are unharmed and pass the information on to the allocated social worker. Health Visiting make a visit when Ms KM denies the assault happened and says it is the family making malicious allegations. March 2018 Children’s Social Care seek advice from their legal services, further independent medical opinion is sought on the nature of the alleged fractured femur but the doctor consulted feels unable to shed any further light on a difference of medical opinion. Children’s Social Care close the case. April / May 2018 Health Visiting continue to visit and see Child K, the local Children’s Centre visit and attempt to work with Ms KM but she is reluctant to take up any offers of help. Child K is not being taken to hospital follow–up appointments. June 2018 An ambulance is called to Child K’s home where he was found to be unresponsive. Investigations into the cause of his death are ongoing. SCR Child K, Final Report Page 8 Child K - Pregnancy and Early Life 14. Ms KM had suffered with pre-eclampsia with her first child, Child KS, who had been born prematurely and spent two weeks on the neo-natal unit before being discharged home. When Child KS was five months old Ms KM discovered she was pregnant again. 15. Ms KM approached her GP requesting a termination and was referred to an appropriate service. However, having later decided to have the baby, Ms KM was booked in with the maternity services when she was 23 weeks pregnant. Recognition of Vulnerability 16. During the ante-natal booking it became clear to staff that there were factors in Ms KM’s history and current circumstances which suggested she was vulnerable. These included: Ms KM’s previous obstetric history Her response to being pregnant Her “low mood” (she had been prescribed anti-depressants just before Child K was born) The late booking Relationship problems (she and Mr KF were reported to have ended the relationship) Inadequate housing 17. The maternity team referred Ms KM to the Primary Care Liaison Service 6(PCLS) for a mental health assessment, the assessment recommended Ms KM undertake further work with the IAPT team7; Ms KM did not take up this offer of ongoing work. 18. In view of her vulnerability, maternity services referred Ms KM to their specialist “Lotus Team” however before the team were able to begin any effective work, Child K was born by caesarean section at 30½ weeks. This meant that there were only seven weeks between Ms KM’s booking and Child K’s premature birth, which allowed limited time to get to know the family. 19. Child K was taken to the neo-natal intensive care unit and Ms KM received treatment on the maternity ward. In the post-birth period Child K had a number of health problems associated with his prematurity which led to him being cared for by two paediatric teams at two different hospitals. 6 PCLS, Primary Care Liaison Service a mental health liaison service which provides short-term support service to help people with mental health difficulties. 7 IAPT, The Wiltshire IAPT Service (formerly LIFT Psychology) is a free NHS service which supports people in Wiltshire who are experiencing common mental health difficulties, such as anxiety, depression and stress using CBT techniques. It is a self-referral service. SCR Child K, Final Report Page 9 20. The neo-natal team at the local hospital encouraged Ms KM to visit Child K and to telephone for updates on his progress. They noted it was difficult for her to get to the hospital, she was unable to drive having recently had surgery and had an eight-month-old baby at home. 21. Indications were that Ms KM and Mr KF’s relationship was strained and Ms KM told the hospital Mr KF was not to see Child K. During this Review, it was also reported that Ms KM had told Mr KF that Child K had died, her motivation for this was not known. 22. Also noted was the family’s housing situation, Ms KM, the two children and three dogs were living in a one bed-roomed flat, they also had financial problems exacerbated by Ms KM’s extended period of maternity leave. Maternal Ambivalence 23. The implications of Ms KM’s late booking, feelings about the pregnancy and response to Child K indicate maternal ambivalence described in the triennial analysis of Serious Case Reviews, “Pathways to Harm, Pathways to Protection,”8 It states: “One potential indicator of parental risk identified in this triennial review was a sense, in a few cases, of maternal ambivalence towards her child. This could present as an unwanted pregnancy, or ambivalent feelings about being pregnant; and result in late antenatal booking, or non-engagement with antenatal services. Later presentations included an apparent lack of joy or warmth in relation to their baby.” The report makes the following learning point: 8 Pathways to Harm, Pathways to Protection: a triennial analysis of serious case reviews 2011 to 2014, Final report May 2016, Peter Sidebotham et al LEARNING POINT: • A parent who presents as ambivalent about their pregnancy, or who does not seem to be engaging with parenthood provides an opportunity to explore with that parent, their feelings towards the child and any risks that this might pose. SCR Child K, Final Report Page 10 LEARNING THEME 1 - Early Help, Assessment and Planning 24. Working Together to Safeguard Children 2018 states: “Providing early help is more effective in promoting the welfare of children than reacting later. Early help means providing support as soon as a problem emerges, at any point in a child’s life…” “Where a child and family would benefit from co-ordinated support from more than one organisation or agency (e.g. education, health, housing, police) there should be an inter-agency assessment.” 25. In Wiltshire, the CAF Early Help Assessment provides a framework for working in an integrated and coordinated way at Early Help level. 26. An assessment enables a shared understanding of a family’s needs and strengths to inform an outcome focused plan. The assessment should be evidence based and clear about the action to be taken and services to be provided to prevent needs escalating. Team around the child, known as TAC meetings, should take place to bring together those agencies working to support the child and the family. Within this framework information can be shared and progress towards improved outcomes for the child monitored. 27. Despite the recognition of Ms KM’s multiple needs, none of the professionals working with the family considered initiating a CAF and convening a TAC meeting. Discussions in the Practitioner Event, and from the agencies own reflection on their practice, have identified that this was a lost opportunity. What did Happen and Why 28. There was good communication in the handover between midwifery and Health Visiting and the neo-natal unit provided a follow-up outreach service visiting Child K at home. PCLS had carried out an assessment and Ms K had applied to be re-housed and was expecting to move into a larger property in the near future. 29. For the professionals working with the family, the combination of these actions meant that they considered that everything that could be done for the family was being done; the issues had been identified and services were being provided. Therefore no one in the professional network considered the fact that a coordinated Early Help Assessment was necessary and would provide a framework for integrated working and information sharing. 30. Consideration should have been given to initiating a CAF Early Help Assessment on Child K. The focus of help was on the immediate presenting problems and a CAF would have enabled a more structured assessment of the emerging needs, for professionals to share their thoughts in a more considered way and for a plan to be SCR Child K, Final Report Page 11 put in place which could be reviewed. The assessment may well have helped keep Child K at the centre and at the fore-front of professional’s minds. 31. More thought should have been given at this early stage to the implications of Ms KM’s response to being pregnant, Child K’s premature birth and hospitalisation and the concerns about Ms KM’s visiting frequency. It became clear, as time went on, that Ms KM was signposted to numerous agencies for help and support and although this reassured professionals, Ms KM did not engage with any of the services offered. Had a CAF been in place, the implications of this lack of engagement for the care of Child K might have been considered and better understood by all agencies. 32. Lack of an effective CAF Early Help Assessment has been identified before as an issue for Wiltshire (for example see SCR Baby J, 2016). In 2015 Ofsted carried out a thematic inspection of the effectiveness of Early Help which drew on evidence from 12 local authorities; this demonstrates that there are common challenges for LSCBs in evaluating the effectiveness of Early Help and the quality of Early Help assessments. What Needs to be done 33. The Ofsted report reinforces the message that Early Help can prevent the escalation of difficulties which in turn can lead to a deteriorating family situation and children being more at risk of suffering harm. This is acknowledged and accepted in Wiltshire and there is work taking place within the Families and Children’s Transformation Programme (FACT) to improve Early Help assessment and planning, oversight and quality. 9 However, whilst this work is being progressed key messages about the importance of Early Help assessments, clear outcome focussed planning and regular review should be reinforced. 9 See http://www.wiltshire.gov.uk/children-young-people-fact-overview CONSIDERATIONS FOR THE WSCB • Discussions from the Practitioner Event suggest that the Early Help assessment process in Wiltshire is not yet embedded. If Early Help is to be effective, all agencies will need to be fully engaged with this assessment and integrated framework for working. • Where there are examples of good practice these should be shared as exemplars to assist practitioners in their understanding of the process of Early Help. SCR Child K, Final Report Page 12 LEARNING THEME 2 - The Significance of Bruising in Non-Mobile Babies 34. When Child K had been at home for four weeks the outreach worker noticed a small bruise on his forehead; Ms KM was asked about the bruise and gave the explanation that a toy had been thrown by an older child. This explanation was accepted by the worker. 35. Bruising in babies who are not crawling, cruising or walking (non-mobile) is rare and there is wealth of research about its significance as a potential indicator of child abuse. The NICE guidance “When to Suspect Child Maltreatment”10 states that “bruising in any child not independently mobile should prompt suspicion of maltreatment.” 36. Subsequently most Local Safeguarding Boards in the UK have a multi-agency protocol which defines what action is to be taken if a non-mobile baby or child (for example a non-mobile child with a disability) is found to have a bruise or injury. 37. The reason for adhering to the Bruising and injuries in Non-mobile Babies and Children Protocol is that it prevents any one professional having to assess the bruise and the subsequent risk in isolation. In Wiltshire, the protocol in place at the time of these events “Bruising and Injuries to non-mobile children: actual or suspected injuries or bruising in children who are not independently mobile” stated that: “any bruising, fractures, bleeding and other injuries such as burns should be taken as a matter of enquiry and potential abuse unless otherwise evidenced” and that ... “Any other obvious explanations for the injury or bruising should not automatically be referred but a consultation with the safeguarding advisor should take place and the detail of what has been observed and discussed should be recorded, dated, timed and signed in the child’s individual record held by the agency.” 38. This protocol has since been reviewed and replaced with a new version which begins with a much clearer statement “all bruises or injuries to non-mobile babies or children must be reported by phoning the MASH.” 10NICE guidance Child maltreatment: when to suspect maltreatment in under 18s, Clinical guideline [CG89] Published date: July 2009 Last updated: October 2017. https://www.nice.org.uk/guidance/cg89 SCR Child K, Final Report Page 13 LEARNING THEME 3 - Child Protection Investigation and Care Proceedings 39. In December 2017, two weeks before Christmas, Child K was taken for a routine paediatric appointment where the examining doctor noticed three unusual presentations, a bruise to the eye-lid, a sub-conjunctival haemorrhage and a lesion on the roof of Child K’s mouth. A skeletal survey was carried out and the results were reviewed by two radiologists who concluded Child K had an avulsion fracture in the right femoral area. 11 This type of injury is highly indicative of non-accidental injury. 40. A strategy meeting was convened promptly and Section 4712 enquiries began. Child K was placed with foster carers, an application was made to the Family Court and an Interim Care Order (ICO) was granted. Supervised contact was arranged for Child K’s parents. A Looked after Child (LAC) Review was held within accepted timescales. 11 Avulsion fractures are caused by trauma. They usually happen when a bone is moving one way, and a tendon or ligament is suddenly pulled the opposite way. As the bone fractures, the tendon or ligament that attaches to part of the bone pulls this bone fragment away from the rest of the bone. 12 Section 47 Child Protection Enquiries: Section 47 of the Children Act 1989 places a duty on local authorities to investigate and make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and, where these inquiries indicate the need, to decide what to do. LEARNING POINT: • Although most practitioners are familiar with the injury and bruising protocol, human factors, for example a tendency to want to believe parents, can distract staff. Adhering to the protocol ensures focus on the child is not lost and ensures the incident is properly assessed, recorded and forms part of the chronology of events. CONSIDERATIONS FOR THE WSCB • The updated Bruising and Injury in Non-mobile Babies and Children Protocol is clearer about what action must be taken if a pre-mobile baby has a bruise or injury; however, this case demonstrates that human factors can distract staff. Exploration of these factors with staff will help ensure compliance and all agencies need regular reminding about the importance of following the protocol. SCR Child K, Final Report Page 14 41. In line with usual court procedures, a Children’s Guardian was appointed who met Child K and his parents, observed some contact and made a home visit. Children’s Social Care prepared a report for the court. A Cluster of Medical Presentations 42. Studies about child deaths from non-accidental injuries show that these children often have a history of minor injuries prior to a very serious injury or death. Known as sentinel events or sentinel injuries, in one study these injuries were present in 25% of children subsequently diagnosed as abused.13 43. Injuries in babies and infants who are not crawling, cruising or walking (non-mobile) are rare and there is a wealth of research about their significance as potential indicators of child abuse. For example, the NICE guideline ‘When to Suspect Child Maltreatment’14 uses the terms “injuries and presentations” and prompts health practitioners to consider the possibility of maltreatment in forming a diagnosis, or as part of differential diagnosis.15 44. For Child K there were three unusual presentations, one of which was a sub-conjunctival haemorrhage. These are caused when blood vessels on the surface of the eye are broken and whilst common in adults, are rare in babies. If there is no obvious explanation for sub-conjunctival haemorrhages in babies, for example whooping cough, they are an indicator of possible child abuse. 45. An example from the literature states: “sub-conjunctival haemorrhages in infants and children can be a finding after non-accidental trauma. We describe 14 children with sub-conjunctival haemorrhages on physical examination who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, sub-conjunctival haemorrhage may be related to abuse. Non-accidental trauma should be on the differential diagnosis of sub-conjunctival haemorrhage in children, and consultation with a child abuse paediatrics specialist should be considered.”16 46. For this reason, hospital safeguarding protocols often list sub-conjunctival haemorrhage as a “red flag” presentation which should be referred to the safeguarding team. 47. The presentations were discussed with Child K’s mother who could not offer any explanation and Child K was then seen by different paediatric consultants, each with 13 Sheets LK et al paediatrics 2013:131(4) 14 See: http://guidance.nice.org.uk/CG89 15 A differential diagnosis is considering which of several possibilities might be producing the symptoms 16 Sub-conjunctival Haemorrhages in Infants and Children: A Sign of Non accidental Trauma, Paediatric emergency care 29(2):222-6 · February 2013, Catherine A Deridder et al SCR Child K, Final Report Page 15 specialist knowledge of the specific injury. The report written following the examination concluded that: “the combination of an unexplained bruise, a sub-conjunctival haemorrhage, mouth lesion and unexplained fracture is highly suspicious of non-accidental injury.”17 48. A Case Management Hearing (CMH) was held at the Court six weeks after the ICO had been granted, during the hearing the Judge drew attention to a perceived lack of clarity about the alleged fractured femur. The Court ordered that further evidence was required about the nature of the fracture and an independent expert radiologist was instructed to review the x-rays. This radiologist reported that, in his opinion, there had been “no metaphyseal fracture of (Child K’s) femur...” 49. Following the radiologist report, Children’s Social Care had to consider whether, in the absence of a fracture, they had sufficient evidence of harm to meet the threshold for Care Proceedings. Children’s Social Care took advice from their legal team and withdrew the application. 18 The other unusual presentations, the cluster of injuries, were not considered sufficient to meet the threshold for Care Proceedings. 50. Children’s Social Care in their written report for this Review say that “the collective medical view at this time became that Child K’s cluster of injuries were not of significant concern.” 51. Enquiries conducted during this Review have not been able to ascertain how injuries considered by doctors to be “highly suspicious of non-accidental injury” became “not of significant concern.” 52. It seems likely that the focus of the Court became the fractured femur and the need to seek further medical opinion and consideration of the other issues was overlooked. It is also possible that the language used by professionals has different meanings for different agencies, for example a presentation which is “not of concern” to a doctor may have a different meaning for a social worker. Challenging Medical Opinion 53. It is very difficult for non-medical professionals to question or challenge medical opinion whether it is definitive, as in this case, or in other cases, when it fails to reach a conclusion. Neither Children’s Social Care nor Cafcass formally questioned the difference of opinion between the radiologists about the nature of the alleged fracture or discussed the significance of the cluster of presentations. 17 From Report of Community Paediatrician, Dec 2018 18 Threshold criteria as defined by section 31 of the Children Act 1989 are the facts that a local authority have to prove if they want the court to make an order. If the facts are not found, the threshold is not met and the Judge cannot make any public law orders, then the Care Proceedings will come to an end. SCR Child K, Final Report Page 16 54. Children’s Social Care did try to obtain another medical opinion about the potential fracture but the doctor was not able to comment beyond the fact that there had been a difference of opinion about the diagnosis. 55. Previous SCRs have commented on the hierarchy of evidence, demonstrating that in the professional hierarchy, doctors are more likely to be believed than other professionals and their diagnosis can significantly influence the nature and outcome of an investigation. There are a number of reasons for this, for example different professional understanding about the nature of “evidence,” the natural human optimism in wanting to believe the best of people and the difficulties of achieving medical representation in multi-agency meetings.19 56. In this case, despite the general understanding among all professionals of significant injuries in babies and the added implications of there being a cluster of injuries, there was no challenge to the medical opinion on the fracture diagnosis or other presentations. Because of the difficulties in questioning medical opinion, some LSCBs have developed guidelines for staff. 20 19 Scie have produced a fact sheet, Practice issues from Serious Case Reviews Confusion about interpretation of medical information on cause of injury. 20 See for example Wakefield LSCB, Guidance on Challenging Medical Opinion in Section 47 Cases LEARNING POINTS: • The presence of a number of apparently minor injuries to a baby can be considered sentinel injuries and may be an indication that the child is at risk of harm. • Medical evidence is a crucial part of risk assessment, it is important that other agencies are clear about the meaning and significance of medical evidence and seek clarification when necessary. • Ensuring health staff are aware of the family history, background and contextual information may influence the medical opinion provided. • Focussing on the child’s experience, particularly when there are a number of unusual presentations, can help practitioners frame questions and encourage discussion between all the agencies which contribute to assessment of risk. • Practitioners should be aware of the role of the Named Professionals and the support and advice they can give in Child Protection cases. SCR Child K, Final Report Page 17 Referral 57. Towards the end of the Care Proceedings, Children’s Social Care received information, from members of Ms KM’s extended family which reported that that Ms KM: “had not bonded with Child K, had expressed the view that she “hates” Child K and wished he had died instead of the family dog, that she leaves Child K alone and uses cannabis and has fluctuating moods and aggression.” 58. Children’s Social Care and the Child’s Guardian interviewed Ms KM together and she denied all the allegations suggesting the intention was malicious. The referrer was interviewed and as there was no evidence, no further action was taken. Mr KF was not spoken to; the tendency to overlook the role and responsibilities of fathers is discussed later in this report. LEARNING POINTS: • In order to form a view about the significance of referral information it is essential that it is considered within the family context, the chronology of events and what is already known; if referral information cannot be substantiated this doesn’t mean it’s not true and the significance of the information may need to be reviewed again in future assessments. • Child K’s early history suggested that there were indicators of potential attachment difficulties. Practitioners should be alert to the significance of parental attachment and include their observations in assessments. CONSIDERATIONS FOR THE WSCB • The Safeguarding Board should satisfy itself that all agencies are confident to question medical opinion which is provided as part of Section 47 enquiries in a helpful and professional manner and that medical practitioners are open to challenge. SCR Child K, Final Report Page 18 Outcome of the Care Proceedings 59. At the end of February 2018, when the application to court was withdrawn, Child K returned home; he was aged 8 months and been living with foster carers for 11 weeks. 60. The Children’s Guardian did not challenge the decision to withdraw but made it clear that, in her view, Children’s Social Care should remain involved with the family “to offer support and monitor the situation.” A plan was draw up with Ms KM which stated that a parenting assessment would be completed and that Children’s Social Care would remain involved with the family, working within the Child in Need Framework21. 61. Once Child K was at home, Ms KM indicated that she had been extremely upset by recent events and despite numerous attempts by the social worker to arrange a visit, she would not agree to any ongoing work. 62. In view of the difficulty engaging Ms KM, Children’s Social Care decided that the best way forward in the circumstances was to withdraw and to ask the Health Visitor, who was described as having a good relationship with Ms KM, to start a CAF; this would still enable multi-agency assessment, a plan and reviews to be put into place. However, this decision was not communicated clearly to the Health Visitor and the CAF never got started; the Health Visitor was surprised to find Child K at home when she visited. Impact of the Withdrawal from Court 63. The withdrawal of the application to the Court had a significant impact on the future direction of work. 64. The decision to withdraw the application was primarily based on the medical opinion and Children’s Social Care’s assessment of the family, which had not identified any risk of harm to Child K other than the risk of injury. The “Analysis of the Evidence of Parenting Capacity” in the report to the Court emphasises that the family were not known to Children’s Social Care prior to these events and states that: “the issue of parenting capacity in relation to the safety (of Child K) pertains solely to the parents inability to provide an explanation for significant injuries...” 21 Child in Need Framework - Section 17 of the Children Act 1989 states that it is the general duty of every local authority to safeguard and promote the welfare of children within their area who are in need; and so far as it is consistent with that duty, to promote the upbringing of such children by their families. Working with Children’s Social Care within this framework is entirely voluntary for families. SCR Child K, Final Report Page 19 65. Once the risk of injury had been dismissed, Children’s Social Care considered they had no basis for statutory involvement and therefore no choice except to withdraw the application. Impact on the Workers 66. Withdrawal of the application to the Court had a significant impact on the confidence of the social workers who reported that they were left feeling they had “got it wrong.” This lack of confidence in the process was compounded by Ms KM’s angry response, in particular that she had been denied spending Christmas with Child K. The workers became distracted by their sympathy for Ms KM and the focus on Child K was lost. 67. When Ms KM refused to work with Children’s Social Care they felt they had run out of options; on reflection, they have concluded that the decision to step-down the case from the highest level of intervention, removal of a child and court proceedings, to working through the to the lowest level, the CAF process, should have been scrutinised by managers more robustly. 68. Even though Children’s Social Care did not “get it wrong”, the Section 47 investigations, the application to the court and the protection of Child K were all carried out properly and efficiently, the focus on process, the difficulties in engaging Ms KM in ongoing work and the reluctance to cause Ms KM any further distress deflected from consideration of Child K and his needs and experience. 69. Although Children’s Social Care completed the planned assessment there was insufficient thought about the impact of the events on Child K, his return home after yet another period of separation from his family and what this might mean for him.22 70. As a result of this case, procedures have been changed so any decision to withdraw from Care Proceedings must be agreed by the Head of Service and a meeting held to discuss any case closed as a result of parental non-engagement. 22 Since this case, for Children’s Social Care reflective supervision has changed and the pro-forma for safeguarding supervisors now includes risk and impact analysis as standard headings. SCR Child K, Final Report Page 20 The Value of Multi Agency Assessment 71. A Strategy Meeting or multi–agency discussion at the point of withdrawal of the Care Proceedings would have enabled practitioners to come together to discuss Child K and whether there was a need for further protective action, despite the lack of medical evidence to support the threshold for care proceedings. This would have enabled further discussion about the medical presentations and to consider the implications for Child K if his mother could not be engaged in further work. Although it is common practice for Children’s Social Care to take the lead in preparing evidence for court, this does not preclude other agencies from remaining involved in risk assessment and intervention or providing information to the court. 72. When Child K was placed in foster care a LAC Review was held however, there was a misunderstanding among the practitioners at the Practitioner Event that in order to hold an Initial Child Protection Conference (ICPC) there must be an indication of “ongoing risk” to the child. As Child K was looked after and there was no “ongoing risk” there was no Child Protection Conference; this view does not accurately reflect the procedures which are more permissive and indicate that a decision should be reached and the reasons for not holding an ICPC recorded. 73. The local Child Protection Procedures state: “Children who are already looked after will not usually be the subject of Child Protection Conferences, though they may be the subject of a s47 enquiry. The circumstances in which a child who is looked after may be considered for a Child Protection Conference or may be subject to a Child Protection Plan can vary...” 74. Also, when a child who has been subject to a Care Order returns home, the procedures state that: “the members of the LAC Review must decide and record whether an Initial Child Protection Conference should be convened prior to the change. If it is proposed that a child subject to a care order should be returned to their birth family / returned home, the members of the statutory looked after child case review must decide and record whether an initial child protection conference should be convened prior to the change. ..” LEARNING POINTS: • Withdrawal of Care Proceedings is a rare and unusual event and supervision should address the feelings of practitioners in all agencies and how these might impact on their judgement and the risk of over-identifying with parents. • Reflective supervision, reviewing the case, looking at the events holistically the background and impact of the separation and asking questions such as “what do we know about this baby, about his relationship with his parents?” and specifically addressing the question “how concerned are we about the risk of harm” would bring the focus back to the child. SCR Child K, Final Report Page 21 This discussion would be initiated by the Independent Reviewing Officer. (IRO) 75. None of the practitioners involved with this case were aware of expected practice and the assumption made by agencies at the time was, that the Child Protection Process had been exhausted and there was nothing to be gained by going down that route again. 76. Even if, after careful consideration, the decision had been taken not to hold a Strategy discussion or ICPC, a professionals meeting would have provided an opportunity to re-assess the family situation and discuss the risk assessment and make a plan. This would have avoided the pitfall of others in the professional network being unaware of Child K’s return home, enabled reflection on events and to take a step back from feeling sympathy for Ms KM and focus on Child K’s experience. LEARNING POINTS: • Child Protection Conferences and Child Protection Plans exist to manage risk to children placed at home with their parents/carers. Care Proceedings are initiated when that risk cannot be managed safely enough. When Care Proceedings are withdrawn it is essential to consider risk in a multi-agency forum. • It is unhelpful to decide whether to initiate a Strategy Discussion and the Child Protection process based on an assumption of the outcome. This risks the process becoming more important than the purpose of the meetings and an opportunity for a multi- agency discussion being lost. • The IRO plays an important part in ensuring plans for children are independently scrutinised, this is particularly important when there is a sudden and unplanned change. CONSIDERATIONS FOR THE WSCB • The WSCB should reassure itself that all agencies are aware that anyone of them may request a Strategy Meeting if they have concerns about a child. • None of the staff at the Practitioner Event were aware of the role and responsibilities of the IRO and members of the LAC meeting defined in the procedures and to be followed when a child returns home. This guidance needs to be shared and embedded in practice. SCR Child K, Final Report Page 22 LEARNING THEME 4 - Domestic Abuse 77. There was another opportunity for a Strategy Discussion, consideration of Section 47 enquiries and the possibility of a Child Protection Conference when, two weeks after Child K returned home from foster care, there was a domestic incident; Ms KM punched Mr KF and broke his nose, the injury required hospital treatment. 78. The assault, which was reported to the police by a family member, led to the police informing Children’s Social Care and a home visit being carried out by the Emergency Duty Service (EDS). Child K was observed by the workers during the visit, who noted there were “no concerns about his presentation,” they told Ms KM they would pass on the details of the incident to her allocated social worker. 79. At this time, the allocated social worker was still attempting to persuade Ms KM to cooperate with the plan for the assessment agreed after the Care Proceedings, but without success. 80. Two days after the domestic assault the Health Visitor made a previously arranged home visit during which Ms KM implied it had not happened and that the report was made with malicious intent. 81. Health Visiting and Children’s Social care were aware that Ms KM had been the victim of domestic abuse in a long-standing previous relationship and allegedly in her current on/off relationship with Child K’s father. Despite this history there is little evidence that the impact of Ms KM’s experience on her parenting capacity was fully considered and whether, for example, it impacted on her relationship with Child K; for example, there is no evidence that the circumstances of the pregnancy Child K’s birth were ever explored with her. Ms KM was signposted to a local domestic abuse service but she didn’t take up this option. 82. The police completed a report known as a PPD1 which is used to inform other agencies of the incident and this was sent to Children’s Social Care. The PPD1 assessed the risk as “standard,” a significant mitigating factor being that the couple were no longer living together, this was despite the fact that the assault had occurred after they had allegedly separated. The police did attempt to contact Mr KF but he “didn’t answer his phone” and this was not pursued as the risk wasn’t seen as serious enough to warrant follow up. 83. Shortly after this incident Children’s Social Care assessment was completed and signed off by a manager and the case closed. 84. In summary, the reasons the assault did not lead to a strategy discussion included: • The initial visit was made out of hours and Ms KM would not engage in discussion with the EDS; • The incident was not followed up by Children’s Social Care because Ms KM would not see the social worker; SCR Child K, Final Report Page 23 • Mr KF was not spoken to about the incident; • Children’s Social Care assessment did not consider the implications of Ms KM’s history of domestic abuse or the context of the assault which took place shortly after Care Proceedings. 85. Also, during the Review practitioners reflected on the question of whether the response to the domestic assault would have been different if it had been Mr KF who had assaulted Ms KM and whether gender issues influenced risk assessment. The conclusion was that it is probable that gender was a factor, and that practitioners were unclear whether Ms KM was a victim or perpetrator of violence. 86. The intention was, that following Children’s Services closing the case, a CAF would be led by the Health Visitor but the Health Visitor was not aware of this. LEARNING THEME 5 - Hidden Men 87. Mr KF was not spoken to about the domestic assault and throughout this case there is little information, from all the agencies involved with the family, about Mr KF, his relationship with Child K and his role in Child K’s care. 88. During the practitioner event, participants suggested that there are some barriers which make engaging with men harder, for example visits routinely made between 9 and 5 when fathers might be at work and computer recording systems which don’t include space for information about fathers. LEARNING POINTS: • It is still less common for a recognised perpetrator of domestic abuse to be female however it is important to remember that living with domestic abuse is always harmful to children; it is acknowledged as a form of child maltreatment regardless of the gender of the perpetrator. • When new information comes to light, for example domestic abuse, the significance of the event should be considered in the light of what is already known about the family, the background and the chronology. • When assessments are signed off by managers, and particularly when a case is to be stepped-down or closed, there needs to be a level of scrutiny which reassures practitioners that their analysis is comprehensive, evidence based and retains a focus on the child. SCR Child K, Final Report Page 24 89. Lack of engagement with fathers or significant men is a common theme in Serious Case Reviews, in 2015 the NSPCC published a report called Hidden Men which states: “Men play a very important role in children’s lives and have a great influence on the children they care for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers / female carers.” 23 90. Although there may be some practical challenges, in this case there appeared to be a general lack of curiosity about Mr KF, the parent’s relationship and especially what this meant for Child K, for example reports refer to “the parents’ care” even when they were no longer together. 23 Hidden Men: Learning from Serious Case Reviews, NSPCC 2015, updated 2018 LEARNING POINTS: • Practitioners from all agencies should always consider including in reports and assessments clear and discreet information about fathers or significant male figures. • Recording should include: o the nature of parental relationships; o the relationship with the child; o the part men play in the care of the child; o any observations about parenting capacity. SCR Child K, Final Report Page 25 SUMMARY 91. Child K was a year old when he died in the summer of 2018. Although, at the time of writing, the cause of his death was not known and may never be clear, he was found to have a number of injuries including bruises, scratches and a fractured skull. 92. Looking back, Child K spent almost half of his life living apart from family, either in hospital or with foster carers, and it is likely that this influenced the nature of his relationships. After his death, it also became known that he had been left alone on the day of his death, for a number of hours, on a particularly hot day. 93. However, this was not the whole story of Child K’s life, and to some of the practitioners who knew him, his death came as a huge shock. One worker, who saw Child K shortly before his death, described him as sitting on the floor, playing happily with his mother, looking well. They discussed how well Child K was doing despite his difficult start, and were looking forward to watching him develop in the future. 94. For the practitioners, this highlighted just how challenging it can be to see beyond first impressions and to keep an open mind, to work together and value different professional perspectives, to continually assess, analyse and make sense of complex information. It is vital not to become distracted by procedures and processes and keep the focus on the child at all times. SCR Child K, Final Report Page 26 SUMMARY OF LEARNING a. A parent who presents as ambivalent about their pregnancy, or who does not seem to be engaging with parenthood provides an opportunity to explore with that parent, their feelings towards the child and any risks that this might pose. b. Although most practitioners are familiar with the bruising protocol, human factors, for example a tendency to want to believe parents, can distract staff. Adhering to the protocol ensures focus on the child is not lost and ensures the incident is properly assessed, recorded and forms part of the chronology of events. c. The presence of a number of apparently minor injuries to a baby can be considered sentinel injuries and may be an indication that the child is at risk of harm. d. Medical evidence is a crucial part of risk assessment, it is important that other agencies are clear about the meaning and significance of medical evidence and seek clarification when necessary. e. Ensuring health staff are aware of the family history, background and contextual information may influence the medical opinion provided. f. Focussing on the child’s experience, particularly when there are a number of unusual presentations, can help practitioners frame questions and encourage discussion between all the agencies which contribute to assessment of risk. g. Practitioners should be aware of the role of the Named Professionals and the support and advice they can give in Child Protection cases. h. By the conclusion of this Review ongoing investigations had found that at least some of the referral information was true and Child K was left alone. Child K’s early history also suggested that there were indicators of potential attachment difficulties. i. In order to form a view about the significance of referral information it is essential that it is considered within the family context, the chronology of events and what is already known; if referral information cannot be substantiated this doesn’t mean it’s not true and the significance of the information may need to be reviewed again in future assessments. j. Withdrawal of Care Proceedings is a rare and unusual event and supervision should address the feelings of practitioners in all agencies and how these might impact on their judgement and the risk of over-identifying with parents. k. Reflective supervision, reviewing the case, looking at the events holistically the background and impact of the separation and asking questions such as “what do SCR Child K, Final Report Page 27 we know about this baby, about his relationship with his parents?” and specifically addressing the question “how concerned are we about the risk of harm” would bring the focus back to the child. l. It is unhelpful to decide whether to initiate a Strategy Discussion and the Child Protection process based on an assumption of the outcome. This risks the process becoming more important than the purpose of the meetings and an opportunity for a multi- agency discussion being lost. m. The IRO pays an important part in ensuring plans for children are independently scrutinised, this is particularly important when there is a sudden and unplanned change. n. It is still less common for a recognised perpetrator of domestic abuse to be female however it is important to remember that living with domestic abuse is always harmful to children; it is acknowledged as a form of child maltreatment regardless of the gender of the perpetrator. o. When new information comes to light, for example domestic abuse, the significance of the event should be considered in the light of what is already known about the family, the background and the chronology. p. When assessments are signed off by managers, and particularly when a case is to be stepped-down or closed, there needs to be a level of scrutiny which reassures practitioners that their analysis is comprehensive, evidence based and retains a focus on the child. q. Practitioners from all agencies should consider including in reports and assessments clear and discreet information about fathers or significant male figures. r. Recording should include: o the nature of parental relationships; o the father’s relationship with the child; o the part the father plays in the care of the child; o observations about parenting capacity. SCR Child K, Final Report Page 28 CONSIDERATIONS FOR THE WSCB • Discussions from the Practitioner Event suggest that the Early Help assessment process in Wiltshire is not yet embedded. If Early Help is to be effective, all agencies will need to be fully engaged with this assessment and integrated framework for working. • Where there are examples of good practice these should be shared as exemplars to assist practitioners in their understanding of the process of Early Help. • The updated Bruising and Injury in Non-mobile Babies and Children Protocol is clearer about what action must be taken if a pre-mobile baby has a bruise or injury; however, this case demonstrates that human factors can distract staff. Exploration of these factors with staff will help ensure compliance and all agencies need regular reminding about the importance of following the protocol. • The Safeguarding Board should satisfy itself that all agencies are confident to question medical opinion which is provided as part of Section 47 enquiries in a helpful and professional manner and that medical practitioners are open to challenge. • Safeguarding Board should reassure itself that all agencies are aware that anyone of them may request a Strategy Meeting if they have concerns about a child. • None of the staff at the Practitioner Event were aware of the role and responsibilities of the IRO and members of the LAC meeting defined in the procedures and to be followed when a child returns home. This guidance needs to be shared and embedded in practice. SCR Child K, Final Report Page 29 APPENDIX MEMBERS OF THE SCR REVIEW GROUP Wiltshire CCG Designated Doctor, Chair Wiltshire Council, Children’s Services Head of Support and Safeguarding Wiltshire Police Public Protection Strategic Manager Wiltshire Council, Children’s Services Head of Service Quality Assurance and Principal Social Worker Wiltshire CCG Designated Nurse, Safeguarding Children Wiltshire Safeguarding Children Board Quality Assurance Lead |
NC52458 | Thematic review based on the rapid reviews for three young infants who were born in Suffolk in 2021. Two infants died and one infant was injured whilst in the care of their parents. Learning is embedded in the recommendations. Recommendations include: raise the profile of safer sleeping and associated risks across partner agencies including support to increase knowledge of this area for social workers; embed recognition that house moves and temporary living arrangements are seen as situational risks for babies which need proactive plans that recognise and addresses before babies are born; closer working together between social care and health services in pre-birth assessment and child in need processes; increase recognition of the importance of the health visitor's role; parents own life experiences are explored in depth and understood; fathers are central and must be included whether they are living with the family or not; understanding and use of family network in pre-birth assessments, parents may highlight family as support; professionals need to explore and be respectfully challenging; supervision is used effectively to explore risk and hypothesis, ensuring that information has been verified or explored; pre-birth assessment to remain open until after the baby is born and there has been time for stress testing of plans and support; hospital discharge planning meetings to be considered for child in need cases as part of the plan for younger parents, and parents with other vulnerabilities including where there are several addresses and uncertainties; recognition of the power imbalance between agencies and parents, relationship based case work that starts with this awareness is essential.
| Title: Thematic review for L, M and N: report. LSCB: Suffolk Safeguarding Partnership Author: Maureen Roscoe-Goulson Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This report is the property of Suffolk Safeguarding Partnership. Thematic Review for L, M and N Report Maureen Roscoe-Goulson 31st October 2022 Page 3 of 32 Contents ➢ Introduction and scope of review ➢ Areas of exploration ➢ Methodology for the review ➢ Background and lived experience of the children and their families ➢ Analysis of agencies involvement and actions ➢ Professionals’ perspectives and reflections ➢ Parents perspectives and reflections ➢ Key findings, practice points and recommendations/action plan ➢ Research evidence ➢ References. Page 4 of 32 Introduction and scope of the thematic review This report focusses on three children who were born to three families in Suffolk in 2021 and the children are named for the purpose of this report as L, M and N. The timeline for this review includes the life of the babies to their date of death or injury. L, a baby girl, died at 12 weeks old on 18th December 2021 and N, a baby boy, died at 11 weeks old on 28th November 2021; both died in their respective parent’s care. Baby M sustained a fractured arm at 6 weeks old on 9th December 2021 whilst also in the care of his parents and is now in Local Authority (LA) foster care. All three babies were subject to Pre-Birth Assessments and had been open to Social Care under Child in Need processes. At the time of death, baby Ls case had recently closed to Social Care, baby M and N were open cases with plans for closure. In line with the National Safeguarding Panel procedures, the Suffolk Safeguarding Partnership notified the National Panel. Following completion of rapid reviews for all three children it was agreed that the children’s cases required a Partnership Review and therefore L, M, and N were joined as a thematic review using the key lines of enquiry set out below. Agreed areas of exploration. ➢ A pen picture of the three babies concerned and a summary of their lives in order that we can understand their lived experiences. ➢ An analysis of the common and individual factors in their lives including the impact of domestic abuse, mental health issues, and alcohol and substance misuse on parenting capacities. ➢ Systems findings in relation to the local child safeguarding system regarding the three babies which includes missed opportunities by agencies and the impact of non-engagement, and the work undertaken by Public Health and others regarding overlay and co-sleeping. ➢ An analysis of the pre and post birth assessments undertaken for all three babies. Was the application of the Pre-Birth Assessments applied? What assessments took place and consideration for assessments and what advice was given professionally in supervisions/reflections? ➢ Exploration of the care leaver status of Baby L and Baby N’s parents and how this affected how they were perceived as parents by professionals. Did this detract from the need to ensure there was a clear focus on the needs of the child? How did their experiences as care leavers affect their parenting capacity? ➢ What effective help and support were parents given for their parenting capacity to improve? ➢ A literature review of babies and children under one who have died because of sudden infant death, looking at the National Panel research, local reviews, and any other relevant research. How are these issues considered as standard as part of Pre-Birth Assessments stages? Page 5 of 32 Methodology Professionals took part in one-to-one virtual meetings with the reviewer, with the option of a colleague to support them if required. In total, 31 meetings took place involving Social Care, Health, Youth Justice, the Safeguarding and Reviewing Service, and Norfolk Social Care Services. Consultation took place with Suffolk Police. Parents were invited to take part and offered face to face or telephone meetings. For baby L and N, the home visits were supported by the linked Child Death Nurses working with each family. For baby M, an office visit was undertaken alongside the Suffolk Safeguarding Partnership Acting Board Manager. The reviewer had full access to the rapid review documents compiled by the involved agencies, Social Care electronic records and reports, as well as support from Health professionals who accessed the relevant electronic records for the families. Lived experience of the children and their families A pen picture of the three babies concerned, and a summary of their lives in order that we can understand their lived experiences. Baby L was born in Bury St Edmunds in September 2021 and was a full-term healthy baby girl with lots of hair and blue eyes. She was the second child born to her parents Miss W and Mr B and had an older sister, R, who was 12 months at the time of L being born. After birth L was discharged with her mother to the family home in Bury St Edmunds, which was a new property and provided Miss W with her own home with her two children. Prior to this Miss W and R had been living at Coupals Court, a supported mother and baby accommodation in Haverhill, for about a year and they moved when the new property became available before L was born. Ls parents had been in an unsettled relationship during their time together. They met in 2019 when Miss W was living in the YMCA in Bury St Edmunds having been placed there by the Local Authority when she returned to Suffolk from Northampton after a reported incident of sexual violence towards her by a boyfriend at the time. Consequently, she no longer felt safe and returned to Suffolk. Following this, there were several different addresses where Miss W lived a somewhat transient lifestyle until being supported by the Local Authority to move to Coupals Court after it became known she was pregnant with R. Mr B was living with a friend of Miss Ws locally in Bury St Edmunds when they met. This is understood to have been Miss W first serious relationship and she was believed to have been influenced by what Mr B said during this time. A ‘Claires Law’ disclosure was completed with Miss W in 2020 in relation to the concerns regarding domestic abuse pertaining to Mr. B. However, Miss W believed Mr B when he stated the information was untrue and then continued the relationship. Mr B is understood to have physically assaulted Miss W which led her to end the relationship stating she now believed the information that had been disclosed. They were not living together or a couple when L was born. Mr B was serving a prison sentence at the time of his daughter’s death for an unrelated matter and was told of the death by the prison chaplain which he described as an experience no one wants to have in prison. Page 6 of 32 Miss W had reported that although both pregnancies were a surprise to her, welcomed them and wanted to give her children the best she could. Miss W had experienced a difficult and at times painful childhood and did not want this for her children. She said she wanted it to be different. Miss W had entered Local Authority care in Suffolk under s20 in 2012 aged 12 following a disclosure of physical abuse from her father. Section 47 enquiries determined the concerns were substantiated for her and her siblings. Social Care undertook work with the family, but Miss W’s mother wished for her husband (the children’s father) to return home and asked for her children to be taken into LA care so that they could live as a couple. Miss W’s father died in 2017 in a road accident, and she found it difficult to come to terms with his sudden death and experienced depression. Her own mother had remarried, her current husband had children of his own and they lived as one family. This has been a significant event in Miss Ws life who felt this as a further rejection. Miss W’s siblings also experienced difficult childhoods in the care of their parents. Miss W brother now an adult, continues to have Local Authority involvement through the Leaving Care service in Suffolk and has difficulties resulting in a chaotic lifestyle, including homelessness, drug, and alcohol misuse. Miss W half sibling has Local Authority involvement in respect of her own children in Norfolk. Miss W has a diagnosis of ADHD from 2008 which is not medicated and had a statement of educational needs when at school due to her diagnosis of dyslexia. Miss W reported that she used to self-harm, including scratching and cutting herself. As a teenager in care, she experienced periods of low mood and was known to mental health services. Her last known overdose was December 2019 and took place when living in Bury St Edmunds where Miss W advised another resident was sharing drugs and she took some but did not mean to overdose (a previous overdose took place in Northampton in 2019). Miss W used cannabis and alcohol regularly but stated during assessment this had ceased when she knew she was pregnant with R. Miss W attributes these difficulties to being a child in care and feels that since becoming a mother she has put these behind her. Professionals overall agreed that Miss W had made positive strides and was caring well for both children with the home conditions at times being noted as outstanding. Mr B is not known to have had any Social Care involvement as a child growing up and with his father in the Army moved several times as a family. He reports that his home life was positive, and he cannot recall any anger or violence at home. He feels that he has taken the path he has due to his own actions and not because of anything that he experienced. Mr B has a history with the Police and Courts and served prison sentences, the most recent one for driving offences. Mr B acknowledges he was not involved in Ls care but was with R, being present at her birth and spending time with her and Miss W in the first four months of Rs life. He reports things changed when the Social Worker met him at Coupals court and after that time, he felt Miss W did what Social Care said regarding the relationship as she was afraid of what might happen. He understood her history and involvement with services and expressed that she would be frightened in a way he would not. He now believes the relationship between Miss W and himself was immature. On 18th December 2021 Miss W and her children were staying at maternal grandmother and step grandfathers’ home in Norfolk having been collected from their own home in Bury St Edmunds the day before. It is believed that the sleeping arrangements for that weekend was for Miss W to sleep upstairs in the bedroom with L in a car seat and R in a travel cot in the same bedroom. The family consumed alcohol that evening and went to bed late. It is understood that Miss W wanted to go home with the children but due to the time of day around 5am, grandmother interjected. It is not known why Miss W wanted to leave at that time. During the early hours of the morning Miss W fed L but did not return her to the car seat and remained in bed with her. In the morning maternal grandmother entered the bedroom and found L lifeless with Miss W asleep partially on top of her. Despite attempted Page 7 of 32 resuscitation, first by grandmother and then paramedics attending the address and then at the hospital, it became clear that L had died some hours before whilst sleeping with her mother. Miss W was initially arrested and bailed, pending further enquiries, for child cruelty overlay offences as it was suspected she had laid on L whilst under the influence of alcohol and a blood sample was taken whilst in custody. The bail conditions ended after safe arrangements had been made by the Local Authority for R, Ls older sister. Miss W was then released under investigation. Currently it is understood that the full toxicology report has now been received which has evidenced both alcohol and cannabis in Miss Ws system at the time of Ls death. Police are now considering this added information as part of their enquiries. The parents and family are waiting for the inquest to provide a formal cause of death. As L died so young it is hard to talk about her developing personality, her likes and dislikes and what made her unique. Her sister R at that time was seen to be curious and happy in the visits undertaken by professionals who saw her and that she was physically well cared for. Equally the hospital noted L appeared to be a well-cared for baby and Miss W advised L was starting to try to roll over and was becoming more aware of her surroundings. Baby M was born in Ipswich in October 2021 and was a full-term healthy boy and a first child for his mother, Miss F, who was then aged 19. Her partner and father to M, Mr D, was aged 26. The couple had connected the previous year on the website Tinder and met up after messaging for around a month. After around two months of seeing one another, Miss F became pregnant, and both appeared happy with this. Miss F and Mr D acknowledged they argued but did not feel it was anything more serious than other couples. Miss F had advised her previous relationship had been controlling and violent and she believed this had led to a miscarriage. During conversation with the reviewer Miss F advised this had been Mr D. Miss F was not known to Social Care Services in Suffolk growing up. Miss F was diagnosed with depression and anxiety at 16 but was not medicated at the time of pregnancy but advised she takes prescribed medication to help her sleep at night. Due to this she felt it helpful that Mr D would be present to help with M at night. It was known that Mr D had a period of child in care in Norfolk following difficulties at home as a teenager. Information from Norfolk Social Care details a troubled homelife with Mr D becoming increasingly angry leading to leaving the family home. Mr D was known to have a daughter in Norfolk with whom he did not have any involvement and was within care proceedings at the time of Ms birth. Concerns centred on the mother’s capacity to safely care for her. As part of the care proceedings Mr D was contacted by Norfolk and then put himself forward to care for the little girl. Assessments completed in 2021, including a parenting capacity and a psychological assessment, did not recommend Mr D as a carer for her. M was discharged from hospital into his mother’s care to her home in Ipswich which was a flat near the town centre. It was understood that Miss F’s parents who lived locally would be the main support that most new parents need, and the family plan was for M and Miss F to reside at their home until they moved to Norfolk to reside as a family with Mr D who already lived there. Until this happened it was expected that Mr D would stay with maternal grandparents also. Mr D was understood to have insomnia and had felt this meant he would be able to undertake Ms night feeds. However, M was living in Miss Fs accommodation with Mr D. It is understood the property was at times less than clean and smelled unpleasantly during some professional’s visits. On 9th December 2021 M was brought into Ipswich hospital by parents after M was noted to have a floppy left arm and to be in pain. The hospital was advised by parents that the incident had taken Page 8 of 32 place at around 4 am at maternal grandparents’ home, where they were staying at the time, and there had been an accident caused by father dropping M into the cot. Concerns were raised about a potential non accidental injury to M and the medical opinion formed was that this type of fracture is very unusual and did not match the account of the incident as recounted by Mr D. Joint s47 enquiries resulted in M being placed in Local Authority care under an Interim Care Order on 15th December 2021 where he remains at the time of writing. M has made a full recovery and is developing well and continues to live with the same foster carers with which he was originally placed. He has supervised family time with his mother three times a week and Miss F has been consistent in keeping to this and written reports indicate she is attentive and in tune to Ms needs. Contact between M and his father has been organised by the Local Authority for once a week, but this has not been kept to consistently. Mr D still resides in Norwich and the supervised family time is in Ipswich at a contact centre. Baby N was born in Ipswich on 8th September 2021 and was the first child born to his parents Miss S and Mr K. N was born full term with no complications and was a healthy baby with his parents said, a chubby face. Both parents although young, with mother being 18 and father 17, were excited to become parents, particularly as the pregnancy progressed. Parents said N was a happy baby and very alert to everything going on around him and was beginning to move around more. Miss S when growing up did not have significant Suffolk Social Care involvement. The records indicate a period of CIN involvement in 2012 after Miss S parents had separated and this was a challenging time for parents and the children. Concerns were raised about mother’s care, including neglect and physical chastisement resulting in a period of Child in Need support. In 2018/19 Miss S’s relationship with her own mother became difficult and she moved to the YMCA in Ipswich. Mr K has had significant long-term involvement with Social Care services growing up with domestic violence in the household leading to Care Proceedings in 2007 when he was removed from the family home, then residing with his grandmother under Special Guardianship for several years. The most recent episodes have focussed on his involvement and vulnerability to exploitation, gangs, and associated criminality. Mr K was subject to a Child Protection plan for emotional harm from 2020 until 2021 which then became Child in Need until case closure in September 2021. The couple advised they were using cannabis and smoked cigarettes and reported to professionals to be cutting down whilst expecting N but still using. It is believed that Mr Ks family had a culture of cannabis use, and this is documented in Child Protection reports. Both Miss S and Mr K attended Suffolk Wellbeing services to help with these issues and wanted to do this for the wellbeing of their baby. It is recorded that Miss S and Mr K had argued before the baby was born and there had been verbal incidents where in addition Miss S had pushed him. Mr K has a diagnosis of ADHD and ASD, and this made school difficult for him before his diagnosis. He has struggled with controlling his emotions and his anxieties and knowing that he has a condition has helped him and professionals and family to support him. On occasions Mr K can experience difficulties with expressing his emotions and he felt he could rely on Miss S to support him when needed. N was developing normally and gaining weight and observations from professionals was that N was a well-cared for baby. N had had bronchitis but had recovered from this and there were no concerns. Miss S had her own privately rented studio accommodation in Ipswich which she felt was not suitable for a baby. Professionals agreed that the flat, which was damp and had mould in the bedroom, was not habitable and therefore the parents planned to temporarily live at their respective parents’ homes Page 9 of 32 until suitable accommodation could be found. This meant that N did not have a settled home with his parents during his short life and experienced a lot of movement between properties at a time when establishing routines is important. Both parents were worried about this. On 27th November the family were staying at Miss S’s own family home and had been out for the day with N. Parents did the usual bath and bed routine after Miss S returned with her cousin at around teatime. Parents slept when at the property on an L shaped sofa, with N near to them in a next to me crib. On the morning of the 28th of November 2021, Mr K woke Miss S up as he had noticed N was not moving. Miss S had fallen asleep whilst holding N following a night-time feed and not returned him to the next to me crib N had been sleeping in. N had been pressed against the soft sofa cushion and consequently unable to breathe. Police who attended the address did not suspect either parent as being under the influence of alcohol or substances and therefore did not ask consent for a blood sample from them at that point. The home was in good order and did not smell of smoke. The following day when Police visited the home of paternal grandparents where Miss S was staying with Mr K, when asked then about providing a blood sample, she readily consented to this. No concerns were raised following this and there are no further Police enquiries. Parents and family await the inquest for a recorded reason for their baby’s death. Analysis of agencies involvement and actions The key questions posed for this review are detailed on p4 of this report and will be addressed here and any themes drawn together. There is no suggestion that L and N’s deaths could have been prevented by any agency and it is known that both children died due to being unable to breathe because of unsafe sleeping practices with a parent. It is understood there is no criminal prosecution resulting from either tragedy and both families await the formal decision regarding the cause of death from the inquest hearing. For M, it is known the spinal fracture was caused at grandparents’ home in the care of his parents, specifically Mr D at the time although he disputes how the injury occurred. There is no criminal prosecution at this time but there will be a Fact-Finding Hearing in the family court to determine in law who is responsible for the injury. All three children were subject to Child in Need (s17) services during and after the Pre-Birth Assessment This means that the information gathered and analysed was not considered to reach the threshold for a strategy discussion and Child Protection (s47) enquiries which may have indicated the need for an Initial Child Protection Conference. When professionals are trying to make sense of situations, it is important to understand that risk assessment in prebirth work is often challenging and complex with professionals effectively assessing parenting capacity without a child present and to test out safety plans before birth. Parents and families own accounts are important but are one of potentially many and should not be relied upon alone. Therefore, it is imperative that all known information that either lowers or raises concerns is considered and understood, forming part of a balanced risk assessment. Where areas of information are unclear, conversations must take place between professionals involved or with those who have knowledge. These conversations can support good practice and help navigate difficult areas to avoid over optimism. Pre-Birth Assessments when referred as soon and as early in a pregnancy as possible (given that Social Work Assessment can begin from 12 weeks into pregnancy) are in-depth assessments lasting from the time of Social Work Assessment until birth, often with unfolding and new situations and information emerging as the assessment progresses. Pre-Birth Assessments will assess the most vulnerable and delicate as the children are born and as such need to be given the weight and Page 10 of 32 seriousness that such an assessment requires whether the hypothesis during the start is for Child in Need planning. As the need for Pre-Birth Assessments has grown over time, they have become part of standard social work practice and as such newly qualified SWs are undertaking these. Pre-Birth Assessments will use the skills Social Workers use every day in practice, but this can be a real opportunity to work with parents for some months and build working relationships whilst assessing. However, what is key to this is experienced supervisors who can understand, unpick and question information with the Social Worker and provide meaningful direction on areas requiring more detail where it is needed. No plan when children remain at home can remove all risk, it can only try, following careful assessment, to balance the risk of harm and provide opportunity for professionals and the network to support and guide families. Some families will require a period of Child in Need, and some may begin with Child in Need and progress into Child Protection as needs and risk escalate or a culmination of concerns over time may require this. To families, it is likely not important which plan is in place if they feel it is helping. For professionals, the risk is measured against the type of plan in place and therefore may influence how professionals approach work with families and perceive the level of risk. L, M and N were subject to Child in Need plans which meant they were not considered at risk of serious harm by the professionals who were working with them. However, the Pre-Birth Assessments that led to the Child in Need plans for L, M and N did not explore in depth already known information about the family circumstances and the history. For M, the Pre-Birth Assessment was not completed before he was born and therefore there was level of reliance on the Social Work Assessment and conversations in supervision alone. The pre-birth work was also further weakened by the absence of Mr D, the father, in relation to his own history and the impact that this has had on his own emotional development both growing up and as an adult. For Mr D there were a number of adverse childhood experiences which needed to have been explored with him. Both Miss W (Ls mother) and Mr K (Ns father) experienced difficult childhoods which impacted on their emotional health and wellbeing, at times significantly. Both had witnessed anger and violence in their homes growing up and this may have shaped their perceptions of how adult relationships are. Therefore, the Pre-Birth Assessments needed to have explored this in depth and analysed the impact of this in relation to their parenting capacity but also in their own right. Apart from Mr D who was 26 when M was born, the other parents were young and quite vulnerable. This echoes the finding of reviews both at national and local levels across the UK and in fact even wider. For example, the national review of Arthur Labinjo-Hughes and Star Hobson commented that,” the previous and recent closure of the work with Star with no further action, and the fact that previous referrals from family members had been deemed to be malicious, may well have influenced the decision to undertake a single agency assessment.” For L, M and N the recent positive Pre-Birth Assessments appears to have influenced the direction of planning for the three children and subsequent Social Work Assessments in respect of L. In addition, the review found that supervision was not driving forward practice for the children, and this is particularly pertinent for M. The review was asked to consider whether risks associated to sudden infant death are considered as standard practice as part of Pre-Birth Assessments. For context, 196 babies and young children die every year of SIDS or SUDIC in the UK. Since parents and carers have been following the risk reduction advice first promoted in the early 1990s, the number of infants dying has fallen significantly. Positively, information gathered from Midwives and Health Visitors for L, M and N evidenced that for these babies’ safe ways for sleeping had been discussed with parents and documented within health recording systems. This appears to be very much embedded into health practice and is seen as standard in Suffolk. In addition to explaining the risks of co sleeping, smoking and other factors that Page 11 of 32 could be dangerous to babies is covered. Time is also spent discussing how to cope with a crying baby which is helpful and practical. Suffolk County Council Health and Children’s Centres best practice guidance highlights the factors that can increase the changes of sudden infant death syndrome. • Unsafe sleep position • Unsafe sleep environment – co sleeping in the presence of other risk factors – overwrapping (head covered pillows, duvets), soft sleep surfaces (soft or second-hand mattress), alcohol and drugs • Tobacco – pregnancy and environmental exposure • Alcohol and drugs during pregnancy and when co-sleeping • Poor post-natal care - late booking, poor ante natal attendance • Low birth weight (under 2.5kg) and preterm (less than 37 weeks gestation) • A change in family circumstances affecting routine Where risk factors are identified, the health practitioner can use the risk assessment framework for sudden infant death syndrome found within the main guidance to clarify the level of risk for the baby. Co sleeping on a sofa or armchair is a high-risk factor and boys statistically are at higher risk than girls from sudden infant death syndrome. Parents agreed in all three cases that this work had been carried out with them by their Midwife and again with their Health Visitor. In addition, for baby L, Miss W had already received this advice when pregnant with R and so when this was addressed within her second pregnancy Miss W felt she had a good grasp of safety in this respect. A key factor for baby L and N is that the safe sleeping arrangements which had been discussed and seen were not in place at the time they died. They were not in their own beds and then later during the night and early hours of the morning were co sleeping with their mother which sadly it is believed led to their deaths. For L there is the additional risk factor of her mother having consumed alcohol and used cannabis and then sleeping with her mother in an unsafe way. Whilst it is positive that the risks are being explained clearly to parents by Health and followed up at times by Social Workers as good practice, this needs to be an agreed multi-agency approach as standard. Given the seriousness of risks in relation to sudden infant death syndrome this needs to be a standard part of Pre-Birth Assessments and crucially to be revisited periodically with the family by Health and Social Care, especially where it is known children are moving between addresses with their parents and as part of the Child in Need (or Child Protection) plan. The review also posed the question, “what effective help and support were parents given for their parenting capacity to improve? An important point to note is that for L, M and N no parenting concerns had been identified that warranted continued involvement and therefore it could be suggested that the families’ needs were perceived as being no greater than any other welcoming a new baby into their lives and that universal services would be present as L, M and N grew. In addition, as sadly L and N died at 12 weeks and 11 weeks old respectively it is unknown as to what help and support parents may have benefited from if the cases had remained open in the longer term. Professionals at the time noted warm interactions between parents for both children with no health or welfare concerns emerging prior to the events that led to L and Ns deaths that had been highlighted by professionals. In general, for both Child in Need and Child Protection cases once babies are born following a Pre-Birth Assessments where it has been assessed that there is likely to be some support needs, a Parenting Capacity Assessment is often undertaken which would further inform any support needs Page 12 of 32 parents may have or highlight where there is emerging risk. In L, M and N cases this was not identified as being necessary within supervision or management oversight as the assessments were overall positive. During the pregnancy the Family Nurse Partnership was referred to (a midwifery and health visiting service which offers a complete service for up to two years for younger parents) for the then unborn babies L and M, but it is understood this was not put in place due to capacity issues. Both mothers advised they would have welcomed the extra support. For unborn baby N the Acorn team was put in place and this is a wraparound service for younger, vulnerable mothers providing Midwifery and Health Visiting care combined. The Midwife also wrote a supportive letter in relation to housing needs and the Social Worker contacted the property owner. A key part of assessment is the exploration and understanding of the family and connected network. Family Network Meetings are held with key family and friends to include them in planning and to find out what support they can provide in the short and longer term. For L, M and N this does not appear to have taken place formally. Family Network Meetings can also highlight where there may be difficult dynamics and in Ls case where maternal grandmother was suggested as Miss Ws main support and may have well needed to work with Social Care, this may have revealed the difficulties this could bring. For N, an FNM would have brought together both sets of grandparents and included them formally within planning. For M, it would have provided for the first time an opportunity for both sides of the family to come together and for maternal grandparents, who were supporting parents with accommodation, to be part of creating the family plan as part of the Child in Need process. These are missed opportunities and an important part of assessment, where services are planning to step away, it would have been prudent to try to secure a family led plan for those early months where routines are not yet established by new and vulnerable parents. The review was requested to explore the care leaver status of L and Ns parents and if this affected how they were viewed as parents by professionals. As highlighted within professionals’ perspectives and reflections, the Social Workers involved did not believe that this had influenced their thinking and for L the Social Work Assessments conducted after the Pre-Birth Assessment with the outcomes based on observation and lack of evidence of any concern. For example, professionals could not evidence any concerns regarding Miss W alleged alcohol misuse. For Ns father, Mr K, the Child Protection planning which had moved into Child in Need processes appears to have been a factor in determining what level of plan would be appropriate for the baby rather than considering his history of Child in Care his current vulnerabilities and the impact that the birth of the baby could have on him. At the time of the Birth Assessments and Child in Need planning for M, the information regarding Mr D and his history of Child in Care, family dynamics and other relationships when in Norfolk was not considered as part of the assessment in any depth and therefore no opinion can be formed. Baby Ls sibling R had been subject to a Pre-Birth Assessment in 2020 due to some concerns regarding mothers’ relationships and her own vulnerabilities including a difficult home life leading to child in care procedures, and her young age at the time (nineteen). Overall, the assessment appeared positive and the subsequent child in need planning in 2020 was relatively short term and focused on supporting Miss W as a new parent alongside working with her on her own relationships which could make her and R vulnerable, with a plan for closure knowing that there was continued support at Coupals Court where they were residing. However, during this period Miss W became pregnant with L and the decision was made to continue with Child in Need processes until a Pre- Birth Assessment for the unborn baby could be undertaken and a continuing support plan put in place if required. Page 13 of 32 The Pre-Birth Assessment for L was completed in March 2021 and the case was closed to Social Care in May 2021 after a short period of Child in Need planning before L was born. This was on the basis that Miss W continued to work with services and had the support of Coupals Court staff and sought support if she needed around her mental health or concerns for Mr B re-emerged. Miss W moved with R and L to her new property in Bury St Edmunds and this took her away from the on-hand support she had experienced at Coupals Court. It also meant a change in Health Visitor and GP surgeries. A referral was received from Probation in June 2021 with concerns that the father, Mr B, was visiting the mother and baby accommodation and the case was reopened. A SWA was undertaken, and the SW visited the property and spoke with Miss W and saw R and spoke with the housing provider. There was no evidence that Mr B had been visiting and as CCTV was in place, it was felt this was a reliable source. Mr B advised through his probation officer that he had made it up and the case was closed. Health was not contacted as part of the assessment and Mr B was not spoken with directly as part of the Social Work Assessment. Miss Ws Leaving Care worker was not consulted as part of the Social Work Assessment. Practice point The presenting issue was understood to be concerns of father visiting the property against the Pre-Birth Assessment advice and the housing provider was spoken with. However, consultation and relevant information sharing needs to take place between all involved agencies if assessment is to be reliable and comprehensive. Leaving Care were worried about Miss W’s choice of relationships and the impact of being young and parenting two small children. Liaison with the team could have explored these issues further. Health, if updated during the Social Work Assessment, could have updated their systems and been aware for any future contacts with the family. In addition, conversation with Mr B was not pursued and his motivation for why he told probation he was visiting Miss W and R and then recanted when this information was passed to Social Care was not explored within the Social Work Assessment. Miss W moved with R and L to her new property in Bury St Edmunds and this took her away from the on-hand support she had experienced at Coupals Court. It also meant a change in Health Visitor and GP surgeries. The home was seen by professionals involved who agreed that it was (and continues to be) kept to a high standard of cleanliness and suitably safe for children. Practice point When recommendation is case closure in Pre-Birth Assessment (and subsequent Social Work Assessment), consideration of potential impact for families who may be moving to another area at a time of change for the whole family. For Miss W this meant changing health visitor, midwife, and surgery, very close to L being born whilst moving away from a supported living environment. Days after L was born a new referral was received in September 2001 raising concerns about shouting and smacking R and Miss W misusing alcohol. A Social Work Assessment was undertaken, and a Social Worker visited the home, spoke with mother, and saw R and L and found no evidence to support the allegations. Professionals working with mother were consulted who advised they had no concerns for mother’s care of the children or had concerns regarding levels of alcohol consumption. Attempts were made to see Mr B but was not successful, however he was spoken with by phone. The Social Work Assessment was closed on the 25th of November with agreement for case closure. L died on 20th December 2021 before closure. Practice point Initial professional thinking which becomes accepted in an assessment may be at risk of being replicated in subsequent assessments if information is not sought out that may challenge or question this theory. Page 14 of 32 Baby M had been subject to Social Work Assessment leading to a Pre-Birth Assessment following a referral from Midwifery with concerns for Miss F’s consumption of alcohol, poor periods of mental health with a diagnosis of anxiety, depression alongside ADHD. During the assessment which commenced in June 2021 it became known that the father Mr D had been involved with Norfolk Social Care Services as a young person and as an adult in relation to another child. Mr D reported he had to leave home and became homeless before moving to a shelter in Norfolk. Whilst in this environment it is understood he became involved in confrontations which led to a criminal record. Practice point It was known information that Miss F had experienced periods of poor mental health including self-harm, and this was part of the reasoning for the referral from Midwifery. However, there is no evidence of recorded checks with Miss F’s GP or follow up with ICENI regarding her reduction work for alcohol and cannabis and therefore the assessment relied on mothers self-reporting that she was feeling stable, and this was in the past. Mr B had advised he had completed assessment with ICENI also for alcohol and cannabis use but had not consumed these since February 2021 and this appears to be based on father’s own reporting. It is of note that the Pre-Birth Assessment was written up 6 weeks after M was born and this is acknowledged within the authorising comments. The decision was that the family required a period of Child in Need support. Practice point For M, decisions were made based on the initial Social Work Assessment as well as case discussion as the Pre-Birth Assessment had not been written up or authorised. Key elements in fathers’ life had not been explored or understood and therefore was an unknown quantity which is likely to heighten risk. A key aspect of supervision in Pre-Birth Assessment is to help analyse what is known and provide direction where more information is required to make an informed decision about risk. Norfolk Social Care Services had contacted Suffolk Social Care to share relevant information during the Pre-Birth Assessment period. The Social Worker in Norfolk had advised that Mr D had a child from another relationship who was in care proceedings and that Mr D had been ruled out of assessment. Suffolk did not request further sharing of information or have sight of completed reports which would have been pertinent to the Pre-Birth Assessment and risk management. Mr D took part in a psychological assessment completed in February 2020 which highlighted his difficulty regulating his emotions since childhood, particularly with difficulties controlling his anger. During the assessment Mr D described a poor experience of being parented, witnessing domestic violence, as well as feeling that he was treated differently from the other children in the family. The report concluded that Mr D is likely to behave impulsively and show significant lack of empathy for others. In his relationships including with a child, there is likely be a degree of emotional ambivalence due to his attachment difficulties and his fear of intimacy and that he is likely to be an emotionally highly inconsistent parent who will often respond to a child impulsively who would not understand this, and this therefore poses a significant risk of emotional harm. The psychologist felt that for a relationship to be successful some physical distance would need to be in place between Mr D and his partner to minimise frustrations and chances of disputes. This would have been helpful when thinking about the plan for once M was born and what kind of emotional environment he would be living in if parents were living together. Practice point The omission of information from reports from Norfolk County Council that could have been included in the Pre-Birth Assessment led to a flawed assessment and plan. The information Page 15 of 32 contained within the psychologist report regarding father would have very likely increased the recognised risk of significant harm to M and would have resulted in a child protection plan before birth. In addition, the knowledge that Mr D had been effectively ruled out by Norfolk County Council as a carer for his older child if included and considered within the Pre-Birth Assessment would have raised additional concerns. On the 9th December 2021 parents with grandfathers help, took M to Ipswich hospital as Mr D noticed that Ms arm was floppy and he was in pain. Medical assessment determined that M had suffered a spiral fracture to his arm and that the explanation provided by Mr did not fit with the injury. A joint s47 enquiry began and the Local Authority made an application to court, and an Interim Care Order was granted which meant M was placed locally with foster carers where he remains. Baby N was the subject of a Pre-Birth Assessment following a referral from fathers own Social Worker. The concerns for the then unborn baby focussed on the vulnerabilities of both parents with Mr K being 17 at the time and Miss S being 18. Father had been subject to a Child Protection Plan until 2021 and then Child in Need as it was felt progress had been made in relation to his vulnerabilities to gangs and associated lifestyle decisions. Concerns had been noted about verbal arguments between the couple. During the Pre-Birth Assessment period Mr K’s own case was closed as it was felt he had support from the Social Worker and professional network for the then unborn baby. Practice point Case closure took place at a crucial point for Mr K - two days before N was born without settled accommodation for N and with Mr K about to become a father. Whilst Social Care remained involved with the family through N, this was not in Mr Ks own right as a vulnerable 17-year-old who experienced anxieties and very recent Child Protection involvement. Mr K had developed a trusting working relationship with his Social Worker, and this could have continued (as she remained case responsible to the siblings) until some measure of stability was in place and there were some months to go before Mr K was 18. It was known information that Mr K had entered Local Authority care in Suffolk after a difficult home life and was made subject to an Interim Care Order and then Special Guardianship to grandmother. The dynamics of the family network were complex, and Mr K and Miss S had effectively grown up alongside one another when their respective parents became involved with each other in a relationship. Information from the Child Protection Chair could have been included within the Pre-Birth Assessment as a professional who had, alongside the Social Worker for Mr K, had an overview of the family prior to the Pre Birth Assessment period. In addition, the Youth Justice Service (YJS) worker had met the paternal family and Mr K and the work planned was to focus on his use and understanding of cannabis in relation to the law. Practice point Although some good practice is evident in liaison between the Social Workers for the then unborn N and Mr K, the Pre-Birth Assessment does not explore in depth the dynamics of paternal family and Mr Ks place in this or utilise other involved professional’s insight in any depth. As assessment continued, improved engagement with Midwifery was noted and parents engaged with the Social Worker and other professionals, and this lowered concerns. It was recognised by all professionals involved with the family that housing was inadequate, and that N, once born, was unlikely to have his own permanent accommodation with his parents. Efforts were made by Health and Social Care to help address this but ultimately N left the hospital without a suitable permanent home address. Practice point Babies who are moved between addresses need to be viewed through a situational risk lens and require active plans which recognise this as a risk for families. Page 16 of 32 It appears that because Mr K’s case had become Child in Need, this lowered the concerns in the current assessment and was perhaps viewed in an over optimistic light. An observation is that whilst a Child in Need plan was appropriate for Mr K himself at that point, with Mr K about to become a parent the impact of this event on him was unknown. Professionals’ perspectives and reflections A strength in the review has been professionals’ engagement. Interviews have been opportunities for reflection and discussions about wider practice as well as understanding the facts of each family’s situation. For some professionals who had not been involved at the time of L and Ns death, it was the first opportunity to discuss what had happened to the children, how they as professionals felt about this, and the impact on them. One professional stated, “do I have the right to be upset?”. It is important going forward that when such tragedy occurs professionals who have been involved in the child’s life should be sensitively notified and supported. Professionals need to be reassured their emotions are valid and that this is healthy. Practice point All professionals who have worked with children recently (not only current allocated workers) to be notified sensitively by their agency and offered an emotional wellbeing session in recognition of the impact this can have on professionals. Almost all Social Care professionals reflected that looking back over the known information for each family that there were several red flags and there appeared a lot of reliance on what parents had said which was taken at face value. Most felt that a Child Protection Plan that recognised the risk factors would have been appropriate for the three babies. Heath professionals reflected in discussions that they were unsure of the Child in Need status and if this was the appropriate level for the families. For N, Health advised this was raised at the time and was advised that Child in Need was the correct level as there was family support in place. Wider issues have emerged regarding Pre Birth Assessments in Child in Need with Health professionals noting a marked difference in process between Child Protection and Child in Need in terms of working together and receiving documents and plans. When reviewing health records, no evidence of the Child in Need plan was found for any of the babies or notes of the meetings. Health Visitors advised that they take their own at the meeting, but when added to the electronic recording system, some will be very brief. Baby L Interestingly, the professional who took part in this review was not contacted for the purpose of the Pre-Birth Assessments as this is not seen as standard practice. The Independent Reviewing Officer had known Miss W over a period of seven years and therefore had insight into Miss W, the family dynamics, and impact of those adverse childhood experiences. This professional was also the Independent Reviewing Officer for Miss W’s brother. From what was known and recorded there were several red flags and there appeared a lot of reliance on what mother had said which could have been tested. Practice point Social Workers to consult the Independent Reviewing Officer when assessing parents who are open to the Care Leavers Service, who may no longer be involved but have a long-term perspective and knowledge to share. Page 17 of 32 The Social Worker who had undertaken Pre-Birth Assessments for L (and earlier for R) has moved on from Suffolk County Council, however Social Workers who were involved subsequently reflected that the referrals had followed quite closely on from the Pre-Birth Assessments which had been positive. They therefore focussed on the presenting issues in the referrals and addressed those as required. The subsequent Social Work Assessments was not seen as an opportunity to look at the wider picture and on reflection they felt that the positivity of the Pre-Birth Assessments could have impacted on the approach to the new assessment. One Social Worker liaised with the author of the Pre-Birth Assessments before visiting the home to talk it through which was good practice. Practice point Assessments that are holistic and dynamic. Whilst recent past assessments might be the starting point, to give them too much weight risks confirming past outcomes without thorough enquiry. When thinking about Miss W’s history of care, Social Workers opinions was that this was not a factor in the Social Work Assessments in that more leeway was given, they felt the no further action outcome was based on the evidence and observation. I cannot comment on the Pre-Birth Assessments in this regard, however there were several adverse childhood experiences that were known and recorded within the assessment but not given the weight they might have been. This is not to say that this is because of Miss W’s care experience, but perhaps more about understanding what the information is highlighting. The Leaving Care service commented that they had been concerned about Miss W but emphasised this was in context of a young parent caring for two very small children. The Social Work team had consulted with the Leaving Care worker as part of the Pre-Birth Assessments, and one subsequent Social Work Assessment but the information recorded was that they had no concerns over mother’s care of the children. During conversations with the Leaving Care worker, it was clear that there were troubling family dynamics, and that maternal grandmother still harboured a high level of hostility towards the Local Authority which potentially could influence Miss W in how she viewed Social Care involvement. The Leaving Care Service felt that not enough weight was given to their concerns in this case and at times in others. The recording within assessments suggested either the concerns were not voiced clearly, or they were misinterpreted. Practice point Clear conversations between Leaving Care and Social Work teams resulting in shared understanding of the concerns and how these are expressed to parents jointly are important. There also seemed to be some confusion as to how best to convey worries with a manager from Leaving Care escalating to a County Safeguarding Manager for advice on what to do about raising the concern. The response from the Safeguarding service was to speak with the Social Work team management. This was two days before L died. There is a Suffolk Safeguarding Partnership Escalation Policy in place if more informal efforts have not worked. The Health Visitor reflected that she had seen the family at home after being alerted that the family had moved to Bury St Edmunds; this was when L was 15 days old. Haverhill health visiting service had contacted Miss W and it was then that Health became aware of the move and the transfer out was instigated. During the home visit the Health Visitor saw both children and the sleeping arrangements which were safe with a moses basket next to the bed. Also at the property was a man who was identified as the children’s uncle. In discussions the Health Visitor did not know of the concerns that would be generated by another male being at the property as this had not been shared and she advised that she may have looked through a slightly different lens regarding his presence if she had been aware. Conversations with the GP and the Health Visitor confirmed that there had been no recorded requests for health checks on R or mother at the surgery. In addition, there were no copies of the Pre-Birth Assessment or Child in Need plans. Health colleagues advised this made it difficult at times to know Page 18 of 32 what the plan is, especially if they do not receive copies of the Child in Need notes. If the allocated Health Visitor cannot attend the Child in Need meeting and another goes in their place, health visitors are reliant on the worker returning and writing up their own notes which varies. For Social Workers it can be difficult at times to coordinate and ensure all professionals are part of all Child in Need meetings. When other professionals are on leave or unwell and there is no stand in, this creates challenges. As in other agencies, Social Workers are expected to undertake administrative tasks alongside case work and unlike in child protection cases, there is no allocated resource to help with this work. Practice point Supportive mechanisms to be put in place to assist Social Work teams so that health colleagues receive electronic copies of Child in Need plans and notes of meetings as standard. Practice point Vulnerable families that move across health visiting and GP areas require timely coordination when transferring to avoid confusion and delay and at times this can be challenging. Consistent closer working between Child in Need professionals would support this information being shared sooner. Baby M In conversation with the Social Workers reflection found that at times, the Pre-birth Assessment accepted at face value what parents said at the time without undertaking necessary background checks. In addition, the Social Worker commented that most of the assessment had been completed by phone which provided a limited opportunity to observe and for parents to engage fully and that this was not ideal and something to take forward as learning in the future. (Although not period of lockdown, COVID processes in place and Social Worker had been unwell). Regarding information that Norfolk Social Care had held for father, it seemed in discussion that the Social Worker or the supervisor did not realise the importance of it or how it would impact on the assessment. The Social Worker felt her inexperience at that time meant she did not ask further questions that she would do now and, importantly, think deeper about what the information might mean for M. This was a key piece of information which would have likely moved this family from Child in Need to Child Protection planning. Both the Parenting Capacity Assessment and the Psychologists report has been read as part of this review. These documents provided a great deal of insight into Mr Ds life and how he manages his own relationships and feelings which would have been invaluable. Further to this, the extent of Mr Ds involvement with Norfolk Local Authority became apparent when CAFCASS made some initial enquiries following Suffolk’s application at Court for an Interim Care Order. Some of the information was known to the Social Work team but it had not been considered or explored fully within assessment and therefore no real analysis of this had taken place. CAFCASS considered the chronology of events in the family’s life needed strengthening and the absence of a completed Pre-Birth Assessment highlighted the need for a deeper understanding of this family. Practice point Supervision in Pre-Birth Assessment work needs to unpick information and events with Social Workers and provide meaningful direction, especially for newly qualified Social Workers. Pre-Birth Assessment work can be high risk and high stakes and approached with this understanding in supervision to ensure information is followed up, checked, and analysed so that supervisors and Social Workers understand what the situation is rather than what they may be told it is by parents. In discussions with the Practice Manager, it was agreed that case notes highlighted Mr Ds involvement with Norfolk, but that supervision did not provide any direction in terms of follow up enquiries. The Practice Manager advised that supervision in this instance needed strengthening and should have followed up to clarify if background checks had been completed and then discussed the outcome as Page 19 of 32 well as further liaison with Norfolk. The Practice Manager advised that discussions had already been held with the supervisors as part of the management teams own learning in this case. It was noted that no Family Network meeting was held, and this might have pooled the family resources more formally and helped in the Pre-Birth Assessment, acknowledging that one face to face visit and 2 telephone calls was not sufficient for the Pre-Birth Assessment which had been referred timely and therefore had some time to plan for and complete. The Practice Manager noted that the Social Worker had been unwell and not in work and consequently the Pre-Birth Assessment was not completed (written up and authorised) until 6 weeks after M was born, therefore it was the prior Social Work Assessment that the decision for Child in Need was based on alongside case notes and discussions with the Social Worker when in work. Miss F Health Visitor advised that an antenatal visit had been completed when Miss F was 27 weeks pregnant and both parents were present. Safer sleeping was discussed with parents as standard practice. The Health Visitor knew a Social Work Assessment had been completed but was waiting to hear the outcome. Following this she contacted the Social Worker in November 2021 to introduce herself and asked for the plan after parents advised that they knew who the named professional was. Practice Point Families in Child in Need cases need the same level of relevant information sharing and professional collaboration as families in Child Protection processes. The Health Visitor did not attend the virtual Child in Need meeting but visited the maternal grandparents. When speaking with the Social Worker the Health visitor advised she had discussed safer sleeping and how to cope with a crying baby but had not seen the bedroom and was concerned as there was an unpleasant smell in the home. The Social Worker advised she had seen the bedroom and provided advice to the parents about improvements. The identified plan in supervision was for case closure when M was four weeks old, and this did not take place as Pre-Birth Assessment was not written up. However, management oversight from the case supervisor was clear this was to be closed as soon as possible due to the positive assessment. Baby N A new Social Worker took on the then unborn Ns case in September 2021 following the departure of the allocated Social worker who had completed the Pre-Birth Assessment recommended Child in Need. There was no opportunity for a case discussion or handover visit and it was very much about getting to know the family as quickly as possible. The Midwife felt positive about how parents were coping despite the difficulties with accommodation. In discussions with the Social Worker, reflection took place regarding the Pre-Birth Assessment and the difficulties that father had experienced in his young life including the violence witnessed at home leading to an Interim Care Order and then permanence in the form of Special Guardianship Order with maternal grandmother. His difficulties with sleep and struggles at times to manage his emotions and the noted arguments between the couple. The very recent Child Protection concerns for him in relation to exploitation and gangs and that at the point of his baby’s birth, his own case was closed to Social Care from a short-term Child in Need plan which highlighted father vulnerabilities in terms of his emotions and drug use. Talking it through with the Social Worker felt these were issues which needed unpicking within supervision. The role of supervision is to look beyond the presenting issue and consider the other known factors and how this might impact on the family now and in the future. The Practice Manager reflected that the supervision was lacking depth and in addition the Pre-Birth Assessment was not read and authorised by the manager who would have known the adverse childhood experiences of father, the family dynamics and impact as she supervised both Social Workers working with the family. Reflection was that Mr K was almost missing from the Pre-Birth Assessment and his views were not evidenced Page 20 of 32 and that had the concerns and vulnerabilities been considered and analysed it could have moved from Child in Need to Child Protection. Practice point Social Care Practice Managers to have final authorisation for all Pre-Birth Assessments. Mr Ks and Ns case was open to the same social work team and therefore provided good opportunity for meaningful conversations between the allocated Social Workers. Mr Ks Social Worker invited the then unborn baby’s Social Worker to a core group meeting and so the knowledge was shared and this evidences a measure of good practice. Mr Ks Social Worker had a positive working relationship with Mr K and understood the family dynamics and both parents own relationships. It was felt that the issues that had required a Child Protection plan had diminished, and Child in Need planning was appropriate for him at that point. However, with the known issues that Mr K struggled with, and N being born two days after Mr Ks case closure, the situation felt fluid and in conversation with one Social Worker the view was expressed how important the Pre Birth assessment is in understanding the family dynamics, what support will really look like in reality and in Ns case where his parents were staying as “guests in people’s homes” needed to be explored more. This factor is present in both M and Ns case. The Child in Need plan in place for Mr K did not address the fact that he was about to become a parent or how this might impact on his own emotions or behaviour, even though it was highlighted in the danger statement and the case was closed with N being born the following day. Practice point Where children who are about to become parents have been subject to Child Protection plans, the Child Protection conference chair alongside the operational team will ensure the plan acknowledges and addresses potential impact for the new parent as part of the new Child in Need plan. Practice point For children who become parents and have been open to Social Work teams, consideration for their case to remain open as support for their own needs in the short term until routines are in place. Mr K during this time was open to the Youth Justice Service from 15.10.21 until the 18.02.22 in relation to the Youth Caution Offence due to cannabis use. The youth justice worker reflected that Mr K had initially engaged very soon after being allocated to him and he had had a positive meeting during a home visit where he had met paternal grandmother and seen N in his moses basket and Mr K spoke of his training work and how he wanted to lessen his cannabis use because of N. The work would have been focused on cannabis and the Law. On 09.11.22 following the actual administration of the caution, Mr K appeared to disengage from the service. The work would not have been long term but likely 2-3 sessions. Youth Justice Service was not invited to Child in Need meetings and in Ns case there was a short timespan for this to take place but for wider thinking, this could be important for parents, especially young fathers (who may not have many other professional supports). Reflecting, the youth justice worker was not aware of the Mr K family history when he visited the home. He met with maternal grandmother but was not aware of the history or dynamics and on reflection this knowledge prior to visits is important. Practice point Where Youth Justice Service is involved with a young person who is about to or have just become fathers, Social Care and Youth Justice Service to ensure relevant information about family history and dynamics are shared to inform Youth Justice Service practice. If the young person has recently closed to Youth Justice Service, the Social Worker to include them in Pre-Birth Assessment. Page 21 of 32 One point that has stood out in the review is how engaging professionals found parents to be as people. Both the Midwife and the Health Visitor highlighted this as has Mr Ks previous Social Worker. Mr K has had significant involvement with the Local Authority as a child and young person, however he has remained open to professionals to a certain extent and speaks with clarity, feeling and common sense especially when speaking about the events covered in this report. He has observed that he felt patronised at times by some professionals, due to his young age. However interestingly all professionals reported how likeable and engaging Mr K is and enquired about the couple and there appeared genuine interest in how they are doing. Again, this highlights how different individual perceptions are and how this can be interpreted by both families and professionals. The Health Visitor has moved on from the Health Service, but discussions were held with another health colleague who had oversight of the electronic recordings from the time period and the issue of safer sleeping again was present and that this was evidenced as discussed. The new baby visit to N took place on the 23.09.21 but there were no details recorded of Child in Need reviews in the baby’s notes and limited liaison between the Social Worker and the Health Visitor. The last home visit was completed on 25.11.21 by a different Health Visitor and there appears to have been a plan to have a discussion regarding parents’ cannabis use and how their plan to reduce usage was going. From discussions it seems as though the different health visitors may have had different professional opinions regarding the level of concerns. Practice Point Health Visitors to discuss with their safeguarding leads in reflective supervision if levels of planning are not felt sufficient. Parents perspectives and reflections This section of the report follows on from the professionals’ perspectives and reflections and provides a personal account of how parents felt about the involvement of services both in terms of the Pre-Birth Assessments and any subsequent services. For the parents who had Social Care involvement as children this added another dimension to how they experienced the more recent episode of work. As the reviewer, I would like to take a moment to express appreciation for L, M and Ns parents’ agreement to take part and for L and Ns parents who agreed to talk about a terrible time in their lives when suffering from their loss. Parents understand this is about exploring the period before and after their babies were born and to see if there is any professional learning for the future. Part of this work needed to consider family history and dynamics and any significant involvement with Children’s Social Care because these aspects would be relevant to the Pre-Birth Assessments. These therefore have been included. Baby Ls mother Miss W was visited at home and seemed open and thoughtful during the conversation and despite her distress at times was able to speak about some of her own life experiences which have been difficult even prior to this tragedy. I include this as her life history entwined naturally within the conversation and therefore would be important within any assessment that needed to think about mother’s support network. Miss W said she was “fine” with Social Workers and had had them all her life. She knew that “you had to work with them” and felt she had learnt how to do this. She observed that “they do support you, but the past goes against you”. When younger as a child in care Miss W believed she wasn’t listened to but as she got older, she thought she was. She said, “when children talk, they have a voice” It seemed she spoke with a wisdom that can be found through the lived experience. Miss W recalled she had received advice around babies sleeping safely in both pregnancies from the Midwife and Health Visitor and shared she had the leaflets and understood the risks around sleeping Page 22 of 32 with your baby. Miss W reflected she believed she had more support with her first baby and acknowledged this was due to her living arrangements in a supported mother and baby accommodation which had a professional network around families. When she moved to Bury St Edmunds to her own property, this on hand support was no longer in place. When thinking about the assessments that had been undertaken, Miss W was unaware of the Pre Birth Assessments for L but remembered the one she had taken part in for her first child, R. Miss W advised she was also unaware of the two subsequent Social Work Assessments following the birth of baby L saying, “I didn’t have any assessments, Social Workers came round to check but that was it.” In conversations with the Social Worker about planning before L was born, Miss W remembers being asked about what relationships she had around her. Miss W had told the Social Worker that her mother was “supportive” and that this was accepted. Miss W reflected that she wasn’t asked about the quality of that relationship or what it looked like, so she didn’t say. More recently she has reflected that Social Care would have been aware of her own mothers parenting and the situations of her adult siblings and didn’t understand why this wasn’t considered more. Miss W said when thinking about her baby that she had all the home set up safely for L but the night of her death she was not at home but sleeping at her own mother’s property which was not equipped with a bed and moses basket. Miss W said that “it could happen to anyone” and wants to, when the time is right, work with parents around the important health and safety issue of ensuring babies always sleep safely. Miss W is focused on the supervised family time she has three times a week with R who is in foster care and is working with the Local Authority and hopes that she can be reunited with her daughter in due course. Miss W also shared that she is expecting another baby with a new partner and although this pregnancy came as a surprise, she is happy with this although it does not take away from the pain of Ls death. Baby Ls father Mr B said he was not included in any assessments for either L or R or sent any reports. He was at Rs birth and recalled looking after her for over four months with Miss W. He remembers meeting a Social Worker after R was born who he felt did not like him and Miss W had told him he couldn’t see R because Social Care said so. He does not know more as Mr. B says he was not spoken to directly at that time. He advised Miss W was afraid of Social Care as he understood many people are. He has not had any direct conversations about what happened to L with any professional and was notified of her death by the prison chaplain. Mr B accepts that they had a difficult relationship and were “immature” as a couple but believes he should have been involved in assessments, whatever Miss W had said to the Social Worker as he is the children’s father. He reflected that he knew he had a criminal record and a history with the Police but that he came from a good family and never had Social Care involvement as a child himself. He knows that there are bad people but not everyone is like that. Mr B stated that the negative things, like the arguing and criminal history, is always stuck with him and Social Care “don’t believe that people can change and that they need to focus on fathers more” He wants to see R and from liaising with the current Social Worker for R, Mr B is being kept up to date and is included as part of Care Proceedings. Baby Ms mother Miss F reflected that during the time before M was born, she didn’t feel worried about talking to some professionals, saying she liked the Midwife and spoke to the Health Visitor. Miss F also feels that she is kept up to date with what is happening by her current Social Worker which is important to her. Miss F felt that she worried about Social Care in general and how they work saying, "When you ask for help, you’re made to feel like you can't cope. But when you don't ask for help, you’re made to feel bad because you should have asked." Page 23 of 32 Miss F cannot recall seeing a Social Work Assessment or a Pre-Birth Assessment. Miss F was aware she was on the list for support from the Family Nurse Partnership, but this didn’t take place. Miss F said she “would have taken any kind of help”. Miss F also cannot recall seeing a copy of the Child in Need plan. Miss F advised she understands why her son is in foster care (because of the injury he sustained) but hopes M can return home. Miss F felt that “things get twisted…. they are going to listen to the Social Worker” and feels that some things written subsequently have misrepresented her. Miss F stated she would have left the baby’s father had she read the reports that Norfolk Social Care Services had completed about him. Miss F knew that when the Social Worker arranged the ‘Claires Law’ disclosure for her to hear from Police about the convictions Mr D had, she chose not to believe them. Her partner, she felt, convinced her they were untrue. Subsequently following a domestic incident between them, Miss F realised there was truth in the information and ended the relationship. Miss F maintains she did not see the assessment report that was later referred to which added to the concerns about the father of M and her capacity to protect M from harm. Miss F reflected that a family network meeting might have been helpful, to include her family pre-birth and after as her parents had been supportive to her. Baby Ms father advised that he has found it difficult since his son sustained the injury saying, “after the accident I turned to alcohol to cope with everything.” Mr D also commented that he didn’t fully understand why Social Care had been involved and felt he had been given differing reasons and that some of the reasoning only became clear after Ms injury, specifically, his own history. Mr D shared he was unaware that previous assessments undertaken regarding his other child were unsuccessful. He felt that both he and Miss F embraced the help, but he felt that “they were being watched and didn’t know why, we knew we were young parents but that was all, and we were accepting help because we needed guidance.” Baby Ns mother and father remain in a relationship and appeared relaxed and supportive of one another during the conversation. Both parents shared that they felt “they needed to do what was asked” of them. They advised that “you don’t picture social services in a good way” and that “you can’t be yourself”. This is an important aspect for professionals to acknowledge and in contrast to how professionals perceived their working relationship with the parents. Mr K observed that with all the professionals and meetings the one thing they needed was a proper place to live in. He felt that this was not given enough priority in the Child in Need work. Parents said in the “whole two months (of N’s life) we were moving round.” All professionals agreed Miss S’ flat was not good enough for the family (damp, mould). Parents remembered that the Midwife wrote a supporting letter to the council and the Social Worker liaised with the property owner but that he would not provide a notice of eviction to allow Miss S to access accommodation quicker. They spoke about the impact of this transient living on their lives and that sometimes it was hard to know where they would be and so professionals couldn’t always get in touch to visit. Miss S reflected that her and the baby’s medical notes might be at another address and that it felt disorganised. Mr K observed that now Miss S had her own place, and this was appropriate but,” it was too late” (he meant for them as a family with N). Regarding assessments, they could not recall seeing one and felt, looking back, some things were not explained to them. They didn’t know the reason for the assessment other than what the Social Worker had told them at the beginning which they said was “because Mr K had a Social Worker”. Parents said that if they had seen the assessment, they would have understood better. Part of this they also felt was that the Social Worker did not visit for the purpose of the Pre-Birth Assessment, but it was conducted by telephone-this means there was no opportunity to observe interactions between parents Page 24 of 32 or undertake individual sessions with each parent. Mr K and Miss S recalled the Social Worker coming out for the Social Work Assessment which preceded the Pre-Birth Assessment. Parents shared that sometimes they felt patronised because of their young age (17 and 18 at the time). Dad spoke highly of his own Social Worker during his Child Protection and then Child in Need process saying, “she was a legend” and she listened and tried to help him. He felt this so strongly, they invited the Social Worker to the funeral who attended. Both parents recalled the safer sleeping conversations with the Midwife and understood what it meant. Both parents said living in different places meant they had to make do with what arrangements were in place where they were staying (at paternal grandmothers’ home when N died). Collectively L, M and Ns parents’ reflections are powerful and an important part of this review. For parents who have had significant involvement with Children’s Social Care over the years this unsurprisingly will impact on how they feel about recent involvement in their lives and for parents who did not have significant involvement, opinions are often formed from friends, family, and the media about what to expect alongside their own feelings. When Pre-Birth Assessment is undertaken it is important that professionals really consider the impact of this work on parents and the implication that is often unsaid but thought of by parents, which is that their baby could be taken away from them which is undoubtedly an immobilising fear for parents. For L, M, and N this was not in professionals’ thoughts and therefore the Child in Need plans agreed reflected this. However, from conversations with the parents, this was their starting point and remained an underlying fear despite on the whole positive Pre-Birth Assessments. Sharing of information and reports with parents is essential not only at the end of assessment but to include them as the work develops in what is a period of great change for any family but especially when parents are young and at times vulnerable. In reviewing the reports and recordings for L, M and N, it is evident that visits and conversations took place with parents, Child in Need reviews were held, and supervision discussed the progression of the work, and the babies were looked after through Midwifery and then Health Visitor care. However, when listening to parents, the impact of the work is less clear. Mr K spoke openly and stated that what they really needed was somewhere to live as a family. All the planning carried out did not achieve that for them. The overarching theme of the impact of the work was that parents believed they needed to co-operate with the assessment and were worried about Social Care involvement to a lesser degree for some. In conversations parents acknowledged that the Child in Need plan that resulted from the Pre-Birth Assessment and closure for L and plans for closure for M and N acknowledged that professionals were positive, yet they did not fully understand what was being done to them or with them. The Pre-Birth Assessment procedures are set out within Suffolk County Council policy; however, these do not detail how to tackle the barriers that can prevent good practice when trying to work alongside parents. Professional relationships with parents are built through mutual trust and respect which is gained through openness, honesty, and understanding of the power dynamics with the professional and families. Pre-Birth Assessment work is a balance of listening to parents coupled with incisive risk assessment and being open about this. The national review into the murders of Arthur Labinjo-Hughes and Star Hobson commented that “there is a need for skill in blending care and control functions” and this is pertinent for Pre-Birth Assessment work which is potentially high risk and when parents can be at their most vulnerable. Time and consistency are other elements that are important in building trust. A change of professionals, which is sometimes unavoidable, but which needs a level of understanding of the impact this can have on parents who may feel they have to tell their story again, or as one parent stated that a new professional will advise parents to do something differently which is confusing. Page 25 of 32 Key findings, Practice Points and Recommendations/Action Planning. L, M and N are individual and unique and as such each child is distinct within the report. However, some similarities both in terms of practice and missed opportunities have been found. Speaking with professionals and families has provided valuable insights alongside the reports and documentation. This has led to the following recommendations. ➢ Suffolk Safeguarding Partnership to raise the profile of safer sleeping and associated risks across partner agencies including support to increase knowledge of this area for Social Workers. ➢ Suffolk Safeguarding Partnership works with partner agencies to embed recognition that house moves and temporary living arrangements are seen as situational risks for babies which need proactive plans that recognise and addresses before babies are born. ➢ Closer working together between Social Care and Health in Pre-Birth Assessment and Child in Need processes. ➢ Suffolk Safeguarding Partnership to increase recognition of the importance of the Health Visitor’s role and help advocate a return to working together in partnership with families and professionals including home visits to meet the needs of families outside the Child Protection process in line with the requirements of the Healthy Child Programme. ➢ Parents own life experiences are explored in depth and understood. For young parents who are care experienced it is important to connect with professionals who have known them over a prolonged period of time. ➢ Fathers are central and must be included whether they are living with the family or not. ➢ The understanding and use of family network in Pre-Birth Assessments. Professionals need to understand the family dynamics. While parents may highlight family as support, professionals need to explore and be respectfully challenging. ➢ Supervision is used effectively to explore risk and hypothesis. Supervisors in Social Care to follow up that information has been verified or explored, that raises or lowers concern which could change the trajectory of the case. ➢ Pre-Birth Assessment to remain open until after the baby is born and there has been time for stress testing of plans and support. Practice managers to have oversight of this and authorisation of all Pre-Birth Assessments. ➢ Hospital discharge planning meetings to be considered for Child in Need cases as part of the plan for younger parents, and parents with other vulnerabilities including where there are several addresses and uncertainties. Health to request this if felt necessary. ➢ Recognition of the power imbalance between agencies and parents. Relationship based case work that starts with this awareness is essential. Table of Practice Points. Page 26 of 32 1 The presenting issue was understood to be concerns of father visiting the property against the Pre-Birth Assessment advice and the housing provider was spoken with. However, consultation and relevant information sharing needs to take place between all involved agencies if assessment is to be reliable and comprehensive. Leaving Care were worried about Miss W’s choice of relationships and the impact of being young and parenting two small children. Liaison with the team could have explored these issues further. Health, if updated during the Social Work Assessment, could have updated their systems and been aware for any future contacts with the family. In addition, conversation with Mr B was not pursued and his motivation for why he told probation he was visiting Miss W and R and then recanted when this information was passed to Social Care was not explored within the Social Work Assessment. 2 When recommendation is case closure in Pre-Birth Assessment (and subsequent Social Work Assessment), consideration of potential impact for families who may be moving to another area at a time of change for the whole family. For Miss W this meant changing health visitor, midwife, and surgery, close to L being born whilst moving away from a supported living environment. 3 Initial professional thinking which becomes accepted in an assessment may be at risk of being replicated in subsequent assessments if information is not sought out that may challenge or question this theory. 4 It was known information that Miss F had experienced periods of poor mental health including self-harm, and this was part of the reasoning for the referral from Midwifery. However, there is no evidence of recorded checks with Miss F’s GP or follow up with ICENI regarding her reduction work for alcohol and cannabis and therefore the assessment relied on mothers self-reporting that she was feeling stable, and this was in the past. Mr B had advised he had completed assessment with ICENI also for alcohol and cannabis use but had not consumed these since February 2021 and this appears to be based on father’s own reporting. 5 For M, decisions were made based on the initial Social Work Assessment as well as case discussion as the Pre-Birth Assessment had not been written up or authorised. Key elements in fathers’ life had not been explored or understood and therefore was an unknown quantity which is likely to heighten risk. A key aspect of supervision in Pre-Birth Assessment is to help analyse what is known and provide direction where more information is required to make an informed decision about risk. 6 The omission of information from reports from Norfolk County Council that could have been included in the Pre-Birth Assessment led to a flawed assessment and plan. The information contained within the psychologist report regarding father would have very likely increased the recognised risk of significant harm to M and would have resulted in a child protection plan before birth. In addition, the knowledge that Mr D had been effectively ruled out by Norfolk County Council as Page 27 of 32 a carer for his older child if included and considered within the Pre-Birth Assessment would have raised additional concerns 7 Case closure took place at an important point for Mr K - two days before N was born without settled accommodation for N and with Mr K about to become a father. Whilst Social Care remained involved with the family through N, this was not in Mr Ks own right as a vulnerable 17-year-old who experienced anxieties and very recent Child Protection involvement. Mr K had developed a trusting working relationship with his Social Worker, and this could have continued (as she remained case responsible to the siblings) until some measure of stability was in place and there were some months to go before Mr K was 18. 8 Although some good practice is evident in liaison between the Social Workers for the then unborn N and Mr K, the Pre-Birth Assessment does not explore in depth the dynamics of paternal family and Mr Ks place in this or use other involved professional’s insight in any depth. 9 Babies who are moved between addresses need to be viewed through a situational risk lens and require active plans which recognises frequent moves as a potential risk for families. 10 All professionals who have worked with children recently (not only current allocated workers) to be notified sensitively by their agency and offered an emotional wellbeing session in recognition of the impact this can have on professionals. 11 Social Workers to consult the Independent Reviewing Officer when assessing parents who are open to the Care Leavers Service, who may no longer be involved but have a long-term perspective and knowledge to share. 12 Assessments that are holistic and dynamic. Whilst recent past assessments might be the starting point, to give them too much weight risks confirming past outcomes without thorough enquiry. 13 Clear conversations between Leaving Care and Social Work teams resulting in shared understanding of the concerns and how these are expressed to parents jointly are important. 14 Supportive mechanisms to be put in place to assist Social Work teams so that health colleagues receive electronic copies of Child in Need plans and notes of meetings as standard. 15 Vulnerable families that move across health visiting and GP areas require timely coordination when transferring to avoid confusion and delay and at times this can be challenging. Consistent closer working between Child in Need professionals would support this information being shared sooner. 16 Supervision in Pre-Birth Assessment work needs to unpick information and events with Social Workers and provide meaningful direction, especially for newly qualified Social Workers. Pre-Birth Assessment work can be high risk and high stakes and approached with this understanding in supervision to ensure information is followed Page 28 of 32 up, checked, and analysed so that supervisors and Social Workers understand what the situation is rather than what they may be told it is by parents. 17 Families in Child in Need cases need the same level of relevant information sharing and professional collaboration as families in Child Protection processes. 18 Social Care Practice Managers to have final authorisations for all Pre-Birth Assessments. 19 Where children who are about to become parents have been subject to Child Protection plans, the Child Protection conference chair alongside the operational team will ensure the plan acknowledges and addresses potential impact for the new parent as part of the new Child in Need plan. 20 For children who become parents and have been open to Social Work teams, consideration for their case to remain open as support for their own needs in the short term until routines are in place. 21 Where Youth Justice Service is involved with a young person who is about to or have just become parents, Social Care and Youth Justice Service to ensure relevant information about family history and dynamics are shared to inform Youth Justice Service practice. If the young person has recently closed to Youth Justice Service, the Social Worker to include them in Pre-Birth Assessment. 22 Health Visitors to discuss with their safeguarding leads in reflective supervision if levels of planning are not felt sufficient in the case. Research evidence National Child Safeguarding Practice Panels review, ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm.’ This suggests multi-agency action to address pre-disposing risks of SUDI for all families, and with targeted support for families with identified additional needs; ensuring that safer sleep advice and risk assessment are joined up with wider considerations of safeguarding risk and plans to work with families to address safeguarding concerns; systems and processes that support effective multi-agency practice in working with families, particularly those at high risk of abuse or neglect. According to the study, the most effective programmes were those that started prior to the birth of the child and continued after and were conducted by individuals that the families trust and believe. During the conversations with some Health professionals the issue of pressures from cuts to the services offered and the impact of this came to the fore when thinking about families that move across areas which means transfers of records and a change of health professional including GP and health visitor and midwife if mother is pregnant. Service cuts can mean that a family has been in a new area for some time before being alerted if the family does not get in touch. Health Visitors are not able to undertake supportive visits outside of the national offer and this means much joint working that used to be in place between health and SC cannot happen and lessens the opportunity for Health Visitors to offer support to vulnerable families. The Institute of Health Visitors in a 2019 position statement (see appendices) call for, “Recognition of the advanced specialist nature of the health visitor’s role Page 29 of 32 returning autonomy to work in partnership with families and others to meet the needs of all families in line with the requirements of the Healthy Child Programme”. The National Review of Non-Accidental Injuries in Under Ones includes real examples where the risks from male carers or fathers were not identified with serious and at time fatal consequences. This is relevant to baby M who was harmed at home when his father is believed to have injured him. An area explored within the review is chance or opportunity, alongside the unique feature in such cases is the extreme vulnerabilities of all babies. If the situation arises where the man (in this review all subjects were male) becomes angry or frustrated and there are a number of known adverse childhood experiences the consequences are very likely to be severe for that child. From the interviews conducted it appeared that the incident was at times triggered by a normal occurrence (baby crying for example) but this extreme reaction usually due to a low frustration threshold was also in response to events in the past and at times last weeks-poor mental health, financial and relationship problems. It is therefore important to understand what adverse childhood experiences present (for any adult) and what impact this could have on a child when assessing risk. Page 30 of 32 References Prebirth Assessment Guidance (set of 3 documents) https://suffolknet.sharepoint.com/sites/myscc/CYP%20Content%20Library/Good%20Practice%20Guide/Assessment%20and%20Planning/2012-11-28%20Planning%20Pre-Birth%20Assessments%20V1.2.docx https://suffolknet.sharepoint.com/sites/myscc/CYP%20Content%20Library/Good%20Practice%20Guide/Assessment%20and%20Planning/March%202022%20Pre-birth%20flowchart%20v1.7.docx https://suffolknet.sharepoint.com/sites/myscc/CYP%20Content%20Library/pre-birth%20assessment%20tool.pdf Death in Infancy Review 2020 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf Institute of Health Visiting Statement 2019 https://ihv.org.uk/news-and-views/ihv-position-statements/ National statistics on SIDs 2020 www.lullabytrust.org.uk/professionals/statistics-on-sids/ National Review of Non-Accidental Injuries in Under Ones (Myth of the invisible men) 2021 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf SPP Escalation Policy. https://suffolksp.org.uk/assets/Working-with-Children-Adults/Policies-CYP/Escalation-Policy/2021-11-10-SSP-Final-Escalation-Policy-v6.pdf National Review of the murders of Arthur Labinjo-Hughes and Star Hobson. National review into the murders of Arthur Labinjo-Hughes and Star Hobson - GOV.UK (www.gov.uk) Endeavour House Ipswich Suffolk, IP1 2BX 01473 26 55 00 ‖ www.suffolksp.org.uk |
NC52328 | Non-accidental injuries to an 8-week-old infant. Child L collapsed at home; medical investigation found a severe brain bleed and extensive retinal bleeding. Learning includes: bruising in a pre-mobile baby must always be considered of concern and be investigated further; professional judgement needs to be supported with specific guidance; information for parents is an important part of supporting professionals to deliver clear information regarding processes when bruising in pre-mobile babies is found; commissioners' contractual requirements of a service can be a barrier to professional judgement and exploration of history to inform assessment; fathers play an important role in family life, and should be included in universal services offer as the norm; an environment for safe disclosure, alongside an embedded culture of professional curiosity provides robust evidence that the issue of domestic abuse has been thoroughly assessed; learning can be gained from cases that have had good outcomes as well as those that become serious case reviews. Makes a number of recommendations including: ensure that during a child and family assessment, social workers asks direct question about experiences of domestic abuse, where the case has not been referred due to domestic abuse; seek assurance from health visiting providers and commissioners that the impact of data collection that inform key performance indicators (KPIs) does not impact on the ability and capacity for health visitors to exercise professional judgement; ensure that fathers' needs are considered and met in services.
| Serious Case Review No: 2022/C9493 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Serious Case Review A Review of Learning Related to Safeguarding Pre-Mobile Children Who Present with Bruising Author: Karen Rees Presented to a Safeguarding Children Board 14 August 2019 2 CONTENTS 1 INTRODUCTION 3 2 PROCESS AND SCOPE 3 3 THE REVIEWER 3 4 CHILD L AND FAMILY 4 5 BRUISING IN PRE-MOBILE BABIES 7 6 CHALLENGES AND LEARNING 8 7 CONCLUSION 20 8 RECOMMENDATIONS 21 APPENDICES Appendix One: Terms of Reference Appendix Two: Answers to Generic Questions; Learning from SCRs 23 26 3 1. INTRODUCTION 1.1. A Safeguarding Children Board were alerted to a serious incident related to Child L, an eight-week-old baby who collapsed at home. Following medical investigation, Child L was found to have a severe brain bleed and extensive retinal bleeding believed to be the result of a non-accidental injury. Child L made a full recovery and there are no apparent remaining symptoms from the injury. 1.2. The Community Health NHS Foundation Trust has undertaken an extensive Serious Incident Investigation using Root Cause Analysis, as practitioners within the Trust had contact with Child L, noted the visible markings but did not recognise the need to undertake safeguarding referrals. This report takes into consideration the learning from that review but will not reinvestigate those findings. 1.3. The Safeguarding Board discussed the case and following consultation with the Chair of the Board and Child Safeguarding Practice Review Panel, it was agreed that there was potential for serious harm and that the case met the criteria for a Serious Case Review (SCR). Due to the investigations that had already taken place, it was identified that it would be appropriate to undertake a proportionate review. 1.4. The Safeguarding Board undertook this review in order to identify further learning and blocks and barriers to implementation of best practice when considering bruising to pre mobile children. 2. THE REVIEWER 2.1. The Safeguarding Board commissioned an independent reviewer as chair and author of the review. Karen Rees is an Independent Safeguarding Consultant with a paediatric nursing background. Karen worked in Safeguarding roles in the NHS for a number of years. Karen is completely independent of the Safeguarding Board and its partner agencies. 3. PROCESS AND SCOPE 3.1. The Safeguarding Board formed a panel to oversee the SCR process. The panel set the Terms of Reference and identified that an alternative methodology to that more usual for a SCR would best fit the circumstances. It was identified that the main practitioners involved in the case were not available to be involved in the review. It was therefore not possible to discuss with those practitioners why decisions had been made in the way that they had. The panel agreed to a methodology that would provide a window on the system, using Child L as a case study, that identifies any learning or gaps in the systems that support professionals to assess risk and safeguard pre mobile babies who present with bruising. 3.2. The author reviewed summary reports presented from involved organisations and identified themes for learning. These themes were presented along with a series of questions at a multi-agency workshop. The workshop was moved from the original timeframe in order to engage enough practitioners to enable full and collaborative learning. Full Terms of Reference are included in Appendix One. 3.3. The workshop was attended by relevant professionals who may be in the situation to recognise risk of bruising in a pre-mobile baby. The attendees at the workshop were asked to work in multi-agency groups to debate the issues and challenges that the various areas of practice presented to frontline practitioners. 3.4. The direct work from the multi-agency workshop informed the responses in each section that led to learning and recommendations. The report is therefore written in a style that reflects this different approach to 4 gathering learning in the form often akin to a thematic review. The review therefore retained the use of a collaborative approach. 3.5. In order to include checks and balances, the panel then reviewed the learning to ensure that it met with the understanding of processes and expected practice in organisations and that more senior managers were appraised of the issues, barriers and challenges that the workshop had identified. The panel then supported the formulation of recommendations to improve practice. 4. CHILD L AND FAMILY 4.1. The genogram below provides the context of Child L’s family. In order that genders of the children are anonymised, they are represented by non-gender specific symbols. Ages are denoted as at the time of the incident. 4.2. It is not known when Mother separated from her previous partner, but it is known that Mother and Father had been in a relationship for about two years at the time of the incident. Sibling one and two had contact with their Father. Fifteen months prior to the injury to Child L, following a visit, the Father of Sibling 1 and 2 contacted Children’s social care expressing concerns about the care of his children as Sibling 1 had been noted to have a sore to the leg. A child and family assessment was carried out and no concerns were identified. 4.3. When children’s social care contacted the health visiting team as part of their agency check, the health visiting team indicated that the family were not known to them. The family were new to the area having moved from another county. 4.4. The health visiting team visited the family, undertaking a ‘movement in contact’. The family were deemed as having needs at Universal Services as per the Health Child Programme (HCP)1. The health visiting team requested the records from the previous health visitor, but these were never received. This assessment did not take account of the recent social care investigation or missing history. There was no further communication 1 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk 5 between children’s social care or the health visiting team regarding the outcomes of assessments and visits that related to the referral that had been received. 4.5. Both siblings were in receipt of speech and language therapy input during the timescale of this review. Sibling 2 was investigated for headaches. There were two minor injury unit attendances, one for each sibling. Both of these were assessed in MIU in accordance with safeguarding procedures and no concerns were identified for either attendance. The siblings did not come to the attention of any other services. 4.6. When Mother became pregnant with Child L, she received routine antenatal care from the midwifery service and attended all appointments with midwives and for associated screening appointments. Labour and delivery were normal, midwifery services discharged Mother and baby on day fifteen as is usual for uncomplicated post-natal care. Midwifery services were aware of the social care assessment but did not identify any concerns at the time of their involvement. 4.7. The heath visitor was notified of the birth of Child L four days after birth and competed the new birth visit in line with timescales set out in the HCP. The health visitor saw Child L, Mother and Sibling 2 at this visit. There were no concerns noted by Mother or the health visitor and Universal Health visiting services were offered, the six-week check was booked, and Mother was reminded to register the birth of Child L and to register with the GP. Father was not present at this visit and there is little documentation related to him as Father of the new baby or as a step parent to the other two children. Universal screening for domestic abuse was not undertaken as the sibling was present. 4.8. Three weeks later Mother contacted the health visiting duty line regarding concerns that Child L was constipated. On discussion it was assessed that Child L was not constipated and appropriate advice was given including what to do if Mother was still concerned. 4.9. Ten days later, the health visitor saw Child L and Mother for the planned six-week home visit. No one else in family was recorded to be present during visit. Mother reiterated the symptoms of constipation and again, on assessment Child L was not found to be constipated and further advice was given. Child L had gained weight and was seen to be clean, appropriately dressed, and interacting positively with Mother. Child L was reported by Mother to be smiling. Mother had registered Child L with the GP and booked a post-natal check. 4.10. There is no clear recording that the Domestic Abuse question was asked and no documentation regarding other members of the family. It is not clear who was present at the visit. 4.11. Four weeks later, Mother contacted the health visiting duty line to report that she had noticed a purple mark originating on the side of Child L’s neck now radiating down the arm and side. The health visitor on response to questioning of Mother, recorded that the baby had not fallen or been dropped. Mother also reported that although the baby had not been lethargic, Child L was noted to have been irritable the previous night. The health visitor advised Mother to make an appointment with the GP that day and to call back if that was not possible. The health visitor told Mother that she would inform her allocated health visitor and ask her to make contact. 4.12. Mother contacted the GP and made an appointment as requested. 4.13. Mother took Child L to the GP complaining of a rash. The Mother had noticed marks on the chest the previous week and on the arm that day. The GP ascertained that Child L’s delivery was normal and following the birth, was gaining weight and all examination checks were detailed and reported that baby was developing well. The 6 GP considered that the marks appeared to be bruising. It was agreed to follow up on the rash/bruise a week following the examination to be reviewed and possibly referred to paediatrics. 4.14. Mother took Child L to baby clinic the next day. The summary from the HV service states that Mother told the health visitor that the GP had said that marks were consistent with bruising. It was noted in the red book that Child L had been seen in clinic two weeks earlier and that a bruise had been noted on the sacral2 area. The health visitor noted a new bruise to the cheek of Child L. The health visitor liaised with the GP for an update. 4.15. It is of note that Mother had therefore presented Child L on three occasions to different professionals with concerns about marks to the body that could have been bruising. This possibly indicated that she was concerned. 4.16. Other than what was presented previously there have been no issues reported with the other children that would give rise for concern. 4.17. Apart from a couple of Minor Injury Unit attendances for non-related matters, there has been no reported involvement of services with Father. Father is listed within health assessments by the health visiting team as being Mother’s current partner. 4.18. Child L collapsed at home in the evening following the last clinic attendance. Child L was resuscitated following rescue breaths given by Father on instruction from the ambulance service. On admission to the Emergency department, Child L received recovery treatment. Despite Mother giving a history of the bruising this does not appear to have been taken into account either in the ED or on initial admission to the paediatric ward. It should be noted however, that at this stage the primary concern would be immediate preservation of life and stabilisation of Child L’s condition. The history of bruising was noted as part of the overall assessment, the significance of this was unknown at this point in Child L’s journey 4.19. As is the case where causation of presentation is not immediately obvious, safeguarding procedures were commenced following review by the paediatrician later the next day when physiological causes for Child L’s presentation were being excluded. 5. BRUISING IN PRE-MOBILE BABIES 5.1. The evidence of the link between child abuse and presentation of bruising in pre-mobile children is compelling. A systematic review on bruising3 that included scientific research from 1950-2016 identified that bruising is the most common feature of abuse in children. Of the studies included, it was identified that one had emphasised the need to investigate all pre-mobile children with unexplained bruising and another indicated that three infants found with bruising who were not investigated as child protection concerns, all presented later with severe abuse, two of which were fatal. 2 Sacrum (Sacral Region) The sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). The sacrum is a triangular-shaped bone and consists of five segments (S1-S5) that are fused together. 3 The Royal College of Paediatrics and Child Health (RCPCH) (2017) Child Protection Evidence: Systematic review on Bruising. Cardiff University, funded by NSPCC Published by RCPCH July 2017 https://www.rcpch.ac.uk/sites/default/files/Child_Protection_Evidence-_Chapter_Bruising_Update_Final_020817.pdf 7 5.2. The implications for practice are laid out within the Systematic Review: “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given, full clinical examination and relevant investigations”. Pp9 5.3. Bruising in babies and especially those who are pre-mobile should always raise a concern and be investigated, not only because of child abuse but other undiagnosed clinical conditions and causes. 5.4. Similarly, NICE guidance for healthcare professionals, states that that child maltreatment should be suspected if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition and if the explanation for the bruising is unsuitable i.e. implausible, inadequate or inconsistent. This includes bruising in a child who is not independently mobile. 5.5. There are a variety of guidance documents in use across several areas of the country, offering specific guidance and flow charts for expected responses to bruising in non-mobile children as well as references in Thresholds and Levels of Need Documents. Currently there is no specific guidance in this county and the Support Levels Guidance does not specifically reference bruising to non-mobile children. 5.6. Child L had presented with bruising in three areas of the body on three occasions to different professionals and was 8 weeks old at the time of collapse. There was no explanation sought by professionals or given by parents; the areas of bruising would be of concern even in a mobile child as they are not areas that usually bruise accidentally. The author would therefore argue, notwithstanding hindsight, that the presentation should have raised significant concern and been referred to children’s social care and a paediatrician. 6. CHALLENGES & LEARNING 6.1. Based on how this case unfolded and the evidence-based information, there are several challenges that this case presents that require consideration for the Safeguarding Children Board (and its successor) and across all multi agency partners. 6.2. The issues that this case has presented were formulated into areas for learning and improvement. Questions and considerations were framed using the following model (based on Hampshire Safeguarding Adult Board Reflective Learning Framework) at the multi-agency workshop. Responses from the multi-agency partners who attended the workshop has led to learning points and recommendations in the following sections. 6.3. It is of note that whilst this was a multi-agency workshop, due to the nature of services, the issues of this case are particularly pertinent to those universal services such as health visiting, midwifery and GPs. The learning, however, is applicable to all services who work with children and families. 8 Understanding and Application of Procedures in cases of bruising in pre mobile babies. 6.4. There is no evidence in this case that safeguarding procedures were considered at any stage until Child L was reviewed by a paediatrician the day following collapse, despite presenting with rash and marks thought to be bruising for which there was no explanation. 6.5. On research of several LSCB websites, there is a wide variance of not only what procedures, protocols and guidance there are, but also what is contained within them. Most importantly there is a wide range of how much professional judgement is allowed for within guidance. Some areas stipulate that all bruising in pre-mobile babies must be referred to a paediatrician AND children’s social care. Some guidance states that if, on professional judgement, there are continued concerns, then there is a requirement to refer. Some areas also provide leaflets to be given to parents when bruising is found. Leaflets explain why referral is necessary and what parents can expect to happen next. Response 6.6. Partners attending the workshop had the opportunity to view some of the protocols and guidance that the author had researched from various areas of the country. What is supposed to happen?What is evidence telling us is actually happening?Why is there a difference?What needs to change & how will we achieve it?Barriers to ImprovementQuestions for Multi Agency Partners: • What procedures are available across this county? • Is there specific multi agency protocols and/or guidance regarding bruising in pre-mobile babies? • Are procedures easily accessible? • Are procedures clear on the process to follow? • How is professional judgement accounted for in procedures? • Do we need additional procedure/guidance as per examples? • Are procedures based on current best practice? How will we know when we have achieved it? 9 6.7. Multi agency partners considered that there were no specific procedures for bruising in pre mobile babies across this county. The procedures that are in place are the standard Child Protection procedures that identify what to do in cases of suspected Non-Accidental Injury (NAI). Procedures do identify that bruising in pre mobile babies should be considered as non-accidental unless there is evidence, or an adequate explanation provided. The procedures do not go further as to how to gather evidence or an adequate explanation and what expected practice should be. In the case in question there was no explanation for the bruising. 6.8. This county’s Levels of Support Guidance and the single page overview of the document is widely accessible but does not make specific reference to bruising in pre mobile babies, although that partners at the event felt that the guidance is generic enough to be applied in relevant situations, feedback from GPs find that it is too generic. 6.9. It was felt that professionals need more guidance on what is expected when a bruise is found. There are concerns that if professional judgment is left to an individual practitioner in isolation of any other information, this could lead to biased and non-evidence-based decision making. ‘Checks and balances’ are required in the system. On the other hand, if guidance is too prescriptive it may limit professional judgement and conversations and managerial/peer support with decision making. 6.10. There was also a question raised as to whether the creation of a social care record for children and families, where there were no concerns found on investigation, was the right way forward. There was also concerns expressed about swamping the system with referrals where there was reasonable explanation for the bruising. 6.11. The author would argue that the RCPH research previously referenced3 is compelling and that a presentation of bruising in a pre-mobile baby remains rare. Evidence from areas that have introduced mandatory referral to children’s social care has not led to excessive referrals. What it does mean though, is that practitioners have clarity on exactly what needs to happen in these cases. It must also be remembered that in many cases where physical abuse is or has happened, that the bruise is often only an indicator and other injuries have been found on further specialist paediatric examination, many of these leading to the death or lifechanging injuries for those the infants. 6.12. Medical conditions that result in bruising are rare but equally need thorough paediatric specialist investigation which would be part of any investigation into bruising in this and any age group of children. 6.13. In this case, Child L did survive with no adverse effects of the injuries, but the bruise was not the only injury. 6.14. Partners considered that a single flow chart, to support practitioners, alongside a leaflet for parents, would be helpful alongside relevant training and briefings. 6.15. The Community Health Trust has introduced an incident reporting flow chart for NAI in the health visiting service. The author notes that this is not a safeguarding flow chart but an internal tool to aid managers to identify good practice and where there may be lessons in the reporting and practice regarding NAI. The tool is not a child focussed safeguarding tool to aid decision making and onward referral to Children’s Social Care. 6.16. As a result of this case, there is a protocol being written for all agencies that come into contact with families in this county. The author has reviewed this document and believes it is the start of having a robust procedure. The draft document does indicate there will be a leaflet for parents, which the author strongly recommends. The draft document would benefit from a clear one sheet flowchart of the process. 10 History Informing Assessment 6.17. This family were new to this county. There is very little evidence that services knew very much about their history. Health visiting records were not received from the previous area and it is not clear if the GP had received the previous records for the whole family. The social care assessment in 2016 does not indicate if checks were undertaken in the previous area. 6.18. It is clear in the case of bruising in pre-mobile babies, that context and parental explanations are important to understand. It is also of note that understanding history can be key to safeguarding. Several Serious Case reviews as well as analysis and research indicate the importance of history informing assessment.4,5, 6 . The latest analysis of Serious Case Reviews7 indicates from one case: Response 6.19. Partners first discussed how information is gathered about families who are new to an area as it is relevant in this case. Partners noted that there are many mechanisms to health visiting teams becoming aware that a family has moved into their area. This may be at the time that the family registers with a new GP (although this is problematic if families do not register as soon as they move). Families may come to the attention of agencies by attendance at A & E or other clinics. On occasion a health visitor from another area will make contact to inform the new health visitor that a family is moving. 6.20. A visit by the health visitor is only offered if a child in the family is under one year old. Records from the previous area are requested by the child health department. It is of note that only electronic records are received, and that any information contained in older paper records may not be available. Within the 4 Child N Serious Case Review 5 Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC 6 Brandon, M., Belderson, P., et al (2008) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003–5. London: Department for Children, Schools and Families. 7 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education Questions for Multi Agency Partners: • How do we gather history? • Do records/assessment protocols prompt what information is expected to be gathered in assessments of New to Area/new patient/client contacts? • Is there clear guidance on receiving in records from other areas? • Are our movement in procedures effective? • What is the process for ensuring assessments include history? Learning Points: • Bruising in a pre-mobile baby must always be considered of concern and be investigated further • Professional judgement needs to be supported with specific guidance • Information for parents is an important part of supporting professionals to deliver clear information regarding processes when bruising in pre mobile babies is found. “This case has illustrated that in order to perform a child protection role effectively universal services need to be fully informed of the family ‘history’” 11 Community Health Trust there was a delay in uploading all paper records to electronic systems during the change process; this is now resolved. 6.21. Gathering information from older records can be difficult. The archiving process has led to inaccuracies in how data was recorded and in some cases information gaps have led to records not being able to be traced. It is of note that newer archiving systems are much more efficient with fewer records lost. 6.22. Police and social care systems, as non-universal services, record only information that has been made as a result of referrals and incidents and is therefore different. There are very clearly laid out procedures for transfer of information where children are subject to a Child Protection Plan. Where children have transferred from another area and they are not subject to Child Protection Plan but there is a referral to a new area may lead to a social worker having to travel to another area to read the records as information is not readily shared from another local authority area. This is deemed a barrier to gathering effective information. 6.23. Police systems are national and local. Recent improvements have led to police being able to access all relevant information across the country. Information would only be actively passed between policing areas where there is a serious incident e.g. cases that are subject to MARAC8, MAPPA9. 6.24. When it comes to gathering a history in a new assessment in universal services e.g. new to area or new birth visit there is a current reliance on the health visitor or midwife asking the right questions. Some of these are guided by proformas and assessment paperwork. Health visitors suggested that some of these assessments are based on information gathering that is a contractual requirement of the service from the commissioners. Practitioners argued that this can be overwhelming and leave little in the way of a framework for a health needs analysis for newer practitioners who do not have the experience of what was previously used in analysing family health needs. As this has been learning from another recent case review, the Family Health Needs Analysis Framework is about to be reintroduced which will provide a robust framework for information gathering and assessment. 6.25. Midwives stated that information is gathered over several appointments with a couple. This includes gathering a social history and any previous children of both partners and if they live with the couple. If there are children living elsewhere questions are asked about this. Any concerns are sent to the safeguarding team for further review of family members identified. 6.26. It is of note that this area links to other areas and especially professional curiosity discussed later in this report as it is often this that encourages professionals to seek out more history and make further enquiries when there is a need to understand history in more detail. 6.27. Previously, some detail within health visiting records was recorded in a family record. It was not deemed appropriate to transfer the family record but only the child’s. This is now not the case and individual records can be created for any carer or person that a health visitor is working with. This enables the transfer of records as appropriate. 8 MARAC stands for Multi-Agency Risk Assessment Conference. The Domestic Violence MARAC is a meeting where agencies talk about the risk of future harm to people experiencing domestic abuse and if necessary their children, and draw up an action plan to help manage that risk. 9 MAPPA stands for Multi-Agency Public Protection Arrangements. It is the process through which the Police, Probation and Prison Services work together with other agencies to manage the risks posed by violent and sexual offenders living in the community in order to protect the public. 12 6.28. It is of note that the front door for referrals into children’s social care has improved information sharing where referrals have been made. This can only be effective if assessments in universal services contain enough information to inform decision making should there be a need. Due regard must be given to the family history in the gathering of information to inform assessment. Involvement of Fathers 6.29. When reading all of the information that was provided for this review, there was very little recorded about Father. Father was registered at a different GP practice than Mother and the children. Information gathered during the review, is that Father had very little contact with the GP. He had been registered since 2013. There is no history of any significant illness including mental health. Father had no contact with the surgery in the timeframe that this review is looking at. 6.30. Engaging fathers has been the subject of focus in previous serious case reviews 10. When fathers are either not engaged or where their role in the family is not understood, professionals are left not knowing to what extent a father may be a risk or protective factor within a family. In this case, there was no assessment of Father’s history or wishes and feelings as a parent. It is not known if Child L was his first child or if he had other children. 6.31. Research by the University of Worcester and the Fatherhood Institute11 concluded that health visitors are well placed to include fathers in their work with families using the Healthy Child Programme. An evaluation of a training programme proved to have been positive in raising awareness in the importance of engaging with fathers and provided ideas of new and innovative ways to achieve this. Response 6.32. In universal health visiting services, it is expected that that details of the father are recorded, a genogram should also be included in records and various other helpful data which includes if the father is resident in the household. Meeting with fathers, however, can be problematic due to working patterns of fathers and health 10 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ 11 Nolan, M (2014) Evaluation of a Training Programme and Toolkit to Assist Health Visitors and Community Practitioners to Engage with Fathers as Part of the Healthy Child Initiative: A developmental study using action research. University of Worcester Questions posed to Multi Agency Workshop: • What is expected practice in engaging with Fathers? • Is there any guidance or training? • What are the challenges for professionals? • Is there any local learning regarding this issue? • Are there examples of good practice? Learning Points: • Commissioners contractual requirements of a service can be a barrier to professional judgement and exploration of history to inform assessment • Assessment frameworks are required to ensure that there are prompts to gather the right information and history from a family, thus promoting professional curiosity. • Movement in procedures in universal services must be robust with checks and triggers to ensure that records are shared and received in a timely manner and pursued where necessary. 13 visitors. 6.33. Other services don’t have such an issue. Midwifery services often get to see Fathers as there are improved employment practices that allow fathers to attend antenatal appointments and this is encouraged. Children’s social care and the police in any referral they receive will go out of their way to see and engage with fathers as this is expected and vital to any investigation. 6.34. For midwifery and health visiting this appears to change after delivery though. Midwives and Health visitors report that fathers do not expect that they will be interested in seeing them and the belief is that interest moves to mother and baby. 6.35. When challenged why this is the case, it appears that although encouraged and invited to stay if the father would like, there is not a predisposed expectation that the midwife and health visitor will see the father with the mother and baby. 6.36. Where fathers are present, there is some good work undertaken now particularly with the recognition of mental health issues for fathers after a baby is born. 6.37. There is no specific guidance or training regarding this issue. 6.38. Practitioners feel that the pressure put on them by commissioning requirements mean that they have a lack of power and discretion over which areas a family needs to have input. The hours that the service operates is also dictated by commissioners and therefore the opportunity to work flexibly to incorporate fathers and indeed working mothers is not available. It does not appear that there has been any work done with fathers locally to understand what their needs are. 6.39. It is of interest to note that it was suggested that where a couple may be of the same sex and have had a baby, either by IVF, surrogacy or adoption, then the service received becomes less delineated and more flexible. i.e where there are two mothers, they both get the same service, and where there are two fathers, they would be offered a service on a par with if they were mothers. It only appears to be heterosexual couples where this is so much of an issue. It would be interesting to know if that was the case as policies and procedures do not include services for same sex couples who have a baby. Midwifery services suggested that they would concentrate on the partner that had given birth, or the surrogate mother who had given birth. There is little clarity regarding what services are offered to adoptive parents in same sex relationships. Records do not have the ability to record parents as other than mother and father. 6.40. Health visitors and other services also report that staffing levels are an issue and that the inclusion of fathers takes more time and therefore commissioners and mangers need to support decisions regarding increasing funding and or staffing or reducing other work in order to consider priorities better. It is of note that there has been a step change in the type of service offered now that Health visiting is commissioned by Public Health in that there is more requirement to gather information and deliver services more aligned to public health issues rather than addressing as a routine the broader social and safeguarding, but that expectations are that all areas will be covered. 6.41. There is a suggestion from some that this has led to increasing numbers of staff leaving the service. 6.42. It is also the case that families can decline the universal health visiting service, it is suggested that there may be two reasons for this, either the family do not want the professional to know of concerns or that they do not see 14 what the service has to offer and do not feel involved. Therefore, opting out of a service that it would be expected for families to accept should be challenged to ensure that a rationale is recorded. This should be true of where a father actively opts out of engagement with a service. 6.43. Another issue was thought to be the gender of most health professionals in midwifery and health visiting services, i.e. would more males in the workforce encourage more father involvement? 6.44. It has been noted by some that there are more fathers phoning the duty line and attending clinics in recent years. This may well indicate that fathers do want more inclusion with services that may have been historically perceived to be for mothers and babies alone. It is felt that in the first instance that fathers’ feelings about a service and what would encourage them to attend should be considered before services change to address the gap that is perceived by professionals. It is reported that there used to be fathers’ groups, but these no longer exist. 6.45. Without clarity from universal services that fathers’ health, well-being and role as a parent is as important as mothers’ it is not possible to know if perceived non engagement of a father would or should indicate a risk or if there is other rationale. Screening for Domestic Abuse 6.46. There is no evidence that domestic abuse was a feature in this relationship. Due to the prevalence of domestic abuse being estimated at 1 in 4 women and that domestic abuse often starts or escalates in pregnancy12, it has long been advocated that all pregnant women should be screened for domestic abuse in a safe environment with access offered to support networks should they be required. This is reiterated in more recent NICE Guidance (2014)13 and NICE Pathway (2016)14 6.47. There is no record of successfully screening for domestic abuse in midwifery, GP or health visiting services. 12 Department of Health (December 2005) Responding to domestic abuse: a handbook for health professionals 13 https://www.nice.org.uk/guidance/ph50 14 http://pathways.nice.org.uk/pathways/domestic-violence-and-abuse Learning Points: • Fathers play an important role in family life, and therefore should be included in Universal Services offer as the norm. • Good understanding of the role that a father plays within a family can help the understanding as to whether father plays a positive supporting role and is a positive role model for growing and developing children or whether they are likely to be considered as posing a risk • Knowledge of the role that fathers play can further inform level of service need rather than basing that purely on assessment of mother. • The above is true whether father is resident within the household or not. 15 The absence of any thorough assessment of elements of domestic abuse as a feature within this relationship in line with NICE guidance and pathways, means it could not be ruled out. Research shows that it often takes several opportunities and enquiries before some victims will disclose, and some never do, suggesting that asking once is probably not enough to allow for a victim to come forward for support. Creating space to allow for screening and disclosure may have been an important aspect. Response 6.48. There were various responses to this element of the review. For universal health visiting and midwifery services there is an expectation that routine enquiry to screen for domestic abuse will be undertaken at several contacts. It does appear though that there are various issues with this. The question does need to be asked of a woman on her own. Midwifery colleagues state that they try and screen on two occasions by seeing the woman alone. 6.49. This is not always possible in health visiting services and there are varying degrees of how far practitioners will go to ensure this has happened. There are also issues where the majority of health visiting contacts, and now often the six weeks follow up, are conducted in an open clinic setting. This makes asking the question more difficult and more importantly, responding to any disclosures, challenging. Guidance also states that the question should not be asked if a child over two is present, therefore again adding to limits to situations where the question can be asked. 6.50. The Community Health Trust are currently reviewing the Domestic Abuse and Violence policy. There will be more guidance on expectations if the routine enquiry question has not been asked i.e. ensuring that other methods and opportunities are made to ask the question if there are reasons that it has not been asked. 6.51. The Royal College of General Practitioners provides guidance to GPs regarding domestic abuse. This does not advocate routine enquiry but does state that GPs should enquire sensitively where any indicators may be suggestive of violence or abuse. GPs who responded across this county indicated that this is their usual practice. 6.52. For non-universal services, the system is different. Children’s social care and police are often responding to referrals where domestic abuse may already have been disclosed or is a known feature in a relationship with specific processes to follow upon disclosure or incident. 6.53. Children’s social care identified that if assessing a family, where domestic abuse is not known about, then assessing the relationship would routinely include gleaning information about family history and relationships and therefore a specific question is not prompted in assessment paperwork and nor is it thought to be specifically necessary. 6.54. The author would argue that whilst this may be the case, it does leave this to individual practice, particularly in recording and flagging if domestic abuse has been disclosed, there are indicators of domestic abuse, or Questions posed to Multi Agency Partners: • What is usual practice for screening across agencies? • What is the guidance/policy? • How do we record screening to ensure completed? • What are the challenges? • How are we assured that practice keeps up to date? 16 domestic abuse has been denied. 6.55. The Child and Family Assessment proforma does require an answer regarding if there are factors regarding any domestic abuse. Research leading to the compilation of NICE Guidance would suggest that it is necessary to ask the specific question rather than gleaning information in a ‘round about’ way when frontline professionals are meeting with patients/clients etc. The guidance was reassessed by NICE in 2018 did not identify that any changes were required. 6.56. Partners felt that there were different practices across this county. Some of this was believed to be regarding how much exposure staff may have to cases of domestic abuse but also due to different expectations and leadership styles. It is recognised that NICE Guidance is associated with guidance for health and social care staff. Due to the extensive research methods of gathering best practice, it is useful guidance for all organisations to consider when thinking about their own policies on the subject. The following were also cited as barriers to whether screening using routine enquiry was successfully undertaken and recorded: • Training needs • Policy • Clarity in records as to whether question has been asked/answered. • Confidence to ask the question • Access to regular supervision • Language barriers and difficulties accessing interpreting services • Time pressures • Bank staff and staff turnover Authoritative Practice 6.57. An issue that has come to light at this point of the review is an apparent absence of authoritative practice. Authoritative practice covers skills and competence, child centred practice, support and supervision. 6.58. Previous studies regarding learning from SCRs, the more up to date Triennial Analysis of Serious Case Reviews15 and Lord Laming in his review into the death of Victoria Climbié16, have indicated that it is important to maintain a respectful uncertainty of parents. It is suggested that it is possible to do this without affecting the professional/patient/client relationship. 15 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education 16 The Lord Laming, (2003), The Victoria Climbié Enquiry Learning Point: • NICE Guidance indicates that routine enquiry into domestic abuse should be undertaken. An environment for safe disclosure, alongside an embedded culture of professional curiosity that encourages opportunistic exploration of indicators, provides robust evidence that the issue has been thoroughly assessed. The outcome should be carefully and safely recorded. Without this, any possible impact on the lived experience of the children is not possible. Practitioners should be supported to apply these principles with policies and training that underpin practice. 17 6.59. In order to ensure that assessment is comprehensive, robust and child centred, professional curiosity is needed whilst maintaining a healthy scepticism of the issues that are being presented. Sidebotham (2013)17 identified that this is only possible if professionals are able to adopt authoritative practice. This authority comes from competence and confidence whilst practising. It requires empathy to keep the child at the centre whilst considering the needs of the parents. This then necessitates humility from professionals who are willing to accept the limitations that they may have in their knowledge and skills to seek advice, supervision and guidance. 6.60. The author would suggest that many of the practice issues that the case has highlighted may have been more thoroughly addressed if practitioners had displayed professional curiosity and applied professional challenge. The ability to practice in this way comes when practitioners are authoritative in their practice. 6.61. Agencies therefore need to promote a culture of authoritative practice and provide the systems and mechanisms of training advice and supervision. In agencies where those cultures are in place and there is clear support and mechanisms for robust supervision and training in child protection, these skills are transferrable to all practice. Child L presented with a rash/bruising. There was no clear collaboration between the GP and Health Visiting service. The confidence and competence to apply evidence base to the presenting features, empathy with Mother who was presenting concerns did not follow through with actions to protect, nor accepting that there was at the very least a need to seek guidance and support. Response 6.62. Partners agreed that they knew about authoritative practice but were not clear that it is an embedded culture across all agencies and services. Partners felt that there needed to be clear policies and guidance to support practice to give confidence to practitioners. It was felt that there should be structured time for supervision and specifically safeguarding supervision that should be prioritised. Staff felt that other pressures often meant that supervision was overlooked. 6.63. In response to this the Community Health Trust indicated that there are two types of supervision, clinical and safeguarding supervision. Safeguarding supervision for health visitors is mandatory with non-attendance and cancellations monitored and exception reported to the CCG. Safeguarding supervision is also audited to ensure that it is taking place as required. The Trust have agreed to undertake a further audit to ensure that this is still the case. The Safeguarding team in the Community Health Trust also operates a consultation line that is available during working hours. Supervision for social workers is also mandatory and takes priority unless there is an initial child protection conference or other agreed priority work. 17 Sidebotham, P. (2013) Authoritative Child Protection. Child Abuse Review, 22(1): 1-4 Questions for Multi Agency Partners: • How do we embed a culture of authoritative practice? • How do we ensure collaborative working? • How are we assured that the workforce is competent? • Can we be assured that supervision is targeted at the right cases? • How do we embed messages from SCRs locally and nationally? • How do we engage with authority and maintain sensitivity with parents when there is a concern? 18 6.64. It was also thought that being in receipt of good quality information sharing also helped authoritative practice from robust handovers and information between agencies. 6.65. Practitioners cited that the reasons why authoritative practice is not happening is because there is not enough time in the system to allow for good quality training and reflection. There is not enough training and often training gets fully booked. It is felt that there is not enough multi agency training and reflection. Some services felt that more weight is given to ensuring that KPI’s (Key Performance Indicators) are met than unmeasurable qualitative elements of the service like outcomes from good supervision and reflective practice. 6.66. Other issues that were felt to be barriers to effective authoritative practice were cited as: • Serious Case Reviews can be seen to be a fearful motivator rather than a learning exercise • Fear of raising sensitive issues with families • Lack of time • Staffing issues/turnover and Bank staff • Fear of stepping on the toes of other professionals and lack of confidence to challenge • Putting policy into practice due to focus on KPIs 6.67. Partners also felt that there was value in shadowing other agencies to gain and understanding and appreciation of how other services work and that this would improve collaborative and multi-agency working. It was also indicated that multi agency reflection and supervision. Making use of mentoring for less experienced staff was also felt to be a way of improving confidence and competence in practice. Generic Questions 6.68. There were also some generic questions considered by partners in order to identify how learning from SCRs is embedded in organisations. These are identified in Appendix Two 7. CONCLUSIONS. 7.1. Reviewing the systems that were available to the practitioners in the case of Child L, a ‘window’ on those systems has been viewed. it has been possible to identify areas for learning within the systems, that might afford practitioners the authoritative practice to manage cases where a pre mobile baby presents with bruising. The learning may also give practitioners the skills to identify those that may be at heightened risk of NAI. 7.2. It is apparent that there are no specific multi agency guidance and processes in this county for practitioners who identify markings that may be bruises in pre mobile babies. There is a reliance on the use of usual safeguarding processes for physical abuse and a heavy reliance on professional judgement to know how to respond in each Learning Points • Too much focus on KPIs can be a barrier to authoritative practice • Staff need adequate access to good quality policies and guidance that are readily accessible, supported by appropriate training and reflective supervision. • Learning can be gained from cases that have had good outcomes as well as those that become Serious Case Reviews. • Increasing authoritative practice can be gained from mentoring, shadowing and utilising multi-agency supervision 19 case. 7.3. There is enough evidence to indicate that there should always be a concern when a baby presents with a bruise and therefore, in order to ensure a consistent response, guidance and accompanying information for parents is seen as needed for this county. Due to the numbers of cases of this nature that lead to a Serious Case Review, many LSCBs have produced specific guidance. 7.4. How prescriptive that guidance needs to be will be a matter for the Board to consider; contact with other boards who have considered the pros and cons of very specific guidance may be of help. It is of note that although the case of Child L was related to a pre mobile baby, that any guidance will need to inclusive of all non-mobile children who present with bruising as those situations must also be of concern. 7.5. Alongside guidance, the issues of ensuring that family history is understood also provides early indicators of risk, especially where a family moves to a new area. Inclusion of fathers in gathering that history as well as delivering services to families as a whole have been explored and recognised as important when understanding risks and ensuring equitable services. 7.6. The issue of ability to undertake routine enquiry for domestic abuse has been explored and challenged. 7.7. On all of the associated assessment and risk gathering elements of this review, services have cited consistent themes of that are seen as barriers; workload pressures to ensure that KPIs are delivered and staffing issues of high vacancies and bank staff. These coupled with changes to record keeping and assessment tools are also seen specifically in health visiting as not helpful. 7.8. This review has raised the issue of equity of services in same sex parenting and ensuring that services consider the needs of 21st century families when commissioning and delivering universal services. Do services offer a different service based on gender of parent whether that be in same sex or heterosexual parenting relationships? 7.9. It could be argued that services should be commissioned and offered based on needs of the individuals in the population and a recognition that it is not always easy to identify short term outcomes where it is a qualitative service being delivered. 7.10. Finally, it will be important to ensure that the recommendations from this review lead to the required improvements and it is therefore necessary to make use of audit and appreciative enquiry to evidence that improvements are working in practice and to assess areas that need ongoing work. 8. RECOMMENDATIONS 8.1. This review makes the following recommendations for this Safeguarding Board; Recommendations are made under several main themes and require this Safeguarding Board to ensure that the following are addressed: 1. Policy • This Safeguarding Board should continue to pursue and ratify the protocol that is currently in draft “Protocol for the management of actual or suspected bruising in infants & children who are not independently mobile” This must include the provision of an information leaflet for parents and a clear one page flow chart of the process. 20 • This Safeguarding Board must review the Support Levels Guidance to ensure that it references bruising in non-mobile babies and children and cross references the specific protocol once ratified. A review should also consider feedback from partners on any further amendments that would be helpful. • This Safeguarding Board should request that the local Domestic Abuse Strategy Group ensure that the newly ratified guidelines take account of NICE Guidance that evidences best practice. • The Community Health Trust must assure this Safeguarding Board that their ‘movement in’ guidelines and policies ensure robust information sharing in a timely manner and that there are guidelines to ensure appropriate pursuance and escalation of non-received records. • This county’s Children’s Social Work Services to assure this Safeguarding Board that during a child and family assessment, social workers ask a direct question about experiences of domestic abuse, where the case has not been referred due to domestic abuse. 2. Information informing assessment • This Safeguarding Board to seek assurance that all services who assess families’ needs have assessment frameworks and documentation that has a section to record history of family and household members. 3. Capacity in the system • This Safeguarding Board should seek assurance from Health Visiting providers and commissioners that the impact of data collection that inform KPIs does not impact on the ability and capacity for health visitors to exercise professional judgement. There must be time allowed for relationship building and assessment that may safeguard children. • Commissioners and providers should consider how much the movement away from more traditional health visiting models has impacted on sickness, recruitment and retention of health visitors. 4. Engaging with Fathers • This Safeguarding Board should ask commissioners and providers to ensure that Fathers’ needs are considered and met in services. This is to ensure that full consideration is given to the need to offer services that are inclusive of all parents and carers. • This Safeguarding Board should provide a briefing on the importance of inclusion of Fathers and all carers in assessments and service offers. This topic should feature in all this Safeguarding Board’s core safeguarding training programmes. 5. Authoritative Practice In order that the learning can be addressed there is a need for specific programmes of activities to improve and embed a culture where authoritative practice becomes the norm in practice. Activities need to cover the workforce who work with families. 21 Elements should consist of: • Ensuring all guidance is available, up to date and relevant • Safeguarding Children core training is Multi Agency and includes understanding of authoritative practice. • Supervision in agencies evidences supportive respectful challenge. (Multi-agency Safeguarding Supervisor Training should be considered) • Ongoing safeguarding audit programmes of Board and within agencies include these issues. • Appreciative enquiry is used to identify good practice both at Board and within single agency safeguarding/board meetings/staff meetings (as relevant to each agency). 22 Appendix One: Terms of Reference (Redacted) SERIOUS CASE REVIEW TERMS OF REFERENCE AND PROJECT PLAN SUBJECT: Child L 1. Introduction: 1.1 This Serious Case Review (SCR) has been commissioned by the Safeguarding Children Board because the child has suffered serious harm as a result of abuse or neglect. 2. Legal Framework: 2.1 SCRs and other case reviews should be conducted in a way that: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 3. Methodology: 3.1 This SCR will be conducted using a systems approach, which reflects on multi-agency work systemically and aims to answer the question why things happened. Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements. The model engages frontline practitioners and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written agency reports with a ‘window on the system’ practitioner workshop. 3.2 This model is based on the expectation that serious case reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, minimising hindsight bias. 3.3 The review model adheres to the principles of: • Proportionality • Learning from good practice • Active engagement of practitioners • Engagement with families • Systems methodology 4. Scope of SCR: 4.1 Timescale of the review from 1st August 2016 to 1st November 2017. In addition, agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of Child L’s immediate family. This will include any significant event that falls outside the timeframe if agencies consider that it would add value and learning to the review. 5. Agency Reports: 5.1 Addendum Agency Reports will be requested from: • Police 23 • Children’s Social Work Services and Early Help • The Hospital Foundation Trust • The Community Health NHS Foundation Trust, • GP 5.2 Agencies are requested to use this Safeguarding Board ‘s Report Template. 6. Areas for consideration: 6.1 Agency report authors should consider the following: What was life like for the child in this family? • How was this captured? • How was it acted upon? What was the impact of Single-Agency and Multi-Agency working? • What was known by agencies? • What information was shared? • How was it shared? How were assessments, including risk assessments, undertaken? • What single agency assessments were undertaken? • What agency perspectives were of the risk posed to the child by his parents? • What interagency discussions, if any, took place regarding assessments and risks? 7. Engagement with the family 7.1 A key element of any review is engagement with family members, in order that their views can be sought and integrated into the learning. This Safeguarding Board will inform the family that this review is being undertaken and will offer the child’s parents the opportunity to meet with the Lead Reviewer. 7.2 Their contributions will be included in the Overview Report and they will be offered feedback at the end of the process. 8. Timetable for Case Review: Deadline for agency addendum reports 22nd February 2019 Meeting with family (if accepted) TBC Draft report produced 18th March 2019 Draft report shared with attendees of Practitioners’ event 19th March 2019 ‘Window on the system’ practitioners event 26th March 2019 14th May 2019 Draft report to be presented to the SCR Panel 25th June 2019 Final report to Panel (virtual) TBC Report presented to the Safeguarding Board TBC 24 Appendix Two: Generic Questions; Leaning from SCRs Question Learning points How do we ensure that learning from SCRs reaches everyone in each organisation? There is a need for varying methods of availability of feedback from SCRs to meet all learning styles and to access large numbers of staff e.g. • Bitesize briefings, • Away days • Multi agency inclusion of staff in SCR process (such as this SCR) • Addition of key themes in mandatory safeguarding training How do we know that learning from SCRs is effective? • Supervision • Feedback to board • Peer reviews • Further SCR shows improved practice • Appreciative enquiry at Board and agency meetings. What does our multi agency case file audit process tell us? • Can be important indicator of improvement as long as appropriate topic area is identified. • Appreciative enquiry and multi-agency review of a case that has positive outcomes is an alternative way to evidence what works well when working with families. |
NC043763 | Death of a 4-month-old baby boy from a serious head injury in December 2011. Both parents had been looked after as children, had experienced childhood abuse and were chronic substance users. Father had two older children who had been removed from his care and had been living with adoptive parents for a number of years. History of prolific paternal offending including convictions for actual bodily harm, harassment and threatening behaviour. Identifies themes for learning including: establishing a professional lead in multi-agency processes; need for acquiring comprehensive social histories from parents; understanding the needs of children not yet born or too young to express emotions or feelings; recognising unemployment and poverty as risk factors; recognising disguised compliance and maintaining a sufficient level of professional scepticism; impact of coercive relationships on vulnerable women; and engaging men and fathers. Sets out key findings using a systems based typology developed by SCIE and raises issues for consideration in regards to the identified themes for learning. Includes Lancashire Safeguarding Children Board's response to findings.
| Title: A serious case review: 'Baby E': the overview report LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks Date of publication: [2013] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. overview report baby E publication version Page 1 of 90 Lancashire Safeguarding Children Board A Serious Case Review ‘Baby E’ The Overview Report October 2012 overview report baby E publication version Page 2 of 90 Index 1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review .................................... 4 1.2 The methodology of the serious case review ....................................... 4 1.3 Reasons for the review and terms of reference .................................... 6 1.4 The scope of the serious case review .................................................. 7 1.5 The terms of reference in national guidance ........................................ 9 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews: ............................................................... 10 1.7 Membership of the case review panel and access to expert advice ........ 11 1.8 Independent author of the overview report and independent chair of the serious case review panel ......................................................................... 12 1.9 Parental and family contribution to the serious case review ................. 13 1.10 Time scale for completing the serious case review .............................. 13 1.11 Status and ownership of the overview report ..................................... 14 1.12 Previous serious case reviews ......................................................... 15 1.13 Inspections of services for children in Lancashire and Calderdale ........... 15 1.14 Summary conclusion of the review panel .......................................... 16 1.15 The family and other significant people ............................................ 22 1.16 Cultural, ethnic, linguistic and religious identity of the family ................ 23 2 Synopsis of agency involvement ............................................................. 25 3 The critical reflection and analysis from the individual management reviews. . 30 3.1 Summary .................................................................................... 30 3.2 Significant themes for learning that emerge from examining the IMRs ... 30 3.3 Good practice identified through the review ...................................... 31 4 Analysis of key themes for learning from the case and recommendations ...... 69 4.1 Learning from previous serious case reviews ..................................... 70 4.2 Innate human biases (cognitive and emotional) .................................. 70 4.3 Responses to incidents or information .............................................. 76 4.4 Longer term work ......................................................................... 77 4.5 Tools .......................................................................................... 79 4.6 Management systems ................................................................... 82 4.7 Issues for national policy ................................................................ 84 5 APPENDICES ....................................................................................... 87 Appendix 1 - Procedures and guidance relevant to this serious case review ....... 87 Legislation ............................................................................................. 87 The Children Act 1989 .......................................................................... 87 The Children Act 2004 .......................................................................... 87 Safeguarding Procedures ......................................................................... 88 The local safeguarding children procedures .............................................. 88 Other local procedures relevant to this serious case review ........................ 88 Multi-Agency Pregnancy Liaison and Assessment Group (MAPLAG) .............. 88 National guidance ................................................................................... 89 Working Together to Safeguard Children (2010) ........................................ 89 overview report baby E publication version Page 3 of 90 Framework for the Assessment of Children in Need and their Families 2001 .. 89 Common Assessment Framework (CAF)................................................... 90 1 Preface: 11 July 2013 This report was completed in late 2012 but could not be shared with family members or published until after the conclusion of associated criminal proceedings. Since the report was completed, MO and FI both pleaded guilty to child neglect and received custodial sentences. The final report has been shared with MO and she did not wish to add anything to the content of the report. Following the conclusion of this review in late 2012 the Department for education has published revised guidance for the completion of serious case reviews. This review was completed using the statutory guidance in place during 2012. overview report baby E publication version Page 4 of 90 Introduction and context of the review 1. In December 2011 Baby E, aged four months was admitted to hospital in Lancashire in the early hours of the morning with serious head injuries, said by his parents to have been caused by a heavy object having fallen onto him. He was transferred to a specialist children’s hospital outside of the county, where he died the following day. MO and FI were both present when the incident had occurred and had called the ambulance. 2. The circumstances of the death are still subject of an ongoing investigation by the police and a coroner’s enquiry. 3. Baby E was the only child of MO. She had moved back to the county from Calderdale soon after the birth of Baby E in the summer of 2011. 4. FI was born in West Yorkshire. He has two older children who had been removed from his care and placed for adoption more than ten years previously while he was living in West Yorkshire. 5. The decision to commission a serious case review was not taken until the results of toxicology tests of the parents and other evidence identified that the circumstances of Baby E’s death was suspicious. As soon as this information became available it was referred back to the child death panel and a serious case review panel was commissioned. Further information is provided in section 1.3. 1.1 Rationale for conducting a serious case review 6. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010). 7. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death. 1.2 The methodology of the serious case review 8. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. The panel was chaired by an independent and suitably experienced person. 9. Work began on compiling a chronology in May 2012, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. Neither the chair nor overview report baby E publication version Page 5 of 90 the overview author has worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.8. 10. This serious case review was completed using the methodology and requirements set out in current government national guidance that applied at the time of the review being commissioned and completed. That guidance is being extensively revised following the publication of the Munro Review’s final report and recommendations in 2011. 11. The government has indicated that it supports changes recommended by Professor Eileen Munro that future serious case reviews should be conducted using systems based learning methodology; details about what that methodology and framework will be had yet to be finalised when this review was completed. 12. The LSCB in Lancashire are already working on how future serious case reviews in the county can be developed in order to provide a more productive window into the local systems for safeguarding and protecting children1 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence). 13. In the meantime this review and the overview report have complied with current requirements. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present key learning within the context of local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children2. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions. 1 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004; The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England. 2 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans overview report baby E publication version Page 6 of 90 14. It is important to state that this is not a SCIE review that has used systems methodology to collect and analyse information from the people directly involved with the family. The panel have worked to place the evidence that has been analysed into a framework that begins to explore how the local systems both promote and in some circumstances inhibit professional practice and decision making. 15. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in section1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the children and their parents. 16. An overview of the health agencies was provided in a health overview report. This was provided jointly by Calderdale and Lancashire health services and was co-ordinated by the designated nurses for safeguarding in NHS Calderdale PCT and the PCT for this area of Lancashire. 1.3 Reasons for the review and terms of reference 17. The reason for undertaking this review is that Baby E may have died as a result of negligence. The death was reported to the Lancashire Safeguarding Children Board (LSCB) on 19th December 2011 and considered by the serious case review (SCR) panel on 9th January 2012. At that point there was insufficient information to enable a decision to be made as to whether the circumstances of Baby E’s death met the national criteria for undertaking a serious case review, as it was unclear at that time whether this was more than a tragic accident. 18. The matter was considered again by the SCR panel on 5th March 2012, when more information was available. However, the police investigation was ongoing and it was not yet clear whether anyone might be held responsible for the death. 19. On 13th April 2012 both adults were charged with child neglect and MO was also charged with gross negligent manslaughter. The SCR Panel met on 1st May 2012 and decided, in the light of information that had become available, that the criteria for a serious case review were met. The review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board (LSCB) on the 1st May 2012. A serious case review panel was convened and was chaired by Annie Dodd who is independent of all the services involved. overview report baby E publication version Page 7 of 90 20. The serious case review panel at their first meeting on the 30th May 2012 confirmed the scope and terms of reference. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection. 21. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Lancashire and Calderdale. 1.4 The scope of the serious case review 22. The time period covers the lifetime of Baby E, including the time his mother was pregnant with him. The time of conception was late 2010 and Baby E died in December 2011. 23. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and the health overview report. 24. The SCR also sought to establish if there was anything in the parental history, or the history of either parent, that could and should have led to different actions and decisions being made in respect of Baby E. Therefore all agencies were asked to check their records for mother and father and to include anything of note in their IMRs. 25. All agency chronologies included detailed information about when the child was seen or observations were made about him. 26. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history. 27. Reviews of all records and materials were considered including; Electronic records Paper records and files Patient or family held records. 28. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board (LSCB), and were quality assured and approved by the most senior officer of the reviewing agency. overview report baby E publication version Page 8 of 90 29. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures. Health services in Lancashire that include: o A Lancashire Hospital NHS Trust (provided post natal and paediatric services after MO moved to Lancashire and provided hospital treatment) o Lancashire NHS Care Foundation Trust o Lancashire NHS General Practitioner Inspire (the specialist substance misuse service in Lancashire that worked with MO but not FI) Lancashire County Council Children’s Social Care (received a faxed referral from Calderdale CSC after Baby E and MO had moved to Lancashire) Lancashire Sure Start Early Years (had accepted a referral but had not formally begun involvement prior to Baby E’s death) Calderdale Children’s Social Care (aware of the family from May 2011 through duty service but never an allocated case) West Yorkshire Police Service South West Yorkshire Partnership NHS Foundation Trust (provided specialist substance misuse services who worked with MO and FI) Calderdale and Huddersfield NHS Foundation Trust (provided the midwifery service)3 Calderdale Community Health Services (GP) Calico (housing provider in Lancashire)4 30. Information was sought from other services although these agencies were not required to provide an IMR. Bradford and District Care Trust (FI known to the drug dependency service historically over several years) 3 MO was involved with Calderdale Substance Misuse Service (CSMS), and was therefore under the care of the Eden team specialist midwife service which links into MAPLAG (multi agency pregnancy liaison and assessment group); further information is provided about the protocol in later sections of the report. FI was known to have mental health problems and was also receiving a service from CSMS and was on a Methadone programme. As a consequence of her substance misuse and Methadone programme, MO was managed throughout the antenatal period by a multi-agency perinatal service hosted by Calderdale Substance Misuse Service (CSMS) managed by South West Yorkshire Partnership Foundation Trust (SWYPFT). Included in this service was the Eden team substance misuse midwives (CHFT). Running concurrently alongside this service was the MAPLAG assessment process and a safeguarding integrated care pathway (ICP) 4 Calico was not commissioned to provide an IMR until after the first meeting of the panel in June 2012. overview report baby E publication version Page 9 of 90 Central Manchester University Hospital NHS Foundation Trust (Baby E was admitted by ambulance following the head injury and is where he died) North West Ambulance Service (responded to the initial emergency call after Baby E was injured and transferred him to Central Manchester) NHS Direct Consultant paediatrician’s report for the panel in regard to whether injuries identified after death could have been identified by any of the professionals in contact with or visiting Baby E and his family; the report confirmed that although Baby E would have exhibited symptoms of distress at the time the injury was incurred it would not have been obvious to professionals visiting after the incident Yorkshire Ambulance Service 31. Because of the involvement of services from two other local authority areas, those LSCBs were invited to participate in the serious case review. Calderdale had been involved during the timeline established for the review and provided IMRs from the CSC and health trusts included in the list of agencies in paragraph 24. Bradford’s involvement had been more historic and therefore information reports were provided on behalf of CSC and health services. Reference is made to this information later in the report. 1.5 The terms of reference in national guidance a) Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews. b) To establish a factual chronology of the action taken by each agency; c) Assess whether decisions and action taken in the case comply with the policy and procedures of the Lancashire Safeguarding Children Board; d) To determine whether appropriate services were provided in relation to the decisions and actions in the case; e) To recommend appropriate inter-agency action in light of the findings; f) To assess whether other action is needed in any agency; g) To examine inter-agency working and service provision for the children; h) To establish whether interagency and single agency policies adequately supported the management of this case; i) Consider how and what contribution is sought from the family members; overview report baby E publication version Page 10 of 90 j) To develop a clear multi agency action plan from the overview report. 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews5: 32. In addition to analysing individual and organisational practice, the individual management reviews should focus on: a) Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration. b) Examine whether all agencies kept the child and his experiences at the centre of their assessments of and interventions with the family. c) Examine whether information sharing and communication systems within and between agencies and across boundaries were effective in safeguarding Baby E. d) Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Baby E. This should include any assessments of the mother’s entitlement to support in relation to her care history, drugs, alcohol and domestic violence and any pre-birth assessments of the needs of Baby E. It should also include any relevant information about the father’s older children. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs. e) Examine whether agencies fully understood any issues about parental substance misuse and mental ill health and the impact this had on Baby E and took appropriate actions. f) Examine whether agencies dealt with any domestic violence issues appropriately and considered the risks to Baby E from those issues? g) Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. Consider whether professionals relied for information on the self reporting of parents, and how far this influenced the safeguarding and protection of Baby E. Consider whether there were any barriers or difficulties in the child receiving services. 5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter fours and five of this report. overview report baby E publication version Page 11 of 90 h) Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. Consider whether any organisational changes impacted on work with this family. i) Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of your agency’s actions in relation to these. 1.7 Membership of the case review panel and access to expert advice 33. An independent person was appointed to chair the case review panel from the outset. Section 1.8 includes information about her experience and knowledge. 34. The case review panel that oversaw this review comprised the following people and organisations; Position Organisation Annie Dodd Independent Chair Directorate Safeguarding Manager Children’s Safeguarding Services LCC Early Years Lead Quality and Continuous Improvement Service, LCC Temporary Deputy Head of Children's Social Care Children’s Social Care Services LCC Strategic Safeguarding Lead Nurse Lancashire Care Foundation Trust Detective Chief Inspector Lancashire Police Service Acting Service Manager Safeguarding and Quality Assurance Service Calderdale Commissioning and Partnership Care Senior Young Peoples Substance Misuse Co-ordinator Lancashire Drug and Alcohol Action Team Designated Nurse for Safeguarding Children NHS Calderdale Designated Doctor NHS Lancashire Designated Nurse NHS Lancashire Named Nurse Safeguarding Children South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) Detective Inspector West Yorkshire Police Service Associate Director for Safeguarding Calderdale and Huddersfield NHS Foundation Trust Safeguarding Lead Adults A Lancashire Hospitals NHS Trust overview report baby E publication version Page 12 of 90 Floating Support Service Manager Calico Enterprise Panel Observers/Support Peter Maddocks Independent Author Business Manager Lancashire Safeguarding Children Board (LSCB) Business Manager Calderdale Safeguarding Children Board (CSCB) Business Manager Bradford Safeguarding Children Board (BSCB) 35. The independent author of the overview report attended every meeting of the panel. 36. The panel had access to legal advice from a solicitor in the council’s legal service. 37. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team in Lancashire. 1.8 Independent author of the overview report and independent chair of the serious case review panel 38. The independent chair of the serious case review panel was Annie Dodd. Ms Dodd was previously employed as an assistant director with a local authority children’s social care service and has over 30 years experience as a qualified social worker. Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case. 39. Peter Maddocks was commissioned in May 2012 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the General Social Care Council (superseded from August 2012 by the Health and Care Professionals Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on a previous serious case review in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review. overview report baby E publication version Page 13 of 90 1.9 Parental and family contribution to the serious case review 40. The parents were made aware of this serious case review when it was commissioned. Both have been charged with criminal offences relating to Baby E's death, and contact with them has to be managed very carefully with assistance from the police to ensure their involvement does not impact on the criminal processes. The arrangements are subject of national guidance that has been agreed between chief constables (ACPO), the chairs of LSCBs and the Crown Prosecution Service (CPS) in England. 41. The parents were sent a letter giving them information about the SCR via their solicitor. There has been no response from either MO or FI or from their solicitors. 42. The maternal great grandparents were sent a letter. There was no response. The chair of the panel made contact with them both by telephone to explain the process of the SCR and to establish if either of them wished to make a contribution to the information examined by the SCR panel. Both have confirmed that they did not want to meet the chair of the panel. The maternal great grandfather said that when they saw their great grandson he was fine and therefore he had nothing further to say. The maternal great grandmother expressed her view that parents who are using alcohol or drugs should receive more visits; the review has confirmed that there were additional levels of contact by the health visitor and midwife. Both maternal great grandparents indicated that they felt certain no other member of the family would want to speak with the chair of the panel. 43. The maternal great aunt was contacted by letter initially and no response was received. A follow up telephone call was made by the chair of the panel although was unable to get a reply. 44. The maternal uncle and aunt were contacted by letter and no reply was received. The chair of the panel made contact by telephone and spoke with the maternal aunt who said that she had no issues to report in regard to the services who were in contact with MO. She felt that it was for the family to have noticed if something was wrong and if services were not given any concerns it was not the fault of the professionals. She did not want to provide any further information. 45. Another maternal aunt was also contacted by letter and by telephone although no reply was achieved. 1.10 Time scale for completing the serious case review overview report baby E publication version Page 14 of 90 46. The case review panel met on six occasions between May 2012 and October 2012. The initial chronology of services involvement was completed by June 2012. The first draft agency reviews were completed in June 2012. The first draft of the health overview report was completed in September 2012. This overview report was presented to an extraordinary meeting of the participating LSCBs in October 2012. 1.11 Status and ownership of the overview report 47. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning Board and Calderdale LSCB who provided IMRs and Bradford LSCB that has provided background information. Both Bradford and Calderdale LSCBs had representation at the SCR panel. The overview report and executive summary has been provided to all three LSCBs. 48. Since June 2010, all overview reports provided to LSCBs in England have to be published in full. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Baby E and his family. 49. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning. 50. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Baby H. The review does not investigate the circumstances of Baby H’s death. That is a matter for the Coroner and for the police. 51. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events. 52. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the overview report baby E publication version Page 15 of 90 review and following the submission of the overview report and executive summary to the Department of Education6. 1.12 Previous serious case reviews 53. The LSCB in Lancashire had undertaken nine previous serious case reviews between 2007 and 20107. Calderdale has published three executive summaries of serious case reviews between December 2008 and December 2009. Bradford has published four serious case reviews between 2006 and 2010. 54. Reference is made by several IMR authors to some of these and other previous serious case reviews completed in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. 55. Chapters four and five of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used. 1.13 Inspections of services for children in Lancashire and Calderdale 56. All children’s services in England are subject to inspections. Lancashire was subject to a Comprehensive Annual Assessment (CAA)8. In December 2011 the CAA annual rating given to children’s services in Lancashire was performing well9. This means that services were above minimum national standards. 57. The CAA letter highlights that although many aspects of contact, referral and assessment arrangements for children in need and children who may be in need of protection are satisfactory a number of areas required attention. 6 In England, Ofsted have the responsibility for evaluating the thoroughness of the serious case review. The executive summary includes a statement about that evaluation. 7 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. The coalition government ended the formal evaluation of SCRs from the 5th July 2012. 8 The coalition government announced the abolition of the CAA from 2010. 9 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS). overview report baby E publication version Page 16 of 90 These included the uneven distribution of experienced and newly qualified staff within social work teams and the under-developed use of the common assessment framework across the partnership. However, focused action is being taken by the local authority and plans are in place to address immediate deficiencies. These factors are identified as being contributory factors in how aspects of this case were managed. 58. In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire10. This evaluated safeguarding arrangements as good in Lancashire with a well managed child protection service; Baby E was not subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned. This had already had a positive impact. The quality of referrals made by partner agencies seen was good. Child protection enquiries were prioritised and responded to effectively to ensure children are safe. The CART (children’s referral and assessment team) had already led to improvements in the management of contacts and referrals but there were a small number of examples where referrers had not been satisfied with the CART and not all aspects of the service were subject to rigorous audit. 59. The last annual assessment of children’s services in Calderdale found children’s services to be performing poorly. A full inspection of safeguarding and services for looked after children undertaken in January 2011 had assessed services to be inadequate. The inspectors had found serious weaknesses in services to safeguard children and young people and it continues to be the major area of development for Calderdale. The local authority still needed to improve the inconsistent application of thresholds for access to children’s social care. In front-line services improvements needed include: the quality of referrals from partner agencies; aspects of management in the First Response service; inconsistency of recording, including recording management decisions on the electronic recording system; the timeliness of completing assessments and the frequency of staff supervision. Aspects of these issues are reflected in the case that is subject of this serious case review. 1.14 Summary conclusion of the review panel 60. The purpose of conducting a serious case review is to undertake a detailed examination of the events within the context of understanding how the 10 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey. overview report baby E publication version Page 17 of 90 judgements, decisions and actions were taken by the various professionals involved with Baby E and his family for the purpose of drawing out learning to inform future policy, service development and individual practice. 61. The Munro Review commissioned by the coalition government in 2010 has emphasised the importance for learning and improving services and practice by looking at information within the context of people’s professional and organisational arrangements and the information they knew at the time of events. Hindsight can distort and mislead and cause the focus to fall on how individuals behave and act rather than understanding how they are influenced by a range of contributory factors. 62. The influences on practitioners doing their work effectively include the stability of the organisation they work in, their personal workload and more generally of their services, the quality of their training and knowledge, the clarity of working arrangements in matters such as recording and sharing essential information as well as their cognitive functioning (how they are processing and analysing information). These were all important in understanding this case. 63. When MO became pregnant with Baby E it was recognised as being a pregnancy that required additional support. The Calderdale MAPLAG (multi agency pregnancy liaison assessment group) procedures11 were invoked and were the principal framework for co-ordinating information about MO’s lifestyle and circumstances which were never defined as a significant risk to the safety of her baby. This was because professionals in Calderdale and then in Lancashire initially believed that MO had separated from FI and had no intention of sharing the care of Baby E. 64. Although the MAPLAG involved relevant professionals from different services there was a lack of shared clarity about the purpose of the framework and what was expected from the different participants. There was also insufficient clarity about the leadership and coordination of any action plan. This contributed to a pattern of contact with the family that was characterised by people working within their agency ‘silos’. When information such as MO acknowledging she used drugs shortly before the birth or the faltering growth before and after birth was observed it was largely dealt with as a separate episode along with inconsistencies regarding the status of the relationship. When information was provided to CSC it was subjected to a ‘start again’ approach. These are all familiar patterns identified in other reviews at a regional and national level. 11 The appendix provides a fuller explanation of the protocol which is used in Calderdale but not in Lancashire. overview report baby E publication version Page 18 of 90 65. The HOR comments about how the MAPLAG provided an appropriate sharing of information at the outset but this did not lead on to a more robust assessment of risks or referrals and enquiries using the safeguarding protocols. The fact that CSC attended the MAPLAG may have encouraged other participants to believe that this removed any responsibility to consider whether a referral was required. The parents’ history of substance misuse, domestic violence and mental ill health were known to some extent from the outset (but detailed information was not collated) and should have been recognised as potential and significant sources of risk before and after birth. 66. Information about FI having had two previous children removed from his care was also partially known. The HOR comments about how extensive and significant information was known about both parents that were not accessed at the time. More could have been done to access historical information although the review identifies the difficulties faced by individual professionals knowing who and where to get information from. 67. The HOR comments about the problems that arise in complex service arrangements where there is contact with a family by several professionals who then record their information within their individual patient records. Both HOR authors experienced some difficulty in developing a clear narrative about this case and for busy professionals with limited time for contact and follow up this is a significant issue. 68. The parents’ history of drug and alcohol misuse was known about and there was also knowledge about the domestic abuse that characterised previous and the current relationship; professionals were persuaded that the relationship between the parents had ended before the birth and that MO was intent on establishing an independent household near her family in Lancashire. This provided false reassurance that persisted for several weeks that also reflected insufficient sceptism and understanding about the difficulties facing a pregnant woman leaving a relationship at the point of her first baby being born and the fact that FI was unlikely to relinquish contact with MO or his baby. 69. MO was also expressing intent about tackling her addictions and other problems and professionals were genuinely motivated and wanted to help her. This was a significant influence on how some services approached the provision of help and support and remained an important influence up until a few days before Baby E became injured. They did not feel that they were working with a reluctant or resistant parent and they were led to believe that she was not in a relationship with FI; this involved some deliberate misdirection on the part of both parents. The manner in which professionals especially in the CSMS in Calderdale dealt with the information about the ‘blips’ of drug use reflected a minimisation of concerns and probably provided encouragement to MO and FI that they could influence and misdirect attention. overview report baby E publication version Page 19 of 90 70. Another important influence was the organisational capacity of some key services at the time. For example, CSC in Calderdale had been inspected by Ofsted and this had found safeguarding services to be inadequate. This had immediate repercussions in terms of the senior leadership and overall staffing of the service. Some senior people left or were moved and it also became difficult to recruit or to retain staff. There was a high reliance on temporary staff some of whom were not very experienced. People who should have been providing supervision and guidance had to become involved in direct case work and this further exacerbated the problems of capacity in providing the correct degree of critical challenge and reflection. 71. This had consequences for how the case was handled and the priority that was given to it. Insufficient information was sought about FI as well as MO. Assessments were not adequately conducted. Insufficient notice was given to Lancashire when MO was discharged from hospital and moved to Lancashire. 72. The reliance on MAPLAG whilst the case was managed in Calderdale inhibited the capacity of professionals to identify the underlying patterns and to be misdirected by the apparent openness and engagement of MO. For example, MO missed several midwife appointments before giving birth to Baby E and was also missing appointments with the substance misuse service. Matters were further compromised by insufficient attention to recording and sharing information; for example MO was tested positive for drugs as well being negative for methadone (which signified not taking it over several days which should have raised queries as to how she was managing her drug dependency). Two toxicology tests were not shared outside of the CSMS. The HOR has made recommendations to deal with this significant shortcoming. 73. Although there was an apparently good exchange of medical information that was known to midwifery services and community health (but did not include significant historical information or knowledge about a pattern of drug use) at the point of transfer, there was no pre-discharge meeting in Calderdale; this was a requirement of the MAPLAG. A contributory factor appears to be the uncertainty about where MO was going to be living and the fact that she took her discharge early from hospital. The belief that MO was not going to be living with FI misdirected attention and concern away from the other factors relating to MO’s own history and circumstances which were incompletely known about. 74. For example, the fact that both FI and MO had experienced troubled childhoods that had involved abuse and that they had been looked after in public care was not apparently understood at the time. This comment is not to suggest that adults who have been looked after are not good parents. It is however important for professionals working with a first time mother in particular to understand the potential impact of a history of abuse and overview report baby E publication version Page 20 of 90 attachment difficulties for example and the implications for appropriate emotional as well as physical care of a baby. 75. In this case, the impact of a coercive relationship and substance misuse were additional factors contributing to a potentially toxic interplay and axis of risk and impaired care. MO had begun using drugs during her adolescence including cannabis. There is research evidence about the impact of long term drug use that begins in adolescence exacerbating and influencing the cognitive functioning in adults; this has implications for memory, learning new skills, behaviour control and interpersonal functioning; all attributes that are relevant for the transition to parenthood. 76. The information in regard to social and family circumstances was not complete largely because basic enquiries had not been undertaken at the outset or in subsequent referral and other key moments; this was not initially known and understood in Lancashire in regard to the gaps in the information that existed in Calderdale and therefore persisted in Lancashire; when it was recognised there were further delays in being able to take appropriate action and making enquiries. 77. In particular the history of FI and the fact that he never showed any intention of accepting that the relationship with MO was over was never recognised until he was identified as being in the house in November. The notification to CSC in Lancashire did not highlight any safeguarding concerns. There was a delay in the information being looked at and then further delay in following up historical information particularly about FI. MO had been known to CSC and had in fact been looked after by the local authority for some years; this information was largely overlooked. 78. When Baby E died he and his family were receiving universal and additional support from the community health visiting team (Child and Family Integrated Team CFIT). The mother received regular support from CFIT services however there were regular no access visits and it is now known that she had withheld information from the named heath visitor (HV1) about her relationship with Baby E’s father. Due to the history of vulnerabilities and concerns about the father the family were known to social care and were due to start an assessment at the time of Baby E’s death. The family were seen on two occasions by the specialist safeguarding health practitioner who was co-located with CSC. 79. The family received additional targeted support due to the vulnerability factors within the family. The CFIT service uses a weighting tool which highlights children and families with additional needs to inform the level of help. This family were weighted ‘amber’ (proactive support to maintain and improve family and environmental factors) from 26th August 2011 and changed to ‘red’ (instability with family and environmental factors impacting upon parenting capacity & substance misuse affecting health or impacting overview report baby E publication version Page 21 of 90 upon parenting capacity) on 21st September 2011. This weighting reflected the escalating nature of the needs of the family. It did not at that stage lead to a CAF being raised. 80. The decision to escalate the weighting followed concerns about inappropriate feeding practices; MO was believed to be diluting the formula milk and there were concerns about faltering weight gain. A referral by the specialist midwife for a paediatric opinion resulted in the paediatrician requesting that further information was sought regarding the family’s social circumstances. 81. A telephone discussion took place between the midwife and CSC in Lancashire; this revealed no concerns because at that stage Lancashire CSC were still largely working with information sent from Calderdale and there was a shared belief that FI was not in the household and that he was the primary source of concern. 82. In This part of Lancashire the CAF is routinely used and there is an expectation that a social risk assessment is completed and shared by midwives for all births in this part of Lancashire; this was not completed for Baby E as he had been born in Calderdale. This provides an example of how the application of a national framework such as CAF differs between local areas. 83. Both parents had experienced abuse and violence as children and both had been using drugs and alcohol for which they were receiving help and treatment. Although some of the history of the parents was known there were significant gaps in what professionals knew until well after Baby E was born. This meant that relevant historical information was not considered in terms of assessing risk or providing a more informed assessment about the type of support that MO needed encouragement to take up. 84. Although there was recognition that Baby E was a higher risk pregnancy, and interagency discussions were convened, these were not followed up with enough thoroughness and speed. An important factor was the impaired functioning of the referral and assessment services due to staffing and workload difficulties in both Calderdale and Lancashire. In Calderdale these difficulties were more longstanding whilst in Lancashire some of the issues that had an impact on the handling of this case reflected the fact that more staff had been recruited but were inexperienced and required training. 85. Although professionals were empathetic to MO as a vulnerable young woman, they relied too much on MO’s assertions that the violent relationship with FI was ended. The barriers that MO faced as an abused and coerced woman and the implications of her history of substance misuse were not sufficiently understood within a framework of research informed knowledge and respectful sceptical enquiry and challenge. overview report baby E publication version Page 22 of 90 86. The impact of longstanding problems such as addiction, depression, violence and poverty are significant on parents and families where these are factors. The impact on those trying to help should not be underestimated. Baby E lived in some of the most deprived communities in north England. 87. In the last few days before Baby E sustained the injury that caused him to be admitted to hospital professionals had begun to realise that there was a deteriorating set of circumstances; MO was using drugs and the recognition that the relationship with FI was not over had led to a decision to begin a detailed assessment. Baby E died before this work was started. 88. Although the panel believe that action could have been more urgently undertaken it remains unlikely that Baby E would have been removed from his mother’s care at the time he was injured. The expert paediatric report provided to the panel confirmed that evidence of injuries was only evident to professionals after the post mortem; no injuries had been observed prior to his death. 89. If information had been better shared and managed from before his birth it is highly probable he would have been the subject of either a child in need plan or rather more likely given the range of risks and the disguised parental non compliance, a child protection plan would have been in place. 90. The difference this would have made is that all the services would have been working to a common plan; there would have been a more comprehensive level of enquiry and assessment that gave more adequate attention to historical and current information and there would have been an explicit focus on the risks associated with both parents. This would either have achieved a better informed level of cooperation or would have provided the basis of further escalated action that might have involved taking the matter to court. This would probably have not been completed in the timescale before Baby E was tragically injured even if the work had started prior to his birth. 1.15 The family and other significant people 91. MO was aged 24 years old when Baby E died and FI was 41 years old. 92. MO was looked after by the local authority in Lancashire from 1994 and was subsequently supported by the leaving care service until 2008. MO has a history of using drugs and alcohol. By the time she became pregnant she was on a methadone support programme. MO had experienced domestic abuse over many years. 93. FI had also been looked after in local authority care in Yorkshire from the age of 12 years old. His two older children born to a previous partner when he overview report baby E publication version Page 23 of 90 was not living in Lancashire were the subject of child protection plans because of neglect and have lived with their adoptive parents for several years. 94. MO and FI are both long term users of drugs that have included heroin and cocaine. Both have received support from a range of services that have included substance misuse agencies; for MO in Yorkshire and Lancashire although FI was not in contact with services in Lancashire and therefore kept himself invisible to professionals in Lancashire until November 2011. FI has also had support from mental health services although had withdrawn from this help in late 2010. 1.16 Cultural, ethnic, linguistic and religious identity of the family 95. Baby E’s maternal and paternal families are white British. MO identified herself as being white British, Catholic and unemployed. MO identified FI as being white British, non religious and was also unemployed. MO’s first language is recorded as English and there is no recorded physical or learning disability. There is no record of the social background history or partner history in regard to Baby E. Baby E was living with his parents in rented accommodation at the time of his death. 96. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007). 97. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of this area of the county and in one other area. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston. 98. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation. 99. The area where MO and Baby E were living in Lancashire is within the top one per cent of socially deprived areas as identified by the Index of Social Deprivation- Department of Communities and Neighbourhoods-2010. This in effect means that many families are presenting with extremely high needs such as poverty, ill health, domestic violence, substance and alcohol misuse, overview report baby E publication version Page 24 of 90 infant low birth weight, teenage mothers, isolated single parents and homelessness. The children’s centre has between 2,500 and 3,000 service users registered at any one time and by definition a significant proportion of families and children is vulnerable and requiring substantial help and support. 100. Calderdale has a relatively static population and is relatively prosperous when compared to other metropolitan boroughs but still has significant areas of deprivation. Calderdale is ranked in the lowest third of authorities in the indices of deprivation. Parts of the area where FI and MO lived in Calderdale are considered to be amongst the most deprived areas in the country. These areas are characterised by incomes below the national average, low levels of employment, and below average education attainment and skills levels. The proportion of children currently living in over-crowded conditions substantially exceeds the national average, as does the number living in households without central heating. overview report baby E publication version Page 25 of 90 2 Synopsis of agency involvement 101. This narrative summary of professional contact with Baby E provides an account of the most significant events and decisions from the different services involved with Baby E during the timeframe established for the review. 102. For example there are more contacts and visits with primary health care workers than are referred to in this synopsis. There is historical information that is referred to by IMR authors but is not described in detail. For example FI had contact with CSC in respect of his older children who were placed for adoption; he has had extensive contact with specialist substance misuse services and mental health support. 103. The police have also had extensive contact with FI since the early 1980’s in connection with offences that have been primarily in relation to theft although there had been convictions for ABH and threatening behaviour. The police had dealt with an incident of domestic violence in August 2009 that involved FI assaulting MO until another male intervened; this summary includes details of the incidents that the police dealt with between November 2010 and December 2011. 104. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. 105. MO had originally moved to Calderdale in 2008 because of violence that she was subjected to by a relative. It is not clear when MO and FI began their relationship although in late 2010 she returned to Lancashire to live in a refuge because of domestic violence. 106. FI has a long history being a prolific offender with twenty six convictions for forty nine offences since 1983 for predominantly theft offences. One conviction was for actual bodily harm in 1993, with convictions for threatening behaviour in 1989 and 2000 and a conviction for harassment in 1998. 107. FI first came to the notice of mental health services in Calderdale in 2008; he had previous contact with services in Bradford. FI withdrew from the mental health support services in late 2010. Both parents were supported by specialist drug services. FI was reluctant to allow any information about his involvement with mental health services or drug services to be shared with professionals working with MO. overview report baby E publication version Page 26 of 90 108. In early 2011 FI had made contact with MO following a chance meeting; his efforts to persuade MO to resume their relationship was initially rejected although by early February 2011 MO had become pregnant with his child. 109. It was noted by the specialist drug services that FI appeared to be displaying controlling behaviour towards MO. MO confirmed the coercive nature of the relationship in separate discussions and described FI as being possessive, paranoid and controlling. 110. MO was referred to MAPLAG (Multi-Agency Pregnancy Liaison Group) on 26th February 2011; this is an arrangement that operates in Calderdale but not in Lancashire. The Calderdale MAPLAG was established in response to a recommendation from a previous SCR. The MAPLAG protocol is designed to co-ordinate support for women who are identified as using drugs and/or misusing alcohol. MO’s pregnancy was discussed for the first time at MAPLAG at 20 - 24 weeks of gestation in May 2011. 111. MO was described as ‘engaging very well, having only missed a few appointments’; she missed seven appointments with the CSMS and contact was by text on five other occasions during her pregnancy. No concerns were expressed in relation to MO; however concerns were expressed in relation to FI’s mental health. It is recorded in the minutes that FI’s last clinical record was dated January 2011 with a diagnosis of ‘displaced psychotic episodes, mental health has been stable for 12 months’; FI was reported to not think he had issues with regard to his mental health (that included a specific diagnosis). An action from this meeting was for the SWYPFT representative to do further checks on FI’s mental health history. It is recorded that FI was well known to the police and had two children who live with their adoptive parents; however it was noted that FI was unwilling to share any further information regarding them. 112. There is no evidence that the incident of domestic violence between MO and FI in early December 2010 and MO’s return to Lancashire to go into a refuge was disclosed or discussed at the MAPLAG meeting. Reference to domestic violence is made in the minutes of the meeting held on 6th May; however this appears to be in relation to MO’s move to Calderdale following domestic violence from her relative and in respect of FI and his previous partner. 113. MO continued to be managed throughout her pregnancy by the staff at SWYPFT - CSMS in addition to the Substance Misuse Midwife from the CHFT Eden Team and the prescribing GP’s, employed by SWYPFT. CSMS, who oversaw the prescribing of substitute medication for MO during the course of her pregnancy. MO failed to attend appointments with CSMS on seven occasions, on five of these occasions it is recorded that contact with the service was made by text message with a request that her prescription was overview report baby E publication version Page 27 of 90 either forwarded to the nominated pharmacy or given to FI. FI was informed after one of these missed appointments when he collected a prescription that MO would not issue any further prescriptions without being seen in person. 114. MO underwent urine drug testing on three occasions. The test in May 2011 was positive for methadone only but the two subsequent tests in July were both positive for cocaine with one positive for cannabis. These results were not reviewed and shared by the specialist drug services and therefore collectively analysed by health professionals in the context of the effect these drugs, in particular cocaine, would have on Baby E either before or following his birth. 115. The GP providing the methadone prescription did not review the toxicology results and recording in regard to MO referred to her being ‘abstinent for illicit drugs’. The same information was reported to the MAPLAG. The MAPLAG never made a formal referral to CSC in Calderdale. Although the MAPLAG meeting in July discussed the possibility that FI had previous children removed this was not confirmed and a plan to arrange a follow up MAPLAG was not followed through. 116. By the summer and before the birth of Baby E, MO was indicating her intention to move back to Lancashire and that she intended to separate from FI. The belief that MO was drug free and that FI was the significant source of risk meant that risks to Baby E were regarded as being low although health care professionals continued to recognise the need to provide support through enhanced visiting by health visitors for example. This was formalised through the caseload weighting given to the case. 117. Although CSC in Calderdale attended the MAPLAG meeting this was not regarded as a reason for direct involvement by CSC. When Baby E was born a week prematurely (35 weeks) a referral was made to CSC. CSC contacted Bradford and established that he had two previous children removed and placed for adoption although the precise circumstances were not established during the telephone conversation. 118. CSC made the decision that an assessment would take place if MO remained in Calderdale but if she moved to another area then a referral would be made to that authority. Discussion at MAPLAG in August 2011 had established that FI did not recognise his mental health needs and it was confirmed that previous children had been removed although the circumstances had still not been clarified. 119. The referral to CSC did not lead to a fuller assessment. The fact that Baby E was in hospital and that MO intended to leave Calderdale led the CSC in Calderdale to adopt a wait and see approach as to where MO moved. This decision meant that no detailed information was secured in respect of history overview report baby E publication version Page 28 of 90 or the circumstances of Baby E’s parents. The fact that MO was regarded as being positive about contact and support from other services also reduced any degree of further curiosity. 120. MO discharged herself and Baby E from hospital against medical advice. No discharge meeting had been arranged to plan discharge arrangements; this was a requirement of the MAPLAG procedure. Information was sent from services in Calderdale to their counterparts in Lancashire. The transfer of information between health services involved telephone discussion in contrast to CSC who only sent information by fax. 121. None of the services identified any risk of significant harm to Baby E and all described MO as having separated from FI. Although health visiting services were prioritised to reflect the support that MO required the belief persisted that MO was separated from FI. 122. The referral that was made to CSC in Lancashire after MO had moved to the county continued to describe the main source of concern to be FI’s mental health and his history of having previous children removed. The referral repeated the information that MO and FI were not living together. 123. Two days after the referral had been opened a team manager reviewed the information. This manager identified that there was insufficient information in the referral or the information that had been sent from Calderdale. There had already been delays in processing the information before the team manager reviewed the information. 124. A core assessment was completed in September 2011. This concluded that because there was no evidence that MO and FI were in a relationship and that MO continued to be supported by health services there was no role for CSC. The assessment was not completed by a qualified social worker. 125. By late summer health professionals had begun recognising that there was reluctance for MO to be involved with services. Referrals were made for floating support although this was not taken up by MO. An effort to encourage MO to participate in activities at the children’s centre was also rejected. 126. In October 2011 MO attendance with the specialist drug services was erratic. By November the health visitor and specialist drug worker were concerned about the lack of contact they were managing to achieve with MO. There were also concerns that MO appeared to be involved with old acquaintances that were using drugs. She had again tested positive for heroin and cocaine. This information was shared with CSC in Lancashire. 127. In late November 2011 information was provided through a third party that FI was living with MO. During a visit to the property on an earlier overview report baby E publication version Page 29 of 90 occasion by CSC it appeared that FI was seen but had been introduced as a friend. This was a deliberate misdirection. 128. A referral was made to CSC in the last week of November 2011. A visit was not made for another week and this was undertaken by a specialist health practitioner who was co-located with CSC. 129. The practitioner saw FI who identified himself. After leaving the house she consulted the team manager and agreed that urgent action was required. Although a section 47 inquiry was considered it was decided to proceed with a core assessment instead. A contributory factor was that the team were involved with training. The significance of not managing it as a section 47 enquiry was that work did not commence immediately. 130. Following the visit the practitioner spoke with the team manager who agreed that the case required urgent action. A section 47 investigation was considered although decided to proceed with a core assessment to be completed the following week on the basis that the risks at that stage were not clear. The Inspire worker who had originally made the referral on the 23rd November 2011 had continued to pursue information about what response was being made. 131. The Inspire worker spoke with CSC on the day that the specialist nurse had visited; the worker was concerned that MO had missed doses of methadone. CSC had tried to visit on four occasions without success. 132. During an appointment with Inspire at the beginning of December 2011 MO expressed her upset at CSC visiting and her anxiety that Baby E would be removed. She said that nobody had explained why FI should not have contact with Baby E. She acknowledged during the discussion that she was using heroin, cocaine and was drinking alcohol although presented the information as not being a daily occurrence. 133. Four days later Baby E sustained very serious head injuries. The parents’ account was that the TV fell on Baby E when they were changing a scart lead. The parents were arrested. Baby E died from his injuries the following day. Post mortem examination revealed that Baby E had sustained other injuries on previous occasions. The paediatric report provided to the panel confirmed that there was no evidence that a professional had missed signs of injury that would have been difficult to detect unless the incident causing the injury had been observed. overview report baby E publication version Page 30 of 90 3 The critical reflection and analysis from the individual management reviews. 3.1 Summary 134. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency. 135. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review. 136. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities. 3.2 Significant themes for learning that emerge from examining the IMRs 137. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the finding of national evaluation and research. Important messages for learning from this review include: a) The importance of establishing clarity in regard to who is the lead professional in multi agency processes such as MAPLAG, CAF or TAC (team around the child); b) Clarity about distinct processes such as MAPLAG, ICP (integrated care pathway), CAF and statutory assessment and why and when they are used and their purpose; c) The need for clarity about how assessments are planned and coordinated and quality assured (especially significant with the impending withdrawal of national frameworks); d) Understanding the needs of children not yet born or too young to express or display emotions or feelings by exploring with parents the significance of the child to them; e) The importance of ascertaining sufficient history about parents and their family to inform assessments of need and risk; f) The need for all professionals to have the confidence to ask questions and to maintain a sceptical curiosity; more than one professional commented on feeling overwhelmed or intimidated by the number of people sometimes in the in the house or the presence of FI; overview report baby E publication version Page 31 of 90 g) The threat to effective practice when organisations become stressed or feel overwhelmed by the level and nature of need being presented; h) Understanding the nature of domestic violence and implications for assessment at the point of pregnancy and following birth; in particular understanding the coercive nature of such relationships and the extent of vulnerability it engenders on the part of the victim; i) Understanding the nature of addiction and substance dependency and its significance for assessing and supporting parenting capacity; j) Confirmation of the need to ensure timescales and the attainment of key performance indicators do not perversely impact upon professional practice and the quality of child and family interventions. This will be a key feature of the directorate's response to the recommendation of Professor Eileen Munro's report. However, this must be balanced with the need to ensure a timely response to safeguarding issues. k) Effective assessment requires appropriate knowledge and tools to help make sense of opaque and contradictory information; it cannot just rely on observation; l) Clarity of role and function of "embedded" multi-agency professionals as the momentum for co-located teams’ increases and to ensure the significant benefits of collaborative approaches are fully achieved. m) Develop the skills of front-line practitioners in working with adult males and fathers and making them more visible; n) Ensuring clarity regarding information sharing and requests to other authorities for historical information; a persistence in following up information; o) The value of a chronology of previous involvement and where previous significant historical involvement has taken place with other authorities; p) The pitfalls within assessments of cognitive and confirmation bias and over reliance on self reporting. The value of training and development opportunities to introduce and develop a more assertive, objective professional response; q) The importance for those working directly with a family having access to appropriate and reflective supervision; managers who have a dual practitioner status should not take responsibility for endorsing their own allocated cases. 138. It is important that constructive feedback and reflection is provided to all the practitioners involved in this case. In particular, it will be important to support practitioners who are at a relatively early stage of their career to give them the appropriate positive encouragement for their continued professional development and retention in the workforce. 139. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs. 3.3 Good practice identified through the review overview report baby E publication version Page 32 of 90 140. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance. 141. Examples of good practice identified by the review include; a) The MAPLAG provided an opportunity for early discussion about a higher risk pregnancy and sharing of information across relevant services; b) The midwife in Lancashire identified that Baby E’s weight had become static and made a referral for paediatric advice that was provided the same day; c) The paediatric assessment secured relevant social information including MO’s acknowledgment about using street drugs; d) The ambulance that responded to the emergency call after Baby E sustained his head injury was on the scene within four minutes having been diverted from another call; this is well within the national response target for ‘code red’ calls and indicated that the seriousness of the injury was recognised by the call dispatcher and good management of response teams; e) The ambulance crew ‘scooped and ran’ with Baby E and rendezvoused with a paramedic en-route to ensure that Baby E was receiving medical support in transit to the hospital; f) The ECC call takers provided support to the crew liaising with the police and pre-alerted the hospital. This is an example of good practice where parts of the NWAS system worked efficiently to communicate with external agencies to pass on crucial information; 142. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of reference. Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration. 143. It is striking how little information was collated about the background of MO or FI and insufficient inference given to their social and economic exclusion that was evidenced by their lifestyle and circumstances. The HOR comments on the specific factors that deserved further enquiry such as the childhood histories of being looked after as well as the difficulties and needs they both had. 144. The substance misuse service IMR acknowledges that little information was sought about MO’s sources of support although it was known that she had been in public care for a considerable time as a child. The serious case review panel has had considerable levels of information that could have been overview report baby E publication version Page 33 of 90 available to services but was not accessed effectively at the time. This is explored further in later analysis in regard to the complex systems of information storage that confronts practitioners. 145. The CSC records in Calderdale did not collate information about the social background and culture of the family that included significant levels of abuse in both parents’ histories as well as concerns about domestic violence and substance misuse. This reflected the generally passive approach of managing the case as for ‘information only’ in the absence of a more active role of enquiry and assessment in response to MO’s stated intention to move from Calderdale and to leave FI. It is possible that there was a degree of misplaced reassurance taken from the fact that the MAPLAG was discussing the case. 146. Similar problems persisted in Lancashire where the extensive previous involvement with MO did not feature in any of the assessments and not enough information was collated about FI’s extensive historical involvement with different services outside Lancashire in terms of his own history of childhood abuse and being in care as a child, his subsequent history of mental illness and substance misuse; most significant of all was the lack of information sought about the circumstances of his two previous children being placed for adoption. 147. In contrast, fuller information was collected in the midwifery records although the IMR author highlights significant gaps some of which reflect the design and layout of forms. MO completed her personal information section in the ICP and identified herself as being white British, Catholic and unemployed. MO identified FI as being White British, no religion and also unemployed. MO’s first language is recorded as English; there is no place in the record that raises or allows a record to be made about the question of learning disability for either parent. There is no place in the ICP to record any social background history or partner history; this is a curious omission given the roles and function of the ICP. This case illustrates the significance of such information; MO acknowledged more than once the extent to which she ‘was in the dark’ about FI and his history. 148. The health visiting records included the birth notification as a faxed document that included coding for ethnic group but did not provide an explanation of the individual codes. The IMR comments that it is presumed that people using this information regularly would understand the codes without having to make reference to a guide. However the IMR comments that as records are now more frequently accessed by families and in some cases the court, it would be advisable to ensure that ethnicity and religion feature more clearly in the initial health assessment documentation and that where codes are used they are clearly explained. 149. The other problem with relying on codes is that a tick box mentality prevails rather than seeking and exploring the significance of information. The overview report baby E publication version Page 34 of 90 cultural isolation and erosion of usual mainstream norms and values of families living at the periphery have significance for professionals undertaking child care assessments. 150. The IMR from CHFT comments on how little evidence there was generally in the health service that records how diversity in its widest sense was considered during antenatal and postnatal periods. The authors comment that given the complexity of concerns regarding this family, an understanding of diversity and its influence on engagement and outcomes would have assisted the care planning and in particular raised safeguarding concerns around the discharge of MO and baby. 151. There was no record of the extended family or support networks that would be in place in Lancashire for MO (or information about potential sources of risk given the family history and the fact that other family members were also dealing with their own addictions and problems. Learning that has already come from the SCR is that greater attention needs to be given to acquiring an adequate social history especially from vulnerable parents who are subject of an integrated care plan (ICP). 152. An assumption was made throughout the contact with MO that her level of understanding and comprehension of advice was adequate. The question of her level of cognition, educational attainment and whether she had a recognised learning disability such as dyslexia was never explored. This is curious given her known history of substance misuse that may have had an impact on some of her cognitive and other functioning12. The IMR author for CHFT refers to the strong evidence base that looked after children and care leavers have poorer learning outcomes than their peers; MO’s history of being in care was not known by health professionals and therefore was not considered when planning the support provided. 153. Very little was known about MO’s extended family and her support network; the plan for her to move to her own accommodation in Lancashire did not include an assessment of who would be there to support MO as a first time single parent. There is mention in the postnatal records of sporadic visiting from grandparents, but there is no information of whether they would be in a position to visit MO and provide support to her, or, whether their input would be appropriate, given that she had been in care herself. This is an area of learning together with the other issues that are being 12 For example research finds that persistent cannabis use during adolescence can cause lasting harm to a person's intelligence, attention and memory. Researchers from the Medical Research Council (MRC) Social Genetic and Development Psychiatry Centre at King's College London's Institute of Psychiatry (IoP) collaborated with scientists from Duke University in the USA and the University of Otago in New Zealand on the study published on the 28th August 2012 Proceedings of the National Academy of Sciences Journal overview report baby E publication version Page 35 of 90 implemented as part of learning from the review in terms of screening queries and tools with women early in their pregnancy. 154. Poor social integration and family background were significant factors in the way in which MO worked with agencies aiming to support her and Baby E. MO told HV1 that she had moved back to the area after the birth of Baby E to be nearer her family and end her relationship with FI. HV1 was sympathetic to MO's background and wanted to understand and support her parenting needs. HV1 felt that MO had good family contacts and spent a great deal of time with her sibling, who appeared to be supportive and responsive to MO's and Baby E's needs. 155. Initially the return to Lancashire had appeared to be a positive move for the family and MO was reported, despite some housing problems, to be settled and stable. However HV1 had no detailed discussions with the extended family about their thoughts on what services would best support MO and Baby E. It appears that the extended family were seen to be present and supportive but the extent of the support they actually offered was not known. For example, on a visit in late November 2011 MO had disclosed that when she had missed collecting her methadone prescription she used some of another person’s methadone. 156. This is evidence that some members of MO's extended family and social network, believed to be providing her and Baby E with support, were themselves dealing with significant personal issues which may have adversely affected their capacity to provide the level of support that MO needed to adequately parent Baby E. This may have resulted in MO being reluctant to ask for their support or for professionals having unrealistic expectations of the extended family or a combination of both which is more likely. 157. Despite having moved to be closer to her family MO still appeared to be isolated, and to some degree was self – isolating in her reluctance to access services at the children's centre or to engage with the one to one visits with NN2. The IMR explains that HV1 was one of the only people who managed to have regular contact with MO and Baby E. 158. This in itself is not unusual in single young women with babies, particularly those with a troubled and chaotic family and relationship history, as formal services represent the involvement of agencies that they most mistrust and, as in MO's case, are fearful of; she made clear her concerns about CSC removing Baby E in later conversations with another professional and this was a powerful motivation for keeping information secret and away from all professionals. There may have been other reasons for the self-isolation relating to MO’s experience of being abused as a child and adult. 159. The evidence from SCRs nationally and research evidence describes the range of behaviours that can be exhibited by families who do not want the overview report baby E publication version Page 36 of 90 involvement of services that can be manifested in a variety of ways. Sometimes the rejection of help and contact is explicit and clear whilst for others it can be disguised and intended to make professionals less concerned and curious. It can be seen that in this case that there was a deliberate avoidance of service contact so as not to expose the resumption of MO's relationship with FI and her renewed use of illicit substances. 160. There was a reduced level of contact with HV1 and NN2 in the weeks leading up to the death of Baby E. The IMR author concludes that there is some evidence to suggest disguised compliance in this case and which is very difficult for professionals to identify and deal with13. The panel felt that the lack of compliance was not so much disguised but rather not identified quickly enough by the different people involved with the family. This reflects the complexity of sharing information with several different services especially when nobody is in charge of the overall plan and leading it. 161. The ELHT author refers to the social and lifestyle factors that often complicate the delivery of care to drug dependant women. From Baby E’s perspective the inequalities began before his birth and had the potential to adversely impact on his health and development throughout life. 162. Drug dependant parents along with other marginalised groups are often subject to stigma and prejudice. This attitude within society often hinders social interaction and integration of this group of people. The result of which is often frequent changes of address, lack of employment opportunities and a perceived chaotic lifestyle14. Examine whether all agencies kept the child and his experiences at the centre of their assessments of and interventions with the family. 163. The invocation of the MAPLAG protocol in May 2011 was recognition that Baby E was a higher risk pregnancy requiring additional support. In spite of the significant although incomplete information about the circumstances of both parents the focus was predominantly on MO as a vulnerable and pregnant woman rather than achieving a far clearer interagency focus on the needs of a baby; no pre-birth assessment was completed. After his birth, Baby E was the subject of careful monitoring in aspects such as weight gain although the focus for overall case management generally was too frequently moved on to MO’s presenting needs and wishes. 13 ‘Disguised compliance’ involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. The term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book Beyond blame: child abuse tragedies revisited : 14 The ELHT author refers to the UK drugs policy commission, Sinning and Sinned Against: the Stigmatisation of Problem Drug Users. (2010) UKDPC Publications. overview report baby E publication version Page 37 of 90 164. There was not an explicit discussion in a multi agency setting about the use of drugs. The domestic abuse had implications for how MO could parents her baby. This was not discussed explicitly; in part this may have been a consequence of the misdirection that was achieved in regard to the professionals’ knowledge of FI and MO still being in a relationship. 165. CSC in Calderdale had made a decision to keep details about MO and the unborn Baby E as information only and appear to have based their decision making on the fact that unborn Baby E was at no risk whilst in hospital and that once born, as mother had advised that she would not stay in Calderdale but would move at the point of discharge from hospital to Lancashire, that there was no need to open the case or allocate to a named worker. 166. The plan appeared to be to only consider opening the case if mother had decided to remain in Calderdale following the birth of Baby E. If other services had disagreed with this course of action they could have escalated their concerns although it is borne in mind that at the time CSC was still dealing with the implications of a statutory inspection that had found services to be inadequate. The removal of senior managers and the impact on other parts of the service does not appear to have been recognised by external services. 167. The decision to treat the involvement in MAPLAG as being a discussion of information and not a basis for a referral or involvement of a social worker removed the opportunity for statutory assessment by a social worker. This meant that there was no initial or pre birth assessment which would have required a view about any possible risk from the birth father and given the required impetus to enquiries within Calderdale and other areas where MO and FI had previously lived. This gap in collating information left Baby E vulnerable to any of the unknown or non assessed risks. 168. This was a collective failure to keep Baby E and the possible safeguarding risks at the centre of decision making and had an impact on subsequent case handling. The fact that CSC have statutory duties and responsibilities to lead enquiries (with the police when appropriate) and assessments when children are in need or at risk of significant harm does not remove or reduce the responsibility of other people and services to challenge and to escalate concerns if they believe the response from CSC is inappropriate. Effective safeguarding depends upon people identifying when systems and other individuals are not functioning adequately as much as doing the right things well. 169. The parents were in a relationship that was characterised by unemployment, poverty, domestic abuse and substance and alcohol misuse. MO was a young first time mother, with an untested parenting capacity; FI was considerably older than MO and was known to have two children from a overview report baby E publication version Page 38 of 90 previous relationship who had been adopted. The circumstances for their removal and adoption were unknown to the practitioners involved; FI was known to have mental health issues and showed a reluctance to either acknowledge these or to allow information to be fully shared. Both were chronic substance users who were on methadone, MO originally presented to CSMS in relation to alcohol abuse and there is a record of hospital admission in 2009 for acute pancreatitis related to alcohol abuse. There is evidence that MO continued to drink and may have minimised both the quantity and frequency. 170. The midwives and health visitor in Lancashire visited MO and Baby E at a much higher rate than is routine and allocated a specialist midwife given the known history of substance misuse and paid close regard to issues such as monitoring Baby E’s weight15. 171. There was no clear evidence that professionals adequately recognised unemployment and poverty as risk factors for Baby E; this is a common theme in serious case reviews and represents another difficult area of practice for professionals especially when working in communities that have high levels of deprivation. 172. The family lived in areas of high deprivation in both Calderdale and Lancashire and from that perspective the family were not that unusual or different within their immediate social setting. The health visiting (LCFT) IMR includes information that MO feared being evicted from her flat in Calderdale for non payment of rent and that she was stressed out and reluctant to go out in case the locks were changed and she then became homeless. National guidance in Working Together that applied at the time of the serious case review refers to poverty and unemployment as the most prevalent risk when identifying children in families at risk having very poor outcomes. 173. There was evidence of domestic abuse in this relationship; the arguments between the couple were witnessed in Calderdale by health professionals and on more than one occasion MO had disclosed that FI’s controlling behaviour was an increasing concern for her; in one disclosure she stated that she sometimes didn’t leave the house for 2-3 weeks as it only caused problems; MO had also disclosed that FI kept all the household money. Although this information was recorded, there was little evidence of outcomes or actions from health professionals, or any understanding of the impact domestic abuse had on the unborn or potential harm after the birth of Baby E. The CHFT author refers to national research that establishes the negative impact of domestic violence on the ability of parents to look after 15 The ELHT author discusses the various factors that can contribute to low or inconsistent weight gain that include factors such as the mother’s life style in regard to issues such as the ingestion of substances such as alcohol, drugs and tobacco as well as the significance of social factors such as chaotic or inconsistent parenting practice and domestic violence. overview report baby E publication version Page 39 of 90 their children and is exacerbated when it is combined with substance misuse and mental ill health. 174. The LCFT IMR comments that even where the parental issues were raised that could become overwhelming for professionals, Baby E remained the documented focus of many of the contacts or visits. This was best exemplified in the first visit with MO and Baby E by HV1 and DLM1 on 26th August 2011 (when Baby E’s static weight was noted and the dilution of formula feed). The difficulties in this visit were dealt with well and promptly by both of the professionals in attendance, resulting in Baby E being seen in hospital later that day. Despite this being an unintentional joint visit, both professionals worked well together to address the issues presented by MO whilst ensuring the needs of Baby E were assessed and managed appropriately. 175. As previously mentioned HV1 was sympathetic to MO's history of a very sad and troubled childhood. On 23rd November 2011 MO had explained to HV1 that she hadn't mentioned her contact with FI earlier because she was 'frightened of social services' and that they would remove Baby E from her care. Although it appeared to be an issue that HV1 had some sympathy with she was clear that CSC would need to be informed and made sure this done. These can be challenging and difficult conversations to have with parents but in this the issues were not avoided. This was good practice in difficult circumstances. HV1 did not feel that Baby E was at immediate risk of harm at this time but was aware that the situation had clearly deteriorated. 176. The Lancashire CSC IMR acknowledges that information about Baby E was limited by the low number of physical contacts (two) and on one of those visits Baby E had been asleep. 177. The difficulties that professionals such as social workers and primary health care workers face in considering the needs of babies and very young children beyond their immediate physical care and presentation is a recurring theme in serious case reviews and research. The fact that a baby cannot speak inevitably makes professionals more dependant on what they observe during their contact with families and what information is provided by parents or care givers. 178. Babies are very vulnerable to injury during the first 18 months; they are dependant upon the physical care and emotional empathy of their parent and are very susceptible to serious injury or inhibited development. It is for these reasons that having an adequate understanding about relevant history and taking account of known risks from factors such as substance misuse and violent behaviour have to be the foundation of work with a troubled family. Further comment and analysis is provided in the final chapter of this report. overview report baby E publication version Page 40 of 90 Examine whether information sharing and communication systems within and between agencies and across boundaries were effective in safeguarding Baby E. 179. Good information sharing should be characterised by a clear understanding and a collective knowledge about the journey of a child as they progress through the various systems of help and support that they and their families encounter and that this improves the outcomes for the child. This is the aspiration that is described by Professor Eileen Munro16. Information sharing remains one of the most problematic aspects for multi-agency working. 180. The HOR reflects on the problems identified in health professionals not having any common systems of patient recording; this is a national problem. There was no sense of a common narrative that could identify patterns and inconsistencies. The HOR comments that the use of MAPLAG inadvertently contributed to some of the information problems; some of this might have reflected a belief that by simply meeting, the relevant individual professionals were getting sufficient information to make informed and balanced decisions and did not require further steps such as CAF or safeguarding referrals. 181. The IMR authors identify significant difficulties in how information was shared and the extent to which it impeded a quicker and more informed understanding about Baby E’s needs and circumstances. This is one of the major contributory factors in how this case developed. Some of the difficulties reflected the electronic systems and frameworks within which people had to record information; other factors reflected a lack of more appropriate urgency in following up emerging gaps in information. 182. The problems began at the outset when the MAPLAG first discussed the initial information and identified a number of factors about MO and FI. Although there was an acknowledgment that more information was required, this was not satisfactorily resolved. Some of the momentum appeared to be dissipated by the news that MO was separating from FI and that she was moving out of the area. Because MO presented as a cooperative and willing pregnant woman the risk factors in her own life took on less significance for professionals who had generally busy caseloads that included other families that had more apparent and pressing needs and problems. 183. FI was regarded as the source of the most dangerous risk and even though MO had made previous attempts to end the relationship, there was a belief that her move to Lancashire would allow separation to occur. This was an optimistic appraisal given the personal history of the case and the evidence about the difficulties that women face in leaving violent relationships. In this case it was always highly unlikely that FI would not want to be closely involved with Baby E. 16 The Munro Review of Child Protection Interim Report: The Child’s Journey; Munro February 2011 overview report baby E publication version Page 41 of 90 184. The extent to which MO had sought to separate on previous occasions, the persistence that FI had shown in not allowing MO to leave the relationship, the concerns that MO had about his controlling behaviour and the fact that FI was clearly aware of where MO was moving to were all significant issues that were not adequately discussed or considered across the various people who became involved. 185. The management of information between CSC in Calderdale and Lancashire was not managed effectively. The information provided between other services assumed that FI would not be part of the household. The significance of MO and FI’s dependency on methadone was not adequately discussed outside the specialist substance services and in Calderdale the specialist drug workers displayed a lack of focus on the implications for a pregnant woman and her baby. The pattern of not engaging with services such as the children’s centre, the increasing disengagement from other services such as substance misuse was not adequately known and therefore underlying patterns were not seen. 186. For example, in November 2011 it became apparent after MO had undergone a routine test for drugs that she had begun using street drugs including crack and heroin. This information was not shared with the midwife for a week. The agency is introducing new induction arrangements for staff working with drug using parents to spend time with other services. 187. The CHFT author describes her experience of reviewing all of the records to compile the chronology and from completing ten staff interviews; the process presented her with a difficulty in having a clear understanding of where contacts with MO, FI and Baby E were recorded because of the multiple recording and documents and the different systems that were in place. These documents included hand held records, the ICP, MAPLAG and PAS (the electronic record). 188. As a result of this it was at times difficult for the IMR author to identify a holistic picture and to gain an understanding of the concerns around the case, how risk was being assessed or the clarity of risk factors that might escalate into actual risk, or understand what the care plan was and how it was derived. 189. This has significant implications for busy professionals working with families and explains why they often struggle to achieve a good enough overview of a case. Some hospital based midwives for example stated at interview their feeling that they did not have the whole story resulting in a fragmented understanding of the risks to MO and her unborn child. 190. This is an example of the type of systemic influences that have an impact on the quality of practice and decision making; what the author is describing overview report baby E publication version Page 42 of 90 is a system that does not support effective front line contact with families who have complex histories and problems and maybe reluctant to openly share information. The CHFT author highlights changes already being made to systems. However systems only work effectively when people have the capacity to make the right judgments and decisions and follow them through and can recognise gaps in information that need further follow up. 191. The MAPLAG protocol requires a risk assessment and action plan to be formulated at between 20 and 24 weeks into the pregnancy. At 32 weeks a birth plan should have been completed. For pregnancies at a higher level of risk such as in this case (described as level four or five in the protocol) there is a requirement to convene a pre discharge meeting following the birth. Neither of these requirements was achieved adequately in this case. 192. The convening of the MAPLAG appeared to have limited effectiveness in improving the effective sharing of information; the discussion in general relied on partial knowledge about the current circumstances as well as relevant historical information. The purpose of such interagency arrangements is to both share exiting information, and identify where further knowledge is required. 193. The early information sharing about the concerns especially regarding FI seem to be good enough between MAPLAG and the local authority FRT (family resource team) to indicate sources of vulnerability and need and the potential sources of risk. This does not provoke any formal referral, enquiry or assessment until August. There was no plan for any social worker to visit mother and Baby E on the ward prior to discharge. 194. The police IMR describe how information about the MAPLAG was not recorded on the police NICHE system (the police electronic recording system). The same IMR also comments that there was no direct communication from the West Yorkshire Police to their colleagues in Lancashire when MO moved into their area to alert them to the fact that MO had been a victim of domestic violence and that FI had been the perpetrator. Some of this probably reflected a belief that FI would not be in the household but the ongoing threat of violence given the previous history was sufficient to have passed the information over to Lancashire. 195. The IMR author comments that once aware that MO was pregnant and had been referred into the MAPLAG process, details of the meetings and copies of the minutes of the meetings should have been entered on the NICHE occurrence system. In the future this will be done to ensure that that all the information and tasks created on NICHE can by correctly implemented and monitored by supervision from within the police safeguarding units. 196. Had a NICHE occurrence been created, it would have been evident on this occasion, if West Yorkshire Police had notified Lancashire Police that MO was overview report baby E publication version Page 43 of 90 now resident within their area. The author describes changes to processes and training and although no particular factors are identified for why information sharing was not more effective the author does refer to the significant volume of incidents of domestic violence. 197. The fact that the case was never allocated to a specific social worker in Calderdale prevented a more informed and formal transfer of the case to Lancashire which would have ensured that information was shared and passed over to the other local authority in a full and timely way. 198. Other turning points highlighted are the sharing of information between HV1 and MO's drug worker. Most of the information was obtained by HV1 from the drugs worker by request. However, the first contact between HV1 and the drugs worker on 9th November 2011 was initiated by the drugs worker to discuss concerns about MO's apparent low mood; HV1 updated the drugs worker with the plan for high level support from the CFIT. This should have stimulated regular contact between the services but it was not until HV1 contacted the drugs worker on 17th November 2011 with concerns that MO had disclosed that she had smoked heroin again that the drugs worker confirmed that MO had recently tested positively for heroin and crack. 199. There is no date for the drugs test documented in the records and it is possible that it had been a recent test, but as HV1 was the key worker for the child and family, the drugs worker it would have been good practice to have spoken with MO to discuss sharing this information with HV1. It further reflects a lack of understanding about the respective roles of different people and services; this is explored in later sections. For the CFIT another key issue regarding information sharing was the role of the specialist safeguarding health practitioners based in CSC who visited on two occasions and was used as a substitute social care worker. This had implications for how for example the core assessment was recorded. 200. The transfer of information between the midwifery services in Calderdale and Lancashire was initially quick although important information for example about FI’s previous children, the fact that MO had taken her own discharge from hospital, and her recent use of street drugs was not shared clearly and was therefore not known to the midwives undertaking visits to MO and Baby E. 201. Once social care in Calderdale were informed that MO and Baby E were settled in Lancashire a fax was sent to the appropriate area office with a referral and copies of the referral information from CSMS. There was however there was no person to person telephone call and appeared to indicate that it was being treated as being for information rather than requiring further action. Although the IMR confirms that the practice supervisor is clear that no action would have been entered onto the child’s electronic file unless it was clear that there was confirmation that the fax was overview report baby E publication version Page 44 of 90 received. Good practice would have expected that with a new born child a telephone call may have been preferable followed up by a fax. 202. Once the case was opened to the Integrated Assessment & Support Team (AST) there were further delays that are attributed to the staffing and workload problems in that service. Although the gaps in information were recognised by the team manager, the deficits were not addressed quickly enough. Contact was made with Bradford and although this established that two previous children had been adopted, the circumstances were not inquired into; Bradford required a request in writing to release archived information and this was not done. The referral between Calderdale and Lancashire CSC was both delayed and incomplete. Neither of the services had secured adequate information from Bradford about FI’s previous children and both services were highly reliant on third party judgments about risk. 203. The decision to move immediately to a core assessment could have provided an opportunity for detailed contact and involvement with other sources of information; this did not happen due to workload. One visit to the home was undertaken by the social worker from the initial assessment team with the specialist health practitioner. This health practitioner then took on the task of completing the core assessment. This was inappropriate given she was not social work trained and qualified although was a very experienced and qualified health practitioner. 204. The home visit was not written up and recorded on the ISSIS electronic system (CSC electronic recording system). No discussion took place between the allocated social worker and the health practitioner. The allocated worker then closed the case. 205. The CSC IMR acknowledges that a discussion of the visit completed on the 25 August should have been essential social work practice. This would have enabled two basic actions; a discussion regarding the findings of the visit and the health practitioner’s judgment that the family circumstances required a full examination. 206. A significant contributory factor to the way the case was handled was the organisational stress arising from staffing and workload combining with a lack of information about the parents that had been factors in the handover of information from Calderdale. A high reliance was also given to MO’s assertion that her relationship with FI was over. 207. The CHFT author comments that at the point of transfer from Calderdale to Lancashire the transfer of information and records was very good, records were comprehensive and verbal communication was timely and appropriate, it was also well documented in the ICP. However the information did not indicate that FI and MO may still be in a relationship or the risk factors associated with FI in particular. overview report baby E publication version Page 45 of 90 208. When Baby E sustained his head injury the ECC call taker provided support to the crew liaising with the police and pre-alerting the hospital. This was an example of good practice where parts of the NWAS system worked efficiently to communicate with external agencies to pass on crucial information. 209. The IMR highlights that the ambulance crew who provided a very prompt response to the emergency call and took all necessary action to get him treated and to hospital should have completed a safeguarding referral given that Baby E was alive but very poorly when they transferred him to hospital care and treatment. The information they observed about the parents being intoxicated and being unable to understand the seriousness of their son’s condition were all factors that deserved reporting. Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Baby E. This should include any assessments of the mother’s entitlement to support in relation to her care history, drugs, alcohol and domestic violence and any pre-birth assessments of the needs of Baby E. It should also include any relevant information about the father’s older children. Any relevant historical information prior to the timescale for the review should be summarised and included in the IMRs. 210. The full extent of the parents’ previous involvement with services appeared to remain largely unknown for many of the professionals who came into contact with them in 2011. MO was a looked after child and a care leaver in Lancashire and FI had also been looked after in West Yorkshire and also had extensive involvement that had included the subsequent adoption of two of his children to a previous partner when he had lived in Bradford. 211. Both parents had experienced abusive childhoods; both had significant histories of domestic violence; MO as a victim and FI as a perpetrator; both had become dependent on drugs and alcohol; the mental health of both parents had required ongoing help; both parents had family networks that were not a source of positive help and support. In addition both parents were unemployed and socially isolated and this should have invited queries about the nature of dependence that each parent had of the other and the degree to which this was exacerbated when MO became unintentionally pregnant. 212. However, this extensive history did not feature within any of the assessments undertaken in Calderdale or in Lancashire; the term assessment is used generically to encompass the MAPLAG and ICP processes as well as the statutory assessments that should have been completed by CSC in Calderdale and was only partially undertaken by CSC in Lancashire. Their IMR acknowledges that this significantly diminished the quality of the overview report baby E publication version Page 46 of 90 assessment and decision making that relied on what MO primarily report during the brief contact with her. 213. The consequence is that there was insufficient understanding about the longstanding nature of the problems and the significance for example of chronic drug use on cognitive functioning for example. The HOR comments on how much of the information in regard to drugs, missed appointments for methadone and domestic violence are treated as episodic and separate occurrences and were ‘normalised’. 214. No pre-birth assessment was completed in Calderdale. The referral information from Calderdale was limited and no initial assessment had been undertaken and enquiries with other areas were not complete. The handwritten recording by the worker in Calderdale on the initial referral received by that authority indicated that no action was to be taken until it became known whether mother was remaining in Calderdale. Consequently no immediate risk assessment was completed before birth and no adequate picture could be passed to Lancashire of the family circumstances. 215. The historical information in the case was significant and relevant. For example; it was largely unknown that MO had grown up in public care. She may not have wanted to have this information widely known but as the CHFT author discusses, this information was relevant within the context of what is known about the specific challenges and needs that MO might have and especially in regard to becoming a mother. There was a general lack of curiosity in previous history. Although this SCR has prompted a re-examination of how for example information is sought from especially first time pregnant women, inevitably there will always be a considerable reliance on what is reported or disclosed by the woman. 216. The CHFT author believes that the use of specialist staff such as the midwives might have encouraged an assumption to develop on the part of other people that these specialists were dealing with problematic issues such as the domestic violence; this combined with knowledge that MO planned to live separately to FI led to a misdirected belief that risk of violence was decreasing in spite of no formal assessment or analysis of what the risks were and how they should be managed. 217. This was an optimistic approach given the lack of information in the specific case and considering how common it is for the incidents of abuse to increase in violent relationships during and after pregnancy or when there is a threat of the woman ending the relationship. CSC in Calderdale relied on other services including CSMS to provide information and did not to carry out their own assessment. The lack of rigour exhibited in CSMS has already been commented upon. overview report baby E publication version Page 47 of 90 218. The health visitor took a history from MO during a home visit on the 3rd September 2011 during which an additional history of drug and mental health issues emerged. MO had found her father dead at age 12 years, she was brought up by her maternal grandparents as her mother suffered from mental health problems and she remained a 'long term patient' in a mental health hospital. MO reported a history of depression herself, but had stopped taking anti-depressants when she became pregnant although she had reported feeling happy at the time of the visit. 219. Although the first meeting of the MAPLAG in May 2011 identified that father may have had previous children removed from his care there is an extended delay before contact is made with Bradford in August and even a that stage information about the circumstances for the children’s adoption are not clear. The first MAPLAG discussed father’s controlling behaviour and the plans that MO had for effectively ending the relationship; this had implications in terms of potential for violence given FI’s current behaviour and psychiatric conditions as well as the loss of social support for MO. 220. The Calderdale CSC author is clear that an initial assessment followed by a pre birth assessment should have been carried out and should have been triggered by the information shared about FI at the MAPLAG meetings. Information that MO had lived previously in another area and had spent time in a refuge due to domestic violence should also have alerted social care to make further enquiries. A further opportunity was missed when information was given to the CSC representative at the MAPLAG that FI may have other children who could have been placed for adoption probably in the West Yorkshire region. One call was made in July 2011 by the practice supervisor to Leeds social care to ask if FI was known. That response was negative. Contact was not made with Bradford who would have provided the information that was subsequently given to Lancashire. 221. CSC never made a visit to MO and Baby E at the hospital following the birth and was reliant on health professionals to ensure that all the arrangements were in place and identify any safeguarding risks to address prior to discharge. A more appropriate plan if more information had been known to CSC could have been to hold a pre discharge meeting on the ward and to have invited a representative from Lancashire to attend given that at that point MO had a residential address in their area. 222. Enquiries to other areas were not made until 11th August 2011 in Lancashire and were not done until a further referral was received from the CSMS team. A telephone call to Bradford confirmed that FI was known to them. Two children had been placed for adoption. The files had been securely archived due to the adoption of the children but requests could have been made for further information from the files which may have contained vital information about the background of FI and the reasons why those children were removed. It was already known that FI was a user of illegal overview report baby E publication version Page 48 of 90 drugs and had a diagnosed mental health condition. This did not appear to be taken as an important indicator and a further reason why an initial assessment at least should have been undertaken and information urgently requested for that assessment especially from Bradford. 223. As no case was formally opened and details held as information only no one from children’s social care met with either MO or FI and social care had no first hand information. The outcome was that no information current or historical was obtained by social care which would have been the basis of an informed risk assessment. 224. Although CSC in Lancashire had considerable previous involvement with MO over many years none of this information was apparently used to inform the later assessments in 2011. The IMR author explores the organisational circumstances that led to the two initial assessment and one core assessment being inadequate; the interplay of workload pressures, an inexperienced team, the development of short cuts to cope with back logs combining with training and industrial action were all contributory factors. These and other issues are explored further in later sections. 225. The NWAS IMR comments that they had no information about the history of domestic violence and were alerted to Baby E having been a premature baby by MO. Examine whether agencies fully understood any issues about parental substance misuse and mental ill health and the impact this had on Baby E and took appropriate actions. 226. Although MO was assessed as having a low mood she has not been diagnosed with any additional mental health needs. The low mood is not unusual especially just after birth and given the additional stress that MO was facing before and after the birth of Baby E. 227. In contrast, FI did have diagnosed mental health needs although he was reluctant to acknowledge this and withdrew from mental health services. 228. Although there is involvement of several different and specialist services particularly with FI, it is not apparent that there was sufficient recognition of the potential risks that longstanding substance misuse and mental ill-health had for the baby. Some of this probably reflected the belief that FI was not going to share the care of Baby E. It also appears that some degree of misdirection was occurring as early as the initial MAPLAG meeting when comments such as MO being ‘pleasant’ and was ‘engaging’ with services were recorded. 229. The fact that she had a dependency arising from a history of drug use did not appear to be understood clearly enough. She was largely regarded as overview report baby E publication version Page 49 of 90 having a historical substance problem which combined with her optimistic interaction with professionals contributed to a sense of optimism. This general optimism allowed the relapses to be treated as having less significance. 230. The extent to which adults can relapse especially during periods of crisis or stress was also not appreciated or the speed with which it can have an impact on the physical as well as emotional capability of a parent. It is notable that the specialist health practitioner noticed a significant change in MO’s physical presentation between the first contact in late August 2011 and when she saw her again in December 2011. 231. It is not clear that there was ever any structured discussion at any point about the implications for example of FI’s psychiatric condition (partly because an assumption was made that he was not in a relationship with MO) or the dependence that both parents had in regard to alcohol and drugs. MO’s desire to reduce her methadone was not apparently discussed and by implication was seen as a positive factor and therefore may have inadvertently led to a degree of optimism becoming an influence on how behaviour and information were subsequently viewed. 232. The HOR highlights serious non compliance with standards of required practice and procedure in regard to the conduct of toxicology testing in Calderdale. Information about two positive drug tests was not shared with other relevant professionals despite knowledge about the pregnancy. The consequence was that MO was not challenged and some professionals were not aware of the continuing risk of drug use for Baby E before and after birth. The HOR confirms that further investigation and action is taking place to ensure the problems are resolved. 233. MO’s lack of engagement with substance misuse services especially in the latter part of 2011 and her positive testing for street drugs in November 2011 was significant information and although there was communication between services it required more systematic enquiry than was achieved. The assessment that was planned to start in December was going to be an opportunity to do this. 234. The CHFT author points out that between them, MO and FI possessed four out of five of the highest ranking characteristics of parents found in the biennial analysis of child deaths and serious injury through abuse and neglect17 (Brandon et al 2007) these were; mental health problems / personality disorder, domestic abuse, substance misuse and care history. The fifth characteristic is learning disability; whether either parent had learning 17 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005: Brandon et al: DCSF 2007 overview report baby E publication version Page 50 of 90 disability was not known, but there was nothing to indicate that this was an issue. 235. The positive toxicology result during the antenatal period should in the IMR author’s opinion have been escalated across to social care services as a referral for a pre birth assessment. The Eden team midwife and the CSMS worker judged the positive toxicology to be a ‘blip’ warranting no further action, however, the combination of substances identified in the sample suggests that this was a planned and conscious decision by MO to misuse substances (rather than being impulsive and opportunistic). In the authors view there was a reluctance to see this episode for what it was, it was written off and minimised, was this because it did not fit with the originating assessment of risk in this case, which was that FI was the source of risk to Baby E. 236. It was an example of how professionals became misdirected at important moments. This is analysed further in the final chapter of this report within the context of national research and understanding about the influence of cognitive factors such as capacity to remain vigilant about the basis of judgements and a tendency to repeat patterns such as start again syndrome when confronted with opaque or difficult information. 237. In spite of the practice supervisor at the initial MAPLAG being informed about historic substance misuse of MO and alerted to the concerns of possible past involvement of social care with children of FI, no action was taken by that service; the practitioner did not participate in the following meeting and combined with poor recording undermined continuity from CSC. It appears to the IMR author that CSC took reassurance that CSMS was taking the lead and was monitoring the situation with regard to substance misuse with MO. This was an inappropriate assumption. 238. FI was known to have mental health difficulties although these were clearly regarded as historical although again there is no evidence about how that view was informed over and above what FI self reported. It was stated in the minutes of the MAPLAG on 6th May that FI was then on Subutex, that he was coming to the end of his treatment and if discharged no one would be monitoring his health. MO had already disclosed that FI was becoming controlling and more so since the pregnancy had started and she was indicating that she would want her own accommodation. Appropriate actions were not taken by children’s social care as an initial assessment at least was indicated at this point given that the pregnancy was now said to be at approximately 22 weeks and past the mid way point. Procedures on indicators for initial assessment are clear according to the IMR. 239. The health visitor was provided with information about MO’s historical drug abuse during the history taking on the 3rd September 2011. MO stated that she had not taken drugs for four years but was on a reducing overview report baby E publication version Page 51 of 90 programme of methadone (MO tested positive indicating she had ingested crack and heroin in November 2011); she was hoping to have reduced further but couldn't due to her pregnancy. It is not documented if the nature of MO's historical drug use was discussed in any detail. The impression of HV1 at the time was that MO appeared stable on her current methadone programme. 240. HV1 and the specialist health practitioner in their assessment of MO's apparent stability felt that the substance misuse would not necessarily impact negatively on her parenting capacity. The IMR author comments that this viewpoint, although common, is not supported by research on the impact of parental substance misuse on children. It reflects a tendency to accept a minimisation of risk primarily based on what MO wanted to disclose. This has implication for the cognitive understanding that is referred to elsewhere as well having implications for supervision and the tools that are used. 241. CSC in both Calderdale and Lancashire knew that MO had a history of using drugs and alcohol although believed that she was no longer doing so. MO had disclosed using street drugs in Calderdale just days before giving birth to Baby E. After she moved to Lancashire her compliance with the drug support service became increasingly chaotic and it was apparent that she was using street drugs by November 2011. 242. On MO’s return to Lancashire CSC were informed that she was not using street drugs, had engaged well with drug misuse services and had immediately registered with the local drugs team. However, this position had deteriorated by November 2011 and mother was reportedly using illegal drugs although did not lead quickly enough to a reappraisal of the implications for Baby E. 243. This would have been an essential area of the core assessment that planned to take place in December 2011 although the injury and death of Baby E occurred before the work had been undertaken. The description by the specialist nurse following her visit on the 2nd December 2011 had outlined a picture of potentially quite extensive drug misuse. Baby E was observed in his crib and the home conditions were described as "warm". This contributed to a judgement that the baby was not at immediate risk. 244. The ambulance crew identified that FI and MO appeared to be under the influence of alcohol and/ or drugs when they were called to attend after Baby E was injured. This is referenced in their statements and is recorded on the PRF. They had no prior knowledge of the family and the behaviour of both adults caused significant concern and possible delays in making haste to Hospital 1. The crew statements describe how they ‘hurried’ both adults to get on board the ambulance due to their lack of urgency and generally vague demeanour. overview report baby E publication version Page 52 of 90 245. When the police had arrested FI on the 1st December 2010 to prevent a breach of the peace the custody sergeant was responsible for conducting a risk assessment with FI. This risk assessment included asking for information about his physical and mental health and about any risk of self harm. FI stated that he did not have any mental ill health; this was an example of his denial of his mental health needs. When he subsequently hallucinated a medical examination was arranged. The focus of the assessment and management of FI was on how police officers and staff should handle their contact with him; there was no sharing of information or referral to social care or other service. The IMR author refers to the training that has been undertaken with police officers to improve awareness of the police responsibility to share information about vulnerable adults as well children. Examine whether agencies dealt with any domestic violence issues appropriately and considered the risks to Baby E from those issues? 246. That assumptions were made from a relatively early stage that FI was not going to be part of parenting Baby E was a significant contributory factor in how professionals worked with MO and therefore did not regard domestic violence as a threat unless and until FI and MO resumed their relationship. This reflected the generally optimistic approach and does not reflect a more informed and sceptical understanding about the nature of relationships that are characterised by domestic violence. 247. There was a degree of naivety in understanding how realistic it was that FI would be willing to have no contact with his baby and a lack of understanding that in violent relationships there is an increased risk of violence and injury during and after pregnancy and especially when the relationship being ended by the woman. It also reflected a lack of understanding about the barriers that women face in leaving violent relationships. Women want the violence to stop but also face emotional and psychological difficulties in ending a relationship; it is also exacerbated if they face the prospect of becoming homeless; this was a fear for MO who had described feeling trapped in her flat. 248. The Lancashire CSC IMR comments that MO described the relationship with FI as being ‘on and off’. Even if the information had been correct and MO had been able to separate from FI she had a history of previous relationships with violent men. 249. It was apparent before MO discharged herself from hospital after the birth of Baby E that FI was planning to continue his relationship with MO and knew where she was moving to. The history of both parents would have provided powerful motivation to keep any relationship secret. 250. By November 2011 it was clear that FI was playing a significant role within the family's life in Lancashire and was known to CSC and health and overview report baby E publication version Page 53 of 90 substance misuse services. Following two referrals and MO eventually conceding that she was allowing contact with FI should have led to more urgent discussion and planning of enquiries. The circumstances of the AST did not encourage a more active and urgent approach. Further analysis is provided in the final chapter. 251. The extensive history of FI that was beginning to become clearer, including being a historical perpetrator of domestic violence, should have led to an urgently convened strategy discussion and subsequent section 47 enquiries. This did not occur partly because of the organisational problems that beset the AST at the time as well as perhaps because the original mindset that had been influenced by MO’s ‘pleasant’ determination to turn her life around had not yet adapted in response to the contradictory information that was becoming more evident. There was also probably a lack of understanding about how quickly MO was relapsing in terms of her use of alcohol and drugs. 252. The MAPLAG minutes of 6th May 2011 had recorded that MO had spent time in a refuge in Greater Manchester, where she used to live, due to domestic violence from a relative. There are no further details and is an example of the gaps in information that have beset this case. There is also information in the same minutes from MO that she was finding the behaviour of FI towards her more controlling. As social care did not carry out any assessment there were no further details or evidence of this at this time. There was no recorded contact with any social care services in Greater Manchester to see whether MO was also known to them and if there were further details about her spending time in a refuge. 253. There is a growing recognition that dealing with domestic violence effectively is a challenge for policy development and for professional intervention. There is a growing range of research that provides evidence about the impact of domestic violence on women and children in terms of the emotional damage and the barriers that face both professionals trying to help and the victims of the violence. A recurring theme is the difficulties that women in particular face in seeking and accepting help. 254. At present, systems tend to rely on evidence of violence in terms of visible injury and harm and the willingness of the victim to consent to some form of intervention. In this case there was no apparent recognition about the presence of domestic violence that should include an understanding about coercive relationships. 255. Evan Stark18 for example describes how domestic violence has to be understood more clearly as coercion in order to understand the impact on 18 Coercive Control: How men entrap women in personal life Evan Stark: Oxford University Press 2007 overview report baby E publication version Page 54 of 90 the women and to understand why these relationships endure, why abused women develop a profile of problems seen among no other group of assault victims. In this case mother was isolated from her family, apparently had no close friends or other sources of support and was unemployed and dependant on state benefits. 256. The SMS midwife who did the first antenatal contact recognised the escalation in domestic abuse; she worked on the premise that support and monitoring for MO around this issue was being given by the CSMS workers. The second SMS midwife acknowledged that she did not ask about domestic abuse at her first antenatal contact and in hindsight should have explored this with MO. 257. The CHFT IMR author’s analysis from this would be that there was an assumption that CSMS were addressing escalating domestic abuse as part of their remit, which would have been appropriate if in conjunction with the SMS midwives, however, there is no record of a conversation within the perinatal team that gives assurance that escalating domestic abuse was being risk assessed. 258. MO stated at every ante-natal contact that she planned to move away from FI because of his controlling behaviours and she reiterated this to several different people. This is documented in the ICP record; however, there is no recording of what this meant in respect of the care plan or of what the safeguarding implications for Baby E might be. On interviewing antenatal and post natal staff, the IMR author found that there was little recognition of domestic abuse as a feature in this case, the focus remained firmly on FI’s mental health as the primary safeguarding issue and the plan for MO to move away from Calderdale without FI was known by every member of staff interviewed. This plan was seen by all staff involved as the solution to any safeguarding concerns. 259. The West Yorkshire Police IMR is satisfied that officers dealt positively with the incidents of domestic abuse between MO and FI conducting the initial SPECCS risk assessments19 at the scene, and there was the appropriate intervention from the domestic violence coordinator from the police safeguarding unit. However, the domestic incident on 31st December 2010 was attended and although dealt with as a domestic incident, a Vivid report was not created by the attending officers, which was an omission on their part; established safeguarding and domestic abuse protocols are in place by West Yorkshire Police, including established recording processes of such incidents. 19 SPECCS is an anagram of six high risk factors (Separation, Pregnancy/new birth, Escalation, Cultural issues and sensitivity, Stalking and sexual assault) describing a risk assessment tool. overview report baby E publication version Page 55 of 90 260. According to the police IMR, the quality of the information recorded on the police IT systems concerning all aspects of safeguarding have developed considerably due to an awareness of other high profile cases and the subsequent development of safeguarding training to both the front line and specialist safeguarding officers and staff throughout the police service area. 261. Since 2011, processes are now in place for the front line staff to complete the DASH risk assessment20 when dealing with incidents of domestic abuse. Initial risk identification must be undertaken and the level of risk should be identified to ascertain what level of intervention applies. If the case is classified as high risk, a more detailed risk assessment will be completed by a safeguarding officer and a referral to MARAC will be made. If such a referral is not appropriate the reasons why will be fully recorded on the NICHE occurrence system which replaced the previous Vivid database system. 262. The CSC author for Lancashire includes information about the pilot within the CART that replicated a MASH (multi-agency service hub) within the Preston district. This has improved the gathering of specific multi-agency information regarding domestic violence incidents and linking this to a targeted and prioritised response to cases that have or are likely to result in significant harm to children and young people. The IMR anticipates that this will be launched on a county basis. 263. In This area of Lancashire the CAF is well established with an expectation that a social risk assessment is completed and shared by midwives for all births in this part of Lancashire but this was not completed for Baby E as he had been born in Calderdale. The IMR author believes that practitioners could also benefit from a standardised assessment tool such as the child and family plan which is used in Blackburn with Darwen and has been developed in part to address lessons learned from SCRs. This framework allows routine discussions about key health and social factors at the primary visit and is reviewed at eight months and two years. It covers a range of questions relevant to this family including for example: some women tell me their partners are cruel. Have you ever been in a relationship past or present where you have been hurt physically, mentally or emotionally? Were you or your partner ever in care as a child or teenager? 264. Under the Lancashire Improving Futures Programme there will be a review of the CAF process with the aim of refreshing and implementing a new and 20 The introduction of the Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model from March 2009 meant that for the first time all police services and a large number of partner agencies across the UK are using a common checklist for identifying and assessing risk with the aim of saving lives. ACPO (Association of Chief Police Officers) Council accredited the DASH (2009) model to be implemented across all police services in the UK from March 2009. overview report baby E publication version Page 56 of 90 revised CAF across the county. This will incorporate an updated continuum of need (CON), thresholds documentation and lead professional development. 265. In Wales, there is a national pathway screening for domestic violence that encourages primary health worker such as health visitors and GPs to routinely inquire about a history or experience of domestic violence. No such arrangement operates across England and is unlikely to given the move to less central guidance and more emphasis on local practice. This difference is exemplified in the contrast between arrangements in Calderdale and the more proactive approach described in Lancashire. Reference is made in the final chapter to the national research being undertaken in regard to routine screening for domestic violence. Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. Consider whether professionals relied for information on the self reporting of parents, and how far this influenced the safeguarding and protection of Baby E. Consider whether there were any barriers or difficulties in the child receiving services. 266. The HOR is unequivocal in stating that the information that was known to the MAPLAG should have been sufficient to have generated a referral to CSC under the safeguarding procedures in Calderdale. There may have been a belief that by involving CSC in the MAPLAG discussion was sufficient to ensure that appropriate action was being taken. If that was the belief it was misplaced and a misunderstanding about the purpose of MAPLAG. The HOR concludes that the MAPLAG ‘debilitated’ the process of risk assessment. 267. The HOR comments that services were largely delivered in accordance with the systems that were developed by the providers rather than reflecting an accurate and well informed assessment of Baby E’s circumstances. 268. National research is providing compelling evidence that services have to be embedded in frameworks that understand the importance of child development21 and the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security. 269. The safeguarding and child protection issues were not sufficiently identified and therefore not understood adequately at the outset. When safeguarding concerns were recognised at a later stage in Lancashire there were problems in identifying an appropriate person to undertake the required assessments; 21 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews Department for Education May 2011 overview report baby E publication version Page 57 of 90 this in turn led to delays in escalating the level of enquiries and invoking joint agency safeguarding procedures. 270. Although this was identified as a high risk pregnancy the focus remained largely on how MO presented to the health professionals in particular. She was regarded as ‘pleasant’ and ready to ‘engage’ with the help and support being provided. This appeared to be a significant influence in her relationship with professionals who by and large felt that MO was taking adequate and appropriate action for herself and her baby. 271. Her plan to leave Calderdale and to end the abusive relationship with FI was regarded as positive on the basis that the main threat was from FI and his history of children being removed. Although this was a significant and relevant source of concern; attention was misdirected away from other factors associated with MO’s own history, lifestyle and sources of vulnerability. The declared intention to leave FI should also have been recognised as a source of increased danger and threat. 272. The requirement to have a discharge meeting after the birth of Baby E was substituted by an informal discussion between the midwife and MO. This mindset towards MO did not fundamentally change until December 2011 just days before Baby E died. When concerns were coalescing about the presence of FI in the house and MO’s withdrawal from professional support, the response still lacked a sufficient focus on the potential harm on Baby E’s well being. 273. The MAPLAG and ICP remained the principle framework for multi agency working. Although the MAPLAG is a protocol designed to coordinate help for pregnant women who (and/or their partners) are excessive users of alcohol or drugs implemented through the LSCB, there were some fundamental misunderstandings about the meeting. Some agencies such as CSC for example thought that the MAPLAG was a health meeting that they were just participating in for the purpose of sharing information with the health professionals managing the pregnancy. Although the protocol describes arrangements for completing risk assessments and action plans (which were not completed in sufficient detail) there is no explicit linkage to children’s safeguarding protocols such as s47 enquiries or completion of pre-birth risk assessments for the unborn child. 274. There was a marked deterioration in MO’s circumstances in the weeks after she moved to Lancashire that was being noticed in November. She increasingly withdrew from contact with services and her ingestion of street drugs was increasing in the weeks before Baby E died. 275. The delayed referral to CSC in August 2011 had cited the previous history of FI having children removed from him permanently as the risk factor for undertaking an assessment. Although this historical information was relevant overview report baby E publication version Page 58 of 90 and should have been sought more quickly there were a range of other factors that deserved attention before the birth of Baby E. The fact of his premature birth did not add substantially to any further consideration of vulnerability over and above his immediate physical needs. 276. Issues had been identified during the early MAPLAG meetings kept on the system by social care as for information only and according to the IMR were perhaps only to be opened up as a referral if it was confirmed that MO was to stay in the Calderdale area once Baby E was born. This is concerning as it reflects an organisational approach (it will not be our problem) to the information rather than a far more appropriate child focussed approach. 277. Ironically, there did not appear to be any thought given to the enhanced risk to a very young a premature child moving to a new area where the family apparently had no sources of support and the mother was trying to leave her relationship with the child’s father. No thought was given to how the father would react when he found out or understood the intention of MO to effectively limit his involvement with his child and especially given his loss of other children. 278. There was no consideration of the need to complete an Initial and a pre birth assessment where any safeguarding concerns could have been identified and the statement by MO to separate from FI challenged and confirmed. Unfortunately due to a lack of pre birth assessments social care had collected none of their own information and relied totally on information from other agencies with CSMS acting as lead agency. 279. Once Calderdale CSC were made aware of the concerns of previous drug misuse of mother and particularly of the previous adoption of two children of FI had a statutory duty to assess and complete an initial assessment to indicate the way forward and what supports/interventions were needed. This was not done. There was no consideration of any barriers as CSC had no face to face contact with either parent or Baby E once born. The only barrier which may have been in place was capacity within the social care team as the team at that point was mainly made up of agency workers. The practice supervisor told the IMR author that she had been making all the decisions about case management and information coming in to the FRT team rather than the team manager. The IMR author believes that the team manager now shares those decisions. 280. When there was a positive toxicology result in the antenatal period, the decision jointly made by the Eden team midwife and CSMS worker was that this was a ‘blip’ and the analysis of this episode has been covered. Similarly, Mo’s disclosures of an escalation in FI’s controlling behaviours and the implications for practice have been explored. overview report baby E publication version Page 59 of 90 281. MO’s declared intention to leave FI and move to her own accommodation was considered to be the best outcome for her and Baby E by all staff involved as it was a held belief that FI posed a safeguarding risk to Baby E and arguably distracted attention from the implications of the separation and the absence of support for MO. 282. Health professionals accepted MO’s self reporting of this wish without question. MO had continued to live with FI throughout the antenatal period, and when in the antenatal period, MO was admitted for monitoring of Baby E; FI visited, administered her Methadone and took all her belongings to Lancashire in readiness for the move. FI was present at the delivery of Baby E and he visited sporadically in the post natal period. 283. The CHFT IMR author is sceptical as to whether MO was being open and honest with health professionals as all of these episodes demonstrate a strong dependency or commitment on from the two partners to this relationship. 284. A CAF was completed by HV1 which identified other services which could offer MO support to her parenting and a clear action plan for a team around the child (TAC) meeting was considered. The role of the safeguarding specialist health practitioner is highlighted by the IMR for further consideration. The role is based in CSC and aims to enhance the multi-agency assessment process within the initial assessment team, providing a valuable health perspective to social care assessments. If the visit on 2nd December 2011, had been undertaken by a social worker then the outcome might have been different if the assessment had achieved a more comprehensive and holistic consideration of Baby E’s circumstances; the fact that the AST was experiencing problems of workload and capacity at the time would have been a significant factor for any practitioner. 285. This suggests the inappropriate use of a health practitioner. The specialist safeguarding health practitioner was not attending the address as a social worker but as a qualified health professional and as a result did not have the underpinning of the statutory framework within which local authorities and their representatives operate. This impacted on specialist safeguarding health practitioner as she was visiting alone and acting on behalf of social care. This clearly left her more vulnerable to maternal antagonism as she was seen by MO as a social worker and not a health representative. The CSC author in Lancashire acknowledges that it was inappropriate to have the core assessment led by a health professional. It was also not compliant with current national guidance or local protocols. 286. In this instance although in receipt of enhanced health visiting service and having identified additional needs it was the health visitor’s belief at that time that the support and services that were being provided to the family from the agencies and the extended family were meeting all those needs and overview report baby E publication version Page 60 of 90 until the father was seen in the home HV1 had no reason to believe that Baby E could have been at possible risk of harm and that the mother was unable to meet his needs safely. HV1 acted appropriately and swiftly when she found the father was having contact with Baby E. 287. At this time of his death Baby E and his family were receiving universal and additional support from the CFIT in Lancashire. The mother had received regular support from CFIT services however there were regular no access visits and it is now known that she was withholding information from the named heath visitor (HV1) about her relationship with Baby E’s father. Due to the history of vulnerabilities and concerns about the father the family were known to social care and were due to start an assessment at the time of Baby E’s death. The family were seen on two occasions by the specialist safeguarding health practitioner who is not a qualified social worker and therefore was not in a position to complete a core assessment. 288. The last visit to the family home days before Baby E died resulted in a specialist safeguarding health practitioner leaving the house feeling intimidated and had been required to leave by the verbal and non verbal behaviour of the parents. Although there was a discussion later that day with managers in CSC they decided that although a core assessment needed to be completed they did not decide to have a further and urgent visit made to the house. A key influence was that the team would be away on training for two days (although there was cover from other social workers) and they still believed that MO was a sufficient protective influence counterbalancing the unknown risk about FI. 289. The specialist safeguarding health practitioner was not concerned about Baby E’s immediate safety; the intimidation had been directed at her. However, given the escalating pattern that is now much clearer with the collation of information from the review, the IMR author acknowledges that a strategy discussion involving other services could have made a significant difference to the decision about how quickly to visit. 290. Following the visit a discussion took place between the specialist health practitioner and the assistant and team manager. Unfortunately this is not recorded as a case management decision as it is self reported by the three professionals. A section 47 was explored but a decision is made to undertake a core assessment. 291. Two referrals had now been received outlining key issues of safeguarding concerns, service users were now outlining their own concerns, the specialist nurse had visited and in effect both confirmed these and added direct evidence of a deteriorating situation, significantly a male who on balance is probably FI, and physical evidence of IV drug misuse. overview report baby E publication version Page 61 of 90 292. A contributory factor to decision making was the organisational difficulties that were being managed at the time. These are described in further detail in the following relevant key line of enquiry. 293. The ambulance crew identified safeguarding concerns in relation to parenting capacity as both FI and MO appeared intoxicated. There was a disclosure by FI that MO used methadone (but no apparent reference to his own). The crew noted the positioning of Baby E’s changing mat directly underneath the heavy object which is alleged to have fallen onto him. This indicated a lack of care for the welfare of Baby E and failure to protect him from harm. As previously mentioned the crew did not submit a safeguarding child referral and this lack of recognition of the need to do this has been referred to the Trust Incident Learning Panel Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. Consider whether any organisational changes impacted on work with this family. 294. The HOR does not identify any organisational issues that had an impact on how the case was managed in the health services in Calderdale and Lancashire. 295. In contrast, there were issues that had an impact on CSC services in Calderdale and Lancashire. Organisational capacity is an important aspect to understanding how aspects of this case were handled at the time and the contributory factors that determined how judgments, decisions and actions developed. For example, the social care services in Calderdale and Lancashire were both dealing with significant issues in regard to the staffing of frontline services. 296. In response to the issues identified within this review an independent review of professional practice and resources has been urgently commissioned by Lancashire CSC. This review has also been tasked with developing tools to identify teams in acute stress and develop escalation measures to ensure early identification of teams experiencing similar difficulties and challenges. 297. In Calderdale there were historical issues relating to the quality of practice and recent inspections of services had generated significant pressures for improvement. The IMR describes how the FRT service was highly reliant on temporary agency social workers; nine of 13 posts were being covered. The workload was high and the practice supervisor was involved with a significant personal case load that had an impact on her capacity to provide the level of challenge, refection and oversight that was required. overview report baby E publication version Page 62 of 90 298. In Lancashire there were challenges facing the service in recruiting and retaining practitioners and workloads were also high. Although there was active recruitment taking place this generated pressures to train staff as well as to reconfigure some aspects of service. 299. The team manager described the workload pressures in November 2011 as being significant and exaggerated by the acute staffing difficulties and that this case was one of many that presented with drug misuse and domestic violence. The team manager is acutely aware on reflection that this case required a more rigorous, timely approach. The IMR quotes her description about the pressures of "being bombarded day in day and that the decision making is influenced by volume, working capacity and thinking capacity. I am aware it affects judgment this type of pressure". 300. The initial assessment team within the area that Baby E lived was under considerable pressure due to a combination of vacancies, maternity leave, annual leave and inexperienced staff members. In addition the team manager reported that the month of November was a period of extremely high referral rates and that she had 12 cases managed by the duty system. (These cases are not allocated to but responded to by whichever member of the team is on the duty rota). 301. This had impacted upon the team's ability to prioritise cases and to fulfil the statutory timescales for assessments. The relative inexperience of key segments of the social work workforce was being addressed strategically by the undertaking of a three day district wide training event on "Undertaking Balanced Assessments." This had a perverse impact in this specific case in that ultimately the event impacted upon the team's ability to deal with this referral in a timely manner. This was further compounded by a day of industrial action within the same week as the training. 302. The IMR queries whether there are enough social workers to cope with the level of demand. The IMR describes how the team of five social workers appears low in comparison with other districts and that this needs to be further examined. The district manager in discussion outlined how he ideally would like to reconfigure this team and "front load" its function. However, this is currently prohibited by the workload in the child protection team which has experienced a significant increase in safeguarding court work. 303. The significant issues for learning is the extent to which the organisational stress that was operating within services was recognised at the time and exploring how the action taken to ameliorate operational problems and pressures had unintended and negative consequences for professional practice. This is explored further in the final chapter. 304. A superficial examination of the case will conclude that people in several organisations did not do their jobs well enough whilst acknowledging that overview report baby E publication version Page 63 of 90 several were very conscientious. Although there are problems highlighted about how some aspects of professional work was undertaken, the review has to explore why people were not more effective at the time. It would be wrong to conclude that people did not care about this family or about Baby E. It would be wrong to conclude that nobody ever saw any risk in this case. Professionals are expected to make sense of what are often chaotic lives where issues such as substance misuse and mental health create complexity and risk. Creating opportunities to provide effective help begin with trying to build a relationship with adults who are distrustful. 305. A serious case review offers opportunities to reflect on the options that were available to act differently and to understand the barriers that prevented opportunities either being seen or else followed through. In this case there are issues about the stability and capacity of the service as well as a need to reflect on how professionals make sense of the information being provided or observed. 306. There is an increasing range of research about the importance of organisational arrangements supporting good judgment and decision making. The stability of organisations in terms of their leadership, management and staffing is of course important. The ethos of the organisation and the extent to which it promotes appropriate thinking and action are important factors in analysing why people are able to make decisions or can act in compliance with good standards and policy expectations and can develop good outcomes for children. 307. Good safeguarding work depends on well trained professionals having the systems in place to promote clear communication and have appropriate knowledge and theory frameworks within which to gather and analyse information. 308. In this case it is evident that local protocols were being used when a high risk pregnancy was identified there were significant organisational factors that influenced how information was handled and the quality of decision making. It is important to understand why things happen rather than just what did happen. 309. The practice supervisor in Calderdale who was the point of contact for FRT children’s social care was an experienced senior member of the duty team whose role at the time of the receipt of the information and the referral was to screen and make decisions about the management of that information. The role made decisions about whether information was progressed to a contact and then allocated. 310. The IMR author confirms that the practice supervisor acknowledges that in retrospect a wrong decision was made about how the information and decisions were handled and it should have been properly opened and overview report baby E publication version Page 64 of 90 allocated to a social worker for completion of an initial assessment. The practice supervisor explained that the team were under a considerable amount of stress at the time with most of her colleagues being agency workers who had not been there for very long. At the same time, the whole organisation was also dealing with the implications of being judged a poor service by inspectors that had led to the departure of several senior people. 311. Since that time additional permanent employees have been recruited to assist with some of the admin functions, which allow social workers to be freed up to deal with casework. Referral and Information co-ordinators are now in place that take the initial information and ensure it is entered on the system. The team is now mainly permanent staff and only one agency worker. This has assisted with positive changes. The case and information with regard to MO, FI and unborn Baby E would only have been discussed in supervision had the case been allocated to a worker. It was not allocated. 312. Analysis of the CHFT concluded that the capacity, skill levels, supervision and management support were adequate to good in respect of MO and Baby E’s care throughout the antenatal and postnatal period. There has been a subsequent staffing increase on the postnatal ward and training around the embedding of the new safeguarding ICP and record keeping has been delivered. 313. West Yorkshire Police have recognised that there was a requirement to develop their response to safeguarding and on 2nd April 2012 new safeguarding arrangements were implemented within the organisation. This followed a safeguarding pilot in the Calderdale, commissioned in October 2010, to explore the benefits of combining Crime Division Child and Public Protection Units (CPPU) resources with divisional safeguarding functions. The new arrangements aim to improve service delivery by bringing together, at district level closely related areas of safeguarding business, ensuring that operational accountability, supervision and responsibility is delivered locally for all adult and children safeguarding concerns 314. Additionally police officers and police staff through training, accreditation and a general awareness of the LSCB child protection and adult safeguarding procedures, now have a better understanding of their responsibilities in their day to day dealings with all vulnerable adults and children. 315. The co-location of professionals is becoming an increasingly common practice. The specialist health practitioner within the IAS had extensive child and family experience. 316. The specialist nurse has extensive child and family experience within this case. However, due to the statutory regulations she is unable to complete core or initial assessments. Her extensive knowledge brought a different key dimension to the team. This would have been complimented in November overview report baby E publication version Page 65 of 90 (and addressed some of the staff safety issues via a joint visit with a social worker). This was the accepted process within the team but the backlog led to the inability to prioritise this. This would have brought the key social work safeguarding dimension to the visit. The specialist nurse described her role as being asked to introduce the idea of an assessment to the parent. The team manager asked the nurse to go through the referral and ascertain the nature of the contact and it would be then subsequently allocated. The IMR author comments that that appears in essence a holding exercise due to the staffing challenges. Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of your agency’s actions in relation to these. 317. The HOR comments on the extent to which information was accepted at face value by all the health practitioners. This contributed to serious misdirection especially in regard to the evidence that MO was continuing to use drugs despite her professed intention to remain abstinent. The degree to which everybody shared in a degree of optimism in their dealings with MO in particular contributed to a collective sense of being ‘swept along’. This in itself created the conditions within which the empathetic approach to MO was not tempered by an application of sceptical and research informed analysis. Empathy without reflection and challenge will create the conditions in which dangerous collusion can develop. 318. An executive summary on Child C from 2009 in Calderdale comments on the significant delays in social care services completing an assessment of the family and of the potential risks to the unborn child. Information was taken at face value, little attention paid to risk factors and lack of robust analysis of the overall situation. Risks to the unborn child were underestimated. Child C was under one year old as was Baby E. In the same summary it is commented that care services (and health services) did not engage effectively with the father and knew very little about him. These are issues similar to the current circumstances with this case. 319. After Child C the chair of the Calderdale Safeguarding Children Board was asked to issue a reminder to all agencies for the need to involve both parents in assessments. This was done but Calderdale CSC was aware that a majority of the social workers in the FRT at the time of Baby E were from an agency and may not have had the opportunity for the identified learning. 320. The IMR author comments that it would appear that Calderdale CSC may still have been making the same errors at the time of Baby E and that it is not the absence of procedures but lack of clear decision making at the time information is received. overview report baby E publication version Page 66 of 90 321. The Lancashire CSC author refers to the lessons learnt in a previous SCR regarding the qualification and experience of people responsible for co-ordinating assessments. This issue was highlighted in SCR A undertaken by St Helens LSCB, which Lancashire CSC contributed to. 322. Following this SCR guidance was issued to all District Teams regarding the requirement that assessments must be led by a qualified social worker. In light of the issues again raised within this IMR, an audit of District Teams has been undertaken to review practice in this area. This has confirmed that all other districts are compliant with this requirement. The issues in this district appear to have arisen due to team capacity. 323. This has been addressed and an instruction issued that safeguarding health practitioner's, whilst contributing to the health elements must not lead the assessment. This is the responsibility of a qualified social worker. 324. The same author also refers to the SCR relating to Child AB that identified the need for training for staff in the completion of assessments, including the importance of information gathering, historical information, risk analysis and evidence informed practice to inform decision making. In response to this a significant county wide training programme in balanced assessment was delivered to all District Children's Social Care Teams, Children with Disabilities Teams, Youth Offending Teams and Independent Reviewing Officer's, including front-line practitioners and managers during 2011/2012. The training focused on the assessment process, risk management and signs of safety. 325. The SCR relating to Baby E also highlights the importance of multi-agency assessments. The SCR relating to Child Z in (2008) required that core assessment planning meetings take place prior to the commencement of a Core Assessment. At that time the LSCB re-launched the safeguarding children procedures with an emphasis on multi-agency engagement within the Core Assessment process. In light of the learning in this review the use of core assessment planning meetings needs to be further embedded in practice. 326. The implementation of improvement action from previous SCRs will be monitored within the audit cycle framework and in particular the multi-agency Best Practice audit panels which operate under the auspices of the Lancashire Safeguarding Children Board. These panels examine on a multi-agency basis a small number of cases to examine best practice and explore any learning points that can be applied across the professional network and further multi agency understanding of the interventions provided to families. 327. Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2012 identify that nationally there are problems in how information is sought and shared. Both Calderdale and Lancashire IMRs refer to learning from overview report baby E publication version Page 67 of 90 serious case reviews in regard to the importance of securing relevant historical information in order to inform current assessments. The Lancashire CSC IMR refers to training that has been commissioned to improve the use of chronologies to support improved practice in the future. 328. The ELHT author refers to the fact that Baby E was known to be vulnerable due to MO’s history of substance misuse placing him in the two or three per cent of children in England and Wales who have a parent with serious drug or alcohol problems. (Hidden Harm 2003). 329. The same author acknowledges that with the benefit of more information about MO’s relationship history, drug use history as well as the inevitable hindsight provided through a detailed serious case review there appears to have been overlapping parental stressors which together would increase the risk factors for Baby E. Being a baby under the age of one year also placed Baby E into a vulnerable category22. 330. There also appears to be an ‘invisible father’ who was thought to be uninvolved with MO and Baby E but by the time Baby E sustained the fatal head injury MO’s partner was part of the family unit. There has been a dearth of information about men in most serious case reviews, both nationally and locally. The failure to make an assessment of partner’s and fathers connected to the mother and children has been identified in national evaluations. 331. Three recent SCR's highlighted by the Lancashire CSC author (relating to Baby J and Child AB (undertaken by Lancashire LSCB) and Child L/Child K (completed by Trafford LSCB), which Lancashire CSC contributed to, had highlighted the importance of assessments including adult males within the family. 332. National evaluations of SCR's have also found that fathers or male partners have not been understood well and therefore the risks assessed inadequately. Given the important role that men often play in children's lives it is important that front line workers have the skills and confidence to engage with individuals who may be threatening and aggressive. This case highlights the importance of assessing relationships and going beyond self-reports in the interests of safeguarding children. 22 As evidenced by the IMR author in All babies count: prevention and protection for vulnerable babies: a review of the evidence Cuthbert, Chris, et al (2011). Also noted in Ages of concern: learning lessons from serious case reviews A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 October (2011). overview report baby E publication version Page 68 of 90 333. Misinforming and possible manipulation of professionals often known as ‘disguised compliance’ is also referred to by more than one IMR author as may have been a factor in this case. From ELHT records it is unknown if MO was consistently having contact with Baby E’s father and also if her substance misuse was not stable on methadone alone and if MO frequently used ‘street drugs’. Disguised compliance and manipulation of professionals has also been identified in ‘Baby Peter’ SCR Haringey LSCB) and ‘Child T’ (Surrey LSCB). This is difficult to address but professionals need to feel able to challenge. overview report baby E publication version Page 69 of 90 4 Analysis of key themes for learning from the case and recommendations 334. This report begins with an acknowledgment of the imminent changes that will take place over the forthcoming months in the conduct of serious case reviews throughout England. These changes are driven by the recognition that for any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work within ‘the tunnel’23. 335. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire and/or Calderdale whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings. a) Innate human biases (cognitive and emotional) b) Family-professional interaction c) Responses to incidents d) Longer term work e) Tools f) Management systems 336. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps and inadequacies in the local child protection system and use it as a limited window into the local systems. 337. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action. LSCB response a) Does the Board accept the finding? 23 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. overview report baby E publication version Page 70 of 90 b) How is the Board to take this forward? If not, please explain why. c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported? 338. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published. 4.1 Learning from previous serious case reviews 339. The LSCB in Lancashire had undertaken nine previous serious case reviews between 2007 and 2010. Calderdale has published three executive summaries of serious case reviews between December 2008 and December 2009. Bradford has published four serious case reviews between 2006 and 2010. 340. Reference to the evidence from serious case reviews has been made throughout the IMRs, the health overview report (HOR) and this overview report. 4.2 Innate human biases (cognitive and emotional) Empathetic responses to support the efforts and intentions of a vulnerable woman trying to overcome long term addictions and coercive relationships misdirected professionals from maintaining a sufficiently informed level of sceptism focussed on the needs of the child and the inconsistent information. 341. The circumstances and reported history of MO provoked an empathetic response in the professionals working with her. The importance of making an emotional connection between the people needing help and the person providing support is a well understood foundation for developing the basis of effective intervention. The 'sad' history of MO evoked an understandably sympathetic response from several professionals who generally sought to take a strengths based approach to supporting MO and higher levels of contact24. 24 Strengths based or solution focused approaches enhance the capacities of individuals, groups, families and communities to deal with their own challenges. Empowerment results from being treated with respect and having strengths acknowledged and enhanced. overview report baby E publication version Page 71 of 90 342. The use of such an approach is based upon respect and trust that the parent is able to exercise the appropriate judgments and care; if this is not achievable and there is risk to the child a more assertive approach has to be developed. In this case, the initial approach was unable to identify the inconsistencies and indicators of concern. 343. The decision to invoke the MAPLAG in Calderdale when MO’s pregnancy was confirmed was recognition that she would require an enhanced level of help and support. Although risk was discussed it related primarily to concerns about FI’s history rather than MO’s own history and lifestyle. Given the difficulty that MO had in separating from FI before she became pregnant it remains a source of some puzzlement why many people believed that she would achieve this after hr baby was born. FI made clear very early on that the pregnancy was very significant for him. He was always intending to be part of his baby’s life. 344. The MAPLAG is a protocol that describes arrangements for professionals to meet and share information; it does not require the direct participation of the pregnant woman or her partner. Discussions were therefore largely based on what agency representatives brought to the meeting. This required some action in both preparing for the meeting in terms of undertaking basic checks and then following up lines of enquiry identified during the meeting. This was not consistently achieved and therefore even higher reliance was given to what MO stated were her intentions. 345. There is an inherent dilemma in working with parents who have lifestyles and needs that they know will be a source of concern to health and social care professionals. They will have strong motivation to manage information and this was exhibited in this case. MO appeared to have a good understanding about what would cause professionals greatest concern in regard to her baby and sought to minimise, disguise and to misdirect attention. 346. Even at the point that CSC in Lancashire were making their decision to undertake a formal assessment in December just before Baby E died MO was apparently keen to be seen to cooperate with the process. Up until that point she had displayed a tolerance of contact with the various professionals although had rarely taken up opportunities for example to participate in activities at the children’s centre. 347. The difficult circumstances under which MO was living provoked a strong sense of empathy from professionals providing help and support. This sense of empathy can be a constraining factor on professionals developing a sufficiently sceptical and reflective approach to the information and observations that are made through their contact with high need parents and children. Unless information is challenged and analysed for consistency and relevance there will be a danger of collusion developing. MO expressed a overview report baby E publication version Page 72 of 90 strong desire to create a better life for her child and professionals wanted to help her achieve that but were not able to identify the contradictory information or give enough inference to the barriers confronting MO from her personal and family history, life style and relationship with FI. 348. MO’s history of substance misuse was a significant factor in this case. The nature of addiction and the very significant pressures upon MO required a more informed approach to how for example evidence of MO continuing to access street drugs was viewed. By allowing the information to be regarded as a ‘blip’ or departure from the norm, it created a dynamic between MO and professionals that such ‘lapses’ were unlikely to attract significant attention. Individuals who want to disguise behaviour and attitudes will derive encouragement. There was a difference in how the behaviour was handled between the specialist substance misuse services in Calderdale and Lancashire. In Lancashire there was a more proactive and assertive response although this was not located firmly enough within a multiagency plan of work. 349. The first meeting of the MAPLAG in May 2011 discussed FI’s mental health and his prohibited contact with his previous children although the circumstances were not known and were not adequately enquired into for several more weeks. MO was consistently described as pleasant and engaging well with services and it was understood that she intended to leave the relationship with FI; this was a belief that persisted even when she made contradictory statements and FI also made clear his intention that he fully intended to maintain the relationship. Although MO described him as being controlling which had escalated since MO had become pregnant, it is not apparent that this was understood by the various professionals in contact with her. 350. The impact of coercive relationships on a vulnerable woman such as MO erodes their emotional and practical capacity to leave a relationship especially during and just after pregnancy. 351. Concern was expressed about FI’s mental health especially when he was using crack cocaine. Although follow up action to ascertain more detailed information about FI’s previous children was agreed this was not allocated to CSC. 352. Subsequent meetings of the MAPLAG were advised that MO was intending to establish an independent household. It is also apparent that great encouragement was taken from MO’s apparent determination to not use street drugs although the significance for her of being reliant on a continued methadone script was probably not fully appreciated. 353. When MO disclosed having used street drugs shortly before the birth of Baby E this was regarded as a ‘blip’. This optimistic treatment of information overview report baby E publication version Page 73 of 90 about evidence of opiate and other substance use persisted after she moved to Lancashire largely it seems because of how MO was represented to professionals in transfer information and the belief that MO was not in relationship with FI. 354. MO’s declaration of intent to leave the relationship with FI was accepted at face value. The inconsistencies between what MO was stating as her plan and the apparent refusal of FI to accept that he would not be involved in the care of Baby E was not recognised or explored. 355. A more appropriately informed and sceptical approach might have explored the significance of MO’s history of substance misuse, the implications of this for when she was under stress such as the ending of a relationship, pregnancy and plan to move to another area. 356. Of equal importance was the limited understanding about the barriers facing MO in leaving FI. MO would have been feeling vulnerable as a pregnant woman. There was limited evidence of a research aware approach of the potential barriers that MO might have to confront; for example, a research aware practitioner would understand that women experiencing abuse and violence often minimise the violence, believe that the abuse or violence will not happen again or that the relationship is different to previous violent relationships, feel embarrassed, have low self esteem and lack self confidence, are scared about the future in respect of having somewhere to live, having help with looking after a baby (especially a sick and premature baby) or becoming socially and economically isolated. 357. Although MO presented as a woman determined to leave an abusive relationship it was apparent that she had failed to achieve this on previous occasions. It was apparent that certainly after MO moved to Lancashire she sought to conceal the fact that her relationship with FI had not ended. She had expressed her anxiety about having Baby E taken from her and was therefore strongly motivated to keep any concerning information away from professionals. 358. Cleaver and Freeman25 note that families are often reluctant to admit to a history of problem drinking or drug use or mental illness because they assume it will result in social workers taking punitive action. Subsequent research reinforces this finding. 359. For similar reasons, families can be eager to conceal domestic violence. Farmer and Owen’s research26 suggests that hidden domestic violence may 25 Parental Perspectives in Cases of Suspected Child Abuse. Cleaver, H, and Freeman, P. (1995) London: HMSO. 26 Child Protection Practice: Private Risks and Public Remedies. Farmer, E. and Owen, M. (1995) London: HMSO. overview report baby E publication version Page 74 of 90 account for many mothers’ seemingly uncooperative behaviour and, further, that confronting families with allegations of abuse can compound the mother’s vulnerable position. For example, child protection conferences were often ignorant of whether or not children lived in violent families because in the ‘face of allegations of mistreatment couples often formed a defensive alliance against the outside agencies’ (Farmer and Owen 1995, p.79). 360. In this case it is possible to see that a defensive alliance developed between MO and FI. The disguised compliance with professionals visiting the home provided false reassurance and meant that missed appointments were for example not a source of immediate concern. 361. The abuse that both parents had experienced as children was another area that deserved more informed reflection. 362. Gaps in the sharing of information left all professionals without a complete picture but when episodic incidents occurred they were not apparently seen as symptomatic of longer term historic patterns that went back to the childhoods of both parents. 363. With hindsight, one of the most significant puzzles is why nobody took more interest at an earlier stage in the absence of information about the family generally and about FI in particular; this is partially explained by the cognitive or emotional processing of information about MO and her circumstances. It also reflected the behaviour of people under considerable workload pressure who did not have sufficient challenge from a supervisor or lead professional. 364. The apparent co-operation of some parents may result in practitioners applying the ‘rule of optimism’ cited in an earlier section. This stems from a number of assumptions, the strongest being that parents love their children and want the best for them, and that children’s lives are better if they stay within their family or kinship arrangements, even if that home is very dysfunctional. 365. The application of the rule of optimism may result in overly positive interpretations of what parents say and of the behaviour and circumstances observed. Research suggests that ‘over-confidence in “knowing” the parent or carer, might lead to misjudgment, over-identification with parents or (professionals) not seeing concerns about children.27’ 366. In these circumstances practitioners may too readily accept parents’ explanations of events and be reluctant to challenge them. Insufficient 27 The Child, the Family and the GP: Tensions and Conflicts of Interest in Safeguarding Children. Tompsett, et al. 2009 London: Department for Children, Schools and Families. Although the research is discussing GP practice the learning point is applicable across a much broader professional group. overview report baby E publication version Page 75 of 90 attention to parents wanting to keep aspects of their lives private is another factor; for example disguising aspects of lifestyle and relationships. This was a feature in this case and was a significant contributory factor. 367. Research and SCR findings have also identified that professionals tend to evade frightening confrontations (Brandon et al. 2009, 2010; Department for Education 2010c; Lord Laming 2009). The research suggests that when professionals feel unsupported or must visit alone, visiting and child protection enquiries might not always be as thorough as they could be (James 1994; Denny 2005; Farmer 2006)28. Several of the IMR authors comment on how professionals felt when they went into the house (crowded, voices in other rooms, not sure if they can insist on seeing all of the house, sense of intimidation) and the thoroughness of enquiries was a factor in this case Issue for consideration by the LSCB 1. How will the lessons in regard to assessment and focus on the child be incorporated into local single assessment frameworks? 2. Are the different protocols and frameworks such as MAPLAG, CAF, pre birth assessment and Integrated Pathways a help or a hindrance to supporting effective exchange of information and providing help quickly and effectively? Professionals did not feel sufficiently self confident about their role; some of this reflected inappropriate and pragmatic allocation of tasks arising from organisational stress. 368. Several of the IMRs refer to individual practitioners visiting the house and finding several people in the home. This had some influence on what was discussed on some of the visits. At least one of the professionals referred to asking to see the house but was dissuaded by MO. A lack of certainty about how far to press the issue was evident. Matters were complicated when one of the practitioners who were co-located with CSC in Lancashire was asked to undertake a home visit. The practitioner was very experienced and a skilled and qualified health professional but not a social worker. 369. The last visit to the home when the practitioner felt intimidated was the subject of a discussion with managers. 28 These sources are cited in the Children’s Needs – Parenting Capacity Child abuse: Parental mental illness, learning disability, substance misuse, and domestic violence; Cleaver, Unell and Aldgate; 2011 TSO. overview report baby E publication version Page 76 of 90 370. The emotional and psychological impact on practitioners is a significant factor in complex work such as safeguarding children. Issue for consideration by the LSCB 1) How are practitioners helped to develop the level of confidence and clarity and able to achieve sufficient sceptical curiosity and challenge in their work with vulnerable families? 4.3 Responses to incidents or information Enquiries and management of information did not identify the underlying patterns of behaviour, inconsistencies and inherent suspicion of professionals. 371. The interaction and relationship between professionals and vulnerable families and requires considerable empathy, professional knowledge and interpersonal skills. 372. Reference has been made to how despite MO’s expressed intention to leave FI and her description of the coercive nature of their relationship MO was unable to achieve that objective. 373. The absence of an adequate family history of either parent and the lack of follow up to enquiries with other local authorities on FI’s previous children left important gaps in the knowledge that professionals had. 374. It was highly unlikely that FI would be able to accept the relationship with MO was ending when she had become pregnant with his baby. FI made it clear that he knew where MO was intending to move. 375. None of the inconsistencies and contradictions aroused any sceptical curiosity. For some services such as CSC in Calderdale, there was a preoccupation with the plan for MO to move outside their area and this apparently allowed people to assume they had no responsibility. 376. MO and FI were from disrupted family backgrounds and their life style that had involved the use of drugs had implications for their social integration and was significant in the way in which MO worked with agencies aiming to support her and Baby E. 377. It remains unclear if MO was intending to misdirect professionals in Calderdale in regard to her intentions to leave FI. It became apparent in November 2011 that MO and FI were disguising their relationship from professionals; they were concerned that CSC would become involved and the potential implications in regard to whether they would be considered able to care for Baby E. overview report baby E publication version Page 77 of 90 378. Once the final referral was made to CSC MO sought to manage the response by stating her willingness to participate in an assessment and the importance of understanding FI’s history. 379. Without understanding the underlying patterns to the relationship and the impact of their family history the exchange of information focussed on what was largely reported by MO. With a clearer understanding about their history and the implications for how MO and FI would perceive professionals such as CSC there would have been opportunity for sceptical curiosity and a capacity to anticipate that reluctance, resistance and misdirection might be an underlying pattern to family and professional interaction. 380. Apart from the MAPLAG there were never any structured interagency discussion and sharing of information. There was a high reliance on individual telephone calls, email correspondence and fax. This contributed to a piecemeal picture and undermined opportunity to identify emerging patterns. 381. The work on refreshing the CAF in Lancashire will provide opportunity to review thresholds and referral pathways. Issue for consideration by the LSCB 1) Are the skills for completing appropriate individual and family histories and the use of chronologies sufficiently embedded in service expectations and practice? 4.4 Longer term work Insufficient multi agency understanding about the significance of substance dependency and the implications for working with parents and their inconsistent engagement contributes to inference and interpretation that lacks balance 382. The influence of empathy that is highlighted in regard to the emotional response to MO’s circumstances have implications for longer term work with parents with longstanding substance misuse. 383. Problematic drug use and misuse of alcohol by parents or people caring for children can and does cause significant harm to children and has implications especially for very young and dependant infants. 384. Children living in households where there is a parent with a drug or alcohol dependency will be susceptible to several risks; these range from poverty exacerbated by an inability to maintain a routine of work as well as diverting household income to funding the purchase of substances as well as increasing the risk of inconsistent care that exposes children to the risk of immediate physical harm and longer term emotional damage. overview report baby E publication version Page 78 of 90 385. A persistent factor in this case was the non recognition other than by the Inspire service in Lancashire that MO was dependent upon maintaining her physical and emotional stability with a regular methadone prescription. Several professionals mistakenly regarded MO’s substance dependency as being a largely historical problem that she had overcome and therefore were not sensitised to the potential for relapse and especially during times of heightened stress. 386. This is difficult area of practice where on one hand professionals are trying to establish a relationship of trust with adults who will not want to be open about issues such as relapse. If adults and professionals are both minimising the issue it becomes a source of significant risk in households where children are very young and dependant. 387. Research which explores the association between parental problem drug misuse and child abuse suggests parental drug use is generally associated with neglect and emotional abuse29. Parents who experience difficulty in organising their own and their children’s lives are unable to meet children’s needs for safety and basic care, are emotionally unavailable to them and have difficulties in controlling and disciplining their children30. The chaotic lifestyle and tendency to allow other users into the home may also place children at increased risk of harm31. 388. High levels of parental criticism are also associated with the formation of insecure attachments as children grow older. Research suggests that children living with opiate-using parents are at increased risk of harm because these mothers were observed to rely on harsh verbal responses when communicating with their children.32 389. The Inspire IMR highlights that in November 2012 there appeared to have been a change in the substances used by MO that was identified at a doctor’s appointment on the 10th November 2012 where she tested positive for methadone, heroin and crack cocaine. The fact that heroin and crack cocaine were detected indicated very recent usage (compared to other substances that remain detectable over a longer period of time). 29 ‘Working with substance misusing parents as part of court proceedings.’ Representing Children 14, 36–48. Velleman, R. 2001 30 When Parents Use Drugs: Key Findings from a Study of Children in the Care of Drug-using Parents. Dublin: The Children’s Research Centre. Hogan, D. and Higgins L. (2001) 31 Research Review: Child Care Proceedings under the Children Act 1989. London: Department for Constitutional Affairs. Brophy, J. (2006) 32 ‘Annotation: the psychological development and welfare of children of opiate and cocaine users – review and research needs.’ Journal of Child Psychology and Psychiatry 39, 609–619 Hogan; 1998 and cited by Cleaver et al. overview report baby E publication version Page 79 of 90 390. This information was not passed on to the midwife until the 17th November. The recovery worker understood that the health visitor was going to arrange a multi-agency meeting following a discussion on the 17th; however this did not take place. The recovery worker for Inspire did not follow this up with the Health Visitor as the situation had escalated in the following week resulting in a Section 47 referral being made. 391. There are several references to MO trying to circumvent the tight management of her methadone treatment. MO’s access to other sources of methadone or her use of street sourced drugs was not given any significance. 392. The speed with which MO had physically deteriorated in November 2011 is commented upon in previous sections of this report. 393. Although the MAPLAG, ICP, CAF as well as statutory assessments of a child in need were variously identified as frameworks to assess Baby E’s circumstances, none of these achieved an adequate parenting assessment that had been agreed across the various people working with the family. This is distinct from the separate point that is made later about the absence of tools being used to help professionals make difficult judgments. Issue for consideration by the LSCB 1. Do practitioners have sufficient knowledge appropriate to their role and responsibilities in regard to domestic abuse and substance dependency to understand the implications for safeguarding children? 4.5 Tools The use of tools for collating, sharing and analysing information are not sufficiently embedded into multi agency working to promote analytical discussion and to help reveal underlying patterns of behaviour and risk especially in regard to very young children. 394. Opportunities to complete an agreed programme of assessment of needs or risk were not taken in this case; there were discrete and specific assessments such as Baby E’s weight and MO’s mood but these could not provide the whole picture. Reliance appeared to be given to the use of the MAPLAG when MO was living in Calderdale and may have been misunderstood as representing an assessment and providing false reassurance. This is a protocol for the sharing of information and as such relies on participants having evidence and information that is collated and contributes to analysing relevant factors. 395. In this case there were basic enquiries required in regard to the history of both parents that were not undertaken with sufficient speed or rigour. Information and evidence about domestic abuse and substance dependency overview report baby E publication version Page 80 of 90 and the mental health of both parents were aspects that had a bearing on their capacity to care for their baby. 396. This can be a challenge when several different services comprising different professional backgrounds and training are working with a family. Questions such as whether a child is receiving a good enough level of parenting can be subjective as well as reflect different levels of o understanding around areas such as patterns of attachment for example. Tools help navigate and provide points of reference. 397. The effective sharing and analysis of information within a framework of appropriate and child focused assessment is a perennial challenge for multi professional teams or groups of workers and has been described and discussed in national research, inspections of children’s services as well as being a regular feature in local and national serious case reviews. 398. In Calderdale there was no social or family assessment completed. Information was discussed at MAPLAG although this had limited success in securing the level of multi agency action that was agreed at the meetings. The MAPLAG is a multi agency protocol although there was apparent confusion about its purpose and status. For example CSC believed it was a meeting where they were assisting health professionals in their work. Arguably, the use of MAPLAG may have diverted attention from other recognisable protocols such as CAF or assessing unborn children. 399. CSC in Calderdale did not complete any assessment. In Lancashire, the decisions about assessment were dictated by the workload and organisational stresses that were operating at the time. After MO moved to Lancashire and the decision by CSC in that county to convert the initial assessment to a core assessment did not secure basic enquiries quickly enough and the use of a health practitioner to complete the assessment further undermined the process; this is not a criticism of an individual practitioner but a reflection upon the circumstances that prevailed at the tie and had an impact on how the case was managed and decisions were made. 400. The national framework for assessment is facing radical reform following the publication of the Munro Review and the subsequent consultation on the revisions to Working Together and other national guidance. Local areas will be expected to develop their own local assessment frameworks and standards. In the absence of national guidance in the future, Calderdale and Lancashire will have to ensure that there is clarity about local assessment and a clear understanding about how it achieves appropriate levels of practice. 401. A further aspect in this case is the extent to which the CAF is used as a record of referral rather than being a multi agency process that draws relevant professionals together to work with parents. By the time a CAF was overview report baby E publication version Page 81 of 90 being completed in Lancashire there were safeguarding concerns being identified. 402. A common challenge for all professionals is how to give sufficient focus to the needs of children. It is a theme revealed in this review and which is reflected in national studies33 and concerns the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security are not routinely explored. The same report offers reflection on the important relationship between having a good understanding about all aspects of maltreatment and its relationship with the development of children. Issue for consideration by the LSCB 1. How does the training and development of professionals undertaking or contributing to single assessments across all services provide sufficient understanding about child development and childhood vulnerability? Opportunities are insufficiently developed for professionals to routinely enquire about the prevalence of domestic abuse and understanding coercive relationships as abuse. 403. Reference was made earlier in this report to the national pathway screening in Wales for domestic violence that encourages primary health workers such as health visitors and GPs to routinely inquire about a history or experience of domestic violence. 404. NICE are currently undertaking national research on how social care, health services and those they work with can identify, prevent and reduce domestic violence. 405. It is outside the scope of this SCR to discuss how domestic abuse is prevented. There is debate about the mixed evidence regarding the efficacy of screening pathways. 406. For the purpose of promoting effective safeguarding practice it is legitimate to reflect on the importance of all professionals in direct contact with young pregnant women having sufficient understanding about the prevalence of domestic abuse that encompasses coercive behaviour as much as more explicit physical and verbal abuse. 407. In this case, MO described how much she felt controlled by FI and it was apparent that he had been unable to allow her to end the relationship. The 33 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews Department for Education May 2011 overview report baby E publication version Page 82 of 90 increased risk of violence during and soon after the birth of a child was not explicitly recognised in this case. Issue for consideration by the LSCB 1. What measures can be taken to encourage more routine enquiry and identification of domestic abuse and identifying sources of help and support? 4.6 Management systems Organisational stress has an impact on the capacity of individual professionals and teams to function appropriately in regard to carrying out statutory functions and providing the level of co-ordination the case required 408. This review has highlighted the extent to which the performance and decision making of professionals can be adversely affected by the functioning of other systems and organisational arrangements around them. 409. In Calderdale there had been a recent statutory inspection of children’s services that had identified serious shortcomings. Some of those shortcomings are reflected in the way this case was managed and were further exacerbated when several senior managers left the service. 410. The impact on organisations dealing with a significant event will frequently involve a period of instability that further exacerbates the level of organisational challenge. Complex work such as safeguarding children relies on recruiting and retaining practitioners who have the motivation, skills and capacity to work effectively. The FRT service was highly reliant on temporary social workers; the fact that almost 75 per cent were agency staff no doubt undermined a culture that local practitioners were working for local children; this may have contributed to the mindset that gave a lower priority to completing an assessment on a child known to be leaving the local area. The logic remains unclear why no adequate assessment was undertaken in regard to Baby E prior to his discharge from hospital and the transfer of information from Calderdale to Lancashire CSC took place after MO had taken her own discharge. 411. In Lancashire, there were other organisational stresses. These related to the amount of work being undertaken in the area that MO moved to, the influx of new and inexperienced staff and the need to provide training and development. 412. This led to some pragmatic decisions being made. An example is the decision to convert the initial assessment to a core assessment. This is not overview report baby E publication version Page 83 of 90 necessarily a bad thing to do; for example research by David Thorpe34 and others showed that by reducing initial assessments could free capacity to develop relationships with families and improve the opportunity for enhanced assessment. Professor Munro’s recommendation to end the distinction between initial and core assessments is being implemented across England. 413. Another example of organisational stress having an impact on how professionals behave and make judgments is the decision to use the co-located health practitioner to complete the assessment. 414. The fact that organisations undergo periods of stress is not unusual or especially insightful. The learning to come from this review is to reflect upon the extent to which there was sufficient awareness and acknowledgement of the difficulties. This required local managers to be communicating up their line of accountability as much as senior leaders ensuring that appropriate systems of culture and accountability are identifying when local parts of a service are struggling and becoming a source of risk. It is also important for external agencies to report evidence of organisational stress either in terms of escalation around an individual case or more strategic discussion with senior managers. The LSCB has an important role in monitoring the integrity and resilience of local organisations and arrangements. 415. In the David Thorpe study quoted in the earlier paragraph reference is made to the potential value of developing meaningful performance measures which enable managers to understand and control near and long term events35. Thorpe and colleagues describe the opportunities presented by a new approach that is not constrained by meeting national key performance targets (KPI) but involves the ‘identification of numerical and textual patterns and trends’. In this case a significant factor was the influence of local and national KPIs in regard to the timeliness of assessments but did not identify the risk to quality or insufficiently addressing outcomes for Baby E. 416. The dismantling of national guidance and the increasing emphasis on local areas taking responsibility for the performance of their services will increase the need for developing meaningful measures that promote good outcomes for children. Issue for consideration by the LSCB 34 RIEP & ADCS Funded Safeguarding and Promoting Welfare Research Project; Thorpe, Denman and Regan; September 2011 35 Thorpe et al distinguishes a performance measure from a performance indicator as being ‘a far more active, continuous conversational process involving scrutiny and analysis’ compared to an indicator that is a ‘single numerical signal that does not carry any explanatory power’. overview report baby E publication version Page 84 of 90 1) What are the factors that ensure organisational stress is identified and the strategies for managing that challenge are appropriate and are understood by relevant stakeholders? 2) What measures of performance (rather than targets) will be required to support and provide evidence about the effectiveness of local single assessment frameworks? The delivery of services in areas of high need and deprivation lead to erosion of thresholds of concern and the adoption of locally normalised attitudes and behaviours 417. The process of normalisation is an increasingly well understood influence on human and professional behaviour and decision making. Although it is not made explicit in the IMRs the challenge of delivering services in areas of acute poverty and high deprivation is commented upon in regard to the work of specific services such as the children’s centre. 418. The area where MO and Baby E lived in Lancashire is within the top one per cent of socially deprived areas in England. Families are presenting with extremely high needs such as poverty, ill health, domestic violence, substance and alcohol misuse, infant low birth weight, teenage mothers, isolated single parents and homelessness. The children’s centre has between 2,500 and 3,000 service users registered at any one time and by definition a significant proportion of families and children is vulnerable. 419. The CSC author comments on whether resources are sufficient to meet the level of demand. 420. The impact on professionals working in areas is that they can begin to normalise behaviours that tolerate issues such as substance dependency and adults who do not want to engage and seek to keep professionals from seeing their children. Issue for consideration by the LSCB 1) Is there additional work required in regard to the formulation and allocation of resources especially in regard to indicators of need and workload? 4.7 Issues for national policy 421. The problems associated with no common system of recording patient information are highlighted in this serious case review. Peter Maddocks, CQSW, MA. overview report baby E publication version Page 85 of 90 Independent author 19th October 2012 CONFIDENTIAL overview report baby E publication version Page 87 of 90 5 APPENDICES Appendix 1 - Procedures and guidance relevant to this serious case review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act36 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. 36 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training CONFIDENTIAL overview report baby E publication version Page 88 of 90 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act37 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The local safeguarding children procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review Multi-Agency Pregnancy Liaison and Assessment Group (MAPLAG) The MAPLAG is a local procedure implemented in Calderdale but not in Lancashire. The protocol applies to all professional services working with women and their partners who are using drugs or misusing alcohol during pregnancy. The protocol is not a substitute for the LSCB child protection procedures in Calderdale. The protocol is based upon a model developed in Sheffield and was introduced in to Calderdale following a previous serious case review. The MAPLAG is intended to encourage pregnant women who are using drugs or misusing alcohol to seek early ante natal care and to develop an action plan that also encourages communication between all relevant professionals working with the pregnant woman. The MAPLAG has been highlighted as an example of good multi agency practice by inspections of services in Calderdale. 37 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. CONFIDENTIAL overview report baby E publication version Page 89 of 90 National guidance38 Working Together to Safeguard Children (2010) The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. This guidance is likely to be significantly reduced by the coalition government. Framework for the Assessment of Children in Need and their Families 2001 The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory. The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed. Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. 38 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. CONFIDENTIAL overview report baby E publication version Page 90 of 90 Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. 1 Serious Case Review Baby E Lancashire LSCB Response to Findings June 2013 2 Findings 1, 6 and 9 How will the lessons in regard to assessment and focus on the child be incorporated into local single assessment frameworks? How does the training and development of professionals undertaking or contributing to single assessments across all services provide sufficient understanding about child development and childhood vulnerability? What measures of performance (rather than targets) will be required to support and provide evidence about the effectiveness of local single assessment frameworks? Working Together 2013, which became operational on 15 April 2013 details how each Local Authority should develop and implement a single assessment framework. In Lancashire, this process is well underway and the LSCB hopes to approve the final documentation by the end of summer 2013. The development of this framework has been carried out with partner agencies so that all practitioners will feel some ownership of the process. The roll out of the single assessment training has been agreed and will involve all partner agencies. This is being funded and facilitated by the LSCB. The issues about family history and chronologies will be integral to this training, as will child development. A mechanism for reviewing and evaluating the success of the framework will be developed using qualitative measures about the impact on children's' lives. Alongside this work to develop the single assessment framework, the Common Assessment Framework (CAF) has been refreshed in Lancashire, along with the Continuum of Need and Threshold guidance. There are plans to launch this refreshed guidance and documentation from Autumn 2013, and again this includes significant multi-agency training programmes. Meanwhile, the basic principles of child development and vulnerability are built into all single and multi agency training and LSCB interactions with practitioners. The LSCB runs bite-sized briefings for staff on a variety of child related topics, best practice panels for practitioners, formal multi-agency training and regular large briefings about the findings from serious case reviews. Theories about hypothesizing and 'professional dangerousness'1 are covered in all of these outlets. Practitioners get involved in many case reviews, not just Serious Case Reviews, where they can reflect on practice and have the opportunity to share learning and build their skills and knowledge. 1 “Professional dangerousness” is a process whereby individual practitioners and agencies can be drawn into maintaining situations of risk unintentionally, for example, by being overly optimistic about a child’s safety despite evidence to the contrary. Professional dangerousness can exist at an individual, agency or societal level. 3 Finding 2 Are the different protocols and frameworks such as MAPLAG (Multi Agency Pregnancy Liaison and Assessment Group), CAF, pre birth assessment and Integrated Pathways a help or a hindrance to supporting effective exchange of information and providing help quickly and effectively? Lancashire LSCB considered the MAPLAG process as used in Calderdale, but felt it appropriate firstly to review existing processes. Consequently, reassurance was sought about pre-birth processes across the County. Feedback from midwives and health practitioners reassured Lancashire LSCB that introducing a new, additional process was not only unnecessary, but could potentially confuse what is a well-functioning process. The pre-birth protocol in Lancashire was refreshed and re-launched at around the time of this review being completed, and generated a great deal of discussion and awareness-raising amongst relevant practitioners. Lancashire partner agencies have recently launched a Multi Agency Safeguarding Hub (MASH), which will provide a very quick and effective process of sharing information through the co-location of professionals and recording systems. Details about how this works, along with much more information about improving the way agencies work together with families in Lancashire can be found via this hyperlink: Lancashire Childrens Trust - - Lancashire Improving Futures Programme (or at www.lancashirechildrenstrust.org.uk/resources) Finding 3 How are practitioners helped to develop the level of confidence and clarity and able to achieve sufficient sceptical curiosity and challenge in their work with vulnerable families? Lancashire LSCB recently launched multi-agency safeguarding supervision standards for all agencies to adopt. In addition, Children's Social Care has launched a strategy to ensure all their staff supervision allows space and time for 'reflection' about work with families. This will allow individuals to challenge their thinking about their work and ensure they are applying enough sceptical curiosity. In addition, the LSCB is currently undertaking a supervision audit across partner agencies and will consider the findings and take any necessary actions in due course. Practitioners have the opportunity to become involved in many activities offered by the LSCB. Best practice panels run across the County, where practitioners can bring cases to share their learning and develop their practice. Bite sized briefings are offered on a variety of topics, and large multi-agency briefings run several times a year to feedback learning from serious case reviews. Throughout all the interactions we have with practitioners, in whatever training or forum, we promote theories about 4 hypothesizing and 'professional dangerousness', to help practitioners challenge their own and others' thinking about families. The LSCB is hoping to develop practitioner forums this year, which will provide an additional outlet for practitioners to come together to share best practice and learn from one another. Finding 4 Are the skills for completing appropriate individual and family histories and the use of chronologies sufficiently embedded in service expectations and practice? Following this review, the LSCB sought assurance from partner agencies about their use of chronologies, and there are some issues that relate to systems that can make this difficult. However, the message about histories and collating historical information are reinforced in all of the forums previously detailed. In addition, the MASH will allow the sharing of those histories on a multi-agency basis in a much quicker and more efficient manner. The LSCB is currently undertaking an audit on neglect and the early support and identification of neglect across partner agencies, and this will provide more evidence about how histories are being used to determine future risks. Findings 5 and 7 Do practitioners have sufficient knowledge appropriate to their role and responsibilities in regard to domestic abuse and substance dependency to understand the implications for safeguarding children? What measures can be taken to encourage more routine enquiry and identification of domestic abuse and identifying sources of help and support? The LSCB has chosen the 'toxic trio'2 as the focus of its quality assurance work for the coming year. This will include seeking a large amount of quantitative, qualitative and outcome information that demonstrates the impact agencies are having on the lives of children affected by parental substance misuse, mental ill health and domestic abuse. The implications from the findings of this work will be considered by the LSCB and appropriate actions taken. 2 The term “toxic trio” is used to describe the co-occurrences of mental health problems, substance misuse and domestic abuse in families. 5 The LSCB delivers training about the 'toxic trio' through formal courses and also briefings. In addition, the work around supervision will encourage reflective practice. (See also comments below about practitioner survey) Findings 8 and 10 What are the factors that ensure organisational stress is identified and the strategies for managing that challenge are appropriate and are understood by relevant stakeholders? Is there additional work required in regard to the formulation and allocation of resources especially in regard to indicators of need and workload? Lancashire LSCB has recently completed a practitioner survey across all agencies to determine practitioner views about their employing agencies. This included views about training and support available, along with confidence in tackling certain issues (such as domestic abuse). More than 700 practitioners responded to this survey and the LSCB has required agencies to take action in regards to the findings. The survey can be viewed via this hyperlink: Lancashire Safeguarding Children Board The LSCB has strong links to the Children's Trust in Lancashire and shares information and vies about need within the County. The LSCB is also to publish imminently a thresholds guidance document, to run alongside the refreshed CAF and Continuum of Need. A programme of training will be delivered alongside this. Nigel Burke Independent Chair Lancashire Safeguarding Children Board July 2013 |
NC52470 | Death of a 1-year-old girl in October 2019 from severe head injuries and a spinal fracture. Learnings are embedded in the recommendations. Recommendations include: ensure there are clear records of who accompanies a young person to antenatal appointments; document a richer understanding of parental and non-parental relationships; commission and scrutinise audits of the effectiveness of new services; establish whether there is sufficient recognition of the potential impact of adverse childhood experiences and whether a whole family approach is sufficiently embedded in practice; coercion and controlling behaviour should be addressed in multi-agency training as a contribution to a "think family" approach to practice, and including legal rules to protect victims from domestic abuse; conduct routine audits of social work assessments and managerial oversight of decision-making, with reports scrutinised; undertake audit work routinely to ensure that strategy meetings and professionals' meetings are convened; routinely scrutinise evidence for the impact and outcomes of children's social care's action plan; share learnings from this case with GPs and all members of primary care teams and community health services, and remind staff of the pathway for child protection medicals.
| Title: Child safeguarding practice review – Child 3. LSCB: Wigan Safeguarding Partnership Author: Michael Preston-Shoot Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review – Child 3 (28th September 2018 – 17th October 2019) For Wigan Safeguarding Partnership Completed by Professor Michael Preston-Shoot May 2021 1. Introduction 1.1.Child 3 died on 17th October 2019. A post mortem the following day found severe head injuries and a spinal fracture, indicative of a very severe high impact assault. She had sustained multiple skull fractures and a subdural haemorrhage. This had caused swelling and mid-line shift of the brain and retinal haemorrhages in both eyes. The findings were totally incompatible with a minor domestic fall or accident, such as down a few steps, which was the original story given by Child 3’s Mother and the Adult Male’s sister with whom mother and baby had been staying. There were curved bruises on one arm but no deep bruising beneath these, plus a minor bruise over left side of upper jaw. Pathologists noted evidence of a possible old scar left top of head. There was no other evidence of old or recent trauma. 1.2. Child 3’s Mother was arrested and subsequently charged with perverting the course of justice and causing or allowing the death of a child. An Adult Male, with whom Child 3 appeared to have been left alone, was arrested and subsequently charged with murder. This Adult Male was at the time under investigation for a Section 18 serious assault on an 18 month old child. The Crown Prosecution Service ultimately decided not to charge him with respect to the injuries sustained by this child. On 30th October 2020 the Adult Male was found guilty and sentenced to a minimum term of 18 years. Child 3’s Mother was found not guilty on 2nd November 2020. 1.3.In accordance with statutory requirements1 a Rapid Review was conducted by Wigan Safeguarding Board. The Rapid Review report was concluded on 8th November 2019 and submitted to the National Panel on 15th November. The report considered information from all agencies involved regarding numerous referrals to, and contacts with Children’s Social Care from February 2019 to October 2019. One key issue was the number of contacts and referrals made relating to the Mother of Child 3’s capacity to provide adequate parenting and her own vulnerabilities, as well as risks around her relationship with the Adult Male that never resulted in formal Section 47 Children Act 1989 investigations. The consequence of this meant that risks were not managed at the correct threshold despite the level of concerns being made. The panel overseeing the Rapid Review determined that this should form a key part of this Local Child Safeguarding Practice Review. 1.4. The analysis for the Rapid Review concluded that risks that were clearly at a level where child protection processes should have been followed were not acted upon. There were numerous opportunities to respond to risk and intervene at the appropriate level that were missed. Accordingly the Rapid Review Panel determined that practice and system issues regarding why these missed opportunities occurred would need to be subject to 1 Children and Social Work Act 2017. HM Government (2018) Working Together to Safeguard Children. A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. London: The Stationery Office. 1 the further scrutiny of a Local Child Safeguarding Practice Review. It was also concluded that the focus of this review would need to incorporate key lines of enquiry regarding: 1.4.1. The timeliness and speed with which findings from health-based peer reviews of Child Protection Medicals are communicated and actioned effectively within the child protection system. 1.4.2. Whether the processes regarding response to bruising and suspicion of non-accidental injuries were being followed effectively across the primary care sector; 1.4.3. Whether Community Rehabilitation Company safeguarding checks on offenders were robust when there are changes of address; 1.4.4. The timeliness of the outcome of the police investigation into the Adult Male’s previous section 18 assault charge and the outcome of the IOPC2 investigation into this. 1.4.5. The Rapid Review and case review findings regarding the July 2018 assault on another infant by the Adult Male and impact on the learning in this case. 1.4.6. Other areas/key lines of enquiry that emerge throughout the review, discussed as appropriate within the panel meetings and practitioner event. Other key lines of enquiry have, indeed, emerged, namely: 1.4.6.1. Whether assessments by Children’s Social Care were robust and decision-3making reasonable in response to referrals and information received. 1.4.6.2. Whether the early help offer from Start Well was sufficiently focused and thorough. 1.4.6.3. Information-sharing and liaison between Children’s Social Care and Start Well. 1.5. The Safeguarding Partnership identified the following issues for immediate action: 1.5.1. The degree to which practice and process issues in this case are systemic within the child protection system. The Safeguarding Partnership had identified key issues which would inform further immediate partnership quality assurance work. 1.5.2. Building on an already completed Children’s Services quality assurance exercise on this case and resulting action plan and learning events. 1.6. Thus, in line with statutory guidance4 a Local Child Safeguarding Practice Review was commissioned because Child 3 had died as a result of known abuse. The purpose would be to highlight necessary improvements to the safeguarding of children and the promotion of their welfare, including how practitioners, services and organisations work together. Timely completion of this review was delayed both by the impact of the Covid-19 pandemic but also by the need to await completion of the criminal trial and the conclusion of internal and/or independent investigations focusing on the conduct of practitioners and their employing organisation. 2 Independent Office of Police Conduct. 3 It should be noted that child protection medicals and peer reviews are two separate systems. Child protection medicals form a key part of children’s safeguarding procedures and are well established. Peer reviews are learning opportunities within the Hospital, for which there are no formally agreed, Greater Manchester timescales. It is unusual for letters to be sent as a result of peer review; that this happened in this case is an indicator of the concerns regarding Child 3’s welfare. 4 HM Government (2018) Working Together to Safeguard Children. A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. London: The Stationery Office. 2 1.7. Also in line with the aforementioned statutory guidance this review adopts a systemic perspective that analyses operational practice as well as surrounding organisational structures, policies and procedures. A whole system perspective begins with direct work to safeguard and promote the welfare of Child 3, as required by Section 1 Children Act 1989, moving outwards to consider how the team around the child and family worked with them and with each other, then the culture and environment provided by organisations, working individually but also collectively to support the team around the child, and then the governance oversight and strategic direction provided by Wigan Safeguarding Board and subsequent partnership arrangements. There is also the national context to consider within which children’s safeguarding is situated. 1.8.This systemic perspective is represented in the following diagram. What enables and what obstructs best practice may reside in one or more of several domains, as captured in the diagram. Moreover, the different domains may be aligned or misaligned, meaning that part of the focus must fall on whether what might enable best practice in one domain is undermined by the components of another domain. Legal, policy and financial context Governance oversight Organisational infratsructure Team around the child Child 3 and family 1.9. In addition to scrutinising written information provided by the services that were involved with Child 3, and reading the Rapid Review, a learning event was held with practitioners and operational managers. Interviews were also undertaken with newly appointed senior managers in Children’s Social Care, with some practitioners who had worked with Child 3’s Mother and a manager at the time in Children’s Social Care. 1.10. Invitations to contribute were extended to Child 3’s Mother and Father, with the assistance of their Victim Support Officers. An invitation was also offered to the Adult Male who had been convicted of her murder. 1.11. Child 3’s Mother chose to answer questions asked by the Independent Reviewer in writing, with the support of the Health Visitor and her Victim Support Officer. Her comments have been integrated into this report, in section 3. 3 1.12. Child 3’s Father was interviewed in the presence of his Victim Support Officer, using a virtual link. He was sent questions in advance by the Independent Reviewer. He also asked questions about the review, to which the Independent Reviewer responded. The outcome of this conversation has also been integrated into this report, again in section 3. 1.13. The Independent Reviewer interviewed the Adult Male by video link. He denied being responsible for Child 3’s death. He was unable to offer any points of learning for practitioners and services that had been involved with him or with Child 3. 1.14. The Independent Reviewer has been supported by a panel comprising senior staff from the agencies involved in the case. 4 2. Chronology and Initial Commentary Introducing Child 3’s Mother 2.1. Child 3’s Mother was born in September 2000. For the majority of her childhood she lived with her grandparents. As a child and young person she and her family were known to various services. 2.2. Commentary: evident in Child 3’s Mother’s background are adverse childhood experiences. Adverse experiences in childhood can include abuse and neglect, domestic violence, poverty and parental mental illness or substance misuse.5 2.3.At the end of January 2018 Child 3’s Mother attended her GP Surgery to see the Community Midwife and to be referred for midwifery care. Her history, which Child 3’s Mother had shared with the Community Midwife, was discussed with Children’s Social Care, advice being received that no referral was required unless issues arose during the pregnancy. 2.4. Commentary: liaison between the Community Midwife and Children’s Social Care was good practice. Information submitted for the Rapid Review included a question6 as to why a pre-birth conference had not been held. Most contributions for the Rapid Review noted that this was a teenage pregnancy. The background of adverse childhood experiences, the instability of her accommodation situation, and her documented other needs might have indicated the appropriateness of a whole system meeting to agree a risk management approach. A necessary precursor to a conference would have been a pre-birth assessment. This did not happen and was arguably a missed opportunity. 2.5.On 26th February 2018 she attended Hospital for a booking-in appointment as she was pregnant. She disclosed, when asked, her history. 2.6.Between 10th May and the birth of Child 3 on 28th September 2018, Child 3’s Mother attended antenatal appointments, sometimes unaccompanied and sometimes with a sister, grandmother or undocumented family member. Before Child 3’s birth she was recorded as not being with the baby’s Father but as having good support. 2.7. Commentary: it is unclear how the judgement about good support was reached. It may have relied on self-report rather than being triangulated with information that might have been available from other agencies. Child 3’s Mother had been offered involvement in the Family Nurse Partnership programme in February 2018 but in mid-March declined to participate, apparently because of the programme’s intensity. Both the GP and the Health Visitor were informed of her decision. 2.8. Commentary: the Hospital Trust’s submission for the Rapid Review7 identifies two learning points from this point of the case, namely to ensure that there are clear records of who accompanies a young person to antenatal appointments, and to clearly document a richer understanding of parental and non-parental relationships. 5 Public Health England (2018) Evidence Review: Adults with Complex Needs (with a particular focus on street begging and street sleeping). London: Public Health England. 6 GMP submission. 7 Bolton NHS Foundation Trust. 5 2.9. In August 2018 Child 3’s Mother applied on the Housing Register. The combined chronology records that she was living in an overcrowded situation with her parents. 2.10. Commentary: this reinforces the observations made earlier regarding accurate recording of relationships (and living situation) and the importance of addressing housing need. Elsewhere, at this time, it has been recorded that she was living with her grandmother and mother, for example. Introducing Child 3 2.11. Child 3 was born by caesarean section on 28th September 2018. Contributions to the Rapid Review observe that Child 3’s Mother cared for the baby well in hospital. Child 3 was bottle-fed. Mother and baby were discharged from hospital on 30th September and the case transferred to Community Midwives in Wigan. Hospital records noted that she had help and support at home. 2.12. Commentary: once again, it is unclear how the judgement about good support was reached. It may have relied on self-report, here by Child 3’s Mother and sometimes also members of her extended family, rather than being triangulated with information that might have been available from other agencies. With the number of births per year, it would be unreasonable to expect triangulation of information in every case. However, in this case, Child 3’s Mother had been offered and declined involvement in the Family Nurse Partnership programme. Assessments of need and of risk are clearly dependent on information available and accessible at the time. 2.13. Community Midwives saw mother and baby on five occasions before discharging from midwifery care on 9th November. Advice was given regarding safe sleeping, not smoking around Child 3, and not leaving her or dogs unattended. A Moses Basket was advised as Child 3 had been sleeping in a baby recliner seat. On discharge Child 3 was observed to be alert, pink and well. She was on a lactose free formula and awaiting paediatric review. 2.14. The Health Visitor’s first contact was on 10th October. She observed warm interactions, with Child 3’s Mother speaking fondly about her baby. There were no parenting concerns and no low mood was detected. Child 3 was very responsive to her Mother. The birth Father was in contact. Basic health advice was given. A second contact occurred on 9th November. Child 3 was clean and appropriately dressed. Lots of emotional warmth and stimulation were observed. No parenting concerns were identified. 2.15. GP Surgery records have noted that Child 3 had looked well when seen but was referred to Paediatrics around 24th October and again on 1st November for constipation. She was brought by her Mother for the first appointment but then a pattern developed of Child 3 not being brought. As a result Child 3 was discharged8. A baby check for 13th November was apparently cancelled. Child 3 was not brought for immunisations on 10th December 2018 but was brought on 20th December for her first routine immunisations. GP records for 3rd January comment that Child 3 was still prone to constipation and follow-up with Paediatrics was chased. On 4th January 2019 Child 3 was taken to an A&E 8 Reported in the WWL NHS Foundation Trust submission for the Rapid Review. 6 Department in another Greater Manchester local authority area with bronchitis. Her Mother became very upset when blood was taken from the baby’s heel. Later she was observed cuddling her child9. On 17th January Child 3’s second immunisations were cancelled by her Mother as Child 3 was still unwell. 2.16. Commentary: it is now clear that the pattern of missed appointments was raised with Child 3’s mother by the Health Visitor. This was good practice. However, this intervention did not completely break the cycle. 2.17. Child 3’s Mother attended A&E on 31st October via Ambulance with a PV bleed/passing clots. Records indicate that she had consulted her GP the day before with post-natal bleeding and discharge. At hospital this was treated as endometriosis and she was discharged home. She consulted her GP for anxiety on 27th November 2018 and again on 10th January 2019 when the anxiety is specifically linked to her housing situation and living conditions, regarding which she requested a letter for the Housing Department. 2.18. Commentary: the timeframe for the Rapid Review covered April 2018 to 17th October 2019, when Child 3 died. What is noteworthy is the limited amount of information available to the Rapid Review for the period between April 2018 and January 2019. Only two submissions, from GMP and from Bolton NHS Foundation Trust, contain reflections on how practice might have been improved. It is questionable whether the level of support was sufficient for a teenage mother with a history of adverse experiences. Her anxiety about her living situation is a marker here. Introducing an Adult Male 2.19. The combined chronology first mentions this Adult Male in the life of Child 3’s Mother in February 2019. For that reason, some background information is relevant first. 2.20. He has a background of adverse childhood experiences and behavioural difficulties, which brought him to the attention of various services. A diagnosis of learning disability had been recorded, with ADHD also suspected. He was referred to mental health services but did not attend appointments, possibly because contact details were incorrect. In April 2019 he was referred to secondary mental health for anxiety. Health records contain references to suicidal thoughts and hearing voices inciting violence. He did not attend a review in May 2019. Health records contain at this time a diagnosis of ADHD with psychotic symptoms. 2.21. He has an extensive criminal history involving assaults, theft, hate crime and public disorder. Up to June 2019, 16 incidents have been recorded of him perpetrating domestic violence and he was the subject of a restraining order with respect to the mother of a former partner. 2.22. In July 2018 GMP had intelligence that he was involved in the supply of Class A drugs. In the same month he was arrested for section 18 wounding of a baby10. In September 2018 he was arrested and charged with criminal damage of a window of his 9 Bolton NHS Foundation Trust. 10 The baby had been shaken and was placed by Wigan Children’s Social Care with the child’s father. 7 former partner’s mother’s home. In December 2018 he was referred to Addaction but failed to present for assessment11. On 16th January 2019 he was found guilty of criminal damage and aggravated vehicle taking. A Community Order was made with rehabilitation, which initially required him to attend appointments and complete unpaid work. He was disqualified from driving. 2.23. Commentary: this background information was known to some but not all of the agencies involved with Child 3 at the point when it is first recorded that the Adult Male entered her life and that of her Mother. Information-sharing is a key component of best practice in children’s safeguarding. A strategy meeting would have been the appropriate mechanism to ensure that all the practitioners and services involved were fully cognisant of the risks arising from his involvement. Growing Concerns 2.24. On 1st February 2019 a Health Visitor referred her to Start Well on account of her difficult housing situation. She was living with her grandparents. She reportedly also accepted that she needed support with her emotional health, and with budgeting, financial management, and accessing community resources and education. The Health Visitor has commented that the referral was made in order to ensure that the additional support that she felt Child 3’s Mother needed was offered, and also to enable the Health Visitor to focus on the emotional and physical wellbeing of mother and baby. The Health Visitor referral followed a home visit on 31st January when Child 3’s Mother had been very upset about her home circumstances. The Health Visitor, with consent, also referred Child 3’s Mother for counselling and signposted her back to the GP because prescribed medication had caused her to have “weird feelings.” 2.25. The submission from the NHS Foundation Trust responsible for Health Visiting commented for the purposes of the Rapid Review that there were three Early Help meetings with Start Well but that Child 3’s Mother did not engage fully, with the result that her housing situation and finances were not addressed. The same submission notes liaison between the Health Visitor and Start Well, and between the GP Surgery and Children’s Social Care. Start Well withdrew because of non-engagement in August 2019. 2.26. Commentary: the reported liaison for information-sharing is good practice. Withdrawing involvement without a whole system meeting to discuss the implications of non-engagement, and without assertive outreach, is questionable. 2.27. Health Visitor records first mention Child 3’s Mother having a relationship with this Adult Male in February 2019. On 7th February the combined chronology records that a Social Worker was concerned that Child 3’s Mother was in a relationship with the Adult Male. The Social Worker was supporting an ex-partner of the Adult Male and, because of the history, was concerned about the potential for harm to Child 3. Checks were completed. Child 3’s Mother said that the Adult Male was a family friend, that she was not in a relationship with him, and that Child 3 did not have contact with him. Children’s Social Care was apparently satisfied with this account and took no further action. The Health Visitor was informed that Children’s Social Care had closed the case on 8th February. 11 In August a fire had occurred at the home of his sister and mother but no suspect could be identified. 8 2.28. Commentary: the Health Visitor was rightly concerned about the potential risks to Child 3, given that the Adult Male was under investigation for non-accidental injuries to a baby. The Social Worker does not appear to have triangulated the information provided by Child 3’s Mother with other intelligence that might have been available. This was a missed opportunity and might suggest the influence of the rule of optimism. No multi-agency meeting was convened. The Children’s Social Care and Start Well analysis for the Rapid Review concluded that checks at this point were insufficiently robust and the family history was not considered. The vulnerability of Child 3’s Mother and the extent of the risk posed by the Adult Male were not explored. No strategy meeting was convened. It is hard to disagree with this analysis. Indeed, this critical analysis remains pertinent throughout the remainder of the case. 2.29. Health Visitor records for 18th February contain correspondence from Start Well confirming the focus for Early Help, namely support to pursue housing options and to assist with budgeting and finances, making links with community groups, and building confidence and self-esteem to help Child 3’s Mother manage stress. 2.30. GP records note that Child 3 was seen for conjunctivitis on 25th February. Child 3 had also been seen in A&E on 22nd February when an examination had been normal. On 27th February the Health Visitor on a routine visit observed lots of emotional warmth and stimulation. However, Child 3’s Mother had again been upset about her housing situation and the lack of space she had for herself and her child. The birth Father was said to not be contributing financially and this seemed to have caused some animosity. Child 3’s Mother requested a voucher for the food bank. The Health Visitor’s records contain reference to discussion about the Adult Male and also about domestic abuse, with Child 3’s Mother denying any fear of the birth Father or the Adult Male. 2.31. On 1st March, the Community Rehabilitation Company (CRC) breached the Adult Male but the Court allowed previous orders to continue. CRC was aware by this date that the Adult Male was under investigation by GMP concerning allegations of abuse of a child. 2.32. On the same day, the Health Visitor completed an application form for the Young Persons Accommodation Panel. Child 3 and her Mother were living in an overcrowded house, residing in a box room with a travel cot. By this time Child 3’s Mother was known to be pregnant. GP records note that Child 3 had oral thrush on 4th March. 2.33. Start Well and the Health Visitor did have a conversation on 7th and 12th March to discuss early help and plan the interventions needed. On 11th March a Start Well Officer and an observing manager visited to build a relationship with Child 3’s Mother and to discuss the offer of support. This was the first contact between Start Well and Child 3’s Mother following the referral from the Health Visitor at the beginning of February. It was agreed to make an application for a mother and baby unit. During the visit Child 3’s Mother informed them that she was pregnant and that the father was either Child 3's Father or another male with whom she had slept once. Her low mood was observed. The Health Visitor was to be contacted to arrange an Early Help review. Four messages were left for the Health Visitor between 14th March and 4th April. Health Visitor records also contain reference to four calls to Start Well that were not returned between 27th March and 29th April. This caused a delay in holding an Early Help meeting. During this time the Health Visitor had made a referral to Children’s Social Care and was attempting to inform Start Well of this without success until 29th April. 9 2.34. On 21st March the combined chronology states that Child 3’s Mother disclosed to the Health Visitor that she was two months pregnant. This was during an opportunistic meeting in the street. She did not disclose the identity of the father. On the same day Child 3 was reviewed by a paediatric team12 because of constipation. It was recorded that her weight gain had slowed and a plan was devised involving medication, blood tests and monitoring by the Health Visitor, to be reviewed in a couple of months. Lactulose was to be stopped. It was recorded that Child 3 was living with her Mother, grandmother and other family members. The following day, Child 3’s Mother was seen by Community Midwives and referred to Bolton Hospital for maternity care. Child 3’s Mother informed the Hospital of Children Social Care’s involvement. A Start Well Worker was named as support. On 23rd March GP records note that Child 3 had been seen in an Accident & Emergency Department of a Hospital outside Wigan for a swelling to her right foot. Nothing abnormal was detected. Following assessment she was discharged. There is no evidence that the Health Visitor received any correspondence from the Hospital regarding this attendance. It was also never mentioned by Child 3’s Mother to the Health Visitor. GP records contain an entry on 29th March regarding the new pregnancy and a comment that nothing adverse was being reported by a Social Worker. 2.35. Commentary: the confirmation of the pregnancy does not appear to have triggered a review of what the Health Visitor was told in early February by Child 3’s Mother concerning her involvement with the Adult Male. This may have been because Child 3’s Mother only disclosed to the Health Visitor that the Adult Male was indeed the father of the unborn child once she had miscarried, although she was asked directly about paternity beforehand, at which point she had stated that it could have been Child 3’s Father or the result of a one-night stand. An assumption appears to have been made that the wider family was a circle of support and protection. The accommodation situation had been recognised as unsuitable and two options appear to have been pursued, namely referral to a Young Person’s Accommodation Panel and application to a Mother and Baby Unit. Several agencies are involved but no multi-agency meeting had been convened to share information, assess risk and agree a coordinated plan. Services were working in silos. 2.36. Around 26th March the Health Visitor referred Child 3 and her Mother to Children’s Social Care as it appeared that family relationships were breaking down and they had nowhere to live. On the following day the referral was closed as it did not apparently meet the social care threshold. As the lead professional for Early Help the Health Visitor liaised with Start Well and the Mother and Baby accommodation between March and May13. CAMHS was contacted by a Housing Service supporting young mothers for information. This was provided. A Start Well Worker visited on 9th April. Child 3’s Mother was seen at her mother’s home. Child 3 was clean and well dressed. It was acknowledged that the Adult Male was the father of the unborn child but that he would not be allowed to see the baby when born or Child 3. It is recorded that Child 3’s Mother had seen a Midwife14 and that a scan was planned for 17th April. 12 At an NHS Trust within the Greater Manchester area but outside Wigan. 13 By 22nd March Child 3’s Mother had visited a Mother and Baby Unit and a formal referral was made. 14 This occurred on 16th April at which Child 3’s Mother disclosed that the Adult Male was the father of the unborn child, information which the Mother only told the Health Visitor after she had miscarried. 10 2.37. Commentary: the lengthy delay between the Health Visitor’s referral to Start Well and the beginning of the latter’s involvement displays a lack of urgency in meeting the need for additional support that had been identified. The usual timescale for following-up a referral would be two days. However, the Health Visitor did continue to offer Early Help within the remit of her role and responsibility. It is also unclear why Start Well did not refer the case to Children’s Social Care on learning of the paternity of the unborn child. 2.38. On 4th April GP records note that Child 3 was seen for a cough and wheezing. On 11th April a Community Midwife completed an application for admission to a Mother and Baby Unit15. On 15th April Child 3 was not brought to an outpatient paediatric clinic. On 16th April Child 3’s Mother contacted a Community Midwife. She acknowledged that the Adult Male was the father of the unborn child but stated that they were not currently in a relationship and that he was not allowed to see Child 3. The Community Midwife reported this conversation to Children’s Social Care and was advised to submit a referral, which was done. A Social Worker confirmed that, at a finding of fact hearing, the Adult Male was considered a risk and one of a pool of people who could have injured a 4 month old. 2.39. Commentary: the finding of fact hearing took place on 4th March 2019 in the Family Court. The Crown Prosecution Service had previously concluded that it would be difficult to prove beyond all reasonable doubt when and by whom that baby was injured. Investigations into this case were still on-going when Child 3 died. Nonetheless, the acknowledgement that an Adult Male, under investigation for possibly injuring a baby, was in a relationship with Child 3’s Mother, with possible access to Child 3, did not prompt a strategy meeting or initial child protection case conference. Reliance was placed on Child 3’s Mother’s reassurances and on the support from Start Well. 2.40. Commentary: the documentation collected from agencies for the Rapid Review records that the threshold was not met for Children’s Social Care when the Health Visitor referred the case on 26th March. Considering the events recorded for 26th March, the reflective analysis from Children’s Social Care and Start Well for the Rapid Review is critical of the absence of checks and management scrutiny, and of the lack of professional curiosity regarding Child 3’s Mother’s living situation. It also notes that there was evidence that, for whatever reason, Child 3’s Mother was not being truthful. The referral from the Community Midwife did prompt allocation of the case to a Social Worker. The documentation collected for the Rapid Review records that an Advanced Practitioner directed that an assessment should commence and a strategy meeting be requested. No strategy meeting was convened. Yet, as the analysis from Children’s Social Care and Start Well for the Rapid Review acknowledges, days were passing with no knowledge of where Child 3 was living. Risks were not recognised or assessed. Child 3’s Mother was not being tested on what she was saying about her relationship with the Adult Male. A Social Work response from Children’s Social Care was delayed. 2.41. Child 3’s Mother experienced a miscarriage around 18th April16. She continued to reassure the Health Visitor that the Adult Male was not allowed contact with Child 3. She was not at the family home when a Start Well worker called on 25th April. On 29th 15 24 hour supported accommodation for single women under 25 with a child under 5. 16 She was seen in an A&E Department on 23rd and 24th April, with a scan planned for 29th April. She did not attend this appointment. However, on 7th May she did attend for an ultrasound scan that confirmed the miscarriage. She was discharged. 11 April the Health Visitor contacted Start Well and an Early Help review was set for 13th May. This followed a home visit when the Health Visitor had no concerns about Child 3’s Mother’s parenting. The Health Visitor clearly recorded that there was to be no contact between Child 3 and the Adult Male. Start Well were to support Child 3’s Mother to attend a Mother and Baby Unit on 2nd May. It is recorded that Child 3’s Mother was “gutted” about her miscarriage and stressed about her living situation. 2.42. However, with Start Well and Children’s Social Care, when staff visited on 1st May, she stated that she was aware of the allegations against the Adult Male but did not believe them. She was advised of the risks to Child 3 of the relationship with the Adult Male, being told explicitly by a Social Worker that Child 3 would become subject to child protection procedures if there was evidence of a relationship between them17. There is a record of the Community Midwife attempting to make contact with the Social Worker but there was no response to a left message. Health Visitor records contain three attempts to speak to the Social Worker between 29th April and 3rd May but there was no response to the messages that were left. Contact was eventually made on 17th May when the Health Visitor understood that a child protection plan would be initiated if it was confirmed that the Adult Male was in a relationship with Child 3’s Mother. 2.43. Commentary: the documentation submitted for the Rapid Review notes that the Social Worker asked Child 3’s Mother to reflect on what she had been told would be the statutory response if she maintained a relationship with the Adult Male, and to then respond. It is questionable whether, given the concerns about the risk to young children from the Adult Male, this was a safe approach to adopt. The critical analysis from Children’s Social Care and Start Well for the Rapid Review observes that leaving Child 3’s Mother to reflect was inappropriate. 2.44. Commentary: the critical analysis from Children’s Social Care for the Rapid Review observes that there was a delay in allocating a Social Worker to the case, between 17th April and 1st May. This was outside expected timescales. The direction for a strategy meeting was not progressed and there was no management follow-up. There does not appear to have been a thorough risk assessment that encompassed the risk of homelessness, the impact of the miscarriage, the risks posed by the Adult Male, and Child 3’s Mother’s living arrangements. 2.45. Commentary: the Health Visitor shared information with a Mother and Baby Unit on 2nd May and Start Well on 3rd May, for “safeguarding purposes”. This was good practice. An understanding given to the Health Visitor by a Social Worker that a child protection plan would be initiated if a relationship was confirmed between Child 3’s Mother and the Adult Male was not followed through, reflecting the inconsistent messaging about (the consequences of) that relationship. 2.46. On 1st May the Adult Male’s GP referred him to mental health services for a review of his mood and risk profile. He did not engage with mental health services and was discharged back to his GP on 29th May. 2.47. On 9th May Child 3 was not brought to an appointment with a Paediatrician for weight and bowel monitoring, and blood tests. There were also outstanding immunisations, which the Health Visitor followed up on 16th May. Child 3 had been 17 Recorded by a Community Midwife in the combined chronology for 17th May. 12 observed pulling her hair at either side of her head, causing it to thin. Nonetheless, the Health Visitor had also continuously documented warmth and affection between mother and child. The Health Visitor discussed with Child 3’s Mother age appropriate development and stimulation. On 13th May the planned Early Help review did not take place as Child 3’s Mother was at a hospital. On 15th May an outpatient paediatric appointment was not kept. On 16th May Child 3 was not brought for her second routine immunisation. Around 17th May the Health Visitor discussed concerns with Start Well about a relative who was living with the maternal great grandmother, and how this was contributing to Child 3 and her Mother not living there. Child 3’s Mother had given this as a reason for not wanting to live there in late March and it had been part of the referral to Children’s Social Care at that time. The Health Visitor was also worried that Child 3’s Mother was blaming the Adult Male's ex-partner for the injuries to the other child. The Health Visitor was also reporting concerns about Child 3's slow weight gain. Following advice on more responsive feeding, adequate weight gain was recorded. The Health Visitor referred her concerns again. 2.48. On 18th May an anonymous referral out of hours from a friend was received, reporting concerns about Child 3 and her routine. Child 3 was sleeping in a pram rather than a cot, and with her mother was staying at her maternal grandmother's home that had no heating. On 20th May a Start Well Officer and the Health Visitor undertook a joint visit for the planned review. No concerns were identified regarding Child 3’s health and wellbeing. Start Well was to access a full-size cot and to explore how Child 3’s Mother might access teaching assistant training. The Health Visitor was to follow-up on counselling to support Child 3’s Mother’s emotional wellbeing and information on groups at a Family Centre. She stated that she had ended her relationship with the Adult Male but as a result was being harassed and threatened. The Start Well worker emailed this information to a Social Worker. The Health Visitor shared safeguarding information with the counselling service alongside enquiry about when an appointment would be offered. 2.49. Commentary: information-sharing between practitioners and joint visits are good practice. The Health Visitor’s referrals of concerns was good practice. However, additional risk factors were now emerging, namely Child 3 not being brought to appointments and a disclosure by Child 3’s Mother of the Adult Male’s coercive and controlling behaviour. An anonymous referral had highlighted again risks associated with Child 3’s living situation. Child 3’s Mother was also downplaying concerns about the allegations against the Adult Male. Nonetheless, no strategy meeting was convened, nor does there appear to have been any consideration of how to use legal options to seek to protect Child 3’s Mother from domestic abuse. The mention of harassment could have been explored further and appropriate tools such as a DASH completed. It appears to have been assumed that, because Child 3’s Mother’s relationship with the Adult Male had been stated to have ended, no assessment was required concerning how Child 3 would be kept safe18. With her consent the Health Visitor had made a referral for counselling in February and she continued regularly to chase up an appointment. The delay in offering an appointment was unfortunate since Child 3’s Mother’s openness to the idea of support for her own emotional health and wellbeing was lost. 2.50. Commentary: additional reflections have been provided by Start Well relating to this joint visit. It occurred on the same day that a Social Worker was trying to contact Child 3’s Mother regarding the anonymous referral. This is given as an example of the lack of 18 Start Well response to a question asked by this reviewer. 13 coordination and communication. It also appears that the Early Help review documentation was not uploaded, meaning that there was no shared plan going forward. 2.51. On 21st May Child 3 and her Mother were accepted for a place at a Mother and Baby Unit. The aim of this provision is to prepare residents for a move into their own property. Key worker support is available. Start Well reported that Child 3’s Mother was pleased. Commentary: it has, however, taken several months to make progress regarding accommodation. This is one example where it would have been best practice to consider Child 3’s lived experience. Continuing Concerns 2.52. On 28th May Child 3 was seen in paediatric clinic for blood tests. Nursing staff were concerned at how Child 3’s Mother handled the situation and these concerns were escalated to Children’s Social Care. The allocated Social Worker was not available but a Staff Nurse was informed that the Adult Male was a risk to children. However, the combined chronology indicates that a Social Worker subsequently made contact with Start Well and was told by a worker there that Child 3’s Mother had not been witnessed to be abrupt with her child. This has been confirmed by additional information provided by Start Well, to the effect that the Start Well worker had conveyed that there were no concerns regarding Child 3’s health or interaction with her Mother. There were concerns about Child 3’s Mother’s low mood and the need for counselling to help her manage her emotions19. There is, however, no evidence that Child 3’s Mother kept a counselling appointment on 4th June. 2.53. Commentary: Additional reflective analysis provided by Start Well observes that the advice given to Children’s Social Care was based on just three contacts with Child 3 and her Mother. The same analysis comments that there is a lack of clarity in the recorded notes about how much contact the Adult Male had with Child 3 and an absence of a shared understanding of what might be an acceptable level of contact, if any. Additionally, as commented upon by the Health Visitor, Start Well did not direct the Social Worker to speak to the Health Visitor; nor did the Social Worker contact the Health Visitor. 2.54. Also on 28th May the Social Worker spoke with Child 3’s Mother by telephone. Apparently she confirmed that she did not want a relationship with the Adult Male and had been advised by the Health Visitor to contact GMP if worried. The Social Worker informed Child 3’s Mother that her case would be closed. This was approved by the Team manager three days later. Child 3’s Mother contacted Start Well distraught about the referral to Children’s Social Care. No record has been provided that the Health Visitor was contacted by Start Well with this information although this had been planned. 2.55. Commentary: case closure is an inexplicable decision. Analysis for the Rapid Review from Children’s Social Care is unequivocal. Case closure was inappropriate. The concerns referred by the Health Visitor (and indeed the Community Midwife) had not been adequately explored. There had been no detailed risk assessment of the relationship 19 The Social Worker should have contacted the Health Visitor for information about Child 3 but appears not to have done so. 14 between Child 3’s Mother and the Adult Male, of wider family relationships and family history, of the impact of the miscarriage, an unstable living arrangement and Child 3’s Mother’s emotional health and physical wellbeing. Decision-making was outside expected timescales. There had been no coordination meeting of professionals, no strategy meeting as had been directed, and there was no apparent plan to keep Child 3 safe. Thresholds had been misapplied. A Section 47 Children Act 1989 investigation and strategy meeting through to Initial Child Protection Conference would have been the appropriate pathway to follow. 2.56. Commentary: it appears that Start Well workers had only seen Child 3’s Mother on three occasions. This raises the question of what “early help” was being offered, not least because Children’s Social Care decision-making appears to have been influenced by their apparent involvement. 2.57. On 17th June GP records note that Child 3 was seen with a rash. The same day a Start Well Officer supported Child 3’s Mother to move into a Mother and Baby Unit. During the move Child 3 was cared for by one of her mother’s sisters. In a telephone contact three days later, Child 3’s Mother stated that she was unhappy at a Mother and Baby Unit, did not know anyone, felt she was being watched and disliked the curfew. When advised that, if she left, she would be intentionally homeless, she became angry and hung up. The Health Visitor was informed on 21st June. 2.58. Commentary: Children’s Social Care analysis for the Rapid Review criticises the lack of professional curiosity shown regarding the reasons for Child 3’s Mother being unhappy at a Mother and Baby Unit. However, Health Visitor and Start Well records do contain reference to why Child 3’s Mother was unhappy there, namely that she felt isolated due to having to be back in the accommodation at 20:00 and did not want to sit and stare at 4 walls. The Health Visitor explained that this was reasonable for a bedtime routine for Child 3. Child 3’s Mother was advised that her child needed a routine, a helpful pointer to the need to consider Child 3’s lived experience and perspective. It is also possible that Child 3’s Mother had been unsettled by a sister being offered a property with her boyfriend that week, triggering again her wish for her own property. It was during this time when the Health Visitor made another referral to Children’s Social Care to request more intervention. Thus, equally questionable at this point is whether sufficient and effective “early help” was being offered, adequate wrap-around intervention to support this transition. Indeed, the Health Visitor’s referrals to Start Well and to Children’s Social Care are evidence of a recognition that further support was felt necessary. 2.59. On 24th June Child 3’s Mother left a Mother and Baby Unit and stayed with her mother. This generated concerns about the possible exposure of Child 3 to risks at this address. The Health Visitor received information raising concerns that Child 3 had not been taken to 2 GP appointments, and had unhealed sores by her ears/hairline. The Health Visitor referred these concerns to Children’s Social Care. GP records contain a reference to the Health Visitor being concerned about Child 3’s Mother’s low mood. Health Visitor records note that Child 3’s Mother had missed her counselling appointment earlier in the month and that it was felt that emotional support would be beneficial. An Early Help meeting took place with the Health Visitor, Child 3 and her Mother, Start Well Officer, and maternal great grandmother. Child 3 presented with a rash, scratches on her face and sores on her ears. Child 3’s Mother stated that Child 3 was purposely pulling her hair out and had taken her to the walk in centre. She 15 requested to be supported into her own home and became distressed when she would not get her own way. She did not want to stay with members of her extended family. She stated that she had no clothes or food for Child 3 and left the meeting. The Health Visitor notified the GP of her concern about Child 3’s Mother’s low mood. The Health Visitor recorded that Child 3’s Mother was tearful and frustrated about her housing situation. Nonetheless, warm interactions between mother and child were also observed and recorded. Safe sleeping advice was given as Child 3 and her Mother were sharing a bed. Play and stimulation for Child 3 were discussed. 2.60. On 25th June Child 3 was not taken to a GP appointment arranged by the Health Visitor to treat the sores around her ears. GP records contain an entry that a message was left for the Health Visitor regarding this missed appointment. A Start Well Officer spoke with the Health Visitor about concerns around Child 3's presentation, including the possibility that the hair pulling could be linked to neglect. The Health Visitor had by then spoken with staff in Children’s Social Care, to be told that there was no role for Children’s Social Care unless Child 3 was left alone with her maternal grandmother. The Health Visitor contacted Wigan Family Welfare to get access to counselling and mental health support for Child 3’s Mother. The Mother and Baby Unit offered a slower integration to support her to live there. 2.61. On 27th June Child 3’s Mother was advised that the blood tests would need to be repeated for Child 3. A Start Well Officer tried unsuccessfully to contact Child 3’s Mother by telephone to enquire about her and Child 3. The Start Well Officer discussed with a Manager possible help from another worker in relation to stimulation support for Child 3 and her Mother. The Start Well Officer had not been able to contact Child 3’s Mother by the following day. Also on 27th June the Health Visitor outlined her concerns again to Children’s Social Care and Start Well. She outlined increasing developmental and health concerns for Child 3, slow weight gain and constipation, with Child 3 not being taken to appointments, pulling her hair causing thinning, and scabs to ears. Her Mother was unsure how this happened. She had attended a walk-in centre in Leigh on 19th June after noticing swelling and was given antibiotics. 4 scratch marks seen were consistent with her explanation. She was referred to the GP for further assessment on 24th June. Rash was present to torso and arms. There were also concerns regarding living arrangements. 2.62. Commentary: the Health Visitor continued to raise concerns, which is good practice. There is evidence of good communication between the GP and Health Visitor. However, these were repetitive and arguably escalating concerns, with little by way of a changed approach from Children’s Social Care. Further escalation of concerns would have been appropriate. The “Early Help” meeting between some of the professionals involved and family members was good practice but not all services with a contribution to make were present and it is difficult to discern a protection plan that addressed all the risks and needs that had been identified. 2.63. The Children’s Social Care and Start Well information contribution to the Rapid Review records that in supervision on 28th June concern was noted that a Social Worker had been unable to contact Child 3’s Mother. The case was to be reallocated for assessment with a direction to focus on the family’s living arrangements. The same contribution records that on 2nd July a visit took place and the case closed as “reports were accepted.” 16 2.64. Commentary: it is unclear what is meant by “reports accepted” and the decision to close the case is inexplicable given the risks that had been identified and the decision to reallocate for assessment. There was no discussion with the Health Visitor prior to the case closure decision. This was poor practice. Parallel Events 2.65. As already noted, the Adult Male was first recorded to be in contact with Child 3’s Mother in February 2019. He was already the subject of a restraining order to protect an adult female from conduct amounting to harassment or causing fear of violence. He remained under that restraining order for the duration of the period under review here. He was charged as a result of a breach of that order on 13th April 2019. 2.66. GMP were also aware in April of threatening behaviour towards another adult female who did not provide a statement and therefore the charge of assault was dropped. There was a domestic disturbance involving the Adult Male in May 2019, which GMP reported to Children’s Social Care and Health. A neighbour reported concerns about drug dealing in later June, with children known to be present. GMP reported this to Children’s Social Care, Health and Probation20. 2.67. The investigation of the Section 18 wounding of a young child was ongoing throughout this time. Legal Services within GMP applied to the Family Court on 6th August 2019 for evidence, including a finding of fact21. This was preceded by a lengthy process that included needing consent from all parties for the application for disclosure, which began on 7th June. Documentation was released by the Family Court on 10th September 2019 and, in relation to the finding of fact, 16th October. GMP received this two days later and sent it to the CPS for review. 2.68. The Community Rehabilitation Company (CRC) was informed by Children’s Social Care of the allegations of abuse of a young child that had possibly been perpetrated by the Adult Male. Thereafter there were only occasional subsequent updates received by the first Senior Case Manager in CRC, and Officers only saw the Adult Male twice. 2.69. Commentary: by June 2019 GMP were aware of a relationship between the Adult Male and Child 3’s Mother as a result of his electronic tag. The GMP contribution to the Rapid Review comments that this information was not cascaded to partner agencies appropriately. 2.70. Commentary: there is some information-sharing between agencies but, mindful of the preceding chronology, this was clearly partial. The delay in disclosing Family Court documents to GMP to assist with their investigation of the Adult Male is unfortunate. The pattern of behaviour in which he was engaging does not appear to have been factored into assessments of the risks that he presented to women or young children. 20 When GMP report such incidents, recording by Health and Social Care practitioners would be made on a relevant child/parent’s file and not routinely cross-referenced to other families with whom, in this case, the Adult Male was involved. A holistic picture, therefore, is not easily obtained. 21 The Rapid Review report gives the date when the initial request was made as the 17th April. GMP’s own chronology also gives the date of 17th April when the Officer in Charge submitted a request via GMP Legal Services for a finding of fact from the Family Court. 17 Case Unfolds 2.71. On 1st July a Start Well Officer and the Health Visitor applied for welfare priority for a property for Child 3’s Mother as she was on the waiting list. On 3rd July the Health Visitor liaised with Children’s Social Care and was informed that there was no role for Children’s Social Care unless Child 3 was left unsupervised in the care of her grandmother. 2.72. Commentary: this seems a surprising position to have adopted given the history of concerns. 2.73. On 4th July a different Start Well Officer, allocated to offer additional support, spoke with Child 3’s Mother who said where she was staying. A visit was attempted the following day but was unsuccessful. On 8th July, during supervision, a Start Well Worker raised concerns regarding Child 3’s Mother sofa surfing. The Manager advised contacting Children’s Social Care. The Officer later contacted Child 3’s Mother to ask why she had failed to meet the worker three days previously. She stated that she did not like all the questions. She confirmed that Child 3 was living with her between her maternal grandmother and maternal great grandmother. 2.74. Health Visitor records also contain this information. Additionally, there is a reference that Child 3 was not to be left in the sole care of her maternal grandmother, and another that Child 3’s Mother was now declining to access counselling, having missed two appointments. On 13th July Children’s Social Care closed down their involvement on the basis that Child 3’s Mother was to engage with Start Well and prioritise Child 3’s health by taking her for medical treatment. 2.75. Commentary: it was a Social Worker who advised the Health Visitor that Child 3’s grandmother was not to be left in sole charge of the child but there is no indication of what would follow if this was observed. 2.76. Commentary: there is no evidence that the Start Well Officer contacted Children’s Social Care as advised. There is no evidence that Child 3’s Mother’s reaction to attempted contact was factored into a risk assessment and care plan. Children’s Social Care should have known that Child 3 was not being taken for appointments and that her Mother was expressing reluctance to engage with Start Well, as the Health Visitor had informed the Social Worker of this. The closure decision is questionable. 2.77. Commentary: the Children’s Social Care analysis for the Rapid Review observes, correctly, that case closure was inappropriate. There had been no apparent consideration of a professionals’ meeting and/or strategy meeting, as a result of which no holistic or multi-agency accumulative view had been formed. A strategy meeting was necessary. Put another way, involvement was episodic rather than based on a cumulative understanding of the case chronology, with agencies and services working along parallel tracks with little cross-over. 2.78. Commentary: additional analysis provided by Start Well indicates that both Child 3’s Mother and Start Well were now under the impression that a Social Worker was now leading the case. This merely adds to the inter-agency failure to confirm leadership responsibility for this case since, elsewhere, the operational assumption seems to have been that this role fell to the Health Visitor. 18 2.79. Commentary: Health Visitor records contain an entry for 8th July that Child 3’s Mother had been exploring private rented accommodation but would need a guarantor. This possibility does not appear to have been pursued. 2.80. On 11th July Child 3 was not brought to an appointment with a Paediatrician for weight and bowel monitoring. There were also outstanding immunisations. On 12th July she was not brought for her second routine immunisations. This was repeated on 24th July. As a result of the pattern of not being brought, Child 3 was discharged by the paediatric clinic. The Health Visitor was informed of these developments by the GP surgery. 2.81. GMP recorded three notifications in July and August 2019 that the Adult Male had breached his curfew. He was also arrested in July for assault and burglary. He was also reported as being a victim of domestic violence from an adult female whom he had reportedly harassed previously. 2.82. Commentary: the combined chronology records again that Child 3 had been observed pulling her hair at either side of her head, causing it to thin. However, the Health Visitor had continuously observed and documented warmth and affection between Child 3 and her Mother. This might be evidence of the operation of the Rule of Optimism, of being unduly reassured by some observations to the exclusion of assessment of risks arising from her living situation and involvement with the Adult Male. Risk assessment should have included information from GMP regarding the Adult Male’s non-compliance with Court orders and further offending, if that information had been shared with other agencies. 2.83. Commentary: the pattern of Child 3 not being brought to appointments should have been the focus of a multi-agency risk assessment rather than, as in the case of the paediatric clinic, discharge and case closure. Such an assessment might have prompted further attempts to engage Child 3’s Mother. 2.84. Start Well had contact with Child 3’s mother on 23rd July regarding housing and welfare benefit issues. Start Well agreed to contact Housing. Child 3 was seen appropriately dressed, smiling and responsive. Telephone contact was made with Housing. 2.85. Commentary: Start Well, in additional information provided for this review, has provided detail of a management oversight on record for 19th August. It is quoted in full because it summarises key shortfalls in this case. It is recorded that: “There is no episode coordinator on the system and the lead professional is not actually the lead professional. There is no plan and no reviews on the system so direction of involvement is unclear.” Despite these pertinent observations, no action seems to have been taken to remedy the shortfalls. The Independent Reviewer has been told that the Health Visitor’s assessment has been sent in and uploaded onto the case recording system but that no plan or review has been uploaded, even though Early Help reviews did take place. Increasing Concerns and Uncertainties 2.86. On 20th August 2019 Child 3 was taken to the GP surgery suffering from acute conjunctivitis. It was observed that Child 3 had a very flat nose bridge. A Practice Nurse advised that she should be taken to A&E. 19 2.87. Commentary: the Practice Nurse should have sent a referral to Children’s Social Care. There is no Hospital record that the Practice Nurse spoke to staff there. Noteworthy too is that Child 3 was taken to an Emergency Department in an NHS Trust in the Greater Manchester area but outside Wigan. 2.88. At an A&E Department she presented with multiple facial bruises and injury to her nasal bridge. A child protection medical was completed, which identified seven injuries. The examining Paediatrician stated: “Although these injuries could be consistent with the explanations given, and with injuries associated with normal childhood play, it is important that social workers continue to closely monitor this case. In view of the fact that there are background concerns regarding mum’s previous partner, there have been concerns raised regarding non-attendance at paediatric outpatient follow up appointments and that [Child 3] has not had her up to date immunisations. It would be beneficial if the social worker team, in conjunction with the GP/Health Visitor can arrange for [Child 3] to have her immunisations and to help the family to attend these and any future outpatient appointments at Wigan Hospital.” The report also reiterates information provided by Children’s Social Care that Child 3’s Mother had had a year-long relationship with the Adult Male and there was an ongoing investigation regarding him inflicting a serious injury to a child. On the day of the medical the Health Visitor also spoke to a Safeguarding Nurse and shared information again about the Adult Male. 2.89. Staff at the A&E Department notified Children’s Social Care of their concerns. Child 3’s Mother could not explain some of the marks on Child 3’s face; others she attributed to Child 3 banging her head on the pram and bumping her nose while crawling or falling. Child 3 was taken from the Hospital by her Mother despite recommendations to stay and there being outstanding elements of the medical to complete. She was told to return the following day for medical photographs to be taken. 2.90. Commentary: GP records note that concerns were discussed with the paediatric team22 and that a Social Worker informed the team of the missed paediatric outpatient appointments and the presence of the Adult Male. What is recorded in the GP notes illustrates an absence of risk assessment and safety planning. There are entries to the effect that the GP was unaware of any safeguarding concerns regarding Child 3, that Child 3 was “subject to early help social work involvement” and that a Social Worker would need to closely monitor the case. Child 3’s Mother had been advised to have no contact with the Adult Male but there was no recognition of what she had reported previously when she had attempted to end the relationship, namely harassment. The possibility of coercive and controlling behaviour by the Adult Male does not seem to have featured in the work being undertaken by any practitioner in this case. 2.91. Also on 20th August, according to the combined chronology, an email was sent from a Start Well Worker to the Health Visitor outlining concerns about Child 3’s Mother’s engagement and for advice on any further required actions, without which the case would be closed. She had declined to attend groups at a Family Centre. The Health Visitor advised Start Well to inform the Social Worker in Children’s Social Care about 22 See 2.86 – Hospital records have no note of this. 20 non-engagement. Contact was received from the CRC that the Adult Male had attended an appointment with Child 3’s Mother, confirming they had been in a relationship for one year and that they planned to live together. CRC shared concerns for Child 3 and her Mother due to the Adult Male being investigated in respect of serious harm to another very young child and having breached a restraining order in respect of his ex-partner. CRC confirmed a significant family history of abuse. 2.92. Commentary: it appears that neither GMP nor CRC considered the use of Claire’s Law. The Independent Reviewer has since been informed that Start Well is now using Claire’s Law when necessary for the purposes of safeguarding. 2.93. Directed by an Advanced Practitioner, an immediate visit was required from Children’s Social Care as well as a strategy meeting to take place. As staff from Children’s Social Care were unable to contact Child 3’s Mother, GMP were requested to undertake a welfare check. 2.94. The combined chronology records GMP having received information from the Community Rehabilitation Company that Child 3’s Mother and the Adult Male had presented as a couple. An Officer from GMP subsequently spoke with Child 3’s Mother and she denied being in a relationship. She maintained that Child 3 had attended A&E as a result of a fall. GMP, having assessed risk as medium, sent referrals to Children’s Social Care and Health. 2.95. A written report from the Hospital was not received until 9th September. However, it is important to emphasise that information was shared at the time of the medical between the GP and Paediatric staff, and between a Social Worker and Paediatric staff. 2.96. Commentary: the GP practice should have referred the case to Children’s Social Care for a child protection medical to be arranged. The Paediatrician should have referred the case also immediately due to the injuries and possible doubt about some of the explanations that were offered for some of the harm observed. It has been suggested to the Independent Reviewer that discussion between a Paediatrician and a Duty Social Worker constituted a referral, which was followed up with a letter subsequently. It is possible, however, that Children’s Social Care recorded a discussion rather than a referral. No agency requested a strategy meeting and no coordinated plan was devised in response to the risk posed to Child 3 as a result of uncertainties about the relationship between her Mother and the Adult Male. A section 47 Children Act 1989 investigation was not commenced and there was no initial child protection case conference. 2.97. On 21st August Child 3 was taken back to the Hospital for medical photographs following intervention by GMP and a telephone conversation her Mother had with the Health Visitor in which she confirmed her relationship with the Adult Male but denied that he saw Child 3. Start Well received an email from the Health Visitor regarding Child 3’s hospital assessment, with a request that Start Well should share information about Child 3’s Mother’s non-engagement with Children’s Social Care. The following day it is recorded that GMP were told by Children’s Social Care that Child 3 was not to have any contact with the Adult Male until investigations about previous allegations of child abuse had been concluded. 2.98. Also on 22nd August a Social Worker completed a visit. Child 3’s Mother stated that the relationship with the Adult Male was not serious, that they did see each other but 21 Child 3 did not have contact with him. Maternal great grandmother was looking after Child 3 when they did see each other. Health Visitor concerns that Child 3 was taken out a lot with limited routines were disputed by her Mother. Maternal great grandmother confirmed that Child 3 did not see the Adult Male. The Social Worker spoke to the Health Visitor who reported that Child 3 was not at her maternal great grandmother's very often. Child 3’s Mother was staying with friends but would not say who they were. She had stopped engaging with Start Well and had accrued debt. The Health Visitor has been recorded as saying that Child 3’s Mother was vulnerable and required enhanced support. The Social Worker attempted to contact the Adult Male but to no avail. It is recorded that Child 3’s Mother, maternal great grandmother and the Community Rehabilitation Company would reiterate to the Adult Male that he could not see Child 323. 2.99. On 27th August a Start Well Worker contacted Children’s Social Care, as recommended six days earlier by the Health Visitor. The delay was the result of the staff member being on annual leave. The request was actioned immediately on their return to work. There was a sharing of information. It appears that no evidence had been found of Child 3 being left alone with the Adult Male. By 27th August it appears from the combined chronology that Children’s Social Care were considering closing the case, the rationale being that Child 3’s Mother was compliant with advice that Child 3 should not see the Adult Male. Efforts by Children’s Social Care to contact the Adult Male were unsuccessful, with the result that Child 3’s Mother and extended family, and the Senior Case Manager at the Community Rehabilitation Company were to tell him that he should not see Child 324. It was also the case that the Start Well Worker was considering case closure. Around 30th August the Health Visitor was informed that Start Well was indeed ending its involvement with Child 3’s Mother following discussion with a Manager who had agreed to speak to a family centre regarding whether the case could be transferred there. It appears, however, that the Health Visitor was not told by Children’s Social Care of their case closure. As a result, when Children’s Social Care received on 9th September the written report of the examination on 20th August, no action was taken. By 17th September, the Health Visitor knew that both Children’s Social Care and Start Well had ended their involvement, the rationales at that time being given as the case not meeting Children’s Social Care thresholds, the involvement of Start Well and, for Start Well, the Mother’s non-engagement. 2.100. Commentary: no practitioner or agency challenged the closure decisions. No strategy meeting had been convened, as had been directed by an Advanced Practitioner. Too much reliance was placed on the reassurances provided by the family concerning the involvement of the Adult Male with Child 3. The delay in Children’s Social Care receiving the Hospital’s written report on the medical examination on 20th August is unfortunate and demonstrates a lack of urgency. When it did arrive, it was not given due regard because of a prior decision to close the case. The same can be said of the response to the Health Visitor’s expressed concerns, another referral having been sent on 30th August as a result of Start Well’s parallel decision to close down their involvement due to Child 3’s Mother’s non-engagement. These closure decisions, as observed in the Rapid Review, were highly questionable. No professional meeting or strategy meeting had been held, the latter having been ordered in both April and August 2019. No manager challenged the closure decisions. That relating to Children’s Social 23 This may have been what the Social Worker intended should happen but CRC has no record that it was expected to speak to the Adult Male in this way. 24 See note 20. 22 Care appears to have been based on one home visit and not on the accumulation of concerns of risk of harm, including an inconsistent picture of key relationships. There do not appear to have been any unannounced visits and no challenge or concerned curiosity expressed towards the adults involved. 2.101. Commentary: the Start Well Manager did not speak with the Family Centre until 3rd October, a significant delay demonstrating a lack of timeliness and urgency. Further reflection from Start Well provided for this review rightly questions how the closure decision could have been arrived at. 2.102. Information provided for the Rapid Review by the Offender Manager, Community Rehabilitation Company, who was working with the Adult Male, recorded that he was breached in August and resentenced to another Community Order for this original offence in September. He also received another Community Sentence at the end of August for aggravated vehicle taking. In Parallel 2.103. At the pre-sentence report stage the Community Rehabilitation Company had been advised by the National Probation Service that the Adult Male was in a relationship with a young woman who had a child. At the beginning of September the Offender Manager sought information about the status of the investigation into the Adult Male’s possible involvement in allegations of abuse of a child. No further update appears to have been available and the Offender Manager received no information from Children’s Social Care about his contact with Child 3 or relationship with her Mother. At his first meeting with the Offender Manager on 9th September, however, he denied being in any relationship. The Final Weeks – More of the Same 2.104. GP records note for 6th September that Child 3’s eye complaint had not settled. On 10th September a safeguarding alert was added to the GP’s records. Health Visitor records for 10th and 17th September contain notes of conversations with an Advanced Practice Nurse to the effect that different accounts had been given of the injuries observed on 20th August, with the Nurse suggesting a meeting to develop a robust plan. On 17th September the Health Visitor and the Safeguarding Nurse at the Hospital where Child 3 was examined on 20th August were told that the injuries that had been observed then were to be reviewed. This was the same date that Children’s Social Care and Start Well closed down their involvement, leaving the Health Visitor as the only practitioner with continuity of involvement. Commentary: neither the Health Visitor nor the Advanced Nurse Practitioner appear to have received further updates from the Hospital. 2.105. On 19th September Child 3 was not taken for her second routine immunisations. Health Visitor records contain an entry of a suggestion for a meeting with Start Well. Commentary: this was a repeating pattern, despite the Health Visitor discussing the missed immunisations with Child 3’s mother at Early Help meetings on 20th May and 24th June, and immunisation forming part of the Early Help action plans. 2.106. On 30th September the Adult Male informed his Community Rehabilitation Company Offender Manager that he had moved to his sister’s address. His sister was contacted and confirmed this. She denied that anyone else was living there. Commentary: it does not appear that the Offender Manager notified Children’s Social Care. 23 2.107. On 4th October the Hospital sent a letter, written by a Consultant Community Paediatrician, to Children’s Social Care following a peer review25 of the injuries examined on 20th August. It was received by the GP on 10th October and by Children’s Social Care. The review meeting was concerned at the number of bruises/injuries on Child 3’s face: “concerns raised about the number of bruises/injuries on [Child 3’s] face, albeit with histories given to explain them, combined with concerns about missed out patient appointments & lack of immunisations.” There were four areas of injuries on her face all with different explanations. “Following these reviews, we would strongly recommend that social care organise a meeting to review progress with provision of appropriate support and monitoring of [Child 3], to ensure that her needs are being met and that any persisting safeguarding issues are being addressed.” 2.108. Commentary: there is no evidence that the letter, which did not arrive until 11th October, was preceded with verbal communication of the re-analysis of the injuries and the renewed concern and recommendations. This is a significant omission although it should be noted that there is no formal process for circulating the outcomes of a peer review, which is primarily constructed as a learning opportunity for Paediatric and other Hospital staff. 2.109. On 4th October the combined chronology records that Start Well decided to transfer the case to a Family Centre to engage Child 3 and her Mother in sessions. Commentary: it is unclear what prompted this decision. This appears to be another example of the failure to articulate and record the rationale underpinning decisions, and the failure to use an effective chronology to inform risk assessment and management. 2.110. By 7th October the Health Visitor had information that Child 3’s Mother was staying with the Adult Male’s sister, with the Adult Male having contact with Child 3 as both he and Child 3 were also living there, and a referral was sent to Children’s Social Care. Child 3’s Mother knew that the referral was being sent, and had agreed with this. Child 3 was recorded as pulling her hair out and at risk. Child 3’s Mother informed the Health Visitor that Children’s Social Care had told her that the Adult Male was allowed contact with Child 3 as long as she supervised it. This resulted in the Health Visitor making a referral to Children’s Social Care, whereupon it was confirmed by the Duty Social Worker that this was the case and encouraged a referral. The Health Visitor’s contact with Children’s Social Care included concerns about Child 3's 9-12 month review being outstanding, missed paediatric appointments, outstanding immunisations, Child 3 pulling her hair out and instability around living conditions. The Social Worker spoke to Child 3’s Mother who confirmed that she was allowing supervised contact. 2.111. Commentary: so the messaging has changed from the Adult Male not being allowed any contact with Child 3 to one where her Mother could supervise this. This change was not based on any risk assessment. GMP were still acting in the belief that no contact was to be allowed. The messaging became even more convoluted. The combined chronology for 8th October records that a Social Worker contacted Child 3’s Mother who said she had been supervising contact between Child 3 and the Adult Male. She acknowledged the relationship and wanted to move in with him. She was advised not to allow any contact between Child 3 and the Adult Male pending further assessment, to which she apparently agreed. Again, on 11th October a Social Worker visited Child 3’s Mother at 25 Peer review is a meeting held every two months for the purposes of learning. Cases are not automatically placed on a list for discussion. 24 the Adult Male’s sister’s address and advised no contact with the Adult Male when Child 3 and her Mother were seen. It is recorded by Children’s Social Care that a risk assessment of the Adult Male was to be completed. 2.112. Commentary: it is unclear whether this visit was prompted by receipt of the letter from the Hospital, sent on 4th October. Child 3’s Mother said she had been told it was fine for the Adult Male to have contact with Child 3. She was told there must be no contact, which she agreed to. She was staying at the Adult Male’s sister's home who was clear she did not think that he posed a risk to children. She disclosed her own children had been removed from her care. Child 3’s Mother was asked about her lack of engagement with Start Well and missed appointments. She was advised that Children’s Social Care would support her with re-housing. She denied that Child 3 was continuing to pull her own hair out. 2.113. Commentary: there is potentially an issue of disguised compliance here, namely it would be expected that Child 3’s Mother would agree with what the Social Worker was requiring. There is also evidence of minimisation of concerns. 2.114. On 8th October the Adult Male was seen by a Community Rehabilitation Company Senior Case Manager. He stated that there were no children in the property where he was living. A further appointment was given for a week later, with the stated intention to arrange a home visit at that time. Commentary: this information was not shared with other agencies. So, whilst Child 3’s Mother was now acknowledging the relationship with the Adult Male, he appears not to have disclosed the full extent of his contact with Child 3 and her Mother. 2.115. Also on 8th October a new Start Well Family Centre Worker telephoned the Health Visitor. This is the first involvement by Start Well since the closure decision in later August. The worker had been unable to contact Child 3’s Mother. Concern was noted about the outcome of the August medical and that Child 3 and her Mother were living with the Adult Male’s sister and that he appeared to have supervised access to Child 3. The Health Visitor had referred the case again to Children’s Social Care. 2.116. On 10th October Housing Options spoke to Child 3’s Mother about her living situation. She had been staying between her mother and grandmother’s addresses but was asked to leave two weeks ago. Since then she had been living with her partner's sister but had been given two more weeks. She was wanting accommodation for her and her baby only. An appointment was made for 18th October. 2.117. On 11th October there is a final entry from Start Well, a management overview on record to the effect that there were no contact numbers or address for Child 3 and her Mother. 2.118. On 14th October the Health Visitor weighed Child 3. This was satisfactory. This was the last time that the Health Visitor saw Child 3 who was in the care of her maternal great grandmother. A telephone conversation took place on the same day between the Health Visitor and Children’s Social Care/Start Well. Discussion related to outstanding health checks and Child 3's Mother’s plans to stay with relatives/friends in Bury whilst Child 3 remained with her maternal great grandmother for the week. It was agreed that health checks would be completed the following Monday. The Health Visitor raised previous concerns. It was agreed that information would be shared following the 25 completion of a health assessment. The combined chronology records that it was agreed that the child and family assessment timescales would be extended. Children’s Social Care records include an entry on file of management oversight, to the effect that the Social Worker was to undertake a risk assessment of the Adult Male, the deadline for which was extended. 2.119. Commentary: it is unclear who agreed to this extension and why. However, it appears that case management oversight was resting with a Social Worker and an assessment planned. It is clear, however, that despite Child 3 being known to be in the presence of the Adult Male, no practitioner or manager had escalated concerns and no strategy meeting or interim child protection case conference had been held. No risk assessment was completed of the Adult Male. Notwithstanding observations of warmth and affection between mother and child, the Rapid Review documentation observes the absence of any parenting assessment of Child 3’s Mother, of any risk assessment of the harm posed by the Adult Male, and of any assessment of the child in this family context. The Graded Care Profile was not used and there was no assessment of the emotional distress being exhibited by Child 3. 16th October 2019 2.120. On 16th October North West Ambulance Service were called to the address of the Adult Male’s sister by Child 3’s Mother. The initial story was that Child 3 had fallen downstairs but was later seen floppy and white, having been placed in her pram. There were discrepancies between the account given by Child 3’s Mother and the Adult Male’s sister who was also in the house. Paramedics are recorded in the combined chronology as finding the injuries inconsistent with the accounts being given. Child 3 was taken to a local Hospital, subsequently being transferred to Manchester Children’s Hospital. 2.121. GMP Officers took statements at the Hospital. The Adult Male’s sister changed her account and stated that the Adult Male had been left alone with Child 3. He was initially arrested on suspicion of a Section 18 assault. 2.122. On 17th October Child 3 passed away as a result of her injuries. The Adult Male was arrested on suspicion of murder. Child 3’s Mother was arrested on suspicion of causing or allowing the death of a child and perverting the course of justice. The following day the results of a post mortem showed findings indicative of severe head impact of the type usually seen in a road traffic accident or a multiple storey fall from height. Findings were totally incompatible with a minor domestic fall or accident. On 19th October the Adult Male and Child 3’s Mother were charged with the offences for which they had been arrested. 2.123. In parallel, on 18th October the finding of fact was obtained from the Family Court relating to the allegations of child abuse against the Adult Male in respect of another young child. The finding of fact was sent to the Crown Prosecution Service. GMP’s investigation of those allegations remained ongoing at the time the injuries to Child 3 were reported. GMP referred the handling of that case to the Independent Office of Police Conduct. 26 3. Thematic Analysis Direct work with Child 3 and her mother 3.1. Child 3’s Mother was young and she had experienced instability and adverse events during her childhood. There does not appear to have been any consideration given to focused work to support her to plan for Child 3’s birth, other than the offer of involvement in the Family Nurse Partnership programme, which she declined. Prior to Child 3’s birth, therefore, there was no assessment of her parenting skills or attention to where she would live with her baby. Put another way, no early help offer is evident. Children’s Social Care and Start Well have no recorded contacts with Child 3’s Mother in the period before Child 3’s birth. Indeed, the first social work contact was in February 2019 when there were concerns that Child 3’s Mother was in a relationship with the Adult Male. Start Well have no record of any involvement with Child 3’s mother before February 2019. Staff then appear to have attempted to engage Child 3’s Mother at the request of the Health Visitor but attempts at engagement appear to have been reactive rather than persistent. As a result her needs, including her housing situation, were never comprehensively addressed. 3.2. As a result of action by the midwifery team, involvement in the Family Nurse Partnership was offered to Child 3’s mother on 6th February 2018, with an introductory visit taking place on 1st March. This was followed up one week later but Child 3’s mother declined a further home visit. In telephone contact on 16th March, she declined involvement due to the programme’s intensity. At the learning event it was noted that Bolton had a pathway to follow when parents declined this form of Early Help; the pathway did not exist in Wigan. Child 3’s Mother has told the Independent Reviewer that she did not feel that she needed the programme at the time. Looking back, however, she has reflected that support from Early Help would have been better earlier. Commentary: there are lessons here about being clear what is being offered, and why, and about being respectfully persistent in offering support. 3.3.Further opportunities to consider Early Help arose in November 2018 and January 2019 when Child 3’s Mother was expressing anxiety, especially about her housing situation. In November 2018 she reported feeling down. Discussion took place around the support available if she felt she wanted it, including the Wigan Family Welfare Counselling Service. She also spoke of feeling well supported by her family. 3.4.This was reviewed at the next contact on 31st January. An Edinburgh Postnatal Depression scale questionnaire score of 18 indicated that depression was likely. In addition to ongoing Health Visitor support, about which Child 3’s Mother was very positive in her responses to the Independent Reviewer, a referral to counselling was made and also to Start Well. The Health Visitor also signposted her to the GP for a medication review. However, there were significant delays in Child 3’s Mother being offered a counselling appointment, meaning that to some degree at least her mental health needs were not met. Child 3’s Mother has told the Independent Reviewer that, by the time an appointment was offered, she did not feel that she needed it. 3.5.The initial special circumstances concerns raised by the midwifery team should, under service arrangements then in operation, have prompted allocation of a Health Visitor to offer antenatal visits. This did not happen, possibly due to lack of capacity within the team. At the learning event it was clarified that Start Well would receive referrals for 27 expectant mothers with a view to offering early help. It was stated that such referrals are now happening. It was also observed that the Family Nurse Partnership programme has been replaced. A new team, the precise referral criteria for which are being worked out, will be working with “vulnerable families”, including teenage parents. This team might fill a gap that was observed at the learning event, namely when parents rejected an enhanced ante-natal service. 3.6.Recommendation One: As the Early Help offer is being reconfigured, Wigan Safeguarding Partnership should commission and scrutinise audits of the effectiveness of the new service. 3.7.Recommendation Two: Wigan Safeguarding Partnership in partnership with Wigan Safeguarding Adults Board should convene a multi-agency summit. The purpose should be to establish whether there is sufficient recognition of the potential impact of adverse childhood experiences and whether a whole family approach is sufficiently embedded in practice. This should cover but is not restricted to the Early Help offer, and should also include an emphasis on professional curiosity and a trauma-informed approach. 3.8.By the time Child 3 was born, her Mother’s relationship with the baby’s Father had ended. There is no record of any service considering whether he could be part of a circle of support and safety for Child 3. There is no record of his opinion having been sought about the welfare of his child. Health Visitor records include notes of conversations with Child 3’s Mother to the effect that he was having contact with Child 3 but that she did not feel confident in leaving him alone with the baby. 3.9.Child 3’s Father has confirmed that he did engage with Child 3, seeing her most Saturdays. He also contributed financially and sent texts to Child 3’s Mother. He said that he would have gone more frequently but was working. He did not always see Child 3’s Mother when he visited. He felt welcomed and comfortable when seeing Child 3 at her great grandparents’ home but felt less comfortable in the environment of Child 3’s grandmother. He confirmed that he had seen Child 3 the day before she died. He talked about having fed her and made bottles for her. He said that he knew what to do, having grown up with nieces and nephews. Commentary: there are echoes here of Child 3’s Mother being told that she should not leave Child 3 alone in the company of her mother. 3.10. Child 3’s Father confirmed that no-one in the wider family had raised concerns with him. However, he said that Child 3’s great grandmother had not wanted the Adult Male in her home. He recalled one brief telephone call that he had received, around March 2019, saying that the Adult Male was around Child 3. He was not sure of the identity of the person who called. No second call was made. He spoke to the Adult Male subsequently, telling him to “leave Child 3 out of it.” He did not have any knowledge about the Adult Male’s background. He also confirmed that he had seen marks on Child 3’s face but had accepted the explanation, that she had fallen over, as it seemed understandable, based on his experience and knowledge of young children. 3.11. Child 3’s Father said that he had “tried to be the best Father” and had “put effort” into being a parent. However, he had felt left out, not considered, and found it difficult to understand why no-one had contacted him. “I could have done something but I was not given the opportunity.” He felt that he was not seen as a parent. In summary, he wanted to remind practitioners to “put themselves in the child’s shoes”, and to consider the role of birth fathers. “Both parents are important.” He hoped that his contribution 28 would help “to save another child’s life” as the “system had failed.” Commentary: the Independent Reviewer understands that Child 3’s birth was registered jointly by both her Mother and Father. Child 3’s Father had parental responsibility. 3.12. Continuing the theme of “thinking family”, assumptions were made that Child 3’s Mother’s wider family were a protective circle of support26. At the learning event it was clearly stated that the grandparents with whom Child 3’s Mother was living offered a warm and nurturing environment where Child 3 appears to have thrived. Child 3’s Father also expressed warmth towards Child 3’s Mother’s grandparents (Child 3’s great grandparents), seeing them as “the best.” The room in which Child 3 and her Mother were living, however, was small. Subsequently, concerns were expressed should Child 3 be left alone with her grandmother. Nonetheless, there was no thorough (risk) (signs of safety) assessment, including family history. This would have been appropriate, for example, when it was clear that Child 3 and her Mother living with other family members was not sustainable. No risk assessment was undertaken when Child 3’s Mother went to live with the Adult Male’s sister, even when he had given the same address to CRC as his place of residence. A more formalised signs of safety approach would have offered one model for thinking family and for risk assessment. This does not appear to have been in use at the time, giving an appearance that visits, contacts, assessments and plans lacked focus and specified desired outcomes. 3.13. Recommendation Three: The outcome of the adoption of specific practice and operating models for focused assessment and intervention as standard practice by Children’s Social Care should be scrutinised by Wigan Safeguarding Partnership. 3.14. There was an optimistic over-reliance on Child 3’s Mother’s self-reports, for example when she was discharged home with her new-born baby in relation to the availability of support, and when she sought to reassure practitioners in February 2019 that she was not in a relationship with the Adult Male. Insufficient checks were performed; cumulative history was not brought together. Reassurances provided by other family members were also accepted at face value. There is no evidence that disguised compliance was considered. 3.15. Throughout Child 3’s life there were shortfalls regarding risk assessment, for example when she was at risk of homelessness and there were emergent concerns about her relationship with the Adult Male27. Risk assessment would have been appropriate when she disclosed her second pregnancy and when she revealed that she had ended her relationship with the Adult Male but was being harassed. It has been acknowledged by Children’s Social Care that coercive and controlling behaviour was not considered either at this point or subsequently. When Child 3’s Mother was stating that she did not believe what practitioners were sharing with her regarding the concerns about the Adult Male, the implications for safety planning should have been risk assessed. Similarly, the implications for safety planning should have been considered when Child 3’s Mother stated in July 2019 that she did not like all the questions being asked of her. 3.16. Child 3’s Mother has told the Independent Reviewer that, had any practitioner said that they did not believe what she was saying, this would have made her think. She also reflected that “vulnerable mums like me don’t always listen.” She felt that it would have 26 Section 2.35. 27 Section 2.39. 29 been necessary to explain things clearly so that she understood. As Child 3’s Mother pointed out, it is always necessary to consider that people may be wary of social services. She has accepted that she was indeed wary because of her childhood experiences as a child, and a fear that Child 3 would be taken away. Commentary: these observations shared by Child 3’s Mother reinforce the importance of professional curiosity, especially about the impact of past events on present behaviour and presentation. 3.17. On the theme of coercive and controlling behaviour, the Health Visitor did consider the possibility of domestic abuse and did challenge Child 3’s Mother when she did not believe what was being reported about the Adult Male. It has also been suggested that not all practitioners with knowledge of the Adult Male recognised the potential for coercion and control in his relationships. Use of Claire’s Law does not appear to have been considered. 3.18. Child 3’s Mother has told the Independent Reviewer that she does not know why she was not told that the Adult Male was being investigated for possibly hurting a child. She feels that she should have been told this. Child 3’s Mother has also stated that she did not always feel scared of the Adult Male but that he could behave threateningly towards her and Child 3’s Father, especially if there were any signs that she might return to him. She described one incident when the Adult Male punched her; another when he threatened her with social services if she left him. It reminded her of what she had witnessed as a child, so she tried to shield Child 3 from this. Crucially, she has disclosed that the Adult Male did not want her to attend an appointment on 18th October and in the run-up to that date had been saying “you’re not going.” 3.19. Recommendation Four: Coercion and controlling behaviour should be addressed in multi-agency training offered through the Wigan Safeguarding Partnership and Wigan Safeguarding Adults Board as a contribution to a “think family” approach to practice, including legal rules to protect victims from domestic abuse, and should be recorded as having been discussed in safeguarding supervision. 3.20. Risk assessment is a core component of safety planning. As commentary on the chronology highlights, Child 3’s Mother received unclear and/or inconsistent messages from the practitioners involved regarding the implications for her care of Child 3 of her relationship with the Adult Male. This may partly have been the result in delays in receiving from the Family Court a finding of fact with respect to the risks presented by the Adult Male. However, had all the available information been shared across the different agencies involved, and had those agencies met together, a uniform approach would have emerged. Equally, it is hard to fathom how Social Workers could be certain that Child 3 would be safe when leaving her Mother to reflect on the concerns expressed about the Adult Male. Finally, in the final weeks before Child 3’s death, when it was clear that Child 3’s Mother was allowing contact between Child 3 and the Adult Male, a risk assessment of him was planned but not undertaken. 3.21. Child 3’s Mother has stated that the messages from social services were “unclear and inconsistent.” “I thought he could be near her with my supervision or any adult supervision. When (a social worker) came I even said to my nan, are you listening to this and I made him say it again, that the contact can be supervised by an adult, including me.” 30 3.22. Child 3’s Mother has also commented on risk assessment, as follows: “First visit was (a social worker); she explained I would be child in need and known to social care for 6 weeks while there is a risk assessment. Why do an assessment with someone who should not be near kids? Someone should’ve said straight to me, if you want to be with him, Child 3 will be in care. That would’ve been my choice to make then. I may have listened. I still don’t understand what assessments I have had.” 3.23. There were three social work assessments completed by Children’s Social Care on 31st May, 13th July and 2nd September. Judging by what has been recorded, none were adequate. In the first there is no recognition of the Adult Male’s power in the relationship with Child 3’s Mother. Faith is placed in the maternal grandparents to protect Child 3 in the event that her Mother did not prioritise the child’s needs over her relationship with the Adult Male. Sections of the template relating to authorisation by the Manager once the assessment findings had been shared remain incomplete. In the second assessment there is no analysis of the actual relationship between Child 3’s Mother and the Adult Male; it seems to have been accepted that this relationship was not serious, as if that somehow reduced the risks. There is no in-depth consideration of Child 3’s Mother’s engagement with Start Well. Yet, reliance is placed on Start Well assisting with needs relating to housing and finances. There is no reference to Child 3’s Mother having missed an appointment with respect to her mental health. There is no entry in the section of the template concerned with discussion of assessment findings. There are no Manager comments. 3.24. In the third assessment, there is evidence of copying and pasting from previous work. There are no Manager comments. The referral history is given but without critical analysis of it in relation to this referral for assessment; for example, Child 3’s Mother had not engaged with Start Well. It has been suggested that the three assessments represent a “start again” approach rather than each building and re-assessing a cumulative picture. It has also been suggested that the approach to assessment was insufficiently assertive and professionally curious. 3.25. Recommendation Five: Children’s Social Care should conduct routine audits of social work assessments and managerial oversight of decision-making, with reports scrutinised by Wigan Safeguarding Partnership. 3.26. Closely connected with safety planning and with risk assessment is the lived experience of Child 3. From December 2018 onwards a pattern emerged of Child 3 not being brought to appointments. The Health Visitor did follow-up missed immunisations but encouragement alone did not break the pattern. Further practical support was needed to ensure that Child 3 was seen. There was evidence of behaviours indicative of emotional distress, such as Child 3 pulling out her hair. There were some concerns reported about Child 3’s Mother’s attitude towards her, although there were also positive reports about emotional warmth towards Child 3 by her Mother. It is possible that too much weight was given to the positive parenting behaviours that were seen, reflective of over-optimism. The Health Visitor has reflected on how much child friendly interaction Child 3 was given and whether she had to “fit in with an adult day.” Panel members in discussion with the Independent Reviewer have observed that Child 3’s lived experience was not routinely referenced in assessments. 3.27. At various points a lack of urgency is apparent, for example delays in allocating a Social Worker between the Health Visitor’s referral on 26th March and 17th April, in Start 31 Well responding to a referral in early February from the Health Visitor, and in addressing her housing situation. Other than expressed concerns by the Health Visitor periodically throughout Child 3’s life, and concern from Hospital staff as a result of their reflections on their observations in a medical in August 2019, it is difficult to discern any practitioner viewing the world from Child 3’s position. The Health Visitor has suggested that other practitioners and services may have been reassured that she was visiting routinely and that Child 3’s Mother was engaging well with her. 3.28. Throughout the case, from the time Child 3 was born, there was a lack of professional curiosity and of robust assessments leading to planned and focused work by Start Well and Children’s Social Care. There were three referrals to Children’s Social Care from the Health Visitor, in March, June and October 2019. The recorded decision on the first referral was that the threshold for statutory intervention was not met, with a recommendation that involvement with Start Well continued. There was already evidence that reliance could not be placed on the effectiveness of this plan. Child and family assessments in May, June/July and August/September resulted in no further action decisions, again relying on Child 3’s Mother’s involvement with Start Well and compliance with (mixed) messaging about contact between the Adult Male and her child. No-one in Start Well or Children’s Social Care appears to have thought through the implications of Child 3’s Mother not engaging with Start Well. It is possible to conclude, therefore, that practice in this case is emblematic of the findings in OFSTED inspection reports. 3.29. Child 3’s Mother has also commented on the issue of engagement. She has suggested that Start Well did not engage with her, especially after she left the mother and baby home. Commentary: this reinforces the observations made earlier in this section of the report about assertive outreach and the importance of there being a clear and structured Early Help plan of work. The team around the child 3.30. There are examples of liaison between practitioners involved. For example, Midwives shared concerns with Children’s Social Care when Child 3’s Mother was first pregnant. At various points Community Midwives and the Health Visitor referred Child 3 and her Mother to Start Well and to Children’s Social Care. The GP Surgery also contacted Children’s Social Care. The National Probation Service shared information with Children’s Social Care in August about the Adult Male. There were also some instances of joint visiting. 3.31. There were, however, missed opportunities to share information. GMP did not cascade information to other agencies about their involvement with and knowledge of the Adult Male. GMP records indicated that the Adult Male was deemed to be a risk to younger children. Information held by different agencies regarding the Adult Male, for example with respect to his mental health, was not known to all the agencies involved, resulting in a partial picture of the risks he posed. The Health Visitor was not informed of the outcome of the review by the Hospital of the findings of the child protection medical that was undertaken in August 2019. 3.32. When information was shared, it was not routinely triangulated with what else was known, for example when the Health Visitor referred concerns to Children’s Social Care and/or Start Well. At times the significance of shared information was not fully assessed, 32 for example when the Paediatrician reported to Children’s Social Care on the child protection medical and when the Hospital sent a further evaluation of the findings of the medical in October 2019 to Children’s Social Care. There were some delays also in receipt of this information in writing in August and October respectively. The Health Visitor, for example, received a report on the August examination on 4th September. At the learning event those attending reflected that improvements were needed in how concerns were communicated, for example by the Hospital where Child 3 was examined. Bolton, the Independent Reviewer understands, has established a secure email system so that child protection medical examination reports can be sent electronically to avoid delay in receipt by Children’s Social Care. Such a system has not yet been set up in Wigan. There was also significant delay in the Family Court providing a finding of fact regarding the adult male’s involvement in other cases of abuse/neglect involving children. 3.33. At no point in this case did all those practitioners and operational managers involved with Child 3, her Mother and the Adult Male meet. CRC and Children’s Social Care held one discussion in February 2019 about the allegations relating to the Adult Male but there was no further follow-through, possibly because the CRC responsible officer changed. CRC did not undertake further safeguarding checks with other agencies, and neither GMP nor Children’s Social Care updated CRC on their involvement with or concerns regarding the Adult Male. 3.34. There were Early Help meetings in May, June and July, which included the family, but not everyone with a contribution to make was present because the focus was on Early Help and not the overall situation. No strategy meeting or initial child protection conference was held. As a result there was a failure to share all available information and assessments, and to agree an overall strategy. A strategy meeting that was advised by a Manager in Children’s Social Care as being required did not take place. At the learning event it was suggested that this might have been because the decision was reversed as part of step-down of the case to Early Help. If so, no record to that effect has been seen. 3.35. There were other missed opportunities to bring services and practitioners together, even before the direction for a strategy meeting was given. GMP have questioned why a pre-birth conference was not held, given Child 3’s Mother’s adverse childhood experiences, to explore the need for Early Help. From February 2019, as concerns mounted about the Adult Male’s involvement, including when he was named as the Father of the unborn child (later miscarried) and subsequently when Child 3’s Mother was saying that separation from him was proving difficult, multi-agency meetings would have been appropriate. The GP Surgery and the Paediatrician could have formally referred Child 3 for a strategy meeting or case conference in August 2019. 3.36. At the learning event the view was expressed that the absence of professionals meeting together was a key shortcoming in this case. One reason is that not everyone involved appears to have known that any service or practitioner could have called and convened a professionals’ meeting. This is one illustration of an absence of a shared understanding of policies and procedures. Reservations were expressed at the learning event concerning whether this position had changed. The Health Visitor has stated that she has called professionals’ or strategy meetings since the Child 3 case but has been met with defensiveness and some resistance. She has also stated that, when offering to help other practitioners and services to engage with Child 3’s Mother, and when raising 33 her concerns, she did not feel listened to. With each change of worker, the Health Visitor felt that she had to “start again.” 3.37. Recommendation Six: Wigan Safeguarding Partnership should undertake audit work routinely to ensure that strategy meetings and professionals’ meetings are convened. Audit work should capture the experience of different practitioners in convening and contributing to multi-agency and multi-disciplinary case discussions. 3.38. Another point of potential misunderstanding of policies and procedures revolves around the paediatric examination in August. The advice given to Child 3’s Mother was to take her child to hospital. At the point that advice was given the situation does not appear to have been viewed as triggering the Section 47, Children Act 1989 pathway, with an immediate request to Children’s Social Care for a child protection medical. Consequently, on arrival at the hospital a paediatric medical examination was completed but this was not formally designated as a Section 47 examination. The examination took place at the same time that Children’s Social Care had received information from the National Probation Service that the Adult Male had been accompanied to a meeting by Child 3 and her Mother. The absence of Section 47 enquiries and a strategy meeting meant that none of this information was clearly brought together. Nor was there an opportunity, therefore, to interrogate what Child 3’s Mother was saying to the different practitioners and services involved, for example at the GP surgery and then at the hospital about Child 3’s presentation. Nor was there any opportunity to observe the inconsistent messages that had been given to Child 3’s Mother about her contact with the Adult Male, with an opportunity lost to agree and restate the risk management plan in this respect. 3.39. The “grey picture” given as the outcome of the August medical and again in October when the examination was peer reviewed, should have prompted a strategy meeting to collate information and coordinate a way forward. Paediatric medicals will not always reach a judgement that what has been observed is conclusively evidence of abuse. At the learning event it was suggested that engaging Children’s Social Care remained a challenge, especially if “trigger words” were not used. It was suggested that services might have different understandings of “thresholds not met.” 3.40. There was an assumption or expectation that the Health Visitor was the lead professional but there was no multi-agency meeting at which this was agreed. Had this been formally recognised and agreed, it would have given her authority to escalate concerns and to call for a strategy meeting. As it was, services and practitioners were working largely in isolation, in silos, although there was liaison between practitioners as the combined chronology has recorded. Silo working was exacerbated by practitioners using different IT systems to record information, something that has begun to change subsequently to some degree. Further review of who may have access to which modules on different recording systems would be helpful in the spirit of promoting multi-agency working to safeguard children. 3.41. On the subject of recording, there were occasions when Child 3 was seen with her Mother and a friend, for example in June 2019 with sores to her ears. Recording should specify who was present on such occasions, especially given the context of this case involving the Adult Male. 34 3.42. Although some practitioners were diligent in sharing information and referring concerns, there is no evidence of any escalation of concerns about decision-making between services and practitioners/managers involved. Thus, neither GMP nor the Health Visitor challenged Children’s Social Care regarding the failure to convene a strategy meeting or case conference. It has been suggested that, for health practitioners at least, local escalation processes at the time were unclear. No-one appears to have escalated challenge to decisions by Start Well and/or Children’s Social Care to close down their involvement with Child 3 and her Mother, although the Health Visitor did question Children’s Social Care’s closure decision and did request a copy of the child and family assessment to help her understand the decision. No-one appears to have suggested that the repetitive concerns should prompt a review of the approach being taken to the case. As a result, the case demonstrates a “start again” approach. 3.43. In cases involving risk and repetitive concerns, closure decisions should not be made without multi-agency discussion to reappraise the risks, to ensure safety of the child, and to consider the implications for other practitioners and services if one organisation does, indeed, withdraw. In all cases where concerns have been referred, it is good practice for assessors to close the loop by discussing their emergent findings and conclusions. This did not happen. 3.44. Recommendation Seven: Wigan Safeguarding Partnership should convene a summit to review the threshold document and how different services understand and use it. Using this case as an illustration, policies and procedures surrounding the threshold document should be reviewed, especially the approach to re-referrals, the convening of multi-agency meetings and the importance of escalation. Organisations around the team 3.45. There are examples of shortfalls in supervision and management oversight in Children’s Social Care and in Start Well. For example, Children’s Social Care cannot account for why a required strategy meeting did not take place. There are no records that would indicate why a pre-birth assessment was not conducted and why no Children Act 1989 section 47 investigation took place. Recording of decision-making, and the reasons for decisions, is a core requirement of best children’s safeguarding practice, as well as being a requirement of administrative law. 3.46. There was a lack of management oversight in CRC with respect to the Adult Male’s poor compliance with Court orders. Health Visitor supervision prioritised child protection cases at the time but this approach has now been revised so that any case where there are concerns can be raised in supervision. It has been suggested that, at the time of this case, it was unclear how support and supervision were provided to Health Visitors for cases of concern. However, the Health Visitor had discussed this case with her Manager both to ensure support for her approach and as the first step of escalation. 3.47. There are only two references in the combined chronology to supervision records. Around the end of June 2019 a supervision record in Children’s Social Care noted the requirement for an assessment. Shortly thereafter the case was closed following minimal contact with Child 3’s Mother. In July a Start Well supervision record noted that Children’s Social Care were to be contacted about concerns. It appears that this action was not completed. These are two examples where management oversight would have been expected but from February 2019 onwards there is an absence of regular checks 35 and Manager scrutiny in both Children’s Social Care and Start Well. The most glaring example is the failure to challenge why no strategy meeting had been convened when one had been directed. Subsequent information provided by Start Well and by Children’s Social Care includes detail of management oversight on file, one for Children’s Social Care and two for Start Well28. Given the repetitive concerns, this level of oversight is inadequate. 3.48. As the earlier commentary on the chronology in this report identifies, management decisions that authorised case closure were inappropriate and inexplicable given the repetitive and escalating concerns being raised, especially by the Health Visitor. It is unclear whether supervisors and managers in Children’s Social Care and Start Well considered the outcome of the child protection medical in August 2019 and the report in October that contained further reflections on the findings of that examination. It is possible that case closure decisions within Children’s Social Care were based on an assumption that Start Well had fully engaged with Child 3’s Mother and that she was compliant with a requirement to ensure that Child 3 did not have contact with the Adult Male. If so, these assumptions were not tested. 3.49. Recommendation Eight: All services with responsibilities for safeguarding children should provide Wigan Safeguarding Partnership with assurance that records indicate robust management and supervisory oversight. 3.50. As the combined chronology also reveals, there were delays in allocating the case to a Social Worker in March/April/May 2019 and examples where decision-making in Children’s Social Care was outside expected timescales. 3.51. The Independent Reviewer has been told that, at the time of this case, social work practice in Children’s Social Care was not robust and that there was no challenge or follow-up at every supervisory or management level of completed assessments. The Independent Reviewer has been told that referrals were looked at in isolation and that the history of a case was not pulled together. This was in a context of increasing workloads and lack of capacity, with people stepping in and out of cases, with the quality of work compromised by the quantity of work. It has been suggested that Children’s Social Care was in “huge difficulty”; that changes, for example to the duty service or to managerial responsibilities, had destabilised provision. The portfolios that Managers were allocated were too large. There was over-reliance on agency staff, both Managers and Social Workers, in which financial pressures were implicated, and that practitioners were carrying too much work, with limited reflective space, supervision and management oversight. Doubt has been cast on whether the staff involved in the three Children’s Social Care assessments had the time, experience, knowledge and skills required. It has been suggested that temporary staff would not necessarily have known the procedures to follow. 3.52. The picture that has been presented is one of loss of resilience, with permanent staff demoralised and leaving. Work was being moved through rather than robustly reviewed. Some of those interviewed have described the situation as a “horrific time”, suggesting that changes made to the service were not thought-through or evidence-based, demonstrating a lack of connection with risks inherent in the work. This has been attributed in part to poor data reporting at the time, for example with respect to 28 8th July, 19th August and 27th September. 36 caseloads, unallocated work and the types of risk being presented at the “front door” of the service. 3.53. Part of this picture relates to the interface between Start Well and Children’s Social Care. A picture that has been presented to the Independent Reviewer is one of a growing disconnect between Start Well and the rest of Children’s Social Care, at least partly the result of changes in senior management responsibilities but also a failure to think through and appraise the interfaces and transitions (stepping up and stepping down) between Early Help, Children-in-Need work and child protection. It has been suggested that over-optimism permeated the organisational culture of Children’s Social Care, mirroring the over-optimism in assessments of Child 3 case – “it has been alright so far; it will be alright now.” 3.54. Separate management structures at the time for Start Well and Children’s Social Care have been criticised on the basis that it should have been one service. Children’s Social Care has been described as being “an island on its own” at the time, with very high thresholds that resulted in considerable difficulty in escalating cases into social care. Criticism has also been expressed regarding the absence of support for Managers and the fact that some (more senior) managers did not have a practice background. 3.55. The Independent Reviewer has been told that concerns about risks in the system were raised at the time, including staff being taken out of Start Well and into Children’s Social Care, but change did not result at the time. The sense conveyed by those interviewed by the Independent Reviewer is that the system at the time did not feel safe. 3.56. The Independent Reviewer understands that an audit was completed of the step-down arrangements from Children’s Social Care to Start Well after Child 3’s death and that some decisions were found to have been premature, with the outcome that some Start Well cases were stepped up into child-in-need or child protection levels. As a result the Independent Reviewer understands that a new model of working has been introduced with cases remaining at a child-in-need level for longer. Management responsibilities have also changed. 3.57. Concerns expressed to the Independent Reviewer mirror those contained in OFSTED reports. Close monitoring of the outcome of the Children’s Social Care action plan, as recommended earlier, by the Wigan Safeguarding Partnership will be necessary to ensure that systemic shortfalls are being corrected to provide a safer context within which Social Workers and other staff are working. 3.58. Concerns have also been expressed about the availability of support for staff after Child 3’s death. The impact of Child 3’s death continues to be keenly felt by staff involved at the time, not least because of a recognition that there were missed opportunities to act and that there are lessons to be learned. Governance 3.59. Greater Manchester procedures are available online29. The procedures advise that Early Help should be offered as soon as problems emerge, the objective to ensure that services work together with targeted provision. Unlike for some of the other local 29 https;//greatermanchesterscb.proceduresonline.com (accessed 16th February 2021) 37 authorities in the Greater Manchester region, no local Early Help strategy for Wigan appears in these procedures. 3.60. There are procedures for non-engagement and disguised compliance, which include provision for multi-agency meetings, which might have proven useful in this case. There is guidance on Early Help assessment but no website link to Wigan. There is guidance on thresholds but, again, no direct link to a thresholds document for Wigan. 3.61. The procedures advise that there should be a strategy discussion when there is reasonable cause to suspect that a child has, or is likely to suffer significant harm. The discussion is to be chaired by Children’s Social Care. It is not made clear that any practitioner or service can request a strategy meeting. This is an omission. 3.62. Wigan Safeguarding Board also published procedures online30. There is a protocol for the resolution of disagreements, essentially an escalation procedure. This does not appear to have been considered in this case, suggestive that the protocol and procedure should be disseminated again, with teams having to evidence that time has been given to when it should be used. 3.63. Given expressed uncertainty about responsibility for requesting and convening strategy meetings, there is an argument for reviewing available guidance and then through, team meetings and a sequence of multi-agency training, ensuring that the procedures are embedded in practice. 3.64. There is guidance on thresholds, which identifies four levels. There are templates for Early Help assessment, initial action plans, reviews and case closure. Given the findings about Early Help in this case, it would also be timely to review how the threshold document is understood and being used. In particular, how do practitioners understand the interface between cases involving emerging needs or identified needs, those where there are multiple or complex needs requiring more targeted support, and those that are complex and serious? Recommendation Seven above seeks to address this point. 3.65. A further question concerning governance is how well sighted Wigan Safeguarding Board, and subsequently Wigan Safeguarding Partnership, were of the organisational context presented in OFSTED reports regarding Children’s Social Care; further, what assurance it sought and received regarding standards of safeguarding practice within and between agencies. The Independent Reviewer asked several questions of the Independent Chair and the senior representatives of the three lead partners, namely Children’s Social Care, CCG and GMP, for Wigan Safeguarding Board. 3.66. One question centred on what oversight was maintained on implementation and outcome of SCR recommendations. The response to the Independent Reviewer was that “SCRs were a standard agenda item on partnership agendas, with good debate, challenge and discussion about cases and learning. In 2019, some meetings were cancelled, attendance not always consistent from Children Social Care, moving into early 2020. Agendas focused on dealing with the critical issues of Covid-19 in the first half of 2020. The SCR subgroup did meet routinely during this period. We recognise that we have had recent feedback from our Independent Scrutineer and Ofsted visit in October 2020 that we need to evidence how partners have embedded the learning. This is an area of focus for us in the coming year.” Separately, however, the Independent Reviewer 30 https://www.wiganlscb.com (accessed 16th February 2021) 38 has been told that SCRs completed by Wigan Safeguarding Board had not been published, which raises questions about accountability, transparency and dissemination of learning. 3.67. A second question focused on audits through which assurance might be obtained that procedures and decision-making were robust. The Independent Reviewer was told that “there were some multi agency audits during 2019, one on complex safeguarding, and ‘toxic trio’ impacts on children and those adults open to Adult Social Care. In February 2019 a core group dip sample audit took place and a plan on a page action plan agreed. Early Help Assessments audit took place in February 2020. The partnership was not always sighted consistently on the quality of practice across individual agencies nor testing whether the partnership learning from Case Reviews was changing practice in frontline services. A Children Social Care diagnostic was discussed in depth by the partnership alongside the new Quality Assurance and Performance Framework that had been developed in early 2019 including audits, dip samples, data analysis and Practice Weeks. The Learning and Improvement group met routinely throughout this period.” 3.68. Separately, the Independent Reviewer has been told that there was no effective performance management framework in place. This has been acknowledged. Thus, “records of meetings don’t show that there was a routine dashboard of multi-agency performance information given to the board during 2019. In Oct 2019 Q1 Children Social Care data was shared and discussed. This meant that key indicators that were concerning or showing an emerging theme were not available for discussion, debate, or challenge. There was evidence of routine single agency data being available, including CCG data. The challenges with the IoPS31 data base for GMP were also routinely discussed and challenged.” 3.69. A third question asked about how well-sighted Wigan Safeguarding Board, and subsequently Wigan Safeguarding Partnership, were on the challenges being faced by Children’s Social Care. The response to the Independent Reviewer was that “there are always challenges managing a complex service like Children Social Care, these were well understood by all partners. Focusing on 2019, the dialogue was always open, and relationships were strong between the three tripartite leaders. Concerns about the level of agency staff needed to cover sickness, vacancies and additional demand became noticeable during spring/summer 2019. This was unusual as Wigan had always had a permanent workforce and unlike other local authorities had rarely used agency social workers. … It is important to note that most of the agency requirements in 2019/20 came in the later stages of quarter 3 post - October 2019 - and predominantly the final quarter from January 2020. Discussions were being had between the partners in relation to increased capacity from the Police and Health into the MAST in 2019. In the absence of a performance dashboard, indeed asking the right questions, this may not have been known by the partnership.” 3.70. Asked about what assurances were received in relation to the strategic and operational management response, the following reply was received. “Relationships were strong. On reflection, whilst it worked at the time, there is recognition the ‘checks and balances’ didn’t always pick up on every issue. Serious issues were usually dealt with within the partnership and escalated where necessary – Children Social Care did not feel they needed (in summer 2019) to escalate any workforce issues (agency use) as this was an emerging issue- not systemic at the time. We were talking actively about the MAST 31 The GMP data system. 39 arrangements. Escalation arrangements were in place and had effectively been used to challenge on CAMHS service delivery and in relation to IoPS and GMP capacity.” 3.71. The Independent Reviewer also enquired about the oversight exercised by Wigan Safeguarding Board and subsequently Wigan Safeguarding Partnership regarding the OFSTED reports. In response, the Independent Reviewer was told that “the revised partnership arrangements were new in October 2019. We were still trying to introduce accountability and clear governance in the new arrangements. This is reflected in the minutes of meetings. Perhaps too much attention was set on the effectiveness of the governance and the transition to new arrangements at this time. It was only actively determined in Summer 2020 that an Independent Scrutineer was needed, and this was enacted by October 2020. In relation to the Ofsted Visit (March 2019) the partnership leaders were sighted on the reports/reviews and the action plans verbally spoken to at the meetings, including minutes (November 2019) that suggest a Partnership Engagement Group would be set up across the three partners to address the immediate learning from the Rapid Review. It is clear the meetings were established - there was no update to the Partnership Leaders on progress recorded. However, the Partnership Leaders had strong and effective relationships and a strong culture of picking up the phone and talking, challenging, and discussing issues, and this is what happened at the time. This became a period of significant senior management change in Social Care in the early months of 2020 with Director of Children’s Services moving position and Practice Director leaving. Then Covid-19 started in Spring 2020.” Commentary: a clearer performance management framework, considered at each meeting of the Board/Partnership, might have given more robust assurance that the practice and management concerns identified by OFSTED were being effectively addressed, or signalled the need for further action to mitigate risks. The role of the Independent Scrutineer will be significant going forward. 3.72. Finally, the Independent Reviewer asked how the Board/Partnership was informed about serious incidents and the action taken in response to notifications. In response it was stated that “there was a process for referring in cases. Records show a routine number of rapid reviews were convened and took place and the indeed the number was high compared to comparators. There was a good relationship between health and the partnership to ensure routine information was shared via the SUDC32 process and serious incidents within Children Social Care. We do know however that in 2019 we did not notify on one reportable incident, linked to Child 3. In addition, we recognise that some reporting was slow from Children Social Care, so there was proactive chasing by the partnership to ensure notifications took place. There was no escalation into the partnership leaders that the process was not working effectively until Spring 2020. At this point the procedures were reviewed and improved. The partnership then took responsibility for all notifications. The new system included a procedure that any partner could refer in and the three tripartite leaders would agree on suitability.” 3.73. In terms of assurances received and oversight of action planning following the death of Child 3, the Partnership responded as follows. “By March 2020, the meetings had become predominantly focused on our Covid-19 response. Staff were re-deployed from the partnership business team. Normal partnership business was suspended. The CSC action plan was not being monitored by the partnership. Covid-19 was causing significant delays in several work streams. However, the minutes from the November 2019 meeting show that a detailed discussion took place about the following areas: 32 Sudden Unexplained Death in Childhood. 40 thematic areas of concern – responses to neglect, quality of planning, effectiveness of practice standards; support for staff involved in the case; use of resolution process for agencies and ensuring any practice concerns are escalated effectively, and robust review of all under 2s open to Start Well.” 3.74. Some concerns have also been expressed to the Independent Reviewer in relation to the Rapid Review. There are two aspects here, namely firstly Operational Managers with responsibility for practice in Start Well and Children’s Social Care not being allowed to compile or to contribute to the construction of a chronology, with some misrepresentation resulting, and secondly the submission of a combined chronology. Indeed, the Independent Reviewer felt it necessary to request two separate chronologies so that the involvement of each service was clear. 41 4. Parallel Processes 4.1. The agencies involved with Child 3, her Mother and/or the Adult Male completed internal reviews, some prior to and some coterminous with this review. These significantly reinforce the learning available and inform the recommendations arising from this review. 4.2.Recommendation Nine: All agencies should undertake a review of their approach to internal investigations as a result of learning from this case, reporting their conclusions and revised procedure to the Wigan Safeguarding Partnership. In particular, internal investigations must be timely, following a clearly laid-out process, with staff support offered. They must look at systems within which staff have been working and not simply focus on the practice of individuals. 4.3. North West Boroughs Healthcare NHS Foundation Trust 4.3.1. The Trust completed a concise investigation under the NHS Serious Incident Framework of the two referrals that it received in relation to the Adult Male. 4.3.2. Commentary: The Trust’s investigation identifies several shortfalls relating to practice surrounding referrals. The referral was received on the same day that the GP had a consultation with the Adult Male. This is good practice. However, it was made on an older version, not then in use, of the referral form. Nor did the GP answer a question on the form concerning whether the Adult Male was residing with children. 4.3.3. The newer version of the referral form does not utilise the concept “urgent” but rather either “routine” or “emergency”. There is no record to indicate whether the GP was contacted to discuss how to triage the referral using the new terminology. It was screened to be “routine”, which the investigation rightly concludes was not proportionate to the highlighted risks. 4.3.4. The investigation is also critical of the fact that a multi-disciplinary team meeting process was not used to resolve the issue of whether the referral was routine or an emergency, which would have supported defensible decision-making. Commentary: what the investigation might have additionally explored is whether the two concepts then in use adequately capture the range of possible presentations. It is possible to envisage that a case might be regarded by a referrer as urgent because it was neither routine nor an immediate emergency. The terms in use are also somewhat ambiguous. 4.3.5. The referral was not triaged within 24 hours of receipt but rather only after 5 days. The investigation rightly points out that consideration should have been given to a home visit, or attempting contact via other family members, together with a discussion with the GP. That this opportunity was missed is seen as a result of time pressures and workload demands – the number of routine referrals and reduced capacity in the Assessment Team to respond. As a result a task-orientated approach was taken to referral management. Commentary: a safe system requires that close attention is paid to the workplace and the impact of workloads and resources on staff. Practitioners have a responsibility to highlight the impact of the workplace on their practice; managers have a responsibility to oversee and ensure that workplace arrangements enable best practice. 42 4.3.6. Since the episodes reported here, a new clinical model and referral process has been introduced. This includes 24-hour triage and MDT discussion and action planning in the event of non-engagement. Recommendation Ten: Wigan Safeguarding Partnership and Wigan Safeguarding Adults Board to receive an evaluation of the new adult mental health referral process. 4.4. Children’s Social Care Investigation 4.4.1. There are eighteen findings and sixteen recommendations. These have been organised here in line with the systemic perspective outlined in section 1.8. 4.4.2. Domain of direct work with Child 3, her Mother and the Adult Male. 4.4.2.1. There was reliance on the Mother’s self-reporting. Her understanding of what contact the Adult Male could have with Child 3 changed. 4.4.2.2. Previous staff involvement with family members influenced decision-making. For example, a Social Worker thought that the grandmother was a protective factor, which on one occasion resulted in no further action being taken. It is recommended that case history and accumulative information must be fully used to inform practice. 4.4.3. Domain of the work of the team around the child. 4.4.3.1. Information was not shared between Children’s Social Care and Start Well. The two services operated separately, resulting in a lack of cohesion, impacting on judgements and decisions. It is recommended that Social Workers must share information with all the practitioners involved, and vice versa. Commentary: this position has now been rectified, with mutual access to records. 4.4.3.2. There was a “them and us” culture involving Children’s Social Care and Start Well. It is recommended that cross-team working needs to improve. 4.4.3.3. Children’s Social Care and Start Well staff did not have access to each other’s electronic recording systems, perpetuating work in isolation. It is recommended that access to modules within the IT system be opened up. 4.4.3.4. Start Well Workers were not briefed about the Adult Male and the concerns that would arise if he had contact with Child 3. As a result, when he was seen with Child 3 and her Mother on the estate, this was not reported. Commentary: this conclusion is not supported by Health Visitor records. These records indicate that Start Well did know that the Adult Male posed a risk and was not allowed contact with Child 3. A conversation took place on 29th April between the Health Visitor and Start Well Worker informing her of this. During this conversation the Start Well Worker also informed the Health Visitor that Child 3’s Mother had also informed her of the same information. This was again discussed at an Early Help meeting on 20th May at which Start Well were in attendance. 4.4.3.5. Not all discussions between staff involved were recorded. 4.4.3.6. When Start Well staff are not the lead professional for early help, they cannot complete (or add to) assessments, plans and reviews online. This resulted in delays in uploading information. 4.4.3.7. The Health Visitor was the lead professional. Commentary: this is clearly stated but where and by whom was this decided? When the lead professional is external, since there is no one record to which all practitioners can contribute online directly, there are delays in uploading information, with the consequence that information may be omitted from the case file and the danger that staff may hold only a partial view of the case. It is 43 recommended that the role of the lead professional be reviewed, especially when that practitioner is external to Children’s Social Care. 4.4.3.8. Decisions of no further action are not recorded on the electronic record system, again the consequence being an incomplete picture. It is recommended that all key discussions and decisions should be recorded. 4.4.4. Domain of the organisations around the team 4.4.4.1. There were too many agency staff, who were not given any induction or training. It is recommended that the numbers of agency staff be reduced. 4.4.4.2. Cases were allocated immediately to agency staff without induction, training or log-in details for the electronic record systems, which prevented access to case history to inform decision-making. It is recommended that training be provided to all staff on the IT system and that the system itself be reviewed to ensure that it is fit for purpose. 4.4.4.3. The thresholds of need procedural document was not shared with agency staff. Commentary: it is, however, available electronically on the Wigan Safeguarding Board website. 4.4.4.4. Staff knowledge and competence concerning the electronic record system was variable. 4.4.4.5. The IT system was difficult to navigate to find information and details of the person who recorded it. Hence the recommendation for review to ensure it is fit for purpose. 4.4.4.6. No specific timeframes were set for cases, resulting in decisional and practice drift. Early Help reviews were meant to be conducted every four-six weeks by the lead professional but this was not written down to formalise the process. It is recommended that timeframes are required. Commentary: Health Visitor records, however, confirm that 3 Early Help meetings were held, with the one on 20th August postponed because of Child 3’s medical examination in hospital. This would have been one opportunity to consider whether supervision and management oversight of practice and decision-making were adequate. This is a significant omission. 4.4.4.7. Very little support was offered to staff after Child 3’s death. There was no offer of counselling and they were instructed not to discuss the case with each other. The investigation report comments that this is unacceptable. The report recommends the provision of support to promote staff wellbeing. 4.4.4.8. Development of a new culture features in the recommendations, one that promotes critical thinking and professional curiosity, models openness, and balances practice autonomy with management oversight. 4.4.5. Governance domain 4.4.5.1. Some staff had left by the time of the investigation. Commentary: it is unclear why staff who had left were not contacted, if necessary through the agency or professional regulatory body with which they were registered. 4.4.5.2. The delay in commissioning a formal review of the case is noted for its impact on staff and on their recall of their practice. It is recommended that the review process should commence without delay. 4.5. Children’s Social Care Action Plan 4.5.1. The action plan, informed by the aforementioned investigation, contains twelve constituent elements. The domain of direct work with Child 3 and her Mother focuses on the child’s lived experience. This includes managers providing timescales for 44 assessments and home visits, and supervision and scrutiny that clearly focuses and records this element of best practice for assessment and planning. Safety planning should use a signs of safety approach. 4.5.2. The domain of direct practice also includes developmental work on the use of history and accumulated information to inform decision-making. This is designed to ensure that the response to referrals recognises patterns in cases rather than being episodic. Chronologies are to be used, and their use audited. Recording should demonstrate that case history has been analysed. The action plan also recognises the need to improve critical thinking and professional curiosity, and to challenge over-optimism. Assessments should be checked to ensure that case history has informed decisions. Practitioners must not rely on adult self-reporting. On some occasions Child 3’s other was seen in the presence of other family members who reinforced what she was reporting. The caution regarding not simply relying on self-reporting extends to not simply accepting what other family members state, especially when they are part of the same interview. 4.5.3. The domain of the team around the child is represented in the action plan by the need to ensure multi-agency information-sharing and the urgent need to establish a multi-agency front door. There is a whole section on the need to improve working professional relationships and multi-agency working, to develop a culture of teams working collaboratively together, and to promote acceptance of each other’s professional roles. This priority includes development of a contact record and assessment checklist that clearly outline who should be consulted in order to achieve a multi-agency holistic assessment. Finally under this domain is a priority to review the role of the lead professional, especially when that professional is employed within a partner organisation, and to clarify timeframes for the involvement of Start Well in cases. 4.5.4. Several priorities fall into the domain of the organisation around the team. Firstly, management supervision and oversight must ensure that strategy meetings take place. Supervision policy and management capacity will be reviewed, with training provided on management supervision. Secondly, there is a focus on ensuring staff wellbeing, especially when a child dies. There is an acknowledgement that staff were not well supported when Child 3 died and the offer of support to staff is to be clarified. 4.5.5. Thirdly, the case file recording system is to be reviewed, to be followed by training. Managers are to record key decisions. Start Well and Children’s Social Care will have access to each other’s records. Fourthly, reliance on agency staff is to be reduced, with induction and training provided for all staff, including those recruited via employment agencies. An induction package will require development. Fifth, the focus on workforce strategy extends to including the development of a manager network and the establishment of whole service manager meetings. A new workforce model for locality and duty teams is to be developed. 4.5.6. A sixth priority is ensuring robust front door arrangements and the consistent application of thresholds. This includes a review of cases and of threshold documentation. Checklists for assessment are to be provided to facilitate critical thinking. Workshops to disseminate and promote the checklists are scheduled for November and December 2020. Finally, there is a clear priority to develop a culture of autonomy, openness and transparency, with an emphasis on support and safety, 45 partnership working and information-sharing. To that end leadership and culture change programmes are envisaged, with development work to improve relationships within the directorate. There will be a workforce strategy that includes the requirement of regular team and service meetings, and regular supervision. Good practice is to be recognised and rewarded. When staff leave, exit interviews are to be held and their outcomes analysed. Regular newsletters for staff will be circulated. 4.5.7. In the domain of governance it is recognised that there should be regular communication with the staff involved in Child 3’s case concerning completion of the Child Safeguarding Practice Review. 4.5.8. Commentary: there is an implicit and at times explicit acknowledgement in the action plan of the need for change across three crucial domains when safeguarding children – direct practice, the team around the child and the organisations around the team. It is clear that what has long been recognised as requirements for good practice, such as clearly focused and understood information-sharing, multi-agency meetings (such as strategy meetings and case conferences), and management supervision and oversight were not securely embedded. These acknowledgements clearly resonate with the outcomes of OFSTED inspections. It is over one year since Child 3 died so the pace of transformation could be questioned. The Covid-19 pandemic, alongside the impact of turbulence and churn within the senior levels of Children’s Social Care, will have impacted on pace. It is also an extensive agenda that will take time to deliver and then embed. 4.5.9. Recommendation Eleven: Wigan Safeguarding Partnership should routinely scrutinise the evidence for the impact and outcomes of Children’s Social Care’s action plan. 4.6. IOPC Report on GMP’s Investigation 4.6.1. GMP referred their investigation of the Adult Male’s suspected assault on another child and his contact with Child 3 to the IOPC. GMP had been informed on 30th July 2018 of an assault on a seven-month child, causing bleeding on the brain. The Adult Male was made subject to a bail condition that he was not to have any unsupervised contact with any child under the age of 16 unless directed and supervised by Social Services. The rationale is recorded as being “to prevent further offences.” GMP were informed on 7th August 2018 that this bail condition may have been breached but this was not checked immediately as “no units were available.” When GMP Officers visited the property on 14th August, the Adult Male was not present and the occupant stated that they were aware of the bail conditions and that he had not visited the address. 4.6.2. Commentary: there appears once again to be a reliance on self-reporting. The IOPC report observes that “[b]ail conditions are imposed in order to afford a level of safeguarding. Any potential breaches should be investigated, and all available information should be factored into decision making when conditions are reviewed.” The available information included a violence flag on the Police National Computer and an extensive history of assaults, thefts and public order offences between February and June 2018. There was also an incidence of criminal damage on 30th September 2018, the victim being a member of the child’s extended family. Investigation of bail breaches is identified as a point of learning for GMP. 46 4.6.3. The bail conditions were reviewed on 23rd October 2018. The Adult Male and the child’s mother were both released under investigation. The bail conditions were removed, the rationale being that the Adult Male did not have contact with the child and that the relationship with the child’s mother had ended. It does not appear that the possible breach of the bail condition earlier in August was factored into this decision. 4.6.4. Commentary: the IOPC report does not comment on whether, when and how Children’s Social Care were informed of the removal of the bail conditions. The IOPC report does acknowledge that GMP did not share information about the Adult Male and the emerging risks relating to Child 3 with the GMP team investigating the assault on the other child. As the bail conditions had been lifted, no further review would have been undertaken without further information pertaining to that case becoming available. The rationale for the lifting of bail conditions, reviewed in line with new bail legislation, included (in addition to the reasons given in the section immediately above) that the child concerned had been safeguarded, with family court proceedings commenced. 4.6.5. On 25th June 2019 GMP Officers had seen the Adult Male in a property where Child 3’s Mother was present. On this, and other occasions, the IOPC report notes that appropriate referrals were made to other agencies, including CRC and Children’s Social Care. However, the report identifies that incidents were dealt with in isolation rather than being seen as part of a worrying pattern. The IOPC identifies as points of learning for GMP the sharing of information within GMP and with other agencies, and the importance of identifying patterns in order to ensure that risk assessments are robust. 4.6.6. The IOPC report also observes that there were missed opportunities to consider a joint GMP/Children’s Social Care strategy meeting once information was emerging about the Adult Male’s contact with Child 3 and her Mother. The report also observes that GMP would have expected Children’s Social Care to have requested a strategy meeting, especially surrounding the events in August 2019, and to have updated GMP after their meetings with Child 3’s Mother. The report also notes that Child 3’s Father was not informed and that such a decision should have been made by GMP and Children’s Social Care, with the latter taking the lead. 4.6.7. Commentary: whilst GMP may have had such expectations, it appears that there was no follow-up or no escalation of concerns. It is open to any service to formally request a strategy meeting and to escalate concerns when such a request is not then actioned by Children’s Social Care. This does not appear to have happened and is a significant omission. 4.6.8. GMP’s risk assessment, particularly relating to the child protection medical in August 2019, was medium. This assessment, the report suggests, was influenced by reassurance from Children’s Social Care that there were no immediate concerns. The report observes that, whilst the risk assessment made by the attending officer was appropriate, it did not explore the Adult Male’s possible involvement in the assault on the other child. The report suggests that the risk assessment should have been considered when triaged by a specialist officer to be raised to high, to take into account the Adult Male’s history of offending, including of violence, the access he appeared to have to children, and the recent bruising seen on Child 3. Indeed, as the report states, there were 16 public protection incidents involving the Adult Male as perpetrator and 5 as victim. A restraining order was in place relating to a relative of the child whilst he was being investigated for a potential assault. 47 4.6.9. The one occasion when a GMP Officer saw Child 3 was in August 2019 for a safe and well visit. By that time GMP already held information of Child 3’s Mother being the victim of public protection incidents. The Officer was reassured by Child 3’s Mother and grandmother that the Adult Male had not been inside the home and had not had any contact with Child 3. The Officer liaised with Children’s Social Care whilst at the house and believed that a Social Worker was dealing with the case. A referral was sent to Children’s Social Care and Child 3’s Mother advised that the Adult Male was not to have any unsupervised contact with Child 3. As a result the Officer concluded that there were no immediate concerns and therefore no grounds for a Police Protection Order, which is an emergency order requiring that a child would be likely to suffer significant harm. 4.6.10. Commentary: the IOPC report records that risk was assessed as medium and GMP involvement was closed. It should also be noted that there was no independent verification sought of the assurances provided by Child 3’s Mother and grandmother. There does not appear to have been any recognition or consideration of coercive and controlling behaviour, or of disguised compliance. 4.6.11. The IOPC report also considers GMP’s role in seeking from the Family Court a finding of fact relating to the injuries sustained by the 7-month old child. The first record of consideration of requesting documentation from the Family Court occurs on 4th March 2019 but there were substantial delays as a result of the Adult Male not engaging with the Family Court, the need to obtain consent from the parties involved to the release of information, and volume of work in legal services. Information provided for the IOPC review indicates that such delays are apparently normal. A point of learning, not just for GMP, is that risks arise from delays in the release of information by the Family Court to the CPS. CPS was only in a position to make a decision whether or not to charge the Adult Male with offences relating to the 7-month old child by 11th October 2019. 4.6.12. Commentary: crucially, as the IOPC report comments, in the finding of fact was a statement by the mother of the 7-month old child, to the effect that the Adult Male was unsuitable to care for a child due to his character and intolerance towards children. She did not disclose this during police interviews. The Children Act 1989 is clear that the paramount principle is to safeguard and promote the welfare of children. Once this information was known, it should have been disclosed so that appropriate agencies could assess its relevance and significance for risk assessments relating to any child with whom the Adult Male may have had contact. 4.6.13. Recommendation Twelve: GMP should provide assurance to the Wigan Safeguarding Partnership regarding how the findings of the IOPC investigation have been taken forward into their public protection practice with children and their families, and with other agencies involved in children’s safeguarding. 4.7. Community Rehabilitation Company Independent Management Review 4.7.1. Cheshire and Greater Manchester CRC conducted a Serious Further Offence Review, of the practice of three officers who were involved with the Adult Male. 4.7.2. At the point of sentence for breach of a conditional discharge and for failing to stop, on 16th January 2019, resulting in a 12-month Community Order, including 60 hours 48 unpaid work, risk was assessed as low. The case was allocated, appropriately, to a Case Manager. On 25th January 2019 the case was transferred, again appropriately according to CRC policy, to a Senior Case Manager as a result of information received from Children’s Social Care regarding the Adult Male’s involvement in the investigation of an assault on a 7-month old child. On 19th March 2019 the case was transferred to a second Senior Case Manager. 4.7.3. Commentary: the CRC review notes the high caseload carried by the second Senior Case Manager (SCM2). As a result of this, SCM2 did not review the case at the point of transfer and was therefore not familiar with key risk concerns, including child safeguarding concerns. This had an impact on inter-agency communication, information-sharing and joint working. A key component of effective safeguarding practice is management responsibility to ensure that workloads are manageable. This does not appear to have been the case here. The Independent Reviewer has been told that the Officer was “overwhelmed with work.” 4.7.4. Risk assessments were formally undertaken once by the first Senior Case Manager (SCM1) and twice by SCM2. A risk assessment was also completed by the writer of the first pre-sentence report. That writer concluded that risk was low. SCM1’s risk assessment concluded that risk was medium, although information about domestic assaults had been shared by GMP, and information had been received from GMP and Children’s Social Care regarding child safeguarding concerns. The Adult Male was also known for violence towards partners and family members. 4.7.5. Commentary: the review concludes that the assessment lacked some detail but did identify relevant risks. It is surely questionable whether risk was appropriately categorised given what was known about the Adult Male’s offending history. 4.7.6. The CRC review observes that a formal review of low risk cases should occur every six months. This did not happen and was a lost opportunity to address child safeguarding concerns. The report is critical that SCM2 did not act on the Adult Male’s change of address and did not review risks as a result of an escalation in his offending. There was no consultation with Children’s Social Care and no checks were made regarding his sister and the children in her household. This was an omission in terms of standards of child safeguarding activity. 4.7.7. There were further offences in June 2019 involving breach of a restraining order, breach of a Community Order and aggravated vehicle taking. A second Community Order was made on 30th August 2019. SCM2 undertook a risk assessment on 6th September but did not complete a comprehensive review. Only a “holding” assessment was completed due to a perceived lack of information and the Officer’s annual leave. This was outwith CRC policy. The assessment is described as poor. Child safeguarding checks were not completed. 4.7.8. Commentary: a key component of effective safeguarding practice is the completion and regular review of robust risk assessments. Management oversight is an important safeguard to ensure standards of practice and compliance with agency policy and procedures. 4.7.9. The CRC review focuses on effective management oversight of high risk cases. This is a formalised system within CRC. The report notes the absence of effective management 49 oversight in February when the Case Manager was notified of the Adult Male’s involvement in a child protection investigation by GMP. This is observed to have been a lost opportunity. The formalised system was used on 6th September 2019 but it was cursory in nature. Not all the issues linked to children’s safeguarding were explored and appropriate actions set. This too was a lost opportunity. 4.7.10. Commentary: the CRC review is critical of the deployment of effective management oversight but there is no analysis of why the formalised system was not used as CRC policy required. 4.7.11. The review is similarly appropriately critical of the quality and quantity of contact with the Adult Male and of home visits. It observes that the opportunities that home visits presented were not taken up. The Adult Male complied only poorly with the Community Order. He was seen by Officers on only six occasions; 16 appointments were missed. He only completed 24 hours of unpaid work. Enforcement activity was not robust. When he was seen, these occasions were not used effectively to address risk and safeguarding concerns. His assurances about relationships were taken at face value. 4.7.12. SCM2 took no action around 29th April 2019 when he missed an appointment and explained that this had been the result of his partner having a scan. Given the ongoing GMP enquiry about assault of a young child, this was a missed opportunity. No action was taken either around 17th July when, seeking advice about his curfew, he disclosed that he was now living with his sister and her children. It had been recorded that Children’s Social Care had advised that he was not to have any unsupervised contact with children. An opportunity to clarify his bail conditions with GMP and to complete a home visit were missed. Actions expected with respect to risk and child safeguarding were not undertaken. 4.7.13. Commentary: once again, self-reports were taken at face value; information given by an individual was not triangulated with what else was known across the services involved. The IMR is candid in its critique but does not reflect on why the lost opportunities occurred. 4.7.14. On enforcement action, the review concludes that SCM1’s actions were prompt, with breach paperwork lodged on 19th February, resulting in 20 hours being added to the unpaid work requirement one month later. SCM2 failed to take enforcement action until 3rd September. 4.7.15. The review also considers contact with other agencies. It records that CRC was notified by Children’s Social Care about the investigation of the Adult Male with respect to injuries sustained by a 7-month old child. This led to the case being transferred to SCM1 in line with CRC policy. This was good practice regarding multi-agency working and safeguarding activity. On 14th February 2019 SCM1 and a Social Worker met to share risk assessments and formulate a joint plan. This was good practice. 4.7.16. Between 17th April and 22nd April 2019 SCM2 was advised by Children’s Social Care that the Adult Male had failed to attend Court hearings relating to some care proceedings. SCM2 did not act on this information so, whilst the information being shared was good practice, it did not result in a coordinated inter-agency response. 50 4.7.17. In August 2019 the Adult Male advised a Court Report Writer that he was in a relationship with Child 3’s Mother. This information was sent to SCM2, which was good practice, with concerns due to the ongoing GMP investigation. There was also a formal referral to Children’s Social Care. SCM2 did not act on these concerns; no appropriate safeguarding action was taken; no inter-agency work was initiated. 4.7.18. In September 2019, an enhanced management oversight meeting was held. As a result SCM2 was to contact Children’s Social Care and to ascertain progress with the investigation into the assault on the 7-month old child. There was no exploration of the position in respect of Child 3, amounting to a failure to work effectively with Children’s Social Care. 4.7.19. Finally, the review focuses on the case flags and markers on the CRC recording system. It concludes that whilst some markers were correctly registered, for example regarding child protection, other opportunities to place flags on the system were missed. 4.7.20. Commentary: it will be recalled that GMP had a case flag of violence for the Adult Male on his nominal file and on the Police National Computer file. As a result of CRC’s analysis of their involvement with the Adult Male, five actions have been taken. Guidance on case registrations and the use of flags has been issued. Guidance on case transfers, and on enforcement, has been issued also, with staff training on the latter. Staff development is also being offered on child safeguarding, including risk assessment in cases of spousal assault. Finally, a reminder has been issued that the effective management oversight system is to be used quarterly. Personalised development action plans have been created. No actions have been identified with respect to the workloads being carried by Case Managers and inter-agency working other than reinforcement that CRC Managers should keep workloads under regular review. 4.7.21. Recommendation Thirteen: Wigan Safeguarding Partnership should seek assurance from CRC (and from the National Probation Service going forward), based on audits of practice, that the learning from this internal investigation has resulted in practice improvement. 4.8. Bolton NHS Foundation Trust Review 4.8.1. A key episode in the chronology is the child protection medical that took place on 20th August 2019. Following the death of Child 3, the Hospital involved conducted a review of that episode. 4.8.2. Staff in A&E spoke to Children’s Social Care in Wigan within an hour of the arrival of Child 3. Information was shared by the Social Worker about concerns about Child 3’s Mother’s partner and that he should not have contact with Child 3, that Atherton Probation Office had informed Children’s Social Care earlier in the day about their contact with this Adult Male and also that Child 3 should not be discharged home without further discussion with the Duty Social Worker. Commentary: information-sharing and liaison between agencies and practitioners involved was good practice. 4.8.3. Child 3 attended the Children’s Ward and was examined by a Paediatrician. This was a thorough and detailed medical examination carried out by an experienced Locum 51 Consultant acting down on the middle grade rota, thereby requiring joint decision making with the Consultant on call and Social Worker the same evening. This took place and is well documented in the notes. Commentary: detailed case recording is good practice. 4.8.4. Medical opinion was that injuries could be attributed to the explanations offered by Child 3’s Mother and all were over bony prominences in a mobile child. The findings were discussed with the Consultant Paediatrician and Wigan Duty Social Worker. The request to return the following afternoon for medical photographs was due to the fact that this service is currently only available in office hours. Discharge home was agreed with the Social Worker who advised that Children’s Social Care would be attending the family home to review. 4.8.5. The injuries assessed were not conclusively abusive injuries; therefore collaborative decision-making to send Child 3 home was taken with the Consultant on call and the Duty Social Worker. It has, however, been considered further by the Consultant Paediatricians that admission to the ward overnight would have allowed information gathering from other professionals in office hours – for example the Health Visitor and the CRC Senior Case Manager. ”With hindsight it is speculative but possible that admitting Child 3 to the ward would have supported information gathering and sharing ……equally this may not have offered any change to the course of action taken”. It is recommended that there should be a low threshold for admitting children under the age of 2 with bruising overnight unless there are no safeguarding concerns. A further recommendation is to request that a Strategy meeting takes place even if a child is not seen to reach the threshold of significant harm by the Duty Social Worker. 4.8.6. The delay in providing written information was also considered within the review and actions taken in relation to this. A continued expectation is that there is telephone or virtual contact with the Social Worker at the time of attendance, with written communication/reports to be provided to Social Workers within 5 working days. Cases discussed at Peer Review have also been considered with telephone contact to take place in addition to written reports if learning is identified from a particular attendance and if it is agreed that there is a requirement for Children’s Social Care involvement and review. The Medical Secretaries have identified secure email addresses for Children’s Social Care out of area so that written reports and letters can be sent out as soon as possible once completed. The only area unable to provide a suitable email address despite being requested to do so is Wigan. Commentary: the Independent Reviewer has been told (March 2021) that a suitable email address has now been provided. 4.8.7. The nature of the medical peer review that occurred subsequently is that Paediatricians and other staff discuss a number of children who have presented to hospital as a learning exercise. Child 3 was discussed alongside a number of other children – typically 8-10 are discussed at each meeting. This is not a formal review process but a learning exercise for medical staff. It is a retrospective review and is held to primarily ensure consistency of practice and to support and provide training to junior staff. The outcome of the discussion about Child 3 was that a letter would be sent recommending that Children’s Social Care convene a meeting of agencies involved to ensure support and monitoring was in place. 4.8.8. Finally, the report observes that appropriate GP referral pathways were not followed by the Wigan GP surgery. Had the correct process for Section 47 (Children Act 52 1989) medicals been followed by the GP surgery, then Child 3 would have attended a Hospital in Wigan rather than in Bolton. The GP surgery should have informed Children’s Social Care of the need for a child protection medical rather than advising Child 3’s mother to take her to A&E. 4.8.9. Recommendation Fourteen: Wigan CCG should provide assurance to the Wigan Safeguarding Partnership that the learning from this case has been shared with GPs and all members of primary care teams and community health services, and that all staff have been reminded of the pathway for child protection medicals. 53 5. Concluding Discussion 5.1. Children’s Social Care has recognised that there was insufficient focus on the quality of the work at the time of this case. Significant changes continue to take place to ensure culture change and practice improvement, for instance with respect to the composition and structure of the “front door”, sign-off of social work assessments and decision-making by managers, and the adoption of a “Signs of Safety” method of working. This is being accompanied by significant financial investment in social work posts and support in key areas. Internal audits and external checks are underway or planned to provide a litmus test of what is being achieved. There is, therefore, recognition that the Department has experienced a turbulent time, which has meant that the pace of change thus far has not been ideal, and implementation of an active programme of work designed to harvest the learning from the shortfalls in this case. 5.2. The Wigan Safeguarding Partnership must scrutinise the outcome of Children’s Social Care’s action plan. However, its focus must also fall on the outcomes of service improvement and enhancement activity in Start Well and in CRC and the reconstituted National Probation Service, where management, supervision and practice shortfalls have been identified. 5.3.Across all four domains of practice and the management of practice, what has emerged is a picture of unsafe certainty or premature certainty33. There was a lack of curiosity and of authoritative doubt in direct work with Child 3’s Mother and the Adult Male, for example, and in managerial oversight of that practice. A position of safe or safer uncertainty, characterised by respectful curiosity and not understanding or deciding too quickly, was not achieved. The closest those involved came to this position was when the Hospital reflected on the outcome of the paediatric examination conducted in August 2019. 5.4.Both Child 3’s Mother and Father have told the Independent Reviewer that they feel they were failed. Child 3’s Father has pointed out that there was no consistent relationship between a Social Worker and Child 3 and her Mother. He has reminded those involved that he should have been involved as Child 3’s Father. He hopes that his involvement in this review will help to prevent further deaths. Child 3’s Mother has observed that no-one ever asked her to sign anything like a contract or written agreement that clearly spelled out what she was and was not allowed to do; that, she thinks, would have made her realise how serious the situation was. She feels that, after the August paediatric examination, robust interviews should have been conducted, with “proper consequences” and clarity about the potential outcomes if a child is felt to be at risk. She has also said that Social Workers should be honest about their concerns and that parents should be told of the reasons when they are referred to Social Services. 5.5. The components of best child safeguarding practice are well known. It is tragic that lessons are having to be learned again about the centrality of quality (risk) assessments, attention to case chronology, and engagement with significant adults; of not overestimating the ability of parents to keep children safe and triangulating what 33 Mason, B. (1993) ‘Towards positions of safe uncertainty.” Human Systems, 4, 3-4, 189-200. 54 parents report with what is observed and known to practitioners; of robust inter-agency collaboration and management support and oversight of practice. Leadership in children’s safeguarding resides in everyone involved with the safeguarding of children, whatever their formal role and designation. That leadership is ultimately brought together here in Wigan’s Safeguarding Partnership that, going forward, must consistently ensure that best child safeguarding practice is evident in how practitioners are working with children and their parents, and with each other, and how services are supporting that practice. 55 6. Recommendations Recommendation One: As the Early Help offer is being reconfigured, Wigan Safeguarding Partnership should commission and scrutinise audits of the effectiveness of the new service (section 3.6). Recommendation Two: Wigan Safeguarding Partnership in partnership with Wigan Safeguarding Adults Board should convene a multi-agency summit. The purpose should be to establish whether there is sufficient recognition of the potential impact of adverse childhood experiences and whether a whole family approach is sufficiently embedded in practice. This should cover but is not restricted to the Early Help offer, and should also include an emphasis on professional curiosity and a trauma-informed approach (section 3.7). Recommendation Three: The outcome of the adoption of specific practice and operating models for focused assessment and intervention as standard practice by Children’s Social Care should be scrutinised by Wigan Safeguarding Partnership (section 3.13). Recommendation Four: Coercion and controlling behaviour should be addressed in multi-agency training offered through the Wigan Safeguarding Partnership and Wigan Safeguarding Adults Board as a contribution to a “think family” approach to practice, including legal rules to protect victims from domestic abuse, and should be recorded as having been discussed in safeguarding supervision (section 3.19). Recommendation Five: Children’s Social Care should conduct routine audits of social work assessments and managerial oversight of decision-making, with reports scrutinised by Wigan Safeguarding Partnership (section 3.25). Recommendation Six: Wigan Safeguarding Partnership should undertake audit work routinely to ensure that strategy meetings and professionals’ meetings are convened. Audit work should capture the experience of different practitioners in convening and contributing to multi-agency and multi-disciplinary case discussions (section 3.37). Recommendation Seven: Wigan Safeguarding Partnership should convene a summit to review the threshold document and how different services understand and use it. Using this case as an illustration, policies and procedures surrounding the threshold document should be reviewed, especially the approach to re-referrals, the convening of multi-agency meetings and the importance of escalation (section 3.44). Recommendation Eight: All services with responsibilities for safeguarding children should provide Wigan Safeguarding Partnership with assurance that records indicate robust management and supervisory oversight (section 3.49). Recommendation Nine: All agencies should undertake a review of their approach to internal investigations as a result of learning from this case, reporting their conclusions and revised procedure to the Wigan Safeguarding Partnership. In particular, internal investigations must be timely, following a clearly laid-out process, with staff support offered. They must look at systems within which staff have been working and not simply focus on the practice of individuals (section 4.2). Recommendation Ten: Wigan Safeguarding Partnership and Wigan Safeguarding Adults Board to receive an evaluation of the new adult mental health referral process (section 4.3.6). 56 Recommendation Eleven: Wigan Safeguarding Partnership should routinely scrutinise the evidence for the impact and outcomes of Children’s Social Care’s action plan (section 4.5.9). Recommendation Twelve: GMP should provide assurance to the Wigan Safeguarding Partnership regarding how the findings of the IOPC investigation have been taken forward into their public protection practice with children and their families, and with other agencies involved in children’s safeguarding (section 4.6.13). Recommendation Thirteen: Wigan Safeguarding Partnership should seek assurance from CRC (and from the National Probation Service going forward), based on audits of practice, that the learning from this internal investigation has resulted in practice improvement (section 4.7.21). Recommendation Fourteen: Wigan CCG should provide assurance to the Wigan Safeguarding Partnership that the learning from this case has been shared with GPs and all members of primary care teams and community health services, and that all staff have been reminded of the pathway for child protection medicals (section 4.8.9). 57 |
NC52196 | Neglect of a 10-year-old child over a number of years. Child B was born with a disability and needed significant support from health specialists. They lived with mother, father and older siblings. In May 2015, Child B was admitted to hospital to have a toe amputated. Concerns were raised that the infection that led to the amputation was preventable. Child B was not brought to a significant number of health appointments. Further concerns were raised and formally escalated in 2018. In February 2019, Child B was made subject of a child protection plan. Nationality or ethnicity not stated. Learning includes: children not being brought to appointments is an indicator of potential neglect; effective and child focused safeguarding practice with disabled children ensures they are seen, heard and helped; the focus on engaging parents and carers to support disabled children is key, but this should not dilute professional challenge; multi-agency working, information sharing and understanding the responsibilities of others can be complex; the need for professionals to think family and think fathers. Recommendations include: ensure that all services have access to and use a 'Was Not Brought policy across the local health system; the Disabled Children's Service should ensure that meetings that they convene include an analysis of a child's attendance at appointments; ensure that recording systems are sufficient to identify repeating patterns of children not being brought to appointments; ensure that guidance for safeguarding children with disabilities is sufficient in terms of setting out the importance of communication and hearing the voice of the child.
| Title: Serious case review: Child B. LSCB: City and Hackney Safeguarding Children Partnership Author: City and Hackney Safeguarding Children Partnership Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case ReviewChild BApril 2021Contents1.Executive Summary22.Introduction43.Key Circumstances, Background & Context5Child B: Five to Seven Years Old6Child B: Seven to Eight Years Old12Child B: Eight to Nine Years Old14Child B: Nine to Ten Years Old174.Views of the Family195.Findings & Recommendations2011.Executive Summary1.1The publication of this Serious Case Review (SCR) was significantly delayed as aresult of a number of unforeseen circumstances.A first draft of the reportcompleted by the independent reviewer was subsequently finalised and approvedby the SCR review panel overseeing this process.1.2TheSCRmakessixfindingsandninerecommendationsforimprovingmulti-agency safeguarding practice.These have particular relevance for thoseworking with children who have complex needs and disabilities.Finding 1:Children not being brought to appointments is an indicator ofpotential neglect.This is a clear finding of the review and one that has beenseen in other SCRs. Child B, whilst being offered many appointments by differentservices, was not brought to a significant number of these. The hypothesis thatthese were as a result of neglect was not robustly pursued and there was littlepractical support offered to help the family manage these.Finding 2:Effective and child focused safeguarding practice with disabledchildren ensures they are seen, heard and helped. Whilst Child B was seen onmany occasions, there was limited evidence that his voice was consistently heardor that he was directly engaged by involved professionals.However, someprofessionals, particularly school staff were able to effectively engage andcommunicate with Child B.Finding 3:The focus on engaging parents and carers to support disabledchildren is key, but this should not dilute professional challenge whenneeded.Parentalinvolvementfordisabledchildrenwithcommunicationdifficulties is especially important.However, practitioners had no real clarity orguidance within the system about when non-engagement should be a ‘red flag’.This lack of clarity is likely to have been a reason why the identification of potentialneglect to Child B took so long to action.2Finding 4: Multi-agency working, information sharing and understanding theresponsibilities of others can be complex.Clear systems and processescan support effective child focussed safeguarding practice. It is clear that noagency involved with Child B had a clear overview of the family history, itsdynamics or a complete picture of Child B’s needs. Even professionals who knewChild B well were learning new information as part of a practitioner workshopconvened for this SCR.A strong view expressed was that the lack of thiscomplete picture can often arise in the system supporting children with complexhealth needs and disabilities when so many different agencies are involved. This isa known feature and a challenge for both professionals and parents alike.Finding 5:The need for professionals to think family and think fathers. Itwas accepted that there was no clear picture of the dynamics of Child B’s family.Professionals should have been thinking (and acting) beyond the individual theywere working with.There was a need to Think Family.1 There should also havebeen a greater focus on Child B’s father. The SCR recognised an over-reliance oncontact with mother and not enough questioning of the dynamics of therelationship with Child B’s father and what his role was in supporting his child’scare.1 Think child, think parent, think family: a guide to parental mental health and child welfare; Social Care Institute for Excellence, 201132.Introduction2.1Child B was born with a disability that led to urological problems and mobilitydifficulties. Child B has reduced sensitivity in the lower limbs (which means pain isnot felt in the same way as other children), speech and language delay andlearning difficulties. Child B has required surgical intervention to address a rangeof health complications.2.2Despite daily challenges, Child B is an active, friendly and happy child who canmake good relationships with adults. Child B is able to express themself well andsay what they like and want.2Throughout childhood, Child B has requiredsignificant support from a range of health specialists3. This has included routinecare from a specialist children’s hospital (Hospital 1), a local hospital (Hospital 2)and occasionally the services of the local emergency department or outpatients(Hospital 3). Child B is also known to different community-based health services.Child B attended a children’s centre and later a mainstream school. Child B hasalso received social work support as a disabled child and due to concerns abouttheir welfare.2.3For the period under review, Child B lived with mother, father and older siblings.One of the siblings was also in receipt of services as a disabled child andsubsequently as a disabled adult.2.4In May 2015, Child B was admitted to hospital to have a toe amputated.Theopinion of health practitioners at the time was that the infection that led to theamputation was preventable.Child B had not been brought to a significantnumber of health appointments. Had they been, then it is likely that the infectionwould have been treated and managed.On a number of occasions, concernsabout Child B’s welfare were raised internally by health practitioners. Whilst theseconcerns focused on possible neglect, there was no action until the case was3 Neurosurgeons, Orthopaedic Surgeons, Plastic Surgeons and Urologists at different hospitals and from community paediatrics, therapists andnursing, as well as Emergency Department care and GP primary care.2 As described by Child B’s mother and school to the Independent Reviewer.4formally escalated to senior managers in late 2018. Child B was then aged 10years. In February 2019, Child B was made subject of a child protection plan.3.Key Circumstances, Background & Context3.1In 2002, Children’s Social Care (CSC) became involved with the family due toconcerns about domestic abuse and the capacity of the parents to meet the needsof their children.Assessments undertaken by CSC at the time resulted in eitherno further action or the provision of support from early help services, charities andeducation.3.2In 2007 another incident of domestic abuse was reported and in 2008 (the year ofChild B’s birth), there were reported concerns about physical chastisementinvolving one of Child B’s siblings. Assessments were once again undertaken byCSC, with no further action being considered necessary.There were notedpressures in the family as a result of financial difficulties and caring responsibilitiesfor the children.3.3In 2010, all the children were made the subjects of child in need plans as a resultof one of them sustaining a burn injury and ongoing concerns about their collectivewelfare.In the same year, Child B was seen by the GP and referred to the localEmergency Department for a serious abrasion and ulceration to a toe3.4Throughout 2011 and 2012, several health practitioners identified that Child B was‘missing’, had ‘failed’ or ‘did not attend’ appointments.Routine letters wereordinarily sent to the GP and the parents were regularly advised of the need totake Child B to scheduled appointments.3.5Child B started to attend education at the age of three. The assessment processfor a statement of special educational needs commenced.4Child B’s needs atschool were monitored through termly and annual reviews. The school remainedconcerned about Child B and agreed to provide one to one support.4 Later an Education, Health & Care Plan53.6In early 2013, a meeting was convened by the Disabled Children’s Service (DCS)to review the care package for Child B’s older sibling.Professionals reportedfinding it difficult to engage and communicate with the parents. The DCS advisedthe professional network that it was ‘closing the case’ for Child B as there were noconcerns and appropriate services were being provided by health and education.3.7Over the subsequent years covered by the review’s terms of reference, there weretwo main strands of professional involvement with Child B which highlight arepeating pattern of concern.3.8The first was that Child B sustained a number of toe injuries and on occasions,was brought late to the local emergency department of Hospital 3. Child B’sdisability, lack of sensation in the lower limbs and general footcare complicated thewound which did not heal well. This subsequently affected Child B’s ability to wearspecial aids such splints and shoes.3.9The second strand was that both acute and community-based health serviceswere seeing a growing number of incidents of Child B not being brought toappointments.The nature of Child B’s disability meant that ongoing support wasessential for specialist aids and therapeutic services. At times, practical aids weremissing or broken, putting Child B’s limbs under additional strain and potentially atrisk.3.10The following narrative provides an overview of the significant events involvingChild B. Whilst comprehensive, it remains a summary and does not set out everyoccurrence recorded in agency files.This should be taken into account whenconsidering the overall context of Child B’s lived experience and the complexityarising from the number of professionals involved over this time.Child B: Five to Seven Years Old3.11In late 2013, Hospital 2 noted that Child B’s toe required treatment. This led toChild B having successful operations, but they were not brought to a number offollow up appointments, including those arranged for physiotherapy.Child B’smother was reporting that she was finding it hard to manage all the appointments6for Child B and her other children. At the time, none of the missed appointmentswere considered as potential safeguarding concerns.The condition of Child B’stoe subsequently deteriorated.3.12The community nurse contacted the DCS5 recommending that Child B’s motherneeded additional support managing appointments and that a special needskeyworker6 may have a role to play.This was subsequently considered at amulti-agency meeting, although it was agreed that the DCS social worker wouldprovide this support (given their ongoing involvement with Child B’s older sibling).At this meeting, the question was raised as to whether Child B was beingneglected.Critique of PracticeThis appears to have been the first time that the concerns relating to Child Bwere expressed using the term neglect.The DCS was tasked to undertake a‘child in need’ assessment in respect of these concerns.The meeting held to discuss the keyworker did not have access to informationabout the different hospitals’ services to Child B or those from the GP Practice.This would have indicated an even greater pattern of ‘was not brought’.3.13Shortly after this meeting, Child B was not brought to a clinic at Hospital 2 to dresstheir toe. This was not escalated. At a multi-agency school review meeting held inApril 2014, the parents mentioned that Child B’s siblings were helping withphysiotherapy.Critique of PracticeChild B’s siblings should have been considered as possible Young Carers.They weren’t.3.14The following month, Child B was brought to the Emergency Department atHospital 2 following a deterioration in their toe. Child B was scheduled to havesurgery the next day (unrelated to the toe) and it was agreed the toe would be6 from the Centre for Integrated Services for Disabled Children5 A social worker from the Disabled Children’s Service was involved with the family, although there was noted confusion in the networkabout whether the social worker was for Child B or the older sibling.7reviewed then. However, as a result of confusion over appointment times, this didnot take place.3.15The planned surgery was rescheduled and Child B’s toe eventually examined. Adecision was made that it needed to be partially amputated. The wound was to bere-dressed by mother prior to the operation the following week.Critique of PracticeThe Hospital team dealing with Child B’s amputation were unaware of theconcerns in the community network of missed appointments and possibleneglect.Erroneously, it was assumed that mother was a nurse and could appropriatelydress the wound (and so may not attend the planned dressing clinic). Child Bwas not brought to the clinic.3.16On meeting with the physiotherapist, mother expressed her concerns that she wasunclear of the hospital’s plan for the partial amputation of Child B’s toe. She alsomentioned that Child B’s wheelchair strap was broken. Mother was advised tocontact the wheelchair service. The physiotherapist contacted the hospital onbehalf of mother to check arrangements about the planned operation. They wereadvised by the Doctor’s secretary that Child B was not booked for surgery. Thesecretary advised that mother needed to contact the appointments section.Critique of PracticeThis above narrative shows some of the complexity of what Child B’s motherwas having to negotiate across services.3.17Following surgery,a review was scheduled at Hospital 2 .Child B was notbrought to this appointment. Separately over this period, Child B was not broughtto a routine orthopaedics appointment at Hospital 1 and the physiotherapistcontinued to have difficulty contacting mother.3.18As part of a plan to support the parents, the DCS social worker was monitoringmissed appointments and requested other services provide information about8future scheduled appointments as necessary.However no contact was maderequesting this information from the three hospitals or the GP.3.19The child in need assessment was completed by the DCS social worker, althoughthis was several months overdue. Despite identifying the frequently missed healthappointments,theassessmentdid not conclude these were safeguardingconcerns or make any recommendations for ongoing support. Whilst Child B wasplaced on a child in need plan, this did require regular visits to be undertaken tosee Child B.3.20In November 2014, Child B was not brought to appointments at Hospital 1 or to acommunity paediatrics appointment. Child B was also not brought to a re-arrangedappointment by Hospital 1 to complete an orthopaedics review.Hospital 1 wasalso unaware of a recent operation undertaken at Hospital 2.3.21The school, social worker and physiotherapist exchanged emails about Child Bmissing appointments.The school’s Designated Safeguarding Lead noted thatthere was a risk of this becoming a safeguarding issue. In late January 2015, ChildB was not brought to Hospital 2. The physiotherapist sought to escalate this to theDCS, but was told that the case was now ‘review only’ and that there was noactive social work role.Critique of PracticeNot all partner agencies were advised that Child B’s case was now for ‘reviewonly’. Practically, this meant that the only function of the DCS was to coordinatereviews of Child B’s care package. The agreed role of the DCS social workeras a coordinator of appointments had lapsed, but no contingency arrangementswere put in place, such as considering whether a special needs keyworkershould now take up this role.3.22In February 2015, the school was concerned as there was poor communicationwith the parents. The school believed that Child B’s physical and health needswere not being met and asked for a DCS social worker to follow this up.Critique of Practice9The DCS engaged with the family and noted that there was a risk of Child B’smissed appointments becoming a ‘safeguarding matter’. A DCS social workerdiscussed this with Child B’s mother over the phone after she had missed aplanned appointment to meet them. No practical help or solution was offered tosupport this problem. Child B continued not to be brought to a range ofappointments and mother was not responding to several services’ attempts todiscuss this.3.23In March 2015, Child B was not brought to a routine developmental review at theCommunity Paediatric Service. As this was the second missed appointment, ChildB was discharged to the care of the GP. This meant that Child B was longerreceiving general paediatric oversight for their specialist health needs.Child Bwas not brought to a follow up fitting for new splints and also missed anappointment at Hospital 3.3.24At the end of April 2015, Child B was taken to the emergency department ofHospital 2 after injuring their toe. This was a late presentation. The wound wasweeping and discoloured and Child B had difficulty walking without support. Thedelay in seeking treatment for Child B was not immediately recognised as asafeguarding concern or referred to CSC.However, after discussion in thehospital’s psychosocial meeting and escalation to the hospital’s safeguardingnurse, the Disabled Children’s Service was notified of this concern.3.25Child B was later found to be suffering from an infection in the bone and wasadmitted to hospital. Child B was given intravenous antibiotics and it was decidedthat further amputation was required.Child B was an in-patient for ten days.Following discharge, Child B was brought back to the emergency department bymother as the wound was not healing.It was recorded that Child B was notcompliant with advice about weight bearing.Critique of PracticeChild B was six years old and had learning and communication difficulties.Recoding ‘non-compliance’ with weight bearing advice does not appear to haveconsidered Child B’s age and specific needs.Specialist communication may10have been required to assist Child B understand what was being asked. Thereis no evidence this was offered.3.26In May 2015, a review at Hospital 2 established that Child B had not been takingthe prescribed antibiotics. Child B was not brought to the next appointment.3.27In June 2015, Child B was back at school, using a wheelchair. The school advisedthe community physiotherapy service that there were difficulties contacting motherand she was not responding to written communication.3.28The physiotherapist was concerned about the healing of Child B’s toe and whowas changing the dressings. They contacted Hospital 2 and left messages on twooccasions to seek clarification, with no response.In conversation with the DSCsocial worker, mother said that Child B’s wound was being dressed once a week atthe hospital.This does not appear to have been the case. By the end of June2015, Child B’s wheelchair was broken and they were using a walking frame andhopping.3.29Child B subsequently missed an appointment with the community physiotherapist,the third missed appointment in six months. A ‘Did not Attend’ letter was sent tothe parents, but it was agreed that despite the policy (which suggested closure),the service would be continued.3.30Child B was also not brought to Hospital 1 for a neurosurgery appointment.Hospital 1 closed this service to Child B and informed the GP that a re-referralcould be made if necessary.Later in the month, Child B was not brought to anappointment at Hospital 2.Child B was also not brought to a communityphysiotherapy appointment and it was decided that if any more appointments weremissed, Child B would be discharged.In late October 2015, after not beingbrought to three appointments, the wheelchair service closed Child B’s case.3.31The DCS social worker visited Child B’s parents and raised the issue of Child B’smissed appointments.The parents reportedly became angry saying that theyfound taking Child B to so many appointments difficult and that they couldn’t leaveChild B’s disabled sibling at home alone. Both parents were working.Despite the11obvious challenges this presented to the parents, no solution was agreed or plandeveloped to support the parents in this respect.Critique of PracticeDespite the significant number of missed appointments, this was not yet seenas meeting the threshold for neglect.The seriousness was again stressed tothe parents (referring to the possibility of using child protection processes), butthe failure to take any subsequent action lacked any authority or decisivenessto resolve this issue in Child B’s interests. Previous ‘warnings’ to the family hadyielded no results. Neither had the assistance of the DCS social worker to helpthe family manage Child B’s appointments. The next day B was not brought tothe GP for a planned flu vaccination.Child B: Seven to Eight Years Old3.32From the ages of seven to eight, the pattern of concerns about Child B missingappointments continued. Key events included the following:●In April 2016, after attending the emergency department of Hospital 3 withan injured toe, Child B was not brought to a follow up appointment. Motherwas still being seen as competent to dress Child B’s toe at home.●At the same time, community health services noted that Child B had brokensplints and that they were too small. Mother had been previously remindedof the need to inform services when this happened.●The condition of the wound to Child B’s toe was a continuing concern forcommunity health and school staff and mother was advised to take Child Bto the GP.●At school, Child B disclosed that father was hitting mother. A DCS socialworker visited, and denied there was any domestic abuse. During thisengagement, mother explained that Child B’s wound was being followed upat the clinic and by the GP, although this was not happening.Critique of PracticeThere was regular communication between the school, community nursing,community physiotherapy and the social worker about Child B. Professionals12believed that they were regularly raising concerns about possible neglect viathe social worker.However, the DCS had no remit to pursue these concernsunder child protection procedures.In the absence of the DCS recognising achild protection response was required, other agencies were likely to have beenfalsely reassured they had reported their concerns via the correct pathway.3.33In June 2016, Child B was seen at the GP for foot pain.The GP took theopportunity to raise the issue of the number of missed appointments. Mother saidthat it was hard to take Child B to so many appointments as she had other childrenand Child B’s sibling also had special needs. The GP suggested that the familymay wish to find a surgery closer to their home.3.34The following month, Child B was admitted to Hospital 3, having been brought inby ambulance due to breathing difficulties. Child B had viral induced wheezing fortwo days, was unkempt and their eczema was being poorly managed.Critique of PracticeA referral was appropriately made by Hospital 3 to the paediatrician to considerChild B’s social situation. Mother was reported as being uncooperative as shefelt that she had already told the emergency doctor about Child B’s needs onadmission. Hospital 3 noted that Child B was an ‘open case’ to the DCS andthat the social work team had no safeguarding concerns. Child B wasdischarged home the same day, after several hours monitoring.3.35The next professional contact was again at Hospital 3 due to a worsening in thecondition of Child B’s toe. The hospital discussed this deterioration as a possiblesafeguarding issue.3.36An X-ray of Child B’s toe (referred by the GP) was undertaken at Hospital 2. Thisconfirmed the toe was in a poor state. Hospital 2 also noted potential safeguardingconcerns, although no referral was made to CSC in respect of these.3.37The concerns of Hospital 3 were shared with the DCS social worker. They wereinformed that the DCS social worker was seeking to support the parents inmeeting Child B’s needs. The plan was for the DCS social worker to again meet13with the parents to raise the issue of missed appointments. This was the fourthsuch meeting.3.38During an appointment at the foot clinic in Hospital 3, a new and open wound toChild B’s foot was observed. Child B was referred immediately to the emergencydepartment at Hospital 3. Mother reported she had been abroad and was not fullyaware of the circumstances of the injury. She had not sought medical help as shefelt that she was looking after Child B’s foot appropriately. Hospital 3 discussedthis possible safeguarding issue at a paediatric psychosocial meeting. It noted theconcerns and also that the community physiotherapist had already made a referralto CSC7 in the light of these new (but repeated) developments.3.39Other significant event around this time included the following:●Mother was seen by the GP and alleged that father had slapped her and thatthe police were involved. There is no evidence that they were.●On meeting with the CSC social worker (following the referral by thecommunity physiotherapist), mother told them that she had not been givenany advice about the care of Child B’s toe. The social worker was not awareof the allegation of domestic abuse made to the GP. No further action wasdeemed necessary by CSC.●At the end of 2016, Hospital 2 reviewed Child B’s toe and found multipleingrowing toenails. This was not seen as an issue relating to parentingcapacity and a plan was made to review Child B in six months.●It was agreed at a Care Package Review Panel to extend Child B’s support(direct payment for seven hours of care) until 2017. There was no discussionabout potential safeguarding risks and no advice on how support could bearranged to help the parents manage Child B’s appointments.Child B: Eight to Nine Years Old3.40In March 2017, the school was concerned that Child B needed glasses andcontacted the DCS social worker. The DCS social worker visited Child B at home.7 As a child protection concern, the referral would have been made to the First Access & Screening Team, not to Disabled Children’s Services.14Child B’s care package had now ceased based on the rationale that Child B hadtwo parents and needed no additional support.3.41Later that month, mother contacted the police following an argument with fatherover money. This information was passed to the CSC immediately by the police,although it was not followed up for two months. At this point, mother was engagedand declined any further assessment.3.42Other relevant events over this period included:●InMay2017,thecommunityphysiotherapistconsideredcallingaprofessionals’ meeting as she felt that Child B’s needs were not being met.The meeting was not convened for a further four months.●Child B was brought to the emergency department of Hospital 3 withtoothache and was given antibiotics. The toothache was not seen as a furtherpotential symptom of neglect.●Child B was recorded as a ‘did not attend’ to the follow up meeting at Hospital2 for the review of their toe. Child B was discharged from the service.●In June 2017, the community physiotherapist saw Child B at school.Shecontacted the DCS social worker as Child B had missed all the physiotherapysessions since January 2017.Mother was reported to have regularlycancelled the planned sessions.●A planned meeting with mother, the community physiotherapist and the schoolwas cancelled by mother as she was going away for a month. She also askedfor all appointments for Child B to be postponed, even though Child B was notgoing away with her.●The community nurse reviewed Child B’s toe at school at the end of June2017. Child B had pain, possibly as a result of their shoes which were toolarge and rubbing the feet.●At the beginning of July 2017, the physiotherapist wrote again to the DCSsocial worker to say that Child B still had no glasses and that their footwearwas inappropriate, asking for these to be taken up with the family as they weresignificant health needs.Critique of Practice15The community physiotherapist had formally referred similar concerns as asafeguarding issue only a few months prior, but these had not been acceptedas concerns indicating neglect. It is, perhaps, not surprising, therefore, that shedid not make a further safeguarding referral.3.43The community physiotherapist was also concerned about Child B possiblyexperiencing back pain and the risk to their hip, questioning whether this was as aresult of Child B’s disability and gait, and perhaps not using the required aids. Shereferred to Hospital 2 asking for Child B’s hip to be reviewed.3.44At the end of July 2017, the community physiotherapist rang the home to remindthe family of an appointment the following day. The phone was answered by ayoung child and there appeared to be no adult at home, in the school holidays.The community physiotherapist rang the DCS social worker and was advised torefer the concern to CSC. On doing this, CSC advised her to ring the police.Critique of PracticeThe police established by phone ( but did not check) that a 15-year-old hadanswered the phone and that father was reported to be present but asleep. Thepolice told the community physiotherapist that this was not a matter for them tofollow up and she agreed to discuss it with CSC.The importance of a home visit was not recognised in this instance. Someonein the professional network should have taken the initiative to visit the familyhome to assess what was happening and who was looking after Child B. Thiswas particularly relevant in the context of Child B’s complex needs and the carethey required.3.45The next day, the community nursing team decided to discharge Child B from theircare as they could not see Child B (as the school had closed for holidays) and theparents were not responding. The GP was informed.The day after, Child B didnot attend an appointment at the Foot Clinic.3.46In September 2017, there was a Team Around the Child (TAC) meeting at theschool.Some improvement was noted in attendance at some appointments, but16mother was reminded of the continuing need for Child B’s foot and leg care. ChildB was missing a splint and specialist shoes. She re-stated the difficulty that shehad with the large number of appointments. Support plans, including appropriatephysical activities for Child B were to be put in place. However, no contingencyplan was agreed should the situation deteriorate and no review date for a furtherTAC Meeting was set.3.47Other events over this period included:●Child B had to have some teeth removed. Child B was almost nine years old.The possibility of neglect was not considered.●Child B had not been brought to several appointments at the Foot Clinic.●In November 2017, mother was admitted to hospital for several weeks with aserious health problem. Professionals supporting Child B were unaware ofthis. At the time, there were signs that Child B was not being looked afterproperly and that they were hungry. When it came to the attention of the DSCsocial worker (just as mother was being discharged), seven hours additionalsupport in the home were arranged for a month.Child B: Nine to Ten Years Old3.48In January 2018, Child B was not brought to a GP appointment and one of theirsiblings was discharged from another service for not attending appointments.3.49Child B’s mother called CSC asking for Child B’s father to be removed from thehome. She described an acrimonious relationship, but said there was no domesticabuse. She said that he was not supporting her. Mother was advised to call thepolice if necessary. CSC took no further action.Critique of PracticeThis is one of the few times that father featured in the records in any context.He was largely absent from the records and from the professional engagementwith the family.Research is well established in this respect, with the need forprofessionals to actively include a focus on fathers as part of multi-agencysafeguarding practice. It is clear that father’s role was never really explored in17any depth, or what his role was in respect of supporting mother manage thecare of Child B and the other siblings.3.50Other events of note over this period include:●Small improvements in Child B’s attendances at appointments were observed.●Some of Child B’s equipment was noted as being ‘lost’. Child B was notwearing the correct shoes and could not attend school as a splint was broken.●Ongoing tensions in the parental relationship were noted.●Child B was not brought to the gait clinic on three occasions despite remindersand also missed a GP appointment.●At the school annual review, Child B said that they did not want to be seen asdisabled. It was noted that Child B had experienced a deep pressure sore onthe ankle. Child B said they had injured it on the stairs.●The annual review noted this was evidence that the family was still not copingwith Child B’s needs. Appointments were being missed, even though they hadbeen reduced in number. It was recorded that ‘crucial health needs were notbeing met’ and that there was a ‘serious risk to Child B’s wellbeing’.3.51In June 2018, Child B’s mother again called CSC asking for father to be removedfrom the home and alleging physical and verbal abuse. She was again advised tocall the police.She later denied the alleged physical abuse and there was nofurther exploration of the reported domestic abuse. The parents did not attend ameeting with a social worker from CSC to discuss this further.3.52In September 2018, Child B was not brought on two occasions to ophthalmologyand was discharged from this service. A new DCS social worker was appointed toassess concerns about non-attendance at appointments and Child B’s needs notbeing met.The same month, the school reported that Child B’s shoes werebroken, and their feet were exposed. The parents were not responding to theschool’s request to deal with this or contact them. Mother was thought to be awayat the time. A few days later, Child B was noted to be unkempt and dirty and theirbehaviour had changed.It was questioned whether Child B was being fed athome. A request was made to the DCS for an urgent TAC meeting, but there wasno response.18Critique of PracticeThis would have been a further opportunity to consider a child protectionreferral.3.53In late October 2018, Child B was seen at Hospital 2. It was agreed thathip-reconstructive surgery was required.This was scheduled for the Spring of2019.Child B was subsequently not brought to two orthotics appointments inNovember 2018. As a result, the case was escalated by Hospital 3 to the NamedSafeguarding Lead for the Health Trust.The case was subsequently referred toCSC as a safeguarding issue of neglect.3.54In parallel, Child B also disclosed to the school that they were being physicalharmed at home. The school made a referral to CSC. A child protection enquiryunder section 47 of the Children Act 1089 was subsequently initiated.Thisresulted in Child B being made subject of a child protection plan in January 2019.4.Views of the Family4.1Both parents were invited to participate in the SCR.Only Child B’s motherengaged. She met with the Independent Reviewer and the Head Teacher of ChildB’s school.4.2Mother’s expressed her concern about the injury to her child’s toe and thesubsequent treatment this required, including amputation. She said she was toldby health professionals that the toe should heal and she did not understand why ithad not. She was shown how to manage the dressings by health staff, but saysthat she was not confident with this and may not have done it correctly. Inretrospect, she thought that it would have been helpful if a nurse had visited tohelp.4.3She also found the need to take Child B to the many appointments hard tomanage.This was compounded by her own health needs (which had at timesinvolved hospital admission) and her caring responsibilities for her other children.19One of Child B’s siblings also required significant support due to disabilities andanother had health problems, which meant that mother sometimes had care of hergrandchild. Child B’s mother felt that professionals were not listening to her whenshe told them how hard it was to take her child to all the appointments. She saidthey just told her ‘you have to take Child B’.4.4Helping Child B manage their physical difficulties had been a challenge as theyliked to be active and do things such as play and swimming. Child B found walkingto be painful. The direct payments for respite care helped as mother was able toengage a relative to help take Child B to leisure activities and to pay for cabs.4.5Mother questioned whether more could have been done by professionals atHospital 2 to prevent the infection and avoid the amputation of Child B’s toe.However, she believed that overall, the hospital had provided care. Mother notedHospital 1 as being very supportive in helping Child B with walking when younger.4.6Child B’s mother also felt well supported by the Children’s Centre and school. Shenamed a senior teacher who had been very helpful to the family. Child B was andremains very happy at the school and likes the teachers.4.7Community Health staff, particularly the Physiotherapy Service and the Speechand Language Service were also noted by mother as being very helpful in theirsupport of Child B. She also appreciated the provision of transport to school eventhough they did not live far away. Child B’s mother confirmed that she was not anurse but had worked as a healthcare assistant. She juggled her work hoursaround the needs of the children.5.Findings & Recommendations5.1At the time this SCR was initiated, similar concerns about safeguarding practicehad been identified in other cases held by the DCS, albeit not the same extent asthose seen with Child B. This resulted in the management arrangements for DCSmoving to CSC in 2018, as part of a plan to strengthen social work practice andthe identification of safeguarding concerns for children known to this service area.205.2This plan was considered as part of Ofsted’s inspection of Hackney in 2019, withits impact being noted as ‘beginning to have some positive impact in improvedsafeguarding practice and more robust management oversight of the progress ofchildren’s cases’.5.3Whilst recognising the historical context of this SCR (and acknowledging a numberof improvements made since the period under review), there are nonethelessimportant messages for contemporary safeguarding practice. These derive fromthe main question that the SCR has sought to answer, namely why it took severalyears of multi-agency involvement with a disabled child to recognise that theywere experiencing neglect?5.4The messages of this SCR mirror those of a number of other reviews undertakenin respect of children with disabilities and referenced in the NSPCC briefing: Deafand disabled children: learning from case reviews - Summary of risk factors andlearning for improved practice when working with deaf and disabled children;20168.5.5Finding 1:Children not being brought to appointments is an indicator ofpotential neglect.5.6This is a clear finding of the review and one that has been seen in other SCRs.Child B, whilst being offered many appointments by different services, was notbrought to a significant number of these.5.7Some of these were routine for a disabled child, such as regular developmentalmonitoring or therapeutic support. Some could, at times be made as much as sixmonths in advance, and reminder systems were not always in place. Some wereinresponsetonewcrisesorproblems.Onoccasions,long-standingappointments were also changed due to the needs of the particular service. Attimes, appointments for Child B were made by different services in the same weekor on the same day.8 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children215.8The SCR found two issues of relevance in this respect.Firstly, there was noeffective multi-agency co-ordination or oversight of these appointments. Secondly,the missed appointments failed to be seen in the context of potential neglect andas an indicator that the parents’ were unable to meet the needs of their child.5.9In respect of the coordination of health appointments, there was no evidence ofany systematic planning of these or effective information sharing across the threehospitals and the range of community health services. For example, practitionersdid not always know what treatment and support was being offered by others. Asan example, Hospital 3 referred Child B to community nursing for follow up care tothe toe. When it later became infected, Child B was referred to Hospital 2.Hospital 2 assessed the toe to be healing and, unaware of the community nursinginvolvement, decided to monitor Child B directly and to train Child B’s mother todress the toe. They understood that Child B’s mother was a nurse, which was notthe case.5.10Furthermore, despite Child B’s mother stating on several occasions that shesimply could not cope, the practical response to help her was insufficient. Indeed,Child B’s parents were also frequently missing appointments for their own ongoinghealth problems and the challenges they were facing should have prompted amuch earlier and more supportive response.5.11Whilst the DCS tried to support by requesting professionals share the details ofscheduled appointments with them, there was little rigour in this approach. Keyagencies weren’t approached and as such, this response was always going to belimited.5.12During the period under review, services were also not using the phrase ‘Was NotBrought’ when children missed appointments. The policies and practice in place atthe time were mainly in the health services and followed ‘Did Not Attend’procedures. These failed to point to neglect as a potential cause or recognise theresponsibility of parents and carers to bring their child to these.The primarycontingency plan in procedures at the time for continuing missed appointmentswas a referral back to the GP Practice for follow up.Services were ordinarilyterminated at this point.225.13A key lesson for the practitioners is that they need to be more curious about thereasons why a child is not being brought and to look for patterns of incidence.They should thoroughly explore potential options for support and have clearmechanisms for recording events in order to identify themes, patterns and trends.This requirement should be reflected in related policy.5.14Practitioners at the workshop were clear in their view that ‘Was not Brought’should also be embedded in the terminology of agency recording systems, neglectguidance and in the local threshold document.This will ensure that the child’sperspective is central.Recommendation 1:The City & Hackney CCG should provide assurance tothe CHSCP that all services have access to and use a ‘Was Not Brought” policyacross the local health system.Recommendation 2:The Disabled Children’s Service should ensure thatterms of reference and agenda structures for meetings that they convene(involving a review of disabled children and those with complex health needs)include an analysis of a child’s attendance at appointments.Recommendation 3: The CHSCP should seek reassurance from safeguardingpartners and relevant agencies that their recording systems are sufficient toidentify repeating patterns of children not being brought to appointments.Recommendation 4:The CHSCP should review and update its guidance onneglect and the local threshold tool to ensure this sufficiently describes the risksassociated with children not being brought to appointments.5.15Finding 2:Effective and child focused safeguarding practice with disabledchildren ensures they are seen, heard and helped.5.16The participation of children in decision making about their own welfare and in theservices that they receive is a legal requirement. All children can communicatepreferences if they are asked in the right way by people who understand their23needs and have the skills to listen to them. It is never acceptable to say or writethat a disabled child is ‘unable to communicate their views’.A disabled child’spreferred communication method for understanding and expressing themselvesneeds to be given the utmost priority. Where a child has speech, language andcommunication needs, adequate arrangements must be made to ensure that theirviews and feelings can be obtained.5.17Whilst Child B was seen on many occasions, there was limited evidence that hisvoice was consistently heard or that he was directly engaged by involvedprofessionals. Some professionals, particularly school staff, were however, able toeffectively engage and communicate with Child B.5.18They understood Child B’s limited communication and actively sought to help ChildB understand issues in ways that they could – such as why it was important towear the splints and shoes (which Child B did not want to do).The SCR foundthat the school proactively accessed the advice of Speech and LanguageTherapists to support communication with Child B and to suggest ways to talkabout complex ideas. Other services did not. Indeed, across services as a whole,there was little evidence of a similar focus. Child B’s voice in the clinical notes wasnotably sparse.5.19Barriers to communicating with disabled children were identified by the NSPCC intheir 2016 report on learning from case reviews involving deaf and disabledchildren9. These included:●Disability was sometimes linked to impaired speech or comprehension,making it hard for children to express themselves.●Parents were sometimes relied on to interpret what their children weresaying, preventing children from confidentially disclosing concerns.●Sometimes children's disruptive or distressed behaviour was interpreted asa result of their disability without consideration of potential safeguardingconcerns.9 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children24●In some cases letters or written agreements were used with young peopleto arrange access to services or manage their risky behaviour despite themhaving limited or no ability to read.5.20Potential solutions were also suggested by the NSPCC:●Professionals should make sure the child's voice is heard. Where there aresafeguarding concerns children should be spoken to alone and parentsshould not be used as interpreters.●In cases where a child's disability precludes or limits verbal communicationefforts should be made to facilitate communication by other means.●Practitioners should also consider how a child may communicate throughtheir actions. Distressed or disruptive behaviour should not automatically beattributed to the disability.●Educational personal safety resources should be tailored to the child'sneeds. Advice should not be considered to have successfully been givenunless there is evidence that the child or young person has understoodwhat they have been told and is able to apply this.Recommendation 5:The CHSCP should ensure its guidance (and anyrelevant single agency guidance) for safeguarding children with disabilities issufficient in terms of setting out the importance of communication and hearingthe voice of the child and how this can be effectively achieved.5.21Finding 3:The focus on engaging parents and carers to support disabledchildren is key, but this should not dilute professional challenge whenneeded.5.22In the practitioner workshop, there was agreement that parental involvement wasessential in all services and that for disabled children (with communicationdifficulties) it is especially important. However, practitioners also stated that therewas no real clarity or guidance within the system about when ‘non-engagementbecomes a red flag’.255.23This lack of clarity could have been a reason why the identification of potentialneglect to Child B took so long to action. It is also likely to have been influencedby how professionals have historically approached working with disabled children.Indeed, lessons from previous SCRs10 have shown that parents can often be seento be ‘doing the best they can’. Because of this, the threshold for a ‘red flag’becomes higher.Professionals are unwilling to challenge or appear critical ofparents who are looking after children in what are undoubtedly challengingcircumstances.5.24One practitioner at the workshop asked, “are our expectations too low?”.Manyhad tried hard to work with Child B’s mother, but were clearly frustrated by thedifficulties in communicating with her. The attempts at ‘authoritative practice’ onlyappear to have involved repeated warnings about the seriousness of Child Bmissinghisappointmentsandthepossibilityofinitiatingchild protectionprocedures.There was no impact from this approach, no ‘difficult conversations’with the parents, challenge wasn’t sustained and the same pattern of Child Bmissing appointments was allowed to continue without robust action.Recommendation 6:The CHSCP to review related guidance and its trainingto ensure the issues on non-engagement, professional challenge and difficultconversations are sufficiently focused on working with disabled children.5.25Finding 4: Multi-agency working, information sharing and understanding theresponsibilities of others can be complex.Clear systems and processescan support effective child focussed safeguarding practice5.26It is clear that no agency involved with Child B had a clear overview of the familyhistory, its dynamics or a complete picture of Child B’s needs. Even professionalswho knew Child B well were learning new information as part of a practitionerworkshop convened for this SCR. A strong view expressed by them was that thelack of this complete picture can often arise in the system supporting children withcomplex health needs and disabilities when so many different agencies areinvolved. This is a known feature and a challenge for both professionals andparents alike.10 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children265.27Indeed, not only can families be overwhelmed by the number of professionalsworking with them, but professionals can be confused too.In Child B’s case,different information was being shared with different professionals at differenttimes.There was no system to properly coordinate this and engagement wasad-hoc and un-structured.5.28A core systems issue identified by professionals was seen as there being nodefined, ‘central place’ for all the involved professionals to share relevantinformation about Child B, especially as the family was accessing services acrosslocalities (and from different hospitals). There was also a lack of clarity about whomight be a ‘lead professional’. Due to these issues, there was too much reliancebeing placed on the family to be the main source of sharing important information.This hindered the oversight on what was actually happening in the family.Forexample, it was only through the collation of the multi-agency chronology for thisSCR that professionals came to learn just how many occasions Child B ‘was notbrought’ to appointments.The inability of the network to see the bigger picturemasked the growing neglect for Child B.5.29Despite the view that the system lacked a ‘central place’ to collate information,therewereseveral meetings where Child B was being considered in amulti-disciplinary way.There were opportunities at these forums to gain a betterunderstanding of Child B’s lived experience, but based on the respective focus ofthese meetings, none did so in any systematic way.●The termly All About Me meetings at the school reviewed progress and notedChild B’s needs and concerns, agreed actions and followed these up with theparents.●The EHC Plan Annual Review was also held at the school. Relevantprofessionals were not always invited to these meetings (or did not attend)which impacted on information sharing and gaining a complete picture of ChildB and the extent of the building concerns.●The Multi-Agency Referral Meeting (MARS) brought services together forchildren with disabilities and could be used for advice and multi-disciplinarythinking about a child and their needs.27●The Care Package Panel reviewed the provision of support.5.30In respect of a lead professional role, whilst this would ordinarily be a communityor local hospital-based paediatrician, practitioners at the workshop reported thatthere was no clarity about who could or would be a lead professional toco-ordinate the network.5.31There was also an assumption by health agencies that if a DCS social worker wasinvolved, that the lead responsibility lay with them for any safeguarding concernsand agreed actions from meetings. However, there was a lack of understanding ofthe different social work role in the DCS at the time.The team did not holdsafeguarding responsibility or for families receiving respite services or directpayments, they was not always an allocated social worker.5.32Since this time, a number of changes have been implemented in the DCS.Following an expansion of the scope of the work undertaken in the team, socialworkers are now undertaking more Child and Family Assessments whensafeguarding issues arise where children are known to them. This minimisestransitions for disabled children and their families and provides a more consistentapproach. However, the challenge of consistently identifying a lead professional isunderstood to remain. A key systems issue identified by the SCR is that agenciesoften did not allow staff the time for their staff to be lead professionals and take onthe additional tasks this role involves, especially co-ordinating information sharing.A manager at the workshop noted there was no formal local sign-up acrossservices to the lead professional roles in Early Help Services5.33Two recommendations arose from the SCR workshop about this issue.Thesehave been included for consideration as part of a review into Early Help servicesthat is ongoing.Recommendation 7: The review of early help services in Hackney shouldconsider how the identification of lead professionals for cases being ‘steppeddown’ from social work intervention can be improved.28Recommendation 8:The review of early help services should consider theuse and involvement of professionals in developing EHC plans and the EHCPlan Annual Review.This should include addressing aspects such as thenaming of a lead professional, the sufficiency of information sharing in respectof social care needs and the oversight of whether children are being taken toappointments.5.34Finding 5: The need for professionals to think family and think fathers.5.35It was accepted that there was no clear picture of the dynamics of Child B’s family.Many in the network were not aware when one of the parents was away, unwell orin hospital; nor when another young child was temporarily in the house. This was afamily with two disabled children and their siblings. In retrospect there wasrecognition of the need to Think Family11 and professionals should have beenthinking (and acting) beyond the individual they were working with. For example,this was seen in the failure to consider Child B’s siblings for a young carersassessment when they were reported as helping with Child B’s physiotherapy andthe known concerns about the parents’ health needs.5.36It was also seen in the lack of focus on Child B’s father. The SCR recognised anover-reliance on contact with mother and not enough questioning of the dynamicsof the relationship with Child B’s father and what his role was in supporting hischild’s care.Recommendation 9:The CHSCP should promote guidance on ThinkingFamily and Focusing on Fathers as part of multi-agency practice.11 Think child, think parent, think family: a guide to parental mental health and child welfare; Social Care Institute for Excellence, 201129 |
NC52766 | Covers an 18-month period of a parent suffering complex and enduring mental health problems including intrusive thoughts about harming their own children. Learning themes include: mitigating the risks of harm to children where parents have mental health difficulties; the impact of the parent's mental health difficulties on the children; ensuring that children with disabilities and differing communication styles are supported and heard; young carers and help-seeking behaviour; and stability in practical living arrangements and attachment relationships. Recommendations for the local children's safeguarding partnership include: update the guidance 'Children at Risk where a Parent has a Mental Health Problem: Inter Agency Safeguarding and Child Protection Procedure' to include the needs of children specifically and what help and support they might need, including children with disabilities and the requirement for a young carers assessment and factors to consider; update practice expectations to take account of the needs for children with disabilities, making clear that children with disabilities will have many professionals and family members who are experts on a child's preferred communication style; make clear the circumstances in which child and family assessments will be shared with agencies who will be supporting children who are subject to Child in Need plans; update the guidance regarding Child in Need meetings to consider timetabling requirements so that all those agencies working with a family can attend and make clear that the decision to end a Child in Need plan should not be made without a clear step-down process.
| Title: A local child safeguarding practice review: ‘The Siblings’. LSCB: Bradford Safeguarding Children’s Partnership Author: Jane Wiffin Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 A Local Child safeguarding Practice Review ‘The siblings’ Jane Wiffin Lead Reviewer 2 Introduction 1.1 This Local Child Safeguarding Practice Review (LCSPR1) was commissioned by Bradford Safeguarding Children’s Partnership to consider the professional response to the safeguarding and support needs of school age children whose parent have complex and enduring mental health problems including intrusive thoughts about harming their own children and people in the community. The family at the heart of this review are white/British, and one of the children is neuro diverse and communicates non-verbally. No further details are provided about the circumstances leading to the review or the family, including relationships, ages, gender, and dates for reasons of anonymity and privacy. Process of the Review 1.2 This review has been led by Jane Wiffin, an independent person with no practice links to Bradford. The methodology used was the significant incident learning process (SILP). This process is consistent with the requirements laid out with Working Together 2018i for the conduct of an LCSPR. 1.3 The review process was overseen by a panel of senior managers/safeguarding professionals representing all the agencies who had contact with the siblings and the family. They have acted as critical friend to the independent reviewer, and helped with local knowledge, analysis of data and considering key lines of enquiry which form the questions at the end of this report. The independent reviewer would like to thank them for their hard work, reflections and responses to the many questions asked in seeking to understand the sibling’s world. 1.4 Individual agency reports were commissioned, which provided an analysis of the services provided to the siblings and their family and within these there are single agency recommendations. 1.5 The frontline professionals who worked with the siblings were brought together as a group to reflect on the emerging learning and to review the draft report. It is not always easy to review your own practice response to a family, but professionals have done this with openness, intelligence and most of all as a commitment to wanting the best for the siblings and other children in their circumstances. The independent reviewer would like to thank them for their time and help. Family Involvement The extended family 1 A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR)) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_t o_safeguard_children_inter_agency_guidance.pdf 3 1.6 The independent reviewer met with members of the extended family. They wanted professional to know that supporting parents with severe and enduring mental health needs is difficult and they had found the period being considered by this review as stressful. They felt that they were not provided with enough information to understand the parent’s mental health needs or what the risks were. The sibling 1.7 One of the children in this family (the children will be referred to as ‘siblings’ through the report) met with the independent reviewer at school. This child wanted professionals to know that she loves her family and they have been the main source of support. The child also said that school had been a great help, and continues to be so. Overall, the child said ‘It would have made a difference if help had been there right from the start, and then when everything was chaotic and uncertain there had been someone to explain what was happening, provide support and listen. I now have the best Social Worker and that was not the case before. They changed, they did not visit and did not listen to me’. Professionals need to know that you can love your parent, but still feel scared and worried about what is happening. You need someone to say that to’. It was like a weight on my shoulders. 4 2. Professional Involvement: The Review covers an eighteen-month period2. Early Help and mental health support: a six-month period 2.1 At the beginning of the review period the parent sought advice from their GP about worries regarding their mental health and the impact this was having on looking after the children, one of whom had taken on a young carer’s role. The GP submitted a referral to adult mental health who responded immediately; The GP sought permission from the parent to liaise with schools and the extended family; contact was also made with Early Help. 2.2 A month later the parent was admitted to a mental health hospital due to having unwanted and intrusive thoughts about harming adults and own children. The children were being looked after by the extended family. The staff at the mental health unit liaised appropriately with agencies, sought safeguarding advice and it was agreed an ‘Early Help3’ referral would be made to support the family. There should have been consideration by the mental health team and Early Help of a referral to Bradford Children’s Social Care (BCSC) because of the possible risk which was unknown. 2.3 An Early Help assessment was completed, and an Early Help practitioner started work to support the family. A Community Mental Health (CMHT) Care Coordinator and a Support Worker were allocated for the parent and a Psychiatrist was overseeing the care and management of their mental health needs; the GP was prescribing medication. Over the time of this review the parent saw mental health professionals regularly. School supported the children through this stressful and uncertain time. During the Early Help assessment4, the children returned to live with their parent. The schools were unaware of the Early Help involvement. It is not clear why this was the case but meant that the school only knew about what was happening and where the children were living when the sibling spoke to them about it. The sibling reported to the lead reviewer this caused more worry, because it seemed to suggest that there was nothing happening to help the parent. 2.4 Four months into the Early Help plan the parent’s mental health started to deteriorate again, with ongoing intrusive thoughts of harming their own children. The extended family provided a great deal of support. In the next month there were further concerns about intrusive thoughts and the children moved back to 2 No dates are provided to ensure anonymity to the children and family. 3 Early Help, also known as early intervention, is support given to a family when a problem first emerges. It can be provided at any stage in a child or young person's life. 4 An Early Help Assessment is an initial assessment and planning tool that facilitates and coordinates multi-agency support. It assesses the situation of the child or young person and their family and helps to identify the needs of both the children and the adults in the family. 5 live with the extended family. There was a difference of opinion between the Care Coordinator who was concerned about ongoing risks for the children and Early Help practitioner who thought that there was no need for ongoing support. This was resolved through appropriate challenge by the care coordinator; this was good child focused practice. The parent was then admitted into hospital and a referral was made to Bradford Children’s Social Care (BCSC). Child in Need support: a seven-month period. 2.5 BCSC reviewed the referral and agreed to undertake a Child and family assessment (known in Bradford as a ‘single assessment5). Given the level of concern, and the uncertainty about the risks that the parent posed to the children a Strategy Meeting6 would have been appropriate and a discussion about the need for a child protection enquiry. This is discussed in the next section of the report focussed on lessons learned. 2.6 The assessment was completed over a sixteen-week period; longer than the expected timescales outlined in guidance. This was reflective of the pressures within BCSC which have clearly been outlined with the Star Hobson national review (see that publication for detailsii). During this time the children continued to live with their extended family. The parent was admitted to hospital on four occasions because of increasing concerns about their deteriorating mental health. 2.7 There was good liaison between the Social Worker undertaking the Child and family assessment and the Care Coordinator/mental health team, but the schools the children attended were not informed about what was happening. This lack of clarity impacted because the extended family were seeking advice from school about current plans which they seemed unclear about, and the schools were also supporting the children through what was an unpredictable and worrying time. 2.8 During the period the Child and family assessment was being completed the children lived with the extended family; the parent experienced increased anxiety and intrusive thoughts about harming others which they were open about with the professionals they saw. There was a lack of clarity about family time arrangements (previously called contact arrangements7 iii), how much time the children could spend with the parent, and a lack of clarity about where the children should be living safely; there were indications that the 5 A key aim of the Single Assessment is to set out clearly the assessment plan and will: Aid relationship building with children and their families. Consider the balance between managing and reducing risks and promoting resilience • Assist in explaining to children and families why social workers are involved in their lives. 6 Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, a strategy meeting/discussion should be held. They should involve all key professionals known to, or involved with, the child and family. Local authority children’s social care, health and the police should always attend. 7 Good quality contact can benefit children by helping them to: return home where this is in the interests of their welfare; manage issues of loss and separation; maintain family relationships; and make sense of the past. 6 children were sometimes living back with their parent. This lack of clarity about exactly what were the agreed safe arrangements for the children to see the parent continued across the timeline of this review and this is discussed in the next section on lessons learned. 2.9 During the assessment process information was shared by the parent about historic family tensions. These were not included, explored, or analysed in the completed Child and family assessment which focussed on the supportive nature of the family. This support was very real, but there should have a been a more balanced approach with a focus on the strengths and difficulties in family relationships. This was central to the effective working of the subsequent safety plan. This plan required the extended family to make ongoing decisions about safe Family Time and living arrangements for the children, based on the extended family’s understanding of the parent mental health needs and the risks this posed. What made this more complex was that the parent wanted the children to return home and the extended family hoped this would happen. Being asked to make decisions about when children can see their parents, for how long and when put the extended family in a difficult situation, which may have played into past tensions and power dynamics; this is not known because this was not explored. There are glimpses that this was the case here. It is important to say the extended family always put the safety and wellbeing of the children first, they just felt the pressures of restricting family life as they saw it. This is discussed in the next section of the report. 2.10 The Child and Family assessment concluded that the family needed support through a Child in Need89 plan. It was agreed that the children would remain living with their extended family, and they would facilitate the children’s family time with the parent. 2.11 The Child in Need plan focused on support for the extended family to meet practical childcare needs, developing a safety plan regarding family time, support for the children to make sense of the parent mental health difficulties and to talk about their worries; something they said they needed. The children were being supported in school, but there was agreement specialist help was required. This specialist support was often discussed but was never put in place and this is addressed in the in the next section on lessons learned. 2.12 The first Child in Need (CIN) meeting10 took place soon after the Child and family assessment was completed. It was attended by most of the professionals 8 why-do-i-have-a-child-in-need-plan.pdf (proceduresonline.com) 9 The Child in Need Plan must identify the lead professional, any resources or services that will be needed to achieve the planned outcomes within the agreed timescales and who is responsible for which action and the time-scale involved. 10 Child in Need Planning Meetings will follow an assessment where the assessment has concluded that a package of family support is required to meet the child's needs under Section 17 of the Children Act 1989. The 7 involved with the family, and both the parent and members of the extended family. Practical support to manage childcare arrangements remained an ongoing task as did the need to provide individual support to the children; good support was being provided at school. One of the children had told the Social Worker that they wanted help to understand the parent mental health difficulties, but this never happened. This is discussed further in the analysis section. 2.13 In the next four weeks the parent’s mental health fluctuated, with them having worries about their continued intrusive thoughts about harming people in the community and worries about acting on these thoughts. The parent sought appropriate help, which was provided, and the care plan continued. 2.14 The next Child in Needmeeting took place four weeks later. It was attended by appropriate professionals and the parent but not the extended family; the reason for their absence was not recorded, which was surprising given they were caring for the children. It was acknowledged that the parents’ mental health had fluctuated since the last meeting, and concerns remained about their contact with the children. The Care Coordinator said that there were family tensions connected to the organisation and management of family time and it was agreed that a clear plan needed to be put into place. This never happened. The Social Worker reported that the children’s paediatrician had queried the issue of parental responsibility when the parent was unwell and who would be able to consent to any treatment for the children; this was an important issue to raise. It was agreed that this needed to be addressed, though the extended family were reluctant because they hoped the children would return home to their parent soon. It was agreed that this required further discussion, which never happened. Individual support for the children had not been progressed, though a referral to Young Carers support had been completed. The Social Worker said there would be a transfer to a new team and a new Social Worker. The outstanding tasks were to be addressed by the new Social Worker. 2.15 The parent was then admitted to a mental health unit/hospital with an initial plan of a four week stay, which would then be reviewed. They discharged themselves after a short stay and due to continued deterioration in their mental health they had an urgent review with their psychiatrist. Increased support was provided through the Intensive Home Treatment team11. The Care Coordinator visited the next day and discussed long-term plans, including the possibility of a move to residential accommodation for enhanced support. Planning Meeting provides an opportunity for a child and his or her parents/carers, together with key agencies, to identify and agree the package of services required and to develop the Child in Need Plan. 11 Home treatment teams aim to assess all patients being considered for acute hospital admission, to offer intensive home treatment rather than hospital admission, and to facilitate early discharge from hospital. 8 2.16 A day later the police were called due to concerns about the parents behaviour and threats being made by them. Two days later there was an incident where the parent went to the extended family home where the children were living; they remained outside, but their behaviour was of concern and the police were called. The parent left with the support of an extended family member. This was clearly a worrying time for the children and the whole family. One of the children spoke to their school about their worries for their parent, uncertainty about the future and that there was to be a new allocated Social Worker who they had not met, and how difficult it was to start again with a new person. The child reported feeling let down. The school shared their concerns about the children with the Care Coordinator, particularly regarding family time which they believed should be supervised by a professional; this was shared with the Social Worker. The Care Coordinator recognised the severe and enduring nature of the parent’s mental health needs, but the Child in Need plan did not reflect this knowledge, and over time there was a sense that through support and treatment the parent ‘would get better’ and would resume care of the children. There was a mismatch here between the actual mental health needs of the parent, the desire of the extended family for what they saw as ‘normal family life to resume’ for the children and the immediacy of the Child in Need plan. It was focussed on the here and now, not the future. 2.17 The extended family expressed concern to the new Social Worker about the parent’s deteriorating mental health and asked what support could be offered. The new Social Worker asked the extended family member about formalising the living arrangements of the children, but they remained reluctant to do so because they wanted the children to return home when it was safe for them to do so. 2.18 The next Child in Need meeting was held remotely12 and professionals, the parent and extended family joined the call. The parents’ ongoing struggle with their mental health, intrusive thoughts and erratic behaviour were discussed. The Care Coordinator was undertaking a Care Act assessment13 ivto see what further support could be put in place for the parent; her belief was that intensive support was necessary. The children were said to be doing well at school, but one of the children had again expressed feeling upset, worried and sad about what was happening. She had told school again that she did not feel supported by the Social Worker, was angry there had been a change and was feeling let 12 Caused by COVID public health requirements. 13 An assessment under the Care Act 2014 is an assessment of needs for care and support or an assessment of a carer’s needs for support. The nature of the assessment will vary depending on the person and their circumstances. The assessment process should be appropriate and proportionate to the individual and their needs. 9 down and this was shared in the meeting. It is unclear why no action was taken to address this clear signalling by a child that they needed help. The agreed individual work was not in place, and the child with additional communication needs had not been seen to understand how they were feeling. The extended family had stopped family time because of recent worrying events. They said they would like to think about exploring formalising the children living with them; this did not happen and there was no plan to address safe family time going forward. There remained several incomplete actions from the Child in Need plan and the responsibility for organising family arrangements remained with the extended family with no focus on the future. 2.19 A week after the Child in Need meeting the Care Coordinator and Social Worker met with the parent and the extended family. The parent said that their anxiety remained difficult to manage, that they were missing the children and wanted more family time including overnight stays. The extended family said that the parent was not always appropriately behaved during family time which left the children feeling scared and uncertain; they also said they were still unsure about when and how family time should take place, and this remained a strain on family relationships. The parent was accessing support, and the pattern of ringing the Care Coordinator and support worker multiple times a day had reduced; however, this behaviour had now transferred to some members of the extended family and was causing stress. The plan continued to be consideration of some form of supported residential accommodation. The children were to remain living with the extended family until the children’s services Child and family assesment had been completed and the parent’s mental health had improved; it is not clear who would be making that decision. The timescales for this and what ’improvement’ would look like were not made clear. The parent and extended family still wanted the children to return home and so said they did not want to pursue any legal order. This left the children in a continued situation of uncertainty about their future. This lack of permanency for the children should have been a concern for the Social Worker and addressed as part of the plan. 2.20 The final Child in Need plan took place remotely. The school and the Care Coordinator had already said they could not attend on that date and the Special Needs School Nurse tried to join but was not admitted into the meeting. This meant that this was in essence a discussion between the parent, the extended family, and the Social Worker, not a Child in Need meeting. The Social Worker told the family that there was no outstanding role for Bradford Children’s Social Care, no ongoing safeguarding risks and therefore the Child in Need plan would end. The mental health team would continue to provide support to the parent, discuss the family time arrangements and consider when it might be safe for the children to return home. This was not an appropriate role for them, and this 10 is discussed in the next section. The extended family were to manage day to day family time arrangements, making decisions about risk and safety. 2.21 The Care Coordinator had asked prior to the meeting that a contingency plan be formulated, if the social work team decided to end the Child in Need plan, which would outline what to do if there was an escalation of concern. This did not happen and there does not appear to have been any final discussion between the Care Coordinator and the Social Worker to confirm what had been agreed. This is addressed in the lessons learned section of the report. 2.22 Over the next eight weeks there was a great deal of instability with the parent attending A&E eleven times with thoughts of harming others and themselves. The parent made many calls to the police with thoughts of harming others. There were times when an ambulance was also called. The mental health team continued to provide support and follow up after each crisis. The parent was reminded of the strategies to address these unwanted thoughts. Although there were times that the parent seemed to be struggling not to act on these intrusive thoughts, they managed to access help. There were two multi-disciplinary meetings during this time, the parent’s care plan and medication were reviewed. The Care Coordinator met regularly with the parent as did the mental health support worker. There was support provided by this team to the extended family who were struggling with the chaos and uncertainty. There appears to have been no discussion about the needs and circumstances of the children at this time. The extended family were managing family time, but this was a period of instability and chaos which was extremely worrying for the children. There should have been a re-referral to BCSC. 2.23 There was then a period eight weeks without any mental health crises. The parent was becoming involved in the daily lives of the children, attending school parent evenings and having unsupervised family time. The Care Coordinator visited the parent at home, and they reported one of the children was staying with them overnight. At the end of the eight weeks there was an incident of concern which led to the parent being detained in a mental health hospital. The details are not provided for reasons of privacy. The children remain living with the extended family with a permanent legal order in place. 11 3. Analysis and Findings of the Review 3.3 The purpose of a local child safeguarding practice review (LSCPR) is to consider the professional response to children and their family arising out of a critical incident and consider whether this suggests that there are improvements that need to be made locally and nationally to safeguard, promote the welfare of children more generally and to seek to prevent or reduce the risk of the recurrence of similar incidentsv. There are several themes or findings that that emerge from a review of these children and their families’ circumstances which have implications for future practice. QI: Was there a sufficient understanding of the risk of harm posed by a parent with mental health problems characterised by intrusive thoughts to harm THEIR children and were appropriate safety plans put in place? 3.4 Although there was recognition over time of the parents need for support, there was not always consistent understanding or analysis of the risks and no clear articulation of what those risks were. At the beginning of the review period the parent sought help from their GP with worries about their mental health including feeling unable cope with family life and worries about not meeting the needs of the children and ensure? that the oldest child did not have to take on young caring responsibilities; there was no evidence of risk of harm to the children at this point. An appropriate referral was made to the Community Mental Health team (CMHT) and there was a quick response from them. With consent from the parent, the GP contacted the children’s schools to make them aware of concerns. This was a very helpful response. 3.5 A month later the parent’s mental health started to deteriorate, with intrusive thoughts of harming the children and other people in the community. The parent was admitted to hospital and a referral to Early Help agreed. Appropriate safeguarding advice had been sought by hospital staff but given the level of concern and indications of likely risk of harm to the children, a referral to BCSC would have been the more appropriate option. The response here was about need and there was insufficient recognition of risk and therefore no safety plan was put in place. 3.6 The Early Help plan was focussed on support and not risk. Four months into the Early Help plan there was a deterioration in the parent’s mental health with increased thoughts to harm the children and others. An informal plan was agreed whereby the children moved to live with the extended family and the CMHT were informed by Early Help that it was not safe for the children to live with the parent; however, they returned to the parent’s care soon afterwards. It is unclear why this view of the risk had changed. It was proposed that the extended family would monitor the situation. There was a lack of a clear safety 12 plan which would have enabled everyone to understand what was agreed and what was not. 3.7 A pattern developed from this point onwards, whereby the risk to the children was perceived to fluctuate depending on the parent’s own self-reported view of their mental health, how well they were managing their anxiety, and using techniques provided to manage intrusive thoughts. This meant that the perception was that the risk went up and down, and the children could live with the parent at times when the risk was perceived to be low. The risk to the children remained, and there was a lack of reflection on the cumulative impact of the instability and uncertainty on the children’s wellbeing. The sibling reported it flet like living in ‘chaos’ all the time. 3.8 The Early Help practitioner proposed that there was no further need for an Early Help plan or any ongoing risk and asked the school to become the lead professional. They refused, suggesting the risks remained the same and support was still needed. Early Help support continued to be involved. 3.9 The pattern of perception of fluctuating risk continued. After a week after the Early Help practitioner had considered ending their involvement, the parent anxieties increased, and thoughts of harming the children became more intense. The parent was insistent that there was no intention to act on these thoughts; the children moved back to live with the extended family. There was a difference of opinion about next steps between the Early Help practitioner who still wanted to cease involvement because they had not recognised the continuing likely risk, and the Care Coordinator who felt that more support was needed. At this time the parent’s mental health deteriorated further, the parent was admitted to hospital and a referral was appropriately made to Bradford’s Children Multi-Agency Safeguarding hub (MASH)14. 3.10 This referral was screened, and a decision that Bradford Children’s Social Care (BCSC) would undertake a child and family assessment. Given the known risks and the uncertainty of the likelihood of significant harm there should have been a Strategy Discussion and Child Protection enquiries undertaken to evaluate that risk; this would have been in line with the West Yorkshire guidance ‘Children at Risk where a Parent has a Mental Health Problem15’. The reasons why a Strategy Discussion was not considered are not known; the risk of likely significant harm was clear. One possible explanation is that the parent and extended family had always sought help and had engaged well with services. 14 The purpose of a MASH is to bring together different agencies to enable fast information sharing with the purpose of making an efficient and fast decision to safeguard vulnerable children. The MASH setting allows professionals to efficiently and quickly gather and process information in order to assess risk. 15 1.4.10 Children at Risk where a Parent has a Mental Health Problem (proceduresonline.com) 13 This should not make any difference. The child protection process, which is not one intended to blame or stigmatise families, is there to help manage known and unknown risks in a multi-agency forum for the best interests of children. The lack of a Child Protection response also meant that the seriousness of the circumstances was not always made clear to the family. 3.11 It is good practice that at this time the Care Coordinator became aware that the parent was placed in a private hospital out of the local area. Contact was made with them; information was shared about the involvement of BCSC and the ongoing Child and Family assessment. 3.12 The Child and family assessment took place over a sixteen-week period. During this time the children had once again returned to live with the parent and there was no safety plan developed or put in place. The parent was left to self-disclose thoughts of harming the children and others, and the extended family were asked by the Social Worker to respond where necessary. This lack of social work oversight of the known risks was not appropriate and there was a lack of reflection on what this might mean for the children’s wellbeing or sense of stability. During this time there were regular home visits by the Social Worker and the Care Coordinator; the parent’s mental health continued to fluctuate and eight weeks into the assessment process the parent reported thoughts of harming the children to mental health services. This was communicated to the extended family and the Social Worker. Contact was made with the extended family and the children moved again to live with them. 3.13 The Child and family assessment outlined the known risks, and the unpredictable nature of the parent mental health. A safety plan was recorded within the assessment. It provided a confused picture. Initially it is made clear that the children would live with the extended family, that all family time would be supervised, and the police were to be called if there were any concerns. Later in the Child and Family assessment there was a second safety plan included. This may represent thinking at the start of the assessment and at the end (a long period). This safety plan suggested that the parent should contact the extended family and Care Coordinator if they felt unwell. If the parents had care of the children, the extended family were to collect them and inform all agencies. This suggests there was no longer a need for supervised family time. A confusing message. The extended family were critical to this safety plan, yet the Child and Family assessment alludes to tensions from the past without exploring these further and considering the impact on their ability to manage this plan. 3.14 The Child and Family assessment suggested that a lack of diagnosis from mental health services was causing the parent increased anxiety and making it more difficult for the children to return home. This was a critical issue which was 14 not shared with the mental health team, who were unable to respond. It is of note that the Child and Family assessment was not shared with any agency providing a service to the family, so they were unaware of the overall analysis. It is not clear if it was shared with the extended family or the parent and what their views were regarding the conclusions. This sharing of both the Child and Family assessment and the analysis is critical to effective practice to support children and their families. 3.15 At this stage there was no reference to whether there needed to be a safety plan in place for both schools. They were aware of the concerns, but there was no articulation of what they should do if the parent came to school, asking to take the children home. It is not clear if this was allowed or not. The Child and Family assessment and subsequent Child in Need plan and process did not include any discussion of the risk that the parent might pose to school staff, pupils and their families. This should have been part of the safety plan. 3.16 The broad safety plan was decided by the Social Worker and recorded in the Child and Family assessment. This safety plan should have been developed in partnership with the multi-agency group working with the children and family, including the Care Coordinator, the school, and the Special Needs School Nurse. This would have enabled the expertise of these professionals to help shape a plan that took account of the parent’s mental health needs and the children’s known needs including one child’s disabilities. 3.17 The Child in Need plan was in place for four-months, with monthly Child in Need meetings. The safety plan remained the same, despite there being evidence that it was not working effectively. The extended family shared concerns that there were family tensions caused by managing family time and the parent’s behaviour, turning up at the house and not always being appropriate within family time sessions. The Child in Need plan never tackled these tensions, and although there is no evidence that the children were ever left in an unsafe situation (thanks in large part to the extended family) there was a lack of robustness. The extended family were gradually asked to assess risk and organise safe family time arrangements without reflection if this was fair, reasonable, or possible. There is no evidence that this responsibility was fully discussed with them. 3.18 The Child in Need plan ended after four months because BCSC decided there was no role for them, no unmet need and no ongoing risk to the children; this was incorrect. There had not been a change in the level of risk; during the whole of the period of the Child in Need plan there remained fluctuating concerns about the parents’ intrusive thoughts to harm the children or other adults and incidents where the behaviour of the parent caused concern that they might act 15 on those thoughts. This had not happened, but the concerns about acting on those thoughts remained as an unknown. 3.19 The rationale for this decision appears to be a belief that these were manageable risks; the extended family were providing good quality care to the children, they were supervising family time and were tasked with making a future decision about when it was safe for the children to return to the care of the parent. Although the extended family were providing good quality care to the children, they reported that there were family tensions. They often said they did not understand the parent’s mental health and what they needed to do to support them and keep the children safe, making it hard to see how equipped they were to make decision about when the children should return home. They were also concerned about the parent being inappropriate in family time causing the children distress and this had not been addressed. 3.20 The future planning for the parent remained uncertain at this time. The mental health team were at a point of formulating a mental health diagnosis and establishing a care and treatment plan. There was still some discussion about the need for the parent to be in residential care with significant support. This was incompatible with the children returning to the parent care. The extended family did not understand this; they hoped and believed that the parent’s mental health would be so improved that the children would return home. The oldest child wanted to go home. The risk could not be managed without clarity about what the plans were. The North Yorkshire guidance16 around working in the context of parental mental ill health makes clear the importance of contingency planning including a consideration of the future management of a change in circumstances for a parent/carer and the child and how concerns will be identified and communicated. This should include what to do when there is a relapse in the parent/carer's mental health, a failure to maintain medication or a change in family dynamics/relationships. 3.21 When the Child in Need plan came to an end, there was no contingency plan developed, despite the Care Coordinator asking for this to be in place. The Care Coordinator was not aware that the Social Worker had proposed that they would have some professional oversight of the family time arrangements. This was not a reasonable ask. There should have been a stepdown process agreed by all professionals. This did not happen, and this needed to be challenged. It was not. 3.22 Over the next eight weeks there were many concerns about the parent attending A&E in a state of distress and having intrusive thoughts about harming others, including children. The police were called to the parent’s home 16 1.4.10 Children at Risk where a Parent has a Mental Health Problem (proceduresonline.com) 16 as well as the ambulance service. A safety plan was put in place for the parent by the mental health team and support provided. There were two multi-disciplinary meetings to review the treatment and support plan. These all focussed on the parent as an individual, as opposed to a parent who was in contact with their children. There was no recorded discussion about the children or what the risks might be to them. There was a belief that the children were being safely looked after away from the parent. There were many agencies who could and should have considered either a discussion with their safeguarding lead and a referral back to BCSC. There was a lack of a Think Family approachvi at this time, with a narrow focus on the individual. 3.23 The acute hospital A&E department have a safeguarding checklist, including a question about whether the patient has responsibility for children. If the answer is ‘yes’ the paediatric liaison nurse would access the children’s records and make contact with the Health Visitor or School Nurse as appropriate to ensure concerns were shared and children’s needs considered. This question of responsibility was interpreted as ‘living with’ which the children were not, as opposed to having regular contact with. Recommendations have been made regarding this. 3.24 Overall, there was an inconsistent understanding of the risks that the parent posed to the children, what safety plans needed to be made and an over-reliance on an overstretched and stressed family to be able to manage the risks, despite their constant assertion that they did not fully understand it. Why does it matter? 3.25 It is estimated that one in four of the adult population will experience mental health problems at some point in their life and a third will be parents at the timevii. For most children there is minimal impact of their parent’s illness if the right supports are in place. However, when analysing the factors that lead to serious case reviews/local child safeguarding practice reviews or factors that led to children needing to be removed from their parents’ care, mental health problems are identified in a high proportion of cases. There is good evidence about what mitigates the likelihood of harm to children where parents have mental health difficultiesviii: • Can the parent manage their condition well and/or committed and engaged in treatment likely to aid their recovery. • Does the parent have insight into the difficulties caused to parenting by their mental illness and into the potential impact on the child? • Are they able to identify the child’s needs as distinct from their own? This is an important question because it indicates reflective functioning, the ability to put the child’s needs first. 17 • It is of concern when the child is part of a delusional pattern or intrusive and unwanted thoughts. • The child is not the focus of the parent's aggression. • A supportive parent without a mental health problem • A supportive wider family and friendship network • A lack of family discord and a lack of coexisting factors such as domestic abuse and substance misuse • Doing well in school and being supported to be in school and other pro-social activities. 3.26 Effective risk assessments based on an understanding of the factors that mitigate risk or make risk more likely are critical as is an effective safety plan which includes the parent, child and wider family and which is shared with all appropriate professionals with dynamic and regular updating to include acute episodes of mental health needs. . What can be done about it? Recommendation 1: West Yorkshire has a ‘Children at Risk where a Parent has a Mental Health Problem17: Inter Agency Safeguarding and Child Protection Procedure’: those working with this family were unaware of this guidance. This needs to be made more clearly Bradford specific and the content refined considering the findings of this review. Q2: Was the impact of the parent mental health difficulties on the children understood and addressed through appropriate support? 3.27 At the start of the review period the GP recognised that the parent needed support with mental health needs, made a referral to mental health services, liaised with school and extended family and Early Help; there was a clear focus on the needs of the children. Early Help became involved a few months later. The plan they developed included individual support for the children to help them understand their parent’s mental illness and to consider the need for a referral to young carers for the oldest child. Individual work was completed with the oldest child on four occasions (two face to face and two over conference call) over a sixteen-week period. The referral to young carer does not seem to have been made. There was acknowledgement that the child who was neuro-diverse and who communicated in other ways than through language also needed support, but there was no plan to address this. There should have been to consider how best to enable this child to communicate how they were feeling and what support they might need through advice and help from those who knew the child’s communication style well, such as the school and speech and language team. 17 1.4.10 Children at Risk where a Parent has a Mental Health Problem (proceduresonline.com) 18 3.28 Both children were well supported by their schools. School staff were aware of the parent mental health difficulties, and the school for the oldest child provided a counsellor for them. This child reported this as being very helpful. The oldest child often spoke of her worries about her parent and that they wanted more specialist help. The school acted as an advocate for the child by raising these concerns in the Child in Need meetings. The school were concerned that the oldest sibling was often left with the responsibility of telling the school of their parents many mental health crises and that this put the child under a lot of pressure; it would have been helpful if they had raised this with the Social Worker to ensure this was addressed. 3.29 The work of the Early Help team came to an end when the parent was admitted to hospital, and the Child and family assessment was started. The children were seen at home and the oldest child consulted as part of the assessment process. It is unclear how the child who was neuro-diverse was involved as this is not mentioned. There was a tendency across many agencies to consider that different communication styles equalled not being able to communicate. There is no evidence that the assessing Social Worker spoke to either the speech and language team or that they sought information about this child’s communication style from the school. 3.30 The Child in Need plan appropriately highlighted the need for specialist support for the oldest sibling to help make sense of the parent’s mental illness and to address worries and anxieties. There was also a proposal for a referral to young carers; this was delayed and by the time it was discussed with the oldest sibling they said it was not necessary. The planned specialist support was never provided. It remains unclear why. The oldest sibling made clear their concerns that the monthly Child in Need visit from the Social Worker was insufficient to address their worries and that they were unhappy with the change of Social Worker mid-way through the Child in Need process. These concerns were recorded in the minutes, but no action agreed to address them. The oldest sibling must have felt asking them their views was meaningless. The help seeking behaviour of this older sibling was not responded to appropriately. 3.31 There was no plan to ensure that the child who was neurodiverse had a voice or the impact of the parent’s mental illness and of the chaos and instability was understood for the siblings. 3.32 When the Child in Need plan was ended, during a school holiday, there was no step-down plan regarding how the children were to be supported. The oldest sibling had not been helped to understand the parent’s mental illness and the plans for their future were extremely unclear. They had made their desire to return home clear and there was a lack of clarity about what the professional 19 view was of the likelihood or timescale for this. This may have been hard to predict, but it is the lack of transparency and communication with the siblings which is of concern. 3.33 At the end of the Child in Need process, there remained several unmet needs which were not acknowledged. Over the subsequent twelve weeks, characterised by constant crises, the school and the extended family supported both children. 3.34 The impact of parental mental illness was recognised by professionals, but there was a lack of support provided for the family/children. The oldest child asked for help, and this was not provided. There was no plan made to make sense of the world of the child who was neurodiverse or enable communication. Both children were seen but not always heard. Why does it matter? 3.35 Research suggests that around 28% of school age children are living with a parent who has a mental health problemix. Research suggests that for some children there can be a negative impact on their health, development, and emotional wellbeing over time if the specific impact of the parents’ mental illness on the child is not well understood and the right support and help are not provided. Children benefit from age-appropriate information about their parents’ mental health so they can understand it and make sense of it; they also worry that they will develop the same problems and are somehow to blame. Many children experience sadness, anxiety, depression and experience a sense of loss of the relationship with a parent and family life/relationships. Children need an opportunity to talk about those worries. 3.36 Professionals need to think carefully about how to ensure that children with disabilities and differing communication styles are supported and heard. These children often miss out on specialist support through perceived difficulties with communication. Children with disabilities will usually have a network of practitioners who know them well and understand how they are feeling and able to recognise changes in mood and behaviour; they will know a child’s preferred communication style. This will also be true of family members who know children well. All professionals have a responsibility under the Children Act 1989x, the UN Convention on the Rights of the Childxi to ensure that children’s views and needs are known and are central to thinking in the context of child welfare decisions. The Equality Act 2010xii makes clear the need for all public services to make ‘reasonable adjustments’ to ensure that disabled people/children have the same rights and opportunities as their nondisabled peers. This is also enshrined in the Convention on the Rights of Persons with Disabilities (CRPD) section 7 states that ‘children with disabilities have the right to express their views freely on all matters affecting them, their views being 20 given due weight in accordance with their age and maturity, on an equal basis with other children, and to be provided with disability and age-appropriate assistance to realise that right18’. 3.37 Many children also take on additional caring responsibilities; this can be both an additional pressure, impacting on their education, friendships and involvement in everyday child activities. These young caring responsibilities can also be a source of pride, with a sense for the child that they are contributing the wellbeing of the whole family. This will all depend on whether the caring responsibilities are appropriate (no personal care), consistent with age and developmental abilities, they do not interfere too much with day-to-day life and the child feels they are managing and that the caring is making a difference to family life. Many young carers have challenged professional views about their caring responsibility, reminding adults of the need for an individualised response. That is why the local authority is required to carry out an assessment of a young carer’s needs19 and consider what support is necessary. 3.38 It is the central ambition of the child safeguarding and support system that children and young people will ask professionals for help when they have worries. Researchxiii SCRsxiv and the work of the Office for the Children’s Commissionerxv suggest that there are many barriers to children talking to professionals about their worries, concerns, and experiences of abuse. As such more needs to be done to improve children and young people’s help seeking behaviour by professionals. 3.39 Help seeking behaviour is a developmental skill which grows and develops through childhood and into adulthood. For this to happen, help seeking behaviour needs to be nurtured and encouraged through appropriate attachment relationships and warm and supportive parental care. For some children this does not happen; they may be ignored, dismissed or actively prevented from talking to professionals. This leads to children lacking trust in all adults and they are often concerned about the consequences of seeking help. What needs to be done about it? Bradford now has the Mind of My Own App which supports children in contact with Social Workers to be able to communicate about how they are feeling and to raise concerns when they feel they are not being listened to. The Mind of my Own express is aimed at children who have alternative communication needs. These applications were not available when work was being considered with the siblings. It will be 18 Article 7 – Children with disabilities | United Nations Enable 19 “The Young Carers’ (Needs Assessment) Regulations 2015/16 21 important going forward that professionals are made aware of this resource and make use of it. Recommendation 2: In Bradford there is already in place Practice expectations around direct work for children by Social Workers; this does not include the responsibilities regarding children with disabilities and the additional support they might need around communication. It is recommended that this is updated to take account of the needs for children with disabilities. This should make clear that children with disabilities will have many professionals and family members who are experts on a child’s preferred communication style, such as their schools, speech and language therapists and educational psychologists, Special Needs school nurses, to name a few, and these can be a helpful resource. Recommendation 3: The West Yorkshire ‘Children at Risk where a Parent has a Mental Health Problem20: Inter Agency Safeguarding and Child Protection Procedures’ does not talk about the needs of children specifically, the requirement about what help and support they might need, and children with disabilities are not mentioned. This guidance needs to be updated and to include the requirement for a young carers assessment and factors to consider. Q3: Was effective and appropriate support provided to the parent who was mentally unwell and the extended family. 3.40 There was good recognition of the parents’ need for support with their mental ill health. This came initially from the GP and then the Early Help plan. Over time the parent was provided with extensive mental health support which matched the need. Whilst the Child in Need plan was in place there were regular joint visits between the Care Coordinator and Social Worker to think about what help the parent needed. There were two issues that were not fully addressed within the Child in Need plan: • how to help the parent manage their anxiety and mental health needs specifically around the children when having family time. This was an issue raised by the extended family, and addressed within the mental health care plan, but not the Child in Need plan. • An understanding of what was the likely cause of the parents’ mental health problems. There is a growing body of evidence that trauma in childhood and adulthood can be a causal factor for developing mental ill health. A trauma informed approach asks professionals to consider ‘what has happened to an individual’ rather than simply ‘what is wrong’ with an individual’. There were inferences in the Child and family assessment to the complex family relationships and mother’s early life, 20 1.4.10 Children at Risk where a Parent has a Mental Health Problem (proceduresonline.com) 22 but these were not further explored and the possible influences of these factors on the parent’s current mental health were therefore not known. This information was included in the mental health care plan, but not cross referenced to the Child in Need process. 3.41 The extended family were supported by their GP and they were involved in all the Child in Need meetings. Support came through regular meetings with the Social Worker and care coordinator. It is recorded that the family were happy when the Child in Need plan came to an end, though it left them without support in managing family time arrangements and dealing with the many crises. Practical help was provided regarding childcare arrangements and support regarding the needs for the child who was neuro diverse. 3.42 The outstanding issue was helping the extended family understand the parent mental health and how they could support this. They wanted a sense of the future to make plans, and this was not facilitated. The Care Coordinator was not asked to help the extended family understand the complexity of the parent’s needs. 3.43 Overall, the parent was provided with an appropriate package of care and support. The extended family also told the reviewer that they did feel supported, but for them they did not understand the parent needs and how to help in the context of parenting and the children. Why does it matter? 3.44 Parents who experience poor mental health have a right to support as individuals, but also in fulfilling their parenting rolexvi. This is made clear in legislation and guidancexvii. Without the right support children’s lives will be unnecessarily impacted and parenting relationships lost. 3.45 Families who support an adult/parent with mental health needs also need support. One of the mitigating factors for supporting children’s safety, wellbeing and opportunity maintain positive relationships with parents with mental health difficulties is the absence of family discord; support is necessary to help with this. The extended family need the opportunity to understand a parents mental health difficulties, how best to support them and enable them to fulfil their parenting role in whatever way is safe to do so. 3.46 There is a need for all services across adults and children’s services to take a Think Family approach. Something missing from the work with this family. What needs to be done about it? 23 Recommendation 4: The existing West Yorkshire guidance ‘Children at Risk where a Parent has a Mental Health Problem21: Inter Agency Safeguarding and Child Protection Procedure needs to be updated to include support to parents with an enduring and complex mental health need to successfully fulfil their parenting role and needs of the extended family. Q4: Were the living and family time arrangements for the children clearly understood by all? Were they provided with appropriate stability during the time under review and into the future, and were appropriate arrangements in place for effective alternative caregiving? 3.47 In the first ten months of the review period the children moved regularly between their parent home, to different members of the extended family. These moves were governed by the instability in the parent mental health. It must have been unsettling for the children. There is no recorded professional discussion about the appropriateness of these constant moves for two school aged children. The extended family wanted to ensure that the children were with their parent whenever this was possible, largely influenced by the children’s wishes to be at home and their parent wanting to care for them. The family wanted what was best for the children; however, there should have been a clearer professional view about what the impact on the children of this instability was likely to be over time. 3.48 During the Child in Need plan, and as a result of another mental health crisis, the children moved to live with one member of the extended family, with regular planned stays with other family members during school holidays. The extended family brought some stability to the children’s circumstances. 3.49 However, there was further instability caused by the lack of clarity about where the children would be living in the longer term and who would be responsible for them. During the Child in Need process (a period of four months) there were discussions about the parent needing intensive support and this would need to be provided through some form of residential care. At the same time there were still conversations about the children moving back to live with their parent when their mental health was stabilised. These two positions were incompatible, and there needed to be a clearer discussion about what was known about likelihood of the parent mental health stabilising, over what time frame and what this would look like in practice. There was no professional view about how long between crises or what period between intrusive thoughts of harming children or others would indicate change and safety. This responsibility was left to the extended family, without there being a professional view or advice or guidance. 21 1.4.10 Children at Risk where a Parent has a Mental Health Problem (proceduresonline.com) 24 3.50 The third aspect of instability was that there was no formal legal order in place, making clear who had parental responsibility during the times the parent was unwell and formalising the living arrangements of the children. Families are of course able to make private arrangement for where children live and with whom without the state becoming involved. In this situation the local authority in the guise of the Early Help worker and then the Social Worker made clear that there were times that the children could not live with their parent. The extended family agreed, but this met the criteria for some form of legal order to be put in place. A Child Arrangements Order22 would have been an appropriate option. This would have meant a member of the extended family would have shared parental responsibility with the parent and authority for day-to-day decision making about the child would be delegated to the nominated carer. 3.51 This was discussed with the extended family on many occasions. They were reluctant to seek a legal order, because they wanted the parent to resume the parental role; it remains unclear what family relationships and history underpinned this. However, this was evidently the extended family wanting to be supportive approach; there needed to be more discussion about the likelihood of the children returning permanently to their parent in the short term or medium term. Within the timescales of the review this did not seem a realistic possibility, with the likelihood of continued instability. Without a legal order in place the parent could have insisted the children return to live with them, even if this was not in their best interests and there was a lack of a contingency plan for when the parent was unable to provide authority for day-to-day decision making regarding the children. There should have been a clearer Local Authority view about what was in the best interests of the children and to help the extended family understand this, deal with the tensions inherent with taking over the parental role. 3.52 There was a lack of clarity regarding what were safe and appropriate family time arrangements and whether the extended family felt able to manage them. This was never appropriately addressed. There were times that it was reported that family time had always to be supervised, and other times when it was thought appropriate for the parent to see the children alone. There was no written contact plan. As has already been discussed, family tensions over time made both the practical organisation of this difficult and there was an emotional cost to family members of having to tell the children and the parents what family time could and could not take place. The family needed more support with this. They were left at the end of the Child in Need process without a clear plan in place. 22 A child arrangement order can outline where and with whom children live as well as when and how often the children can see a parent or relative (contact). It can also outline shared living arrangements. Each Child Arrangements Order is decided on the circumstances of the individual family and on what is in the best interests of that particular child. This means that there is no such thing as a ‘usual’ arrangement. Child Arrangements Orders are governed by section 8 of the Children Act 1989. 25 Why does it matter? 3.53 Stability in practical living arrangements and attachment relationships is crucial for children’s emotional wellbeing and healthy development. Research shows that instability in attachment relationships can have a long-term impact on children’s wellbeing which lasts into adulthoodxviii. There are additional needs for routine and stability for neuro-diverse children. This is about ensuring permanency for all children. 3.54 Family time, or contact, is critical when children are separated from their parents and familyxix. It helps to maintain connections and attachments relationships. The Life-long links programme developed by Family Rights Group23 has demonstrated how easy it is for contact arrangements to break down and for the negative impact of this on children’s emotional wellbeing. Children also need to feel safe. Regularising contact arrangements, putting boundaries around them and addressing when they leave children feeling anxious or unhappy is important. High quality contact requires ongoing proactive efforts to make it work. Q5: How effective were multi-agency working arrangements and information sharing? 3.53 Across the timeline there were variable multi-agency working relationships and some issues with information sharing. There was also some effective and child focussed practice. What is striking is the inconsistency in who was provided with information about Early Help plans, Child in Need minutes (these were clear and of good quality) and which professional has access to the child and family assessment. There seems a lack of challenge here about decisions which professionals were uncertain about and which they did not believe to be in the best interests of the children. The decision to step down from a Child in Need plan was not questioned by any agency who was involved. The lack of a step-down plan was not noticed. The lack of a formal safety plan was not noticed by any agency or addressed. 3.54 It is of concern that there was such inconsistent communication with the children’s schools, they were providing support to the children and were a safe and predictable place for them. 3.55 The key issues were: 23 Lifelong Links aims to ensure that a child in care has a positive support network around them to help them during their time in care and in adulthood. Lifelong Links - Family Rights Group (frg.org.uk) 26 • The GP liaised well with appropriate agencies and the extended family, having sought permission from the parent. Despite this proactive response, the GP practice were not made aware of the Early Help or Child in need plan, the Child and family assessment and they were not asked to contribute to any of these processes. This did not cause any major issues in these circumstances but has the capacity to undermine effective working relationships in other circumstances. GPs often have the most holistic of a child and their family’s circumstances. • The GP was made aware of the parent’s period of crisis immediately after the Child in Need plan came to an end and the GP appropriately sought further information. The GP did not note these in the safeguarding node for all family members records. If this had been done there would have been a flagging of mother’s mental health needs and current instability. • The paediatrician made appropriate contact with the Social Worker to ask about parental responsibility and who was responsible for providing consent to medical issues. They were not provided with any of the Child in Need paperwork. • The Special Needs School Nurse attended Child in Need meetings and shared information. There is no record of them having received the Child in Need minutes or have any knowledge of the child and family assessment. They were made aware of the decision to end the Child in Need plan., with no other professional being present, but no view was expressed about this, and no information requested about a step-down plan. They were not provided with the safety plan (which was never formally completed – being held in the body of the child and family assessment) and they did not ask for it • The Early Help plan did not include either school, though this appears to have been due to an invite having been sent and not responded to. This should have been chased up. • Overall, there was poor communication with schools across this timeline. They were not fully aware of the move from an Early Help plan to a child and family assessment, but they were then invited to meetings. It emerged that it was left to the oldest child to communicate when a crisis had occurred; this left responsibility on the child’s shoulders and should have been challenged. The schools? were aware that the Child in Need plan was closed during a school holiday, without their views being considered. This did not promote effective multi-agency working practices, and the absence of a step-down plan was not noticed or challenged. • The school was aware that the oldest child was unhappy with the lack of support provided with by the Social Worker, and the change of Social Worker and this was shared within Child in Need meetings. This led to no further action, something the school could have more robustly questioned. 27 • There was a good working relationship between the Child in Need Social Worker and the mental health care coordinator. Several home visits were completed, and there was regular information shared. What was missing was clarity of role; what was the purpose of the joint visits. The Social Worker recorded in the Child and family assessment that a lack of a diagnosis for the parent was hampering progress. This was not shared with the mental health team, so they were not able to explain the process of assessment and diagnosis. This assertion of a problem with one agency and the way they are working, without evidence or discussion, has the capacity to undermine working relationships. • In the period after the Child in Need plan ended there were many crises which were managed well for the parent, but no contact was made by any agency involved to consider the needs of the children. Why does it matter? 3.56 Communicating effectively with other professionals is more than sharing information Difficulties around information sharing have long been recognised as a characteristic of interagency and interprofessional working, and they have been persistently highlighted in the SCR periodic analyses. A crucial distinction needs to be made between information sharing, communicating effectively and understanding each agencies analysis; knowing what that means overall for the child’s safety and wellbeing. What needs to be done about it? Recommendation 5: There needs to be clarity about when and in what circumstances child and family assessments will be shared with those agencies who will be supporting children who are subject to Child in Need plans. Recommendation 6: The guidance regarding Child in Need meetings needs to be updated to make clear that the meeting needs to include all those agencies working with a family. Thought needs to be given to the timetabling of meeting during school holiday, where some professionals will not be able to attend. It must also make clear that the decision to end a Child in Need plan should not be made without discussion with the multi-agency group and without a clear step-down process. 28 References: i Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf ii The Child safeguarding Practice Panel (2023) Child Protection in England National review into the murders of Arthur Labinjo Hughes and Star Hobson Child Protection in England - May 2022 (publishing.service.gov.uk) iii contact-six-key-messages-nuffieldfjo.pdf iv Care Act 2014 (legislation.gov.uk) v Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf vi Social Exclusion Unit Taskforce (2008b) Reaching out: think family, London, Cabinet Office. vii Child mental health: recognising and responding to issues | NSPCC Learning viii Ryan, M. (2018) Parental mental health: frontline tool. Research in Practice rip_frontline_briefing_parental_mental_health_web.pdf ix Child mental health: recognising and responding to issues | NSPCC Learning x Children Act 1989 (legislation.gov.uk) xi Convention on the Rights of the Child | UNICEF xii Equality Act 2010: guidance - GOV.UK (www.gov.uk) xiii Allnock, D. and Miller, P. (2013) No One Noticed, No One Heard: Disclosures of Abuse in Childhood. London: NSPCC. xiv Department for Education (DfE) (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017. Final report (PDF). London: Department for Education xv Cossar J, Brandon M, Bailey S, Belderson P and Biggart L (2013) ‘It takes a lot to build trust’. Recognition and Telling: Developing earlier routes to help for children and young people. Available online: www.childrenscommissioner.gov.uk/wp-content/uploads/2017/07/It_Takes_a_lot_to_build_trust_EXECUTIVE_SUMMARY.pdf xvi Support for parenting | UNICEF 29 xviii Boddy, J. (2013) Understanding Permanence for Looked After Children: A review of research for the Care Inquiry. London: The Care Inquiry xix Nuffield Family Justice Observatory (2022) Contact between children in care or adopted and their families: six key messages from research Briefing paper. contact-six-key-messages-nuffieldfjo.pdf |
NC52692 | Death of a 16-year-old boy by suicide in May 2021. Dawit had arrived in the UK from Africa in October 2020 to live with his sister after both his parents had died. His family had suffered religious persecution in their home country. Learning themes include: developing a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met; supporting the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs; and the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK. Makes no specific recommendations but reflections suggest: every child/family should be given the right advocate/support to navigate complex systems and bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them; there is a need to increase professionals' knowledge and confidence in being curious about and exploring parental responsibility; all services must commit to using high quality translation services for all spoken and written information and in a school environment good quality English as an Additional Language (EAL) support is essential; and children's social care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing.
| Title: “Dawit”: local child safeguarding practice review. LSCB: Lambeth Safeguarding Children Partnership Author: Lambeth Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. “Dawit” Local Child Safeguarding Practice Review Version 1: 15 March 2022 1 Introduction In May 2021, 16-year-old “Dawit” was found hanged in the building in which he resided. He was found by his younger brother. He was suspended by a rope. London Ambulance Service and Police attended. There was no suspicion of 3rd party involvement. Following this tragedy, the Lambeth Safeguarding Children Partnership completed a Rapid Review in June 2021. Several areas for learning were identified in this process. However, the local rapid review panel agreed that there was the need for further exploration about how the partnership should adapt practice guidance to ensure that assessment is inherently multi-agency and that any child arriving in Lambeth, under similar circumstances to Dawit, is appropriately safeguarded. Subsequently, the LSCP Executive agreed that a Local Child Safeguarding Practice Review should be initiated, and this takes the form of a learning event resulting in concrete changes to practice guidance and implementation. Dawit’s story: A summary Dawit was born in an African Country. He had a large family of seven siblings (two sisters and five brothers). His family faced persecution because of their religious beliefs. In 2015, Dawit’s parents were both imprisoned. Around this time, two of his siblings were also imprisoned. In 2020, Dawit’s parents sadly passed away in 2020, with their death reportedly being attributed to abuse by the authorities in his home country. Dawit’s sister, is a Lambeth Care Leaver, having previously arrived in the UK as an accompanied asylum-seeking child. On 30th September 2020 the sister’s Personal Advisor (from Lambeth’s 16+ Leaving Care Team) wrote to Lambeth’s No Recourse to Public Funds Team (NRTPF) to seek advice as the sister reported that she was bringing her brothers aged 14 and 15 over to the UK from Africa. Another sister had borrowed money to pay for their air fare. On 19th October 2020 the Personal Advisor was informed that her brothers were with her in the UK. They were reportedly living with their sister in a one-bedroom flat, where at least one of the brothers slept on the floor. They had arrived on 1st October 2020. On 3rd November 2020, the 16+ Leaving Care Services referred Dawit and his brother to Children’s Social Care and a decision was made to undertake a Section 17 Child and Family Assessment. The assessment was completed on 5th January 2021. The outcome was for no further action as the assessment identified no concerns about the boys and it was thought that there was sufficient support in place for their sister to look after her brothers. She did not have parental responsibility for her brothers. She continued to receive support from her Personal Advisor. 2 The assessing social worker noted concern about the impact of trauma, however both Dawit and his brother, as well as the sister from Leaving Care, said they were not ready to access counselling and resurface painful memories and would consider it later when they felt able to do so. Dawit said he had bad dreams, but he did not want to talk about them as he did not want difficult memories to re-surface. The sister reported that she felt emotionally supported by her PA, her previous foster carers, and some friends in London. The social worker advised they could access counselling via their GP. The sister received Universal Credit and Housing Benefit and was studying at college when the boys arrived. It was thought that she was unlikely to get Child Benefit, due to the boys’ immigration status - so finance would be an issue. The sister was signposted to Asylum Help UK to get financial advice. She said she needed money to buy the boys winter clothes. The social worker contacted charities and managed to get a donation of new, unused winter clothes for the boys from the St Michael's Fellowship (a Lambeth-based community charity). The social worker also arranged for a one-off food parcel donation. The sister was given the phone number for Vauxhall Food Bank for future needs. While Dawit’s brother had been offered a school place at a secondary school on 4th January 2021, it became known on the 23rd of April 2021 that the family were not aware of this. It was during a routine visit that the sister told her PA that she did not know what was happening in relation to a school place for her brother. It appears that a letter regarding the school place was sent to the family. It is unclear if this letter was received. Regardless, the letter was written in English and the family were unable to read English. The PA contacted Lambeth Education Admissions and was advised that enquiries would have to be made directly with the school. The PA sent an email to the school, but the response is not on file. When the PA visited the sister on 23rd April 2021, it was noted that she said she was doing well and looked in good spirits. The home was clean and tidy, and Dawit’s brother was present. The sister said she had some difficulties with her universal credit payments, as they had been deducted due to Dawit transitioning to college. The PA contacted Universal Credit and they explained that the sister would need to submit evidence that Dawit was on a course. The PA contacted Lambeth College and requested a learner agreement for Dawit so this could be submitted to the sister’s Universal Credit account. In relation to Dawit, the PA was told post 16 applications to college for ESOL would need to be completed. The Personal Advisor was advised to contact a local college. Dawit was offered a place and he started on the 6th May 21, the day before he died. He attended school for 3 hours and, although he appeared withdrawn and shy, there were no safeguarding concerns raised that day. The College had not been given any information or handover information about Dawit’s history, significant trauma and family set up. Tragically, Dawit was found the next morning, having died by suicide. 3 Review questions The following questions set out the key lines of enquiry identified in the initial rapid review: Question 1: How can we develop a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met? Question 2: How can we support the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs? Question 3: What is the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK to ensure their needs are met? Participating Agencies The following agencies contributed to the LCSPR Learning Roundtable: • Lambeth Children’s Social Care ● Lambeth Education & Learning Team ● Southeast London Clinical Commissioning Group (Lambeth) ● Guy’s and St Thomas’ NHS Foundation Trust ● The Metropolitan Police Service Methodology Representatives from partner agencies came together in an online meeting on 22 February 2022. During this learning workshop, participants explored the review questions, collaborated in identifying solutions, agreed recommendations and formulated an action plan to deliver the learning identified. These findings are shared in this report. The event was chaired by Dr Efun Johnson, Lambeth’s Designated Doctor for Children Looked After. To facilitate equal participation of all agency representatives, especially given the online format for the event, a digital tool, Axis, was employed. This allowed equal participation for all participants who could freely share and evaluate ideas. 4 Family Involvement Dawit’s brother and sister were notified of the review and were invited to contribute their voices and experiences to the review. Governance The Review Learning Panel Meeting was Chaired by Dr Efun Johnson, Designated Doctor, Children Looked After, Lambeth. The report will be presented to the LSCP’s Serious Incidents & Reviews Subgroup, with final sign-off sitting with the LSCP’s Executive. The review’s recommendations and actions will be monitored and evaluated by the LSCP’s Performance and Quality Assurance Subgroup. Learning Lessons learned from this local child safeguarding practice review will be disseminated via multi-agency briefing sessions, updated training materials and LSCP communications. Below are the key reflections in response to the review’s key questions. Question 1: How can we develop a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met? The multiagency panel agreed that a single multi-agency protocol was needed to ensure that all unaccompanied children, regardless of the route of their arrival in the UK, are appropriately safeguarded in a consistent way that all agencies understand. It was noted that there was an established process in place to ensure unaccompanied asylum-seeking children were given the most effective and timely support, and that we should use the processes and systems already in place and widely understood. It was equally understood that no one single protocol can be employed without a full consideration of context. When considering Dawit’s case, partners recognised the need to foster a greater culture of consultation and professional discussion across the partnership. It was recognised that there is expertise available throughout the partnership and there is a need to better promote the availability of this knowledge, encouraging contact, discussion, and advice. To ensure the loop is closed in any intervention or referral, it was agreed to ensure that every child/family should be given the right advocate/support to navigate complex systems and 5 bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them. While not specifically relevant to Dawit’s story, the panel noted that the rates of notification for Privately Fostered Children are very low, so it is likely that we would potentially have the same challenges in identifying children without a carer with parental responsibility. This reflection suggests a need to increase professionals’ knowledge and confidence in being curious about and exploring parental responsibility. Question 2: How can we support the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs? The multiagency panel agreed that that to best support migrant children’s integration into schools and the wider community, a holistic approach is required. This would involve, for example, providing accessible information directly to children and families; an advocate to work alongside the child or family to support their integration into community groups and services; support for schools, and other universal services, with clear strategies to best support migrant children; and ensuring that all services make better, and more consistent use of translation services. Exploring these ideas in more detail, the panel agreed that an introductory welcome pack on arrival could signpost local services, community, and support groups. It was noted that additional practical resources could also be provided, like the already available Separated Children packs. Linked to this, as well as the question above, was the identified need for a support worker or advocate to work alongside the child and family to facilitate integration into services and groups and follow up and liaise with other services as needed. Regarding information for schools, education colleagues suggested that it would be helpful to articulate clear strategies that schools can use to support migrant children, which sets up some “non negotiables”, as well as examples of good practice, including resources to help operationalise them. It was agreed to use existing school networks, for example the Lambeth Schools’ Designated Safeguarding Lead Forum, to create a safe space for school leads to drop in to discuss challenges, opportunities, ideas, and good practice with colleagues, as well as receive key information and training. As was identified in the initial Rapid Review, all services must commit to using high quality translation services for all spoken and written information. It was recognised that in a school 6 environment, where this would be impractical for daily provision, good quality English as an Additional Language (EAL) support is essential. Question 3: What is the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK to ensure their needs are met? It was agreed that any assessments should ideally be holistic and multi-agency. This would not necessarily require one single coordinated assessment, which could prove logistically challenging. It would, however, require sharing of information as part of the assessment, as well as afterwards. As an initial practical step, it was agreed that Children’s Social Care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing. It was recognised that this action would ensure that universal services are made aware and would likely trigger proactive outreach – from a GP making contact to initiate an appointment. It was highlighted that on 7 November 2019 council officials in the London Borough of Camden sent a letter to directors of children’s social services nationally alerting them to learning from the council following the death of a child from Dawit’s home country who had died by suicide. The letter stated that young, unaccompanied asylum-seeking children face a range of challenges including trauma, loss and separation, disconnection, language barriers and racism and that for some a stigma around mental-health problems makes them reluctant to accept help and support. This led the panel to reflect on how the partnership has a role to play in keeping learning alive for professionals, as well as sharing new and ongoing learning, and how we track and monitor this. It was agreed that this should be reflected in all structures within the partnership – from the use of the partnership website and training programme to share new learning, as well as the outcomes framework and data dashboard monitored and evaluated by the partnership’s Performance & Quality Assurance Subgroup. 1 |
NC047804 | Life-threatening injuries of a 6-month-old girl, Child W, in April 2015. The injuries remain unexplained but were suspected to be non-accidental. Mother and her partner were arrested on suspicion of grievous bodily harm (GBH) but not charged. Child W and her siblings, S, aged 1 and R, aged 4, were placed in foster care. All three siblings were subject to child protection plans for neglect. During this process they moved from one local authority area to another. The case transferred between local authorities but the family were reported as missing. Mother was vulnerable, her own mother had suffered serious mental illness and she had spent much of her childhood in the care of her grandmother. There were concerns about domestic abuse, lack of engagement with services, mother's young age and her mental health problems associated with childhood trauma. Lessons learnt include: responses from children's social care were incident-led and opportunities were missed to assess the children's needs over time to assist in measuring the impact of the help already offered; local authorities need to have clear 'step up / step down' procedures for families who reject Early Help services. Recommendations for both LSCBs include: make sure multi-agency training ensures the voice of the child is central to any contact or assessment; develop a range of resources for practitioners to use when assessing children's needs, including very young, pre-verbal children.
| Title: Serious case review: Children R, S, W. LSCB: Croydon and Lewisham Safeguarding Children Boards Author: Jane Doherty Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Croydon and Lewisham Safeguarding Children Boards Serious Case Review Children R, S, W Author: Jane Doherty 2 1 Introduction 1.1 This is the overview report of a Serious Case Review (SCR) jointly commissioned by Croydon Safeguarding Children Board (CSCB) and Lewisham Safeguarding Children Board (LSCB) following the serious injury of Child W, a 6 month old baby girl. In April 2015 Child W was presented to hospital vomiting blood; she had multiple injuries and the appearance of neglect and as a result of her injuries she required specialist neurosurgical intervention. Child W and her siblings were in the care of their mother and her new partner at the time. The injuries remain unexplained, but were suspected to be non-accidental. At the time of writing the report care proceedings were on-going and Child W and her siblings were placed in foster care. 1.2 A criminal investigation was started at the time the injuries were discovered and both mother and her partner were arrested on suspicion of Grievous Bodily Harm (GBH). The investigation concluded in March 2016 with no charges or prosecutions being brought due to difficulties in establishing firm evidence in how the injuries were caused. 1.3 The case highlights and pertains to: The serious injury to Child W whilst in the care of her mother and her mother’s partner The identification and recognition of neglect over the lifetime of very young children The frequency with which the family moved between at least 3 London boroughs Concerns about the long term impact of domestic abuse and mother’s mental health problems, largely associated with childhood trauma The challenges faced by young parents (20 and 21 at the time) caring for 3 children who at that time were aged 4 and under. 1.4 The following is a summary of the events leading up to Child W’s injuries. 3 1.5 This very young family of mother, her 3 children and her partner (father to the youngest two children) were living together in Lewisham. In January 2015 police attended an incident when the father had allegedly tried to strangle the mother and also tried to kill himself. As a result the London Borough of Lewisham commenced s471 enquiries. Before the enquiries were concluded the family left Lewisham to take up residence in Croydon, but soon after moving their mother went to stay with a new partner at another address in Croydon taking the 3 children with her. 1.6 At the conclusion of the s47 enquiries Lewisham made all 3 children subject to Child Protection Plans for Neglect. However, following their Initial Child Protection Conference (ICPC) on 25.2.2015 mother and the three children were reported as missing as no one knew of their exact whereabouts. Lewisham and Croydon Children’s Social Care were then in communication about the transfer of case responsibility from Lewisham to Croydon. 1.7 On 13.04.15 her mother and her mother’s new partner presented Child W, aged 6 months, to hospital. She was vomiting blood, having sustained multiple injuries, and had the appearance of neglect. Her injuries which were life threatening included 26 bruises on her body; she also had very bad nappy rash and appeared malnourished. Further tests revealed a number of suspected non-accidental injuries including trauma to the head causing bleeding on the brain, healing rib fractures and healing fractures to bones in the right leg and foot. These injuries were so severe they required specialist neurosurgical intervention. 1.8 All 3 children were removed into foster care and Lewisham commenced care proceedings. Croydon subsequently accepted case responsibility and took over in the early stages of the proceedings. 1.9 The children’s mother and her new partner were arrested on suspicion of GBH to Child W. As stated in paragraph 1.2 the police investigation concluded with no further action. 1.10 Child W has since made a full recovery from her injuries. 1S47 enquiries refers to section 47 of the Children Act 1989 which places a duty on the Local Authority to investigate where they suspect that children are suffering significant harm 4 2 Arrangements for the Serious Case Review 2.1 After the serious injury to Child W, CSCB took the view that the criteria for an SCR had been met which is entirely consistent with the guidance in ‘Working Together’2 (WT) 2015. As much of the work with the family had taken place in the London Borough of Lewisham, a collaborative approach was agreed upon between the two LSCBs and a joint SCR process commenced. CSCB agreed to take the lead and host the review with appropriate representation from Lewisham’s Board to inform and contribute towards the process. 2.2 The case meets the two criteria below set out in WT: 5(2)(a) Abuse or neglect of a child is known or suspected and 5(2)(b) (ii) a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child 2.3 Working Together (2015) Chapter 4 Para 11 states a Serious Case Review should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 2Working Together to Safeguard Children (Working Together) is the government’s overarching guidance on safeguarding. 5 seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 2.4 The purpose of the review is to; Look at what happened in the case and why and what action will be taken to learn from the review findings Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children. Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children. 2.5 Arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. Ms Sally Trench was appointed as the Chair of the SCR panel. Sally has had a lengthy career in local authority social work, in adult mental health and children and families services. As an independent consultant, she now acts as both Chair and author of Serious Case Reviews, and is accredited as a reviewer using the Social Care Institute of Excellence (SCIE) Learning Together model. Ms Jane Doherty was appointed to produce this overview report. Jane is an Independent Social Work Consultant with a considerable background in Child Protection and Quality Assurance. As an independent consultant she now specialises in multi-agency learning reviews including partnership reviews and SCRs. 2.6 CSCB appointed a Review Panel to manage and oversee the review. The membership of the panel is set out below: Name/Designation Organisation Role Sally Trench Independent Chair of the panel Jane Doherty Independent Overview author Designated Doctor for Child Protection, Croydon Health Services NHS Trust and NHS Croydon CCG Croydon Health Panel member Head of safeguarding/Designated Nurse, Children Croydon CCG Croydon Clinical Commissioning Group Panel member 6 Associate Director of Nursing, Integrated Women’s, Children and Sexual Health Directorate Croydon Health Panel member Named Nurse South London and Maudsley Trust (SLaM) Panel member Review Officer, Specialist Crime Review Group Metropolitan Police Service Panel member Head of Service, Safeguarding and Quality Assurance Social Care and Family Support Croydon Panel member Head of Service, Early Intervention Social Care and Family Support Croydon Panel member Head of Service, Safeguarding and Quality Assurance Lewisham Panel member Board Manager Croydon Safeguarding Children Board Panel member Business Manager Lewisham Safeguarding Children Board Panel Member Development Officer Lewisham Safeguarding Children Board Panel Member Named Nurse Safeguarding Children Lewisham and Greenwich NHS Trust Trust lead Named Nurse Panel Member Assistant Director of Quality (Children) Designated Nurse Safeguarding and Looked After Children NHS Lewisham Clinical Commissioning Group Panel Member 2.7 It was determined through the emerging facts of the case that the following agencies had had contact with the family and should therefore contribute to the review: Agency Nature of contribution Croydon Children’s Social Care Chronology and IMR Lewisham Children’s Social Care Chronology and IMR Croydon Health Services (covering Health Visiting, Croydon University Hospital and) Chronology and IMR South London and Maudsley Trust Chronology and IMR Lewisham and Greenwich NHS Trust Chronology and IMR Chelwood Nursery Lewisham Chronology and IMR Metropolitan Police Service Chronology and IMR NHS England (GPs) Chronology and IMR 7 Kings College Hospital Summary Report Guys and St Thomas Hospital Summary Report Lambeth Children’s Social Care Summary Report London Ambulance Service Chronology 2.8 The Terms of Reference (ToR) agreed by the Panel were that the period under detailed review would be from 1 October 2013 to 20 April 2015 with the proviso that agencies would summarise any other relevant information pre-dating this period, to add context and background to their report. In line with this some background information about events prior to October 2013 and the current position of the siblings is also included in the report. 2.9 The methodology used by the CSCB in this review is a hybrid model, in that each agency was asked to complete a chronology, and undertake an Independent Management Review (IMR). Those agencies who have had minimal contact were asked to complete an Agency Summary Report (see table at 2.7) 2.10 The CSCB held a series of SCR Panel meetings, chaired by the Independent Chair, where all the agencies and the overview author contributed to the process of gathering and analysing the material provided. 2.11 Two consultation and learning events were held in November and December 2015 to enable those practitioners who worked with the family to contribute to the overall findings and lessons from the review. Two separate events were held – one in Croydon and one in Lewisham. 2.12 A further joint event was held in February 2016 prior to the final publication of the report to feedback findings from the Review and to ensure views from the practitioners had been captured. Where relevant their views have been incorporated throughout the report. 2.13 CSCB plan to hold further learning events at the conclusion of the review both for practitioners and other staff from the children’s multi agency workforce as well as other board partners. 3 Family Contribution 8 3.1 In line with expectations laid down in WT consideration was given to involving the family in the review process and family members were advised that the review was underway. Despite many attempts to contact them, family members did not feel able to contribute at this stage and therefore the report has been prepared without their input. Whilst this was not ideal, the panel were satisfied that all avenues to try to include family members’ views had been explored. Due to their very young ages it was not thought appropriate to seek the views of the children. 4 Methodology used to draw up this report 4.1 This report is informed by: The agency chronologies, IMRs and summary reports Background information from agencies involved in the review Panel discussions and analysis Dialogue with IMR authors Input from practitioners via the consultation and learning events held on the 12th November 2015, the 8th December 2015 and the 18th February 2016 Research findings. 4.2 The report consists of: A factual context Analysis of how the agencies worked together from the information provided in their IMRs Commentary on the family situation Key themes and lessons learned Recommendations 9 4.3 The review has been conducted and written with the benefit of hindsight, which often distorts the reader’s view of the predictability of events, which may not have been evident at the time. It is important to be aware as Munro (2011) states just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once an outcome is known we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. This is not necessarily the case, and information often becomes much clearer after an event has occurred. The review is therefore sensitive to this ‘bias’. 4.4 The review is also sensitive to pressures on agencies and the demands of the work which are sometimes overwhelming for even the most capable of workers. It is therefore important to disseminate the learning and reflect on how the lessons from this review can help support better practice, rather than apportion blame to agencies or individuals. 10 5 Factual Narrative Chronology Family Structure Names Age at the time of the incident Gender Relationship Ethnicity Child W 6 months F Subject White British Child S 1 year, 6 months F Subject White British Child R 4 years, 1 month F Subject White British Ms A 20 F Mother White British Mr C 21 M Father of Child S and Child W White British Mr B 18 M Father of Child R White British Mr D 18 M Mother’s new partner and where children were staying at time of incident White British Ms E 36 F Maternal Grandmother White British Ms F 61 F Maternal Great Grandmother White British Mr G N/k M Paternal Grandfather to Child R White British Ms H 35 F Paternal Grandmother to Child R White British Background Information 5.1 Each of the agencies involved in this review submitted a detailed chronology of their involvement with the family members in the period under review. Those submissions have been coordinated into an integrated chronology which is summarised here. Further factual information is provided in some subsequent sections where relevant. 5.2 All the adults involved in this review (Ms A, Mr B, Mr C and Mr D) grew up in Croydon. All but Mr C were known to CSC at some point in their childhood. Ms A and Mr B 5.3 Ms A and Mr B (father to Child R) met when they were very young and Child R was born when they were 16 and 14 respectively. The multi-agency professional network in Croydon had known Child R since her birth in March 2011 when Croydon CSC completed an assessment. 11 5.4 The parents had somewhat troubled childhoods. Ms A’s mother (Ms E) had very serious mental health problems and consequently Ms A spent much of her childhood living at her grandmother’s home. At 16 Ms A had her own social worker due to the risk of being homeless whilst pregnant. Mr B had his own social worker as he and his siblings were subject to Child In Need (CIN) services in Croydon at the time of Child R’s birth and had previously been subject to Child Protection Plans. Mr. B had also lived with his grandmother under a Special Guardianship Order (SGO) until 2010 when his grandmother died and he moved back to live with his mother. He was subject to the SGO due to his own mother’s difficulties with substance misuse. 5.5 When Child R was born in 2011 the family were in receipt of services under s17 (Children Act 1989) from Croydon CSC for a period of approximately 8 months. In that time both Initial and Core Assessments3 were undertaken. The concerns raised were about the very young age of the parents, their unstable relationship, the basic care and safety of Child R and Ms A’s partial engagement with services. 5.6 The assessments conducted took account of both parents’ vulnerabilities (as above). It was also noted as a significant factor that both parents’ childhoods had been disrupted by lengthy periods of living with extended family e.g. grandparents, due to their own parents’ difficulties. 5.7 The assessments concluded that Child R was not at risk of significant harm and that the parents had demonstrated some progress over time and had become more confident in their parenting. Child R was said to be meeting her developmental milestones and it is recorded in the assessment that there were ‘no concerns about her attachment’. 5.8 By November 2011 Ms A and the baby were living with a friend and her mother and this was seen as a more stable and supportive arrangement. As a consequence of this change in circumstance Child R’s case was closed to CSC. Mr B remained living in his family home but continued to have some contact with Child R. 5.9 The IMR provided by Croydon CSC does however note that it is possible that Child R fell between two sets of social workers who were allocated to the parents and she was not allocated a social worker in her own right. The assessment was conducted by the same social worker allocated to Mr. B and his siblings with whom the social worker had an established relationship. The IMR makes the point that this may have led to an over optimistic assessment of the parents’ parenting capacity. Nonetheless it is a pattern throughout the review period that with consistent periods of involvement with professionals Ms A did make progress. 3 In 2011 Local Authorities were required to assess families in need under the National Assessment framework (NAF) which consisted of initial and core assessments. These have since been replaced by the Single Assessment Process 12 5.10 The Family Nurse Partnership (FNP)4 were involved for the first two years of Child R’s life and offered an intensive amount of support over that time. 5.11 Throughout the period of this review Ms A lived in at least 3 London boroughs Croydon, Lambeth and Lewisham. The exact details of the moves have not been established for the review but rough timelines indicate that Ms A moved from Croydon to Lambeth at some point during 2013 (possibly earlier) when she was pregnant with Child S. Just prior to Child S being born the family moved to Lewisham and in February 2015 the family moved back to Croydon. Mr C 5.12 Mr C was not known to services as a child and it is not currently known where he and Ms A met. Mr D 5.13 Mr D, his siblings and half siblings, have a long history of involvement with Croydon CSC and he and five of his siblings were removed from their mother’s care permanently. At the age of 3 Mr D was made subject to a full Care Order (s31 Children Act 1989) and subsequently adopted. 5.14 Mr D was however living with his birth mother when Ms A moved herself and her children into Mr D’s mother’s house in February 2015. Their presence in the household made it substantially overcrowded and it transpired during the investigations surrounding the injuries to Child W that there was a seven year old half sibling of Mr D also living in the house. 4 The Family Nurse Partnership (FNP) is an evidence based, voluntary home visiting programme run by the NHS for first time young parents, aged 19 years or under. A specially trained family nurse visits the parents regularly, from the early stages of pregnancy until their child is two. Their role to educate and advise on parenting. 13 Practice Episode 1: (17th September 2013 – 31st December 2013) 5.15 The ToR for this review start at the beginning of October 2013; however as there was a significant event in September 2013 (an assessment was conducted by Lambeth CSC), this practice episode begins at that point. At the time of the referral the family resided in Lambeth but it would appear that they (Ms A, Mr. C and Child R) had moved to Lewisham by the end of September that year. Ms A was heavily pregnant with Child S who was due in the middle of October and a referral had been made to Lambeth CSC by Midwives from KCH. 5.16 The midwives had originally made the referral via a Common Assessment Framework (CAF) in March 2013. At that time it was practice to commence a pre-birth assessment after 26 weeks but it is not clear why the assessment was not followed up by Lambeth CSC until September when Ms A was due in October. The referral was made as the midwives were concerned about Ms A’s low mood and the fact that she had missed some antenatal appointments. Lambeth CSC allocated the family to a social worker for a pre- birth assessment. 5.17 The Lambeth Social Worker concluded the assessment at the end of October having seen the family twice (at their Lewisham address) and made the decision that the family should transfer to Lewisham CSC for support under a CIN plan. Lewisham CSC reviewed the information in January 2014 and assessed that the family would be better supported by a Team Around the Family (TAF) and did not open the case to CSC. 5.18 At this time Ms A was receiving a service from the Perinatal Team5 as she had been referred by her GP in August 2013 having presented to him with what was described as a ‘severe depressive episode’. As well as the referral to the Perinatal Team the GP had also prescribed sertraline6 to assist with her mood and anxiety. 5.19 Ms A had disclosed to the Psychiatrist in the Perinatal Team that she was repeatedly raped by a ‘previous partner’ during their relationship and this was causing her some considerable distress which manifested itself in the form of anxiety, flashbacks, hallucinations and ultimately in severe depression. Practitioners from the Perinatal Team visited Ms A at home for a period of 7 months (August 2013 to March 2014) though towards the end of this period Ms A had largely withdrawn from their service. 5 The Perinatal Team operated by SLaM specialise in the treatment of antenatal and postnatal mental illnesses. The service is for women who develop or have a relapse of serious mental illness during pregnancy, and women who have developed postnatal depression, post-partum psychosis (also known as puerperal psychosis) or have had a relapse of serious mental illness following the birth of their baby. 6 Sertraline is a medication used to treat the symptoms of depression and anxiety disorders including PTSD. 14 5.20 On the 17th October Child S was born at home and immediately transferred to hospital where they were discharged after two days. Mother and baby were both medically fit on discharge. Despite an agreement between the Perinatal Team, the midwife and Lambeth CSC that a Discharge Planning Meeting should take place before mother and baby were discharged home no such meeting took place. 5.21 There were several visits by professionals following the birth from the midwives, the health visitor (HV), the Lambeth Social Worker and the Perinatal Specialist Nurse. Child S was seen throughout these visits, but Child R was often not seen and parents reported her to be with either PGM, MGM or with her cousins. 5.22 Ms A did not keep a planned home appointment by the Perinatal Nurse Specialist on the 12th November and instead a telephone review was conducted. The plan was that Ms A should be discharged from this service as there did not appear to be any further concerns in relation to her mental health. As a result of this the nurse arranged for a review by the psychiatrist for the beginning of December. 5.23 The HV conducted a home visit 2 days later and Child R was present in the home. The HV recorded that the flat was untidy and smelt heavily of cigarette smoke. The HV advised the parents of the health risks particularly to children through smoking inside and suggested they smoke outside and if possible try to cut down. Child S was weighed and noted to be gaining weight slowly. The HV also advised parents to increase the feeds and although Ms A agreed, she was apparently reluctant to do so. 5.24 The family was seen twice at the beginning of December – once by the GP at the surgery and once by the HV the following day. It is however significant to this review that between the birth of Child S and the end of December the family had DNA’d7 or cancelled a total of 6 health appointments (3 with the Perinatal Team, 1 with the HV and 2 with the New Born Hearing Clinic for Child S). Practice Episode 2: 1st January 2014 – 31st March 2014 5.25 In January 2014 the family continued to reside in Lewisham and the HV conducted a home visit. Child R was present but the health visitor was unable to assess her speech as she would not engage. The HV was again concerned about the condition of the flat as it was in a disheveled state with takeaway containers and cans lying around. Despite advice on the previous visit, the flat again smelt heavily of cigarette smoke. Child S was said to be developing within normal limits and her weight gain was improved. The parents had not accessed any of the supports such as the Children’s Centre also suggested at the last visit. 7 DNA’d – Did Not Attend 15 5.26 The Perinatal Team also visited the same day and although there were no concerns about Ms A’s mental state they also noted concerns about the state of the flat. 5.27 As a result of this visit the Perinatal Team made contact with CSC in Lewisham regarding Ms A’s DNAs and their concern about the conditions of the home. CSC reported that the case was not open to them and that Ms A seemed to be engaging in a TAF process and they were not planning to open it. 5.28 The HV made plans for more formal early intervention via a CAF including referring Child R for a paediatric assessment of her development. The HV was concerned about her speech delay and her interaction with adults was limited possibly due to lack of stimulation. Despite the HV’s attempts to engage the parents in help from the Children’s Centre and secure childcare for Child R under the government’s Early Education Scheme for two year olds,8 the parents were not proactive about arranging this. As a result the HV became concerned about the amount of stimulation and play Child R was receiving. 5.29 On the 7th February 2014 Child R and Child S were accommodated for a brief period as they were being cared for by their MGM (Ms E) when she suffered an episode of mental ill health while out in Croydon with both children. She became aggressive and was sectioned under the Mental Health Act and taken to a psychiatric hospital. It transpired that Ms A and Mr C had gone away for a few days and were not contactable. As a result the children were in foster care for 3 days and Lewisham CSC commenced an assessment under s17 Children Act 1989. 5.30 An assessment of the parents was completed by Lewisham CSC which concluded that there was no further role for them and the children returned home. The social worker recommended Targeted Family Support (TFS), but the family did not take up this service at this time. 8 This is a scheme that allows eligible children to receive free early education from the funding period after their second birthday. This is part of a national offer from the Department for Education (DfE) and has been developed to improve outcomes for identified two year olds who would benefit from access to high quality early years and childcare provision 16 Practice Episode 3: 1st April – 31st December 2014 5.31 Ms A became pregnant with Child W (her third child) at some point early in 2014 with the baby due in November. Ms A had her booking appointment with the midwife at the end of April and disclosed some details about her past including recent involvement with CSC and her depression. As a result of the disclosure the midwife made a referral to the Perinatal Team and they became involved once more. They visited Ms A in May when she told them that she did not feel the need for their input at present and she was referred back to her GP. During the visit she presented as guarded and suggested that she was being ‘checked on’. Ms A told them that she continued to take her medication (sertraline) although this medication had not been prescribed at that time. 5.32 As the parents had not taken up the offer of the Early Education Scheme earlier in the year, in April the HV completed an application for a nursery placement for Child R. When it became apparent that the parents had not been proactive in pursuing this place either, the HV facilitated communication between the two parties and both parents attended a pre-admission interview at the nursery on the 19th June. Child R was also present. The outcome of the interview was that Child R was allocated a priority place to commence as soon as a vacancy became available. 5.33 At the interview the nursery were concerned about the parents’ presentation in the meeting and in particular about Ms A’s reluctance to share any information. In addition the parents were unwilling to give emergency contact numbers and this remained an issue throughout the coming months. 5.34 In July the previous social worker from Lewisham made another referral to TFS. The parents reluctantly engaged with a key worker from that service who was assisting them with Housing Benefit arrears. 5.35 On the 2nd of September the parents, along with Child R, attended a welcome day at the nursery for new starters. The nursery were again concerned about the parents’ presentation as the family all had a strong odour about them. Child S was not present and Child R was said to be ‘blank and emotionless’. 5.36 As a result of their concerns the nursery staff planned a home visit for the following day (3rd September) as a pre-admission home visit. It is not clear if this is standard practice or they visited because they had concerns. Again Child S was not present in the home and there was no satisfactory explanation about where she was. The home was unclean and the parents were reluctant to engage. 17 5.37 The nursery made a referral to CSC in Lewisham as they were concerned about neglect of the children. The referral wasn’t progressed to assessment at that stage as the Targeted Family Support (TFS) team were already involved. 5.38 Throughout this period Ms A and Mr C were erratic with attending various appointments – Child S missed her developmental review and Ms A did not attend one of her antenatal appointments. The parents DNA’d two appointments in respect of Child R – one was her developmental assessment and the other was her Speech and Language Therapy (SALT). 5.39 Child R started nursery on the 10th September and her attendance was also erratic. It would appear that the nursery, the HV and the TFS team were now in communication and a picture of concerns and the type of support the family may need was building. 5.40 As a result of the growing concerns, the first Team Around the Family (TAF) meeting was held at the nursery on the 23rd October 2014. The lack of engagement by the parents and Child R’s poor attendance at nursery (among other issues) were discussed. The key worker allocated to the family from TFS shared that she had been assisting the family with rent arrears, which had accrued to £6000 due to non-payment of Housing Benefit. Ms A and Mr C had attended court and she had attended with them. The family was still facing the prospect of eviction although the key worker reported at the meeting that they had had a reprieve at court when the eviction notice was put back by ten weeks. 5.41 The meeting set out a plan of action which included ensuring that Child R got to nursery every day to enable her to take up a full time place by Christmas. TFS would continue to support the parents with their housing situation. 5.42 Ms A’s pregnancy progressed well throughout this period and Child W was born, with no complications, on the 25th October, two days after the TAF meeting Mother and baby were discharged home to the care of the midwives who visited a number of times during the latter part of October and the beginning of November. Agencies were in communication with one another but there was no formal Discharge Planning Meeting planned. The HV completed her new birth visit on the 7th November where Child S and Child W were seen but Child R was said to be with her PGPs. She was however present at a subsequent visit on the 14th November. 5.43 Ms A cancelled a planned visit by the HV early in December due to ‘family problems’ but she attended the Child Health Clinic (CHC) the following week. 18 5.44 A further TAF meeting was held on the 16th December and improvements were noted. Child R had made the transition from part time to full time nursery and was much more settled. The family’s housing problems had largely been resolved by some of the arrears being paid and they were no longer facing imminent eviction. The younger children (Child S and Child W) had begun to attend a play session at the nursery with the parents each week, though it was mainly Mr C. who attended. Practice Episode 4: 1st January 2015 – 20th April 2015 5.45 On the 10th January a domestic incident occurred whereby Mr C called the Police to say he had assaulted Ms A as he believed she was cheating on him. He stated that he had held a knife to his own throat as he was worried that he would go back inside the house and kill her. Police attended and Mr C was arrested. 5.46 When interviewed Mr C said he regretted what had happened and admitted that three months before, he had started to self-harm (not clear what form this was taking). Ms A refused to press charges but later the same day she called the police to say that she wasn’t coping with the children and wanted CSC to look after them. Lewisham CSC were consulted and advised the police that the children would be best remaining with their mother. Officers visited the address and Ms A changed her mind during the course of the conversation and the children remained at home. 5.47 As a result of these incidents Mr C was given a formal police caution for common assault and criminal damage and a referral was made to MARAC in Lewisham. A strategy discussion between the police and CSC resulted in a decision to commence a single agency S47 enquiry to be conducted by Lewisham CSC 5.48 On the 19th January Mr C attended a GP appointment ostensibly for advice for a physical problem and whilst there he asked for help with anger management. In response to this request the GP gave Mr C information to be able to self-refer to Improved Access to Psychological Treatment (IAPT). It is not clear how Mr C pursued this as there were differing explanations from the parents as to what happened to the application form. Ms A told professionals that she assisted Mr C in filling in the form and posting it, whilst Mr C told professionals he had filled in the form but it had not been posted as it was the day that the family were moving house. 5.49 A TAF meeting was held on the 26th January and was attended by the allocated social worker conducting the s47 enquiries. Ms A was present but not Mr C. According to Ms A the couple had reconciled, though she acknowledged that she was finding this hard and it was reported at the meeting that the family were again faced with eviction. This was due to happen at the end of January. 19 5.50 Throughout January Child R’s attendance at nursery had once again become poor and the nursery staff were unable to contact the parents to ascertain why Child R was not attending. 5.51 On the 1st February the parents and all 3 children moved to an address in Croydon. It is not clear if they were evicted but they were assisted in their move to a private tenancy by the worker from TFS. Lewisham agreed to pay their arrears which were less than the £6000 originally thought and the family were given an Incentive Scheme grant operated by Lewisham Housing of £1000 to cover their new deposit. 5.52 Lewisham CSC continued with the s47 enquiries they had started earlier on in the month and an ICPC was held in Lewisham on the 25th February. Croydon CSC were invited to attend but this was not possible due to the amount of requests of this nature and pressures of workload. Mr C but not Ms A attended the conference. The 3 children were made subject to Child Protection Plans (CPP) under the category of neglect. 5.53 At the ICPC it transpired that Ms A had left the family home in Croydon with the 3 children and no one (including Mr C) knew of her whereabouts. Ms A and the 3 children were reported as missing to the police. Mr C told the conference members that he believed Ms A was having a relationship with Mr D and named him in the meeting. 5.54 Mr C also disclosed at the ICPC that before leaving the family home Ms A had accused him of sexually assaulting Child S. The discussion and concerns around this issue were not fully reflected in the minutes of the ICPC and were not the subject of an action to be completed in the outline Child Protection Plan. 5.55 The allegation was not followed up immediately after the ICPC as Ms A and the children were missing. When they were found at Mr D’s address in Croydon on the 3 March there was a further delay and the investigation was not carried out until the 2 April when Lewisham CSC and the police undertook a joint s47 investigation. This was as a result of Croydon CSC requesting this outstanding action be completed before accepting the case for transfer. The outcome of the investigation was No further Action (NFA) as Ms A denied having made the allegation and Child S made no disclosures. 5.56 Lewisham CSC continued to hold case responsibility for the family but over the course of March and the early part of April the two boroughs (Lewisham and Croydon) were in communication about transferring the case from one to the other. This proved to be a protracted process and the request for a Transfer in Conference (TIC) was not officially accepted by Croydon until 13 April, the same day that Child W presented to hospital with her injuries (see below). Croydon CSC agreed to hold a Child Protection Conference but did not accept case responsibility at this stage stating that the decision would be made at the TIC. 20 5.57 On the 13 April Ms A and Mr D presented Child W to hospital. She was vomiting blood. On examination at hospital, Child W was observed to have 26 bruises on her body, very bad nappy rash and appeared malnourished. Further tests revealed a number of suspected non-accidental injuries including trauma to the head causing bleeding on the brain, healing rib fractures and healing fractures to bones in the right leg and foot. Her injuries required specialist neurosurgical intervention. Ms A and Mr D were arrested on suspicion of GBH and interviewed by police. 5.58 All three children were removed to foster care and Lewisham CSC commenced care proceedings which were subsequently taken over by Croydon CSC. 21 6 Key themes identified by the review process 6.1 Thresholds for intervention when assessing neglect over time 6.1.1 As described in the background information Child R and her parents received statutory services under a Child in Need plan for a period of 8 months after she was born. The input demonstrated some progress over time before the case was closed. Ms A (not sure if it included Mr B) also received an intensive service from the FNP for a period of two years as per their remit. It is not clear what impact the FNP services had on the family but it is perhaps significant that a referral to CSC was made in April 2013 (to Lambeth) towards the end of their input. Child R would have been 2 years old and Ms A was pregnant with Child S. 6.1.2 The hospital midwives made a referral to Lambeth CSC via a CAF, as Ms A’s mood was low. The referral was not dealt with by Lambeth until September that year when it was allocated for a pre-birth assessment. Ms A was 8 months pregnant at this time and was also being supported by the Perinatal Team, the midwives, the HV and the GP. 6.1.3 The assessment conducted by Lambeth CSC which concluded in November 2013, made the recommendation that the family (having recently moved) should transfer to Lewisham CSC under a CIN plan. Lewisham CSC however did not accept the assessment and instead it was deemed that as the family were responding to Early Intervention Services they should continue to engage and be supported in this way. There is in fact scant evidence that the family were engaging and progressing so it is not clear how this decision was reached. 6.1.4 A number of professionals were concerned about neglect of the children throughout the period under review and between November 2013 and September 2014 at least five contacts or referrals were made to CSC in Lewisham in connection with their concerns. Only one of these referrals resulted in a formal assessment. Despite these referrals and the one assessment that was conducted, the family continued to be offered services from Universal Services or Early Intervention teams. This changed in January 2015 when s47 enquiries commenced and the family were presented to ICPC. 6.1.5 In the IMR presented by Lewisham CSC the author makes the point that the decision not to make the family subject to CIN plans after receiving the assessment from Lambeth was a ‘flawed decision’ and prevented Lewisham from making a fuller assessment and providing more co-ordinated services. This pattern seemed to repeat itself in the decision-making around the assessment undertaken by them in February 2014 when again a formal CIN plan for the family would have been beneficial. 22 6.1.6 The concerns were serious in both episodes. The former was about the state of the home and Ms A’s mental health difficulties, which had been a concern for some time, and the latter when the parents went on holiday leaving the children in the care of their MGM who suffered with serious mental health problems. 6.1.7 In the latter instance the children came to the attention of CSC because the arrangement broke down when the MGM became unwell and was sectioned under the Mental Health Act 1983. As a result the children were accommodated for a period of 3 nights. The parents were not contactable during this period which added to the concerns. 6.1.8 The assessment, whilst containing some good analysis and identification of risk, reached the wrong decision. Although some positives were also included the IMR author identifies that the body of the assessment was at odds with its conclusions. The identification of several risk factors indicated a co-ordinated multi-agency response under the auspices of a CIN plan would have been beneficial. These factors included the following: The parents leaving the children with someone they knew to be suffering with longstanding mental health difficulties The parents’ lack of availability during this time Domestic abuse Mental Health problems (mother) Developmental delay in Child R The parents’ basic mistrust of professionals Information from other agencies which indicated concerns of neglect 6.1.9 In the event, the support that was offered to the family via the Targeted Family Support (TFS) Service was not taken up at this time and it is a concern that mechanisms which could have led to the family being reconsidered as needing more targeted support were not deployed. 6.1.10 Two possible mechanisms could have been used to step the family back up to statutory services, the first being an Early Intervention Panel (EIP) which would have re-considered the family’s needs. This would have potentially facilitated a new contact with the Referral and Assessment service and opened the door to reallocation following the failure of the family to take up services with TFS. The panel would have been able to reflect on the family’s lack of engagement and consider how this impacted on the risk assessment. In the event the family were not referred to the panel and this left them without the recommended support. The second possible pathway to the provision of services at this stage was for a TAF meeting to have been convened. This also did not happen until much later in the year. 23 6.1.11 Referrals to CSC in Lewisham made by the Perinatal Team and the nursery in January and September 2014 respectively were not considered to reach the threshold of intervention for statutory services other than early intervention. This was despite them having similar concerns about the conditions in the home, the partial engagement of the parents and the ability of the parents to provide adequate care and stimulation to the children. It is not clear therefore if the referrals were considered in light of the other information held about the family or if the length of time these concerns had persisted was considered a significant risk factor. 6.1.12 The referrals that were responded to and assessed by Lewisham CSC were those where a specific event had occurred – e.g. the parents leaving the children with MGM in February 2014 and the domestic abuse referral in January 2015. Of significant concern given Ms A’s mental health needs and other prominent issues, there were no pre-birth risk assessments undertaken to plan for the needs and protection of the children once they were born. 6.1.13 The length of time the family were supported by Universal Services rather than more targeted services was problematic and is explored further in the following paragraphs. 6.1.14 As the outcome for the children was poor it is necessary to analyse the reasons the family did not appear to reach the threshold for statutory intervention at an earlier stage. Ofsted provide some insight into this issue in their report published in 2014 ‘In the child’s time: professional responses to neglect’, when they state that: ‘Incidents, rather than the child’s on going experiences, were assessed and chronologies were either not used or were not robust enough to evidence the level of neglect and the impact of support.’ 6.1.15 In this particular case reasons may also include: The erratic nature of the concerns which were not static – e.g., at times the family presented as being able to cope while at other times concerns were heightened The isolated nature in which professionals were working with the family and therefore no one professional had a complete picture of the history and presenting concerns A perception in 2014, particularly by Lewisham CSC, that the family were involved in Early Intervention services when in fact they had refused many of the services offered The lack of a co-ordinated chronology detailing risks and strengths over time 24 The nature of the services offered was voluntary and when the parents did not engage it was difficult for professionals to impose services where they had not been requested. When the parents did engage they made progress, leading professionals to be optimistic about their level of engagement. 6.1.16 It is evident with hindsight that the family would have benefitted from more statutory intervention carrying more weight at an earlier stage. The family would no doubt have tried to resist this but there is evidence to suggest that Ms A, at least, responded to a consistent, authoritative approach. 6.2 The challenges faced by young parents 6.2.1 Ms A was 16 when she became pregnant with her first child (Child R) and by the time Child W was born, Ms A and Mr C were 20 years old and caring for 3 children aged 3 and under. The difficulties associated with this for parents especially those barely out of childhood themselves should not be underestimated. Ms A had a complex personal history and had herself experienced poor parenting from her mother who had mental health difficulties. This undoubtedly impacted on her day to day functioning and the accumulated effect of this on her parenting was largely un-assessed by professionals. 6.2.2 These factors should have been considered much more closely as they are potentially major risk factors. This review has sought to understand what information professionals knew and understood about the parents’ particular circumstances and has found significant gaps. For example the Perinatal Team held significant information about Ms A’s childhood experiences but this information was not shared with other professionals (except the GP) and when she began to withdraw from services this was not followed up with other professionals involved with the family. 6.2.3 The review has highlighted that Ms A’s vulnerability was not sufficiently recognised or responded to especially in light of the fact that she was caring for 3 very young children. Other SCRs have highlighted the issue of young parents and the lessons are repeated here in terms of the depth of knowledge about Ms A’s mental health problems, how she was assisted to address them and how this affected her parenting. The Perinatal Team, for example, diagnosed Post Traumatic Stress Disorder (PTSD) but did not provide treatment to address this. 25 6.2.4 The cause of the PTSD has not been completely clarified for this review, which may be symptomatic of the fact that professionals did not have a clear understanding of this. This may have been because Ms A disclosed that she had had some counselling and repeatedly said that she felt much better and therefore did not feel the need for mental health input. 6.2.5 Ms A also claimed that she was prescribed (and was taking) sertraline. The evidence from this review would suggest that this was in fact not the case and that one prescription of sertraline was provided in 2013 but then was not prescribed thereafter. 6.2.6 In its summary of findings of SCRs dealing with children under one year old Ofsted identify a number of common shortcomings, including the lack of pre-birth assessment; underestimation of the needs of young parents and insufficient support being provided, bearing in mind the vulnerability of babies.9 6.2.7 Evidence that the parents were struggling was apparent when professionals noted the poor home conditions, the partial engagement from Ms A and more crucially the uncertain whereabouts of the children at particular times. There were numerous occasions when one or more of the children were not present in the family home (or at appointments) and were said to be with relatives (usually grandparents). Although practitioners noted this and enquired about them this was rarely followed up. On one occasion when it was followed up by the nursery in September 2014, when they were concerned about the whereabouts of Child S, the parents gave differing vague accounts of where the child was. 6.2.8 Through the practitioner events more information came to light that some family friends had looked after the children and appeared to be very supportive to the parents. They did not however make themselves known to CSC until the care proceedings were well underway. 6.2.9 Mr C’s mental health difficulties which became apparent in January 2015 when he disclosed to the police that he had begun to self-harm are not well known about or documented by professionals. This adds to the complex picture of young vulnerable parents and their needs. 9 OFSTED, (2011) Ages of Concern: Learning Lessons from Serious Case Reviews a thematic report. 26 6.3 The role of Early Intervention in cases of neglect 6.3.1 A theme of this review, also connected to the issue of the young age of the parents caring for very young children, is one of the role of Early Intervention services. The Department for Children, Schools and Families (now known as the Department for Education (DfE) ‘Getting Maternity Services Right for pregnant teenagers and young fathers’ document summarises the complexities of assessing the root causes of negative outcomes for teenage parents and their children thus: “There has been considerable debate over whether poor outcomes for teenage mothers and their babies are a consequence of the mother’s age, or of her often disadvantaged circumstances, or of limited uptake of antenatal care. Current research suggests that all three factors can contribute to poor outcomes, but that timely access to appropriate care and support can help to overcome the risks of poor outcomes and can maximise young people’s potential for achieving a healthy and happy transition to parenthood.” (DCSF 2009)10 6.3.2 Over this review period practitioners did provide some helpful services to the family and their limited success was not through lack of trying to support and engage them. The second referral to TFS in July 2014 appears to have come about as a result of some informal liaison between the team and the social worker who completed the assessment in February of that year. Although the family did reluctantly engage with them it is also significant that no formal TAF meetings took place until October 2014. This was the first time all practitioners involved came together to look at what they could offer collectively, share information and make a plan. 6.3.3 This approach did seem to work to a certain extent and at the second TAF meeting in December 2014 some progress had been made – e.g. Child R was in nursery full time, the couple’s housing situation was on its way to being resolved and the other two children were attending a play session at the nursery. 6.3.4 There is a question as to why there was a lack of a more co-ordinated response prior to this time. The family were known to several agencies throughout 2014 and there was some limited communication between them – e.g., the HV kept the GP updated about her concerns via regular link meetings and liaised with the Children’s Centre. 10 Getting Maternity Services Right for pregnant teenagers and young fathers’ DCSF p4 27 6.3.5 The HV did some proactive work and completed a CAF which was sent to the Children’s Centre in order to try and engage the parents in groups that would provide support for them and an outlet for Child R to spend time in the company of other children. When the parents failed to engage with this the HV insisted that the family register with the nursery by ‘almost frog marching them over there’ (recorded in the ICPC minutes dated 25.2.2015). This is perhaps an indication of how committed professionals were to assisting the family and how frustrated they became when offers of help were rejected. 6.3.6 The catalyst for the more formal early intervention appeared to be the involvement of the nursery and their concerns which were immediately apparent on meeting the family. TFS became involved and the co-ordinated, supportive approach seemed to have an impact at least in the short term. 6.3.7 Over this period practitioners did provide some helpful services to the family. Their limited success was not through lack of trying to support and engage them but what was lacking was a comprehensive multi-agency assessment detailing the accumulative risks over time. WT makes the point that: ‘The assessment of neglect cases can be difficult. Neglect can fluctuate both in level and duration. A child’s welfare can, for example, improve following input from services or a change in circumstances and review, but then deteriorate once support is removed. Professionals should be wary of being too optimistic. Timely and decisive action is critical to ensure that children are not left in neglectful homes’ (WT 2013 p24) 6.4 The impact of childhood trauma on parenting capacity 6.4.1 It has been established during the course of this review that Ms A had a troubled childhood. Her mother had serious mental health difficulties which were severe and enduring and led to her being sectioned at least once during the time period of this review. Ms A spent much of her childhood living with her grandmother. She became pregnant with Child R at 16 and the baby’s father was younger still at 14. 6.4.2 What is less clear are the circumstances around an alleged rape in her teenage years. 28 6.4.3 The trauma associated with this event however, manifested itself in her becoming anxious, experiencing derogatory auditory hallucinations, flashbacks and nightmares. In particular Ms A described these symptoms becoming worse when she became pregnant with Child S as they reminded her of the event. The revelation of this resulted in a diagnosis of PTSD as mentioned earlier in the report 6.4.4 The impact of Ms A’s mental distress was not assessed in terms of her capacity to care for the children and although therapeutic support such as psychotherapy was discussed Ms A did not pursue this option. The risk factors associated with maternal mental health problems were missed and despite often visiting the family on the same day, the HV who had most contact with the family had no knowledge of the Perinatal Team’s involvement. 6.4.5 Further to this Ms A was seen a number of times by her GP throughout the period under review, when her mental health was not assessed nor was her medication reviewed. The issue of medication is worthy of note as it would appear that Ms A told a number of professionals that she was prescribed (and taking) sertraline. There is, however, no indication Ms A ever took regular anti-depressants from when she was first started on treatment at the end of 2013 by her GP. This was never addressed by the GPs who saw her throughout her pregnancy with Child W and during the postnatal period. 6.4.6 The routine assessment of Ms A’s mental health may have been overlooked by the GP Practice in Lewisham because the original assessment (when she was presenting with severe symptoms) was conducted by the GP Practice in Lambeth and so therefore they had not noted this as a problem worthy of regular monitoring. They were however proactive in referring her back to the Perinatal Team once she became pregnant with Child W. 6.4.7 Neither of the GP practices screened for domestic abuse and this may have been because Ms A was often accompanied by either Mr C or the children. There were however at least two occasions when Ms A attended on her own and these opportunities could have been taken. 6.4.8 There was good communication about the family between the HV and the GP by virtue of their GP Liaison Meetings which were introduced to Lewisham GP practices in 2010. The meetings were held approximately every 6 weeks and although they acted as a good source of information sharing they did not result in any actions to support the family. 29 6.4.9 The GP Practice had not applied ‘safeguarding codes’ on the family’s records so when notifications came in such as DNAs for medical appointments these were not highlighted as being significant and therefore not always followed up. DNA’d appointments should have been viewed as a wider indication of neglect as the children were not having their health needs attended to. 6.4.10 The IMR provided by the GPs surmises that there may have been many assumptions by the GP practice about the care Ms A was receiving. For example, there may have been an assumption that she was already under the care of the Perinatal Team and that the HV had taken steps to bring in support from TFSS. Later on the children were also on CP Plans and the practice may have assumed that services were engaging the family. There was an opportunity to clarify these matters via the liaison meetings and the author of the GP IMR makes a helpful recommendation about how these meetings can be strengthened. 6.5 Interpretation of procedures when families move across Local Authority boundaries 6.5.1 The delay of the transfer of this case between Lewisham and Croydon CSC has been a source of much discussion among panel members and practitioners alike. In order to analyse it clearly it is necessary to take account of the facts which are set out below. 6.5.2 The family moved to Croydon from Lewisham on the 1st February 2015 and according to information from the Lewisham CSC IMR they had been planning to move to Croydon for some time. The exact details are not clear but it would appear that the housing arrears accrued on their Lewisham property were paid off and the family were assisted with the deposit to put down on another property in Croydon. It is not clear if they were actually evicted from the Lewisham property but they did have an address to move to. 6.5.3 The s47 enquiries taking place in Lewisham due to the domestic violence incident began in mid-January prior to the family moving to Croydon. Lewisham exercised good practice and continued to undertake the assessment despite the family having moved to another borough. 30 6.5.4 At the conclusion of their assessment when the decision to present the family to ICPC was made, the social worker and manager sought advice from a Child Protection Advisor (CPA) as to whether or not to go ahead with the conference on account of the family’s move. Again good practice prevailed and as the children were deemed to be at risk of significant harm the decision was to go ahead with the ICPC, invite colleagues from Croydon and then to transfer the case as a Transfer in Conference (TIC) in accordance with the London Child Protection Procedures (LCPP). This would ensure consistency of CSC involvement and continued risk assessment for the family. 6.5.5 Lewisham made contact with Croydon Multi Agency Safeguarding Hub (MASH) team on the 9th February to inform them that the family had moved to their area. The conference took place on the 25th February; colleagues from Croydon CSC were not able to attend but a HV from Croydon did attend. 6.5.6 The children were all made subject to CP Plans under the category of neglect. Mr C attended the ICPC but not Ms A and it was at the conference where plans were made to report Ms A and the children missing – an action that was taken immediately following the conference. Ms A and her children were located at Mr D’s address at the beginning of March and from 9th March Lewisham began the process of case transfer. 6.5.7 A series of transfer in requests and telephone conversations took place between Lewisham and Croydon and they were turned down. Requests for a TIC were received by Croydon on the 9th and 13th March and on the 8th April. It is likely that there was much more contact between the boroughs than has been recorded but what it clear is that it was a source of great frustration for both sets of practitioners and impacted on other work. 6.5.8 It is important to note that the requests came into the MASH team in Croydon. MASH is a non-case holding team whose core task is to filter requests for services and signpost them to the most appropriate place. The team have a period of 24 hours to make a decision as to where a case should be located and there is an emphasis on ensuring that cases are dealt with in a timely manner. 6.5.9 MASH teams across London are under immense pressure due to the number of referrals received. By the nature of how they are set up and resourced they are not equipped as a service to deal with cases on a medium or long-term basis. 31 6.5.10 The TIC request from Lewisham on the 9th March was not rejected as such – the worker dealing with the call asked for clarification of the address and some additional information so that the request could be processed. The case was however closed whilst Croydon awaited the extra information. In this process the practitioner sent incorrect forms to Lewisham and this is likely to have caused some confusion. This erroneous practice has now been addressed. 6.5.11 The information requested was provided to Croydon and Lewisham made a further request to transfer the case across on the 13th March. In this process they tried to ascertain why the TIC request had not yet been accepted. This request appears not to have progressed at this time, due to the manager’s annual leave and the fact that there was no one taking responsibility for their work whilst they were absent. Staff vacancies and the lack of a Deputy Team Manager impacted further on the delay. 6.5.12 On the 24th March the manager in Croydon reviewed the information and made the decision that the case could not transfer in at this time for two reasons. One was that the family had not made an application for housing in Croydon and the current address for Ms A and the children was overcrowded and not a long term option. The other was in relation to an allegation that Ms A was said to have made about Mr C sexually assaulting Child S. Mr C had disclosed this information at the ICPC and this had not yet been investigated. The manager’s view was that it was Lewisham’s role to investigate and this outstanding task needed to be undertaken before the case could transfer. 6.5.13 The allegation of sexual assault notwithstanding, the issue of housing is a complex one. Whilst Croydon were correct in being guarded against a family whose current accommodation was totally unsustainable due to overcrowding, they overlooked the fact that the family already had an address in Croydon. Not only that but also that Ms A had grown up in the area, had family connections and had been planning to move back for some time. 6.5.14 The break-up of Ms A’s relationship with Mr C was the catalyst for the move in with Mr D but in actual fact the family had already made their move at the beginning of February. They were renting accommodation privately and therefore had an assured tenancy in the Croydon area. It is also worthy of note that there was disagreement between professionals about the suitability (size wise) of Mr D’s address as it was a large three bedroomed house. Although technically it was overcrowded the property was deemed big enough to absorb the extra occupants at least in the short term. 32 6.5.15 The London Child Protection Procedures (LCPP) make no distinction between permanent and temporary accommodation but in the text of the procedures ‘permanent’ is defined in brackets as ‘more than 3 months’. (LCPP 6.4.1). This is confusing as on the one hand there is a very clear statement in the procedures that children are (with some defined exceptions) the responsibility of the borough in which they live, be it temporarily or permanently. On the other hand the addition of the 3 month rule skews that clarity in that it suggests a more permanent arrangement should be in place before a case is accepted. 6.5.16 In any event the nuances of this case render the procedures unhelpful as the family’s circumstances changed completely after they had moved and should have been subject to reassessment after the move due to the circumstances and new adults now involved in the children’s lives. These difficulties were exacerbated by the lack of shared understanding between the two boroughs of the family’s intentions. Lewisham were clear that Ms A (who had the children with her) intended to stay in the area with her new partner whilst Croydon maintained that this could not yet be determined due to the unsuitability of Mr D’s address. 6.5.17 It is not clear if Croydon were consulted on their view of the suitability of the accommodation not only in terms of overcrowding but also given their past knowledge of Mr D and his background. This may have given rise to a ‘negotiated alternative’ as described in 6.1.6 (LCPP) given the information Croydon held. In any event the suitability or otherwise of Mr D’s address was overlooked in the dialogue between the two boroughs and this led to a delay in the identification of risk. This is a significant factor given it would appear that Child W sustained her injuries whilst staying at that address. 6.5.18 It is significant to note that the transfer of case responsibility between HVs went smoothly with an exchange of verbal and written information very quickly following the family moving into the borough. That said, the children were not seen by a Croydon HV during this period and it was a source of frustration for the Lewisham social worker that no HV attended the core groups. 6.5.19 The internal transfer between HV teams within Croydon once Ms A moved to Mr D’s address proved to be a stumbling block in allocating the family to a HV. A HV assessment to assist the social worker in terms of the children’s health and development and in particular the impact of the latest moves would have been helpful. 33 6.5.20 Although lack of engagement has been highlighted as an issue, this review has revealed no evidence that any of the family’s moves (other than possibly the move to Mr D’s) were precipitated by avoidance or detection by statutory services. The threat of eviction triggered the final move to the Croydon address though it is understood that the family’s preference had been to move to Croydon for some time. 6.5.21 Two things may have helped resolve this dispute at an earlier stage. One difficulty lay in the fact that the Croydon MASH team held on to the information, which was not the most appropriate place for it to be held. Due to the nature of the team and the way they function it was not possible for them to deal with the technicalities of where the case should belong. 6.5.22 A system whereby the process of considering and arranging a TIC can be more effectively managed other than in the MASH team would be beneficial and the Croydon CSC’s IMR makes a helpful recommendation about which other staff could assist in this process. 6.5.23 The other beneficial addition to this process as pointed out in the IMR provided by CSC would have been consultation with a CP advisor (as advised in the LCPP) who then could have been tasked with negotiating between the two boroughs whilst keeping the children in mind. That said it is to Lewisham’s credit that they continued to make attempts to progress the CP Plan from a distance and without knowledge of local resources. 6.5.24 The spirit of the LCPP is encapsulated in Para 6.1.2 which states ‘In order to provide mobile families with responsive, consistent, high quality services, London local authorities and agencies must develop and support a culture of joint-responsibility and provision for all London children (rather than a culture of 'borough services for borough children')’. Child focused solutions are at the core of that statement but the burden on front line services coupled with ever dwindling resources places an enormous pressure to restrict the flow of cases requiring a service from CSC. 34 6.6 The voice of the child 6.6.1 The three very young children in this family had many contacts with professionals over the review period and their voice does not stand out strongly in the IMRs provided. Sections 6.1 and 6.3 cover aspects of professionals’ responses to neglect and notes that agencies did not assess risk over time. Therefore the accumulative effects of long term neglect and the children’s lived experience were missing. 6.6.2 Professionals did identify support needs for the children especially in relation to Child R and her apparent developmental delay. Services were offered to help with her difficulties but when these weren’t accepted the children’s needs were not assessed in isolation from the needs of the parents. The ICPC held in Lewisham in February 2015 was the first time that the impact of the parents’ lifestyle on the children had been considered fully. The impact of the frequent moves was specifically referenced as a risk factor. The outcome was the decision to make the children subject to CP Plans and the outline plan although brief was outcome focused and child centred. 6.6.3 The nursery were proactive in identifying Child R’s emotional needs from the outset and the TAF process was initiated and this led to Child R being more stable and settled in nursery albeit for a short period. 6.6.4 The IMRs provided by agencies are largely silent on the subject of the children’s lived experience, including what security was provided to the children, but the paragraph below gives some indication of this. 6.6.5 The nursery provided a helpful insight into the world of Child R for this review where they describe her as a child with significant difficulties in making relationships with peers. As she settled into nursery she became more confident but would prefer to spend time with familiar adults and found sharing their attention challenging. The nursery noted in January 2015 following the domestic abuse incident and subsequent police involvement, Child R became reluctant to go home and was on several occasions very distressed when she was collected. 35 7 Lessons learned 7.1 Assessment of neglect 7.1.1 Neglect of children is generally not a single event and the negative effects of emotional and physical neglect accumulate and become compounded. Responses from CSC were incident led and opportunities were missed to assess the children’s needs over time to assist in measuring the impact of the help already offered. As a result the children did not receive the help they needed in a timely fashion. 7.2 Interface between Early Help services and statutory intervention 7.2.1 This case has highlighted the need for Local Authorities to have clear ‘Step Up/Step Down’ procedures in relation to families who reject offers of Early Help. The mechanisms for ensuring that families receive the appropriate service did not work as intended in this case. 7.3 The vulnerability and needs of young parents who are caring for very young children 7.3.1 The parents’ needs in this case were great. Less is known about Mr C but in relation to Ms A agencies held significant information particularly around her mental health needs. The risks for the children arising from the parents’ own needs were underestimated and this case has highlighted the need for Adult services and GPs to be fully involved in Early Intervention processes. A full assessment of Mr D incorporating his history was not undertaken by any agency prior to Child W presenting with her injuries. 7.4 Interpretation of procedures 7.4.1 Policies and procedures, whilst designed to be helpful, are not always sensitive to the demanding nature of Child Protection work. In this case there was a different interpretation of the London Child Protection Procedures between the two boroughs (Croydon and Lewisham) and local nuances influenced practice. This ultimately led to a delay in assessing the new circumstances in which Ms A and the three children lived when they moved in with Mr D and his mother. As this is where Child W was living when her injuries were discovered this assessment was a significant omission. 36 7.5 The children’s lived experience 7.6 It is important that the focus of any assessment or work with a family has the child or children at its core. There are often barriers to engaging with children, but some means of engagement are necessary in order to get a sense of who they are, what their daily experiences are and how living with neglect impacts on them. The children’s lived experience was poorly assessed and this may have been as a consequence of how difficult the family as a whole were to engage. On occasions when professionals did engage with the children (particularly Child R) they were unresponsive. The adults in this family were often uncooperative and defensive making it more difficult to keep the children’s needs in mind. 8 Recommendations for the LSCBs These should be read in conjunction with recommendations from the agency IMRs 8.1 Lewisham LSCB 8.1.1 The LSCB to oversee a review of arrangements of the ‘Step up/Step Down’ procedures to ensure that families who need help but reject offers of ‘Early Help’ do not slip through the net. 8.1.2 The LSCB to develop (or review if one exists) a multi-agency strategy for dealing with families who experience neglect. 8.1.3 The LSCB to oversee a review of ‘repeat referrals’ to MASH specifically to ensure that families who are subject of repeat referrals to the MASH receive the appropriate service. 8.1.4 The lessons from this review to be shared with members of the Safeguarding Adult Board to ensure a joint approach to vulnerable adults who are also parents can be established. 8.2 Croydon LSCB 8.2.1 CSCB to review the current arrangements for managing the process of Transfer-In Conferences. 8.3 Croydon and Lewisham LSCBs 8.3.1 The LSCB to review its learning programme to ensure it includes multi-agency training on ensuring that the voice of the child is central to any contact or assessment. 37 8.3.2 The LSCB to develop a range of resources of Direct Work tools for practitioners to draw on when assessing children’s needs, including very young children (who may be pre-verbal) 8.3.3 A joint letter from both Boards to be sent to London Children Safeguarding Board to seek clarity regarding consistent practice to children and families moving across LA’s particularly (but not exclusively) London boroughs. This is to ensure that guidance is in line with Working Together 2015. Jane Doherty Independent Social Work Consultant March 2016 38 APPENDIX 1 Recommendations from agency IMRs Children’s Social Care - Croydon Agency Recommendations Action Date Lead Outcome (what must be achieved) Evidence & RAG Rating Croydon Children’s Social Care 1.Strengthen Management Support Review management support & cover arrangements for leave of duty manager Strengthened Management Support when duty manager on leave Croydon Children’s Social Care 2.Strengthen Oversight on duty cases Review process for monitoring & reviewing cases held on duty Process for monitoring & reviewing cases held on Duty strengthened Croydon Children’s Social Care 3.MASH should consider seconding social workers for a time limited period or identify opportunities for continuation of practice skills in working with families Role of social worker in MASH reviewed MASH social workers continue to have practice experience working with children/families Croydon Children’s Social Care 4. Ensure cases are escalated to Senior Managers and CP Advisor involved in line with LCCP Professional Conflict Resolution Review and strengthen current arrangements in relation to TIC Monitoring in place to ensure cases are escalated appropriately to senior managers and CP Advisor in line with LCCP Professional Conflict Resolution Croydon safeguarding Board with Children’s Social Care 5.Croydon Safeguarding Board support LSCB CP Advisors Group in clarifying transfer in conference requests for Mobile Families & Housing Letter to London Children Safeguarding Board to support more consistent practice to children and families moving across LA’s particularly London boroughs Agreed understanding and more consistent practice to TIC particularly between London boroughs to mobile families and housing issues Croydon Children’s Social Care 6.Information sharing should include relevant information including history of fathers/male partners and paternal extended families Supervision/audits. Ongoing relevant training Relevant information on fathers & male partners and their families is included in information sharing. Assessments have family trees and genograms. Croydon Children’s Social Care 7.Basic information on ESCR is kept updated Audit Clarity of roles & responsibilities on ESCR recording when cases have transferred Family Justice Centre 8.Mandatory training programme Risk identification Checklist ‘Safe lives’ continued Monitor attendance by practitioners/ Managers on programme Increased knowledge and consistent approach to risk assessment where domestic abuse across social care 39 Children’s Social Care – Lewisham Transfer arrangements between the Referral & Assessment service and the Family Social Work team for children in need should be reviewed to give assurance that systems promote allocation of these cases in line with need. A review of the step down process from Referral and Assessment to Early Help services with a particular focus on the management of risk should be undertaken. A process review for Early Help services to refer back to the Referral and Assessment Team in the event of non-engagement of families should be undertaken, to ensure appropriate follow up is made as required. The Lewisham Safeguarding Children Board conflict resolution process should be reissued to promote use at an earlier stage in the event of problematic case transfers. An audit of Children’s Social Care service thresholds should be included in the thematic audit programme as part of on-going Quality Assurance activity. Health Overview Report (Lewisham) Each health IMR completed has its own recommendations that will be followed up by the individual organisations and the LSCBs involved. The following recommendations are in addition to these: - To evaluate the maternity pathway to improve the communication between maternity services in out of borough districts and the patient’s local health services. The Lewisham Health Overview Author suggests that the recommendation by the NSPCC 2015 to change the name ‘Did not attend (DNA)’ to ‘Was not brought’ since this may identify vulnerable children more readily. Review of health professional’s supervision as requested by Lewisham LSCB. Action: The audit will be presented to the LSCB March 2016. This audit is coordinated by the author of this health overview report. The health overview author suggests that the recommendation by the NSPCC 2015 to change from using the phrase “Did Not Attend” (DNA) to “Was Not Brought” since this may identify vulnerable children more readily. 40 Action: The author will discuss this suggestion with the LSCB in Lewisham as part of the revision of the DNA LSCB fact sheet. The Lewisham LSCB requested an audit of health safeguarding supervision to explore whether there are cases of vulnerable families not being discussed at supervision. This audit began in September 2015. Action: This audit is in progress and includes GP services, LGT and SLaM. This audit will be presented to the LSCB in March 2016, by the author of the health overview. Health Overview Report (Croydon) All organisations to consider how the convening of discharge planning meetings is strengthened in order to sure that there is a robust multi agency plan in cases where there are safeguarding concerns and/ or complex needs. Perinatal services to consider how they can ensure that other key health professionals are made aware of cases which raise significant concerns and that information is shared effectively.(SLaM) Croydon health services to consider how a standard can be developed which ensures that information from MARAC is responded to effectively and in a timely fashion. (CHS) All organisations to consider how they can support staff in their safeguarding practice and encourage them to challenge other professional’s views when there are differences. Strengthen the Croydon IMR author’s recommendation re child protection allocation in order to ensure that it is also child focussed. (CHS) Chelwood Nursery School If they do not already exist – better cross borough procedures for managing the support/ safety of vulnerable children families who move from one borough to another is needed to ensure continuity of support and prevent needs going unaddressed or a sharp fall-off in support. Where such procedures do exist they need better implementation / monitoring/ system of oversight to ensure they are sufficiently robust to avoid children in vulnerable circumstances being put at further risk when their support networks are removed in this way. Croydon Health Services NHS Trust 1. Child protection allocation process to be more robust. 2. Transfer of records within and out of Health service 1 to be more robust. 3. All staff employed by Health Service 1, including volunteers and contracted staff, need to understand their responsibilities in relation to Domestic Abuse and Sexual Violence. This includes understanding actions to be taken when information liaised out from MARAC. 41 4. All staff employed by Health Service 1, including volunteers and contracted staff, need to understand their responsibilities in relation to ill parental mental health. South London and Maudsley NHS Foundation Trust Recommendation 1 There is an audit of Perinatal Team and MAPPIM records to evaluate whether service users are being asked appropriate questions about domestic violence during pregnancy. This should be followed up by an action plan where standards fall below those expected. Recommendation 2 The expectation of robust communication with Children’s Social Care and the documentation of MDT discussion should be addressed in supervision with members of the Perinatal Team. General Practice (Croydon and Lewisham) Previous serious case reviews in Lewisham have resulted in learning about areas which are highlighted in this Review i.e. mental health assessment and domestic violence screening during antenatal and postnatal contacts, about maternity-related safeguarding risk factors, and about importance of having a DNA policy. In addition, importance of coding using recommended child safeguarding codes, and the importance of having regular HV-GP safeguarding meetings and working as part of a multi-disciplinary team to improve early intervention processes to safeguard children, all have been highlighted in training and in Practice Leads supervision meetings. Thus recommendations for Lewisham GPs are an extension of previous recommendations in these areas and an assurance of implementation by practices. Problem Recommendation Action Measure of implementation By whom Due date RAG 1.The practice did not record actions resulting from HV-GP meetings HV-GP meetings must have minutes and an action log, which is reviewed at each meeting, and where appropriate, recording of discussion and actions on patient records. Named GP will disseminate this recommendation. After 3 months, all GP safeguarding leads to send to Named GP the minutes of their last HV-GP meeting. 90% of practices can show minutes are taken and there is an action log Named GP Safeguarding Leads March 2016 42 Named GP 2.Mental health assessment and screening for domestic violence is not regularly being carried out by GPs during antenatal and postnatal contacts Increase awareness of domestic violence and mental health screening and assessment during antenatal and postnatal periods through training and supervision. The antenatal and postnatal templates which includes questions on mental health and DV screening will be disseminated again. Survey monkey for GPs and PNs specifically around mental health and DV issues during pregnancy will partly be used to inform content of training. Include in Level 3 training for 2016-18 specific emphasis on DV screening and assessing mental health during pregnancy and postnatal periods. IRIS to be commissioned for Primary Care in Lewisham and Practice 2 to be in Phase 1 of implementation. Survey monkey will be repeated 1 year later. Named GP April 2016 for survey monkey and development of Level 3 training for 2016-18. June 2017 – review of survey monkey results. 3. DNAs (children missing appointment) were not acted on. Every practice should have a DNA policy for children. There is an on-going DNA audit being carried out. This will be completed. A report from the audit will be completed. Named GP December 2015 43 4. Mental health needs of Mr C were not explored fully. The role of male figures in serious case reviews should be highlighted more in training. Role of men and mental health screening for men will be included in Level 3 training in 2016-18 Content of Level 3 training for 2016-18 will be passed to the training (PTT) sub- group of the LSCB once it has been developed. Named GP April 2016 Recommendations for GPs in Croydon 9.2 This Review did not involve any GP practices in Croydon. However, the learning from this Review can be extended to the GPs in Croydon. 9.3 Each practice in Lewisham has a Safeguarding Child Practice Lead who attends bimonthly supervision meetings with the Named GP. The Lead signs a form which states their responsibilities for this role. The lead participates in audit, ensuring staff training, dissemination of safeguarding information received from the Named GP, and ensuring the General Practice Safeguarding Standards are implemented. If Croydon practices do not have practice leads for children safeguarding, it is recommended that this system be introduced. 9.4 HV-GP meetings every 4-6 weeks to discuss vulnerable families is now firmly implemented in Lewisham. Both doctors and health visitors find these meetings useful in order to exchange information and formulate plans for early intervention to help support these families. An action log and good minutes is important for each meeting. 9.5 A practice DNA policy for children who miss hospital appointments and surgery appointments for immunisations is strongly recommended. The Lewisham suggested policy is available for practices to follow3. 9.6 Increasing awareness of mental health problems and domestic violence during pregnancy and the postnatal period is needed amongst GPs and PNs. This should be incorporated in Safeguarding training specifically delivered for general practice. Commissioning of a training and screening program such as IRIS (Identification and Referral to Improve Safety) may be considered. Greenwich and Lewisham NHS Trust Training staff to recognise signs of neglect and understand the impact this can have on a child Training of staff to recognise and understand the impact that mental health and domestic abuse has on families Review Health Visitor Guidelines to clarify criteria and expectations of all levels of health visiting support that are offered to families Training of staff to enable them to feel confident about challenging families or other agencies Review Safeguarding Supervision Policy 44 Guys and St. Thomas’s NHS Foundation Trust Health Visitors to maintain centile charts for all children as opposed to writing narrative in the progress records of a child. Kings College Hospital Foundation Trust No recommendations Metropolitan Police Service No recommendations |
NC52290 | Death of a 4-week-old boy in July 2020 attributed to non-accidental head injuries. Learning includes: the family should have continued to receive the right level of support when they were transferred to another local authority; disagreements between local authorities over the transfer and status of the family caused delays in the family receiving the appropriate level of service; housing services not being aware of the neurodiversity and safeguarding needs of the family; lack of communication between mental health services and children's services; bruises or marks observed on a non-mobile baby should have triggered a robust multi agency response. Recommendations include: current approaches to risk assessment through child protection enquiries or child in need processes obtain and take sufficient account of family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties; strengthening education and training on the think family approach, as well as neurodevelopment disorders and what such difficulties mean for parents' understanding and interpretation of information and advice; raise the role of housing services in statutory child protection processes as an issue of concern with the Child Safeguarding Practice Review Panel, including how housing services share information with partners and how they assess vulnerable families who need accommodation; ensure practitioners understand the significance of bruising in infants and the need to act.
| Title: Baby ‘R’ – local safeguarding practice review. LSCB: Bexley S.H.I.E.L.D. Author: Jane Doherty Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Baby ‘R’ - Local Child Safeguarding Practice Review (Bexley S.H.I.E.L.D.) Reviewer – Jane Doherty – Independent Social Work Consultant 2 1 Introduction 1.1 This Child Safeguarding Practice Review was conducted in response to the death of a 4-week-old baby in 2020 who at the time of his death was subject to a Child Protection Plan in the London Borough of Bexley. Baby R’s parents presented him to hospital with non-accidental head injuries and he died a few days later. 1.2 The family had been known to multi agency child protection services since the birth of Baby R’s older sibling (known in the report as Child S), amid concerns around neglect. 1.3 Baby R’s death was notified to Bexley SHIELD and at a Rapid Review meeting which took place shortly after the baby’s death, members recommended a Local Child Safeguarding Practice Review should take place. They notified the National Panel who agreed with their recommendation. 1.4 The incident led to Child S being placed in foster care and a police investigation commenced. 2 Terms of Reference 2.1 The time period for the review is from July 2019 (a year before the incident to August 2020). This included an expectation that relevant information prior to that would be summarised to add context to the information. Agencies also provided brief information for the period May to July of 2019 as that is when the family first moved out of Bexley to Kent. 2.2 The full Terms of Reference are attached at appendix 1 but the Panel members requested specific information about the following areas. • The identification and response to risk (individually and on a multi-agency basis) for the parents and the children including the following areas: parenting capacity, mental health, the parents young age and troubled childhoods, learning disability and neurodiversity, drug use, domestic abuse, and resistance to engagement • Issues arising from diversity • What was known about father’s other child and how curious were practitioners about this situation, including how agencies ensured that father was engaged in assessments • How did agencies understand the transient nature of this family and how was this dealt with? • How agencies understood and implemented escalation processes between the local authorities 3 • What impact did COVID 19 have on the circumstances of the child / family and/or on the capacity of services to respond to their needs. • Practitioners’ understanding of policies and procedures and how they support their work – e.g., bruising policy, transfers, escalations, access to previous records and information etc • Areas of good practice 3 Summary of professional contact Background history 3.1 Mother experienced early childhood neglect and was in care as a child. She was subsequently adopted into a family where she spent most of her childhood. The adoption broke down when she was in her late teens, and she became Looked After by Croydon Children’s Social Care. She has suffered with poor mental health since she was a teenager and at times expressed suicide ideation. She was diagnosed with a reactive attachment disorder, a moderate social disability and (latterly) autism. At the time of the incident, she was supported by Croydon’s Leaving Care Service. 3.2 Father is also reported to have experienced disruption in his childhood and was known to Lewisham Children’s Social Care. His parents died when he was a child, and he went to live with an aunt in Bexley. He was diagnosed with a speech and language disorder, dyslexia, and autism traits in his early teens. 3.3 Mother became pregnant in 2018 with Baby R’s older sibling. He was on a Child Protection Plan (pre-birth) in another London borough and the plan was subsequently transferred to Bexley. The concerns at that time were Mother’s unstable mental health, lack of engagement with ante-natal appointments and poor financial management. There were worries about how the couple would manage a new-born baby given their own difficulties. Key Period of Involvement May 2019 – November 2019 Family moved from Bexley to Kent. 3.4 At the start of the period under review the family were living in Kent, having moved from Bexley in May 2019. Child S had been subject to a Child Protection Plan in Bexley for seven months and remained on the plan until September 2019. 3.5 When the Child Protection Plan in Bexley ended, a referral was made to Kent Children’s Social Care as a Child in Need. The family were offered Early Help services in Kent but despite efforts, after a very short period of intervention the family did not engage. 4 PRACTICE LEARNING POINT When the Child Protection Plan ended in September 2019, Child S was effectively stepped down to an Early Help Service in Kent which, when the parents declined this, meant that they were without support. The circumstances surrounding the Child Protection Plan being stepped down is elaborated on in paras 4.7 – 4.9. Good practice would have been to ensure that the family continued to receive the right level of support in transferring of the family from one Local Authority to the other. Key Period of Intervention 2; December 2019 – March 2020 Kent CSC undertake an assessment/Family move back to Bexley 3.6 In December 2019, Mother’s Leaving Care worker in Croydon made a referral to Kent Children’s Social Care and a family assessment was undertaken under s17. The worker was worried about an arrangement for the older child to go abroad with a family friend had not been well thought through. She further noted that Mother was pregnant with Baby R and was concerned about how the parents would cope with two very young children. 3.7 Kent’s assessment recommended a Child in Need plan but before this could be implemented, the family moved back to Bexley in March 2020. NB this coincided with the COVID-19 pandemic and the subsequent lockdown which made visiting and supporting the family much more difficult. 3.8 There were disagreements between Bexley and Kent about the status of the family, e.g., Practitioners in Bexley felt that the Child Protection framework was more appropriate than Child in Need. There was subsequently a short delay with the transfer. To avoid further delay Bexley accepted them as a Child in Need transfer at the end of March 2020. PRACTICE LEARNING POINTS The disagreements between Kent and Bexley over the transfer and status of the family caused delays in receiving the appropriate level of service. Good practice was however seen in the second transfer when these were escalated further in line with Kent and Bexley’s escalation protocol. This is discussed in paras 4.1 – 4.4 Housing moves were very difficult for this family, given their needs around neurodiversity and their challenges in making relationships. Good practice would dictate that Housing departments be cognisant of these needs. This family’s needs in terms of neurodiversity and safeguarding were not understood by housing. In addition, their difficulties were exacerbated in March 2020 by the Covid-19 global pandemic. This is discussed in paras 4.13-4.16 5 Key Period of Intervention; April 2020 – June 2020 Family become subject to a second Period of Child Protection Plan 3.9 Amid growing concern about the parents’ capacity to care for Child S and a newborn baby, the Social Work team discussed with the Child Abuse Investigation Team with a view to undertaking s47 enquiries. The police were not in agreement and thought this decision was premature. The assessment continued and support was offered to the family, albeit with limited face to face contact during this early period of lockdown for the United Kingdom. 3.10 In May the couple separated briefly and this caused stress to them both – Mother had contemplated suicide and Father had reportedly ‘hurt himself’. The couple reunited the following day, but a strategy meeting was held and single s47 enquiries were agreed between police and Bexley Children’s Social Care. An Initial Child Protection Conference was booked for early June. This was cancelled due to an administrative problem and took place later that month. Both children were made subject to a Child Protection Plan under the category of emotional abuse. 3.11 In relation to Mother’s suicide ideation, there was some confusion about which service to refer Mother to. This caused a delay to her having an immediate assessment. There was some liaison between Children’s Services and Mental Health Services, but mental health professionals were not involved in the multi-agency meetings about the care of the children. A Family Network Meeting took place Just prior to Baby R’s birth. This was attended by Father’s family and a family friend and good support was offered, especially around the time of the baby’s birth. 3.12 Child R was born in mid June 2020. PRACTICE LEARNING POINTS Mental Health services were key for this family given the parents troubled backgrounds and previous difficulties. A holistic service to the family was hampered by the lack of communication between mental health services and children’s services. A more collaborative approach would have meant that services were appraised of each other’s involvement and concerns and joint planning would have been a priority. Mental Health professionals were not part of the core group for this family. This is discussed in paras 4.23– 4.26 The delay to the Child Protection Conference caused by an administrative error, falls short of acceptable standards of practice. This has been addressed with the relevant service as part of the review process and a recommendation is made to ensure that there is appropriate oversight of decisions such as these. Key Period of Intervention 4: July 2020 - Observation of bruises 3.13 In early July, the health visitor visited the family at home. Whilst there, she observed bruising on Baby R’s left cheek and ear. The parents were unsure how this had happened 6 but thought Child S may have thrown a toy into Baby R’s cot. There was a delay in the health visitor telling the social worker about the injuries but a core group meeting which took place about a week later discussed the bruising. The explanation changed but this was not questioned further. 3.14 In July 2020 – the incident which led to this review unfolded and Child R sadly died. PRACTICE LEARNING POINT Best practice for bruises or marks observed on a non-mobile baby is the triggering of a robust multi agency response including s47 enquiries and a Child Protection Medical examination. This did not happen in this instance and the review noted that there was a lack of knowledge among the professional network about the high risks associated with bruises in non-mobile infants. This is discussed in paras 4.17 – 4.22 4 Findings Transfer of Case responsibility across local authorities for children subject to child protection and child in need plans Initial transfer from Bexley to Kent – May 2019 4.1 The panel identified key issues arising from the family’s moves in terms of how services were able to work with them and these are examined in turn in the paragraphs below. 4.2 At the start of the review period (May 2019), Child S was subject to a Child Protection Plan in Bexley under the category of neglect, but the family had moved to Kent. The Bexley social worker and Bexley health visitor continued to work with the family whilst they were in Kent until September 2019 when the Review Child Protection Conference in Bexley decided to end the Child Protection Plan. Expected practice in this area would be that the family would transfer to the Local Authority in which they were living. Bexley CSC did not inform Kent that a child on a Child Protection Plan was residing in their area so that they could place the child on their temporary register. This would have been an avenue to start the negotiations of transfer at a much earlier stage. It also meant that Child S was not flagged as a child with a Child Protection Plan, had an emergency occurred in Kent. 4.3 According to the case records in both Bexley CSC and Bromley Healthcare, the reason for not transferring in this case was due to Bexley Housing assessing the family’s housing needs, prior to accepting them to be permanently housed. This was delayed and the social work and health visiting teams were cautious in case housing transferred them back to Bexley which was their preferred borough. Part of the reason for the delay was due to the parents not being proactive in submitting the correct paperwork for the housing assessment. Significantly, housing was not party to the safeguarding process. 4.4 At the Review Child Protection Conference, the plan was to transfer to Kent Children’s Services on a Child in Need Plan but the need for this was disputed by Kent Children’s 7 Social Care. Their view was that Bexley should continue with the Child in Need plan and continue to work with the family across the border. Bexley however closed the case as the family were no longer living in their borough and Kent declined to accept them as a Child in need. 4.5 This is a complex situation made more complex by the lack of formal procedures about transferring Child in Need cases from one local authority to another especially (as in this case) where the two local authorities do not share a set of child protection procedures. A more child centred approach (and procedurally correct in both local authorities) would have been for Bexley to make a request to Kent for a Transfer in Child Protection Conference soon after the family moved there in May of 2019 regardless of their housing status. There is a clear process to follow in this circumstance and this would have alerted Kent to the family and allowed for some joint planning between the local authorities. Although the family were placed in temporary accommodation (which is sometimes an argument for not transferring a case), often, this is for lengthy periods of time - ten months in this instance. This family were using local resources in Kent during this period so it would make sense for a transfer to occur. 4.6 Consideration of timing of the transfer and a thought out transition plan was needed for this family. Unfortunately, between the two local authorities, the family were left without support when they declined the offer of Early Help in Kent. Despite many attempts, Kent workers were unable to establish contact and had declined to accept the family on a Child in Need basis. In this circumstance, it would have been prudent for Bexley along with services in Kent to review their positions and if necessary, use their internal escalation processes to ensure that the family received the right level of support. 4.7 On reviewing the minutes of the Child Protection Conference of September 2019, it is difficult to see the rationale for the decision to ‘step down’. Of the four professionals who attended the meeting, three of them thought that the child protection plan should continue but they were overruled by the Chair. The child protection plan had not been progressed and although there had been some improvements, there was much that was outstanding. Mother did not have mental health support in place and there had been a police call out due to an argument between the parents. Those who knew and worked with the family felt that the parents were very dependent on professionals to organise themselves and that without structured support in place they would struggle to maintain the progress they had made. The decision was based on the ‘here and now’ rather than considering the history and additional needs of this family. 4.8 It is extremely unusual practice to end a child protection plan without having a clear transition plan of support and this fell short of expectations of good practice. It is difficult to conclude anything other than the decision being overtly influenced by the fact that the family were no longer living in Bexley, rather than considering who and what service could best support this vulnerable family. Child S’s voice and his lived experience do not come through strongly in this feature of the practice. 4.9 Bexley Children’s Social Care missed another opportunity to revise their plan, when shortly after the Review Child Protection Conference a concern was raised by a member of the network about the ending of the Child Protection Plan. This was good practice on their part. The decision was reviewed by a manager who upheld the original decision. It 8 is not clear who else was consulted at that time to review the decision, but this was hampered by the premature case closure. The manager did recommend that a handover meeting take place between Bexley and Kent, but this did not happen as there was no practitioner in Kent to handover to. Second period of transfer from Kent to Bexley March 2020 4.10 The family were offered accommodation back in Bexley (their preferred location) in February 2020. As described in the narrative, Kent Children’s Social Care had conducted a Children and Family Assessment just prior to the move and this necessitated a further transfer from Kent to Bexley Children’s Social Care. 4.11 There was disagreement between the two boroughs about the appropriate framework in which to work with the family. This caused delay to Bexley Children’s Social Care accepting the family as Child in Need. Kent’s practitioners escalated the difficulties, and this was resolved between the two relevant service managers. This is an example of this process being used to good effect, but this was more protracted than it needed to be due to the disagreement. Added pressures at that time would have been evident in both Kent and Bexley as this happened as the UK went into the first lockdown because of the global C-19 pandemic in March 2020. Local authorities had to adjust very quickly to new circumstances, and this caused anxiety and stress within the workforce. Good practice was noted by Kent who continued to visit the family whilst the dispute was negotiated despite the national lockdown. 4.12 There was also good recognition of the impact of the moves in the work done by Bexley and the parents preferred method of communication it is noted at the Initial Child Protection Conference in June 2020. Housing Participation in the safeguarding process 4.13 Within the many assessments conducted during the period under review, the family’s housing situation was always recognised as an added pressure for them. In the timeframe, the family moved out of Bexley to Kent and then back again but prior to that they also moved around. Many moves are inevitably destabilising for families, and this is case is no exception. 4.14 Mother was entitled to be housed as a care leaver but the only option for her would have been to be housed as a single person in Croydon and she did not want to reside there. The family were therefore allocated temporary accommodation which was (as is often the case), in another borough. 4.15 The nature of families living in temporary accommodation means that they have little or no say in the moves that are required of them. In this instance it was detrimental to the family, not least because of the parents’ needs around neurodiversity and finding it difficult to make new relationships. In this situation, there is a complex dynamic to negotiate as the responsible housing department is different from the one providing local services. This was then further exacerbated by the move to virtual visits and consultations used by many agencies when the C-19 pandemic made face to face visiting more difficult. 9 4.16 There was some liaison with housing departments between agencies but there was a disconnect in the safeguarding process as housing providers were not engaged in multi-agency assessments and plans. Housing was therefore not aware of how agencies were seeking to reduce the risks in this family and the impact that moves would have on them. There is no evidence that housing departments sought to understand the family’s safeguarding needs or the needs of the adults in relation to their neurodiversity. They were therefore unable to contribute to the plan. 4.17 A positive move forward because of this review has been an agreement by Housing that families with children subject to a Child Protection Plan will not be moved out of the borough in which they are residing . This is a welcome move and will reduce the stress and impact of many moves for vulnerable families. Agencies understanding and response to bruises or injuries in non-mobile babies 4.18 The observation of bruises to Baby R’s face and ear (aged 3 weeks) in early July were not dealt with in a robust manner. The parents were unable to offer a definitive explanation which should have aroused suspicion, given the very young age of the baby and the need to always supervise a toddler. The health visitor told the social worker two days later as an adjunct to a separate matter. Core group members discussed the bruise, and the parents’ explanation had changed. Members of the core group did not challenge the family about their change of explanation or seek to investigate further. 4.19 It has emerged that the practitioners involved with this family lacked an understanding of the high risk indicators associated with bruises or marks in non-mobile infants. The significance of them is a well-rehearsed theme from other multi agency case reviews. The National Institute for Clinical Excellence (NICE)1 provide very strong guidance based on extensive research on this subject. The current health policies in existence stress the high risks associated with bruising in babies but the evidence from this case indicates that the everyday application of this in practice needs to be developed. Regardless of the circumstances and the explanation (however plausible) there should be a standard response. The absence of consultations (through the process of s47 enquiries) with colleagues to check out the explanation given and treat the incidents with a degree of uncertainty was poor practice. Bromley Healthcare have strengthened their safeguarding training and supervision in a response to this. 4.20 It is necessary to consider the possible impact of the C-19 global pandemic on the response to the bruising. As a result of the pandemic, offices were generally closed and although in this case face to face visits occurred workers became much more isolated in their work. Working from home and conducting meetings via the internet became the norm and the team working of a busy office environment was lost to many. Child protection work is very complex and those on the front line rely on being able to reflect and check things out with their colleagues and managers. The absence of this supportive environment may have contributed to a lack of reflection. This also meant some management oversight was lost and created space for more errors of judgement made by frontline practitioners which went unchallenged. Usual checks and balances were not 1 National Institute for Health and Clinical Excellence. (July 2009 Last Modified October 2017) When to suspect child maltreatment. NICE clinical guideline 89. 10 present to take time to step back from a situation and agree a way forward. An additional stress was caused by many health workers having been redeployed which at one stage was nearing 50%. Their workload therefore fell to practitioners who were still in their main role. 4.21 In the period March – October 2020, OFSTED reported a 20% increase in non accidental injuries to infants2. This was attributed to the added pressure that parents were under, coupled with the complexities of trying to offer support to during the pandemic. This is an alarming figure, given that a significant proportion of non-accidental deaths of children is already high in that age group. 4.22 To support early implementation of the learning from this review, the panel were made aware that Bromley Healthcare have taken several actions to ensure staff have relevant knowledge and training. This includes updating their general safeguarding policies to be more explicit about non-accidental injuries in non-mobile babies, additional training covering this specific subject and an emphasis on the policy and the need to treat this as a high-risk event. Bromley Healthcare have since completed an audit on under 1’s. Children social care have also completed an audit on work with under 1’s to provide assurance of how well the needs of under 1’s are being responded to. 4.23 At the time of the incident, Bexley SHIELD did not have a policy that covered the expectations of a multi-agency response, but this is now in train. The policy will be officially launched with a multi-agency training offer to embed the practice fully. This is due to begin in September 2021. Practice will be strengthened by a requirement of an immediate referral to the relevant social worker or to Bexley’s front door services. Usual practice for such incidents would then be to ensure that the baby is subject to a multi-agency strategy discussion, s47 enquiries and an assessment by a specialist paediatrician. Requirements for which agencies must attend the strategy meeting will be made explicit within the new policy and this includes the presence of a community paediatrician to advise and assist with decision making. Updated information will also be available to parents in line with the new protocol. Liaison between Mental Health Services and Children’s Services 4.24 The parents’ mental health was a key issue for this family. As previously noted, they both had troubled histories and had received support from services in the past. They both had diagnoses in relation to their neurodiversity which added to their complex presentations. Both parents would have benefitted from a ‘trauma informed’3 approach. 4.25 Mother received support from mental health services during both of her pregnancies. She had a pattern of engaging well during a crisis but disengaging once she felt better. She was aware that she needed support but was not always forthcoming with attendance at appointments and this became more of an issue once the C-19 pandemic prevented face to face visits. 4.26 The information provided by Oxleas about their services makes some important points in 2 https://www.gov.uk/government/speeches/amanda-spielman-at-ncasc-2020 3 An approach which considers a person’s adverse experiences such as severe domestic abuse, unformed or broken attachments to carers, parental substance and/or alcohol misuse and chaotic or unpredictable routines in childhood. 11 relation to how they supported Mother and some comprehensive recommendations for improvements. To summarise there was some delay to services in Mother’s second pregnancy and poor internal communication between the Perinatal Mental Health Service and the Primary Care Plus services. 4.27 From a multi-agency perspective, Mother’s mental health workers were not embedded within the network of professionals supporting the family and this was problematic. They were not therefore party to the discussions that happened at the Child Protection Conference and did not contribute to the children and family assessments conducted by Bexley in 2020. They therefore did not form part of the core group which is designed to implement the child protection plan. This is particularly pertinent given Mother’s suicide attempt in the month prior to the meeting being held as that was the trigger to initiate child protection enquiries. There was a need for practitioners to ‘Think family’ and to work with them in a more holistic way. 4.28 Positive changes have been made in the Perinatal team since this incident. Practitioners are now required to complete a Safeguarding children assessment for every new service user (and their unborn/baby), this is in addition to a comprehensive mental state assessment. This is an encouraging step and compliance, and quality of the information will be monitored by senior managers. 4.29 As result of learning from this review members of the panel recognised that there needs to be an improved response to parents with mental health problems and their families. To address this, SHIELD and the Adult Safeguarding Partnership have started work on a joint ‘Think Family’ Protocol to strengthen this approach in the borough. There is ongoing development of restorative practice and an emphasis on adopting a collaborative approach with families. The priority will be joint learning events for children’s and adults’ workers together with the launch of the protocol. Senior leadership from across both partnerships will champion this practice to ensure it is embedded across agencies. The impact of the learning identified will be reviewed and evaluated through the Bexley multi-agency learning forum. This will be further supported by a focus on the Department for Education’s ‘Think family’ evaluation project which includes multi agency processes outside of statutory meetings. This will ensure an ongoing review of the impact and outcomes from the learning in this review. Impact of the parents’ identity and presentation on their day to day lives and capacity to parent 4.30 The parents of Baby R were vulnerable. They had both suffered trauma in their childhoods and struggled to communicate effectively with each other. Mother spoke of their arguments and their somewhat tempestuous relationship. Whilst they agreed a safety plan with professionals to address this, it was becoming a more frequent occurrence. They had little in the way of family support to help them care for two very small children and at times managed this by the older child being cared for, for lengthy periods of time by friends. More is said about this in the following section. 4.31 In the first period of child protection planning the review has highlighted that their vulnerability was not sufficiently assessed. Other multi agency reviews have highlighted 12 the issue of young parents with additional needs and the lessons are repeated here in terms of the depth of knowledge about Mother and Father’s mental health problems, how they were assisted to address them and how this affected their parenting. Mental health services were not sufficiently engaged with the safeguarding process throughout the review period. Greater recognition and account of their difficulties was made in the second period of child protection planning with some proposed targeted work about their histories and support with parenting. Sadly, this was curtailed due to the events on this review. 4.32 The parents were very open about their additional needs and recognised themselves as finding certain things hard such - making and maintaining relationships, being proactive in completing tasks and contacting professionals by telephone. During the C-19 lockdowns this difficulty was exacerbated by several services being provided over the telephone or via the internet. Good practice was exercised by Bexley CSC and Bromley Healthcare who continued to visit the family face to face. 4.33 Father’s child from a previous relationship with whom he had no contact was not explored with him as part of the assessments. Given his childhood experiences and concerns raised, it would have been helpful to be more curious about this and have had more specific details, not only in terms of him being a safe carer but also the impact for him of not being in contact with this child. 4.34 The information provided by agencies is mostly silent on the issue of how their conditions impacted on their parenting. This indicates that the records also do not reflect detailed consideration of it and the ‘think family’ approach has yet to be embedded. Issues of neurodevelopment (neurodiversity) and an understanding of these on the impact on parenting need to be developed and although worked has started (see following paragraph), a recommendation is made to this effect to keep this on track. 4.35 To address these issues, SHIELD jointly with children’s social care have commenced a training programme and the first round of ‘trauma informed’ practice training has been delivered. This will be followed up by complementary training which will equip practitioners to better understand neurodiversity and its possible impact on parenting capacity. The overall aim is to improve multi agency risk assessment that considers the whole family and this is now a main priority in Bexley. This training package and its impact will be monitored through single agency and multi-agency audits as part of the council and SHIELD’s quality assurance frameworks. Assessing the children’s lived experience and the capturing the voice of the child. 4.36 Following on from the above in terms of assessing the complex needs of the parents, the two very young children (more so Child S) in this family had many contacts with professionals over the review period. Their voice does not however stand out strongly in the information provided. In the first period of intervention, the interruption of services when the family moved out of the borough meant that agencies did not assess the risk of neglect over time. Therefore, the accumulative effects of long-term neglect and Child S’s lived experience were missing and as stated elsewhere the Child Protection Plan ended. Professional curiosity was not exercised when it was noted that Child S spent considerable amounts of time being cared for out of the family home. 13 4.37 In the second period of intervention, the subsequent Child Protection Plan (although short lived due to the circumstances of the review), was much more child oriented and the focus of the plan was to achieve security and stability for the children. Good practice was seen when the family were assessed as high risk and therefore despite COVID restrictions practitioners continued to visit face to face as much as they could. There were stronger descriptions and discussions of the likely impact of the parents’ behaviour on the children and these were clearly set out. The conference made good use of previous information about the parents’ struggles to care for one child and related this to the arrival of a new baby and how challenging this would be for them. The multi-agency network recognised the parents’ own difficulties and were beginning to put plans in place to address some of these. Sadly, these plans were curtailed as a result of Baby R’s death. 5 Parental Contribution 5.1 The parents were notified that a Child Safeguarding Practice Review was taking place at the start of the process and to invite them to contribute. Despite several attempts they have not contributed to date, and this represents a key gap in the information and analysis. It is however an understandable decision by them, given the stressful situation they have found themselves with the loss of their child in and pending police investigation. Both parents have been made aware that this option remains open to them if they wish to take this up in the future. 6 Recommendations 6.1 Bexley SHIELD should seek assurance through audit that current approaches to risk assessment (through Child Protection enquiries or Child In need processes) obtain and take sufficient account of family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties. Trauma informed training has taken place to support further learning. Bromley Health care and Children’s Social Care have both conducted separate audits on children under 1 to inform ongoing work measuring impact of learning from this review. Education on neurodiversity and awareness raising on Think Family approach should remain as part of ongoing areas of practice for review within Children Social Care and beyond. 6.2 To support the above Bexley SHIELD should continue to seek to strengthen education and training across the partnership on Think Family, neurodevelopment disorders and what such difficulties mean for parents’ understanding and interpretation of information and advice. This should be made available for all agencies in contact with parents and children. 6.3 Assurance should also be sought that those relevant adult services such as mental health and housing are consulted as an integral part of the assessment and planning process. The Director of Children’s Social Services has held discussions with housing department and shared the learning from this review. A multi-agency protocol on completing assessments has been refreshed to reflect the recommendations and learning from this review. 6.4 Bexley Housing Services should ensure that they respond to invitations to multi agency 14 meetings and that their policies and procedures reflect their responsibilities to attend these. The agreement made by Bexley Housing Services that families with children subject to Child Protection Plans will not be moved out of the borough of residence, needs to be embedded in local practice. 6.5 As a result of learning from this review and similar multi agency reviews where a family’s housing situation has been noted to be challenging, Bexley Safeguarding Children Partnership should raise this as an issue of concern with the National Panel. This is regarding Housing’s role in statutory child protection processes, how they share information with partners and how they assess vulnerable families who need accommodation. 6.6 The initial findings from this review have been shared with Bexley Safeguarding Adult Board with a view to working jointly on the ‘Think Family’ protocols and training. The newly developed protocol addresses the importance of a collaborative approach to assessments and the need to establish a link with housing providers to ensure that they are sufficiently versed in a family’s circumstances. 6.7 SHIELD should review and adapt, if necessary, the process undertaken when the decision of a Child Protection Conference is challenged by another professional. The multi-agency practice guidance currently being reviewed should provide clarity about the process and minimum expectations to be laid down about who should be consulted. Bexley guidance will now include in all cases, the requirement for there to be senior management oversight of the decision, and for evidence of this to be visible on the records. as part of this process. Clarity should be provided to agencies attending Child Protection Conferences about what pathway to follow in cases where they wish to register a formal dissent. SHIELD in conjunction with the Independent Chair Manager is reviewing Practice guidance to include the above changes. 6.8 In addition, Children’s Social Care should provide assurances to SHIELD that the process of postponing Child Protection Conferences that occur due to administrative or technical errors is robust and has children’s safeguarding at its core. 6.9 Work began immediately by SHIELD to ensure that practitioners understand the significance of bruising in infants and the need to act. Going forward this should include clarity about the referral pathway to MASH, increased awareness raising of existing policies (frontline practitioner events, audits of practise, visual aids etc) and that it remains a focus for all safeguarding partners as the learning is embedded. As part of this work SHIELD should update information available to parents to ensure it is in line with their new protocol. 6.10 In addition, through regular audits of practice in this area, SHIELD should be assured of its continued high profile and partner agencies’ consistent compliance with its application. Any decision not to adhere to the Bruising Policy should be escalated to a senior manager to review. 6.11 SHIELD and Kent Safeguarding Children’s Partnership to undertake some joint work in reviewing the lessons of this CSPR and agree a protocol for case responsibility for families who are placed between the two boroughs 15 Jane Doherty Independent Social Work Consultant September 2021 |
NC046599 | Death of a 22-month-old boy on 20 February 2013. Child S was taken to hospital after his mother found him lifeless. A post mortem examination established that he had suffered severe abdominal injuries. Mother and father were both convicted of causing or allowing the death of a child in December 2014. Child S had been the subject of referrals prior to his birth and had been subject to a child protection plan for emotional abuse since August 2012. Mother had a history of substance misuse and mental health issues and father had a history of domestic abuse and drug dealing. Learning points identified include: difficulties in working with individuals who disguise their compliance resulting in an overly optimistic view of outcomes for the child; misunderstanding between agencies about what and how information about adults who may post a risk to children can be shared; poor attendance by some agencies at initial child protection conferences. Recommendations include: development of clear joint information protocols for the police and children's social work services and a review of the booking system for initial child protection conferences to ensure a minimum notice period is given to professionals across all agencies.
| Title: Independent overview report of the serious case review following the death of Child S. LSCB: Solihull Local Safeguarding Children Board Author: Mike Harrison, Jim Stewart Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SOLIHULL LOCAL SAFEGUARDING CHILDREN BOARD Independent Overview Report of the Serious Case Review following the Death of Child S Date of Serious Incident: 20.02.2013 This report has been commissioned and prepared on behalf of the Solihull Local Safeguarding Children Board. Until publication this report is confidential and must not be shared with non-relevant parties. References relating to the subject child, family members, organisations, and professionals have been coded and anonymised. Independent Authors, Overview Report Mr Mike Harrison: March 2013-December 2014 Mr Jim Stewart: December 2014- September 2015 Independent Chair, Serious Case Review Panel; Ms Jane Held: March 2013 – November 2013 Independent Chair, Solihull LSCB Ms Marion Davis CBE: May 2013 - September 2014 Ms Edwina Grant OBE: September 2014 - present day Agreed by Solihull Local Safeguarding Children Board: 15th September 2015 CONTENTS Foreword by Independent Chair ............................................................................................................ 3 1 INCIDENT LEADING TO THIS SERIOUS CASE REVIEW ......................................................................... 4 2 THE SERIOUS CASE REVIEW PROCESS ............................................................................................... 4 3 PARALLEL INVESTIGATIONS ............................................................................................................... 9 4 FAMILY INVOLVEMENT IN THE SERIOUS CASE REVIEW .................................................................... 9 5. KEY TO PERSONS LISTED .................................................................................................................... 9 6 GENERAL FAMILY BACKGROUND .................................................................................................... 10 7 CHRONOLOGY OF SIGNIFICANT EVENTS IN RELATION TO THE INVOLVEMENT OF THE AGENCIES 10 8 ANALYSIS OF AGENCIES’ INVOLVEMENT ......................................................................................... 16 9 CONCLUSIONS ................................................................................................................................. 38 10 LESSONS LEARNED ........................................................................................................................... 40 11 RECOMMENDATIONS ...................................................................................................................... 43 Appendix 1: LSCB Action plan; Position statement. ............................................................................. 47 Appendix 2: Individual Agency Recommendations .............................................................................. 54 Appendix 3: Roles of Agencies ............................................................................................................. 57 Appendix 4: Glossary of Terms ............................................................................................................. 59 Appendix 5: Bibliography ...................................................................................................................... 61 2 Foreword by Independent Chair The death of a child is a tragedy. This little boy, “Child S” was born in April 2011 and died on February 20th 2013. Investigations into his death revealed that he suffered traumatic abdominal injuries sustained in a way that the experts say cannot have been accidental. The investigation also revealed that only two people could have been responsible for his death. His parents were sentenced at Birmingham Crown Court on 22nd December 2014 for causing or allowing the death of a child under the Domestic Violence Crime and Victims Act 2004. All those who knew him, or worked with him, want to know what happened and why he died. Solihull Local Safeguarding Children Board (LSCB) began this serious case review process in 2013 in order to help those who worked with this child and his family to establish if there is anything we can do to improve how we work together in Solihull to help protect and support children in this situation better in the future. This serious case review took place over a period of 2 and a half years. The process took so long as during that time it was suspended to allow criminal proceedings to complete. Producing this report has involved staff and family members as well as leaders in the organisations involved working hard to convey their reflections and bring this learning together. The delay in publication did not prevent everyone who worked on this report making changes as soon as they realised they were necessary to deliver better practice following lessons learned. Actions plans were produced by the LSCB as well as by each of the agencies involved and all have been delivered. A summary of the current position of the LSCB action plan is provided at the end of this report. Each organisation involved continues to improve and the Local Safeguarding Children Board coordinates the way we act on lessons learned from this review and also from reviews carried out in other areas in the country. In the time it took to write this report, organisations have changed, some have re-structured, procedures and training have been reviewed and new quality assurance arrangements have been put in place. All these changes are delivered with the single objective to strive for excellence in how we work together to safeguard children. Edwina Grant OBE LSCB Independent Chairperson 3 1 INCIDENT LEADING TO THIS SERIOUS CASE REVIEW 1.1 Ms M, the mother of Child S, called an ambulance to her home address in the early hours of 20 February 2013 having found Child S lifeless. Child S was 22 months old at the time. Ms M reported that Child S had been ill for the previous two days. Child S was taken by ambulance to the local accident and emergency department and he was pronounced dead at 5.32 am that morning. 1.2 A post mortem examination was carried out and expert medical opinion was given at the subsequent criminal trial. It has been established that Child S had suffered severe abdominal injuries likely to have been caused by a blow or blows of some kind, the injuries probably having been sustained up to approximately twelve hours before his death occurred. It was also confirmed that there were older abdominal injuries which indicated that Child S had been the victim of a trauma about two or three weeks earlier. 1.3 Child S had been the subject of referrals prior to his birth and had been the subject of a child protection plan since August 2012 for emotional abuse. His mother, Ms M, had had involvement with a number of statutory agencies over a period of some years in connection with her substance misuse, experience of domestic violence and fluctuating mental health and mood. 1.4 The partner of Ms M, Mr N, who is believed to be the father of Child S, was staying in the family home at the time of Child S’s death. His presence in the home was in contravention of the child protection plan and a working agreement with the local authority. The agreement was that he should not be staying at the home when Child S was there, whilst an assessment was being completed due to his history of suspected drug dealing and domestic abuse. 1.5 Both Ms M and Mr N were arrested and bailed by West Midlands Police and interviewed on suspicion of the murder of Child S. They were subsequently charged and then remanded. A criminal trial took place between November – December 2014 and Ms M and Mr N were both convicted of causing or allowing the death of a child. 2 THE SERIOUS CASE REVIEW PROCESS 2.1 The events surrounding the death of Child S were considered by an independently chaired serious case sub group of the Solihull Local Safeguarding Children Board (LSCB) on 11 March 2013. 2.2 The relevant guidance on the holding of Serious Case Reviews at that time is contained in Working Together to Safeguard Children. 2010 (Chapter 8) Paragraph 8.9 and states that: “When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family. These SCRs should include situations where a child has been killed by a parent, carer or close relative with a mental illness, known to misuse substances or to perpetrate domestic abuse.” 2.3 The LSCB Chair agreed with the sub group’s recommendation that the appropriate threshold criteria for holding a Serious Case Review were met and the Department for Education (DfE) and Ofsted were notified of the decision on 22 March 2013 and agency files were secured. 4 2.4 Guidance on the conduct of Serious Case Reviews (SCR) was revised by the Department for Education in March 2013 and later in March 2015 in revised editions of ‘Working Together to Safeguard Children’. This SCR has been conducted under the guidance in force at the time of the death of Child S (Working Together 2010), although the circumstances for holding such a review would also apply under the revised guidance. The contents of the new guidance issued in March 2013 has also been taken into consideration in the preparation of this Serious Case Review and the guidance subsequently issued in March 2015 in its conclusion. Purpose of the review 2.5 The purpose of the review was to: Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children. Identify clearly what these lessons are, how they will be acted upon, and what is expected as a result. Improve inter-agency working, better safeguarding and promoting the welfare of children. 2.6 In accordance with the guidance contained within Working Together (2010) a SCR panel was formed and an Independent chair and Independent author appointed. 2.7 Ms Jane Held was appointed as the independent chair. Ms Held has an extensive background in children’s services having formerly been a Director of Social Services and a senior manager within the Commission for Social Care Inspection. At that time Ms Held was also currently the independent chair of both Leeds and Birmingham LSCBs and highly experienced in the conduct of Serious Case Reviews. 2.8 Mr Mike Harrison was appointed as the independent author. He is an experienced SCR author with over thirty six years’ experience in children’s social care services. He has held a number of senior management posts in local authorities including as an assistant director of children’s services. He is a former National Inspector of Children’s Services and HMI with Ofsted and has received training in authoring Serious Case Reviews from the National Safeguarding Delivery Unit and the Social Care Institute for Excellence. He is fully independent of all of the safeguarding agencies comprising the Solihull Local Safeguarding Children Board. 2.9 Mr Harrison retired before the criminal trial took place following Child S’s death. A further independent author, Mr Jim Stewart, was commissioned to update the report in the light of any further information and learning identified during the criminal proceedings and subsequent interviews with family members who agreed to assist this Serious Case Review. Serious Case Review Panel 2.10 A Serious Case Review panel was established with the following membership: • Independent Chair: Jane Held (From March 2013- November 2013) • The panel was chaired by the LSCB independent Chair, Edwina Grant from September 2014 until it was completed. • Solihull Local Authority Children’s Social Work Services 5 • Birmingham and Solihull Mental Health Foundation Trust • Welcome • Solihull Integrated Addiction Services (SIAS) • Heart of England NHS Foundation Trust • West Midlands Police • Solihull Community Housing • Solihull Clinical Commissioning Group Please see Appendix 3, page 57 for a description of these agencies. 2.11 In addition the following post holders formed part of the SCR panel • The Domestic Violence Coordinator • Local Authority Legal Representative • Drug and Alcohol Action Manager • LSCB Safeguarding Officer/Manager • LSCB Lay members The independent author attended panel meetings but was not a member of the panel. Terms of Reference 2.12 The terms of reference for the review were initially drawn up by the SCR Sub Group and subsequently modified and agreed by the SCR Panel in respect of the compilation of Individual Management Reviews. The terms of reference for the review drew on the guidance contained within Chapter 8 Working Together (2010). 2.13 Specific terms of reference were set for the compilation of this overview report. The report should identify the key inter agency system learning, good practice and specifically address: a) The effectiveness of multi-agency identification, analysis and management of risk and information sharing arrangements including any identified barriers to achieving effective management of risk b) The quality of risk assessments and validity of any tools or processes used to identify protective factors as well as risk factors c) The quality and impact of multi-agency planning and review processes used to promote improved outcomes for children d) The impact and quality of professional supervision and its contribution to securing child centred practice including exploration of the ‘rule of optimism’ or any over reliance on protective factors e) The application of ‘thresholds’ and the degree of shared understanding and agreement across the partnership of those thresholds 6 f) Any ’cultural practice norms’ that could impact on the professional network’s capacity to deliver child centred practice including responses to domestic abuse or substance using parents g) The degree to which the multi-agency system operates with the child at the heart of its intervention and any ‘system’ barriers to securing this 2.14 The scoping period for the review was set between August 2010 being the onset of Ms M’s pregnancy with Child S and 20 February 2013 being the date of Child S’s death. Methodology 2.15 The following agencies were asked to produce Individual Management Reviews (IMRs) • West Midlands Police • Birmingham and Solihull Mental Health Foundation Trust • Heart of England NHS Foundation Trust • Solihull Community Housing • Solihull Clinical Commissioning Group (on behalf of and in collaboration with their member practice) • Solihull Metropolitan Borough Council • Welcome 2.16 Information reports which did not constitute IMRs were received from the following agencies: • HMP Eastwood Park • Staffordshire and West Midlands Probation Trust • West Midlands Ambulance Service 2.17 Independent authors who had had no previous involvement with the case were identified by those agencies which had been asked to produce an IMR. A briefing for those authors was held on 8 April 2013 led by the chair of the Serious Case Review Panel and involved the SCR panel members. 2.18 The terms of reference and scope of the review were provided to the IMR authors together with a standardised format for the production of the IMR reports. The IMR authors were asked to compile a chronology of their individual agency’s involvement with the child or family using both electronic and paper records held by each agency and to comprehensively review that involvement. 2.19 In doing so the IMR authors conducted personal interviews with the key individuals who had involvement with Child S and Child S’s family. The aim of the interviews was to look openly and critically at what happened in the case, to evaluate what actions were taken or not taken and why, to indicate any lessons to be learned for future practice and to make recommendations for action. In completing the individual management reviews the authors were asked to take cognisance of the relevant guidance on such matters as contained in Working Together to Safeguard Children (2010) Paragraph 8.39. 7 2.20 The SCR Panel were provided with the completed IMRs and had the opportunity to question and challenge those reviews at panel meetings held on 10 June 2013 and 8 July 2013 where the IMR authors were present. As a result of those challenges, the IMR authors completed further investigations and the IMRs were modified and enhanced, which improved their quality and analysis. The SCR overview author was present for all of the case discussions, and was able to question the IMR authors and fully debate the issues in the case with the SCR Panel from an independent perspective. 2.21 The individual management reviews contain reference to relevant research in a number of areas and the independent author has had the opportunity to review that research and its bearing on this case, as well as reviewing other guidance and research independently. Those sources of research are fully referenced at the end of this report. All IMRs received by the SCR Panel were certified by a senior officer in each individual agency as having been completed to the standard required by Working Together (2010) Paragraph 8.35. 2.22 A Learning Event was conducted on 19 August 2013 facilitated by the independent chair of the panel and the independent author. The aim of the event was to involve relevant staff in the SCR process, based on restorative practice principles, and to gain their insights into why events happened as they did, and to assist in identifying and disseminating learning from the case. A total of 14 professional staff attended the event with representation from across the safeguarding agencies involved in this case. 2.23 A health overview report comprising information derived from the IMRs of the various health agencies involved was compiled by the designated nurse for safeguarding children. This report was accepted by the SCR Panel as the health overview report on behalf of the Clinical Commissioning Group in its role as commissioner of health services in accordance with requirements in Working Together (2010) Paragraph 8.35. 2.24 The SCR independent overview author has prepared this overview report based on the IMRs received by the SCR Panel, the detailed discussions in panel meetings, the content of the learning event, and relevant guidance and research. 2.25 A meeting of the Solihull Local Safeguarding Children Board (LSCB) held on 16 September 2013 considered an initial draft of this overview report. As a result of those considerations the Board issued a request for additional work on the review. 2.26 This additional work was commissioned by the LSCB Chairperson which was carried out under the leadership of the Independent SCR Panel Chair and in conjunction with the Independent Overview Report Author. 2.27 The aim of this was to inform the LSCB approach to embedding the learning identified in the Overview Report and focused upon: • Testing out the hypothesis originally formed • Exploring what had got in the way of embedding learning into practice in the past • Focus on the ‘why’ question with the aim of identifying root causes or influences on front-line practice • Identifying any cultural norms or patterns of practice affecting service delivery • As appropriate, producing outcome focused recommendations 8 • Critically appraising the extent to which agency IMRs address the ‘why’ question and, make additional outcome focused recommendations for individual agencies, as required 2.28 The work involved front-line staff and first line managers as well as senior managers and was to be completed within three months. 2.29 In order to address these additional terms of reference the Chair of the SCR Panel and the Overview Author undertook a further four learning events with personnel directly involved with the case. The learning events took the form of small group workshops aimed to engage directly with the professional staff involved with the case in order to focus specifically on why events had taken place as they did. These events were held on 20 December 2013, 23 December 2013, 8 January 2014 and 10 January 2014. A total of twenty nine professional staff members across the agencies attended these events. 2.30 The results of the additional work have been integrated into the report which has been produced for full publication. The report focuses on the professional involvement and inter agency working with the family. 3 PARALLEL INVESTIGATIONS 3.1 West Midlands Police conducted an investigation into the death of Child S and subsequently passed information to the Crown Prosecution Service (CPS). Ms M and Mr N were charged with murder, causing or allowing the death of a child and neglect. Their trial took place between November and December 2014 and both Ms M and Mr N were found guilty of causing or allowing the death of a child. 4 FAMILY INVOLVEMENT IN THE SERIOUS CASE REVIEW 4.1 The mother and father of Child S were informed of the decision to conduct this SCR. 4.2 Following the criminal trial, Solihull Local Safeguarding Children Board (LSCB) invited Ms M, Mr N and maternal grandmother Mrs K to meet separately with the independent author to contribute to the Review. The Independent Author and the LSCB Business Manager interviewed all three adults separately to inform this Review. 5. KEY TO PERSONS LISTED Child S Subject Child Child T Child S’s Half sibling Ms M Child S’s Mother Mr N Child S’s Putative Father Mrs J Child S’s Maternal Great Grandmother Mrs K Child S’s Maternal Grandmother Ms A Child S’s Maternal Aunt Mr L Child’s Maternal Grandfather PGM Paternal Grandmother PGF Paternal Grandfather Ms E Previous partner of Mr N and mother of Child T Mr W Previous partner of Child S’s Mother 9 6 GENERAL FAMILY BACKGROUND 6.1 Child S was born in April 2011 and died in February 2013. He lived with his mother throughout his life and had regular contact with his mother’s extended family. His putative father reportedly moved into the family home in October 2012. His mother describes Child S as a lively, happy child. He had a fish tank in his bedroom and he enjoyed feeding the fish. Professionals reported that Child S had made good developmental progress during his short life. 6.2 Child S’s ethnicity is dual heritage as is his mother and father’s. 6.3 Ms M, the mother of Child S, had informed the overview report writer that she has experienced traumatic incidents as a child and an older teenager and that she has had on-going difficulties with depression. She also experienced domestic abuse during relationships prior to and following Child S’s birth. She had significant issues with substance misuse, including cannabis, crack cocaine and heroin. Her parents had separated but she remained in contact with both of them. Ms M had been arrested on ten occasions which resulted in criminal convictions for nine offences committed between October 2009 and August 2010. Much of her criminality appears to have related to her drug use. 6.4 Ms M served a short prison sentence in 2010 during which she discovered she was pregnant with Child S. She described the pregnancy as unplanned but was positive about becoming a mother. 6.5 Mr N, the father of Child S, was looked after by a different local authority as a child. He returned to live with his mother as an older teenager. Mr N had a long term relationship with Ms E with whom he had a child and Ms E also had two other children. Mr N was known to Adult Services as a carer for Ms E. There were reports of domestic violence in this relationship. Mr N had known Ms M for many years. He did not see Child S until the baby was six months old when he and Ms M resumed their relationship. 6.6 Mr N has accepted he was the biological father of Child S (although paternity has not been proven). Between September 1999 and June 2011, prior to Child S’s birth, Mr N was arrested by West Midlands Police on seven occasions resulting in nineteen convictions for drug related issues. He also has convictions for robbery, theft and assault. Mr N has allegedly continued involvement in the use and sale of drugs but he has consistently denied this. He has admitted to regularly using cannabis. 7 CHRONOLOGY OF SIGNIFICANT EVENTS IN RELATION TO THE INVOLVEMENT OF THE AGENCIES 7.1 The chronology below describes what the authors consider to be the key events in the case in relation to contact with and involvement of agencies with the family. It is not intended to be a comprehensive record and does not include all of the events, visits or actions undertaken by the professionals or others involved. 7.2 The chronology seeks to capture an illustrative summary in order to provide a framework for the detailed analysis and to assist learning from the case. 7.3 In August 2010 Ms M was convicted of theft from her own maternal grandmother, Mrs J, for which she received a short custodial sentence. Her pregnancy with Child S was confirmed during her sentence. While in prison she participated in a detoxification programme. Just prior to release Ms M was linked with the Solihull Integrated Addiction Services (SIAS) to assist her to continue her drug abstinence, particularly in light of her pregnancy. 10 7.4 Upon release from prison in 2010, Ms M went to stay with family members including her mother, Mrs K, and her sister, Ms A. Ms M made a homelessness application to Solihull Community Housing and was granted a tenancy with effect from December 2010. 7.5 Two referrals were made to Children’s Social Work Services from Midwifery Services in November 2010 due to concerns about Ms M’s substance misuse difficulties and her pregnancy. A risk assessment was carried out by Children’s Social Work Services which resulted in a decision to take no further action. 7.6 During this period Ms M was seen on an intermittent basis by professionals at ‘Welcome’ a substance misuse service. There was a pattern of missed appointments. Ms M initially led ‘Welcome’ staff to believe that she was free of drugs. 7.7 In December 2010, following a referral from the Welcome service, Children’s Social Work Services undertook an initial assessment of Ms M’s unborn child (Child S) because she was approximately five months pregnant and her lifestyle had potential consequences for the health and welfare of the baby. Ms M admitted lapsing into cocaine use. The outcome of the initial assessment was a judgement that Ms M would be able to meet the needs of her child when born and no further action was taken. A third referral from the midwives was completed on 21st December 2010. 7.8 At the end of December 2010 drug testing was undertaken by the Bridge Service (Birmingham and Solihull Mental Health Foundation Trust) and proved positive for a number of ‘Class A’ illegal drugs. Ms M disputed the validity of the tests citing the use of a urine sample she had submitted being some weeks old. 7.9 In January 2011 the Bridge wrote to Solihull Children’s Social Work Services to confirm that Ms M was continuing to use crack cocaine and to smoke cannabis on occasions. A ‘team around the family’ (TAF) approach was adopted in order to work with Ms M. 7.10 A child in need plan was drawn up by the social worker (SW5) which required Ms M to work with the local authority and other agencies, including substance misuse services, undertake weekly drug screening and attend all of her ante natal appointments. 7.11 Later in January 2011 ‘The Bridge’ undertook a drug test of Ms M which proved negative. Ms M had stated that she would attend drug treatment services for testing to satisfy the requirements of Children’s Social Work Services. She did not believe that she needed treatment or support for substance misuse. Because of the criteria for the service, the Bridge specialist drug worker explained to Ms M that this meant they could no longer work with her. 7.12 In February 2011 the case was reallocated to SW7 by the local authority Children’s Social Work Services as the previous social worker had left the authority. While the possible relapse into drug usage was recognised by the professionals involved, drug screening at this time had proved negative. 7.13 The social worker (SW7) commenced a pre-birth core assessment in late February 2011 to assess the potential risks to the unborn child from drug misuse and domestic violence, both of which had historically been difficulties for Ms M. 7.14 During the assessment process SW7 was told by Ms M that the father of her unborn child was a perpetrator of domestic abuse and she did not wish him to know about the pregnancy. She also confirmed she was in another relationship. She did not give details of the father to agencies although there is a child in need plan which includes the first name of the father. 11 7.15 In order to complete the core assessment SW7 undertook a total of two visits to Ms M and one visit to her mother Mrs K. Child S was born in April 2011. 7.16 The core assessment was completed by SW7 in early May 2011. The assessment indicated that Mrs K, Child S’s grandmother and Ms M’s new partner, Mr W, were viewed as sources of support and the case could soon close. 7.17 In late May and June 2011 Child S was seen by the health visitor (HV5), no concerns were recorded and a ‘good relationship’ was noted between the mother and child. 7.18 This view was confirmed by Children’s Social Work Services in July 2011 when SW7 received supervision on the case from Assistant Team Manager (ATM4). It was noted that Welcome had had one telephone contact with Ms M and had discharged her from the service. 7.19 Child S was seen by SW7 throughout this period April – July 2011, and although observed to be often left in a baby chair, the child was assessed to be well. 7.20 During late July 2011 the Police visited the home responding to a referral about domestic violence. The incident was not reported to Children’s Social Work Services or Public Protection Services and would be the first of five visits to the home in 2011 made by the Police responding to allegations of domestic abuse. 7.21 In August 2011 Child S was noted by HV5 to be gaining weight appropriately, feeding well, smiling and laughing and was clean and well dressed. HV5 recorded no concerns. 7.22 In August 2011 Children’s Social Work Services received an anonymous allegation of drug misuse at Ms M’s home which was investigated by both Children’s Social Work Services and the Police. Limited evidence was available to support the allegation and Children’s Social Work Services decided to commence closure of the case. 7.23 In late September 2011 the Police and Children’s Social Work Services’ professionals became involved again when Mr W, who was living in the household, was arrested for being drunk and disorderly and an anonymous allegation was received about drug dealing and loud arguments at the home. 7.24 SW7 in conjunction with the ATM5 decided that the case should remain open with a pattern of unannounced visits. A safety plan was put in place and a ‘signs of safety’ evaluation completed. 7.25 HV5 carried out a home visit in early November 2011 and recorded Child S as clean, appropriately dressed, able to crawl, roll both ways and vocalise. Appropriate weight gain was noted and Child S then weighed just over 8 kilograms from a weight of 4.2 kilograms twenty days after birth. The health visitor expressed no concerns. 7.26 In November 2011, during a visit from the SW7, Ms M was noted to have sustained scratch injuries to her face. She stated that these injuries were self-inflicted and minimised them, denying that domestic abuse had taken place. A referral was received by Children’s Social Work Services from the Public Protection Service within the Solihull Local Authority with a total of eleven incidents over the previous month listed of alleged noisy arguments, drug abuse and domestic violence. 7.27 SW7 consulted the Team Manager (TM1) who directed that a further core assessment be undertaken. SW7 met with Ms M who admitted she had relapsed into heroin use and was 12 having loud, aggressive arguments with her partner Mr W. SW7 warned that if the aggressive arguments continued a child protection conference would be called. 7.28 Welcome re-engaged with Ms M at this time although she missed several appointments with them. When she was seen in late December 2011 she admitted only to the use of cannabis. 7.29 In December 2011 SW7 undertook a home visit following a police referral because Mr W had damaged the property and left. Ms M confirmed the relationship between herself and Mr W was over and he had gone abroad. 7.30 SW7 left the local authority at the end of December 2011 and the case was reallocated to SW11. 7.31 In January 2012 a Children’s Social Work Services’ service user made an allegation that Ms M was smoking heroin in front of Child S. In response SW11 made three unannounced visits to the home during January, all of which were unsuccessful. A substance misuse worker from ‘The Bridge’ visited on 23 January 2012 and also found no one in. Professionals later understood that Ms M had taken Child S out of the country to see Mr W, and had subsequently returned. Ms M and her mother have informed the independent author that Child S stayed with his maternal aunt during this period. Ms M was seen by staff at ‘The Bridge’ later on 23 January 2012. 7.32 It is unclear when SW11 saw Child S, if at all, in the period between taking on the case in December 2011 and late March 2012. 7.33 In late March 2012 a record of supervision between SW11 and ATM5 note a number of unannounced home visits had taken place as well as checks with the health visitor working with Ms M and Child S. The case was discussed with an indication for closure. No records of the visits or their content are available to support this account. 7.34 Also in late March 2012 Ms M’s GP and Children’s Social Work Service were informed that she had been discharged from Welcome and The Bridge as being ‘drug free’, using the national definition of this term. 7.35 During April 2012 SW11 met with Ms M and Mr W (who had returned to live with her) at the Children’s Social Work Service’s office to discuss another two reported incidents of domestic violence which had been notified to Children’s Social Work Services. 7.36 Following supervision between SW11 and ATM5 on two occasions in May and June 2012, a closure summary was completed on 20 June 2012. The reason for closure is unclear in the information available to this review. 7.37 In July 2012 the Police contacted the emergency out of hour’s service in social care as Ms M had alleged to them that her family was keeping Child S away from her. The extended maternal family informed the Police that they were concerned that Ms M was using drugs and was incapable of caring for her son. Police protection powers were not used and the Police appear to have focussed on the adults involved rather than the impact of the adult’s behaviour on Child S. 7.38 There is a lack of clarity about the detail of the arrangements put in place. Police reported that arrangements were made for Mrs K, maternal grandmother, to look after Child S over the weekend and an agreement was made not to return Child S to Ms M before the involvement of Children’s Social Work Services. Mrs K does not accept that such arrangements were put in place and in fact she returned Child S to Ms M the following day. 13 7.39 At this time, in July 2012, Child S had not been seen by the health visitor for a period of several months. The last contact Child S had with professional staff was with Children’s Social Work Services prior to their closure of the case in June 2012. 7.40 Following the referral from the Police to Children’s Social Work Services, a family support worker (FSW1) became involved together with a duty social worker SW9 and a different assistant team manager ATM 7. 7.41 Information was gathered by Children’s Social Work Services that Ms M was no longer in a relationship with Mr W. A family member alleged that Ms M had threatened suicide and was using illegal substances. ATM7 directed that a risk assessment be completed, and if Ms M failed to comply then reallocation of the case would be considered together with what would be a third core assessment. On the same day an anonymous referral to Children’s Social Work Services alleged Ms M was again using heroin and cocaine. 7.42 An unannounced home visit was attempted four days later but Ms M was not in. Contact with family members established that they were unsure of the whereabouts of either Ms M or Child S and therefore the Police were informed of the situation by Children’s Social Work Services. Subsequently a strategy discussion was held on 20 July 2012 and a Section 47 investigation undertaken. Ms M and Child S were located at the home of Ms M’s grandmother. 7.43 An initial child protection conference was called and Child S was made the subject of a child protection plan under the category of emotional abuse in early August 2012. The conference was poorly attended, was not quorate, and key personnel, for example the Police and Welcome, were not present. 7.44 At the conference Ms M stated that she had had contact with Child S’s birth father, Mr N, although she was not interested in having a relationship with him or him with her. Ms M contradicted the information she had previously given about him as him being ‘abusive’ and ‘dangerous’ saying she was referring to another previous partner. Ms M refused to give any details of the father’s identity at the conference. 7.45 The social worker (SW3) who attended the conference informed the Police Child Protection Unit by telephone that Child S had been made the subject of a Child Protection Plan. However, this phone call did not trigger the action intended by SW3 of the placing of a ‘Flag’ in the police information system. The aim of the flag was to alert officers attending the home of the child protection status of the child. The accepted protocol that Children’s Social Work Services generate an email or fax to inform the Police and trigger a ‘flag’ did not occur, therefore officers attending the home subsequently had no knowledge of the child protection plan in place for Child S. It is significant that there was also no marker on the address in respect of domestic violence. 7.46 A series of core group meetings were planned as part of the child protection plan. Child S was not allocated to a social worker (SW10) until September. A further core assessment, the fourth in the timeframe of this review, was directed by ATM7 in accordance with the decision taken at the initial child protection conference. 7.47 Child S was seen during home visits during this period, and although home conditions were dirty Child S was always found to be clean, well fed and demonstrated good interaction with Ms M. In October 2012 Ms M confirmed that Mr N, the birth father of Child S, was living with her. SW10 began to undertake checks on Mr N in mid-October 2012. 14 7.48 A working agreement was put in place between Children’s Social Work Services and Ms M which included an expectation that Mr N would not be in the home property at the same time as Child S. Mr N was not asked to sign the agreement which did not include any contact arrangements for Child S and Mr N. 7.49 A risk assessment of Mr N (separate to the core assessment) commenced in late October 2012. Ms M was thought to be continuing to use substances intermittently throughout this period and Welcome confirmed that the last appointment Ms M had attended was in August 2012. 7.50 On 8 November 2012, the Police received an anonymous referral that Ms M was using drugs and that Mr N was dealing drugs from the address. The caller also stated that Child S was on a child protection plan. The police officer involved did not refer this information to Children’s Social Work Services or visit the family. 7.51 The core assessment was completed in mid-November 2012 and recommended that Ms M engage in relapse prevention work in respect of her drug misuse, the completion of a risk assessment of Mr N, and work with Ms M on protecting herself and Child S from domestic abuse. 7.52 In January 2013 the Social Care Duty Assessment and Referral Team (DART) were contacted by the Police regarding a domestic violence issue at Ms M’s home. There was some confusion as to who the alleged perpetrator was. Ms M denied that it had been Mr N and minimised the incident. The Police appear to have focussed on the adults involved rather than Child S and the possible effects of the domestic abuse on the child. 7.53 ATM7 and SW10 agreed that the referral did not require a strategy meeting. Ms M reported that the incident had been a ‘joke’, and that the alleged perpetrator was an old school friend, not Mr N. This explanation was accepted by the ATM7 and SW10. It was agreed that the risk assessment of Mr N should be completed by February 2013, and that ‘signs of safety’ work should be completed with Ms M. It was recorded that the thinking at the time was that Mr N did not pose a physical risk to Child S. 7.54 Child S was only seen once by a GP after being made the subject of a child protection plan; this consultation took place on 11 January 2013, “following a minor fall”. The GP was aware of Child S’s status as subject of a child protection plan and therefore potentially vulnerable. The GP confirmed that she was satisfied with the mother’s explanation for the minor injury and was reassured by her observations of the relationship between mother and child. 7.55 Child S had begun to attend a nursery in December 2012. Child S did not attend nursery on 11 January 2013 (Ms M informed them that he had sickness), 31 January 2013 (he was reported to have sickness and diarrhoea) and 15 February 2013 (no reason was provided for this absence). Also, the nursery had noted that Child S was collected from nursery by Mr N on 8 February 2013. 7.56 The Police received a further anonymous call about domestic violence on 6 February 2013 reporting that a man was assaulting a woman at Ms M’s address. Two police officers attended and found no signs of any violence. Child S was seen asleep on a man’s lap. The officers did not record the names of the adult or child in their record. The call was considered malicious, the incident was not recorded as a domestic abuse incident and there was no referral to Children’s Social Work Services or other agencies. 7.57 A core group meeting was held on 12 February 2013 although there is no record of the meeting. SW10 contacted an anti-social behaviour (ASB) Officer from Solihull Community Housing prior to the meeting in response to the ASB5’s telephone contact. The anti-social behaviour worker raised concerns about the welfare of Child S although there is no record outlining the reasons for 15 those concerns. The ASB Officer was not invited to the core group meeting although the social worker indicated the officer would be in the future. The risk assessment of Mr N was shared with the couple at the meeting; they were unhappy about it although nothing was recorded as to why this was. 7.58 SW10 made an announced visit to the family home on 13 February 2013. Ms M and Child S were seen and no concerns were raised. 7.59 Child S died on 20 February 2013. 8 ANALYSIS OF AGENCIES’ INVOLVEMENT 8.1 This review considers and reflects upon events and the actions taken with hindsight, and with the aim of learning lessons hopefully to prevent similar events from occurring in the future. Every effort has been taken to avoid hindsight bias and to consider the wide variety of situational factors that the participants in the case have experienced such as time constraints, capacity issues, budgetary constraints, system inflexibility or other contributory factors 8.2 In order to minimise hindsight bias it is important to consider not only what happened in the case but why it happened. In this SCR it has not always been possible to answer the ‘why’ questions for a number of reasons including the departure of staff (so therefore unavailable for interview), poor or missing records, or simple lack of staff recollection of events. The author has reflected on the information available within the individual management reviews, the integrated chronology, together with the benefit of discussion, facts, and opinion expressed within the Serious Case Review Panel Meetings and formed hypotheses on possible causes. The accuracy of the hypotheses has been strengthened by the opportunity to hold direct conversations with some of the professional staff involved in the case through their inclusion in a total of five separate agency learning events. Root cause analysis techniques were used in the learning events by the chair and overview author of this SCR which have lent considerable validity and substance to the hypotheses formed. 8.3 It is the role of the independent overview author to gather the information, views and analysis, and analyse them from an independent perspective. 8.4 In such a complex case rather than addressing the individual terms of reference in isolation, the author has approached the analysis by identifying a number of key themes present in the terms of reference and considered them under those headings. These are: • Thresholds for intervention • Assessment and analysis of risk • Development, implementation and review of safeguarding plans • Management systems Thresholds for Intervention 8.5 In Solihull the threshold criteria for the involvement of agencies with children and their families is widely available and published as part of the overall safeguarding procedures. The criteria includes a proportionate response to each child and family’s needs moving from relatively low level support through to statutory involvement where children need to be made the subject of 16 child protection plans or taken into the care of the local authority. 8.6 Children’s Social Work Services have a primary role in supporting children in need and safeguarding children as defined in the Children Act 1989. It is essential that Children’s Social Work Services work with other agencies to ensure a multi-agency approach to assessment, planning, intervention and reviewing of services to children and their families. The evidence in this SCR indicates that in this case Children’s Social Work Services operated a high level ‘gate keeping’ function where access to the service was difficult to achieve and exit facilitated at the earliest opportunity. 8.7 The early referral of Ms M and her unborn baby by the Prison Worker and subsequently by midwifery and substance misuse workers to Children’s Social Work Services was entirely appropriate and an example of effective practice. 8.8 The Heart of England Foundation Trust (HEFT) IMR reported that professionals in the Trust experienced ‘mixed messages’ about what response they could expect from Children’s Social Work Services and noted that staff “are conscious that Local Authorities are encouraged to manage cases outside of child protection processes where possible”. It seemed reasonable to the midwives, working in this context, to progress the ‘Team around the Family Approach’ and see how Ms M responded to the intervention”. 8.9 The use of supportive frameworks such as the “Common Assessment Framework” to assist families with low level needs has been a well-established starting point in work with children and their families. This approach was used in the early period of involvement with Ms M who at the time was pregnant with Child S. ‘The “Team Around The Family” approach relies on a ‘lead’ professional to co-ordinate a group of local professionals to focus on helping and supporting the family. The lead professional does not need to be a social worker although it was in this case. The risk of de-sensitisation and generalisation/ the importance of assessing each individual child and family 8.10 During interview for this SCR, an Assistant Team Manager commented that this case was similar to so many the service currently deals with. It is of concern that professional staff may have developed a general view of families and a tolerance over time to some of the risks to children they see due to the prevalence of difficulties they encounter in the families they are working with. 8.11 At the learning events, staff acknowledged that the saturation effect was a real issue and that the poorer care of some children in the community had the potential to become ‘normalised’ when viewed and assessed by agencies involved in safeguarding. 8.12 Professional staff described a large number of ‘Child in Need’ cases, which theoretically they knew were of higher priority but in practice represented such a large group that only when they were designated ‘Child Protection’ were they allocated a higher priority for focus across the agencies. Feedback and Communication 8.13 Davies and Ward (DfE 2011) note in the key findings in respect of their research into identifying and responding to child maltreatment, “There is insufficient agreement and clarity over thresholds for referral to children’s social care and initiating procedures in the family courts. Poor feedback from professionals working in these settings to other professionals can have a detrimental effect on inter agency working”. 17 Multi- agency Early Help 8.14 It is important that there is coordinated service provision at every level of agency involvement. While there were discussions internally in Children’s Social Work Services, there is no record that a formal multi-agency meeting took place to develop and review any plans or progress of intervention between October 2010 and July 2012. However, there are references in reports to Team Around the Family (TAF) meetings taking place. 8.15 There is reference to consideration of a parenting course for Mr W; although this never took place before the couple’s relationship ended. There is also reference to plans for attendance at a children’s centre for Child S but no evidence that this was achieved. The Threshold for Child in Need and Child Protection Intervention 8.16 By December 2010 the specialist midwife made a total of three referrals to Children’s Social Work Services over a short time period about concerns for Ms M’s circumstances and pregnancy. 8.17 The initial assessment carried out in December 2010 concluded there were no concerns regarding Ms M’s ability to meet her child’s needs when the baby was born. This finding was made less than two weeks after a report that Ms M was lapsing into using heroin and crack cocaine. The social worker contacted the specialist midwife to confirm that Children’s Social Work Services intended to close the case. While the specialist midwife did challenge the social worker personally, being unhappy with the decision because of the concerns, the matter was never escalated within the Trust (HEFT) despite there being policies and procedures in place for this to happen 8.18 The evidence in this SCR demonstrates that in this case Children’s Social Work Services operated a high level ‘gate keeping’ function where access to the service was difficult to achieve and exit facilitated at the earliest opportunity. It is the authors’ view that the thresholds for intervention in this case in respect of a child protection response were high. As a result the level of risk to which Child S may have been exposed appears to have been quite high before a Section 47 investigation was triggered or a child protection conference called. 8.19 During the period of this review professionals identified significant risk factors to Child S which met the criteria for a formal Section 47 investigation. For example, in November 2011 and December 2011, when Ms M had broken working agreements with Children’s Social Work Services, Section 47 investigations or strategy meetings should have taken place but did not. Children’s Social Work Services were not pro-active in becoming involved in the case despite clear concerns being expressed by fellow professionals such as midwifery. What followed was a series of events including the results of assessments detailing no concerns, occasions where the case was discussed for closure or in June 2012 where it was actually closed despite outstanding concerns and unknown and unassessed males being part of the household and their risk to the child unknown. 8.20 There was a lack of clarity in the Police and Emergency Duty Team (EDT) response to the incident on 6/7 July 2012 and their recording at the time of the event. This is reflected in very different accounts of the response to Child S going missing. The West Midlands Police IMR notes that the Police contacted the EDT whose initial response was to confirm that Child S was not in care. The Police IMR suggests that the Police Service were left to handle the report of a missing vulnerable child, probably involving safeguarding issues on what had been an open case to the Children’s Social Work Services only a few weeks before. The addendum to the Local Authority Children’s Social Work Services IMR describes a more proactive response by the EDT worker who made checks by consulting their records and verbally agreed a plan of action with police colleagues, 18 subsequently agreeing a temporary placement for Child S with Mrs K. There were missed opportunities for joint working; EDT staff did not make a joint visit with the Police, a written agreement was not drawn up with family members and the family was not visited by a social worker until Monday two days later. The Police IMR clarifies that the police officers and social workers did not speak directly to each other but communicated through the Police call handlers. 8.21 This situation warranted at least a strategy discussion and a joint Police and EDT home visit to the home of Mrs K later on 7 July 2012 to ensure that Child S was adequately safeguarded. Child S was made the subject of a child protection plan only three weeks after this incident therefore illustrating the escalating concerns. 8.22 A strategy discussion was eventually held on 19 July when social workers had been unable to locate Child S and his mother. It would have been appropriate to hold a further strategy meeting whilst Child S was residing with Mrs. K. This was another opportunity for professionals to reflect on Child S’s situation and plan proactively rather than reactively. It would have been appropriate for Children’s Social Work Services not to have allowed Ms M to return to her home with Child S before the child protection conference was held on 8 August. 8.23 There were further occasions when child protection procedures could have been initiated but were not. It would have been appropriate for a strategy meeting to be held following the Police notification of a domestic abuse referral on 8 January 2013 and also when the Anti-Social Behaviour Officer shared concerns with the social worker in February 2013. Assessments and the Analysis of Risk 8.24 During the period under review, child in need and child protection assessments were carried out by social workers using the national assessment framework for children in need and their families (2000). Following recommendations made in the Munro report (2011) initial assessment and core assessments have been combined into one single assessment process in Solihull but were separate in 2012. 8.25 The first of many assessments Children’s Social Work Services carried out in respect of Ms M and her then unborn child (Child S) was completed in November 2010 using the “signs of safety” methodology. Despite concerns expressed by midwives at the time and Ms M’s history of substance misuse, the assessment identified ‘no current concerns’ and resulted in ‘no further action’. Assessments should consider any current needs or indications of significant harm but also the likelihood of significant harm in the future. 8.26 A further “signs of safety risk assessment” was carried out in late November 2010 which concluded that an initial assessment of the unborn baby was required. Holistic Assessment 8.27 All assessments should be multi-agency and should encompass the three dimensions of the Assessment Framework – child development, parenting capacity and the wider family and environment. It is a common criticism of assessments of children that too little attention is given to the wider family and the child’s environment and this is a feature of this case. • A comprehensive genogram was not available to the Review Panel at the outset of this process. • Ms M received significant support from her birth father Mr L who was diagnosed with a terminal illness during the period under review. There is no evidence that he was involved in any of the assessments under review. 19 • Ms M’s mother, Mrs K, was involved in the early child in need planning and work in 2011 but does not feature in the child protection planning after August 2012. The information provided suggests that Mrs K continued to be in regular although reduced contact with Child S and Ms M during the last 6 months of Child S’s life. Child S had been in the care of his maternal grandmother for three days in February 2013; he had eventually returned home with Ms M on 17 February 2013. • It is essential that fathers and any other men who are significant in a child’s life are included in assessment work. The social worker did not meet Mr W, Ms M’s partner, who was involved in the early care of Child S for some time and had recommended closing the case before doing so. There was limited and delayed assessment work with Mr N when it was established that he and Ms M had resumed a relationship. The role of Mr L in supporting Ms M and the lack of exploration of this has already been mentioned. • There has been no information provided to this Review about the other adults, family friends and/or other adults with substance misuse problems who regularly came into contact with Child S. • Ms M had financial problems related to the funding of her substance misuse but there was no consideration or planning in respect of this reported in any of the agency individual management reports. The Use of Chronologies 8.28 There is no evidence that a simple up to date chronology was produced or maintained by professional staff working with Child S and his family. Such a chronology can greatly assist multi-agency assessment of a child’s circumstances. This may be a systemic issue linked to the limitations of the electronic records systems and/or a wider training issue more linked to professional practice. The Assessment Process 8.29 A total of four core assessments were carried out in respect of Child S within the period of this case review. The fundamental stages of children’s social work are assessment, planning, intervention and review. In many ways they mirror work completed many years ago by Kolb and Deming in respect of learning theory which also highlighted four steps -. Plan, Do, Check, Act. 20 8.30 Instead of progressing through the cycle, successive social workers, assistant team managers and in one instance a team manager contributed to a pattern of unnecessary repeated assessment, rather than following assessment with planning, putting an intervention in place and then reviewing its effectiveness and adjusting the plan and services as necessary. 8.31 The concept of the ‘start again syndrome’ (Brandon et al 2008) whereby prior knowledge and case history, and case ‘experience’ is discounted in favour of searching for new information, is an established phenomenon. It is the author’s view that there is a pattern of ‘starting again’ evident in this case. After the Initial Child Protection Conference in August 2012, a fourth core assessment was recommended despite there being a wealth of assessment information already available. 8.32 The importance of high quality assessment cannot be overstated and this view is supported by research findings. “While it is not always straightforward to show that good outcomes for children necessarily follow from good assessments, there is certainly evidence to support the link and conversely, to demonstrate that bad or inadequate assessments are likely to be associated with worse outcomes”. ‘Social work assessment of children in need: what do we know? Messages from Research’ (DfE 2011) 8.33 The quality of the core assessments completed is an issue in this case. The Local Authority Children’s Social Work Services IMR concluded that the core assessment completed in November 2012 (three months prior to Child S’s death) was “high quality and robust in terms of risk assessment”. However, the Overview author disputes this as the assessment did not consider one of the major risks to Ms M and by implication Child S. It did not explore Ms M’s relationship history, which included a number of partners over time who perpetrated domestic violence against her and not considering the impact on Child S. Adult Risk Assessment 8.34 Ms M was the focus for professional intervention throughout this review period with little focus on the potential vulnerabilities for Child S from her and Mr W and Mr N’s behaviours 8.35 The completion of the risk assessment of Mr N took too long. A risk assessment of Mr N began as soon as Children’s Social Work Services became aware of his presence in the household in October 2012. However, the process took four months to complete. Children’s Social Work Services’ professionals did attempt to take protective action during the four month period; Ms M was asked to ensure that Mr N left Ms M’s home where he had been living in October 2012 and a working agreement was put in place. However, the onus placed on Ms M to ensure that Mr N left the family home was inappropriate given her experience of domestic abuse in this and other relationships. 8.36 The social worker did not know the correct procedure for seeking police information about Mr N and instead sought to complete Criminal Records Bureau checks which contributed to the delay in the risk assessment of Mr N. Use of the Signs of Safety model 8.37 The use of the “signs of safety” model in Solihull includes the completion by social workers of a risk assessment tool which contains questions around a number of domains. The answers provided lead on to a numerical score between 1 and 10 where 1 is extreme concern and 10 is no concern. The model is based on research (Turnell) 1997 and “uses the ethos of solution-focused work, building on strengths and enabling families to find their own solutions. It encourages the use of solution-focused techniques, including scaling questions and goal-setting 21 as the vehicle for obtaining good quality assessments.” The model is referenced in The Munro Review of Child Protection (2011). 8.38 An NSPCC review of the ‘signs of safety’ approach has noted that the model is ‘designed to be the action plan and central case record for organising interventions right from the beginning of a case through to closure’. The tool was used on two occasions in this case as part of a brief and ‘one off’ risk assessment intervention by duty social workers. It was not implemented as part of a longer term multi-agency intervention where the veracity of the answers elicited from Ms M could be verified or in any way tested. No long term relationship existed between the workers and Ms M where trust had had time to develop based on Ms M’s response to interventions. In the author’s view, there may be pitfalls in using this form of risk assessment in this manner. In this case there was a reliance on the self-reported views of Ms M a woman who was in denial about her drug dependency and the level of domestic abuse in her relationships and how this was detrimental to her child’s well-being and safety. Other family members and other professionals were not always consulted within this process. 8.39 There is also an issue about the interpretation of the scoring system in the risk assessment tool. In November 2012 an overall numerical score of six was recorded; in interview, the assistant team manager interpreted this score as indicating, “a situation moving toward improvement”. However, the score is in the ‘middle range’ of the scale. 8.40 The overview author would also challenge the basis of the score which is not supported by a review of the facts of the case over time using a skeleton chronology or application of basic safeguarding knowledge. The assertion made by the assistant team manager is not credible. The author is concerned that the model has not been accurately used to interpret and identify the risk and needs of Child S. Strengths led practice and the Rule of Optimism 8.41 The overarching philosophy of the ‘signs of safety’ approach used in this case promotes a strengths led approach. Commentators, including Tuck (2011), have raised a note of caution about the growth of the ‘strengths led approach’ in child protection work. There is a need for balance in considering strengths and deficits. Tuck notes that “condemning the notion of coming to a realistic view of non-compliant behaviours is to run the risk of partial and unbalanced assessments of children’s circumstances”. 8.42 Professionals need to be mindful in their work of the potential for ‘fixed thinking’ about children and families and also for an over optimistic view of a child’s circumstances and parents’ potential for change ( the latter often referred to as ‘the rule of optimism’). This would not be disputed by the architects of the ‘Signs of Safety’ approach. 8.43 The facts of Child S’s case do support a hypothesis that professionals involved very much wanted to see Ms M succeed in her parenting of Child S and assumed that she would. 8.44 The Bridge discharged Ms M in March 2012 and although the term ‘drug free’ used in a discharge letter has a nationally agreed definition, the BSMHFT IMR author noted that the term did not accurately reflect the circumstances ‘because (Ms M) failed to attend a number of appointments prior to her discharge and subsequently her drug status was, in fact, unknown’. The Service could have highlighted that Ms M ‘had failed to attend appointments, had stopped collecting her medication and felt that she no longer needed a service (which) would have reduced the chance of other professionals misconstruing mothers discharge as successful and planned’. 22 8.45 The Local Authority Children’s Social Work Services closure record in late June 2012 states that ‘A period of stability, engagement with The Bridge and successful completion of treatment’ and ‘Case no longer requiring Children’s Services intervention’. The facts contained in the case history at the time did not support such an analysis. 8.46 The decision by Children’s Social Work Services to allow Ms M to return with Child S to the family home on 23 July 2012 is a further example of an over optimistic view of Child S’s circumstances. Child S and his mother had been missing since his grandmother had returned him to Ms M’s care on 8 July. The Police and social workers had been very concerned about home conditions to the point that Police arranged for forensic photographs to be taken. Ms M had admitted to a relapse in using drugs and it had been reported by extended family that she had debts and was concerned about being sought out by debtors. In these circumstances, it would have been appropriate to have implemented the written agreement and ensured that Child S resided with his grandmother until the initial child protection conference took place. 8.47 The Local Authority IMR author highlights ‘differing perspectives’ between social work and health professionals in that the health professional viewed the family situation from a more positive viewpoint than the social work professional, who in turn was beginning to sense that Ms M was manipulating that situation. 8.48 There were some sharp differences of opinion between professionals in respect of fundamental issues such as the condition of the family home. The health professional did not seem concerned about the condition of the home over time acknowledging it as ‘messy’ but suitable for a child. However, a number of different social workers and indeed police officers expressed concern about the state of the property. 8.49 The HEFT IMR author concluded that the Health Visitor may have had difficulty in revising her original positive opinion of Ms M despite clear evidence of mounting concern. Information about Ms M’s previous history in relation to substance misuse and domestic abuse was not initially communicated to the health visiting service from the midwifery service due to a clerical system error which has since been addressed. A liaison form had been mislaid in the system and as a result did not reach the health visitor. 8.50 Although there was significant evidence of on-going issues around domestic abuse, substance misuse, fluctuating parental cooperation and periodic concerns about home conditions, the Health Visitor maintained a view that she had no concerns about the care of Child S throughout conferences and core groups. 8.51 The ‘Learning Together’ model of “systems focused serious case reviews” developed by the Social Care Institute for Excellence (SCIE) notes a facet of human reasoning as “once we have formed a view on what is going on there is a surprising tendency to fail to notice or to dismiss evidence that challenges that picture”. Other Assessment Tools used by Agencies 8.52 Welcome, in their role as a single point of contact, used a Pan Birmingham Tool for needs and risk assessment to assess Ms M. The IMR gives little detail about what form the assessment took although for each assessment action plans were formulated around Ms M’s needs which aimed to assist her with her substance misuse problems, gaining employment and housing. 8.53 There is little detail regarding how Welcome’s assessment linked into other assessment processes, for instance the Children’s Social Work Services core assessments. In April 2012 Ms M was discharged from the Bridge service and whatever the misinterpretation of the terminology 23 ‘drug free’ followed, no multi-agency discharge plan was drawn up in respect of Ms M which was a missed opportunity to challenge her about her current drug use and to confirm that professionals involved were clear about her pattern of drug usage at that time. Placing the Child at the centre of professional interventions 8.54 There was no clear pattern of regular visiting to see Child S when he was a young baby regarded as a child in need. When Ms M left the country in December 2011, agencies appear to have assumed that Child S travelled with her. However, the family state that Child S was cared for by his aunt Mrs A. 8.55 When a child is subject to a child protection plan, the lead social worker should see a child at least once every 28 calendar days in the family home and this is explicit in procedures for all child protection cases. In the author’s view it would have been helpful if the visiting arrangements and frequency had been made clear and explicit for professionals and the family at the child protection conference. 8.56 Planning in respect of substance misuse issues appears to have been insufficiently child focussed and in some instances lacked co-ordination. Welcome had little contact with Ms M in February and March 2012 prior to her discharge from the service in April 2012. This was due to staff sickness and annual leave. Contact took place largely by telephone and reports that Ms M had ceased taking drugs were dependent largely on her own self reporting. There were no observations of her parenting or relationship with Child S. 8.57 Child S was not seen by the Police or Emergency Duty Team workers over the weekend of 7 and 8 July 2012. A duty social worker attempted to visit on the following Monday. However, the home visit was unsuccessful and professional contact with Child S and Ms M was not achieved until 20 July 2012. 8.58 Events in July 2012 following the closure of the case by Children’s Social Work Services highlight that the knowledge of Child S’s circumstances by key professionals at that time was limited. The health visitor had not seen Child S for over 4 months at this point. 8.59 The Health Visiting Service contact with Child S and Ms M appears to have been quite minimal. It appears that the Health Visitor focused on the physical presentation of Child S when seen more than the risk factors present in Child S’s circumstances. Apart from a visit to the clinic in March 2012, the health professional did not see Child S until 30 July by which time developmental checks had been missed three times. There is no record that Child S’s 8-12 month old developmental checks were ever carried out. 8.60 There were delays in social workers making home visits following reports of domestic abuse in late 2012 and early 2013. It is not clear whether this was due to workload pressures or a positive view of the case which mitigated against a more appropriate urgent response. Professional Challenge, Respectful Uncertainty and Healthy Scepticism 8.61 Ms M and Mr N independently and in different ways have both described to the Overview Author that they felt trapped in their involvement with Children’s Social Work Services. Both parents have stated that they were afraid that Children’s Social Work Services would remove Child S from their care if they were honest with agencies about their situation. Ms M told the second Overview Author and the LSCB Manager that she could not be honest about her substance misuse for these reasons. It is clear that Ms M did not cooperate with professionals or comply with child protection plans or written agreements. 24 8.62 The pattern established by Ms M over time was one of resistance to making changes in her lifestyle, sporadic attendance for services such as drug testing or counselling, minimisation of her use of drugs and exposure to domestic abuse which is now, in hindsight, clear. However, it may have been considerably less clear for those working with the family at the time, when two factors, ‘disguised compliance’ and the rule of optimism’ came together. 8.63 Ms M’s non-attendance at the Welcome service should have been challenged by Health professionals and social workers. The Children’s Social Work Services’ IMR author acknowledged that “more might have been done to challenge the lack of engagement and the impact this might have had on increasing risk to the child”. 8.64 There were several examples of Ms M attempting to dictate the terms of her cooperation with services: • Ms M did not attend appointments with the specialist midwife for peri-natal mental health on 28 January 2011 or 3 February 2011 • Ms M only wished to undertake drug tests with the Bridge in 2011 and did not want treatment or counselling; the lack of motivation to tackle her drug misuse even at this early stage would have been obvious • She later wanted to have a naltrexone implant and would not agree to take the medication in tablet form • On one occasion, Ms. M refused to attend SIAS because she did not have a rain cover for her pushchair and stated that if it rained the following day, she would only attend if a taxi was provided These examples present a picture of non-compliance or barely disguised compliance. The Health Overview author highlights that in total there were eight missed health visitor appointments or failed contacts. It was reported at the criminal trial that Mr N would hide in a bedroom during, or leave the home prior to, visits by professionals to conceal his presence in the home. 8.65 The overall approach of the professional staff involved was one of ‘high support and low challenge’, where the urge to help seems to have dominated the thrust of the work with the family. There was an absence of a more sceptical approach through the adoption by social workers and health professional of what Laming in 2003 termed an “open and inquisitive approach with professional curiosity” and ‘respectful uncertainty”. Managing risks to children in families where domestic violence is taking place 8.66 Two of the major risk factors to Child S presented by Ms M, and Mr N were domestic violence and drug misuse. 8.67 The first responders to many incidents involving both of these issues were West Midlands Police. The Police IMR highlights at least six separate incidents of domestic abuse which were attended by officers over a relatively short period of time. 8.68 In respect of domestic violence, the Police IMR is clear in its analysis that the officers attending the incidents at the home of Ms M were “often task driven and focussed upon Ms M” and “appear not to have adequately considered the possible consequences of the subject child’s wellbeing”. The overview report author supports that view. 8.69 It is essential that the Police make referrals promptly to Children’s Social Work Services. 25 8.70 The Police IMR has shown that the child protection risk was not identified in every reported incident and that on a number of occasions there was a failure of officers to appropriately notify Children’s Social Work Services of domestic abuse concerns. Police officers were not consistent in their decisions about when to complete Domestic Abuse, Stalking and Harassment risk assessment forms. From February 2011, officers were permitted to exercise professional judgement, dispensing with the need for DASH forms to be completed where no crime had occurred or where the domestic incident was very minor (such as a verbal altercation). Officers were inconsistent in reaching judgements about the level of risk present in situations they were responding to. Professional judgement should always be used in judging levels of risk and not reliance on the score reached through use of any assessment tool. 8.71 On some occasions the officers who attended the family home appeared to be more concerned about evidential matters i.e. about whether a particular assault had taken place or not, rather than a consideration of the effects the domestic violence could have on Child S who was present at the time. 8.72 The Police IMR author notes “several reports where specific allegations concerning physical abuse of Ms M involving Mr W and later Mr N were received. On the evidence found in some cases police did not record the incidents as a domestic incident or do not appear to have challenged accounts given by Ms M to establish the truth”. 8.73 The Police IMR highlighted a cultural norm in the force of referring to children in Child S’s position as ‘safe and well’. It notes that this term is unhelpful in conveying meaningful information yet the use of the term has become a norm among police officers. 8.74 Some of the uniformed police officers involved in the case attended a learning event held with the chair of this SCR and the overview author. They explained that they regularly attend potential domestic incidents with little or no knowledge of the previous history at the property they are about to visit. Antecedent history such as the number of previous incidents of domestic abuse or information about vulnerable children in the household is often not readily available. West Midlands Police have clarified that officers should always make robust enquires whilst at the incident in order to establish what has occurred and who is resident there. These enquires would include establishing if any children normally live at the address and if there are any discernible risks. Intelligence can become less accurate as time passes and so good investigative and professional practice is always preferable to relying too heavily on intelligence. Basic and necessary intelligence checks are generally available over the personal radio but these are generally only sufficient to inform immediate decision making. There is now an emphasis on ensuring that officers are aware of the importance of making comprehensive intelligence checks once they return to the police station and prior to completing the initial investigation. In the event that those checks led to the identification of a significant risk to the welfare of any of the parties involved, especially to children or vulnerable persons, then immediate action by the officer to reduce the risk is expected. This may well include returning to the address. 8.75 During the period post August 2012 the officers were unaware that Child S was the subject of a Child Protection Plan as the fact was not flagged on the Police Information System. Normally the presence of such a flag would have been notified to them by radio en route to a call out. While the social worker (SW3) had notified this to the Police CPU by telephone it had not been noted on the Police Information System. Also the Child Protection Conference Service confirmed that the information had not been sent to the police in the normal way by email or fax which was an oversight. It has not been possible to establish why receipt of the telephone call from SW3 providing the necessary information verbally did not trigger a ‘flag’ on the Police Information System. 26 8.76 In November 2012, and in January and February 2013, prior to Child S’s death, the police answered calls from neighbours to the home address but were effectively persuaded by Ms M and Mr N that no problems had occurred. Without the previous history to alert them to the chronic problems in the family, (including the child protection status of Child S although one caller shared this information) they were unaware of the difficulties and therefore may have been more easily persuaded by Ms M that all was well. This may not have been the case had they had further information. 8.77 The lack of information available to front line police officers attending difficult domestic situations, often out of normal office hours, is of concern. It has been reported to the Overview Author that while police officers are in radio contact with a central control the information they receive is often limited and is only available if individual officers specifically request further details. It has been suggested that that the use of the radio to elicit further information during call outs was discouraged on the basis that radio contact with control incurs additional costs for the Police Service. 8.78 There was a lack of accurate and timely inter agency communication between the Police and Children’s Social Work Services in respect of whether or not Mr N was continuing to spend time at the home with Ms M. The facts surrounding incidents which occurred in both November 2012 and January 2013 are confusing and different interpretations are given of events in both the West Midlands Police IMR and the Local Authority Children’s Social Work Services IMR surrounding Police visits to Ms M’s home on these dates. 8.79 Communication difficulties between the Police and Children’s Social Work Services in late 2012 and early 2013 led to missed opportunities to verify that Mr N was living at Ms M’s home. If Mr N’s presence had been verified, the failure to cooperate with the child protection plan and the risk posed to Child S could have been substantiated and action taken. Had a police representative been present at the conference this would have potentially provided a further route into the police systems and provided a ‘failsafe’ in notifying the Police Information System of Child S’s protection plan status. 8.80 The local arrangements for considering domestic abuse referrals in Solihull are through a joint agency ‘screening’ system where personnel from the Police, Children’s Social Work Services and Health Agencies meet regularly to share intelligence, grade the needs of the child involved and to take these forward for further assessment or action where necessary. 8.81 The screening or ‘triage’ system depends on a number of processes including an initial grading by Children’s Social Work Services of the severity of the incident of domestic abuse that officers have attended, a discussion at a panel, a further grading of severity into four scale categories and onward action or ‘no further action’ by the agencies. The system was originally developed by Barnado’s and its use began in Solihull in 2009, and is linked to the Solihull Domestic Abuse Strategy published by the Solihull partnership in 2011. 8.82 The system, in a variety of forms, is in operation in a number of LSCB areas. When the system is operating well it can be a helpful way of focusing on children in complex domestic abuse situations. 8.83 At points where the Children’s Social Work Services representative acknowledged Ms M as a service user who was an ‘open case’ to the service, the procedure was for the panel representative to feed back the information to the case worker involved with the family. There was a lack of clarity in the screening meetings as to what action would then result from the referral back to the worker and poor recording practice in terms of outcome, with little or no feedback to the panel. 27 8.84 Following an audit in 2011, a number of changes to the screening process were piloted from December 2012 until February 2013. They included ensuring that some of the most serious cases discussed by the panel, involving children, (deemed level 4 in the triage process) should be the subject of a strategy meeting. One of the criterion for the triggering of a strategy meeting was that a case was already an open case to Children’s Social Work Services, or that the child of the family was subject to a plan of support or a child protection plan. The changes to the triage system should have strengthened the process. 8.85 It is the author’s view, based on the evidence from this case and from the 2011 audit that the use of the screening system tool as outlined in the Police IMR is potentially problematic. 8.86 Triage Panel members were in an excellent position to monitor the regularity and severity of the incidents of domestic violence in Child S’s family home. However, the recording of incidents by the panel appears to have been inadequate in providing what would have been a valuable overview. If this situation pertains to all cases valuable trend information could be missed not only in this serious case but also others. 8.87 None of the professionals involved in the panel escalated concerns about the safety of Child S either within their own organisation or with others. 8.88 One of the inherent dangers of systems designed to promote safety, such as the domestic abuse screening process is that its very existence leads to a misplaced sense of security both for the users of the system and wider organisations. Solihull LSCB will want to satisfy themselves that action taken since the audit in 2011 has been effective in addressing the concerns and acting on the recommendations of both the audit and this serious case review. 8.89 This Review has raised concerns that police officers are not referring cases involving domestic abuse immediately to Children’s Social Work Services for action and there may be a delay until a panel meeting. 8.90 There was no referral for a multi-agency risk assessment conference (MARAC) for Ms M and no risk management strategy was put in place. There was also no referral of Ms M to domestic abuse support although it is recognised that she may have declined such a service. It appears that because not all incidents were recorded as domestic abuse and because individual incidents were reviewed in isolation, opportunities to assess the pattern of incidents and the escalating level of risk were missed. Solihull operates the MARAC process for high level domestic abuse cases in line with national guidelines. The decision to refer into the process remains one of professional judgement. Managing Risk where parents use drugs 8.91 This review has highlighted a lack of coordinated working between Children’s Social Work Services and the Specialist services provided by Welcome and The Bridge through the SIAS partnership, and a need for improved understanding of professional roles and responsibilities and a shared common language. 8.92 The Welcome IMR author highlights that the initial care episode involving Ms M during her early pregnancy with Child S did not incorporate a joint plan between The Bridge (BSMHFT) and Welcome as would have been expected. Joint care plans were in place for the other two episodes of treatment although the IMR author notes during the second treatment episode that “there is no reference to how low engagement (from Ms M in respect of her substance misuse treatment) might increase risk to the child that this might cause”. 8.93 There was a high degree of liaison between The Bridge (BSFMHT), Welcome and social workers 28 which is highlighted in the Welcome IMR as good practice. However, there was no integration of plans between the services which could have enabled them to address together central questions about how committed Ms M was to her treatment, how she was responding to the treatment she was receiving and whether her progress or lack of progress over time was increasing or decreasing the risks to Child S. 8.94 The lack of an integrated plan at an early stage which all agencies were signed up to was very significant. A co-ordinated approach under the Common Assessment Framework or Child in Need procedures should have taken place. 8.95 The IMR author highlighted that a ‘Think Family’ approach had not been embedded in the specialist substance misuse services. The Children’s Social Work Services professionals clearly recognised an adult focus and felt that they had insufficient knowledge and were therefore reluctant to challenge the expert knowledge of their colleagues. 8.96 Children’s Social Work Services professionals explained that they were of the view that because Ms M’s involvement with the SIAS partners (Welcome and the Bridge/BSMHFT) was of a voluntary nature, they were also reluctant to challenge either Ms M about her involvement and progress with her substance misuse or Welcome and The Bridge (BSMHFT). This reluctance appears to have persisted even when Child S became the subject of a Child Protection plan. 8.97 A social worker involved at the time explained that reports on Ms M’s progress had been obtained from Welcome and the Bridge (BSMHFT) to provide a check on accuracy of information from Ms M. However, the information contained in these reports was based upon Ms M’s own self reporting. The fact that it did not provide a professional assessment of progress was not clearly understood. 8.98 The issue of a reliance on ‘self-reporting’ by substance misuse professionals was discussed at a learning event. Their view was that throughout their involvement with Ms M, compulsion for treatment was not an option and that methodologically they worked on the basis of a trusting relationship with Ms M in relation to reports of her improving condition. Professional staff from The Bridge (BSMHFT) and Welcome explained for instance that it was not normal practice for them to undertake home visits to their service users. Therefore they were totally reliant on the information and the presentation of a service user at their premises. 8.99 It appears that each agency had its own method of working which was not understood by the others. While inter agency communication took place, the safeguarding of Child S was hampered by a lack of real challenge or questioning between the agencies in order to keep Child S as a focus of the interventions. 8.100 Both social workers and specialist workers recognised that Ms M’s involvement with Welcome and The Bridge (BSMHFT) were voluntary. However there appears to have been insufficient recognition and focus on the implications of non-cooperation for the welfare of Child S. Through the review process, substance misuse workers confirmed that they had voiced concerns about Ms M to Children’s Social Work Services staff on occasions throughout the review period but had not persisted in pursuing their concerns, thinking that perhaps they were not serious enough to warrant action from Children’s Social Work Services. 8.101 Substance misuse also formed a significant focus for the Police as first responders. Ms M and Mr N (Child S’s natural father) were heavily involved in drug usage and in the case of Mr N, the suspected supply of drugs. 29 8.102 The Police IMR highlights a lack of any correlation between the use and supply of drugs such as heroin and cocaine and safeguarding concerns in respect of Child S in the mind of police officers attending the home of Ms M. These factors should have been seen as triggers which should have prompted joint assessment processes. 8.103 The link between drug abusing parents and safeguarding concerns for children has been the subject of considerable research. 8.104 The Solihull Integrated Substance Addiction Service (SIAS) service is commissioned by the Solihull Partnership and is a partnership between Birmingham and Solihull Mental Health Foundation Trust and Welcome. 8.105 Welcome provides a general advice service and The Bridge forms part of the Birmingham and Solihull Mental Health Foundation Trust offering a specialist prescribing service for drug users. These agencies were primarily involved with Ms M in respect of her substance misuse problems. Ms M’s contact with the services commenced as she left prison and continued during her pregnancy and following the birth of Child S. 8.106 The overview author has recommended a more effective communication strategy in order to clarify the relationship between Welcome and The Bridge (BSMHFT). The commissioning, structure, eligibility criteria for service, reporting pathways and accountability of the different aspects of the organisation, should be clarified for local professionals and service users. 8.107 Three treatment episodes encapsulating lengthy time periods are identified by both The Bridge (BSMHFT) and Welcome and an assessment was carried out by Welcome and is referred to in the Welcome IMR. 8.108 There was no clear understanding of the extent of drug misuse by Ms M and Mr N and the case raises issues about how best to engage reluctant parents or parents who do not provide accurate information. Maternal Mental Health and Mood 8.109 Ms M consistently reported to professionals that she had suffered from depression since her teenage years and this is reflected in agency records and reports. It is recorded that she was prescribed anti-depressants when she was in hospital in 2010. She was offered two appointments with the peri-natal mental health service in early 2011 which she did not attend. Ms M periodically attended her GP to discuss her mood and mental health and was prescribed medication– in January 2011, September 2011, and August 2012. In January 2013 Ms M was prescribed medication by her GP when she reported that she was having difficulty sleeping. 8.110 There is no evidence that information about Ms M’s mental health or related treatment/ medication were communicated to social workers or considered and reviewed in the core assessments undertaken or as part of the reviews of the child protection plan by the core group. 8.111 This was a complex case and it is essential in such circumstances that professionals carefully consider all of the issues which could negatively impact on the parenting that a child receives. The Development, Implementation and Review of Safeguarding Plans 8.112 Good assessments can lead to sound planning which must include all of those professionals involved with the family and the family members themselves. Plans need to be put into action and their effectiveness critically reviewed. 30 8.113 The Local Authority IMR refers to the existence of a Child in Need Plan but the IMRs do not detail agency input into the plan, the roles to be performed or monitoring arrangements. The author could find no recorded review of this plan involving any of the agencies. The Initial Child Protection Conference 8.114 The initial child protection conference in respect of Child S held on 6 August 2012 was poorly attended. Some of the key personnel with knowledge of Ms M, Child S and the family situation were absent, for example the Police and the Welcome service, although they did send a written report. Apologies were received from two community paediatricians and the family GP did not attend the conference. Inevitably the poor attendance at the conference will have hampered informed discussion, planning and decision making. It contributed to a continuing cycle of repeat assessments by ordering another core assessment be completed. At this juncture three previous core assessments were available on which to base initial plans. 8.115 The meeting did little to focus planning on the case. It failed to set objectives or the required outcomes for the family. Importantly, the visiting frequency was not specified for either the social work professional in the case or the health professional. This was a poor start to a child protection intervention and seems to have failed to give sufficient focus to the risks posed to Child S despite a considerable amount of history in the case for the chair of the conference to draw upon. 8.116 The recommended actions were not SMART (specific, measurable, achievable, realistic or timely). They did not always identify professionals responsible for the action and did not include completion dates for each action. 8.117 The lack of attendance by some of the agencies at the initial child protection conference, core groups or other meetings was discussed at length with professional staff at the learning events. A general consensus emerged that the short notice period for attendance at some meetings was an issue together with high with personal workload issues. It struck the author of this review that the reasons for and importance of attendance at key safeguarding meetings such as initial child protection conferences was unclear to some of the professionals across the agencies. 8.118 Professional staff attending the Learning Events highlighted difficulties in agency representatives attending child protection conferences. There was a shared belief across the partner agencies represented at the event that there was a lack of understanding about the importance of attending conferences in some agencies and the belief that sending an information report was adequate. 8.119 The poor attendance at conferences was confirmed as causing longer lasting problems because core group dates were set at the initial conference and those agencies absent were often unable to commit to the dates thus having a knock on effect to the core group meeting cycle with the result that they in turn were poorly attended. 8.120 Inquorate meetings have been a common problem in the period under review and not limited to this particular case. The options available to a Conference Chair are to proceed or to postpone conferences putting interim protection plans in place to manage risks. At the learning event, the perception of conference chairs and Children’s Social Work Services staff was that there was a lack of inter-agency understanding of the importance of such meetings and a lack of prioritisation of child protection conferences. General, poor or sporadic attendance by a number of agency personnel at child protection conferences raises concerns about a systemic dysfunction in this key part of the safeguarding system more widely applicable than just in this case. 31 8.121 Following the initial child protection conference, Child S remained unallocated for a month before a social worker (SW10) took on the case and commenced another core assessment. The delay in allocation meant that the initial core group meeting was chaired by a duty social worker which was less than satisfactory. Core Group Working 8.122 The initial core group developed a child protection plan for Child S but also failed to set visiting patterns for the key professionals. The core groups which reportedly followed have been poorly recorded and there was a lack of clarity of expectations of Ms M and subsequently Mr N by agencies involved to reduce risk to Child S and promote his safety. This situation arose despite there being a well-structured Core Group Meeting minutes template which was introduced in January 2012 by the Solihull LSCB. 8.123 The housing provider for the family and also the nursery which Child S attended from December 2012 should have been invited to become a member of the core group. 8.124 Crucially in October 2012 a decision to prevent unsupervised contact between Child S and Mr N was taken but apparently ineffectively communicated to the couple. The Child Protection Review in November 2012 8.125 The Child Protection Review for Child S was held within statutory timescales. Agency attendance was again poor. The social worker and health visitor attended and apologies were received from the GP and SIAS counsellor. There is no indication that either the GP or SIAS provided a report for the conference. Given the concerns about home conditions, it would have been appropriate to have invited the housing provider to the conference and to have included them as a member of the core group. Given the concerns about domestic abuse, it would also have been appropriate for the Police to have attended the conference and to have provided a written report. 8.126 There was no systematic review of all the recommended actions within the child protection plan or challenge as to why they had not been completed. The conference noted that Mr N should not reside in the family home but did not clarify or record a current address for him. 8.127 At the review, Mr N stated that he wished to have as much contact with Child S as possible. Contact arrangements had not been addressed in the written agreement drawn up with Ms M prior to the conference and there was no recommendation at the conference setting out contact arrangements or charging the social worker and core group with agreeing a contact plan within a brief timescale following the meeting. 8.128 The recommended actions were not SMART (specific, measurable, achievable, realistic or timely). They did not include completion dates for each action. 8.129 A date for a core group meeting was agreed and a further child protection review was planned for April 2013 which would have been well within statutory timescales. 8.130 The date at the end of the review conference minutes is 20 February 2013. This is the day that Child S died and the conference minutes therefore were not circulated to agencies including core group members within three months of the meeting. Contingency Planning 8.131 It is important for professionals and family members to be clear what the contingency plan will be if parents do not cooperate with a child protection plan or there is insufficient progress to 32 safeguard and promote the welfare of a child. There was no contingency plan agreed and recorded at the initial child protection conference. 8.132 The following recommendation was agreed at the review child protection conference; ‘The Children’s Social Work Team will consider seek Legal Advice if (Ms M) does not work openly and honestly in terms of her drug misuse’. It would also have been appropriate to record that legal advice and further action to safeguard Child S would have been considered if either Ms M or Mr N did not cooperate with the child protection plan. Written Agreements 8.133 The use of ‘Working or written Agreements’ by professionals was ineffective in safeguarding Child S. The agreements appear to have been insufficiently detailed and the agreements were only partially adhered to or not adhered to at all by Ms M, Mr W and Mr N. 8.134 A working agreement and safety plan was drawn up in November 2011 which outlined expectations of Ms M and Mr W to engage with drug services and refraining from aggressive arguments. 8.135 The use of a written agreement between Ms M and Mrs K following Ms M’s referral to the Police on 6 July 2012 could have avoided any confusion about the care arrangements for Child S and agency expectations of family members. Unfortunately, there was no direct contact with the family or any agreement drawn up. 8.136 A written agreement was drawn up later in July 2012 stating that Child S would reside with his maternal grandmother and it would have been appropriate for this to have been implemented until the initial child protection conference in August but it was set aside within three days. 8.137 There was a working agreement in October 2012 for Mr N to leave the home and a safety plan in which work is to be completed with Ms M in respect of domestic violence and its impact upon children. 8.138 The Local Authority IMR author notes for example “It is not evident that any risk assessment sessions had taken place with Mr N bar the initial session on 24 October 2012.” 8.139 The Local Authority IMR notes that “The working agreement did not determine contact arrangements between Mr N and the Subject Child and nor was it a requirement for Mr N to sign the working agreement. SW10 reflected during interview that it would have been good practice for Mr N to have signed the written agreement. With regard to contact between him and the Subject Child, SW10 stated that Mr N should not have been having contact but accepted that the working agreement was not clear regarding this and that Ms M may not have been clear about this requirement either.” 8.140 Audit activity was completed within the Solihull LSCB in September and October 2012 and shows an example of the use of such agreements. One finding in respect of a case states “there were a plethora of working agreements on the children’s social work file which related to constantly changing contact arrangements for children with their parents, brought about by on-going instability both in respect of where they lived and the circumstances of contact. The working agreement did not appear to be shared with the core group and were limited to children’s services and parents”. 8.141 The Local Authority IMR states that the social worker suspected that Mr N had been with Ms M over the Christmas period but there was no plan of announced and unannounced visits over the holiday period to clarify the situation. 33 8.142 The lack of clear plans, clear decision making, and minutes of the Core Group meetings copied to Ms M and Mr N and all professionals, in this case, did not hold the parents to account and probably made it easier for Ms M and Mr N to manipulate situations. The use of research and the assessment of Actual and Likely Significant Harm 8.143 The Children’s Social Work Services IMR author highlighted a key point that while a plethora of research exists on the effect of substance misuse, the incidence of domestic violence and mental health difficulties, the focus for actual professional activity in safeguarding children such as Child S often relies on waiting until actual harm has taken place, rather than clearly identifying and acting upon the ‘likelihood’ of harm using research evidence to prove a case. 8.144 Despite a variety of concerns developing about the family situation, Child S was seen to be well cared for, well fed, cleanly clothed, well stimulated and with an appropriate attachment to his mother, Ms M. The police officer logs include the comment ‘seen safe and well’ despite the child having been exposed to numerous episodes of domestic violence. 8.145 The safeguarding system often concentrates on actual harm to a child rather than the likelihood of harm being fully considered. The Children’s Social Work Services IMR author notes that “As it stands the multiagency system does not readily allow for the use of expertise or research to predict future harm. Interventions are evidence based, and the difficulty in evidencing emotional harm within infants and very young children is a clear inhibitor to full risk assessments. In some respects the wider safeguarding system does not support interventions until children, especially those that are very young, display the impact of significant harm. The relevance of research when completing assessments of infants and young children where domestic abuse, drug misuse and mental ill-health are factors cannot be underestimated. It is imperative that practitioners feel empowered to use research as evidence of harm and predictor of future harm when considering the risks posed to very young children whose physical care needs appear to be being met.” 8.146 Professionals undertaking assessments could have evidenced the likely harm caused by domestic abuse and drug misuse through the use of research evidence. The facility to consider the ‘likelihood’ of significant harm promoted within the Children Act 1989 and its guidance was not sufficiently used in this case. 8.147 At the learning event, practitioners across disciplines described a number of organisational ‘hurdles’ within the local authority which encouraged an approach of further assessment, described as “thresholds within thresholds”. In practice this meant that in order to escalate a case in terms of safeguarding action in order to demonstrate actual harm, further assessment was frequently ordered as more and more evidence was required in order to move the case past the next ‘gate’. The consensus about the effect of this approach was that it encouraged repeat assessments and militated against proactive safeguarding action in all but the most obvious ‘emergency’ situations. 8.148 The LSCB partnership will want to examine the issue further in order to discover the drivers behind the approach. Management Issues Workload Management/ Caseloads 8.149 Workload issues, temporary or agency staffing, sickness or lack of capacity have not been raised explicitly in the agency reports for this SCR. 34 8.150 Children’s Social Work Services described a system of managing unallocated cases on a duty basis although no details of the type or number of cases is described. Child S’s case was managed on a duty basis for a period in the summer of 2012 and remained unallocated for a month following Child S being made the subject of a child protection plan. Dealing with the case in that way over the time period was, in the author’s view unsatisfactory. Given that the case had been closed in late June 2012 only to reach crisis point some four weeks later should have signalled difficulties and should have resulted in immediate reallocation. 8.151 The effects of the case being dealt with on a ‘duty’ basis were numerous. A number of different social workers together with different assistant team managers were involved in dealing with the case. The absence of a consistent manager or worker with a building knowledge of Child S’s circumstances at a key time may have led to an inconsistent approach and contributed to repeat assessments. Within the context of the climate of ‘disguised compliance’ discussed earlier, this potentially allowed a situation where different workers could be told different things by Ms M which in turn could be viewed differently by different managers. 8.152 The delay in allocation may have contributed to the situation whereby a duty social worker who convened the first Core Group failed to rectify deficits in the child protection plan such as specifying the frequency for the professionals to visit. This will likely have hampered the social worker eventually allocated the case in September 2012 as the parameters for working the case had recently been set, or rather not set, by another worker. Children’s Social Work Services staff confirmed at a learning event that operational difficulties caused by staff shortages at the time had led to the delay in allocating Child S’s case but that all current Child Protection cases have an allocated Social Worker. 8.153 The community midwife involved in Ms M’s care had a caseload of approximately 115 at the time with no reported staffing, sickness or capacity issues identified at the time. It is recommended that caseloads should not exceed 98, however 110 being an acceptable average (RCM 2009). The combination of heavy workload and the increasingly complex nature of the work is, in the author’s view likely to impact on professionals in terms of the saturation effect described earlier. The potential effect of this may impact on how they view thresholds for intervention or the ‘severity’ of safeguarding situations within a given set of circumstances. 8.154 The HEFT IMR highlights the perception of the health visitor as having “a heavy child protection workload”. Evidence provided in the IMR, that the health visitor had no more than three child protection cases and a working week of 32 hours per week did not support that contention. 8.155 The overview author was struck that while workload was not highlighted by the authors of the IMRs as an issue in this case, workload pressures were mentioned frequently by professional staff who indicated that these hampered the allocation of cases, limited case recording, prevented attendance at some meetings and restricted appropriate time for case reflection. Supervision 8.156 A number of the agencies involved in this SCR confirmed in their individual management reviews that safeguarding supervision policies were in place. These included HEFT, Welcome, the Bridge (BSMHFT) and the Local Authority Children’s Social Work Services. The actual effectiveness of the safeguarding supervision process was hard to judge from agency IMRs as it was insufficiently covered. The quality of reflection and challenge provided during the supervision of this case was more difficult to determine, and was agreed by those staff participating in the learning events to have been variable. 8.157 Welcome identified that while supervision takes place for its staff the recording of it is largely 35 absent which requires addressing. 8.158 The Health Overview Report author notes that “Child protection supervision was provided to the Health Visitor over the time frame covered by the review and practitioners are given reflective time to discuss specific cases.” Because of organisational changes there have been problems identified with the supervision policies which are being addressed. 8.159 The term ‘supervision’ has a particular meaning in the context of Local Authority social work and there is a wider debate about what the exact support, oversight, challenge and advice to those professional staff working in safeguarding require. The Health Overview Report author touches on the need for the inter relationship of these elements to be more clearly defined. 8.160 Lord Laming (2009) refers to supervision as the ‘cornerstone of good social work practice” and Munro also highlighted its importance in her review of child protection in 2011. 8.161 There is evidence in this case that the supervisors across the agencies did not provide sufficient challenge to their front line staff. They did not provide feedback that was accurate, diagnostic and reasonably timely or sufficiently provide new insights and lessons from mistakes. It appears that they too provided ‘high support and low challenge’ thus mirroring the safeguarding practice of the frontline professionals. 8.162 During July 2012, the supervision of neither the health visitor nor the social worker provided a reflective overview of what was actually happening in the family at the time. 8.163 The volume of work of both practitioners and supervisors was a key reason given for the lack of time available to reflect on case issues and case analysis. The supervision of child protection cases was given priority over cases involving children in need. 8.164 The judge in the criminal trial described SW10 as a relatively newly qualified social worker in his summing up of the case. Social worker 10 had been qualified for almost two years and the Children’s Social Work Services IMR does not raise any issues about the level of experience of social workers allocated to the case of Child S. 8.165 There was insufficient shared understanding across agencies about what the task of safeguarding supervision actually was and how it contributed to keeping children safe. It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had. The recording systems in Children’s Services 8.166 At a learning event, Children’s Social Work Services professionals recognised the importance of keeping clear records. 8.167 Both social workers and team managers clearly stated that the format of the assessment available on the electronic client information system presents a number of challenges and is often problematic to operate: • It is not possible to ‘amend’ or update an assessment as the system default requires a new assessment to be completed; this may explain why so many assessments were found on the electronic system that appeared to have been cut and pasted. • The professional staff also felt that the free flow of an assessment was hampered by the rigid electronic fields or prompts that the system demands. Some staff resorted to creating separate ‘Word’ documents in order to allow a more fulsome format and approach to assessment. The negative of this approach was that there was a danger of the creation of 36 disparate documents and potentially not all the information on a child and family was kept in one place. The chair and author of this SCR were concerned to hear that such ‘workarounds’ were required to compensate for the electronic system’s inflexibility. 8.168 These problems were compounded by the existence of paper based files, containing information which was not on the electronic system. The existence and location of the paper based files were not identified on the electronic system to alert a system user to their existence or whereabouts. Staff believed the problem had arisen because there is a limited resource available to scan in the paper files onto the electronic system at its introduction, although the system has this facility. If this is indeed the case, it is of concern and is a potentially unsafe way of working, reducing the service’s ability to fully protect children. 8.169 The chair and authors of this SCR have noted that the introduction of an electronic system intended to streamline and improve record keeping and assessment practice had in fact had a number of unintended consequences. At a learning event, reference was made to the use of the electronic system as a process of ‘feeding a beast’. 8.170 The importance of key records such as core group minutes in safeguarding children generally and Child S in particular cannot be overstated. Social workers described being under considerable time and work pressure and therefore on some occasions minutes had not been produced for Core Groups and rather just rough notes which were not circulated. Children’s Social Work Services staff described reluctance by other agency partners to take minutes at core groups with a culture prevailing that such tasks were always the role of social workers or managers. Social work staff stated that they had raised the issue with line management. In any event the issue seems not to have been sufficiently recognised or remedied by managers. 8.171 The absence of minutes of meetings when working with difficult parents exhibiting ‘disguised compliance’ behaviour is of particular concern. It may have made it considerably easier for Ms M and Mr N to play each agency off against the other and harder for agencies to stand their ground about safeguarding issues in the absence of a clear written statement outlining progress on actions within the child protection plan and what had been discussed, agreed and expected. 8.172 Professional staff described difficulties in creating a ‘chronology’ in a case using the electronic system format as the system was difficult to manipulate to generate the correct amount of detail. To create a chronology in the format intended by Lord Laming would require the creation of a separate document and a trawl of the electronic file which was thought too time consuming. Information sharing, the conduct of police checks and the interpretation of Data Protection Legislation 8.173 The Overview author has drawn to the attention of the LSCB an apparent perception across the agencies involved that a lot of information necessary for the protection of children is not shared because of a particular interpretation of information sharing and data protection guidelines and a perception by social workers that colleagues in both health and the police are reluctant to be open about information, for example pertaining to the male partners in families where domestic abuse may be an issue. 8.174 The social worker tasked with completing the risk assessment of Mr N did not understand the correct process to request background information from the Police and attempted to undertake checks through the Criminal Records Bureau (now the Disclosure and Barring Service) rather than directly from the police as partners in the safeguarding process. 8.175 The government has published information sharing guidance in March 2012 and recently in 2015 which emphasises that Data Protection legislation is a support and not a barrier to the effective 37 safeguarding of children. However, this review has revealed that local practitioners in Solihull may perceive or experience something different, which is likely to require work with the local Caldicott guardians in particular. Audit Activity and Multi-agency Child Protection Training 8.176 To assist with this SCR, the author has been provided with a number of documents reflecting audit activity within the Solihull LSCB including the results of a review of the domestic violence screening ‘triage process’, a pro forma for core group structure and of a case mapping exercise. These documents have been very useful and aspects of their findings run parallel to the findings in this SCR. It appears that the learning contained within other reviews and audits has been insufficiently embedded into actual safeguarding practice across the LSCB agencies. 8.177 It appears that there has been an absence of systems in place to ensure the effective dissemination of developing best practice, This was exemplified by recent developments in substance misuse services which were described during the learning event and which were pertinent to the way the service was said to be developing. However, these developments were unknown to other agencies for which they had potential relevance. A clinician attending one of the learning events found it difficult to identify how the content of the work of the service in which he worked was being effectively communicated across the agencies many of whom were undoubtedly key stakeholders. 8.178 The issue of a lack of understanding of the roles and expectations between agencies was commonly highlighted during the learning events. There had been limited inter-agency child protection training available prior to April 2012 due to a vacancy in the learning and development role and there had also been poor take up of training in the nine months prior to the commencement of this review. Inter-agency training can be an effective method of overcoming organisational barriers and promoting role clarity. 8.179 It has been reported to the panel that since 2013 that the provision of multi-agency training has been on target and that take up of multi-agency training has been much improved with a number of recent courses fully subscribed. 9 CONCLUSIONS 9.1 A jury has concluded that the parents of Child S were guilty of causing or allowing the death of their child. The author is sure that those professionals involved with Child S took actions and made decisions in the case that they thought to be in the child’s best interests at the time. The author has not identified specific instances of good practice which he would wish to highlight and which could be defined as practice of a quality over and above that which would normally be expected. 9.2 The review has identified and highlighted a series of serious failings in professional practice and weaknesses in safeguarding systems in Solihull. Ms M, the mother of Child S, clearly had a variety of difficulties including mental health issues, drug misuse problems and being subjected to domestic abuse by a number of partners. These issues were all well known to a number of agencies. The initial response to reports of domestic abuse was inadequate and the potential impact of domestic abuse on Child S’s welfare and safety were not properly considered by the systems and processes set up to consider the issue. 9.3 The developing risks to Child S were not sufficiently recognised or acted upon. The reluctance of Ms M, Child S’s mother, to work with professionals to address her problems and the lack of 38 honest cooperation by Ms M or Mr N were not effectively highlighted by the assessments conducted by professionals across the agencies. 9.4 There is considerable evidence of the rule of optimism influencing professional practice in this case: • The case was inappropriately discussed within Children’s Social Work Services for closure on a number of occasions and was eventually closed following a mistaken judgement that Child S’s situation was improving. This conclusion was not supported by any reasonable interpretation of the facts of the case, which were available to those involved in that decision at the time • Specialist substance misuse workers and the other professionals recorded and shared Ms M’s self-reported abstinence from using drugs without critical commentary • The health visitor and social workers appeared to focus on Child S’s physical development and not the range of risk factors in his circumstances • Police officers accepted denials of any domestic abuse by Ms M and her partners without reflecting on the pattern of call outs following referrals from a variety of sources 9.5 The combined impact of Ms M’s background of domestic violence and substance misuse on her mental health and her parenting and care of Child S, and the risks to which Child S was exposed as a result, were insufficiently recognised. The risks presented by Mr N’s presence in Child S‘s life were not fully identified or assessed in a timely manner. 9.6 Professionals did not set out clear expectations of both parents through the use of written agreements and child protection plans. There was also insufficient scrutiny of the adults’ compliance or, more accurately, non-compliance with the agreement and plans. 9.7 There were opportunities for investigative and protective action in respect of Child S based on the evidence of the mother’s lifestyle which professionals did not take. This culture of optimism was compounded by an inter-agency misunderstanding of the term ‘drug free’ in respect of Ms M. This misunderstanding aside, Ms M’s progress in ceasing her drug misuse was largely self-reported with little evidence to support Ms M’s statements of progress. Assessments were not timely or comprehensive. 9.8 Both the author and the SCR panel were particularly concerned about the reliance the professionals placed on Ms M’s ‘self-reporting’ of progress in addressing her drug misuse and domestic violence problems. Professionals did not test or triangulate information which could have ascertained an accurate picture of what was actually happening. Professionals did not demonstrate what Lord Laming called ‘respectful uncertainty’ and ‘healthy scepticism.’ 9.9 The misunderstanding by social workers following the use by a Bridge worker of the National Treatment Agency defined term ‘drug free’ highlights the need for improved understanding between agencies of the terminology. Clear differentiation between self-reported information and independently verified information is necessary. 9.10 When the case eventually progressed to a strategy meeting, child protection investigation and child protection conference, the processes which should have enhanced Child S’s safety did not do so. The conduct of the initial child protection conference, the delayed allocation of a lead social worker, the quality of child protection planning and multi-agency core group working to monitor the plan all fell below a standard that it would be reasonable to expect. 39 9.11 This Review considers that Child S’s death was not predictable. The Child Death Overview Panel (CDOP) will further consider whether or not the death of Child S was preventable and consider any modifiable factors for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level”, in line with the guidance contained in Chapter 5 (Working Together 2015). 9.12 There are a number of significant and potentially modifiable factors which have been identified within this review. These include improvements in the assessment of the likely risks to Child S, an increased child focus, coherent joint case planning, the timely and proactive assessment of the risk Ms M’s partners posed to Child S, increased challenge of his mother’s denials of domestic abuse and drug use and the use of positive protective action at key junctures and in particular when important ‘working agreements’ were not adhered to by parents. 9.13 Changes in any or all of the areas of service outlined above would have likely improved the safety of Child S over time. Child S could have been better safeguarded collectively by the local services working with him and his family. 10 LESSONS LEARNED 10.1 This review of agencies’ involvement with Child S and the circumstances of his death has revealed a significant amount of learning for all of the agencies involved in safeguarding children in Solihull. It has highlighted errors in professional judgement and weaknesses in the systems to safeguard children in Solihull. Agencies have reassured the Board that work has been undertaken with individual practitioners involved in working with Child S and his family to ensure that personal learning and development have taken place as necessary. This section outlines key learning about the child protection processes and systems in Solihull. 10.2 The key learning points are: Domestic Abuse I. When incidents of domestic abuse are reported or detected it is essential that prompt referral and investigation takes place and that follow up action is timely, clearly child focussed and takes into account existing research into the impact domestic abuse may have on the safety and well-being of a child (including babies and very young children). It is also important that patterns of domestic abuse are considered as well as individual episodes. II. The ‘Triage’ system in place to ensure appropriate responses to domestic violence and abuse should enable agencies to identify high risk cases early, alert the relevant professionals and act as an information hub which stimulates and monitors the actions of the agencies, escalating concerns in the agencies where necessary. Good record keeping and communication between agencies are required to support the efficiency and effectiveness of the system. The system should also not provide false assurance. III. Ms M was not referred to a Solihull Multi-Agency Risk Assessment Conference (MARAC) and therefore the criteria for referral to MARAC should be considered further. IV. The Police who provide an immediate response to domestic violence should ensure that frontline officers are provided with adequate background information before undertaking visits and understand the research findings about the potential implications of domestic abuse, mental health and/or drug misuse on parenting and the likely effect on children in 40 the home where these issues arise. Officers should be alert to repeat low level calls which if looked at together show a pattern of behaviour and offer an opportunity for pro-active intervention. V. Research evidence in respect of the long term damaging effects of domestic abuse on children should be considered and used by all professionals in working with families. Despite domestic abuse being an on-going theme in the life of Ms M and her partners, by the agencies working with her and Child S did not challenge her or address the issue sufficiently or the collective impact of domestic abuse alongside parental substance misuse. Substance Misuse VI. The commissioning processes for substance misuse treatment for adults needs to specify how the safeguarding of the children of substance misusing adults will be achieved, and how the partners being commissioned relate to each other. They need to ensure close collaboration with partner agencies such as Children’s Social Work Services and joint care planning for the children of those adults they are working with is likely to assist in this process and ensure there are clear lines of communication and accountability built into the system. There must be careful consideration of the evidence required to provide reassurance about parent’s self-reported stability or abstinence from substance misuse and safe withdrawal or closure by specialist services. Eligibility criteria and the operation of thresholds for services VII. The eligibility criteria for access to both child in need and child protection services needs to be fully embedded, understood across agencies and operated consistently. The threshold for access to services needs to take into account the historical and current concerns of the partner agencies. Assessment Practice VIII. The review has highlighted that the practice of repeating rather than developing or updating assessments several times wastes resources and does not drive safeguarding action for children forward. IX. Multi-agency assessments led by social workers or lead professionals need to be thorough, to clearly identify risk and need, and to lead to clear plans which have a clear outcome focus and include specific interventions built into them against which progress toward improved safeguarding can be judged. X. Assessments must be holistic and include consideration of the child’s wider family and environment. Professionals need to consider the impact of domestic abuse, substance misuse and/ or mental health issues on parenting and share the outcome of any specialist assessments to inform the single assessment for the child. XI. The key features of quality assessments are that they are relevant, timely and contain all of the elements of potential risk to a child including an analysis of those living in the home with a child or believed or confirmed to be spending significant periods of time there, and that they lead to explicit plans of action to meet the needs and risks identified by the assessment. XII. Before progress can be recorded, information and evidence about progress needs to be checked and triangulated. It is essential that verifiable information from professionals is 41 considered alongside self-reported progress by parents or carer and that there is not over-reliance on the latter. XIII. The ‘tools’ that are available to assist professional staff, such as the ‘signs of safety’ risk assessment, are valuable assets although they are fallible. They need to be applied only when sufficient training in their use has been completed and users are confident of their value as an aid. The results they register should be used in conjunction with the professional judgements of their users and should not be used to override those professional judgements or relied on as giving assurance when the evidence does not support that. Agency roles and multi-agency working XIV. There was an insufficiently robust shared understanding of the roles each agency plays in the safeguarding process particularly where there are concerns about parental substance misuse. Increased joint safeguarding training should be commissioned and multi-agency protocols reviewed to ensure the required shared understanding of professionals’ complementary roles. Information sharing XV. The use of information sharing protocols that facilitate the prompt sharing of information between agencies which may potentially safeguard children was not sufficiently effective and information which could be vital to safeguarding children may potentially not be shared. The protocols which are in place need to be understood by all the professional staff in the agencies and effective in allowing the free flow of relevant information between them. Where information blockages occur there needs to be mechanisms to allow the problem to be solved quickly. Supervision XVI. Professional consultation and supervision is a key mechanism by which staff involved in safeguarding children can reflect on their work with families and its effectiveness. The quality of the support and challenge provided by skilled and experienced supervisors is vital in countering the potential effects of over optimism or the saturating effects of dealing with the complexities of the safeguarding task. Audit and Review XVII. Solihull’s on-going audit and review activity is one mechanism by which the Board can seek reassurance that the recommended actions are implemented and improve the quality of practice and management necessary. It is essential that when learning is revealed, such as that which occurred through the ‘Peer Review’ audit mechanism, it is widely shared, embedded across the agencies involved in safeguarding to ensure service improvements. 42 11 RECOMMENDATIONS 11.1 The overview author makes the following recommendations in respect of issues identified in the review. Given the strategic overview role in respect of safeguarding held by the Solihull Local Safeguarding Children Board these recommendations will be most effectively achieved on a multi-agency basis under the auspices of the Board. Learning Point 1 Difficulties have been identified by the review in respect of the use of a range of the ‘tools’ available to professional for working with children and families across the agencies. Recommendation 1 A review of the ‘tools’ used in child protection cases, should be undertaken on a multi-agency basis focusing in particular on those for the implementation of the ‘signs of safety’ model and also including: •Triage Processes •Single Assessment/Risk Assessment Processes •Domestic Abuse, Stalking, Harassment (DASH) tools. The review should take account of the operational situations in which the tools are used, the appropriateness of training in their use and their relationship to the level of expertise of the practitioners using them. An underlying tenet of the review and subsequent training in the use of these tools should include an highlight the false assurances such tools can potentially provide. Expected outcome Professional staff will have an improved understanding of the benefits and limitations of the tools they are using. They will improve their abilities to assess risk situations based on an interaction between their own professional expertise, knowledge and experience and the evidence and indications gathered by using the tools at their disposal and the precedence their professional expertise must take in decision making. 43 Learning Point 2. The content of the review has highlighted a number of difficulties across the agencies involved in this case in respect of working with non-compliant individuals or those who disguise their compliance while working with agencies undertaking safeguarding activities with children. These difficulties resulted in an overly optimistic prognosis of outcomes for the child. Recommendation 2 An inter-agency initiative, based on research evidence should be mounted to examine and develop the local response and expertise in working with non-compliant individuals in child protection settings. Expected Outcome Professional staff involved in safeguarding activity across the agencies will develop a greater understanding of risk analysis and risk management. The concept of triangulating information to either support or discount the hypotheses about the ability of parents to safeguard their children will become embedded leading to both high support and high challenge and to safe and realistic planning for children. Learning Point 3 The review has identified significant weaknesses in the communication and working arrangements between the Police and Children’s Social Work Services. Recommendation 3 In light of the major review of public protection arrangements in the West Midlands Police Service, the working arrangements between the Police and Social Work Services, in particular the Emergency Out of Hours service (EDT) should be considered as part of that overall review. The review should include a focus on the effectiveness of information systems which can be jointly interrogated by each agency together with the development of clear joint information protocols which are clearly understood and communicated across the agencies. Expected Outcome There will be clear protocols about the working arrangements between the Police and Social Services (in this case Children’s Social Work Services and the Emergency Duty Out of Hours Service) in respect of joint visiting in safeguarding cases and increased access to relevant information in both agencies will be made available. 44 Learning Point 4 The review has highlighted considerable misunderstanding between agencies in respect of what information about the antecedent history of Adults who may pose a safeguarding risk to children can be gained from the Police records, the method by which that information can be obtained and in what timescale. Recommendation 4. Systems for sharing information between agencies in child protection cases should be clarified and improved. These systems should include paper and electronic systems together with a focus on the way professional staff verbally communicate information between agencies. The results should be widely communicated to professional staff within the relevant agencies, and should include check mechanisms to ensure that staff have fully understood any changes or developments and have implemented them. Expected Outcome Agencies such as Children’s Social Work Services will have improved access to information from Police Service records on Adults about whom they have concerns in respect of posing safeguarding risks to Children. Learning Point 5. The attendance of all appropriate agency representatives at Initial Child Protection Conferences and attendance at Core Groups is significantly problematic. Recommendation 5. A review of the booking system for initial Child Protection Conferences should take place. The review should ensure that a booking system is in place where a minimum notice period is given to professional staff across the agencies to allow for attendance. The review should highlight the importance of attendances at conferences and core groups and promote a wider understanding of the significance of such meetings in safeguarding children. The review should consider systems which include arrangements for substitutes to attend where necessary, the provision of reports to be presented in cases of unavoidable absence and arrangements for non-attendees to be available to present information or opinion by conference telephone call where applicable or necessary. The review should also include the provision of systems to ensure that the taking of minutes of key meetings such as Core Groups are facilitated and resourced on a multi-agency basis. Expected Outcome Understanding of the importance of Initial Child Protection Conferences improves as does the attendance at such conferences and subsequent core group meetings. Minutes of all such meetings are taken accurately and circulated to all members of core groups in a timely way. 45 The Overview Author makes the following Recommendation in respect of West Midlands Police specifically: Learning Point 6 The review has highlighted that there was insufficient shared understanding across the agencies involved in safeguarding about what the task of supervision in safeguarding cases actually was and how it contributed to keeping children safe. It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had. Recommendation 6 Using examples of national best practice underpinned by relevant research the Solihull LSCB should mount an inter-agency development initiative for those supervising front line safeguarding practice. The initiative should include a focus on the importance of shared analysis and challenge within the supervisory relationship process. Those facilitating the initiative should not only focus on improving individuals supervisory skills but also an improved multi agency understanding of the importance of supervision and its key role in refining safeguarding assessment, planning and review. Expected Outcome Individual member agencies of the Solihull LSCB acting collectively will be confident that each agency has in place robust practical arrangements, supported by that agency, to ensure that relevant and challenging safeguarding supervision is being accessed by all those involved in safeguarding cases. Learning Point 7 Police officers attending domestic violence and aggression incidents often have limited information about the antecedent history of incidents of DV or of the involvement of other services into the household they are visiting when responding to a call out. Recommendation 7 The West Midlands Police should improve the information available to front line officers when attending actual or suspected DVA incidents. The force may wish to consider using the results of this SCR and existing information on the Pilot Scheme on the introduction of new technology (Tablet Computing) to assist in this aim. Improved information gained from Recommendations 3 and 4 above are likely to assist this process in the future. Expected Outcome Front line Police officers will be provided with increased information on which to base their assessments in suspected DVA cases. Where those Adults involved are in denial and potential safeguarding children concerns are evident antecedent history will be readily available to provide a fuller picture of previous events. 46 Appendix 1: LSCB Action plan; Position statement. SOLIHULL LOCAL SAFEGUARDING CHILDREN BOARD This is a summary of progress made to address the recommendations in this serious case review. As this review took 2 and a half years to produce, the LSCB did not wait for publication to deliver on recommendations but began implementing them as soon as possible. Below is a summary of actions carried out, the current position and what the LSCB aims to do to sustain improvement in relation to each of the recommendations made. Action plans for each agency were also produced and will be audited under Section 11 of the Children act 2004, in the Autumn of 2015 and Spring of 2016. SCR Learning Point Recommendation 1 Action Current position To sustain improvement Difficulties were identified by the review in respect of the use of a range of the ‘tools’ available to professionals for working with children and families across the agencies. A review of the ‘tools’ used in child protection cases should be undertaken on a multi-agency basis focusing in particular on those for the implementation of the ‘signs of safety’ model and also including Triage processes, Single assessment/risk Assessment processes and Domestic Abuse, Stalking and Harassment (DASH) tools. Revision of tools has been carried out by the Practice and Procedures sub-group. Thresholds guidance has been agreed in November 2014 and a leaflet produced in March 2015.A comprehensive training review has resulted in a new integrated workforce strategy incorporating various assessment tools. A sound evidence based rational for the development of the graded care profile in social care is in the final stage of production. It is included in the workforce development strategy for social workers. While the use of the tools is clear in LSCB procedures and case audits 2014-2015 have established that progress has been made, continuous work is needed to embed in practice. The threshold document has been widely distributed. The LA aims to increase the cohort of social workers having “graded care profile” training. Specific Multi-agency training on the use of tools has been set up. Case audits 2015-2016 will establish application by practitioners. The LSCB will ensure regular communications to practitioners and managers. A conference in November for managers will ensure they embed this in practice. Training evaluations will indicate practitioners understanding of tools and the thresholds. 47 SCR Learning Point Recommendation 2 Action Current position To sustain improvement The content of the review has highlighted a number of difficulties across the agencies involved in this case in respect of working with non-compliant individuals or those who disguise their compliance while working with agencies undertaking safeguarding activities with children. These difficulties resulted in an overly optimistic prognosis of outcomes for the child. “An inter-agency initiative, based on research evidence should be mounted to examine and develop the local response and expertise in working with non-compliant individuals in child protection settings.” Over 400 practitioners took part in the training review, some of whom indicated non-compliance as a continuing training need. The LSCB neglect strategy was approved by the LSCB. This Includes the use of the “graded care profile” and working with families with a combination of factors, parental mental health, substance misuse and domestic violence as well as non-compliance. Addressing non-compliance is a continuing feature of all LSCB safeguarding training. The training review has resulted in new core safeguarding competencies and a new multi-agency workforce strategy incorporating the learning from this review. A new training faculty has been created to actively engage practitioners in training plans and design to ensure training is in line with practice needs and a more direct engagement of the LSCB with front line practice. Common standards for supervision have been agreed and are being audited by the case audit sub-group. Case studies used in training feature families with complex combinations of features. Detailed evaluation of the training will be carried out post course and retrospectively to establish practitioner understanding. Case audits will establish practice application. Case audit will also examine practitioners’ confidence in recognising and challenging non-compliance and supervision in providing challenge and reflective practice. 48 SCR Learning Point Recommendation 3 Action Current position To sustain improvement The review has identified significant weaknesses in the communication and working arrangements between the Police and Childrens Social Work Services “In light of the major review of public protection arrangements in the West Midlands Police Service, the working arrangements between the Police and Social Work Services, in particular the Emergency Out of Hours service (EDT) should be considered as part of that overall review. The review should include a focus on the effectiveness of information systems which can be jointly interrogated by each agency together with the development of clear joint information protocols which are clearly understood and communicated across the agencies.” New arrangements, developed in 2013, include quarterly meetings between the Assistant Director in children services social care and the Police Detective Inspector. A “Dip sampling” of 354 children receiving services in Solihull was carried out in 2014 and involved police, social care, health and education. This work highlighted the benefits of a local Multi Agency Safeguarding Hub (MASH). Findings also led to agreement on more effective triage of notifications from the police incidents involving children. There are clear protocols in place in the LSCB procedures. The emergency duty team have access to relevant information. There is clear evidence of immediate escalation and management of emerging concerns. Co-location of police with social care in a Multi-Agency Safeguarding Hub plans are at the advanced stage. A new Multi-Agency Safeguarding Hub will be operational from October 1st and will ensure direct and immediate communications at front-line operational levels. New arrangements to manage police notifications of incidents involving children have been set up and this process will work alongside the MASH team allowing immediate escalation of serious child protection concerns. New multi-agency training improves competencies on communications and information sharing. The LSCB monitors MASH developments with direct reports from social care and police. The LSCB monitors progress through scrutiny of the performance data set, discussion and analysis. 49 SCR Learning Point Recommendation 4 Action Current position Sustaining improvement The review has highlighted considerable misunderstandings between agencies in respect of what information about the antecedent history of adults who may pose a safeguarding risk to children can be gained from the Police records, the method by which that information can be obtained and in what timescale. “Systems for sharing information between agencies in child protection cases should be clarified and improved. These systems should include paper and electronic systems together with a focus on the way professional staff verbally communicate information between agencies. The results should be widely communicated to Professional staff within the relevant agencies, and should include check mechanisms to ensure that staff have fully understood any changes or developments and have implemented them.” AD social care and Police DI have revised processes in 2014 and raised awareness in their respective agencies. Police capability has been enhanced and systems embedded through training to enable information sharing on adults who may pose a risk to children with particular reference to CSE but which also includes child protection risks. MASH plans have been agreed allowing faster access to police computer systems. Formal structured information sharing on adults who may pose a risk to children takes place in Multi Agency Risk Assessment Conference (MARAC), the Children Missing and Operational group and in child protection conferences and strategy meetings. The Multi-agency Safeguarding Hub is operational on 1st October. From 1st October 2015 MASH will be operational with agreed information sharing protocols and systems. This will ensure that Childrens services have improved access to information from Police Service records on Adults about whom they have concerns in respect of posing safeguarding risks to Children. The early help performance framework will monitor DV incidents and report regularly to the LSCB executive. LSCB multi-agency training places emphasis on information sharing. 50 SCR Learning Point Recommendation 5 Action Current position Sustaining improvement The attendance of all appropriate agency representatives at Initial Child Protection Conferences and attendance at Core Groups is significantly problematic. A review of the booking system for initial Child Protection Conferences should take place. The review should ensure that a booking system is in place where a minimum notice period is given to professional staff across the agencies to allow for attendance. The review should highlight the importance of attendances at conferences and core group and promote a wider understanding of the significance of such meetings in safeguarding children. The review should consider systems which include arrangements for substitutes to attend where necessary, the provision of reports to be presented in cases of unavoidable absence and arrangements for non-attendees to be available to present information or opinion by conference telephone call where applicable or necessary. The review should also include the provision of systems to ensure that the taking of minutes of key meetings such as core groups are facilitated and resourced on a multi-agency basis. Logistics, administration and communications around child protection conferences have been revised in 2014 and attendance at CPPC is monitored directly by the LSCB. The LA re-structure in social care means that all child protection issues are dealt with by the child protection team, providing consistency and continuity. The role of the social worker in chairing core groups has been made clear. A template to record notes of core groups has been developed and is monitored internally. There has been overall steady improvement in attendance at child protection conferences. Core group management and logistics is managed by team managers and regularly audited. The multi-agency training programme includes child protection conferences and core groups. Child protection conference attendance will continue by be part of the LSCB quality assurance process. The Case audit programme for 2015-2016 will identify practitioners’ experience of core groups, child protection conferences and other information sharing meetings. Training evaluations will provide information on practitioners understanding of the importance of prioritising, preparation for, reporting to, and taking part in child protection conferences and core groups as well as recording. 51 SCR Learning Point Recommendation 6 Action Current position Sustaining improvement The review has highlighted that there was insufficient shared understanding across the agencies involved in safeguarding about what the task of supervision in safeguarding cases actually was and how it contributed to keeping children safe. It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had. “Using examples of national best practice underpinned by relevant research the Solihull LSCB should mount an inter-agency development initiative for those supervising front line safeguarding practice. The initiative should include a focus on the importance of shared analysis and challenge within the supervisory relationship process. Those facilitating the initiative should not only focus on improving individuals supervisory skills but also an improved multi-agency understanding of the importance of supervision in its key role in refining safeguarding assessment, planning and review”. Supervision standards were developed by the policy sub-group using national research and have been included on the LSCB website. A case audit showed variation in models of supervision used by partner agencies. The Case audit group further devised an agreed set of auditable standards, including minimum frequency, enabling reflective practice and providing challenge. The training programme incorporates a module on safeguarding supervision for those supervising front line practice. The case audit group is currently auditing against agreed standards. A training programme for managers on analysis and judgement in safeguarding children will deliver training to supervisors and managers on their role in enabling sound reflective practice and providing challenge to front line practice. The outcome of case audit will inform LSCB so that individual member agencies can be confident that each agency has in place robust arrangements to ensure relevant challenge to practitioners. The safeguarding faculty informs the LSCB more directly on the needs of practitioners in relation to supervision and training. A conference for managers in November will deliver this key message. 52 SCR Learning Point Recommendation 7( police) Action Current position Sustaining improvement Police officers attending domestic violence and aggression incidents often have limited information about the antecedent history of incidents of DV or of the involvement of other services into the household they are visiting when responding to a call out. West Midlands Police should improve the information available to front line officers when attending actual or suspected DV incidents. Flagging of addresses to alert officers attending is now embedded in police operational practice. All incidents involving children are effectively triaged alongside the MASH team and within the Early Help framework. Revised policy, published Dec 2013 means that safeguarding officers within PPU must add a SIG marker/check to medium and high risk incidents. All officers have access to intelligence systems/OASIS and PNC prior to their arrival at an incident. Sig markers are used to identify risk and vulnerability of persons and addresses. Quality assurance to the LSCB will take place through the monitoring of Early help triage Case audit Training evaluations Section 11 audit will require police to report on this recommendation and whether the expected outcome has been achieved. 53 Appendix 2: Individual Agency Recommendations The following recommendations have been made by the IMR authors who completed their report in September 2013 and are supported by the overview author and the Serious Case Review Panel. Many of these recommendation will have been delivered. This will be assessed as part of a wider audit by the LSCB under Section 11 of the Children Act 2004. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT); 1) BMHFT to have clear and useable child protection policy accessible on the intranet site. 2) BSMHFT - Safeguarding Governance across SIAS is clarified with commissioners and The Bridge has a clearly defined understanding of Governance and their role within this structure. 3) The Bridge must improve their management of cases worked jointly within SIAS. 4) The Bridge Clinical Leads (with the help of SIAS Safeguarding Working Group) will embed the ‘Think Family and Early Help Principles’ into all interventions for Service users who are parents or carers of Children and Young People. Heart of England Foundation Trust (HEFT); 1) Information shared as part of the discharge process between Maternity staff and Health Visitor and GP colleagues should be reviewed to ensure that children’s safeguarding issues are being properly identified and shared appropriately by maternity staff at discharge. 2) To see if existing Maternity Liaison processes are fit for purpose. 3) To establish an agreement regarding resource to ensure Child Protection Supervision for all community midwifery teams is in place. 4) To hold a briefing event for HVs and MWs in relation to learning from the case. 5) To undertake a review of the health visiting records and record keeping guidance. 6) Review current supervision policy and produce revised policy, supervision documentation and monitoring arrangements. 7) To launch the new Trust Domestic Abuse Policy 2013 and implement awareness raising in the ED. The Welcome Service 1) The Welcome Child safeguarding policy should be reviewed and Welcome should continue to review the policy annually in line with LSCB protocols. The Policy should also be reviewed alongside that of SIAS partners to ensure consistency. 2) Welcome needs to improve the management of cases across the SIAS partnership. 3) HR processes and procedures in response to staff absence should consider consistent case management, particularly in relation to high risk cases. 4) Management supervision should be expanded to address safeguarding. NHS England; 1) The surgery adopt the suggestion in the RCGP’s Safeguarding Children and Young People in respect of recording the name of the accompanying adult and if possible identifying the relationship to the child and this recommendation is cascaded to all GP practices in Solihull. 2) The surgery adopt the point in the Toolkit for General Practice in respect of establishing a system to mark the records of a parent of a child (as a significant adult) on the child protection register as well as the child’s records to prevent de-escalation. Whilst this is dependent on receipt of this information from Social Services this information could be actively sought following case conferences. That this recommendation is cascaded to all GP practices in Solihull. 3) CCG 3 - That the surgery considers its practise with regard to filtering records of children on the Child Protection Register in order to ensure they have a holistic view of issues and that this recommendation is cascaded to all GP practices in Solihull. 4) The CCG Chief Nurse will discuss with the Director of Nursing at NHS England’s Area Team (health visiting commissioned through NHSE) the limitations regarding Health Visitor deployment. Specific recommendations will be identified and agreed to ensure system wide learning as a result of this SCR. Solihull Community Housing (SCH); 1) For all cases involving substance misuse, SCH’s frontline housing management teams will routinely refer to the Joint Service Protocol re: Families and Children Affected by Parental Drug / Alcohol Misuse, when assessing potential referrals due to safeguarding concerns. 2) Investigate the basis for perceptions within the ASB context that information sharing and multi-agency working can be improved. West Midlands Police (WMP); 1) Police officers acquire knowledge of the risks to children associated with domestic violence and can identify the elements of a robust investigation and its effect in protecting vulnerable adults and children. 2) By deploying current systems to their full potential, we will reduce the need for multiple intelligence checks of systems when dealing with public protection matters, by attaching to a nominal record an up to date summary of current risk assessments and protection plans and strategies identifying known risk factors and protective factors. 3) WMP will ensure that necessary information and full participation as partners in key decisions to safeguard and promote the welfare of children is delivered. 4) To provide West Midlands Police officers and staff with essential information about the potential for children to be at immediate by alerting them to the existence of Children who are the subject of a Child Protection Plan (CPP). Solihull Council 1) The local assessment protocol considers the requirement, timeliness and threshold for assessment. 2) Implementation of a single comprehensive assessment tool for social work services. 3) Effective and comprehensive Quality Assurance Framework in place. 4) Use of chronologies is standardised. 5) A standardised template for Core Groups is considered by the LSCB. 55 6) The addition of visiting frequency / arrangement for seeing a child subject to Child Protection Plans is considered by the LSCB. 7) Sponsored placements are routinely informed of who can and cannot transport a child to and from their provision. Health Overview Report 1) Health Commissioners and NHS providers (BSMHFT & HEFT) make arrangements to ensure that the services they contract out to others are provided having regard to the need to safeguard and promote the welfare of children (Children Act 2004, Section 11 (2) (b)). Where standard NHS contract (including information requirements) are not used, then the commissioner and/or provider should have in place a contractual agreement and/or service specification/ formal arrangement to ensure and secure safeguarding quality assurance through formal written arrangements with all providers that are commissioned and/or sub contracted. 2) All thirty two Solihull CCG Member Practices facilitate formalised practice meetings where families of concern can be discussed in a formalised way, evidencing components of key principles, actions and effective practice. 3) An audit of current learning opportunities, including in-house domestic violence training should be undertaken by the NHS agencies participating in this review to establish that it addresses the recognition & management of cases where substance misuse, domestic violence & mental health issues are seen as a cluster; and to ensure that the organisational learning opportunities promotes collaborative working to respond to children and victim’s needs. 56 Appendix 3: Roles of Agencies 1.1 Whilst local authorities play a lead role, safeguarding children and protecting them from harm is everyone’s responsibility. Everyone who comes into contact with children and families has a role to play. 1.2 Safeguarding and promoting the welfare of children is defined for the purposes of this guidance as: • protecting children from maltreatment; • preventing impairment of children's health or development; • ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and • taking action to enable all children to have the best outcomes. 1.3 Local agencies, including the police and health services, also have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions. 1.4 Under section 10 of the same Act, a similar range of agencies are required to cooperate with local authorities to promote the well-being of children in each local authority area. This cooperation should exist and be effective at all levels of the organisation, from strategic level through to operational delivery. 1.5 Professionals working in agencies with these duties are responsible for ensuring that they fulfil their role and responsibilities in a manner consistent with the statutory duties of their employer. Solihull Local Authority Children’s Social Work Services 1.6 Local authorities have overarching responsibility for safeguarding and promoting the welfare of all children and young people in their area. They have a number of statutory functions under the 1989 and 2004 Children Acts which make this clear. This includes specific duties in relation to children in need and children suffering, or likely to suffer, significant harm, regardless of where they are found, under sections 17 and 47 of the Children Act 1989. The Director of Children’s Services and Lead Member for Children’s Services in local authorities are the key points of professional and political accountability, with responsibility for the effective delivery of these functions. 1.7 Solihull Borough has a resident population of approximately 50,200 children and young people aged 0 to 19, representing 24.4% of the total population of the area. 1.8 An initial response to service users is provided by the Duty, Assessment, and Referral Team (DART). When cases are deemed to require longer term interventions they are moved onto other teams such as the Child in Need Team. Heart of England Foundation Trust (HEFT) 1.9 HEFT is a large, multi-site, NHS Trust providing acute and community care to an ethnically diverse and predominantly urban population of approximately one million. Heart of England NHS 57 Foundation Trust has maternity units across three sites; Birmingham Heartlands Hospital (BHH), Good Hope Hospital (GHH) and Solihull Hospital (SH). Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) 1.10 The Trust was established on 1 April 2003. The function of the Trust is to provide secondary mental health care to the population of Birmingham and Solihull. It provides both in-patient and community mental health services to adults (All those over the age of 18). In Solihull, Solihull Integrated Addiction Service or “SIAS” provides the addiction provision. This is a partnership of both statutory and third sector addiction services commissioned by Solihull MBC. It offers a range of drug and alcohol interventions via different providers. Within SIAS, BSMHFT provide a specialist prescribing service, known as The Bridge. Welcome 1.11 Welcome is a small local charity with the function of providing drug and alcohol treatment services and family support services in the borough of Solihull. Welcome is commissioned by Solihull MBC to deliver services in partnership with BSMHFT and other partners in the umbrella body, Solihull Integrated Addiction Service (SIAS). The Welcome service provides a single point of contact for those wishing to access treatment services and provides a drop in facility, psychosocial interventions, counselling service, employment support and a structured day care programme. A prison through care and after-care programme is also provided. Solihull Clinical Commissioning Group 1.12 Solihull Clinical Commissioning Group (Solihull CCG) was authorised to lead the local NHS by commissioning (planning, buying and monitoring) high quality healthcare services for the people of Solihull from April 2013. It is also responsible for improving the quality of primary care services but it is not responsible for the commissioning of primary care, this lies with NHS England. 1.13 It is comprised of GPs from every practice in Solihull, and Church Road practice in Sheldon, and has a governing body of GPs, CCG executives and lay members. Prior to authorisation, services in Solihull were commissioned by Solihull Primary Care Trust. The designated nurse for safeguarding is employed by Solihull CCG and the CCG has supported the practice involved in this case with its individual management review. West Midlands Police 1.14 West Midlands Police is the second largest police force in the country. 1.15 The region sits at the very heart of the country and covers the three major centres of Birmingham, Coventry and Wolverhampton. It also includes the busy and thriving districts of Sandwell, Walsall, Solihull and Dudley. 1.16 The force deals with more than 2,000 emergency calls for help every day, as well as patrolling the streets and responding to incidents 24-hours-a-day, seven days a week. 58 Appendix 4: Glossary of Terms Initial Assessment An initial assessment is defined as a ‘brief assessment...should address the dimensions of the assessment framework.... determining if the child is in need and the nature of any services required’. (National Assessment Framework 2000). Core assessment: A core assessment is defined as ‘an in-depth assessment which addresses the central or most important aspects of the needs of a child and the capacity of his or her parents or caregivers to respond appropriately to these needs within the wider family and community context’. The end purpose of the core assessment is defined as ‘At the conclusion of this phase of assessment, there should be an analysis of the findings which will provide an understanding of the child’s circumstances and inform planning, case objectives and the nature of service provision’. The definition leads on to outline the multi-agency requirement of a core assessment, “while it is led by social services invariably it will involve other agencies... (who will) contribute specialist knowledge or advice or specialist assessments”. Disguised compliance In their publication “Beyond Blame”, Reder, Duncan and Gray define disguised compliance as “a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention”. The phenomenon features significantly as an issue in working with families as outlined in forty seven case studies analysed in The Biennial Study of Serious case Reviews 2003-2005 (Brandon et al). Hindsight Bias Dekker (2010) notes that “hindsight causes us to oversimplify history; relative to how people understood events at the time they were happening”. Shiller, (2000) describes it as “a tendency to think that one would have known actual events were coming before they happened, had one been present then or had reason to pay attention. Hindsight bias encourages a view of the world as more predictable than it really is”. Professional Learning and Supervision In her review of child protection in 2011, Munro usefully reflects Klein’s (2000) work on ways in which experts learn: • Engaging in deliberate practice, and setting specific goals and evaluation criteria; • Compiling extensive experience banks • Obtaining feedback that is accurate, diagnostic and reasonably timely and • Enriching their experience by reviewing prior experiences to derive new insights and lessons from mistakes In respect of the children’s services profession, Munro goes on to say, “This account of professional expertise is crucial for thinking about how both individuals and the profession as a whole can be supported to develop their knowledge and skills in helping children and families”. 59 Rule of Optimism Dingwall, Eekelaar and Murray (1983) highlighted the rule of optimism as meaning” that professional staff want to think the best of those they work with and want things to work out, exhibiting a positive bias in that direction”. Start Again Syndrome The concept of the ‘start again syndrome’ (Brandon et al 2008) whereby prior knowledge and case history, and case ‘experience’ is discounted in favour of searching for new information, is an established phenomenon in child protection work. 60 Appendix 5: Bibliography Advisory Council on the Misuse of Drugs (2003) Hidden Harm – responding to the needs of children of problem drug users Advisory Council on the Misuse of Drugs (2007) Hidden Harm Three Years On: Realities, Challenges and Opportunities Cleaver, Unell and Aldgate (2011) Children’s Needs – Parenting Capacity Child Abuse, Parental Mental Health, Learning Disability, Substance Misuse and Domestic Violence 2nd edition HMSO. Davies. C & Ward. H (2012) Safeguarding Children Across Services: Messages From Research. Kingsley Publishers : London. Dekker. S (2010) The Field Guide to Understanding Human Error. Surrey: Ashgate. Department for Education. (2012) New learning from serious case reviews: a two year report for 2009-2011. London: DfE. Department of Health, Department for Education and Employment and Home Office (2000). Framework for the Assessment of Children in Need and their Families, page 32. London: The Stationery Office. Department of Health, Cox A. and Bentovim, A. (2000) The Family Assessment Pack of Questionnaires and Scales. London: The Stationery Office. Dingwall.,R Eekelaar. J and Murray. T (1983) The Protection of Children: State Intervention and family life. Blackwell Oxford : England. Fish, Sheila and Munro, Eileen. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews (Report 19). London: SCIE Galvini. S (2015) Alcohol and Other Drug Use. The Role and Capabilities of Social Workers MMU HM Government (2015) Information sharing. Advice for practitioners providing safeguarding services to children, young people, parents and carers. Crown Copyright Kadushin, A. (1992) Supervision in Social Work, Third Edition. New York: Columbia University Press Laming. H et al (2003) The Victoria Climbie Inquiry Report. London : TSO Laming. H (2009) The protection of children in England: a progress report. London: TSO Munro, E. (2011) The Munro Review of Child Protection: Final Report A child-centered system. London: The Stationery Office National Children’s Bureau (2013) The role of Independent Reviewing Officers in England London. Ofsted (2008). Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008. London: Ofsted. Reder. P Duncan. S and Gray. M (1993) Beyond Blame : Child Abuse Tragedies Revisited Tuck, V. (October 2011) ‘Resistant Parents and Child Protection: Pointers for Practice and Implications for Policy. Child Abuse Review. Turney, D., Platt, D., Selwyn, J. And Farmer, E. (2011). Social work assessment of children in need: what do we know? Messages from research, Executive Study. London: Department for Education, School for Policy Studies, University of Bristol. |
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